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ch apte r Body Language and Nonverbal Communication 1 Learning Outcomes After reading this chapter, you should be able to: 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Key Terms Adornment Atmosphere for communication Behavioral observation Boundaries Chronemics Cultural sensitivity Haptics Ideal communication model Kinesics Locomotion Neutral position of behavior Nonverbal behavior Nonverbal language Nonverbal message Oculesics Olfactics Posture Proxemics Silence Sound Symbols Vocalics Define nonverbal behaviors. Recognize the effect on communication of using nonverbal language. Illustrate several nonverbal behaviors and interpret a patient’s nonverbal message. Assess the message you are sending in nonverbal communication. List the components of the ideal communication model. Utilize the correct boundaries between patient and professional, especially where gender differences exist. Explain sensitivity to cultural issues in communication. 3


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4 Chapter 1 Body Language and Nonverbal Communication Introduction What you know is important, but deciding what and how to share this knowledge is just as essential to your success as a health professional. The basic elements of communication are that there is a message, a sender, and a receiver. The message that needs to be sent (e.g., “You must get at least 30 minutes of aerobic exercise three times a week if you hope to prevent or delay cardiovascular disease”) is an example of your professional knowledge. Your role as a health professional makes you the appropriate sender of that message (e.g., “I want to speak with you about an important matter as your [dietitian, nurse, physical therapist, sports medicine consultant, medical assistant, doctor] as there are preventive health strategies that will be very helpful to you.” You then focus on the receiver to determine what may affect his or her ability to hear your message, such as cultural and age issues. Remember that messages may be sent in many ways, such as verbally, nonverbally, and in various written and electronic formats by the health care worker. Nonverbal skills are essential to being sensitive and effective and well received by the client. This chapter helps you to focus on the nonverbal messages that augment those that are spoken or delivered face-to-face. Often nonverbal messages are made instinctively or unconsciously and deliver their own strong message. In the context of a professional setting, you must become aware of the messages you are sending nonverbally as well as those you are observing. Nonverbal Behaviors Throughout the day you witness many behaviors. But few people put their observations to use. Have you ever worked with someone who seemed so good at understanding others and predicting their behavior that you thought they might be psychic? Chances are they just use their observational skills more intensely than most people. Observing body language is a valuable skill, especially for those in the helping professions. What is worn is also important in nonverbal communications because attire sends a message of its own. Have you ever noticed someone who wears a white lab coat all the time? What might be learned from this observation? When someone wears a lab coat, whether or not he or she is in the lab or treating a patient, it can safely be assumed that there is some meaning to this behavior. Perhaps the person has a busy schedule and no time to change out of the coat between jobs. Perhaps the person is selfconscious about his or her wardrobe and uses the coat to hide his or her clothing. Or perhaps the white lab coat has become a strong part of that individual’s identity; that is, he or she wishes to be set apart from others and enjoy the visible recognition of being seen as a health professional. This latter possibility has a definition as a defense mechanism called identification which will be studied in a later chapter. The important thing to note here is that you might easily misinterpret the meaning of the lab


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Nonverbal Language and Communication 5 coat if you do not ask. But be sure, if someone is engaged in a non-neutral behavior such as constantly wearing a lab coat, then there is some meaning there. What a person wears is just one example of nonverbal behavior. As health care providers you must be careful in your interpretations. You must learn to recognize universal neutral behaviors and to use this information to better understand your patients. A neutral position of behavior is the body’s natural position. A neutral position is having your hands relaxed at your sides; other positions are purposeful and have some meaning. Dressing “as others do” is also neutral. ✱ Key Points Nonverbal behavior or kinesics using observational skills or reading body language to understand a patient’s underlying feelings. Neutral position of behavior the body’s natural position. Hands relaxed at sides is a neutral position; other positions are purposeful and have some meaning. Nonverbal language composite of eye contact, facial expressions, appearance, posture and proximity. Components of Nonverbal Language The main components of nonverbal language are listed as follows. • Kinesics: Body motions such as shrugs, foot tapping, drumming fingers, clicking pens, winking, facial expressions, and gestures • Proxemics (proximity): Use of space to make contact or to provide privacy • Haptics: Touch • Oculesics: Eye contact • Chronemics: Use of time; pausing, waiting, speeding up • Olfactics: Smell • Adornment: Dress, cleanliness, jewelry, tattoos, piercings • Posture: Body position, stance • Locomotion: Walking, jumping, swaying, and moving with a wheelchair • Sound Symbols: Grunting, ahs, pointed throat clearing • Silence: Long pauses, withholding information, secrecy • Vocalics: Tone, timbre, volume Throughout this chapter, please refer back to this list as you learn to list examples of how nonverbal language is recognized and what effect it has on communication. Nonverbal Language and Communication In a classroom or hospital setting, you can learn a great deal about others simply by observing them. You will note that some people sit with their backs straight whereas others sit with their feet up on the chair in front of them; some sit close together while others seem to place themselves apart. Look around the classroom. Do you see students twisting hair or fidgeting with a pen or doodling? Perhaps you interpret these behaviors as reflections of what is going on inside these individuals. Many people reveal more through their facial expressions (part of kinesics) than they may wish to convey. They may sit alone and frown at what appears to be nothing at all; others may exhibit a faint pleasant smile or offer a nearly vacant blank stare. Just by observations you can begin to formulate opinions about others and react according to your impressions.


