- Research article
- Open access
- Published: 03 July 2018
Verbal and non-verbal communication skills including empathy during history taking of undergraduate medical students
- Daniela Vogel 1 ,
- Marco Meyer 1 &
- Sigrid Harendza 1
BMC Medical Education volume 18 , Article number: 157 ( 2018 ) Cite this article
Verbal and non-verbal aspects of communication as well as empathy are known to have an important impact on the medical encounter. The aim of the study was to analyze how well final year undergraduate medical students use skills of verbal and non-verbal communication during history-taking and whether these aspects of communication correlate with empathy and gender.
During a three steps performance assessment simulating the first day of a resident 30 medical final year students took histories of five simulated patients resulting in 150 videos of physician-patient encounters. These videos were analyzed by external rating with a newly developed observation scale for the verbal and non-verbal communication and with the validated CARE-questionnaire for empathy. One-way ANOVA, t-tests and bivariate correlations were used for statistical analyses.
Female students showed signicantly higher scores for verbal communication in the case of a female patient with abdominal pain ( p < 0.05), while male students started the conversations significantly more often with an open question ( p < 0.05) and interrupted the patients significantly later in two cases than female students ( p < 0.05). The number of W-questions asked by all students was significantly higher in the case of the female patient with abdominal pain ( p < 0.05) and this patient was interrupted after the beginning of the interview significantly earlier than the patients in the other four cases ( p < 0.001). Female students reached significantly higher scores for non-verbal communication in two cases ( p < 0.05) and showed significantly more empathy than male students in the case of the female patient with abdominal pain ( p < 0.05). In general, non-verbal communication correlated significantly with verbal communication and with empathy while verbal communication showed no significant correlation with empathy.
Undergraduate medical students display differentiated communication behaviour with respect to verbal and non-verbal aspects of communication and empathy in a performance assessment and special differences could be detected between male and female students. These results suggest that explicit communication training and feedback might be necessary to raise students’ awareness for the different aspects of communication and their interaction.
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Verbal as well as non-verbal communication and empathy play an important role in patient-physician encounters. Affiliative styles of communication were shown to be positively related to patients’ satisfaction with a physician while a negative association of patients’ satisfaction with a physician correlated with dominant/active communication styles [ 1 , 2 ]. An affiliative style of communication reduced patients’ anxiety and facilitated their openness whereas a dominant/active communication style displayed reprimanding or condescending features, which resulted in reduced patient disclosure and compliance [ 1 ]. A physician’s communication style seems to be very important for the first encounter with a new patient, because patients build their first impression of a physician by a strong focus on his or her communication style [ 1 ]. Furthermore, patients’ outcomes are congruently associated with their feelings about aspects of communication after the consultation with a physician [ 3 , 4 , 5 ]. In patient-physician communication, a patient-centred approach is crucial which includes five aspects: a biopsychosocial perspective, the ‘patient-as-person’, sharing power and responsibility, therapeutic alliance, and ‘doctor-as-person’ [ 6 ].
Communication in medical encounters comprises verbal and non-verbal aspects. If these forms of communication are inconsistent or contradictory, the non-verbal messages tend to override the verbal messages [ 7 ]. Mehrabian and Ferris even developed a formula for verbal and non-verbal effects of a message: total impact = .07 verbal + .38 vocal + .55 facial [ 8 ]. For patient-physician encounters, important non-verbal signs by a physician, which influence a patient’s disclosure of history details in a consultation are eye contact, posture, the tone of voice, head nods, gesture, and the postural position [ 9 , 10 , 11 , 12 ]. Relationships could be detected between some of these non-verbal signs, patients’ satisfaction [ 13 , 14 ], physicians’ workload [ 15 ], physicians’ malpractice claim history [ 10 ], patients’ recall of medical information, and compliance with keeping appointments and medical regimens [ 7 , 16 , 17 ]. Furthermore, the position of the patients facing forward to the physician in a 45-degree angle was the best regarding the frequency of eye contact [ 18 ]. Several studies reported a correlation between using records like computer or paper and the loss of eye contact while making notes. This lead to a reduced frequency of asking about psychosocial aspects in a patient’s medical history, a reduced response to emotional aspects provided by the patients, and to a reduced disclosure of history details by the patients [ 19 , 20 , 21 , 22 , 23 ].
