Small, PhD, Assistant Professor, School of Audiology and Speech Sciences,. University of British Columbia, 5804. Fairview Avenue, Vancouver, B.C., V6T.
Conflict Resolution Styles A Comparison of Assisted Living and Nursing Home Facilities
ABSTRACT In this exploratory study, the authors investigated how interpersonal conflict is resolved in assisted living and nursing home facilities. In particular, the authors examined whether conflict resolution styles differed between type of facility and between residents and staff in each type of facility. Four focus groups were conducted—two with residents and two with staff from each type of facility. The focus groups centered on discussing the occurrence of conflict and how each participant handled it. Discourse analysis was em-
ployed to identify participants’ use of three styles of conflict resolution: controlling, solution-oriented, and non-confrontational. The results indicate that staff in each care context showed a preference for the solution-oriented approach. Residents in each setting reported equal use of the non-confrontational and solution-oriented styles. The findings suggest that preferred conflict resolution styles may vary more as a function of the role of each communicator than the context of the care setting.
JEFF A. SMALL, PhD, AND JULIAN MONTORO-RODRIGUEZ, PhD JOURNAL OF GERONTOLOGICAL NURSING
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T
he quality of care in a nursing home (NH) or an assisted living facility (ALF) is determined to a considerable extent by staff attitudes and communication behavior when interacting with residents (Baltes, Wahl, & Reichert, 1991). Although communication skills have been rated by some NH staff as one of the most important patient care skills (Curry, Porter, Michalski, & Gruman, 2000), it appears that communication training is rarely provided (Richter, Bottenberg, & Roberto, 1993). The purpose of this study was to explore
LITERATURE REVIEW The presence of conflict in interactions between NH staff and residents has been noted frequently in past research (Foner, 1994; Small et al., 1998). Conflict is manifested, in part, by negative staff behaviors (e.g., yelling), which may be a response to the physical strain and emotional wear of caring for the residents. In addition, conflict may emerge when residents exhibit behaviors arising from their cognitive and emotional impairments (e.g., linguistic problems, abusive behavior, depression). Conflict may also reflect intergenerational tensions be-
Elderly residents who were formerly independent are often dependent on the much younger nursing staff for meeting their daily physical and social needs.
one dimension of communication in ALFs and NHs: how staff and residents in each type of facility resolve conflict. Although previous research has studied communication patterns in long-term care contexts (Caris-Verhallen, Kerkstra, & Bensing, 1997), the occurrence of conflict (Small, Geldart, Gutman, & Clarke Scott, 1998), and resolution of organizational conflict by staff (Hullett, McMillan, & Rogan, 2000), there appear to be no investigations of how staff and residents handle interpersonal conflict in their interactions with one another. The rationale for this study is that the quality of communication and relationships between staff and residents is determined to a large extent by whether they use cooperative and complementary styles of conflict resolution (Bergstrom & Nussbaum, 1996).
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tween elderly residents and younger nursing staff. Elderly residents who were formerly independent are often dependent on the much younger nursing staff for meeting their daily physical and social needs. The residents’ loss of independence may cause them to be more irritable when interacting with their caregivers (Rossby, Beck, & Heacock, 1992). Greater resident dependency also places the staff in a position of power, and the staff’s perception of the residents’ dependency will likely affect how they interact with the residents (Baltes, Neumann, & Zank, 1994; Bergstrom & Nussbaum, 1996; Hewison, 1995). Abusive and patronizing communicative behavior reflects misguided use of the staff’s power as caregivers. Although only a minority of NH staff appears to use abusive speech (Foner, 1994), patronizing
