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Nonverbal communication in health settings

Chapter · January 2014

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Gaëtan Cousin Marianne Schmid Mast

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Encyclopedia of Health Communication

Nonverbal Communication in Health Settings

Nonverbal communication is communication without words. Although the interest

for caregiver and patient nonverbal communication is relatively young, studies on nonverbal
behavior in the realm of caregiver-patient interactions have yielded many interesting results
during the last decades. First in correlational designs and then in experimental ones,
researchers have shown that healthcare providers’ nonverbal communication predicts
several important patient outcomes. For instance, we know that affiliative nonverbal
behaviors such as smiling, nodding, or leaning forward increase patient satisfaction, trust,
and adherence. Moreover, we begin to gain insight into how patient individual
characteristics shape their reactions to a given caregiver’s communication style. Researchers
have not only investigated caregivers’ nonverbal behavior but have also looked at patients’
nonverbal behavior. In the psychotherapeutic context, in particular, patients’ nonverbal
behavior can contain important information about the patient’s disease (e.g., depressive
disorder, schizophrenia, autistic troubles). Also, enhancing patients’ nonverbal skills ‒
defined as correctly reading and interpreting others’ nonverbal behaviors, as well as
expressing oneself nonverbally in a way that is congruent with one’s communicative goals ‒
can be part of the therapy. As the field of caregiver-patient communication developed, both
theoretically and empirically, we have gained more knowledge about how physicians,
nurses, therapists, and other healthcare providers should best communicate with their
patients, interpret their patients’ nonverbal behavior, and adapt to their patients’ nonverbal
behavior in order to ensure best possible care.

Definition, types, and functions of nonverbal behaviors

Nonverbal communication includes facial, postural, gestural, and vocal

(paralinguistic) cues. Nonverbal cues serve different purposes, such as signaling personal
characteristics (e.g., extraversion, intelligence) and interpersonal orientations and goals
(e.g., interest, attention, antipathy, intimacy, or status), coordinating verbal speech, and/or
expressing emotions. Face cues include, for instance, gazing, smiling, frowning, eyebrow
raising, and general facial expressivity. Postural cues are, for instance, arm and leg positions
and movements, body orientation, and interpersonal distance. Gestures can be emblematic
when having a defined linguistic content (e.g., saying no by doing repetitive left-right
movements of the forefinger), illustrative when gesturally expressing a concept or an object
(e.g., indicating the size of a box with the hands), regulative when facilitating verbal
exchanges (e.g., indicating with a movement of the hand that the interaction partner should
continue to talk), adaptive when responding to a personal need (e.g., scratching one’s itchy
head), or emotional when conveying an emotion (e.g., clenching one’s fist when feeling
irritated). Vocal cues include, as examples, loudness of the voice, voice pitch, speech rate,
and voice tone variations.

Nonverbal communication can complement, repeat, reinforce, substitute, regulate,

or contradict verbal communication. When there is contradiction between the two
communicative channels, it seems that people rely more on nonverbal cues than on verbal
cues when trying to infer meaning from the communication. For instance, when someone
says “I like you” with a stoned expression that conveys the opposite message, people will
typically form their judgment of the other person’s liking by relying on the facial cues and
deduce that the person is not serious or honest when saying that he or she likes them. A
common explanation for the preference given to nonverbal cues when decoding others’
messages is that nonverbal behaviors are under less of a conscious control than verbal
behaviors. As a consequence, people would tend to consider nonverbal cues as more
difficult to fake and thus as more indicative of their interaction partners’ real intentions
and/or states.

Caregivers’ nonverbal behavior

In the caregiver-patient relation, two aspects of nonverbal behaviors are commonly

studied: affiliative behaviors and controlling behaviors. Affiliative nonverbal behaviors
encompass all nonverbal behaviors that aim at creating a positive relationship between the
caregiver and the patient by communicating attention, interest, empathy, and/or
friendliness. They include, for instance, reinforcing behaviors such as smiling and nodding, as
well as signs of involvement such as facial expressiveness, facing body posture, and forward
leaning. Controlling nonverbal behaviors are all nonverbal behaviors that aim at gaining or
maintaining control over the interaction partner. They include, for instance, talking in a loud
voice or adopting an expansive body posture (i.e., occupying a maximum of space).

