expertise
More than communication skills: experiences of
communication conflict in nursing home nurses
Hsiu-Hsin Tsai,1 Yun-Fang Tsai,1,2 Li-Chueh Weng1 & Hsueh-Fen Chou1
CONTEXT Communication conflicts are inev-
itable in nursing homes. Understanding com-
munication conflicts experienced by practising
nurses could provide insights to guide the
development of sound communication educa-
tion programmes.
OBJECTIVES The purpose of this study was
to explore the experiences of nurses in nurs-
ing homes of communication conflict in
encounters with nursing home residents and
their families in Taiwan.
METHODS Data were collected from April
2010 to December 2011 through audiotaped,
individual, in-depth interviews with 26 nurses
at five nursing homes in Taiwan. Data were
analysed according to van Manen’s interpre-
tive phenomenological method.
RESULTS Data analysis revealed that nurses’
experiences of communication conflicts
Medical Education 2013: 47: 990–1000
doi: 10.1111/medu.12233
Discuss ideas arising from the article at
www.meduedu.com ‘discuss’
1
School of Nursing, College of Medicine, Chang Gung University,
Tao-Yuan, Taiwan
2
Department of Nursing, Chang Gung Memorial Hospital at
Keelung, Keelung, Taiwan
990 ª 2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 990–1000
during encounters with nursing home
residents and their families could be
categorised under three themes: differences in
perspectives of nursing home services;
differences in views of nurturing health, and
mediation between family members and
others.
CONCLUSIONS The findings of this study
can be considered by clinical educators and
policymakers when designing communication
education programmes for nurses and other
clinicians. These programmes should include
ways to increase nurses’ independent thinking
in settings in which power differences exist, as
well as their cultural sensitivity as embodied in
Leininger’s culture care theory. These pro-
grammes should also include education in
telephone communication and alternative
methods of communication (e.g. videoconfer-
encing).
Correspondence: Yun-Fang Tsai, School of Nursing, Chang Gung
University, 259 Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan 333,
Taiwan. Tel: 00 886 3 211 8800 (ext. 3204, 5958);
E-mail: yftsai@mail.cgu.edu.tw
 Experiences of communication conflict in nurses
INTRODUCTION
Competence in communication skills, demonstrated
by the ability to communicate clearly and effectively,
in health care professionals has been shown to pre-
dict family satisfaction and quality of care.1–4 Com-
petence in communication is essential for both
doctors and nurses if they are to assess patient needs
and tailor care to individual needs effectively.1,3–5
Communication skills also enable nurses to resolve
communication conflicts,6 which are inevitable in
some clinician–patient communication situations.7–9
According to conflict theory, conflict occurs when a
social group experiences a differential in power, val-
ues or culture.10,11 As power differences and hierar-
chical authority are evidenced in most health care
settings, conflict is embedded in health care ser-
vices12–15 and is common in the nursing home set-
ting.16,17
Nursing home care is unique because it involves not
only care for the daily needs of individual residents,
but also consideration of the needs of the resident
group as a whole (group needs). Relationships
between nurses and residents are more complex
than those between nurses and patients in hospitals
or other settings because nurse–resident interac-
tions are more frequent and their relationships are
more long-term. In nursing homes, a majority of
residents receive only weekly in-person visits from
their families,18 which means nurses represent the
main source of residents’ social interaction.5 These
daily interactions among residents, family members
and nurses create many opportunities for conflict.
Furthermore, most nursing homes are managed by
nurses and do not have a full-time doctor on the
premises. This situation, combined with nurses’
overall powerlessness and low status in the health
care hierarchy,19–21 leads to the exercising of power
or control over residents by nurses. In addition, Tai-
wanese nursing home residents believe that they live
in the nursing home to ‘nurture health’,22 whereas
nursing home care is a kind of extended in-patient
care based on a supportive model of nursing care.23
These factors cause differences in power, culture
and values to arise among nursing staff, residents
and their families, which result in opportunities for
communication conflict that are unique to the nurs-
ing home setting.