speech (i.e., “elderspeak”) is often observed in speech directed to elderly individuals and NH residents (Kemper, 1994). The use of elderspeak is based on negative stereotypes of the physical and cognitive limitations of elderly individuals. It is characterized by exaggerated pitch and intonation, short simple sentences, slower speaking rate, increased loudness, and repetitions (Kemper, 1994). Although the use of this simplified speech register can convey a nurturing attitude in some contexts (e.g., speech addressed to infants or cognitively impaired individuals), most older adults react negatively to its condescending overtones (Kemper, 1994; Ryan, Hummert, & Boich, 1995). Conflicting communication goals can also lead to staff–resident conflict. In a study eliciting staff and resident interaction goals, Nussbaum (1991) found that elderly NH residents reported relational closeness with the staff as being very important (Bowers, Fibich, & Jacobson, 2001). The staff, on the other hand, reported being much more task-oriented. Staff may take this approach for a number of reasons, including wanting to maintain control, wanting to satisfy organizational demands for efficiency and economy, and wanting to distance themselves from the emotionally taxing aspects of caring for individuals who are impaired and dying (Bowers & Becker, 1992; Hullett et al., 2000). The non-complementary interaction goals of residents and staff may lead to conflict in communication and could influence how both parties handle the conflict. For example, the task-oriented perspective of the staff would likely be accompanied by a controlling style of conflict resolution because the focus is on getting a job completed in an efficient manner (Foner, 1994). Conversely, the relational preference of NH residents would likely be associated with the use of a solution-oriented style of conflict resolution because of the residents’ desire to cooperate and build friendships with the staff (Nussbaum,
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1991). The latter orientation may also reflect the residents’ perception of being in a subordinate role. How staff and residents respond to negative and conflicting communication goals may vary by the care context in which it occurs. For example, residents in NHs have serious functional limitations (e.g., physical, cognitive), which may reduce their ability to handle interpersonal conflict. As a result, the staff may assume a greater role in resolving conflict. In ALFs, on the other hand, the functional abilities of residents are generally higher (Pruchno & Rose, 2000), so a more egalitarian approach to conflict resolution may exist. Much of the previous research has focused on staff–resident interactions in a NH context. However, the importance of enhancing communication through conflict management is equally appropriate for an ALF context because assisted living is defined as a resident-centered model of care. Despite the rapid growth of ALFs and the increasing number of studies on assisted living (Hawes, Rose, & Phillips, 1999; Sikorska, 1999), little is known about the communicative behavior of staff and residents in assisted living environments. Sikorska (1999) examined the assessment of quality of resident life in ALFs and recommended that policymakers focus on the aspects of assisted living more likely to affect resident satisfaction, such as providing residents with more opportunities to develop friendships and encouraging more personal contacts with staff. PURPOSE The goal of the present exploratory study was to identify preferred styles of conflict resolution among staff and residents in NHs and ALFs. Three dimensions or styles of conflict resolution have been identified in the interpersonal conflict literature (Bergstrom & Nussbaum, 1996): ● Controlling: Arguing persistently for one’s position; aggressive and uncooperative behavior in response to conflict.
EXAMPLES OF THE THREE CONFLICT RESOLUTION STYLES Controlling: Confrontational, arguing persistently for one’s position, hostile imperatives, uncooperative Assisted living facility (ALF) staff: “Sometimes you do, you have to just take the initiative and just be stern with ‘em and, you know...” Nursing home (NH) resident: “Just tell ‘em to shut up and get out.” Solution-oriented: Supportive, make concessions, cooperative NH staff: “The most important thing is to just give a hug or just put your arm around someone—that is very important.” ALF resident: “Uh, go about it in as kind of way as I think that would probably work for her, too.” Non-confrontational: Denial of conflict, topic shifts, non-committal statements, avoidance or withdrawal ALF resident: “I’d just ignore them or else I wouldn’t, I wouldn’t have anything to do with him.” NH resident: “I just brush it off and go on ‘cause they don’t listen to me....” ● Solution-oriented: Finding a solution satisfactory to both parties; cooperation and concern for the relationship. ● Non-confrontational: Indirect strategies for handling a conflict (e.g., avoidance).
