Review
Association between nonverbal communication during clinical interactions and outcomes: A systematic review and meta-analysis

https://doi.org/10.1016/j.pec.2011.07.006Get rights and content

Abstract

Objective

To conduct a systematic review and meta-analysis of studies reporting associations between patients’ and clinicians’ nonverbal communication during real clinical interactions and clinically relevant outcomes.

Methods

We searched 10 electronic databases, reference lists, and expert contacts for English-language studies examining associations between nonverbal communication measured through direct observation and either clinician or patient outcomes in adults. Data were systematically extracted and random effects meta-analyses were performed.

Results

26 observational studies met inclusion criteria. Meta-analysis was performed for patient satisfaction, which was assessed in 65% of studies. Mental and physical health status were evaluated in 23% and 19% of included studies, respectively. Both clinician warmth and clinician listening were associated with greater patient satisfaction (p < 0.001 both). Physician negativity was not related to patient satisfaction (p = 0.505), but greater nurse negativity was associated with less patient satisfaction (p < 0.001). Substantial differences in study design and nonverbal measures existed across studies.

Conclusion

Greater clinician warmth, less nurse negativity, and greater clinician listening were associated with greater patient satisfaction. Additional studies are needed to evaluate the impact of nonverbal communication on patients’ mental and physical health.

Practice implications

Communication-based interventions that target clinician warmth and listening and nurse negativity may lead to greater patient satisfaction.

Introduction

Clinicians increasingly use telephone and electronic communication to provide care, but communication during face-to-face interactions remains a central component of patient-centered care and has been shown to influence clinically relevant outcomes in a variety of settings [1], [2], [3]. Most research on the links between communication and outcomes has focused on verbal communication. However, a large body of research has shown that nonverbal communication also plays a central role in face-to-face human interactions and is especially important for conveying emotional and relational information [4], [5]. Largely because of this research, nonverbal communication is considered an important component of face-to-face clinical interactions [6], [7], but whether nonverbal communication influences outcomes subsequent to interactions remains poorly understood [8]. Better understanding of the association between nonverbal communication and clinically relevant outcomes (e.g., patient satisfaction, adherence, and health status) is important for designing interventions to improve patients’ and clinicians’ communication skills and to promote patient-centered care [8].

Unfortunately, evaluating the links between nonverbal communication and clinically relevant outcomes is difficult for several reasons. The criterion standard for evaluating nonverbal communication is direct observation of clinical interactions (e.g., video recordings or real time observation), which is often intrusive and resource intensive [9], [10]. Potential causal pathways linking nonverbal communication and clinically relevant outcomes are also difficult to determine. For example, patients’ nonverbal communication can both influence and be influenced by the patient's health status, perceptions of the clinician, and the clinician's communication behaviors [11]. Similarly, a clinician's nonverbal communication may reflect not only a patient's health and the topic being discussed, but also the clinician's perceptions of the patient and the patient's communication behaviors [12], [13], [14], [15]. Therefore, associations between nonverbal communication and clinically relevant outcomes may reflect confounding by participants’ characteristics, perceptions, or contextual factors. Studying nonverbal communication is also difficult because many aspects of nonverbal communication, such as changes in voice tone and body language, often take place without participants’ explicit awareness [16]. Finally, research studies often evaluate nonverbal and verbal communication separately, but verbal and nonverbal communication typically occur simultaneously and are interpreted together during face-to-face interactions [11], [17].

For all these reasons, studies of nonverbal communication in clinical interactions have often focused on controlled settings (e.g., interactions involving trainees or actors) rather than on natural settings with real clinicians and patients. Findings from these studies have generally confirmed that nonverbal communication plays a central role in conveying emotional and relational information during clinical interactions [18], [19], [20]. These studies have made important contributions to our understanding of nonverbal communication in clinical settings, but interactions involving research participants, students, and actors differ in many important ways from interactions involving real clinicians and patients [21], [22], [23], [24]. For example, frequent eye contact between standardized patients and physician trainees has been shown to improve standardized patient satisfaction ratings [25], but these findings may not generalize to real clinical interactions. Thus important questions remain about whether and how patients’ and clinicians’ nonverbal communication during clinical interactions is related to clinically relevant outcomes.

We conducted a systematic review and meta-analysis of studies reporting associations between patients’ and/or clinicians’ nonverbal communication during real clinical interactions and clinically relevant outcomes. We had no a priori hypotheses about expected findings. Our goals were to evaluate the published research linking nonverbal communication and these outcomes and to identify any consistent associations with relevance for clinical practice.

Section snippets

Data source and searches

We searched the following databases: Ovid MEDLINE, CINAHL, PsycINFO, ISI Web of Science, SCOPUS, Anthropology Plus, Communication & Mass Media Complete, EMBASE, ProQuest Dissertations & Theses, and ERIC. A review protocol was not specified in advance. Working with experienced research librarians, we compiled an exhaustive list of nonverbal communication terms from the existing literature (e.g., nonverbal communication, facial expression) and cross-referenced them with terms indicating

Results

The database search retrieved 6536 articles. Of these, 6269 were excluded after reviewing article titles and another 210 were excluded after reviewing article abstracts. After reviewing the remaining 51 English-language publications in full, 26 studies met our inclusion criteria. Fig. 1 summarizes the study selection process. Included studies (23 cohort studies and 3 case-control studies) are described in Table 2. Most studies were conducted in the United States (77%) and in primary care

Discussion

Only 26 studies met inclusion criteria for our review, compared to the wealth of published studies of nonverbal communication in laboratory, simulated, and non-clinical settings. In meta-analysis, overall ratings of clinician warmth were associated with higher patient satisfaction scores, with a small-to-moderate effect size (r = 0.3). This association was relatively consistent across studies measuring tone of voice [26], [45], global affect [50], and body language [49]. Ratings of clinician

Conflicts of interest

The authors have no conflicts of interest to declare regarding this study.

Acknowledgements

The authors wish to thank Deborah L. Lauseng, AMLS and Mark P. MacEachern, MLIS of the A. Alfred Taubman Health Sciences Library, University of Michigan for their assistance developing and conducting database searches for this review. They also wish to acknowledge Terrance L. Albrecht, PhD and colleagues at the University of Michigan for helpful advice on earlier versions of this manuscript, and Joseph Jasperse for editorial assistance. Dr Henry is supported by the Department of Veterans Affairs

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