9608_An Investigation into the Perceptions of Elderspeak and How It Effects Mood Among an Assisted Living Population

Minnesota State University, Mankato
Minnesota State University, Mankato
Cornerstone: A Collection of Scholarly
Cornerstone: A Collection of Scholarly
and Creative Works for Minnesota
and Creative Works for Minnesota
State University, Mankato
State University, Mankato
All Theses, Dissertations, and Other Capstone
Projects
Graduate Theses, Dissertations, and Other
Capstone Projects
2020
An Investigation into the Perceptions of Elderspeak and How It
An Investigation into the Perceptions of Elderspeak and How It
Effects Mood Among an Assisted Living Population
Effects Mood Among an Assisted Living Population
Paige T. Shoutz
Minnesota State University, Mankato
Follow this and additional works at: https://cornerstone.lib.mnsu.edu/etds
Part of the Clinical Psychology Commons, and the Gerontology Commons
Recommended Citation
Recommended Citation
Shoutz, P
. T. (2020). An Investigation into the perceptions of elderspeak and how it effects mood among
an assisted living population [Master’s thesis, Minnesota State University, Mankato]. Cornerstone: A
Collection of Scholarly and Creative Works for Minnesota State University, Mankato.
https://cornerstone.lib.mnsu.edu/etds/1030
This Thesis is brought to you for free and open access by the Graduate Theses, Dissertations, and Other Capstone
Projects at Cornerstone: A Collection of Scholarly and Creative Works for Minnesota State University, Mankato. It
has been accepted for inclusion in All Theses, Dissertations, and Other Capstone Projects by an authorized
administrator of Cornerstone: A Collection of Scholarly and Creative Works for Minnesota State University,
Mankato.

An Investigation into the Perceptions of Elderspeak and How It Effects Mood Among an
Assisted Living Population
by
Paige T. Shoutz
A Thesis Submission in Partial Fulfillment of the Requirements for the Degree of Master of Arts
In
Clinical Psychology

Minnesota State University, Mankato
Mankato, Minnesota
May 8th, 2020

May 8th, 2020
An Investigation into the Perceptions of Elderspeak and How It Effects Mood Among an
Assisted Living Population
Paige T. Shoutz

This Master’s Thesis has been examined and approved by the following members of the
student’s committee.

_________________________________________
Jeffrey Buchanan, Ph.D., Chairperson

_________________________________________
Daniel Houlihan, Ph.D., Committee Member

_________________________________________
Kristen Abbott-Anderson, Ph.D., Committee Member

Table of Contents
Introduction……………………………………………………………………………..…1
Method……………………………………………………………………………………..8
Results…………………………………………………………………………………….13
Discussion……………………………………………………………………………..…18
References………………………………………………………………………………..24
Tables
1. Positive and Negative Affect Averages and Change Scores…………………………….13
2. ETRS Subscale Paired-Samples T-Test Results Summary………………………………15
3. Means and Standard Deviations of Length of Stay in ALFs and Perceptions of ES
Appropriateness………………………………………………………………………….16
4. Summary of ANOVAs on Length of Stay in ALFs and Perception of ES
Appropriateness…………………………………………………………………………..16
Figures
1. The Communication Predicament of Aging Model……………………………………….3
Appendices
A. Brief Interview for Mental Status………………………………………………………..27
B. Video Scripts……………………………………………………………………………..28
C. Mood Measure: Positive and Negative Affect Schedule…………………………………34
D. Communication Perception: Emotional Tone Rating Scale……………………………..35
E. Qualitative Interview…………………………………………………………………….36
F. Informed Consent Form…………………………………………………………………39

Abstract
This study aimed to examine perceptions of ES and its effect on mood among older adults
residing in assisted living facilities (ALFs). Residents (N=6) were exposed to two videos
comprised of an interaction of a nursing assistant aiding an older adult resident during activities
of daily living. One of the videos demonstrated neutral communication, whereas the other video
demonstrated communication with elderspeak. A mood rating was obtained prior to and
immediately following exposure to each of the videos. Participants also provided ratings of the
nursing assistant, and completed a qualitative interview that gathered their opinions, perceptions,
and perceived differences between the videos. Results indicated that exposure to ES did not have
a significant effect on negative or positive mood states. Differences in perceptions regarding the
nursing assistant were present, as ES was found to be less caring and respectful and more
controlling. Qualitative data suggest that differences in the communication styles were noticed.
Future research with larger sample sizes is warranted to determine how communication using
elements of ES affects the mood of older adults residing in ALFs.

