What are the four types of communication in nursing?

This article, the third of a six-part series on communication skills, discusses body language and non-verbal communication

Abstract

It is impossible not to communicate in an interaction, and non-verbal communication can sometimes be more powerful than words. Our body language may betray what we really think or feel, but it can also be used as a positive tool by nurses to reinforce the spoken word and help you understand how a patient really feels. This third part in our six-part series on communication looks at verbal and non-verbal communication and their unintended consequences.

Citation: Ali M (2018) Communication skills 3: non-verbal communication. Nursing Times [online]; 114, 2, 41-42.

Author: Moi Ali is a communications consultant; board member of the Scottish Ambulance Service and of the Professional Standards Authority for Health and Care and former vice-president of the Nursing and Midwifery Council.

• This article has been double-blind peer reviewed
• Scroll down to read the article or download a print-friendly PDF here
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• Read Moi Ali’s comment

Introduction

It is impossible not to communicate in an interaction. Even when silent, we transmit messages – deliberately and accidentally. The nurse who stands when a patient enters a room and steps forward with a welcoming smile is in stark contrast to the colleague who remains behind a desk looking at the patient’s notes.

The Nursing and Midwifery Council’s Code (NMC, 2015) identifies non-verbal communication as a tool, stating that nurses should: “use a range of verbal and non-verbal communication methods, and consider cultural sensitivities, to better understand and respond to people’s personal and health needs”.

Verbal communication

Verbal communication includes what we speak or write, and also how something is said: whether the tone or volume matches the message; whether friendly words are said in an irritable pitch or one word or phrase is emphasised above others. Tone, pitch, volume, pauses, fluency and speed of speech consciously or unconsciously add additional meaning to words.

Face-to-face communication involves an interaction between spoken words and body language. The listener ‘decodes’ these, resulting in the receipt of intended and unintended messages. In your interactions, you will ‘read’ patients and interpret what is said and what is meant, in conjunction with body language and other non-verbal signs. Patients in turn will ‘read’ you – consciously or unconsciously.

Non-verbal communication

Non-verbal communication is primarily about body language, but other factors such as the layout or decoration of a room, or someone’s clothing or appearance, can also communicate messages. A warm and restful waiting area communicates a welcoming message; an untidy, uncomfortable reception room may do the opposite.

Body language is a complex interplay of factors including:

• Position: how we position our bodies (folding arms or inclining the head) and where we position ourselves in relation to others;
• Facial expression: smiles, frowns and raised eyebrows;
• Eye contact: whether we look at others, and how we do it (staring; looking away, sideways or over someone’s shoulder);
• Touch: how and where we touch ourselves, others, and objects (spectacles, clothing or pens);
• Physical reactions: perspiring, blushing or breathing rapidly.

Each encounter is unique and the effect of non-verbal communication will be individual to each situation. It may be affected by:

• How one is regarded: people may be more tolerant of negative body language from a person who is seen as brusque than one who is usually kind and helpful;
• The recipient’s sensitivities: some people are more sensitive than others and sensitivities may change according to the situation;
• The situation: there might be greater sensitivity to non-verbal communication in emotionally charged situations, such as in A&E.

Non-verbal communication can:

• Supplement spoken communication;
• Reinforce or substitute a spoken message:
• Undermine communication: for example when non-verbal cues contradict spoken words.

Research has shown a relationship between non-verbal behaviour and patients’ perceptions of clinicians’ empathy. Montague et al (2013) found that eye contact and social touch (a handshake or pat on the back) made patients see health professionals as more empathetic. Other studies have also found that moderate, appropriate eye contact boosted patient ratings of rapport (Harrigan et al, 1985). Montague et al (2013) concluded that clinical environments should be designed to facilitate positive non-verbal interactions such as eye contact and social touch.

Using body language

It is important to understand body language and use it to:

• Aid communication;
• Avoid unconscious messages;
• Decode and react appropriately to other people’s visual cues.