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6 Chapter 1 Body Language and Nonverbal Communication CASE STUDY 1-1 Two friends, a man and a woman, annually attended tournament games for which all attendees purchased tickets for two games on one night and one game on a subsequent day as a package. This meant that some fans at the end of the first game would know their team was out of the play and they would no longer be interested in staying around for the second or the final game. When their team was not playing in the first game, these friends would wait near the sections containing the preferred seats in which the losing team’s fans were seated and approach them as they walked out, hoping to receive their seats for the remaining games. The woman always wore an expression of great sympathy and concern, but year after year she rarely received better seats. Her male friend, however, always upgraded his seat and usually had tickets to share with her and others they knew. Finally, the woman observed him in action and noticed that he approached each group with a kind smile on his face. Although some folks rebuffed him, most would stop and talk and invariably pass on their tickets. At the following tournament she approached the fans with a smile and her luck changed. A warm and engaging smile appeals to those he approaches. Observe two strangers from a distance. Jot down the behaviors you see. Guess at what may be communicated between or among them. Bring these notes to class for possible class discussion of what their behaviors may mean, describing one or more possible explanations or interpretations. Once individuals begin to interact, verbal behaviors and mannerisms such as nail biting, pen flicking, and hair tossing enter the picture. For example, without examining content, what would you think of an individual whose speech was rapid and who twisted around in his or her seat throughout your interaction? Vocalics and sound symbols refer to the pitch of a voice. Whereas a certain pitch may be pleasant to some ears, for others it will be difficult to detect. If you speak too rapidly or stumble with frequent “ahs,” you may be hard to follow. When you think of the voices you enjoy in the broadcasting business, there are qualities and variations of tone. Certainly no one likes to hear a lecturer speak in a monotone unless he or she needs a nap! Training your voice to exude the feelings needed for the situation is part of a professional image. The sounds you make can convey confidence and warmth or frustration and fear. Discuss this response with your classmates: CASE STUDY 1-2 Margie was a shy 14-year-old with a bad knee injury when she entered the physical therapy clinic. Her physical therapist was a hardworking and dedicated fellow about her dad’s age named Jim. Jim was often anxious when faced with a new case because he wanted to do his best for every patient. His anxiety manifested itself in a chronic throat-clearing tic. When he first met Margie, he began clearing his throat and continued to do so every few minutes throughout their 30-minute session. Margie had her mother call the clinic the next day and ask for a different therapist. What do you think happened? Margie, being shy, felt embarrassed every time Jim cleared his throat. She believed it called attention to her and to her problem. She couldn’t bear having people look over every time Jim made that noise. They were not well-suited to working together.


