Best practices in communication with older adults.

Johnston, Linda M. ; Womack, Deanna F.

Best Practices in Communication with Older Adults

As adults live longer, many more than in the past will require assistance with activities of daily living or nursing care. While some will receive home-based care, many adults who need care beyond the ability of family members will move to residential settings. Effective adjustment to life in a residential care facility requires effective communication to maintain dignity and independence; interpersonal and organizational communication are especially important in creating positive experiences for residents, families, and facility staff. The U.S. Administration on Aging and other government agencies have sought to establish best practices to meet this growing demand. However, the literature contains little research on evidence-based practices related to effective communication with older adults. Therefore, this article represents a first attempt to create a best practices model of effective communication to assist families, care providers, and older adults in skilled nursing facilities and assisted living residences. We posed the following research question: In assisted living facilities and skilled nursing facilities identified as having excellent communication with residents, families, and staff, what are the best practices in effective communication for older adults, their families, and caregivers?

Review of the Literature

Although much has been written about skilled nursing facilities and assisted living residences, we found few articles dealing directly with communication except as exchange of information. We identified three lines of research related to effective interpersonal and organizational communication with older adults: communication characteristics that older adults desire or consider effective; ineffective communication practices with older adults; and ways in which these ineffective communication practices lead to problems in health care delivery and management. Finally, we discovered research indicating some suggestions for effective communication with older adults in residential settings.

Effective Communication with Older Adults

To build a model of best practices in communicating with older adults, one must first identify what communication behaviors are most effective with this population. In 1985, Nussbaum proposed a model relating life satisfaction to frequency of communication interactions and perceived closeness with family and friends. Interestingly, nursing home staff interpreted complaining as positive because it indicated interest and involvement in previously withdrawn individuals. In addition, Weitzman and Weitzman (2003) emphasized the need for developing and refining training efforts for older adults in effective communication techniques, especially with their doctors. However, this research did not identify specific communication strategies effective in creating successful relationships with friends and family or caregivers. Thus, we found few suggestions for specific behaviors.

However, the nursing literature contains articles reporting behaviors patients desire in skilled nurses and skilled nursing facilities. For example, in her exploration of patients' experiences in Ireland, McCabe's (2004) interviews with patients indicated that they wanted nurses to use patient-centered rather than task-centered communication. She found four themes that summarized ineffective and effective communication: (1) lack of sufficient information, including instances in which nurses made decisions about changing medication without consulting patients, (2) attending to patients, including open, honest communication and genuineness, (3) empathy, and (4) friendliness and humor. These characteristics are similar to those found in theories and studies in the U.S. Although not directly related to aging, Wiemann's (1977) six-dimensional model of competence incorporates both attitudinal and behavioral variables and has been tested to determine whether older adults concur that the behaviors it identifies are effective (Downs, Smith, Chatham, & Boyle, 1986). Wiemann's variables include: (1) affiliation/support; (2) social relaxation; (3) empathy; (4) behavioral flexibility indicated by particular speech choices and verbal immediacy cues; and (5) interaction management. Individuals who are positively evaluated on any of the components tend to be judged as high on a global communicative competence dimension. Using Wiemann's (1977) conceptualization, Downs, Smith, Chatham, and Boyle (1986) interviewed 295 participants aged sixty and older about their perceptions of competent communication. Older adults identified characteristics of communication competence consistent with Wiemann's (1977) model. The logical inference is that older adults judge others as competent communicators if they display at least one of the behaviors described in Wiemann's communication competence model.

The evidence is clear that effective communication is important to the elderly. Communication affects interpersonal relationships and social interaction and thereby affects the quality of life as adults age (Shadden & Raiford, 1984). Recommendations for identifying and modifying communication deficiencies also exist in the literature, as do recommendations for resident-centered care (Doty, Koren, & Sturla, 2008). The research focuses on deficiencies and ineffective communication toward older adults.