Affiliative nonverbal behaviors in the caregivers have been shown to positively

influence patient outcomes. Experimental studies suggest that when caregivers adopt
affiliative nonverbal behaviors such as doing moderate to high eye contact with the patient,
rarely looking at the patient chart, using concerned facial expressions, smiling frequently,
leaning forward, and sitting relatively close (two feet) to the patients, patients are more
satisfied with their caregivers, trust them more, and recall more medical information than
when caregivers adopt less affiliative behaviors (e.g., little eye contact, frequent looking at
the chart, neutral facial expressions, leaning backward, and sitting four feet away from the
patient). In the same way, when physicians touch their patients gently on the forearm for
one to two seconds at the end of the visit while stressing the importance of following the
medication, patients were more likely to actually take their medication as prescribed (i.e.,
they showed more medication adherence) than when the physician stressed the importance
of following the medication without touching the patients.
 Correlational research has revealed many associations between caregivers’ affiliative
behaviors, as expressed nonverbally, that replicate the results of experimental studies in real
medical settings. For instance, meta-analytical results show that physicians’ and nurses’
affiliativeness (warmth) and listening to the patient are associated with more patient
satisfaction. Correlational research also suggests associations between caregivers’ nonverbal
affiliativeness and patient outcomes that have not (yet) been shown by experimental
research. For instance, caregiver’s gazing at the patient has been related to more
successfully identifying his or her psychological distress. Caregivers’ expressiveness
(operationalized differently across studies, e.g., through more nodding, more smiling, more
frowning, more gestures, and/or more variations in the tone of voice) is related to more
patient satisfaction in patients of different ages, as well as to better physical and cognitive
functioning in elderly patients.

Research on caregivers’ controlling nonverbal behaviors (e.g., visual dominance

through looking at the patient while talking to him or her and not looking at the patient
while listening to him or her, expressivity, close interpersonal distance, loud tone of voice,
postural expansiveness) is comparatively scarce, and mostly correlational, but it shows that
those behaviors are generally associated with less patient satisfaction. Also, surgeons whose
tone of voice is more dominant have more malpractice claims. In particular, patients seem to
dislike controlling nonverbal behaviors when such behaviors are expressed by female
caregivers ‒ probably because controlling behaviors contradict the female gender role
stereotypes. Conversely, patients seem to show more satisfaction when male physicians
show more controlling behaviors such as talking with a louder voice and showing postural
expansiveness, probably because controlling behaviors are in accordance with the male
gender role stereotypes.

Despite the fact that the above mentioned findings hold true on average, a more fine-
grained view on the type and intensity of caregiver nonverbal behavior ‒ as well as on the
characteristics of the caregiver and of the patient ‒ is in order. The effect of caregivers’
nonverbal behaviors on patient outcome sometimes depends of the exact form of the given
nonverbal behavior. For instance, soft touch increases patient adherence, while touch
perceived as dominant or controlling seems to have a negative effect on patient outcomes;
the effect of physician touch thus probably depends on the kind of touch (slight tactile
contact vs. brusque or invasive contact). Moreover, the rule ‘the more the better’ cannot
systematically be applied to physician nonverbal behaviors shown to share positive
associations with patient outcomes. For many behaviors, moderation seems better than
extremes. For instance, too much or too little of physician gazing seem equally detrimental
to patient satisfaction, and moderate levels of gazing are related to the highest satisfaction
rates. And, caregivers’ and patients’ individual characteristics (e.g., personality, attitude,
gender, age, educational level) might moderate their reactions to caregivers’ degree of
affiliation and control. For instance, patients who are anxious (as judged from their voice by
independent raters) are more tolerant, or even prefer, physicians who sound angry than
patients who are less anxious. Also, nonverbal behavior might have different effects on
patient outcomes depending on the type of healthcare provider who expresses it. Meta-
analytical results show, for instance, that physicians’ negativity (e.g., expressed anger or
hostility) is not related to patient satisfaction, whereas nurses’ negativity is. Even if we lack,
at this stage, clear explanations for such differences in influence of caregivers’ nonverbal
communication on patient outcomes depending on the caregivers and on the patients, such
effects are documented and need to be taken into account.

Patients’ nonverbal behavior

Patients’ nonverbal behavior is influenced by physicians’ nonverbal behaviors.

Research shows for instance that patients tend to mirror affiliative behaviors in the physician
(e.g., gazing, facing orientation) and that interactional synchrony between the physician and
the patient with regard to nonverbal behavior (i.e., when physician and patients display
similar behavior at the same time) is associated with more interactional comfort (i.e.,
patients and physicians feel more at ease). In the psychotherapeutic domain as well,
therapists are perceived more positively by patients when therapists and patients mirror
each other’s body movement and posture than when they do not. This might be explained
by the fact that mirroring is associated with greater perceived rapport and liking between
the interaction partners.

Nonverbal sensitivity (defined as correctly inferring others’ traits and states on the
basis of their nonverbal behavior) is an important skill for physicians to possess. Physicians
might lack nonverbal sensitivity when it comes to recognizing affective states in their
patients or to evaluating patient satisfaction and liking of the physician. Female medical
students show more nonverbal sensitivity than male medical students. Lack of nonverbal
sensitivity in physicians is potentially a problem, notably because this skill is associated with
more patient satisfaction and better appointment keeping in the patients.