Physicians who express empathy in patient encounters by acting in a warm, friendly and reassuring way seem to be more effective in reaching patients’ satisfaction and recovering [ 24 ]. Empathy is of great significance for better healthcare outcomes as part of a warm and friendly communication style [ 25 , 26 , 27 , 28 ]. Communication trainings are an effective teaching method to improve technical communication skills as well as empathy as a communication skill [ 29 , 30 ]. However, the focus of communication trainings for undergraduate medical students is often on particular aspects of communication, e.g. informed consent or breaking bad news [ 31 , 32 ]. Whether medical students are able to pay attention to all aspects of adequate and patient-centred communication in complex situations they will encounter in their future workplace is not known. Furthermore, gender has been reported to have an effect on patient-physician communication. Female physicians showed greater engagement in patient-centered communication and their consultation times were longer [ 33 , 34 ]. On the Jefferson Scale of Physician Empathy, female medical students scored significantly higher than male medical students [ 35 ]. The aim of our study was to analyze, whether and how well final year undergraduate medical students use skills of verbal and non-verbal communication during history taking and whether a correlation can be found with the empathy shown towards a standardized patient as observed by an external rater and with gender.
Until 2012, the undergraduate medical curriculum at the medical faculty of Hamburg consisted of two pre-clinical years, three clinical years, and a sixths practice year [ 36 ]. During the two pre-clinical years, history taking is taught in seminars with a focus on verbal communication skills and history taking techniques. In the three clinical years, which were organized in six thematic blocks, verbal and nonverbal history taking skills are practiced in bedside teaching courses on the hospital wards in the different medical disciplines. Seminars with standardized patients were scheduled in the thematic block “psycho-social medicine”, with a particular focus on empathetic communication including feedback by the actors.
In July 2011, 30 undergraduate medical students near graduation from the medical faculty of Hamburg University participated in a performance assessment resembling the first day of a beginning resident in hospital called UHTRUST (Utrecht Hamburg Trainee Responsibility for Unfamiliar Situations Test), which had been developed in a cooperation between the universities of Utrecht and Hamburg [ 37 ]. This assessment consisted per student of five 10-min consultations for history taking with standardized patients, followed by 3 hours where participants could gather further information and also interacted with nurses and other staff, and ended with a report to the individual supervisor about the five patients (30 min). All 150 patient interviews were videotaped and the content of the patient cases is described in further details elsewhere [ 38 , 39 ]. In brief, the contents for the five different cases are: Case 1: coeliac disease (the mother of a 5-year-old girl describing the girls fatigue and abdominal pain), case 2: granulomatous polyangiitis (a 53-year-old missionary from Africa visiting his sister in Germany, complaining of hemoptysis and weakness), case 3: perforated sigmoid diverticulitis (a 58-year-old woman presenting with abdominal pain), case 4: myasthenia gravis (a 65-year-old female with difficulties to speak and to swallow who is accompanied by her husband), case 5: varicella zoster infection (a 36-year-old male under immunosuppressive therapy for rheumatoid arthritis and complaining of fever). The medical scenarios were developed by medical experts from the universities of Utrecht and Hamburg based on certain facets of competences as described earlier [ 37 ].