Ineffective Communication with Older Adults

In addition to the literature investigating the communicative competence of older adults or their conversational partners, there is research identifying physiological components of aging that challenge older adults' competence. Because much of the research is grounded in the communication predicament of aging model (Ryan, Giles, Bartolucci, & Henwood, 1986), it takes a "deficit" approach (Seligman & Csikszentmihalyi, 2000). This research identifies older adults' communication challenges and experiences of demeaning and infantilizing communication (Hummert & Ryan, 2001). From a social identity theory perspective (Taifel & Turner, 1986), Harwood (2007) summarizes the communication research on age identity. Both older and younger adults hold negative stereotypes of aging (Kite, Stockdale, Whitley, & Johnson, 2005) similar to those found in the media (Harwood & Giles 1992; Robinson, Skill, & Turner, 2004).

The nursing literature contains studies using questionnaires and interviews that identify other communication practices that older adults consider ineffective. Park and Song (2005) developed a Communication-Barriers Questionnaire based on barriers reported in the literature including those related to patients' aging; verbal and nonverbal communication; and the environment in which communication takes place. Comparing the rankings of barriers by hospital patients and nurses in Korea, Park and Song found that older patients perceived communication barriers related to nurses (e.g., poor attitudes toward older patients and poor communication skills) as more important than barriers related to the patients themselves (e.g., being hard of hearing, being forgetful). Older patients identified specific nurse communication barriers such as violating conversational norms (including using jargon, suddenly changing the subject or presenting several subjects at the same time, interrupting, and not making eye contact). They also identified attitudinal and content barriers to communication: being authoritative, insincere, unfriendly, disrespectful, and making the patient feel hopeless.

Using Park and Song's (2005) Communication-Barriers Questionnaire, Ruan and Lambert (2008) reported similar findings with hospital patients in China. Elderly hospital patients identified the following ineffective nurse behaviors: disliking or showing disrespect for the elderly, being unfriendly, "working without a sincere attitude," and "transferring a sense of hopelessness to the patient" (p. 112).

A qualitative study based on unstructured interviews with patients in skilled nursing homes in Slovenia confirms communication behaviors considered ineffective by older adults (Habjanic, Saarino, Elo, Turk, & Isola, 2012). Slovenian patients identified insufficient or terse communication and lack of nurses' willingness to listen as communication barriers. They also confirmed behaviors on Park and Song's (2005) Communication-Barriers Questionnaire: interruptions and unkind communication.

It seems reasonable to conclude that negative stereotypes may prompt nurses to be disrespectful, unfriendly, and to make decisions without patients' input. Furthermore, the barriers created by these attitudes result in ineffective communication practices that have been confirmed by studies in different countries around the world.

Physical communication challenges related to aging. Many studies indicate that age-related differences impair the physical communicative abilities of older adults. For example, Lieberman, Rigo, and Campaign (1988) used the Profile of Nonverbal Sensitivity test (PONS; Rosenthal, Hall, Archer, Dimatteo, & Rogers, 1979) to contrast older and younger adults' skills in decoding audio, visual, and audiovisual nonverbal cues. They found that the older group was less successful in decoding nonverbal behaviors in all three presentation modes. As they age, adults experience reductions in capacity to sense, process, and store information (e.g., Pascual-Leone, 1970; Weiss, 1982). Rosenthal (1979) also believed increased distraction and fatigue and decreased concentration accounted for older participants' poorer testing performance on the PONS. Lieberman et al. (1988) conclude that: "Age may be a primary factor contributing to inaccurate nonverbal behavior decoding and consequently dysfunctional communication" (p. 296) and call for intergenerational communication training in areas such as improved conversation regulating, listening skills, voice and articulation elements, paraphrasing, and back channeling. This training would be appropriate for both family and caretakers of older adults.

Communication deficits. Brink and Stones (2007) related the communication deficits described above to mood and social engagement of residents in complex continuing-care facilities. Their data analysis supported the following model: hearing impairment affects communication, impaired communication affects mood, and lower mood reduces social interaction. In addition, Carmichael (1976) related mass communication to information processing deficits. Brink and Stones (2007) recommend improving the quality of life for residents by improving communication through hearing aids or alternative techniques.