Each conflict resolution style may be appropriate in handling different kinds of conflict, depending on the goals and status of the parties involved. In most interactions, the solution-oriented style is preferred because it respects the goals and “face” of each party, and is associated with a greater chance of successful and satisfying conflict management (Hocker & Wilmot, 1995; Sillars & Zietlow, 1993). The use of a solution-oriented style, however, may not always be effective. When an individual exhibits extremely uncooperative behavior, the use of a non-confrontational style may be preferred. The use of a controlling or confrontational style is not preferred because it conveys a critical, demanding, and uncooperative attitude, and is one of the least effective strategies for resolving conflict. Because of variations in the functional status of residents in NHs and ALFs, differences might be expected in the staff’s and residents’ reported conflict resolution styles across facil-
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ity types. Residents in NHs are more dependent on the staff for meeting many of their health care needs. As a result, staff are in a position of power and may exercise it in the form of a controlling response to interpersonal conflict (Hewison, 1995). In addition, staff members in NHs are typically under severe time constraints because of the low staff-to-resident ratio (Curry et al., 2000). Such constraints may lead staff to use a transactional style of interaction that undermines or ignores the preferences of the resident (controlling or nonconfrontational styles) (Burgio, Engel, Hawkins, McCormick, & Scheve, 1990). Staff members are also called upon to handle disruptive resident behavior, which they may manage by distracting the resident or withdrawing from the situation (non-confrontational style) (Richter et al., 1993). Residents in NHs, on the other hand, may desire relational-oriented interactions with the staff but, because of their dependent status, be inclined to submit to the staff’s more controlling interaction style. This may lead the residents to respond to conflict in a more cooperative or non-confrontational manner. In ALFs, the residents’ greater independence may reduce the caregiving demands on the staff and
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TABLE FREQUENCY OF MENTIONING EACH CONFLICT RESOLUTION STYLE BY STAFF AND RESIDENTS Controlling
SolutionOriented % n
NonConfrontational % n
n
%
Assisted living facility staff
8
16.7
32
66.7
8
16.7
Assisted living facility residents
7
21.9
13
40.6
12
37.5
Nursing home staff
4
7.5
40
75.5
9
17.0
Nursing home residents
5
25.0
7
35.0
8
40.0
leave more time for building relationships. This relational orientation to interaction should lead to a preference for a more cooperative style of conflict resolution that is mutually favorable to staff and residents. METHOD Participants
A series of focus groups were conducted to assess the prevalence of staff–resident conflict resolution styles in NHs and ALFs. A focus group is a qualitative data collection technique involving interviews of a small group of individuals who discuss a particular topic under the direction of a moderator (Greenbaum, 1998). Focus groups offer a more in-depth understanding of the participants’ perspectives or opinions than is obtainable through surveys (Edmunds, 1999). Data were collected from two groups of 12 staff care providers (7 NH, 5 ALF) and two groups of 13 residents (7 NH, 6 ALF) from four NHs and four ALFs in Georgia. All participants worked (staff) or lived (residents) in their respective facilities for at least 6 months. Krueger (1988) suggested that participants in focus groups be both reasonably homogeneous and unfamiliar with one another. Therefore, in each focus group, the authors brought together individuals who were similar to one another in terms of their roles (i.e., staff care pro-
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viders or residents in ALF or NH), but who were also from different facilities in the area. The staff in each facility included Certified Nursing Assistants (CNAs), Licensed Practical Nurses (LPNs), and Activity Directors. Although staff members varied in their background training and practice, previous research has shown that the staff–resident interaction styles of CNAs and LPNs do not significantly differ (Burgio et al., 1990; Hullett et al., 2000). To control for the cognitive status of residents, the authors recruited only residents who were able to communicate and who did not have a diagnosis of dementia. Communication ability was determined by the moderator through a conversation with the resident. Procedure
The four focus groups were conducted during a 2-month period. The sessions with staff members were held at the State University of West Georgia. The sessions with residents occurred at one of the ALF or NH facilities. The moderator for the focus groups was a community counselor. During the focus group session, the participants were asked to reflect upon the quality of interactions between staff and residents in their facility. They were also asked to comment on conflicts that arose in daily living and how they approached resolution