Body language is a positive tool to reinforce the spoken word and can help you to understand how people really feel. A patient who claims to be fine may display body language indicating the opposite, or sit in a way that suggests pain or discomfort. Being alert to body language enables you to probe a little deeper, rather than simply accepting verbal responses at face value. Reading a patient’s body language can be as important as observing clinical symptoms (Box 1).

Box 1. Tips on body language

• Avoid poor posture (slumped shoulders suggest a lack of confidence, which may undermine professional credibility)
• Use positive body language: smiling when greeting someone; and making appropriate eye contact
• Avoid glancing at the clock/your phone or towards the door – it suggests you wish to bring a conversation to an end. If you need to leave, or draw a session to a close, use words: “I’m sorry, but we have run out of time for this week…” (consider setting expectations at the outset: “We need to finish by 2pm today.”)
• Remember, someone biting their lip may be anxious, or just concentrating. Ask open questions to confirm: “How are you feeling?”

Misreading body language

Be aware of misinterpreting body language or relying on it as your sole source of information. Check for disparities between what is said and what you observe. It is important to triangulate information from different sources to form a holistic picture by listening to what patients say and considering what you know about them. Look at clusters or combinations of behaviours rather than a single indicator (Borg, 2013). A sweating patient may be nervous – or just hot or experiencing symptoms of the menopause. It might be safer to conclude it is nerves if the sweating is combined with hand-wringing and poor eye contact.

Cultural differences

How close people stand or sit varies across cultures. Proxemics codifies personal space into distinct ‘distance zones’ depending on the nature of the relationship: intimate, personal, social and public. Commonly we let sexual partners and close friends get closer to us physically than we would allow strangers (although in crowded situations we may tolerate strangers being closer than we would otherwise).

Discomfort occurs when our personal space is ‘invaded,’ or when we feel the distance is inappropriately large. In clinical situations, you may need to enter a patient’s personal or intimate zone, creating discomfort or embarrassment regardless of any cultural differences. Be sensitive to this. Consider acknowledging how normal that feeling is: “No one likes this, but it won’t take long”.

In some cultures, direct eye contact is considered rude; averting the eyes may indicate respect rather than shiftiness or untruthfulness. Some people with conditions such as Asperger’s may find eye contact uncomfortable and will keep their eyes down, or focus on something other than the speaker. Body language may vary across different age groups and according to gender, but basic human emotions tend to share universal facial expressions regardless of culture, age or social class. Consider asking permission before touching a patient, even for task-related touching such as taking blood pressure or pulse.

Conclusion

Non-verbal messages can be more powerful than words. As a nurse, observing patients’ body language can be as important as looking out for clinical symptoms. To be a truly effective communicator, learn how to keep your own body language in check, and how to read patients’ body language (Box 2).

Box 2. Reflection

During your next shift:

• Be conscious of your body language
• Notice how much eye contact you make
• Consider whether this is appropriate
• Reflect on whether you avoid eye contact in some situations (such as when nervous or talking to senior colleagues)
• Consider why and reflect on how you can address this

Key points

• Verbal communication includes the written and spoken word
• Non-verbal communication includes facial expressions, eye contact and posture
• Body language can enhance or detract from communication with patients
• Observing patients’ body language can provide important cues to how they are feeling
• It is important to reflect on verbal and non-verbal communication skills and how these affect relationships with patients

Also in this series

• Communication skills 1: benefits of effective communication for patients
• Communication skills 2: overcoming the barriers to effective communication
• Communication 4: the influence of appearance and environment
• Communication 5: effective listening and observation skills
• Communication skills 6: difficult and challenging conversations

Borg J (2013) Body Language: How to Know What’s Really Being Said. Harlow: Pearson Education.

Harrigan JA et al (1985) Rapport expressed through nonverbal behaviour. Journal of Nonverbal Behavior; 9: 2, 95-110.

Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives.

Montague E et al (2013) Nonverbal interpersonal interactions in clinical encounters and patient perceptions of empathy. Journal of Participatory Medicine; 14: 5, e33.

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