Also, ageism itself decreases older adults' amount, frequency, and quality of communication. For example, grandchildren may communicate less with grandparents who show signs of impaired health (Soliz & Harwood, 2006). Perhaps because of these age-related differences and associated ageism, older adults regularly encounter demeaning forms of communication.

Studies in U. S. long-term care settings have also identified ageist communication and behaviors as a problem. Carpiac-Claver and Levy-Storms (2007) examined videotapes of nurse-aide initiated communication with residents of two skilled nursing and one assisted living facility. They identified babytalk and repetition as types of elderspeak and recommended these behaviors as topics for training programs. In their study of an assisted living facility, Williams and Warren (2009) also mentioned infantilization of older adults as a communication problem.

Communication accommodation theory research.

Most research on communication with older adults identifies ineffective or demeaning communication practices in communicating with the elderly. Communication accommodation theory suggests that speakers should adjust to mirror others' communication, but not to make unnecessary adjustments, for example to age-associated behaviors (e,g,, Giles, Mulac, Bradac, & Johnson, 1987). Young people with ageist stereotypes (Coupland, Coupland, Giles, & Henwood, 1988) often overaccommodate when speaking to older adults, by using patronizing language for example ("baby talk" or elderspeak) (Hummert & Ryan, 2001). When they encounter adults with ageing cues like gray hair (Harwood & Williams, 1998), younger speakers change their normal speech patterns by speaking more slowly, over-clarifying, exaggerating pitch variations, or using simpler vocabulary (Kemper, Finter-Urczyk, Ferrell, Harden, & Billington, 1998; Ryan, Giles, Bartolucci, & Henwood, 1986). Elderspeak or overaccommodation is associated with negative stereotypes of older adults (Hummert & Shaner, 1994) and negatively affects older adults' self-esteem, identity, and even communication skills (Ryan, Hamilton, & Kwong See, 1994).

Examining conversations between older and younger adults, Ryan et al. (1986) identified four types of ineffective accommodation strategies. The first, overaccommodation to a sensory handicap such as hearing loss, may involve behaviors such as simplification, exaggerated carefulness, and the prosodic adaptations indicative of baby talk. Dependency-related overaccommodation, the second form, results from the role reversals between caregiver and client and is often found in institutional settings. Dependency-related overaccommodation manifests itself as patronizing speech that is overly directive or regulating. The third type is intergroup overaccommodation. This most widely used strategy involves overaccommodation because of membership in a group. Intergroup overaccommodation is often triggered by negative stereotypes about the elderly, who are seen as "less competent, more forgetful, slower, more dependent, and less active" (Ryan, Bourhis, & Knops, 1991, p. 443) than younger adults. Speakers underestimating the competence of older adults are likely to restrict topics of conversation, speak more slowly, simplify grammar and vocabulary, and be inattentive, impatient, or patronizing. In part, overaccommodation to the elderly reflects their lower power and social status. The fourth and rarest form of overaccommodation involves linguistic divergence emphasizing the younger speaker's difference from the older adult and is characterized by speaking rapidly, using slang appropriate to the younger speaker's age cohort, and expressing disinterest in the elder's topic choices (Ryan et al., 1991). Over time, overaccommodation can harm recipients by causing them to avoid speech situations, behave more dependently, displace anger toward others, and gradually accept the overaccommodation even though it is impolite.

Further research by Harwood, Ryan, Giles, and Tysoski (1997) confirms both older and younger adults believe patronizing speech is ineffective. As Harwood et al. (1997) note, "The recipient of patronizing talk is 'aged' by the talk addressed to him, and his prior behavior is interpreted in accord with this 'constructed,' rather than chronological age" (p. 188).