Keywords: elderspeak, mood, perceptions, older adults, assisted living facility

1
An Investigation into the Perceptions of Elderspeak and How It Effects Mood Among an
Assisted Living Population
For older adults living in long-term care (LTC) settings, the practice of quality
communication by staff during cares and other interactions plays an imperative role in the health,
well-being, and successful aging of residents. For example, effective communication between
caregivers and residents is associated with a higher quality of life (Zimmerman et al., 2005),
lower rates of depression, and fewer occurrences of verbal and physical aggression (Toseland et
al., 1997). Furthermore, research has demonstrated that mortality rates decrease when older
adults have the social support and close relationships with their caregivers (Williams et al.,
2005).
For many caregivers in LTC settings, the use of a patronizing communication style, often
known as elderspeak, is common. Elderspeak (ES) is a type of communication that encompasses
a wide range of verbal and nonverbal features that is based on the stereotypes that older adults
are less competent and more dependent compared to younger communication partners, which in
turn leads to oversimplified speech (Ryan et al., 1995). Examples of the verbal features of ES
include: the use of collective pronouns (e.g., “we”), terms of endearment (e.g., “honey”,
“sweetie”), and restricted vocabulary, as well as frequent repetitions, recurrent interruptions, and
exaggerated praise for minor accomplishments. Examples of the nonverbal features of ES
include: elevated vocal pitch and volume, slowed rate of speech, exaggerated facial expressions,
and inappropriate touches (e.g., pats on the head or hugs). Early reports of communication in
LTC settings concluded that over 22 percent of speech as used with older adults was categorized
as ES (Caporael, 1981). Furthermore, LTC resident reports have concluded that as much as 40
percent of speech as used by caregivers is perceived as patronizing (Williams et al., 2005).

2

When used by caregivers of older adults, ES is not only considered disrespectful, but also
diminishes the competency and promotes the dependency of older adults (Caporale, 1981; Ryan
et al., 1995). Although presented in a patronizing demeanor, the intent of using a communication
style that comprises aspects of ES may often be a well-intended attempt by younger
communication partners to effectively communicate with older adults in a caring manner
(Grimme et al., 2015). For example, one study found that caregivers rated ES to be more
appropriate when assisting with personal cares, which may have suggestions of nurturance
during intimate tasks (Lombardi et al., 2014). However, even with the intent of benevolence, the
Communication Predicament of Aging Model postulates a framework that describes how the use
of ES fails to reach the goal of effective and caring communication with older adults (Williams et
al., 2005).
Theoretical Framework of Elderspeak

As proposed by Ryan and colleagues in 1986, the Communication Predicament of Aging
Model (CPAM) intended to conceptualize the use and features of patronizing communication and
identify the theory of speech modification used towards older adults. Based on the
communication accommodation theory, this framework argued that speakers modify their speech
and nonverbal behaviors towards older adults based on stereotypes and old age assumptions of
dependence and incompetence. As a result of modifying speech towards older adults in response
to old age cues, negative age stereotypes are reinforced, which in turn limits opportunity for
fulfilling conversation, and leads to negative consequences for an older adult’s quality of life and
overall well-being.

As demonstrated by Figure 1, the model begins with an individual having an encounter
with an older adult. This interaction then leads to the recognition of old age cues, such as

3

physical characteristics (e.g., gray hair, slumped posture), mobility aids (e.g., cane, walker), or
social roles (e.g., role of a grandparent). The recognition of old age cues then leads to
stereotyped expectations about communication competence and the requirement of speech
adaptations. Although prior research has identified positive and negative stereotypes associated
with older adulthood, the communication predicament predicts accommodations to occur
following the recognition of negative stereotypes (Ryan et al, 1995). For example, stereotypes
that shed a negative light on older adults recognize them as depressed, hopeless, dependent,
slow-thinking, incompetent, incapable, bitter, or being hearing or cognitively impaired. If one of
these negative stereotypes is identified by the speaker, speech modification is likely to occur
compared to if a positive stereotype was identified (e.g., active, lively, nostalgic).
Figure 1

The Communication Predicament of Aging Model (Ryan et al., 1995)