For example, 67% and 11% of nursing home resi-
dents’ families were reported to engage in verbal
conflict and aggressive behaviours, respectively,
toward nursing home staff.16,24,25 The greatest
ª 2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 990–1000
incidence of conflict has been found to occur in
the largest nursing homes (  325 beds).24,25
However, the experiences underlying these conflicts
have not been studied, leading to a lack of in-depth
understanding and a gap between education in and
the practice of communication.26 In this regard,
qualitative studies have been suggested24 to provide
better understanding of the experiences of stake-
holders in nursing home conflicts and thereby to
help to improve conflict resolution training. Experi-
ences of communication conflict of the type that
occurs in Asian nursing homes may be unique to
this region of the world because of the impact of fil-
ial piety, which is an important virtue in Chinese
culture.27 Indeed, Chinese people take for granted
the notion that old, ill parents will be cared for by
their adult children,27,28 but parents and adult chil-
dren may have different views about how this care
should be enacted.29
Nurses typically use avoidance to deal with con-
flict,30 but such a management strategy does not
resolve the conflict, but simply postpones it and
neglects the nurse’s own needs.31,32 Such experi-
ences lead nursing professionals to perceive conflict
as a negative experience.30 Furthermore, nursing
home staff have been reported to lack knowledge
about managing communication difficulties and
conflict with families.33,34
Changing the conflict resolution behaviours of
nurses requires that they be educated in conflict res-
olution skills.35,36 However, communication skills
are taught to nursing students in Taiwan only in
fundamental nursing courses and courses related to
psychology and mental health, similarly to nursing
schools in Western countries.37,38 Hence, many
nursing educators have recommended strengthen-
ing communication education in the nursing curric-
ulum.39 Nursing school communication education
can also be supplemented by in-service or other life-
long education in communication, thus increasing
the number of programmes that emphasise commu-
nication training for nursing staff. However, com-
munication education programmes to remedy
communication problems in Western countries have
been difficult to evaluate because of weaknesses in
study design.4,26,40,41
Furthermore, these training programmes have not
been designed for nursing staff engaged in long-
term care, who have more opportunities to commu-
nicate with residents or family than staff in other
clinical areas.1,2,42 Understanding the communica-
tion conflict experiences of nurses in nursing
991
H-H Tsai et al
homes may provide insights to guide the develop-
ment of effective communication education pro-
grammes to avoid or minimise such conflicts. As
these issues have not been addressed in Taiwan, this
study was undertaken.
Purpose and research questions
The purpose of this study was to explore nurses’
experiences of communication conflict in their
encounters with nursing home residents and their
families. To this end, we asked the following
research questions: What are the power issues within
the nursing home environment? What are the cul-
tural issues within the nursing home environment?
METHODS
Design
A qualitative design was used. In-depth, individual
interviews were conducted.
Settings and sample
Before starting the study, the authors obtained
approval from their university’s institutional review
board. The authors also secured permission from
nursing home directors to conduct the study
because Taiwanese nursing homes do not have insti-
tutional review boards. Six nursing homes were cho-
sen from 390 nursing homes registered with the
Taiwan Department of Health in 2010.43 These
nursing homes were selected because they were
within 100 km of the researchers’ university and the
researchers had maintained relationships with nurs-
ing home staff since 2004. One nursing home
refused to participate because its staff were not
interested in the study topic. The five participating
nursing homes were private (care is paid for by resi-
dents and their families) and had on average 190
beds.
Nursing home directors at these five nursing homes
provided lists of nursing home staff members who
met these criteria: (i) they were able to communi-
cate in Mandarin or Taiwanese; (ii) they had experi-
enced communication conflict with residents or
families, but no communication conflict with resi-
dents with dementia, and (iii) they were willing to
participate in the study. Following the granting of
permission, a research assistant met with the
nursing home staff who fulfilled the study criteria to
explain the purpose and process of the study.
992 ª 2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 990–1000
Information was also given concerning the potential
risks of participation and the right of participants to
withdraw at any time was confirmed. Assurances
were given that questions need not be answered.
The strategies in place to protect confidentiality
were explained. Nursing staff who agreed to partici-
pate provided signed informed consent before inter-
views.
Data collection
Data were collected by the first author, a PhD-
qualified nurse with 11 years of qualitative research
experience, using in-depth narrative interviewing
techniques. The initial questions were broad
enough to encourage participants to share their
experiences of communication conflict in the nurs-
ing home.44 Sample questions were: ‘Would you
please share with me the most conflict you encoun-
tered with residents or families?’ and ‘How did that
make you feel?’ Interviews lasted approximately
1 hour and were audio-recorded with the partici-
pant’s permission. Verbatim transcripts were first
made in Mandarin. Data were collected and analy-
sed simultaneously until data saturation was reached
(i.e. no new categories were found). Saturation was
reached with 26 participants.