of those conflicts. The discussions were semi-structured to ensure that all participants were provided with opportunities to speak and to keep the discussion on topic. Participants were encouraged to be spontaneous and to comment or follow up on other participants’ comments. To stimulate discussion, the moderator provided scenarios involving staff–resident interactions. All discussions were audio recorded for the purpose of transcription, coding, and analysis. Coding and Analysis
The audio recordings were transcribed verbatim and checked for accuracy by another research assistant. The data were coded along the three dimensions or styles of conflict resolution (i.e., controlling, solutionoriented, non-confrontational) (Putnam & Wilson, 1982). Participants’ comments on how they attempted to resolve interpersonal conflict were individually coded based on which style of conflict resolution was being conveyed. Examples of comments for the conflict resolution styles are given in the Sidebar on page 41. Percent agreement between two coders for the association of participants’ comments with each conflict style was as follows: ● Controlling = 87%. ● Solution-oriented = 89%. ● Non-confrontational = 83%. Although the sample size was small, the authors conducted statistical analyses to identify trends in the frequency of mention for each conflict resolution style across groups (staff, resident) and facility type (ALF, NH). RESULTS Overall, differences were observed in the frequency of comments representing each style of conflict resolution by staff and residents across ALF and NH facilities (2 [2, N = 153] = 51.10, p .001) (Table). Sixty percent of the staff members’ and residents' comments related to conflict resolu-
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tion indicated that their preferred approach was a solution-oriented style. A non-confrontational style was the next most frequently mentioned strategy for handling conflict (24%), followed by a controlling style (16%). The pattern of preferred conflict resolution styles differed between the residents and the staff, but not between the ALF and the NH facilities (2 [2, N = 25] = 15.47, p .001; 2 [2, N = 25] = 1.48, p .10, respectively) (Table). Staff in both ALF and NH contexts indicated a preference for using a solution-oriented style of conflict resolution (71%) (2 [2, N = 12] = 65.84, p .001). Residents in ALF and NH contexts mentioned using solution-oriented and nonconfrontational styles to an equal degree (38.5%) (2 [2, N = 13] = 2.46, p .10). The controlling style was the least preferred strategy for resolving conflict for both residents and staff, although it was mentioned more frequently by residents (23%) than by staff (12%). Further qualitative descriptive analyses were conducted to explore whether individual staff or residents, or the context (i.e., nature of the conflict) in which each style of conflict resolution was mentioned, were associated with preferences for particular resolution styles. Examination of the nature of the conflict associated with each resolution style suggested differences between residents and staff, but not as much among the three resolution styles. That is, ALF and NH residents mentioned the use of each of the three conflict resolution styles in response to staff members’ snappy or cranky remarks or to the staff ignoring residents' requests. The ALF and NH staff typically mentioned using a nonconfrontational or controlling style when residents yelled or were violent. The solution-oriented style was also used in the latter contexts, but was mentioned as an effective response to residents' agitation (reflecting depression), demands for attention, distress over events from the past, and problems in taking medication.
The analyses by participant (staff and resident) indicated that of all respondents, one NH staff mentioned using only one conflict resolution style (solution-oriented). All other respondents made comments associated with two or three of the styles. Thus, it does not appear that participants preferred exclusive use of one conflict resolution style over another. DISCUSSION In the present study, staff from both ALF and NH contexts reported a strong preference for using a solu-
ships with staff (solution-oriented), as well as the possible influence of a power relationship between residents and staff (non-confrontational). Ryan and Heaven (1988) investigated horizontal (benevolence) and vertical (status–competence) dimensions of social life and found that situations stressing the need for solidarity-related social skills were viewed as more typical of older than younger adults. On the other hand, situations stressing the need for status and competence were viewed as more typical of younger than older adults. In the
Residents in both assisted living facility and nursing home contexts preferred using styles of conflict resolution that convey cooperation or avoid controntation.