Another investigation of responses to patronizing speech focused on nursing home residents. Ryan, Kennaley, Pratt, and Shumovich (2000) conducted two studies investigating residents' conversational accommodation strategies to patronizing speech. Their description of the dilemma in which older adults find themselves is both consistent with Harwood et al.'s (1997) observations and particularly apt:

"Older adults who are repeatedly subjected to negative communication patterns may begin to feel helpless, less respected, too old, and invisible. Such experiences of demeaning communication lead to a dilemma regarding an appropriate response. Older adults may still want to appear polite and nonoffensive, yet they want to appear competent. They must also consider the danger of appearing impolite or aggressive to individuals who provide them with continuous care. On the other hand, passive acceptance by the older adult may encourage this demeaning behavior and facilitate even more negative stereotyping" (Ryan et al., 2000, p. 272). Ryan et al. (2000) suggest that appropriate communication can improve the lives of aging adults in residential settings.

Improving Communication with Older Adults

It is not surprising that findings related to ineffective communication with older adults have been applied to improve communication in assisted living and long-term care facilities. For example, in a study involving audiotape-recorded conversations between caregivers and residents of a long-term care facility, Jones and Jones (1986) found that commands (compared to sentences and questions) comprised the primary form of conversation. A large number of questions asked by residents remained unanswered, and the percentages of unanswered questions varied considerably between ethnic groups. Jones and Jones (1986) recommended training workers about residents' cultural needs to improve communication.

Communication between caregivers and older adults. In addition to amount or types of interaction, researchers have studied the quality of communication between caregivers and older adults. Teeri, Leino-Kilpi, and Valimaki's (2006) study of ethically problematic experiences reported by long-term care nurses, residents, and residents' families revealed connections between communication and adults' self-determination and dignity. The researchers identified two types of communication violations of psychological integrity: (1) offensive or derogatory treatment (e.g., staff members' rude or derogatory behavior, nurses' indifference, etc.) and (2) lack of respect for patients' self-determination (e.g., unwillingness of staff to listen or respond to requests, lack of information provided to residents or their relatives, etc.). Other problematic behaviors including indifference, insufficient information, lack of respect for patients' self-determination, and "lack of respectful touching" (Teeriet al., 2006, p. 123). The consistency in the types of ethical problems identified by long-term care residents, families, and nurses indicate that communication needs of families and patients may go unmet. For example, nurses reported communicating more information than patients and families reported receiving (Teeri et al., 2006). Franklin, Ternestedt, and Nordenfelt (2006) remark: "Care focusing on and aiming to promote an elderly person's identity and dignity demands interest and a desire to know the person" (p. 144). This observation supports the importance of caregivers' effective communication with nursing home residents, as does Sloane, Zimmerman, Hanson, Mitchell, Riedel-Leo, & Custis-Buie's (2003) recommendation that assisted living and nursing home staff provide communication support to patients nearing death. A study of Taiwanese long-term care facility residents identified examples of effective and ineffective communication with caregivers (Hwang, Hsieh, & Wang, 2013). Content analysis of interview transcripts revealed that residents identified respectful communication as indicating caring by facility staff. Respectful communication was characterized by initiating conversations with residents and respecting their autonomy. These behaviors seem to be the opposite of the communication barriers identified above in the nursing studies: not communicating enough with residents and interrupting.

Additional research has focused not just on communication as information-giving but as communication that leads to resident well-being. Bauer and Nay (2011) interviewed twelve family members with residents in five Australian assisted-living facilities. While the family members mentioned the importance of formal communication when residents were first admitted and when conflicts needed to be resolved, they also mentioned the importance of informal communication in creating collaborative relationships between the family and residence staff. One daughter summarized, "Communication [is the key to a successful relationship], just telling us every step of the way, what to expect ... not giving you any false information. Giving you the facts. [It's having] the reassurance that you can ring and check on things if you're not sure, because you go there [to the facility] and you don't know initially what to ask. (Daughter)" (p. 1235). Williams and Warren (2009) mention the importance of affective communication identified by assisted living residents in interviews including emotional support, praise, and encouragement.

Also, a study of resident-staff relationships in U.S. assisted living facilities focused on the importance of communication in helping staff develop relationships with residents (Ball, Lepore, Perkins, Hollingsworth, & Sweatman, 2009). These relationships not only benefit residents as well as caregivers, but they also may improve medical outcomes by improving staff job satisfaction and retention. The authors found that the emotional aspect of the relationships helped caregivers find meaning in their work. As one worker expressed, "They [the residents] are the reason I come to work" (p. 37).