4

Even if the negative stereotypes are inaccurate, the individual advances with a
modification of their speech, which includes the use of restricted topics, using simple or childlike
wording, and demonstrating loud and exaggerated speech and nonverbals. The result of such
modifications limits the opportunity for communication and reinforces age stereotype behaviors,
such as incompetence, while conveying a sense of declining capability, loss of control, and
helplessness. Constant exposure to ES then reinforces dependency, social isolation, and
depression, all of which can contribute to the decline of physical, cognitive, and functional status
of older adults. Because the patronizing communication reinforces negative stereotypes
associated with being an older adult, elders often adapt to such stereotypes, which is when
decline accelerates. For example, if an older adult who receives ES falsely believes they are
incapable, as inherited through the patronizing messages of ES, they may actively seek help for
tasks that they are able to complete independently (Balsis & Carpenter, 2005), and therefore
diminish their existing abilities.
Previous Research of Elderspeak
Primary investigations into the communication styles used with older adults in
institutionalized settings revealed ES, or “baby talk” as it was first described as, to be commonly
used (up to 22% of speech) by caregivers and indistinguishable from baby talk speech as used
with children (Caporael, 1981). In fact, Caporael’s study (1981) found that 75 percent of speech
used by nursing home caregivers that was directed towards residents was misidentified as speech
towards children.
Views of patronizing speech may be either positive or negative among public perception.
Those who view ES positively deemed it to be more comforting and less irritating and arousing
compared to neutral, normal speech (Caporael, 1981), whereas those who view ES to be negative

5

deemed it to come across in a less respectful, nurturing, competent, and benevolent manner that
fostered dependency and helplessness in the targeted residents compared to neutral, normal
speech (Ryan et al., 1991). Research into the public perceptions provide insight into the
paradoxical use of ES, as caregivers may assume ES to convey messages of care and nurturance,
but ultimately it reinforces negative views of dependence, vulnerability, and incompetence
(Williams et al., 2005).
Previous research regarding older adult perceptions of ES have targeted both community-
dwelling and nursing home residents. In a study conducted by O’Connor and Rigby (1996), older
adults who lived in the community or in a nursing home were asked to imagine themselves in a
scenario that portrayed either ES or normal communication as an attempt to identify the
relationship among ES and self-esteem. The results indicated that for those older adults who
perceived ES as undesirable and who had frequently been recipients of ES often ranked the
lowest in self-esteem. Although significant differences were not found regarding community or
nursing home status, differences in appropriateness regarding age and gender were found. In
other words, older participants and females perceived ES to be more appropriate.
La Tourette and Meeks (2000) also examined a population of community-dwelling older
adults and nursing home residents. After watching two videotaped vignettes of an interaction
between an elderly woman and a nurse portraying either patronizing or non-patronizing
communication, both the community-dwelling and nursing home residents rated the nurse more
favorably and the elderly actress more satisfied in the nonpatronizing video. Moreover, for those
participants who were community-dwelling, they ranked the woman in the video receiving care
by the patronizing nurse as less competent.

6

Similarly, Balsis and Carpenter (2005) concluded that among an older adult sample,
negative perceptions exist for both the one using ES and the target of ES. After reading scripts
that depicted different communication styles, it was found that speakers using ES were rated as
having a worse demeanor compared to the speaker who used normal communication. The targets
of ES were not only seen as possessing decreased abilities and competencies, but were also
viewed to exhibit negative affect states, including frustration, anger, unhappiness, and
displeasure.
Other research investigating perceptions among long-term care residents have found
patronizing communication to diminish resident’s view of their living experience and quality of
life within the facility (Lagacé et al., 2015). Additionally, it was found that although residents
had negative perceptions of ES among caregivers, residents would rather accommodate
caregivers rather than challenge them when patronizing communication is used. These passive
responses, in turn, reinforce negative stereotypes associated with aging, including dependency
and incompetency, as described by the CPAM (Ryan et al., 1995).
Perceptions of ES among caregivers in LTC settings to assess contextual variables that
may increase the occurrence of ES have also been examined. As reported by Lombardi and
colleagues (2014), ES was considered to be more acceptable to use with older residents (i.e.,
>70), for those who are cognitively impaired, for those who present as sad or happy, in situations
where no one else is present, and when providing hands on tasks, such as personal cares.
Grimme et al. (2015) provided support for similar findings, as ES was considered to be more
appropriate when staff needed residents to complete a task and when residents demonstrated
cognitive impairments.