Data analysis
As soon as possible after interviews, audiotapes were
transcribed. Transcripts were analysed according to
van Manen’s method,45 which enables the
researcher to explore and understand participants’
everyday experiences and the meanings they ascribe
to those experiences46 because we believe that peo-
ple are experts in making sense of their own experi-
ences. We applied this method by looking for
themes in the first transcript, connecting the
themes, and continuing the analysis with other tran-
scripts.47 The transcripts were first coded individu-
ally by the four authors, who then compared and
discussed themes and codes. Discrepancies were
resolved by discussion to reach agreement.
Rigour
The trustworthiness of the findings was enhanced
by four criteria: credibility; transferability; depend-
ability, and confirmability.48 Credibility was ensured
by the first author’s prolonged engagement in the
field (7 years), which contributed to the building of
trust with participants, peer debriefing among all
authors, and member checking (sharing results with
participants for validation, clarification or
 Experiences of communication conflict in nurses

questions). Transferability was augmented by collect-
ing data from five different nursing homes and pro-
viding thick descriptions of data. Dependability was
improved by using a standard form for interviews
and audits. Another strategy for improving depend-
ability required the first and third authors to analyse
the transcripts separately and to discuss the mean-
ing of each emergent theme until they achieved
consensus. Confirmability was promoted by main-
taining an audit trail. To ensure consistency and
accuracy, taped interviews and transcripts were
checked by the first and third authors. Selected
transcripts were translated from Mandarin Chinese
to English by the first and third authors and back-
translated to Mandarin by a bilingual (Mandarin
and English) medical student.
paying for. Nursing staff who did not understand this
expectation experienced communication conflicts
characterised by three sub-themes: they expected to
provide group care, not individualised care; they
expected to safeguard the group environment, not
the individualised environment, and they expected
to provide group security, not individualised security.
Expecting to provide group care, not individualised care
Each resident is unique and needs tailored care, but
staff reported they were unable keep an eye on each
resident every minute. Residents’ and families’ expec-
tations of individualised care may have increased the
stress imposed on nursing staff, resulting in negative
effects on residents. One nurse participant said:

‘The family of a resident with a high risk of falling

RESULTS
insists that we should not use a limb restriction belt
on him. The family also insists that the resident has
Participant characteristics
to be out of his wheelchair every day. However, we
use a wheelchair belt to fix him in place. The resi-
The sample of 26 nurses had a mean  standard
dent stands up once we are not paying attention to
deviation (SD) age of 34.69  8.28 years (range:
him. We can’t babysit for him 24 hours a day. One
25–57 years) and had worked for a mean  SD of
day the resident fell down…’ (Participant 8)
10.68  6.66 years (range: 2–27 years). All partici-
pants were female and half were single. Nearly half
This type of expectation on the part of residents
the nurses (n = 12, 46.2%) had graduated from uni-
was also reported:
versity. Five participants (19.2%) were head nurses.
They had received a mean  SD of 7.12  9.58
‘Some residents think that because they pay
hours (range: 0–40 hours) of communication educa-
money, they are the boss. Once they ring the
tion during nursing school and a mean  SD of
bell, they expect us to deal with their issue imme-
11.38  23.99 hours (range: 0–100 hours) of
diately. How can this be possible? Sometimes the
continuing communication education at work. The
staff are too busy to answer immediately. The res-
ethnic background of most participants was Han
idents ring again and again. They are angry when
Chinese (96.2%); only one was Taiwanese
we do find the time to deal with them… They
aboriginal.
even shout and yell at us.’ (Participant 19)
Participants’ experiences of communication conflict
Expecting to safeguard the group environment, not the
Data analysis revealed that the communication con- individual’s environment
flict experiences of nursing home nurses could be
categorised under three themes: differences in per- The nursing home environment, including some
spectives of nursing home services; differences in rooms, is shared among residents. However, resi-
views of nurturing health, and mediation between dents often continue to behave as they did in their
family members and others. own homes. As this participant described:

Differences in perspectives of nursing home services
Residence in the nursing homes in this study was
paid for by residents or their families rather than
being government-funded. However, understaffing in
these nursing homes often prevented nurses from
providing the individualised services some residents
and their families expected and considered they were
‘He [the resident] does not throw anything away.