Best Practices in Residential Settings for Older Adults

Finally, we turn to the small number of research articles exploring effective communication practices related to organizations caring for older adults. Ryan, Meredith, MacLean, and Orange (1995) developed the communication enhancement of aging model in contrast to the communication deficit model. They recommend communicators assess older adults' needs individually rather than through stereotyping. Conversations based on this model show that more appropriate accommodation empowers elders and enriches interpersonal communication (Nussbaum, Pitts, Huber, Raup, Krieger, & Ohs, 2005; Ryan et al., 2000). Similarly, Levy-Storms, Claver, Gutierrez, and Curry's (2011) findings that individualized care can increase both physical and psychological well-being are consistent with Ryan et al.'s (1986) enhancement of aging model. Furthermore, in the most comprehensive research to date, Hickman, Newton, Halcomb, Chang, and Davidson (2007) identified 26 studies that reported controlled trials of interventions to benefit older adults in acute care settings. The best communication practices between members of a multidisciplinary medical team and between patients and team members involved identifying and communicating risk factors; implementing individualized treatments and nursing plans to promote patient independence; and planning and delivering care designed to meet individual needs.

While researchers emphasize communication, many define communication as information gathering and exchange between team members. For example, the Hickman et al. (2007) model does not distinguish effective from ineffective communication. Because none of the strands of literature presented a comprehensive model of best practices of communication with older adults, we posed the following research question: In assisted living facilities and skilled nursing facilities identified as having excellent communication with residents, families, and staff, what are the best practices in effective communication for older adults, their families, and caregivers?

Methods

To investigate the research question, the authors contacted experts with extensive knowledge of skilled nursing facilities and assisted living facilities in northwest Cobb County, Georgia and asked them which facilities had excellent reputations. After compiling a list of facilities identified by the group of experts as effective in communicating with older adults, the authors contacted the facilities and conducted in-depth interviews with staff, residents, and family members. During a training session, the authors recruited nine additional potential interviewees representing assisted living facilities and county and regional services organizations for older adults.

In all the authors interviewed 24 individuals representing 11 facilities, including five assisted living facilities, one skilled nursing home, and one facility with both assisted living and nursing home residents. (Some assisted living facilities offered Alzheimer's care; others did not.) The authors individually conducted telephone or face-to-face interviews with respondents from different facilities. They conducted one joint face-to-face interview. Face-to-face interviews were conducted at the facilities. Before proceeding with the interviews, the authors presented the consent forms and explained the purpose of the interview. Interviews began only after respondents agreed to participate and agreed to be tape recorded. Residents interviewed clearly understood the procedures and were capable of giving consent. The interviews lasted between thirty minutes and an hour and were audiotaped for further analysis. The staff members included administrators who recruited and had primary contact with residents' families and others such a director of nursing and a chaplain who communicated regularly with residents. The authors also interviewed three residents and three family members from the facilities and representatives of three government senior services organizations.

Because the literature did not provide a set of pre-existing categories to describe best practices in communication with older adults, the authors asked open-ended questions (see Appendix). Taking an appreciative inquiry approach, the researchers framed all questions positively. The questions were adapted slightly for the resident and family interviews. Then, using a grounded theory approach (Glaser & Strauss, 1967), researchers identified common themes from the interview data.

Results

Because of the number of different facilities and roles represented by the interviewees, the authors summarized resultant themes related to communication. Four preliminary themes emerged from the data analysis: (1) Effective interpersonal communication skills and behaviors, (2) Organizational culture, (3) Organizational communication structures, and (4) Components unique to a particular environment.