7

Among studies that examined staff perceptions, reports have concluded that the use of ES
derives from a genuine nature to provide comfort and care to the residents when providing
assistance (Grimme et al., 2015). One study supports the usefulness of ES, as Kemper et al.
(1996) discovered that older adults who drew routes on a city map performed better when they
were instructed with elderspeak. The findings of this study support the notion ES may be
presented sincerely to assist an older adult in completing tasks, such as in the case of personal
cares.
In sum, although many studies have reported negative outcomes related to ES, some
studies have found potential benefits. The differences in outcomes appear to be related to
variables such as gender, age, place of residence, and severity of dependency on others.
Therefore, additional research is needed to determine situations under which ES is more or less
appropriate and/or acceptable.
Purpose of the Study
Among the literature that exists on elderspeak and its perceptions, much has focused on
either community dwelling older adults or older adults requiring extensive care residing in a
nursing home, and little research has focused on older adults residing in assisted living facilities
(ALFs). Older adults who live in an assisted living setting are a unique population because
functionally they fall between the population of older adults who are community dwelling and
independent, and those living in skilled care facilities who are institutionalized and need a
greater degree of assistance with activities of daily living. Typically, residents of ALFs possess
some independent living skills, yet require some assistance with care tasks to make sure their
personal needs are achieved. As a result, those living on ALFs have somewhat less contact with
caregiving staff but are still immersed within a healthcare facility where elderspeak is quite

8

common. Previous literature on elderspeak has failed to expand upon the circumstances of this
unique group of older adults. Previous research has also provided limited insight into the effects
on mood of targets of ES.
Therefore, the purpose of this study is to expand the literature on elderspeak by
examining perceptions among older adults residing in ALFs, and to assess its effect on mood.
Moreover, this study will specifically aim to ascertain: 1) how communication using elements of
elderspeak affects the mood of older adults residing in ALFs compared to communication that
does not use elements of elements of elderspeak, 2) if residents of ALFs perceive communication
with elderspeak or without elderspeak differently, and 3) if the length of time spent living in an
ALF contributes to resident communication preferences.
In this study, it is hypothesized that greater negative mood states will be reported after
exposure to elderspeak (ES) communication compared to non-elderspeak (N-ES)
communication. Furthermore, it is predicted that the communication style comprising of
elements of ES will be perceived as more controlling, whereas the N-ES communication will be
perceived as more caring and respectful. Lastly, it is predicted that the greater amount of time
spent living in an ALF, the more appropriate ES communication will be perceived.
Method
Participants
Participants included six older adults residing in ALFs. Participants were recruited from
two assisted living facilities located in the Midwest. Inclusion criteria to enter the study included:
being age of 65 or older, having no documented cognitive impairment as reported by direct
caregivers who has access to medical records, and the presence of adequate verbal abilities to

9

respond to assessment instruments. Participants meeting these criteria were identified by facility
staff and were then referred to the researchers to be screened for study eligibility.
In order to verify the lack of cognitive impairment, participants were required to score at
least a 13 on the Brief Interview for Mental Status (BIMS; Chodosh et al., 2008). The BIMS is a
cognitive functioning screening tool that measures attention, temporal orientation, and memory.
Scoring for the BIMS ranges from 0-15, with a score of 13 or higher indicating “cognitively
intact.” Of the eight participants identified for the study, five scored 13 or higher on the BIMS.
One participant scored below the minimum requirement, but an absence of cognitive impairment
was verified through a medical records review completed by a staff member, which granted
inclusion. The mean BIMS score for all six participants was 14.00 (SD = 1.26), with scores
ranging from 12 to 15. See Appendix A for a copy of the BIMS.
In addition, all participants were white females whose ages ranged from 83 to 102 years
(M = 90.33, SD = 6.74), had an average of 14.50 years of education (SD = 2.51), and had been
residing in their current assisted living facility between .50 to 8.50 years (M = 3.58, SD = 3.44).
Materials

Videos. The videos used in the experimental conditions were written by students and
faculty who had experience in clinical psychology and nursing. The caregiver-resident
interactions depicted in the videos were based on the experience of nursing students who had
professional experience working in long-term care settings with older adults. Both of the videos
were similar in content and length (approx. 6-minutes) but differed in terms of the type of
communication style portrayed. Each of the videos depicted a scene of a nursing assistant in a
long-term care facility aiding an older adult woman with physical impairments. Specifically, the
nursing assistant is depicted waking the resident from a nap, helping the resident out of her bed,

10

assisting the resident with putting on her socks, shoes, and a sweater, aiding the resident to the
bathroom to groom, and helping the resident out the door.

