On a busy hospital ward, a nurse says “wonderful, wonderful” as a patient with dementia completes a task. It sounds simple, but moments like this can play an important role in how care gets done.
Building on my doctoral research, a recent study I co-authored with colleagues examines how praise is used in the care of people living with dementia in acute hospitals (which provide short-term treatment for serious illness, injury or urgent medical needs).
This work forms part of my ongoing investigation into elderspeak: speech that is simplified and often includes terms of endearment, a high or sing-song tone, and repeated or exaggerated praise. Elderspeak is typically directed at older adults and is often compared to the way people speak to young children. That has led to debate about whether it is supportive, patronising or insulting.
My previous work on terms of endearment found that words such as “sweetheart” or “love” can sometimes have supportive functions, depending on how they are used. Praise raises a similar question. Can it help care happen, or can it cause trouble?
In this study, we looked at praise in terms of talk that supported, encouraged or strengthened a patient’s action. The data came from a wider body of research examining how to improve communication with people living with dementia on hospital wards.
The research involved video recording, with consent, real-life ward interactions between people living with dementia and healthcare professionals. We then examined how conversations unfolded in practice and how people responded to different kinds of talk.
Praise during questions
In hospital, healthcare professionals often need to ask patients a series of questions. These questions might be part of a medical assessment, a memory check or a conversation about treatment.
In the following example, the praise word used is “brilliant”:
Healthcare professional: “Do you know what month it is?”
Patient: “October.”
Healthcare professional: “Brilliant, and what’s your date of birth?”
Here, praise does multiple things. It signals that the patient has given a suitable answer and that the answer has been accepted. It also helps move the conversation on to the next question.
This can be useful for people living with dementia, especially when answering questions is difficult. Praise may encourage them to keep responding, even if they are unsure. It can also help healthcare professionals gather more information. Even an incorrect answer may be clinically useful, because it tells the professional something about the patient’s current understanding, memory or orientation.
Praise during tasks
We also found that praise often occurred during or after tasks that could be uncomfortable, tiring or difficult. These included physiotherapy exercises and medical procedures such as injections.
In these situations, praise appeared to do two main kinds of work.
First, it could act as a signpost. It helped show when a patient was doing something in the way the healthcare professional needed. On a busy and disorientating ward, this kind of feedback may help a person with dementia stay focused on the task.
Second, praise could acknowledge effort. That effort might involve a physical action, such as standing, walking or lifting an arm. It might also involve enduring something uncomfortable, frightening or painful.
In both cases, praise helped treat the actions of people living with dementia as relevant and important to the care being provided. It was more than background politeness. It helped coordinate care.
Looking at the whole picture
Praise does not work in the same way in every situation. It depends on what is being praised, who has the right to evaluate it, and whether the person being praised understands what the praise refers to.
Conversation analysts use the term epistemics to describe how knowledge is managed in conversation: different people have different access to different kinds of knowledge. Patients are usually the best authority on their own thoughts, feelings and experiences. Healthcare professionals have medical expertise about illness, treatment and care.
In one example, a patient tells a doctor that he drinks a lot of water. The doctor replies: “Good man, good man.” The patient accepts the praise without difficulty. Here, the patient introduced the topic himself. Drinking water is generally understandable as a good thing, and the doctor can reasonably assess it as a medical professional. Both people can recognise what is being praised.
In another example, a doctor tells a patient: “Your walking is doing pretty good at the moment.” They had not previously been discussing walking. The patient responds with confusion: “Is it? What we doing?” Even after the doctor explains and offers more praise, the patient asks: “Where?” The praise is not accepted smoothly.
The difference is important. In the first example, the patient understands what is being evaluated. In the second, the praise refers to something the patient may not recognise as the current topic or activity. As a result, it creates conversational trouble rather than reassurance.
Although dementia can affect communication, people living with dementia often responded to praise in ways that fitted the conversation. This is known as interactional competence: the ability to take part meaningfully in interaction, even when communication is affected by illness or disability.
For example, patients might accept praise modestly, as people often do in ordinary conversation. They might also challenge praise when it seemed misplaced or unclear. This shows that people living with dementia were active participants in the interaction.
Praise can therefore support care, but it does not always lead to cooperation, especially when patients are distressed or resisting care.
In acute hospitals, praise can help healthcare professionals keep conversations moving, guide people through difficult tasks and acknowledge the effort involved in care. But it needs to be used carefully. Praise is most helpful when the person understands what is being praised and when the praise fits the situation. When it is unclear or poorly timed, it may cause confusion instead.
A simple “wonderful” can support care, but only when the praise is clearly connected to what the person is doing.
This work was supported by a Mildred Blaxter Post-Doctoral Fellowship from the Foundation for the Sociology of Health and Illness. The original PhD research was funded through an ESRC Midlands Graduate School DTP collaborative studentship between the University of Nottingham and Nottingham University Hospitals NHS Trust (ES/P000711/1). The data on which this paper draws were collected as part of the NIHR funded VOICE (13/114/93) and VOICE2 (NIHR134221) research. The views expressed in this paper are those of the author and not necessarily those of the FSHI, ESRC, NIHR or the Department of Health and Social Care.