Therefore his room has a lot of trash.’ (Partici-
pant 10)
Similarly, another nurse reported:
‘One resident comes from the countryside. When
she first arrived here, she threw all her used

ª 2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 990–1000 993
H-H Tsai et al
tissue paper on the floor, and we were not happy
with this. After communicating with her, we
found that this was her habit at home. She
believes she is here to enjoy her life, and others
should clean up after her.’ (Participant 18)
Expecting to provide group security, not individualised
security
Both residents and families expected that the nurs-
ing home would be a safe place for them to stay.
However, residents sometimes lost personal belong-
ings. One participant said:
‘Families always complain to us that their rela-
tive’s clothes [have] disappeared, or some towels
or food. They think this is the first time such a
thing has happened.’ (Participant 4)
Likewise, another nurse reported:
‘One elderly woman kept her cherries in the pub-
lic refrigerator. She wrote her name on the box,
but it disappeared, making her angry.’ (Partici-
pant 9)
Differences in views of nurturing health
Health was the major concern of residents, families
and nursing staff and the main reason for residents
moving in, families paying for services, and nursing
staff being hired. However, these three groups had
different views on how to nurture health. The nurs-
ing staff were trained in Western medicine, whereas
the majority of residents and families believed in
traditional Chinese medicine. Nurses and residents
and their families also belonged to different age
groups. These different backgrounds led to differ-
ences in views on how to nurture health. Further-
more, nursing homes had regulations to improve
residents’ health. Families did not visit nursing
homes daily and only saw health outcomes when
they visited. This theme was characterised by three
sub-themes: nurses expected to promote healthy
lives, not happy lives; nurses expected to provide
Western medicine-oriented care, not Chinese medi-
cine-oriented care, and nurses focused on overall
health outcomes, not 1-day health outcomes.
Expecting to promote healthy lives, not happy lives
Some residents wanted to continue habits even
when they did not promote health:
994
‘Smoking is a tough problem in our institution.
The residents who smoke here have had this
habit for a long time. Smoking may have some
meaning for them such as releasing anxiety or
relieving upset feelings. This may be their only
interest or activity here. They ask their family to
bring them cigarettes, but this habit is restricted
in the nursing home. Our owner is a doctor who
insists upon this regulation.’ (Participant 4)
Expecting to provide Western medicine-oriented care, not
Chinese medicine-oriented care
Some residents and their families preferred to use
their own methods for treating residents’ ailments.
One participant observed:
‘We have an elderly woman with a corn on her foot.
At home, she used to treat the corn by soaking her
foot in vinegar… She deeply believes that this
method is the best way to deal with the corn. There-
fore, she … asked the cook for vinegar to soak her
foot and wrapped it in plastic bags. However, the
wound got bigger … and looked like cellulitis. We
told her not to do this and that we wanted to help
care for the wound. She is very angry and can’t
accept our suggestions.’ (Participant 3)
Residents’ families and residents may also use
Chinese medicine to improve residents’ health:
‘Some families bring herbs to residents. We have
no way to verify the ingredients of those herbs.
We suggest that they not bring herbs for resi-
dents and that they visit the traditional medicine
clinic in our hospital. Some are not happy with
this. They insist upon using their herbs.’ (Partici-
pant 9)
Focus on overall health outcomes, not 1-day health outcomes
Families that may not have time to visit residents
daily sometimes behave in ways intended to reduce
their guilt, particularly in relation to residents’
health care outcomes:
‘Some families pick on the staff and check you
occasionally. They will show up one day and
assume that that day represents all other days. It is
unfair to us. This happens because some residents
only occasionally see their family.’ (Participant 12)
Another nurse reported:
ª 2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 990–1000
 Experiences of communication conflict in nurses
‘One family member checked her mother’s leg
temperature every time she visited. Once she felt
that her mother’s legs were cold, and she criti-
cised us for not providing enough blankets to
cover her mother. However, the daughter is not
always here. She doesn’t know that her mother
sweats easily, so we don’t give her so many blan-
kets.’ (Participant 26)
Furthermore, residents may want their family to pay
more attention to them, so they sometimes com-
plain on the day of the family member’s visit:
‘Residents are happy most of the time, but when
their family visits they act like spoiled children.
They start to complain of headaches, stomach
pains, or some other ailment to get their family’s
attention. The family becomes unhappy with us
and thinks we do not care well for their relative.’