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Nonverbal Behavior and Interpretation 7 A relaxed, steady gaze If you have a nervous condition, then you may need to work on it in order to avoid conflict for you in a professional setting. In most cases, however, vocalics simply refers to changeable habits or vocal qualities that skill and practice will allow you to correct. The use of oculesics (eye contact) differs among cultures, but for the moment we will focus on what is typical for most Americans and later look more thoughtfully at cultural considerations. Certainly, all body cues need to be interpreted with a view toward the receiver’s ethnic background. Typically, a relaxed yet steady gaze is ideal eye contact unless cultural information leads you to a different approach. Contrast a conversation with ideal eye contact with a conversation (same words) in which the speaker stares at the floor. Try this to exemplify the point: Client [staring at the floor] “I stopped taking my medication over the weekend.” Now the same client states those words while making direct eye contact. In the first version you would instantly suspect a problem, but in the second your first thought might be that the client is feeling better. Nonverbal Behavior and Interpretation Unfortunately, you cannot always be sure of what certain behaviors indicate. For example, if you observe patient X sitting with her arms folded across her chest, you must take care not to misinterpret her position. Perhaps she wants to protect herself from others, is hugging herself as a form of comfort, is self-conscious about her figure, or is simply cold and trying to warm up. Or, you might leave a party quickly because your beeper went off. The casual observer might guess you were bored or rude when neither was true. What is your immediate response to the patient with her arms folded? Can you think of several other explanations?


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8 Chapter 1 Body Language and Nonverbal Communication If you are working with someone and wish to understand what they are communicating nonverbally, you must first take in the observation. Then you must follow your observation up with a question about what this behavior means to the individual. For example, you might say, “I see you’ve turned away from me and your arms are folded across your chest.” You could follow that observation with one of the following comments: “I’m wondering what that means to you.” or “I guess you’re feeling a little alone and frightened.” Either of these responses may be correct. The second, however, is recommended only if you have already established a rapport with the client. Otherwise you risk losing the client by labeling his or her feeling too quickly or inappropriately. Remember, first you make a strictly behavioral observation (nonjudgmental) such as “I see your arms are folded across your chest.” Then you want to identify accurately what this non-neutral behavior means to the client. This type of reflection is very helpful in a clinical setting when you are first meeting a new patient. Another benefit to making these observations in communication relates to conflicting messages. Often a patient will verbalize one message while indicating the opposite with his body. For example, a person may smile broadly while telling you how afraid he is of returning to work following a heart attack. By reflecting this obvious conflict back to the patient, you will be better able to appreciate what he is actually feeling. Hostile teen “What does it mean to you when you are smiling while talking about your heart attack?” “I wonder if you are smiling because that helps mask how frightened you really are.” ✱ Key Point Behavioral observation studying the patient’s kinesics, specifically, oculesics, facial expressions, appearance, posture, and proxemics. Behavioral observation may also be the only tool you have for communicating with patients who are speech impaired or are unwilling to speak (silence). If the patient can hear and speaks a language you know, you may respond to them simply by reflecting what you see. For example, an adolescent may sit grimly and silently in the health professional’s office after being dragged in by a parent. The health professional may find that the adolescent meets most verbal approaches with more silent resistance. But, if the following approach is used, the patient may decide to talk simply because someone has conveyed understanding. “You’ve been sitting on my couch for nearly 20 minutes now without saying a word. You’ve kept your eyes on your hands, and your whole body is leaning forward. I’m getting the message that you don’t want to speak with me.” or


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Assessing Nonverbal Communication 9 “You haven’t spoken in 20 minutes and you won’t even look at me. Perhaps you are angry with your mother for bringing you here. If I were you, I’d probably feel the same way.” Again, the second approach involves some risk because it brings in more feelings. You should use feeling words with patients only when you are confident that you understand the emotional issues involved. How and when to use feelings is discussed in more detail in the section on empathy in Chapter 2. Now that you have begun to see the value of body language in understanding others, you should also look at the messages you may be sending. Assessing Nonverbal Communication Perhaps the most obvious nonverbal message you send is your appearance, which includes adornment such as clothing, jewelry, tattoos, piercings, and hairstyles. To fit in as an entry-level health professional, you may want to begin by playing the role of the health professional complete with “costume.” If professionals in your field generally wear white lab coats, uniforms, or tailored suits, you would do well to dress as they do, at least until you have Woman listening established yourself professionally. Typically, jewelry should be modest in size and not detract from the health professional’s message. Hairstyle and clothing should also fit the image of the professional. Many health facilities ask that piercing jewelry beyond a few modest earrings be removed when an individual is at work, although exceptions may be made if the clients being served are likely to be similarly adorned. Typically, it is also appropriate to keep tattoos hidden from view while at work. All these examples are subjective, and some health care employees choose to assert their individuality by persons of either gender keeping a nose stud or a male wearing a long ponytail, both of which may be a topic of negotiation within the workplace. However, one study found that patients want their health professionals to be dressed formally, not in blue jeans or sandals, as a carefully dressed provider may convey that he or she is meticulous and careful in practice. Good hygiene—a clean body and neat, clean clothing—coupled with a pleasant or benign odor is ideal. Heavy perfumes or aftershaves are inappropriate in a work setting. If oral disease or spicy foods make others back away from you, you will suffer for it professionally. These examples are grouped under the classification of olfactics, which relate to the way humans smell; in a professional setting, a neutral or nondetectable odor is recommended. Your sense of smell may also assist you clinically: If you smell sugary/fruity breath on a patient, he or she may be having trouble controlling their diabetes, or if you smell urine or alcohol, he or she may be homeless or exhibiting a drug problem. The nose gives health professionals another cue to focus in on with patients. ✱ Key Point Nonverbal message: communicating without using language. The most powerful way of communicating with patients. A relaxed yet steady gaze is generally ideal eye contact in the United States. Facial expression and professional appearance and adornment are key to sending the correct message. Adopt a relaxed posture with hands relaxed.