tion-oriented conflict resolution style over either controlling or nonconfrontational styles. It appears that although staff members were in a position of power, they preferred not to exercise it in the form of a controlling response to interpersonal conflict with residents. Residents, on the other hand, were expected to respond to conflict with staff in a cooperative manner because of their dependent status and because of a desire for meaningful interactions with the staff. The results support this position in that residents reported equal preference for using a solution-oriented and non-confrontational style of conflict resolution. Residents in both ALF and NH contexts preferred using styles of conflict resolution that convey cooperation or avoid confrontation. These findings may reflect the residents’ desire for solidarity in their relation-
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present study, the residents’ reported preferences for resolving conflict appear to support this pattern; namely, their desire to resolve conflict in a solution-oriented manner may serve to promote solidarity, and their desire to avoid confrontation may reflect deference to the younger staff’s superordinate status as caregivers. The assumed functional (in)dependence of residents in ALF versus NH contexts did not appear to have a strong influence on the staff members’ and residents’ preferred styles of conflict resolution. Much previous research has documented the relationship between the perceived dependence of elderly individuals and stereotyped behavior toward them. Based on this relationship, it was expected that staff would report a greater tendency to use a controlling style of conflict resolution when interacting with NH than with ALF
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Active listening. Perspective taking. ● Reframing. ● Brainstorming. Weitzman and Weitzman’s training of older adults included having trainees discuss challenging interpersonal situations, the trainer role-playing the use of the conflict resolution skills, and the trainees role-playing with one another. This training protocol could be integrated with a person-centered model of interaction to meet the needs and challenges of resident–staff interactions in longterm care settings. In addition to promoting better communication, the benefits of training staff in conflict resolution may extend to other aspects of the care context. Research in intensive care units suggests that positive conflict management styles and communicative interactions are associated with lower nurse turnover, higher technical quality of care, and greater ability to meet the family’s needs (Shortell et al., 1994). Similarly, training nursing staff to work and communicate with residents can assist in alleviating staff burden and burnout (Chappell & Novak, 1992; Ripich et al., 1998). ● ●
KEYPOINTS
CONFLICT RESOLUTION STYLES Small, J.A., & Montoro-Rodriguez, J. Conflict Resolution Styles: A Comparison of Assisted Living and Nursing Home Facilities. Journal of Gerontological Nursing, 2006, 32(1): 39-45.
1
The quality of communication and relationships between staff and residents in care facilities is influenced by the occurrence and resolution of interpersonal conflict.
2 3
Conflict in interactions between staff and residents may arise because of their different positions, abilities, and interaction goals. The majority of staff members and residents in four assisted living and four nursing home facilities reported a preference for using cooperative styles of conflict resolution (i.e., solution-oriented and non-confrontational versus controlling).
residents because of their different levels of independence. The findings, however, indicate that staff in four NHs respond to conflict in the same way as staff in four ALFs—all showed a preference for finding a resolution that respects the resident’s desires. These results suggest that the staff’s reported interaction styles are not motivated by negative age stereotypes, but rather are consistent with a perspective of “successful aging” and affective support (Baltes et al., 1991; Hullett et al., 2000). A cooperative approach to conflict resolution reflects an attitude toward interpersonal interaction rather than a rigid adherence to a particular response style. This philosophy of interaction, conveyed by both staff and residents in the present study, harmonizes with a number of behavioral intervention programs grounded in a humancentered or holistic model of care (Baltes et al., 1994; Baltes et al., 1991; Gottlieb-Tanaka, Small, & Yassi, 2003; Orange, Ryan, Meredith, & MacLean, 1995; Ripich, Ziol, & Lee, 1998; Wells, Dawson, Sidani, Craig, & Pringle, 2000). A common theme across caregiver intervention programs is an orientation away from
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the medical model, which focuses on impairments, to a biopsychosocial model that additionally addresses the individual’s psychological and social abilities, needs, and desires (Kitwood & Bredin, 1992). In practical terms, this perspective is exemplified in a comment made by one ALF staff member: “Each one’s different. You have to find whatever works for that person.” Although the majority of staff in the present study showed predominant preference for cooperative conflict resolution styles, with the differences in education, personality and communication styles among nursing staff (Hullett et al., 2000), in conjunction with organizational demands on staff to complete tasks efficiently (Bowers & Becker, 1992), there is likely a need for providing nursing staff with training on how to use effective conflict resolution strategies. In their review of the literature on interpersonal communication and conflict resolution, Weitzman and Weitzman (2003) concluded that the following skills promote “good communication and aid in the constructive resolution of conflict” (p. 525): ● Self-disclosure. ● Explaining.