(Participant 19)
Another participant commented:
‘One elderly woman complained of abdominal
distension. We therefore gave her congee [por-
ridge]. However, she phoned her son to com-
plain that we didn’t give her rice and that the
food was terrible. Her son then came to visit. It
was very strange that all her discomfort disap-
peared when he arrived. Everything became nor-
mal.’ (Participant 2)
Mediating between family members and others
Because the nursing homes were directed by nurses,
and most families did not visit the nursing homes
daily, nursing staff often acted as a bridge between
families and others. As one participant said:
‘In my opinion, most of my communication prob-
lems stem from dealing with families.’ (Partici-
pant 10)
This theme of mediation was characterised by four
sub-themes: mediating between family members and
the hospital; mediating amongst different family
members; mediating between family members and
their hired attendant, and mediating between family
members and the resident.
Mediating between family members and the hospital
Residents sometimes needed to go to hospital for
treatment. Under Taiwanese nursing home regula-
ª 2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 990–1000
tions, a nursing home resident must be taken to
hospital by a family member if this is possible.
However, if family members do not have time, a
nursing home employee may accompany the
resident. If the hospital report on the resident’s
health is unclear or negative, conflict may arise
between nurses and family members. As one
participant said:
‘One of our residents needs dialysis. After a nurs-
ing home employee brought him to the haemodi-
alysis centre, we received a call that his blood
vessel was blocked. As soon as we got this infor-
mation, we phoned his family to tell them the
resident’s condition and that they must go to the
hospital. When they heard this, they blamed us
for letting this happen… Why should I take this
kind of responsibility? I am just the person who
parrots what the hospital said. Why should I have
to explain the resident’s condition to his family?’
(Participant 3)
Mediation may be especially crucial for end-of-life
issues. For example, as one participant shared:
‘One family member signed a DNR [do not resus-
citate] order for a resident. One day the resident
was transferred to the hospital as an emergency.
His family members went there after we [had]
informed them. However, one of our nursing staff
was too busy to inform the hospital of the DNR,
and the emergency room doctors didn’t ask the
family members for their opinion. Therefore, the
hospital had begun endotracheal intubation for
him. The family was very angry about this. They
said they would sue us for not telling the hospital
about the DNR.’ (Participant 3)
Mediating among different family members
Many residents had several children, who were often
divided by opinion. One participant said:
‘Take DNR for example; one resident has five
children. However, communication among his
children is not so good. Two of his daughters
who live in the USA agree with the DNR, while
the other in Taiwan does not agree to this. The
resident’s son said he would sue us and asked us
to compensate for this.’ (Participant 7)
Another issue described by participants as generat-
ing conflict concerned the exchange of information
about the resident’s condition among family
995
H-H Tsai et al
members by telephone. For example, one partici-
pant said:
‘When I phoned a family member to tell him of
his relative’s condition, he asked me to phone
another family member. However, when I called
the second family member, that person asked me
to call the other one back. How can I call so
many people? I really don’t know who should
take this decision-making responsibility.’ (Partici-
pant 3)
Mediating between family members and their hired attendant
In Taiwanese nursing homes, a resident’s family will
often hire an attendant to care for the resident all
day as a way of showing their filial piety. Families
place substantial levels of trust in the hired atten-
dant and accept the attendant as a family member.
This situation sometimes creates conflict:
‘Some residents have had their own attendant for
a long time. Sometimes we have to correct the
attendant’s skills or food preparation for the resi-
dents, and they don’t accept this. The attendant
will report directly to the family. When attendants
complain about us, the family will phone us. No
matter what, the family still believes their atten-
dant is right. Families will not allow us to inter-
rupt their hired attendant’s care.’ (Participant 11)
Mediating between family members and residents
Residents may move into nursing homes involuntarily
and may have emotional problems their families do
not know how or are reluctant to deal with. Families
expect nursing staff to deal with such problems:
‘One old man asked us to call his son to take
him home. However, his son was very angry. Why
couldn’t we deal with his father’s emotional
state? We asked the son to visit the resident to
comfort him. His son did visit after we called.
When he came, the resident blamed his son for
putting him here. His son was very angry because
he paid a lot of money for his father to live here.