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10 Chapter 1 Body Language and Nonverbal Communication A less obvious consideration is your own facial expression. Just as you formulate a subliminal or unconscious opinion of another from his or her facial expression, others are responding to your facial expression as well. Few people realize how they look in random or candid moments. Generally, one prepares the face subconsciously for a moment before looking into a mirror. Shock may occur when viewing a photograph taken during an unexpected moment. Try to observe objectively what you see in such candid shots of yourself. Sometimes, because of chronic pain or worry, an individual carries a sad or sour face into the world even long after those difficulties have been resolved. Others may look tough and unapproachable even though they are warm and friendly. Your colleagues and patients will observe you beyond the time you spend directly with them. They may form an opinion of you simply by observing how you walk down a hallway (locomotion). Try to get an objective analysis of your candid, off-guard expression, and train your face to change slightly if a problem is evident. Videotaping can be especially valuable, particularly if you record yourself interviewing another person. Just as the man with the smiling face got the positive response in the earlier example, so will the health professional who smiles on the job, but instead of tickets, positive patient interactions will be the reward. CASE STUDY 1-3 Two medical technologists (MTs) graduated from college together in a large midwestern city. Because they were friends, they applied to the same major metropolitan hospital for jobs, and both were hired with the same job title and salary. Both were young men of the same age and ethnic background. Both occasionally had a problem drawing blood from a patient. One man became quite agitated with himself when the draw did not go right, and this frequently resulted in a second missed attempt or in the patient refusing to let the MT try again. But the other MT would smile warmly at his patients, apologize for any inconvenience, and then calmly, and nearly always successfully, complete the second blood drawing. Obviously the effect demonstrated by the smile and warm response of the second MT made a difference to the patients observing him. After a year of work the second MT received a raise and promotion that his friend did not. The kind of body language that makes you comfortable with others makes others comfortable with you. If you want to encourage your patients to talk openly, then you must offer open, approachable nonverbal as well as verbal cues. The rushed and tense health practitioner, an attitude perhaps conveyed through rapid speech (chronemics), does not stimulate dialogue nor does she or he escape detection. Recognizing the patient’s nonverbal messages isn’t enough; you must send the right nonverbal messages yourself. Ideal Communication Environment To review, you will have noted that health care providers must take responsibility for sending out appropriate messages regarding their desire to interact with the patient. Through their behavior, they convey the following traits to patients:


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Ideal Communication Environment 11 • Friendliness • Confidence • Professionalism Further, health professionals must develop highly attuned observational skills and learn by observing the patient. They use their observations to better establish rapport and to better understand patient problems and conflicts by appropriately reflecting them back to the patient. The next aspect of nonverbal communication training entails creating the best atmosphere for communication to take place. A lot of this involves proxemics. Health practitioners and patients should not be separated by great distances or large barriers such as desks or machines. An arm’s length apart is culturally acceptable in the United States. This distance is close enough for intimate conversations without making most Americans feel Is this woman too close? that their personal space is being violated. Reportedly, the “comfort zone” for standing is 30 inches apart for Americans. Key Points Hospital settings can pose barriers or distractions that are less than ideal. The lack of privacy in most hospital rooms may necessitate some Atmosphere for communicacreative rearranging when professionals need to deal with sensitive question being at the correct tions. The patient’s right and need for privacy can become a major stumdistance from the patient, bling block to communication progress if the health professional does not usually at arms length and take it into account and will lead to problems with HIPAA and accreditawithout barriers. tion as discussed in Chapter 11. No matter what the barriers are, health Proxemics nearness, distance, or position from another. professionals should strive for confidentiality by: ✱ • Not holding discussions in hallways • Closing doors when possible • Gently suggesting that visitors wait outside when you must examine or treat • Pulling drapes around inpatients when a roommate is present during a discussion Patients may need to be touched (haptics). It was believed a few years back that there was an increased rate of healing in those who receive stroking or massaging as part of their treatment compared with those who are not intentionally touched. This may be especially true among elderly patients but also differs widely on the basis of ethnic variables (see the section Cultural Sensitivity in Nonverbal Communication in this chapter). Certainly you want to be close enough to your patients to hold a hand, pat a shoulder, or offer a tissue if emotions are strongly expressed. It is easy to believe that patients who may feel isolated and lonely will respond positively to the familiar yet missed sense of another person’s touch on their arms. In times of psychological stress, a touch may be the only message that penetrates their pain; your hand on a patient’s shoulder could feel like a lifeline. Yet, health professionals are wise to ask before touching a patient who is not well known to them to simply be certain that touching is okay with this person.


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12 Chapter 1 Body Language and Nonverbal Communication Ideal Communication Model ✱ Key Point Establishing the ideal communication model with respect to nonverbal skills and settings involves the following: • A professionally attired health practitioner sits approximately an arm’s length from the patient. • The room is privately occupied for at least the duration of their interaction. • The health professional is relaxed but in an attentive posture. • The health professional’s facial expressions and vocal tone are friendly and interested; eye contact is held throughout most of the interaction. • The health professional focuses attention on the body language of the patient, reflecting out loud any aspects that may seem to contradict what is being said. The health professional reflects back to the patient and interprets any body language that appears to carry a message of its own (such as tightly crossed legs or clenched fists). Ideal communication model professionally attired; arm’s length from the patient; private setting; relaxed, attentive posture; friendly expression and vocalics; holding patient’s gaze; focusing on patient’s body language and reflecting conflict. Correct Boundaries ✱ Key Point Boundaries a mental or physical line delineating territories between two people that cannot be crossed, especially with gender or cultural differences. Gender differences as well as cultural ones are a significant area of concern when you are practicing health care. Note the previous discussion of touching and proximity and the discussion in the section on cultural sensitivity. Boundaries are a concept essential to appropriate health care. Entry-level workers may need supervision to be certain they know the dangers of crossing boundaries. When men treat women or women treat men, it is especially necessary to be careful not to touch too often or perhaps not to touch when you are alone with the patient except as needed to strictly carry out your treatment. Certainly, male gynecologists have traditionally refused to treat their patients if a female assistant, usually a nurse, is not in the room. Not only does this custom add to the comfort of the patient, but it also helps protect the male practitioner from accusations of improprieties. Providers must also be alert that some patients are seductive, needy, or have mental health issues that may cause them all too easily to misinterpret a gesture. Therefore, it is the health care worker’s responsibility to be certain all acts and comments are professional and not easily misunderstood. A later chapter on ethics reviews the boundaries that must be maintained when dealing with any activities outside of the professional setting. It must be mentioned here that the chief concern is to be certain that no health professional becomes involved with a client outside of the professional setting and especially in a manner that could cloud or compromise the client–professional relationship. Certainly there should be no dating of a former patient until at least one year’s time post-professional contact has elapsed or whatever guideline is established by the health provider’s professional organization. Likewise, hiring of patients to provide any contractual service to the health care provider should also be avoided so that no conflicts can emerge. If health care providers stay within their professional boundaries, studies indicate that patient responses to sensitive questions do NOT differ