One of the videos demonstrated neutral “normal” communication. For example, the
nursing assistant addressed the older woman by using her title and last name, talked to the
woman in a neutral tone, pace, and volume, and used singular pronouns. Furthermore, the older
adult in the video was given the opportunity to make her own decision, such as if she was ready
to get out of bed and what clothes she wanted to wear.

The second video that portrayed patronizing communication included specific behaviors
of ES, such as addressing the woman with terms of endearment, demonstrating elevated pitch,
and using collective pronouns. Additionally, the older adult woman was provided with little
opportunity for choice in decision making. Refer to Appendix B for the transcripts of the videos.
Both videos were validated by a sample of caregivers who had experience in working in
long-term care settings. Caregivers were asked to view the videos and answer several questions
regarding the relevance and accuracy of the videos in terms of setting, the tasks completed by the
nursing assistant, and the communication styles used. All caregivers interviewed reported that
they have observed both of the communication styles demonstrated in the videos. All but one
caregiver reported using ES, and all caregivers reported also using N-ES. The caregivers
reported that the setting, interactions, and behaviors demonstrated by the older adult in both of
the videos were realistic.
Mood measure. In order to assess current mood state, the Positive and Negative Affect
Schedule (PANAS; Watson et al., 1988) was administered prior to and immediately following
each of the two videos. The PANAS is a 20-item, self-report questionnaire that aims to measure
to what extent the participant is experiencing a variety of positive or negative mood states. Items

11

comprising the positive affect subscale include descriptors such as interested, enthusiastic, and
inspired. High positive affect scores indicate full concentration and pleasurable engagement.
Items comprising the negative affect subscale include descriptors such as disinterested, irritable,
and ashamed. High negative affect scores indicate distress and unpleasurable engagement.
Participants were required to rate how they “feel right now at the present moment” by ranking 20
emotions. The items on the PANAS are scored on a 5-point Likert scale, ranging from “very
slightly or not at all” (1) to “extremely” (5) (Watson et al., 1988). Refer to Appendix C for a
copy of the PANAS.

Communication perception. To measure the affective qualities of the communication
style used by the nursing assistant in the video, participants completed the Emotional Tone
Rating Scale (ETRS; Williams et al., 2012) after watching each video. This 12-item self-report
scale consists of three dimensions of messages that are commonly portrayed during
communication with older adults: 1) care (i.e., nurturing, caring, warm, supportive), 2) respect
(i.e., polite, affirming, respectful, patronizing), and 3) control (i.e., dominating, controlling,
bossy, directive). Participants were asked to rate the communication style of the nursing assistant
in the video, which were scored on a 5-point Likert scale, ranging from “not at all” (1) to “very”
(5). See Appendix D for the qualities of communication measure.

Additional information was gathered about perceptions of communication styles via a
qualitative interview. The interview consisted of closed and opened-ended questions regarding
opinions and experiences of the participant related to the communication styles observed in the
videos. Sample interview questions included: “Have you directly experienced this type of
communication style with a staff member?”, “How do you think the patient in the video felt?”,
and “Would you want this nurse to take care of you?”.

12

After viewing both videos, participants also answered qualitative questions that assessed
their opinions and perceptions about the differences among the two videos. Sample interview
questions included: “Do you believe there are any important differences between the two videos
you just watched?”, “In your experience, of the two videos you watched, which one is most
similar of typical staff-resident interactions that occur in care facilities?”, and “Of the two videos
you watched, which one was a better example of how nursing staff should interact with
residents?”. Refer to Appendix E for the full interview.
Procedure

After obtaining consent from the participants, a trained researcher administered the
BIMS. Those participants who were identified as cognitively intact (i.e., scored ≤ 13) were
included in the study, and were scheduled to complete the experimental procedure on another
day. Prior to watching the first video, the PANAS was administered. Then, using a within-
subjects design, participants were randomly assigned to watch either the N-ES video or the ES
video. The presentation order of the videos was counterbalanced across all participants. After
viewing the first video, participants were asked to complete the mood measure again, followed
by the ETRS and qualitative interview. Following a five-minute break, the procedure was
repeated with the remaining video, with the addition of administering the interview regarding the
similarities, differences, and preferences amongst the two videos.

