Educational/Counseling Model Health Care
Exploring physicians’ verbal and nonverbal responses to cues/concerns: Learning from incongruent communication

https://doi.org/10.1016/j.pec.2017.06.027Get rights and content

Highlights

  • VR-CoDES and NDEPT are used to code verbal and nonverbal emotional communication.

  • Consultations ‘Congruent’ and ‘Incongruent’ in verbal and nonverbal aspects are identified.

  • One type of ‘Incongruent’ consultation occurs when patients needs are hard to meet.

  • Patients perceptions of ‘Incongruent’ consultations may depend on their needs.

Abstract

Objectives

Explore physicians’ verbal and nonverbal responses to cues/concerns in consultations with older-patients.

Methods

Two teams independently coded a sample of Norwegian consultations (n = 24) on verbal and nonverbal dimensions of communication using VR-CoDES and NDEPT instruments. Consultations exploring older-patients’ verbal emotional expressions were labeled ‘Acknowledging of patients’ emotional expressions’, and ‘Distancing from patients’ emotional expressions.’ Based on type and extent of nonverbal expressiveness, consultations were labeled ‘Affective’ and ‘Prescriptive.’ Congruency of verbal and nonverbal communication was assessed and categorized into four types. Incongruent consultations were qualitatively analyzed.

Results

Types 1 and 2 consultations were described as ‘Congruent,’ i.e. both verbal and nonverbal behaviors facilitate or inhibit emotional expressions. Types 3 and 4 were considered ‘Incongruent,’ i.e. verbal inhibits, but nonverbal facilitates emotional expressions or vice versa. Type 3 incongruent encounters occurred most often when it was challenging to meet patients’ needs.

Conclusions

Frequently physicians’ display incongruent behavior in challenging situations. Older patients’ may perceive this as either alleviating or increasing distress, depending on their needs.

Practice implications

Type 3 consultations may shed light on reasons for physicians’ incongruent behavior; therefore, independent measurement and analyses of verbal and nonverbal communication are recommended. Older-patients’ perceptions of incongruent communication should be further explored.

Introduction

With the rapid growth of the older population, person-centered care (PCC) has become a priority around the globe [1], [2], [3]. Older-patients often present with complex healthcare needs, visual and hearing challenges, and/or cognitive impairments. As such, they present challenges on several fronts for providers trying to offer PCC. PCC itself is a complex multidimensional concept [4], with many definitions [5], aiming to develop a “comprehensive picture of the patient” [6]. A recent conceptualization of PCC emphasizes two simultaneous needs of patients: (1) to “know and understand” (“What is the problem?” and “How can it be taken care of”) and (2), to “feel known and understood” (seeking socio-emotional support) [7]. These needs expressed in clinical consultations often manifest as emotional expressions in the form of cues or concerns, implying their importance to patients. The Verona Coding Definitions of Cues and Concerns (VR-CoDES), developed to identify these moments [8], has been validated to capture patientś perspectives in consultations [9]. Cues are defined as “verbal or nonverbal hints which suggest an underlying unpleasant emotion that would need clarification from health provider;” and, Concerns constitute “a clear and unambiguous expression of an unpleasant current or recent emotion”[10].

A number of recent studies have focused on examining the verbal aspects of providers’ responses (PR) to patients’ cues/concerns and their need for feeling understood [11], [12], [13]. Sundler et al. [14] showed focusing on instrumental tasks in home-care settings made patients’ disclosures of emotional expressions more challenging. Hafskjold et al. [15] found that expressions of worries captured many aspects of what is known to challenge successful aging and suggested that allowing nurse-assistants time for psychosocial talk would improve quality of life in homecare settings; (see also, Street et al., [16]). These studies [11], [12], [13], [14], [15] underscore the increasing importance of examining providers’ verbal responses, especially to older-patients’ cues/concerns.

On the other hand, the importance of nonverbal behavior for expressing socio-emotional aspects in clinical communication has been emphasized by many researchers [17], [18], [19], [20], [21], [22], [23], [24], [25], [26]. In a recent systematic review of nonverbal expressions of empathy in cross-cultural clinical settings, Lorie et al. [27] found that “nonverbal communication plays a significant role in fostering trusting provider-patient relationships and is critical to high quality care.” Other studies have focused on specific nonverbal dimensions and shown eye contact and social touch to be significantly related to patient perceptions of clinical empathy [28]. Further, Gorawara-Bhat et al. [29], [30] showed the salience of “looking” and “listening” in patient-centered communication, and highlighted the need for studying the conjoint unfolding of both verbal and nonverbal aspects—“looking,” “listening” (nonverbal) and “talking” (verbal)—of communication [31].

From older-patients’ perspectives, both verbal and nonverbal behaviors are imperative for understanding the gestalt of cues/concerns and providers’ responses to them. To the best of our knowledge, the processes of simultaneous unfolding of verbal and nonverbal behaviors over the duration of consultations have yet to be fully explored. The present study explores how physicians and older-patients (>65 years) communicate through verbal and nonverbal channels simultaneously. The point of departure for the present research is to understand the processes and conditions under which patient emotions, expressed through both verbal and nonverbal cues/concerns, elicit different types of verbal and nonverbal physician responses.

This study is part of an international project to promote the quality of healthcare communication with home-dwelling older-people in Norway, Sweden and The Netherlands to be more person-centered [32]. Specifically, the aims are to:

  • 1)

    Identify emergent cues/concerns and physicians’ verbal and nonverbal responses to them

  • 2)

    Overlay and describe physicians’ verbal and nonverbal communication to assess consultations

  • 3)

    Analyze qualitatively specific consultations and their implications

Section snippets

Overview

This secondary analysis of videotaped clinic and in-patient encounters in a large Norwegian teaching hospital highlights verbal and nonverbal aspects, and the ways in which they conflate to constitute the totality of communication. Two research teams independently coded verbal and nonverbal dimensions (henceforth Verbal and Nonverbal teams). The Verbal team (LH and HE) are native Norwegian speakers (also the spoken language of physicians and older-patients). The Nonverbal team (RGB and

Demographics characteristics

Demographic data (Table 3) indicate two-thirds of patients were male; and their age ranged from 65 to over 85 years, with the majority in the 75–84 age range. Physicians were equally split between male and female, and mainly in the 31–40 age range. Major specialties represented were Neurology and Cardiology. Most consultations were dyadic, with an average duration of 18:55 min.

Verbal dimensions

Table 1 indicates physicians initiated about twice the cues/concerns compared to patients (65% versus 35%), and, PR were

Discussion

The following sections discuss ways in which congruent and incongruent communication unfolds in consultations, and how older-patients may perceive such communication.

Conflicts of interest

None.

Acknowledgements

Grant support for this study and the larger research project was provided by the Norwegian Research Council Grant no. 226537 (H Eide). Research assistance support (for RGB) was provided by The Section of Geriatrics and Palliative Medicine in The Department of Medicine at the University of Chicago, Chicago, Illinois, USA. The funding sources had no direct input into any of the research processes and investigators retained full independence in the conduct of this research. Shrikant P. Bhat and

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