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Cultural Sensitivity in Nonverbal Communication 13 significantly, irrespective of gender differences between patient and provider. Remember good kinesics: Give positive, self-confident, professional, nonverbal messages to your clients, being especially sensitive to gender or cultural differences. Cultural Sensitivity in Nonverbal Communication The world is frequently described as a “global village,” indicating how much interdependence each country has. With today’s technology and transportation, all but the most remote areas are quickly accessible. Naturally, the more overlap there is among peoples of the world, the more necessary it becomes to find ways of being culturally sensitive to and understanding each other. Not long ago, Americans tended to believe that people from different cultures must adopt American customs and were unwilling to learn anything of foreign peoples residing in the States. But the global marketplace and large increases in immigration have set the stage for Americans, and especially health care workers, to focus on learning about non-native peoples. A discussion of “body language” would not be complete without addressing the many nonverbal customs, signals, and gestures that are part of cross-cultural communication. One caveat at the beginning of this discussion: It is not the authors’ intentions to stereotype along ethnic or cultural lines; certainly there are exceptions to all that is stated. Further, customs and even food preferences are beginning to blur all over the world as markets collide and cross-pollinate. In this section, you will find behaviors that are considered “typical” of a group, and to the extent possible, these behaviors will be contrasted or compared with behaviors of people from different backgrounds. See also Table 1.1 that follows. The following is a brief review of cultural preferences: • The current predominant culture in the U.S.: Haptics—Americans may wish to be touched during difficult times or by close friends but generally stand 30 inches apart. Americans do shake hands. Young Americans do demonstrate affection publicly. Oculesics—Americans are taught to make eye contact. In terms of general kinesics, Americans use hand gestures to indicate “okay,” give “a thumbs up” for a good job, and use head nodding to affirm a speaker’s message. • African Americans: Haptics—African Americans most commonly exhibit behaviors typical of all Americans, but this group tends to touch more, especially around other African Americans. Further, as a group, they stand closer to each other and display more emotion through laughter and touching than is typical of Euro-Americans. In the last chapter of this text the history of mistrust between whites and people of color in this country is reviewed. In this chapter on nonverbal communication, it is essential to mention that distrust is a major barrier to communications between patient and health professional. There are not enough health providers who are people of color, so health providers must find ways to bridge the trust gap, and nonverbal gestures can provide a good foundation. ✱ Key Point Cultural sensitivity learning the differences among a culture’s views of even haptics and oculesics. This will assist cross-cultural communication.


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14 Chapter 1 Body Language and Nonverbal Communication Table 1.1 Generalized Nonverbal Behaviors by Ethnic/Cultural Background Nonverbal Behaviors Non-verbal Behaviors Kinesics (Body motions, gestures) Used to signal; head nods affirm This is a Table Span Head Posture Vocalics (Tone, volume) Wide range varies by gender, age, social situation (Body position, Stance) Wide range; erect posture admired ——— Proxemics (Use of space) 30” apart Chronemics (Time, speed, waiting) Often in a hurry Cultural Background Typical American Haptic (Touch) Generally like touch; shake hands; youth show affection in public Touch more, especially with friends Oculesics (Eye contact) Eye contact expected African American* (Generally Fit as Typical American) Africans ——— ——— More laughter and emotion in talking Stand closer than EuroAmericans Varies More formal; expect respect Quick eye contact Nod heads to show listening Smiling covers many emotions ——— Erect More formal Varies distance until know others ——— ——— Asians Limited touch, both bowing and shaking hands; no public affection; do push in crowds Touch Avoid direct eye contact Never interrupt due to respect Erect and balanced posture valued Filipinos Avoid long gaze Avoid due to respect ——— Laugh masks emotion Observe others ——— ——— ——— Hispanic Enjoy touch Read others Observe others Stand close Anti-rushing • Africans generally behave in a more formal manner, showing politeness with quick eye contact, erect posture, a nod of the head, and careful listening. They may be less interested in touching. When in the States they also expect to be treated with the same courtesy. This will differ somewhat by country and station in life; the more affluent and welleducated Africans tend to be more formal. • Asian cultures (Chinese, Pacific Islanders, Japanese, and Koreans share much of the following): Haptics—Asians are generally not a touchoriented society, although many cultures now use handshaking as well as bowing; public displays of affection are avoided, but pushing in crowds is common. Oculesics—Direct eye contact is typically avoided. Facial expression—Smiling covers a wide range of emotions, so be certain to reflect back what you see to clarify. Posture—Erect, balanced posture is highly valued. Silence while being spoken to is offered as a