Effective Communication Skills and Behaviors

Effective communication behaviors were often related to the organization's culture. Several interviewees stressed being open and honest with residents and co-workers in order to create good relationships and to assist in serving the residents. They mentioned listening to information from other staff and other residents about a particular resident's needs and respecting the privacy and dignity of residents. For example, an interviewee mentioned talking directly to both an Alzheimer's patient and her husband rather than addressing only the husband. Finally, one interviewee suggested staff should consider the background and context if a resident or family member responded harshly: "I don't take it personally if families or residents lash out at me; they're scared." The interviewee further stressed that employees should keep focused on the goals for the resident, not on specific behaviors at a particular time.

These behaviors mirror the kinds of communication mentioned above in the review of the literature. Studies involving interviews with hospital patients or residents of long term care facilities in China (Ruan & Lambert, 2008), Ireland (McCabe, 2004), Korea (Park & Song, 2005), Slovenia (Habjanic et al., 2012), Taiwan (Hwang et al., 2013), and the U.S. (Ball et al., 2009; Williams & Warren, 2009) mentioned their desire for respectful, sincere communication. While respectful communication might take different forms in different languages and cultures, the fact that it is mentioned in studies around the world indicates that this is a widespread characteristic of effective communication with older adults.

The remaining themes did not correspond to the categories developed in the review of the literature. Because we used an appreciative inquiry approach, interviewees discussed effective practices and did not repeat topics mentioned in the literature review such as ineffective communication, physical communication challenges, or communication deficits. Since we focused on effective communication practices, our findings differed from the literature, especially Hickman et al.'s (2007) meta-analysis that revealed practices related to communicating risk, for example.

Organizational Communication Structures

Organizational communication structures tended to be consistent across the different kinds of facilities, perhaps due to federal or state regulation. Best practices included providing extra administrative support for residents and families, including completing paperwork. Almost all interviewees mentioned periodic resident evaluation meetings as an effective communication practice. These meetings include staff representing multiple disciplines, although not necessarily the same disciplines in every facility. For example, one facility with more than 200 beds, which included independent living residences as well as assisted living apartments, included the chaplain and the head of housekeeping, but not the activities coordinator, as part of the weekly evaluation meeting. Other, smaller assisted living facilities included the activities coordinator but had no housekeeping supervisor or full-time chaplain.

An example of effective communication during resident evaluation meetings included a prior planning meeting for staff members only. The staff brainstormed ways to achieve the goals for the resident and tried to anticipate the family's questions so that they could agree on a team response. The interviewee said: "They'll persuade [the health care team] if you haven't talked about these things" before meeting with the family. The interviewee described a meeting to decide whether a resident who had been hospitalized could return to independent living with his wife or needed to move into nursing care, a change that would have separated him from their shared living quarters. The interviewee stressed that the health care team tried to help the family be realistic by honestly expressing concerns regarding transfers from his bed to a chair, for example. In this case, the facility was able to provide a reclining chair that enabled the resident to live with his wife for a few more months.

Multiple interviewees also mentioned approaching health care for individuals as a team effort. In one example, the husband of a couple living together was taken to the hospital, but no one could locate the wife to inform her. One staff member knew the wife had her hair styled at a particular salon on a certain day and time every week. The resident services coordinator located the wife at the salon, drove her to the hospital, and remained at the hospital with her for a short time. Staff members mentioned that it was easy to recognize and work with representatives from other departments, even if they did not know each other's names. Certified nursing assistants might recognize a physical therapist and know what department she represented, for example.

Low employee turnover contributed to strengthening team members' abilities to know and work with each other effectively. Until staff got to know each other, turnover caused communication difficulties.

In addition, interviewees mentioned the importance of on-the-job training programs for new employees and periodic in-service training programs in areas such as teambuilding, ethics, and Health Insurance Portability and Accountability Act (HIPAA) rules and regulations. Two interviewees provided an example of an especially effective orientation and training program at a continuing care retirement community that had residents who lived independently, in assisted living, and in a nursing wing. A marketing director employed at the facility for less than one year mentioned the full-day orientation program offered to all new employees, regardless of their positions in the organizational hierarchy. (The details of this program will be discussed below). After the orientation, employees were paired with experienced volunteers particularly helpful at training new employees. There was no effort to punish or criticize workers who did not want to help with training or mentoring, but those who did were encouraged to volunteer to demonstrate the proper way to do tasks and procedures and to make the new employee feel welcome.