However, when he visits his father, he gets
blamed.’ (Participant 21)
Furthermore, families do not always appreciate hear-
ing information about the deterioration of the resi-
dent’s health. The majority of residents live in
nursing homes because their families do not have
time to care for them. They may not want the nurs-
996 ª 2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 990–1000
ing home to inform them that they must take their
relative to see a doctor. However, nursing homes do
not have doctors or enough staff to take residents
to the hospital. Therefore, nursing home staff are
obligated to inform families if a healthy resident
begins to have problems. These different viewpoints
cause conflict:
‘Some families feel they have spent a lot of
money to have residents live here. If someone
from the nursing home phones frequently to tell
them that the resident has some health prob-
lems, how can they [the family] feel at ease?
Many families have residents here because they
have neither the time nor the ability to care for
them. If you phone them often, this makes them
nervous.’ (Participant 4)
DISCUSSION
The experiences of nursing home nurses in Taiwan
of communication conflict were represented by
three themes: differences in perspectives of nursing
home services; differences in views of nurturing
health, and mediation between family members and
others. These findings provide new insights into
communication conflicts within nursing homes and
can be used to design more effective communica-
tion education and conflict management pro-
grammes for nursing students or staff in Taiwan
and other Asian countries, and countries with large
Chinese immigrant populations. Such an approach
is feasible as 83% of US nursing schools have used
nursing homes as clinical sites in which to teach
communication skills.49 Our findings can also be
used as scenarios in problem-based learning to
teach nursing36 and medical50,51 students how to
resolve conflicts in practice.
Differences in perspectives of nursing home services
demonstrate that the existence of power differences
among residents, families and nursing staff in nurs-
ing homes is a unique phenomenon by virtue of
which the nursing home differs from other care set-
tings. This theme may derive from the fact that all
the nursing homes in this study were self-funding
institutions, in which residents and families perceive
their power to be greater than that of the nursing
staff. Thus, nurses in public nursing homes may
have different experiences of communication con-
flict. This result suggests that nurses in private, self-
paid nursing homes should be educated about resi-
dents’ and families’ perspectives to help them better
manage conflicts. Nurses should be taught to
 Experiences of communication conflict in nurses
develop independent thinking so that they can
express their opinions and manage conflicts rather
than avoiding them,30 especially in long-term care
settings in which nurses dominate the provision of
care.
Furthermore, residents’ and families’ expectations
that nursing staff should provide individualised care
may impose work-related stress on nursing staff,
which has been shown to lead to abuse by nursing
aides of elderly nursing home residents.52 Nursing
home staff have also been shown to be more likely
to abuse residents in for-profit nursing homes.53
However, the issue of elder abuse has not been
reported in Asian nursing home settings. Further
research is suggested to compare the prevalences of
abuse and related factors (such as nurse–resident
power differences) between Asian and Western nurs-
ing homes.
Conflicts that derive from differences in perspectives
of nursing home services should be resolved carefully
because otherwise residents may perceive that staff
do not readily respond to their needs54 and may feel
disempowered, dehumanised and devalued.55 These
outcomes may also cause nurses difficulty in achiev-
ing major communication tasks, including building
creative, therapeutically effective relationships, show-
ing understanding and empathy, and providing com-
fort and support.41 All of the sub-themes within this
theme can be used in role-play during communica-
tion education programmes, which may increase
both nurses’ and social workers’16 sensitivity to the
meanings of resident behaviours and help them to
deal appropriately with them.
Another core theme in our research on staff nurses’
experiences of communication conflict referred to
differences in views of nurturing health. This theme
may reflect the dynamic nature of nursing home life
and the numerous daily interactions that depend
upon daily communication,56 by contrast with
nurse–patient communication issues in acute care
settings. This theme may reflect both that ‘nurtur-
ing health’ is a fundamental aspect of both the lived
experiences of residents22 and their families’ expec-
tations. This theme may also reflect differences in
the backgrounds of nurses, and residents and their
families, respectively, as well as their different cul-
tural perspectives of health.
As this core theme reflects different cultural views
of nurturing health, we suggest that such views be
included in communication education for nurses in
long-term care settings, particularly in Asian coun-
ª 2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 990–1000
tries where traditional medicine is widely practised.