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Cultural Sensitivity in Nonverbal Communication 15 sign of respect; great care is taken not to interrupt. People from Taiwan follow behaviors similar to these but are more likely to use handshaking than any other greeting. • Filipinos: Haptics—The Philippines is generally a touch-oriented society, and people of the same sex often hold hands in public as a sign of friendship. Filipinos commonly shake hands irrespective of gender or may greet each other with a quickly raised eyebrow, the “eyebrow flash” (facial gesture). Oculesics—Prolonged eye contact is avoided as rude. Vocalics such as laughter may be used to mask embarrassment over another person’s difficulties as well as to show joy. • Latino/Hispanic cultures are extremely diverse; therefore, the following generalizations are made only in the interest of providing a guideline. Haptics—This is generally a culture that is comfortable with touching and closeness and requires far less personal space than do EuroAmericans. Men frequently greet each other with hugs and pats on the back. Oculesics—Avoiding eye contact may be a sign of respect. Children are often taught not to make direct eye contact with adults, and this can carry over to the patient-professional relationship. If a patient from a Hispanic culture does not wish to make eye contact with you, do not assume that there is a negative connotation as it may be a sign of respect. Vocalics and chronemics—Hispanics tend to read body language—vocal tone, speed of speech, gestures, and facial expressions plus posture—with great intensity. If you are impatient, for example, this can harm the patient-professional relationship as negative implications may be drawn from your nonverbal language that will indicate that you are rushing. CASE STUDY 1-4 Provider (Anglo-male standing next to a Latina woman seated on an examination table): “Hello Mrs. Sanchez. What can I do for you today?” Patient (spoken while staring at the floor): “I have a pain in my back.” Provider (stepping back from patient and speaking more loudly): “Well, where in your back, how bad is it, and how long have you had it?” Patient (beginning to perspire): “I’m sorry to bother you, but I just bent over in the shower, and now it is hard to straighten up.” Provider (beginning to pace, looking at his watch, and reading some notes on his desk): “Well, let’s have a look at the area.” Patient (shaking and eyes filling with tears): “No, that’s okay; I have to go now.” The class should discuss what was happening here and describe alternative ways the health provider might have handled the situation. The topic of cultural diversity is reviewed further in the last chapter of this text. Obviously, volumes can be written about the subject. In this chapter you should gain at least an insight into the necessity of making cultural sensitivity part of your arsenal as a health professional concerned with kinesics and peoples’ health. Just to underscore the diversity of the world, this section closes with an additional cross-cultural gesture: The American signal for “okay” means zero in France; in Japan it means coins


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16 Chapter 1 Body Language and Nonverbal Communication or money; and in Brazil, Germany, and the Commonwealth of Independent States it is an obscene gesture. Sensitivity and care will help improve our nonverbal communications with patients from different backgrounds and help avoid potentially dangerous miscommunications. Summary Nonverbal communication skills serve the health professional well as you learn to observe and interpret the behavior of others. That which is non-neutral has some meaning. When nonverbal behavior contradicts verbal behavior, your attention must be focused there. Nonverbal interpretations also help you in establishing communication with those who cannot or will not talk. The nonverbal is often more revealing than the spoken word. The key elements of nonverbal language are kinesics, proxemics, haptics, oculesics, chronemics, olfactics, appearance and adornment, posture, locomotion, sound symbols, silence, and vocalics. You must be aware of what specific physical positions, such as encountering a patient with arms crossed who is staring at the floor, might mean. You must always check your perceptions rather than assuming the meaning of nonverbal behavior, especially when cultural differences may exist. Good observational skills are an important component of the nonverbal process. As health providers, you must cultivate the message you wish to send nonverbally. The right attire, good hygiene, and attention to body language are essential to success. You want to appear open, interested, and approachable. Facial expressions and proximity are significant, as is vocal usage. How you use your voice can significantly alter the way your message is received. Focusing on specific behaviors in a nonjudgmental way can be a primary communication tool for the health professional. The ideal model for nonverbal communication is reviewed as follows along with suggestions of behaviors to avoid. Ideal Communication Style • • • • • • • • • • • • Facing patient/client, holding gaze Arms at sides or gently folded Legs upright or gently crossed Posture erect but not rigid Distance of approximately one arm’s length between professional and patient/ client No barriers between health practitioner and patient/client Professional attire Good hygiene Facial expression relaxed or matching that of patient/client Vocal tone moderate and clear Providing privacy whenever possible Demonstrating gender and cultural sensitivity Communication Pitfalls • Poor hygiene • Inappropriate attire • Too relaxed or rigid posture



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