For the observation of the videos, three different instruments were used. Empathy was rated with the German version of the so-called CARE (Consultation and Relational Empathy) questionnaire [ 40 ]. The questionnaire was developed originally for assessment of physicians’ empathy by patients and contains 10 items, which have to be rated on a 5-point Likert scale (1: “I totally disagree” to 5: “I totally agree”). We used it in our study for external rating of empathy with only eight items because two items refer to therapy, which is not applicable in our setting of mere history taking. For verbal communication, six aspects have been adapted from the literature and were combined in a newly designed observation form: “uses suitable language” [ 41 ], “keeps the conversation running” [ 42 ], and “summarizes what has been said” [ 42 ], which were rated on a 3-point Likert scale (0: “does not apply”, 1: “applies partly”, 2: “applies fully”). For these aspects, a maximum score of 6 could be reached per patient case. Two further aspects, “opens the conversation with an open question” and “closes the conversation with an open question” were adapted from Sennekamp et al. [ 43 ] and answered dichotomously. Furthermore, the number of W-questions (what, when, why etc.) was counted per patient interview. For nonverbal communication, five aspects were combined in a new observation form: adequate body posture, appropriate facial expressions, eye contact, and appropriate tone of voice [ 18 , 42 , 43 ] were rated on a 3-point Likert scale (0: “not shown”, 1: “partially shown”, 2: “completely shown”). If all components were complete shown, a maximum value of 8 points per scenario could be reached. Additionally, the time between the end of the first question of the participant to the first interruption during the patient’s answer was measured.
All rating forms were piloted. Two raters rated 15 patient interviews (in each case five interviews of three patients) independently. The limit of acceptable difference was defined in the following way: two points for the non-verbal form and one point for the verbal form. Difference in agreements were 1.5 for the non-verbal and 1.2 for the verbal form. Hence, no further revision was necessary. The CARE questionnaire was piloted with ten patient interviews (five interviews of two patients) by two independent raters (MM, a physician, and DV, an educationalist). A maximum difference of eight points for the total score was defined as acceptable. After repeated discussion of the rating aspects, an acceptable agreement was reached. The videos were watched once for each questionnaire, i.e. three times in total. One-way ANOVA as well as t-tests and bivariate correlations were used for statistical analyses.
Of the 30 participating final year students, 22 were female and eight were male. This resulted in 150 patient interviews altogether with 110 patient histories taken by female students and 40 histories taken by male students. Fifty percent of the students were between 24 and 25 years old, 46.7% were between 26 and 30 years old, and one student was 36 years old. All students were in the final year of their undergraduate medical curriculum lasting 6 years in total.
All students showed the highest verbal competence in case 4 (woman with difficulties to speak and swallow, accompanied by her husband) (Table 1 ). Female students were rated significant higher for their verbal communication over all cases ( p < 0.05) and particularly in case 3 (woman with abdominal pain) than male students ( p < 0.05). All students asked the highest number of W-questions in case 3 (Table 2 ). This number was significantly different versus case 2 ( p < 0.05) and case 4 ( p < 0.01). Significant gender differences could not be found.
Students interrupted the patient in case 3, compared to all other cases, significantly earlier, already after 7.5 ± 6.4 s, while they interrupted the patient in case 2 latest after 32.7 ± 22.0 s (Table 3 ). Male students interrupted the patients over all cases significantly later than female students ( p < 0.05), particularly in case 1 ( p < 0.01), case 2 ( p < 0.05), and case 5 ( p < 0.05). About 65% of the students started the interview with an open question, 87.5% of the male and 56.4% of the female students, which shows a significant gender difference of p < 0.05. This difference is also found for the first, fourth and fifth case ( p < 0.01; p < 0.01; p < 0.05). The interview of case 5 was started significantly more frequently with an open question than the interview of the second case ( p < 0.05). Only one third of the students closed the interview with an open question (32.7% of the female students versus 30.0% of the male students). The interview of case 1 was closed significantly more frequently with an open question (46.7%) than the interview of case 4 (23.3%, p < 0.05). With respect to non-verbal communication (Table 4 ), female students displayed significantly more signs of non-verbal communication over all cases ( p < 0.01), particularly in case 3 ( p < 0.05) and 4 ( p < 0.01) than male students did.