As health reflects a person’s complete physical,
mental and social well-being,57 health care profes-
sionals should notice whether a resident’s mental
health would suffer if that person was unable to use
a traditional Chinese treatment he or she strongly
believed to be effective. Fortunately, culture is a
dynamic and learned value,58,59 and thus individuals
experiencing conflict related to this theme can be
taught to understand one another’s views and adapt
their own perspectives to reach consensus. To this
end, we suggest that nurses’ communication educa-
tion programmes include training in cultural sensi-
tivity such as that embodied in Leininger’s culture
care theory.58,59 In this kind of education, the sub-
themes of our second major theme may be used as
scenarios to educate nurses in applying cultural
preservation, cultural accommodation, cultural re-
patterning and cultural brokering.58,59
Our research also revealed the theme of mediation
by staff nurses between family members and others.
Asian families play a more important role than Wes-
tern families in patient care, even in long-term care
settings, probably as a result of traditional Chinese
beliefs and culture.60 Taiwanese family caregivers of
nursing home residents have been shown to have a
higher prevalence of depressive symptoms than those
in Western countries.61 Therefore, we suggest that
family members should be recruited to participate in
Asian nurses’ conflict management education.
Another issue related to this theme referred to the
fact that the majority of family members did not
visit nursing homes daily and therefore relied on
the nursing staff to inform them about residents’
health. They often phoned the nursing staff to
obtain information, but expected the staff to medi-
ate with the resident, other family members, hospi-
tals and hired attendants. To circumvent such
expectations, nursing home staff could use video-
conferencing as an alternative way of informing all
family members of specific situations regarding the
resident.18 Further research might also clarify which
method (telephone, in person, videoconference) is
best suited for communicating with families about
nursing home residents.
Despite its contributions to understanding commu-
nication conflict in Taiwanese nursing homes, this
study had some limitations. Firstly, we did not
include nurses’ experiences of communication con-
flict with residents with dementia and their family
members, which is a challenging area for nurses in
long-term care settings.62 Further research is
997
H-H Tsai et al
suggested to emphasise communication problems
with residents with dementia. Secondly, we exam-
ined perceptions of communication conflicts from
the perspective of nursing home staff only. Further
research is suggested to understand experiences of
communication conflict as they are perceived by res-
idents and their families. Thirdly, the study sample
was small as determined by data saturation, which
limits the transferability of the findings to all nurs-
ing home staff in Taiwan. Another limitation on
transferability was imposed by the fact that the sam-
ple was referred by the directors of the respective
nursing homes. Finally, all of the nursing homes in
our sample were private and thus the transferability
of our findings to public nursing homes is limited.
However, this limitation may be minimal because in
Taiwan most (87%) nursing homes are private and
only 2.8% of public nursing homes offer free ser-
vices to low-income veteran residents, and thus non-
veteran residents are usually required to pay out of
their own pocket.63 Moreover, nurses in public nurs-
ing homes provide care similar to that provided by
nurses in private nursing homes except when resi-
dents are veterans, who usually have no family.
CONCLUSIONS
Nurses’ experiences of communication conflict in
Taiwanese nursing homes were characterised by
three themes: differences in perspectives of nurs-
ing home services; differences in views of nurtur-
ing health, and mediation between family
members and others. To teach nurses how to
communicate in conflict situations with power dif-
ferences, communication education programmes
should include ways to increase independent
thinking. Nurses and other health care profession-
als would benefit from education programmes to
improve cultural sensitivity as embodied in Leinin-
ger’s culture care theory.58,59 Furthermore, the
themes and sub-themes that emerged in this study
may be used as scenarios in problem-based learn-
ing classes for teaching all clinicians or students
how to manage emotional issues in communica-
tion conflict. Another strategy would be to teach
effective ways to communicate by telephone and
by using other means of communication (e.g. vid-
eoconferencing).
Contributors: H-HT contributed to the conception and
design of the study, the collection and analysis of data
and the drafting of the paper. Y-FT contributed to the
conception and design of the study, the collection and
998 ª 2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 990–1000
analysis of data and the drafting and critical revision of
the paper. L-CW and H-FC contributed to the analysis of
data and the drafting of the paper. All authors approved
the final version of the manuscript for publication.
Acknowledgements: none.
Funding: this study was funded by the National Science
Council, an agency of the Taiwan government (NSC 100-
2511-S-182-005).
Conflicts of interest: none.
Ethical approval: This study was approved by the Institu-
tional Review Board, Chang Gung Memorial Hospital,
Tao-Yuan, Taiwan (no. 100-1303B).
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Received 6 September 2012; editorial comments to author 10
December 2012, 27 February 2013; accepted for publication 15
March 2013
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