CONCLUSION Growing evidence shows that a relational and resident-centered orientation to care leads to enhanced communication, fewer conflicts, and more effective management of conflict. This promotes a higher quality of life for staff and residents (Gilbart & Hirdes, 2000). The findings from the present study suggest that a sample of caregiving staff and residents in ALFs and NHs are aware of effective means of communicating and handling interpersonal conflict. Each group showed preferences for using cooperative styles of conflict resolution. Although the findings must be replicated with a larger sample, the participants were from eight different facilities, and thus the observed patterns are not unique to participants or residents in just one setting. Further research is also
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needed to validate staff and resident self-report responses against behavioral observations of staff–resident interactions (Kahana & Kiyak, 1984). Questions for further research include whether cooperative attitudes are carried over into actual daily interactions between staff and residents, how the perceptions of staff and residents on self-reported questionnaires and interviews compare, and the extent to which conflict resolution styles in long-term care contexts vary by the participant’s gender, age, experience, language and cultural background, and the resident’s cognitive status. REFERENCES
Baltes, M.M., Neumann, E., & Zank, S. (1994). Maintenance and rehabilitation of independence in old age: An intervention program for staff. Psychology and Aging, 9(2), 179-188. Baltes, M.M., Wahl, H.W., & Reichert, M. (1991). Successful aging in long-term care institutions. Annual Review of Gerontology and Geriatrics, 11, 311-337. Bergstrom, M.J., & Nussbaum, J.F. (1996). Cohort differences in interpersonal conflict: Implications for the older patientyounger care provider interaction. Health Communication, 8(3), 233-248. Bowers, B., & Becker, M. (1992). Nurse’s aides in nursing homes: The relationship between organization and quality. The Gerontologist, 32(3), 360-366. Bowers, B.J., Fibich, B., & Jacobson, N. (2001). Care-as-service, care-as-relating, care-as-comfort: Understanding nursing home residents’ definitions of quality. The Gerontologist, 41(4), 539-545. Burgio, L.D., Engel, B.T., Hawkins, A., McCormick, K., & Scheve, A. (1990). A descriptive analysis of nursing staff behaviors in a teaching nursing home: Differences among NAs, LPNs and RNs. The Gerontologist, 30(1), 107-112. Caris-Verhallen, W., Kerkstra, A., & Bensing, J.M. (1997). The role of communication in nursing care for elderly people: A review of the literature. Journal of Advanced Nursing, 25, 915-933. Chappell, N.L., & Novak, M. (1992). The role of support in alleviating stress among nursing assistants. The Gerontologist, 32(3), 251-359. Curry, L., Porter, M., Michalski, M., & Gruman, C. (2000). Individualized care: Perceptions of certified nurse’s aides. Journal of Gerontological Nursing, 26(7), 45-51. Edmunds, H. (1999). The focus group research handbook. Chicago: NTC B. Books.
Foner, N. (1994). Nursing home aides: Saints or monsters? The Gerontologist, 34(2), 245-250. Gilbart, E.E., & Hirdes, J.P. (2000). Stress, social engagement and psychological well-being in institutional settings: Evidence based on the minimum data set 2.0. Canadian Journal of Aging, 19(2), 50-66. Gottlieb-Tanaka, D., Small, J.A., & Yassi, A. (2003). A program of creative expression activities for seniors with dementia. Dementia, 2(1), 106-111. Greenbaum, T.L. (1998). The handbook for focus group research. Newbury Park, CA: Sage. Hawes, C., Rose, M., & Phillips, C. (1999). A national study of assisted living for the frail elderly. Retrieved November 9, 2005, from http://aspe. hhs.gov/daltcp/reports/facres.htm Hewison, A. (1995). Nurses’ power in interactions with patients. Journal of Advanced Nursing, 21, 75-82. Hocker, J.L., & Wilmot, W.W. (1995). Interpersonal conflict (4th ed.). Dubuque, IA: W.C. Brown. Hullett, C.R., McMillan, J.J., & Rogan, R.G. (2000). Caregivers’ predispositions and perceived organizational