Other structural aspects of communication involved using a variety of media to communicate with residents and families: telephone (including families' cell phones), email, and facility newsletters. No interviewees mentioned social media.

Organizational Culture

A common theme in the interviews was an organizational culture that supported caring attitudes from top to bottom of the organization. One worker at a church-sponsored facility mentioned that she viewed her job as a mission to care for others. Several interviewees mentioned that the staff, who are generally low paid, sincerely care about the residents. The staff members look at family pictures, get to know family members, and come to know the residents as individuals. Interviewees from the continuing care retirement facility mentioned that some residents had lived in different parts of the facility for ten years. The residents enter the community living independently in houses or apartments, then move to assisted living, and finally to nursing home beds as the need arises for increased levels of care.

The interviewee who described her recent orientation session also provided an interesting example of a supportive organizational culture. At the orientation luncheon, she noted, employees were made to feel that they all contributed equally and all contributions were valued, even though the contributions ranged from housekeeping to skilled nursing care. All new employees introduced themselves and described their jobs so that everyone at the luncheon understood the variety of jobs performed at the facility. The human resources director shared information about her personal background, and this helped the others introduce themselves and develop personal relationships at the orientation session. Managers showed an interest in employees as individuals with families and lives outside work, as well as employees. This organizational culture emphasized making everyone feel important, needed, and part of a team. Staff sent flowers and fruit baskets to each other and even visited on personal occasions such as a hospitalization and a death in the family. This organization also had an incentive program for workers to meet quality of care standards in their areas.

Unique Components. While the themes above were common to many organizations, we should also note one practice that made communication especially effective in a continuing care retirement community. Because residents live on campus for a number of years in different levels of care, they are well known to staff members, who recognize them when they move to new locations as health care needs require. This organization schedules regular weekly opportunities to enable assisted living residents to visit those in the nursing area. In this faith-based facility, residents at all levels of care attend religious services together as members of the same community. The residents are encouraged and enabled to maintain contact with each other as they move to different housing when their medical needs change.

Discussion

This paper has provided a preliminary analysis of the oral interviews. Perhaps because the questions led them to do so, interviewees tended to respond in organization-wide terms rather than to provide multiple individual accounts of effective communication. Thus, we did not find specific effective communication behaviors that matched those in the communication competence model, for example. None of the interviewees mentioned patronizing speech or negative stereotypes as a problem to be overcome. It is possible that training or self-selection prevents staff from adopting negative communication practices or that we only interviewed employees at good institutions and asked about effective practices, as we had intended. Perhaps the most helpful information to come from the interviews centers on effective U. S. organizational communication practices such as the types of orientation and training sessions conducted, deliberate forms of communication such as regular newsletters, and aspects of organizational culture that support effective communication between staff, residents, and family members.

Best Practices in Communication in U.S. Residential Settings for Older Adults

Many of the best practices identified above reflect organizational characteristics associated with high levels of organizational efficiency and effectiveness (Youssef & Luthans, 2010). The focus on effective organizational communication, rather than individual communication, is perhaps an effect of the number of administrators included in the interviews. Effective communication supported residents, families, and staff. Effective organizations typically held regular evaluation meetings and used a variety of communication media to keep everyone informed. Our data revealed three categories of best practices in communication with older adults living in U.S. residential settings: caring organizational cultures, high-performing organizational teams, and communication skills and behaviors.

Caring organizational cultures. The facilities we studied focused on hiring individuals who wanted to work with older adults and sincerely cared about residents. Continuing care retirement facilities in our sample provided continuity of caregivers and community involvement, benefitting residents who had lived there as long as ten years. As a result, staff members related to residents as individuals. Higgs' (2010) research associates positive emotions with adjusting well to change and with overall well-being, important issues for adults who may need increasingly higher levels of assistance.

