Non-Verbal Communication
And Patient Care
Non-verbal communication is a subtle form of communication that
takes place in the
initial three seconds after meeting someone
for the first time and can continue through the entire
interaction. Research indicates that non-verbal communication
accounts for approximately
70% of a communication episode. Non-
verbal communication can impact the success of communication more
acutely than the spoken word. Our culturally informed
unconscious framework evaluates gestures, appearance, body
language, the face, and how space is used. Yet, we are rarely
aware of how persons from other cultures perceive our non-verbal
communication or the subtle cues we have used to assess the
person.
The following are case studies that provide examples of non-
verbal miscommunication that can sabotage a patient-provider
encounter. Broad cultural generalizations are used for
illustrative purposes. They should not be mistaken for
stereotypes. A stereotype and a generalization may appear
similar, but they function very differently. A
stereotype is an
ending point; no attempt is made to learn whether the individual
in question fits the statement. A
generalization is a beginning
point; it indicates common trends, but further information is
needed to ascertain whether the statement is appropriate to a
particular individual.
Generalizations can serve as a guide to be accompanied by
individualized in-person assessment. As a rule, ask the patient,
rather than assume you know the patient’s needs and wants. If
asked, patients will usually share their personal beliefs,
practices and preferences related to prevention, diagnosis and
treatment.
Eye Contact
Ellen was trying to teach her Navaho patient, Jim Nez, how to
live with his newly diagnosed diabetes. She soon became extremely
frustrated because she felt she was not getting through to him.
He asked very few questions and never met her eyes. She reasoned
from this that he was uninterested and therefore not listening to
her.1
It is rude to meet and hold eye contact with an elder or someone
in a position of authority such as health professionals in most
Latino, Asian, American Indian and many Arab countries. It may
be also considered a form of social aggression if a male insists
on meeting and holding eye contact with a female.
Touch and Use of Space
A physician with a large medical group requested assistance
encouraging young female patients to make and keep their first
well woman appointment. The physician stated that this group had
a high no-show rate and appointments did not go as smoothly as
the physician would like.
Talk the patient through each exam so that the need for the
physical contact is understood, prior to the initiation of the
examination. Ease into the patients’ personal space. If there are
any concerns, ask before entering the three-foot zone. This will
help ease the patient’s level of discomfort and avoid any
misinterpretation of physical contact. Additionally, physical
contact between a male and female is strictly regulated in many
cultures. An older female companion may be necessary during the
visit.
Gestures
An Anglo patient named James Todd called out to Elena, a Filipino
nurse: “Nurse, nurse.” Elena came to Mr. Todd’s door and politely
asked, “May I help you?” Mr. Todd beckoned her to come closer by
motioning with his right index finger. Elena remained where she
was and responded in an angry voice, “What do you want?” Mr. Todd
was confused. Why had Elena’s manner suddenly
changed?2
Gestures may have dramatically different meanings across
cultures. It is best to think of gestures as a local dialect
that is familiar only to insiders of the culture. Conservative
use of hand or body gestures is recommended to avoid
misunderstanding. In the case above, Elena took offense to Mr.
Todd’s innocent hand gesture. In the Philippines (and in Korea)
the “come here” hand gesture is used to call animals.
Body Posture and Presentation
Carrie was surprised to see that Mr. Ramirez was dressed very
elegantly for his doctor’s visit. She was confused by his
appearance because she knew that he was receiving services on a
sliding fee scale. She thought the front office either made a
mistake documenting his ability to pay for service, or that he
falsely presented his income.
Many cultures prioritize respect for the family and demonstrate
family respect in their manner of dress and presentation in
public. Regardless of the economic resources that are available
or the physical condition of the individual, going out in public
involves creating an image that reflects positively on the family
- the clothes are pressed, the hair is combed, and shoes are
clean. A person’s physical presentation is not an indicator of
their economic situation.
Use of Voice
Dr. Moore had three patients waiting and was feeling rushed. He
began asking health related questions of his Vietnamese patient
Tanya. She looked tense, staring at the ground without
volunteering much information. No matter how clearly he asked
the question he couldn’t get Tanya to take an active part in the
visit.
The
use of voice is perhaps one of the most difficult forms of
non-verbal communication to change, as we rarely hear how we
sound to others. If you speak too fast, you may be seen as not
being interested in the patient. If you speak too loud, or too
soft for the space involved, you may be perceived as domineering
or lacking confidence. Expectations for the use of voice vary
greatly between and within cultures, for male and female, and the
young and old. The best suggestion is to search for non-verbal
cues to determine how your voice is affecting your patient.
1, 2 Galanti, G. (1997). Caring for Patients from Different Cultures. University of Pennsylvania Press.
Hall, E.T. (1985). Hidden Differences: Studies in International Communication. Hamburg: Gruner & Jahr.
Hall, E.T. (1990). Understanding Cultural Differences. Yarmouth, ME: Intercultural Press.
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