expectations for the provision of social support to nursing home residents. Health Communication, 12(3), 277-299. Kahana, E.F., & Kiyak, H.A. (1984). Attitudes and behavior of staff in facilities for the aged. Research on Aging, 6(3), 395-416. Kemper, S. (1994). Elderspeak: Speech accommodations to older adults. Aging, Neuropsychology, & Cognition, 1(1), 17-28. Kitwood, T., & Bredin, K. (1992). Towards a theory of dementia care: Personhood and well-being. Ageing and Society, 12, 269-287. Krueger, R.A. (1988). Focus groups: A practical guide for applied research. Newbury Park, CA: Sage. Nussbaum, J.F. (1991). Communication, language and the institutionalized elderly. Aging and Society, 11, 149-165. Orange, J.B., Ryan, E.B., Meredith, S.D., & MacLean, M.J. (1995). Application of the communication enhancement model for longterm care residents with Alzheimer’s disease. Topics in Language Disorders, 15(2), 20-35. Pruchno, R.A., & Rose, M.S. (2000). The effect of long-term care environments on health outcomes. The Gerontologist, 40(4), 422-428. Putnam, L.L., & Wilson, C.E. (1982). Communicative strategies in organizational conflicts: Reliability and validity of a measurement scale. In M. Burgoon (Ed.), Communication yearbook 6 (pp. 629-652). New Brunswick, NJ: Transaction. Richter, J.M., Bottenberg, D., & Roberto, K.A. (1993). Communication between formal caregivers and individuals with Alzheimer’s disease. The American Journal of Alzheimer’s Care and Related Disorders & Research, Sept/Oct, 20-26. Ripich, D.N., Ziol, E., & Lee, M. (1998). Longitudinal effects of communication training
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on caregivers of persons with Alzheimer’s disease. Clinical Gerontologist, 19(2), 37-55. Rossby, L., Beck, C., & Heacock, P. (1992). Disruptive behaviors of a cognitively impaired nursing home resident. Archives of Psychiatric Nursing, 6(2), 98-107. Ryan, E.B., & Heaven, R.K.B. (1988). The impact of situational context on age-based attitudes. Social Behaviour, 3, 105-117. Ryan, E.B., Hummert, M.L., & Boich, L.H. (1995). Communication predicaments of aging: Patronizing behavior toward older adults. Journal of Language and Social Psychology, 14(1-2), 144-166. Shortell, S.M., Zimmerman, J.E., Rousseau, D.M., Gillies, R.R., Wagner, D.P., Draper, E.A., Knais, W.A., & Duffy, J. (1994). The performance of intensive care units: Does good management make a difference? Medical Care, 32(5), 508-525. Sikorska, E. (1999). Organizational determinants of resident satisfaction with assisted living. The Gerontologist, 39(4), 450-456. Sillars, A.L., & Zietlow, P.H. (1993). Investigations of marital communication and lifespan development. In N. Coupland & J.F. Nussbaum (Eds.), Discourse and lifespan identity (pp. 237-261). Newbury Park, CA: Sage. Small, J.A., Geldart, K., Gutman, G., & Clarke Scott, M. (1998). The discourse of self in dementia. Ageing and Society, 18, 291-316. Weitzman, P.F., & Weitzman, E.A. (2003). Promoting communication with older adults: Protocols for resolving interpersonal conflicts and for enhancing interactions with doctors. Clinical Psychology Review, 23, 523-535. Wells, D.L., Dawson, P., Sidani, S., Craig, D., & Pringle, D. (2000). Effects of an abilities-focused program of morning care on residents who have dementia and on caregivers. Journal of the American Geriatrics Society, 48(4), 442-449. ABOUT THE AUTHORS
Dr. Small is Associate Professor, School of Audiology and Speech Sciences, University of British Columbia, Vancouver, British Columbia, Canada. Dr. MontoroRodriguez is Associate Professor, School of Family and Consumer Studies, Kent State University, Kent, Ohio. Research supported in part by a grant from the Georgia Gerontology Consortium Seed Grant Program 1999-2000 from the University of Georgia, Athens, GA. The authors acknowledge the assistance of Rona Kertesz in data coding and analysis. Address correspondence to Jeff A. Small, PhD, Assistant Professor, School of Audiology and Speech Sciences, University of British Columbia, 5804 Fairview Avenue, Vancouver, B.C., V6T 1Z3, Canada.
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