All data collection occurred in participants’ individual room, and both of the videos were
displayed on the researcher’s laptop. With the exclusion of the administering the BIMS, the
experimental procedure took approximately 45-minutes to complete.

13

Results
Mood. To assess the effect of the different types of communication on participant mood,
a “positive affect” and “negative affect” score was calculated by establishing an average score
for all the positive and negative items on the PANAS, respectively. This was done for all pre-
and post- video ratings. Additionally, change scores were calculated for both the positive and
negative affect scales by subtracting the average post-scores with the average pre-scores. The
change scores were then compared between each video. Changes in mood were examined
through a series of paired-samples t-tests. Although changes in negative affect were of primary
interest in this study, exploratory analyses regarding differences in positive affect were also
examined.
When examining the negative affect change scores between pre- and post-video
measurements, the results of the paired-samples t-test revealed that there was no significant
differences between the ES (M = .44, SD = .52) and N-ES (M = -.02, SD = .04) videos, t(5) =
2.11, p = .09, d = -.56. When examining the positive affect change scores between pre- and post-
video measurements, the results of the paired-samples t-test resulted in no significant differences
between the ES (M = -.47, SD = .52) and the N-ES (M = -.31, SD = .55) videos, t(5) = .50, p
= .64, d = .22. See Table 1 for a summary of change scores for both conditions.

Table 1
Positive and Negative Affect Averages and Change Scores
Variable
ES

N-ES

Positive
Mood
Mean
(SD)
Positive Negative
Mood ∆
Mood
Mean (SD)
Negative
Mood ∆
Positive
Mood
Mean (SD)
Positive Negative
Mood ∆
Mood
Mean (SD)
Negative
Mood ∆

14

Pre
2.89
(.64)
-.47
1.02 (.04)
.44
2.58 (1.18) -.31
1.02 (.04)
-.02
Post
2.40
(.91)
1.46 (.50)
2.27 (.74)
1.00 (.00)

To test whether there was a difference in post-video mood measures between the two
conditions, a paired-samples t-test was conducted. When examining the results of post-negative
affect scores, the analysis found no significant differences, t(5) = -2.24, p = .08, between the ES
(M = 1.46, SD = .50) and N-ES (M = 1.00, SD = .00) videos. No significant differences were
found among the post-positive affect measures between the ES (M = 2.40, SD = .91) and N-ES
(M = 2.27, SD = .74) videos as well, t(5) -.53, p = .62, d = -.20,
Lastly, a paired-samples t-test was conducted to examine if pre- and post-video affect
scores differed for only the ES video. The results indicated that there were no significant
differences regarding negative affect on pre- (M = 1.02, SD = .04) and post-measures (M = 1.46,
SD = .50) following the ES video, t(5) = 2.07, p = .09, d = 6.46. No significant differences were
found among the pre- (M = 2.87, SD = .64) and post-measures (M = 2.40, SD = .91) for positive
affect following the ES video, t(5) = -2.20, p = .08, d = -1.26.
Communication perception. A series of paired-samples t-tests were conducted to
examine how participants rated the nursing assistant on the three ETRS subscales (i.e., care,
respect, and control) in the ES video compared to the N-ES video. Results are summarized in
Table 2. Significant differences and large effect sizes between post ratings on the ES and N-ES
videos were found on all three subscales: care, t(5) = 2.65, p < .05, d = 1.25; respect, t(5) = 3.88, p = .01, d = 1.57; and control, t(5) = -3.56, p = .02, d = -1.24. 15 Table 2 ETRS Subscale Paired-Samples T-Test Results Summary Video Condition ETRS Subscale ES Mean (SD) N-ES Mean (SD)_ t-statistic Significance Care M = 2.42 (1.29) M = 3.79 (1.44) 2.65 .046 Respect M = 2.42 (1.39) M = 4.13 (1.07) 3.88 .012 Control M = 3.75 (1.39) M = 2.00 (.74) -3.56 .016 Perceptions of ES and length of stay in ALF. In order to examine how perceptions of ES were related to the amount of time participants had spent living in the ALF, participants were divided into three categories of length of time spent living in their current assisted living facility. The length of time spent living in the facility was categorized as “relatively new” (those living in AL for less than one year), “moderate” (those living in AL for 1-3 years), and “experienced” (those living in AL for more than three years). Then, a series of one-way ANOVAs were conducted to assess if length of time spent living in assisted living would affect participant perception of how appropriate they find ES communication to be. Appropriateness was measured by scores on the positive affect subscale of the PANAS and the care and respect subscale of the ETRS. The results revealed that there were no significant differences found related to time spent living in AL and post-video positive affect subscale scores, F(2, 3) = .98, p = .92, care subscale scores, F(2, 3) = 1.89, p = .29, or respect subscale scores, F(2, 3) = .93, p = .48. The means and standard deviations of the positive affect subscale and the ETRS subscale scores for each category of length of time spent living in the assisted living facility are provided in Table 3. A summary of the ANOVAs is provided in Table 4. 16 Table 3 Means and Standard Deviations of Length of Stay in ALF and Perception of ES Appropriateness Length of Time in Current AL N Positive Affect Mean (SD) ETRS Mean Subscale (SD) Care Respect < 1 year “Relatively new” 2 M = 2.40 (1.41) M = 1.25 (.00) M = 1.38 (.53) 1-3 years “Moderate” 1 M = 2.00 (*) M = 2.00 (*) M = 2.25 (*) >3 years
“Experienced”
3
M = 2.53
(.98)
M = 2.42
(1.39)
M = 2.75
(1.30)
* = no standard deviation, only one participant
Table 4
Summary of ANOVAs on Length of Stay in ALFs and Perception of ES Appropriateness
Subscale
F-statistic
Significance
Positive Affect
.98
.92
Care
1.89
.29
Respect
.93
.48