Nonverbal sensitivity is important in the psychotherapeutic domain as well. Patient

nonverbal behaviors can be used for diagnosis by therapists because nonverbal
characteristics accompany most psychopathologies (e.g., mood disorders, schizophrenia,
autism, substance dependency). Individuals suffering from depression or from schizophrenia
typically show reduced emotional expressiveness (e.g., non-expressive facial displays, gaze
aversion, scarcity of gestures, monotonous voice tone). Also, such patients have a poorer
ability to correctly infer others’ states (e.g., emotions) on the basis of others’ nonverbal
behavior (i.e., less nonverbal sensitivity) compared to healthy individuals. Moreover,
patients’ nonverbal behavior can provide information about the patient to the therapist that
the patient is not willing or able to give verbally (e.g., distress, deception). Finally, nonverbal
training can be part of the therapy, for instance when patients with nonverbal deficits (e.g.,
autistic patients who typically have difficulties in understanding others’ emotion) are trained
to encode and decode nonverbal behavior in order to enhance their social skills.
Methods and perspectives

Most research in the field of caregiver-patient communication is correlational. This

typically ensures high external validity (good potential for generalizability of the findings) but
does not allow for causal inferences and sometimes poses problems of interpretation
regarding the direction of the discovered relation. For instance, an association between
physician nonverbal expressivity and patient positive health outcomes can be interpreted in
different ways: 1) physician expressivity might have positively influenced patient health
outcomes, or 2) physicians might have been more expressive with patients who were in
better health, or 3) a third variable (e.g., the weather) might have influenced both physician
expressivity and patient health status. This is why other researchers have built experimental
design. These designs, by manipulating physician nonverbal behavior and maintaining a high
level of control over potential confounding variables, have enabled researchers to establish
causal association (e.g., between physician nodding and patient satisfaction). However,
experimental designs in the field of caregiver-patient interactions have often relied on so-
called analogue patients (healthy participants asked to put themselves into the shoes of real
medical patients) and/or on actors playing the role of physicians (i.e., simulated patients)
and are more likely to suffer from low external validity (limited potential for generalizability
of the findings). Some researchers have attempted to go beyond the respective limitations
of correlational field studies and experimental analogue studies by running experimental
field studies (i.e., studies using experimental designs but in real medical settings). However,
such attempts are still scarce and will need to be developed in the future.

Researchers in the field of caregiver-patient communication sometimes lack

consensus regarding the terminology. Very similar but not completely overlapping
constructs (e.g., affiliativeness, warmth, communion, friendliness, immediacy) are typically
used in an interchangeable way, which makes comparisons between studies difficult. Also,
the same constructs are not always operationalized in the same way by different
researchers. Some attempts have been made to put order in the field, such as proposing to
apply the principle of the interpersonal theory to the field of caregiver-patient interaction
and to organize past research along two main dimensions: the dimension of affiliation
(which encompasses all verbal and nonverbal behaviors going from extremely hostile to
extremely friendly) and the dimension of control (which encompasses all verbal and
nonverbal behaviors going from extremely submissive to extremely dominant). Future will
tell us if such organizing framework and terminology will actually be adopted by researchers
in the field.

The field of caregiver-patient communication is sometimes criticized for not building

or relying enough on theory. Initiators of the criticism point out that few theories exist in the
field, and indeed ‒ with a few exceptions such as the typology of physician-patient
relationships or the E4 model for physician-patient communication ‒ very little theories exist
that were built in the field and exclusively focus on caregiver-patient interactions. Many
 theories exist within the broader field of communication (e.g., the parallel process model of
nonverbal communication, the equilibrium theory, the discrepancy arousal theory, the
interaction adaptation theory), but they are sometimes too general for making predictions
within the specific context of caregiver-patient interactions.

Despite those current limitations, the study of nonverbal communication in

healthcare settings has considerably enriched the domain of caregiver-patient interactions.
We now have evidence that nonverbal behavior plays a key role during medical and
psychotherapeutic interviews. As research shows, enhancing caregivers’ nonverbal
communication and gaining knowledge about both caregivers’ and patients’ nonverbal cues
can enhance the quality of care as a whole.

Gaëtan Cousin & Marianne Schmid Mast

University of Neuchatel, Switzerland

See Also: Adherence to medical regimens; Doctor-Patient Communication; Interpersonal

Communication Skills; Patient/relationship-centered communication/medicine; Satisfaction
as related to communication

Futher Readings:

Beck, R. S., Daughtridge, R., & Sloane, P. D. (2002). Physician-patient communication in the
primary care office: A systematic review. The Journal of the American Board of Family
Practice, 15, 25-38.

Hall, J. A. (2011). Clinicians’ accuracy in perceiving patients: Its relevance for clinical practice
and a narrative review of methods and correlates. Patient Education and Counseling, 84,
319-324.

Mead, N., & Bower, P. (2002). Patient-centered communication and outcomes in primary
care: A review of the literature. Patient Education and Counseling, 48, 51-61.

Robinson, J. D. (2006). Nonverbal communication and physician-patient interaction. In V.

Manusov & M. L. Patterson (Eds.), The Sage Handbook of Nonverbal Communication.
Thousand Oaks, CA: Sage Publications.

Schmid Mast, M., Hall, J. A., Klöckner, C., & Choi, E. (2008). Physician gender affects how
physician nonverbal behavior is related to patient satisfaction. Medical Care, 46, 1212-1218.

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