The caring cultures also help employees thrive in their work. Employees are encouraged to know each other and develop team relationships. Managers and workers show an interest in each other's personal lives and offer support in both difficult and happy times. These attitudes make staff members feel needed and important. The positive organizations literature indicates that employee training programs support both work and personal growth and development (Hodges & Asplund, 2010). Rath (2007) found that supervisors who focus on strengths are more than twice as likely to have engaged subordinates as those who focus on weaknesses. Harter and Blacksmith (2010) associated supportive cultures with employee engagement and retention.

High-performing teams. Caring cultures also facilitate effective teamwork. Richardson and West (2010) state that high-performing work teams improve organizational performance and outcomes. Their model includes involvement in team tasks, positive relationships leading to team identification, clear but evolving team roles, and valuing diversity, all characteristics reflected in our data. We also found evidence of social support, programs that included training in teambuilding, and employee coaching (Grant & Spence, 2010). These team characteristics have been associated with transformative cooperation between team members (Sekerka & Frederickson, 2010). Such positive communication relationships and environment allow workers to align their individual goals with those of the organization (Steger & Dik, 2010) and create a "flourishing workforce" (Grant & Spence, 2010, p. 175).

Effective communication. Finally, the organizations we studied reflected interpersonal communication skills and effective communication practices. Authentic leadership and followership are hallmarks of the recent literature on positive organizations (Avolio, Griffith, Wernsing, & Walumbwa, 2010). Authentic leaders who are self-reflective provide rewards and helpful feedback that improves followers' emotional states. Thus, communication creates high-quality social environments that increase members' positive emotions (Staw, Sutton, & Pelled, 1994). Positive emotions increase workers' job satisfaction, productivity, motivation, and personal satisfaction (Sekerka & Frederickson, 2010).

Our interviewees emphasized using honest communication with staff and residents. They mentioned listening carefully about individual needs. They respected residents' privacy and dignity. Staff members further emphasized forgiveness and focusing on overall goals for residents rather than occasional negative encounters. These characteristics reflect the affiliation/support, empathy, and behavioral flexibility elements of Wiemann's (1977) communication competence model. They also suggest Peterson, Stephens, Park, Lee and Seligman's (2010) character strengths of hope, gratitude, curiosity, zest, and spirituality. These strengths increase resiliency, helping employees to cope with difficult situations and helping residents adjust to changes in their lives. Residents and family members also reported that workers' positive emotional states improved residents' well-being.

Limitations. This best practices model of effective communication provides evidence that supportive cultures, high-performing teams, and effective interpersonal communication both reflect and promote positive emotions and attitudes. Future research should explore more characteristics like those from the positive organizations literature that relate effective communication to enhanced well-being. Scholars should also further test the relationships suggested between effective communication and positive outcomes for residents, staff members, and other stakeholders. Because we interviewed only 24 individuals and most of those were administrators, future research involving residents, family members, and direct resident care staff is needed. We used an appreciative inquiry model; more research on communication barriers like that reported above is also needed. Since much of the research around the world finds consistent characteristics of individual behavior, more international research into effective organizational practices is needed. Furthermore, the results of this research should be confirmed and extended to other kinds of organizations providing services for older adults.

Conclusion

This research revealed a combination of categories related to best communication practices in assisted living and skilled nursing homes in the U.S.: effective communication skills and behaviors such as respectful, supportive, and honest communication, caring organizational cultures, and high performing organizational teams. The effective individual communication skills are consistent with those reported in many interview studies in a wide variety of countries. Additional research into organizational

communication will help to inform caregivers of best practices in communicating with older adults in residential settings. It will be interesting to see whether the effective organizational cultures and team characteristics are the same in different cultures around the world.

Correspondence to:

Linda M. Johnston, Ph.D.

Executive Director

Siegel Institute for Leadership, Ethics & Character

Kennesaw State University, USA

Deanna F. Womack, Ph.D.

Department of Communication

Kennesaw State University

402 Bartow Ave., MD# 2207

Kennesaw, GA 30144

Email: dwomack@kennesaw.edu

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Linda M. Johnston & Deanna F. Womack

Kennesaw State University, USA