Qualitative Interviews. After watching each of the videos, participants were asked a
series of closed and open-ended questions. First, participants were asked if they had directly
experienced the type of communication style demonstrated in each the video. Two participants
reported they had directly experienced ES with a staff member, and four said they had not. Of
the two participants who experienced ES, they reported experiencing ES daily (N=1) to several
times a week (N=1). ES had been reported to be experienced with every interaction with a staff
member, from morning to night, and specifically during meals.

The majority of participants (N=5) reported directly experiencing non-ES communication
with a staff member. These participants reported experiencing this communication style daily
(N=2) to several times a week (N=3) in several specific places in their living facility, including
their apartment/room and the dining room. When asked during what times of the day and during

17

what activities participants experienced N-ES communication style, participants reported a
variety of responses, including a time frame of morning and evenings, and during activities such
as exercise, mealtimes, when getting dressed, and when alone with a staff member.

Participants were also asked if they had observed the different communication styles
during staff interactions with other residents. From the ES condition, half (N=3) of the
participants had reported observing ES. Observations of ES occurred during activities,
mealtimes, and overall, in “most places” daily (N=3). For the N-ES condition, five participants
identified observing the communication style. Participants reported observing the N-ES
communication in the dining room, hallways, and in other people’s living areas as often as daily
(N=2) to several times a week (N=3). Some of the specific times of day N-ES was observed
included during dining hours, facility programs, activity hours, and in the mornings.

Each participant was also asked how they thought the resident in each video felt. The
responses towards the ES video were mostly negative (e.g., hurried, not relaxed, upset,
disrespected, irritated) compared to overall positive responses towards the N-ES video (e.g.,
positive, accommodated, cared for, respected, not embarrassed). Moreover, all of the participants
indicated that they would want the nursing assistant in the N-ES video to take care of them for
reasons such as the aid was observant, qualified, respectful, caring, interested in what the woman
wanted, and took her time with the resident. Only two participants reported wanting the nursing
assistant in the ES video to take care of them (e.g., friendly, knowledgeable, caring). Of those
(N=4) who did not want the ES nursing assistant to take care of them, participants found her to
be too much in a rush, having little patience, and being too rigid and bossy.

Lastly, participants were asked if the interaction that they watched in each of the videos
was realistic of typical interactions between residents and staff during personal care tasks. Five

18

participants reported that the ES portrayal was realistic, with one participant reporting that the
video was not realistic because the nursing assistant did not allow the woman a choice on what
type of sweater she wanted to wear. Four participants reported that the N-ES video was realistic,
with one participant reported that it was not realistic, and one participant could not answer
concretely whether to video was or was not realistic. For the participant who reported that the
portrayal was not realistic, the participant stated that staff never have as much time as the video
demonstrated to spend one-to-one with all of the residents, and therefore was not realistic.

Participants were also asked about perceived differences between the videos. Foremost,
all participants indicated that they noticed important differences between the two videos. Among
the identified differences were: the pace of the nursing assistant (e.g., if she was in a rush or not),
the nursing assistant’s attitude (e.g., differences in level of kindness, respect, and desire to help),
the autonomy given to the resident (e.g., if the resident was given options to make her own
decisions or not, if the resident was being listened to), and the attitude of the resident (e.g., if she
was being combative or accommodating).

When asked which of the two videos was most similar to typical staff-resident
interactions, results indicated that half (N=3) found the ES video to be most similar, and the other
half indicated the N-ES video to be most similar. Finally, all participants reported that the N-ES
video represented a better example of how nursing staff should interact with residents.
Discussion

This current study attempted to examine perceptions of a type of patronizing
communication style and neutral communication style among older adults residing in ALFs, and
to assess its effect on mood. Inconsistent with previous research findings, the results of this study
did not demonstrate notable differences in negative or positive mood states after exposure to a

19

communication style that demonstrated aspects ES. As determined by Balsis and Carpenter
(2005), recipients of ES are viewed to possess more negative mood states compared to recipients
of neutral communication, including frustration, anger, unhappiness, and displeasure. Other
conclusions have also determined that targets of ES ranked lower in self-esteem (O’Connor &
Rigby, 1996), which could have implications for increased negative affect due to damaged self-
esteem. The findings of this study do not support the hypothesis that exposure to ES would result
in greater negative mood states compared to neutral communication. In fact, there were no
significant differences found between pre- and post-ES negative mood scores, nor differences in
ES and N-ES post-negative affect scores. Although negative affect was of primary interest, the
exploratory analysis of positive affect also did not result in noteworthy differences between the
two conditions. These findings imply that exposure to the different communication styles did not
affect participants’ mood in a negative or positive way. Although the PANAS is a reliable
instrument for measuring current mood states, perhaps total positive and negative scale scores
are not sensitive enough to detect momentary changes in mood compared to instruments with
fewer items. Because each PANAS subscale is comprised of many individual mood states, this
could have dampened the sensitivity to detect changes in specific moods where subtle changes
were observed, but not large enough to contribute to a significant change. For example, through
observation, noticeable differences were found between measures on distress, upset, and
irritable. However, because these items were grouped with other negative affect measures that
did not demonstrate noticeable differences, the overall effect dampened the individual results
that could have revealed significance.

The second hypothesis of this study proposed that the communication style comprising of
elements of ES will be perceived as more controlling, whereas the N-ES communication will be

20

perceived as more caring and respectful. This hypothesis was supported, and significant
differences were demonstrated between the two communication styles and ratings on the care,
respect, and control subscales. These findings are consistent with the conclusions of several
previous research studies (La Tourette & Meeks, 2000; Ryan et al., 1991).

Contrary to the third proposed hypothesis, the length of time spent in an ALF did not
have any effect on how appropriate participants perceived ES to be. Regardless if participants
were classified as “relatively new” or “experienced”, the results of this study did not demonstrate
any significant differences among how appropriate they found ES to be. This finding is
inconsistent with previous research that suggests older adults living in an institutionalized setting
may become habituated with the constant demonstration of patronizing communication overtime,
and therefore are more tolerable to the communication style (Caporeal, 1981). Perhaps with a
larger sample size and an equal number of participants in each category distinctions among
appropriateness ratings may present, and therefore reveal conclusions as to whether or not length
of time spent living in an ALF changes perception of appropriateness.

Although the distinctions in the videos did not evoke different emotional responses, the
results of the analyses regarding communication perception and qualitative data support the
notion that all participants were able to notice differences among the two communication styles.
The qualitative data provided in this study offered valuable insight into the occurrences of ES,
whether directly experienced or observed. Interestingly, the reported occurrences of ES and N-
ES did not directly align with the reports of how similar each communication style reflected
typical staff-resident interactions. In other words, although five of the six participants reported
both directly experiencing and observing N-ES, overall, only half reported the N-ES