With respect to empathy, no differences were found for all participants between the five cases (Table 5 ). For case 3, female students were rated by an external rater to be more empathetic than male students ( p < 0.05). Overall verbal communication correlated significantly with non-verbal communication ( p < 0.01; r = .524) but not with empathy. Empathy correlated significantly with non-verbal communication ( p < 0.01; r = .371).
The objective of the study was to analyze how well final year undergraduate medical students use skills of verbal and non-verbal communication during history-taking and whether these aspects of communication correlate with empathy. We found a significant correlation between verbal and non-verbal communication in our study. This could be interpreted as a sign for congruent communication, which is important for the interpersonal relationship [ 44 ]. This study also showed that inconsistent messages were associated with greater interpersonal distances, which might hamper the patient-physician relationship. The significant correlation of empathy with non-verbal communication but not with verbal communication supports the finding that physician involvement was associated with higher patient ratings of empathy and satisfaction [ 45 ]. Gaze and body orientation, two aspects of non-verbal communication, which were part of our observation scale, have been demonstrated to be important links to the perception of clinical empathy [ 46 ]. Furthermore, our findings support the idea, that non-verbal behaviour might be more important than verbal messages in the communication of empathy [ 47 ] and serves as the primary vehicle for expressing emotions [ 45 ].
Participants reached the highest scores for verbal and non-verbal communication skills with case 4, the female patient with difficulties to speak and swallow whom her husband accompanied. The fact that the patient’s speech was slurred and that a relative accompanied her might have drawn the students’ attention to particularly careful communication. From patients with aphasia it is known, that family members want physicians to try to communicate with the patient [ 48 ]. Whether students behaved in this manner instinctively or whether they were encouraged to behave in this way by training cannot be distinguished. With respect to gender differences, female students reached significantly higher scores than male students for verbal and non-verbal communication skills over all cases and in case 3, the woman with abdominal pain, and they received significantly higher scores for empathy in case 3. For communicating error disclosures, it is known that female physicians smiled more and were more attentive than male physicians were [ 49 ]. This might also be the case in our patient scenario with a female patient who was brought to the consulting room in a wheelchair because of severe abdominal pain. Another study reports empirical evidence for more signs of non-verbal and verbal ways of communication in female physicians including smiling, disclosing information about themselves, and encouraging and facilitating others to talk more freely [ 50 ]. The higher ratings for empathy are in line with another study, which showed that female students were more patient-centred than male students [ 51 ]. Furthermore, students in this study were more attuned to the concerns of patients of their own gender [ 51 ], which also might be the case with the patient in case 3.
The patient in case 3 was interrupted most frequently after the shortest interval from the start of the conversation and the highest number of W-questions was asked. Furthermore, in case 3 students have been shown to have asked significantly more questions about medical details than in any other case [ 38 ]. Case 3 covers the symptom abdominal pain, which is taught repeatedly in our 6-year undergraduate medical curriculum [ 36 ] and W-questions are important to distinguish differential diagnoses [ 52 ]. Our results might demonstrate, that students have studied the workup of patients with abdominal pain well. However, female students were found to interrupt patients significantly earlier than male students over all cases. With respect to interrupting a conversation, the important finding in the literature is that the quality of the interruption needs to be distinguished as there is a cooperative and an intrusive way of interrupting [ 53 ]. In physician-patient interviews, female patients exhibited cooperative interruptions more frequently than male patients [ 54 ]. Whether this might be the case for the female students in our study and account for the higher frequency of interruptions by female students requires further investigation. In general, female as well as male students in our study interrupted patients less frequently – except for that patient in case 3 – than primary care physicians who interrupted their patients on average after 12 s [ 44 ].
The medical students in our study show a decline of empathy during their undergraduate medical education [ 55 ]. Unfortunately, this is in line with observations of other groups in undergraduate [ 56 ] and postgraduate [ 57 ] medical students. As potential reasons for the decline of empathy, the hidden curriculum [ 57 ] as well as a lack of role models, high learning-volume, time pressure, hierarchy, cynicism, bureaucracy, and an atrophy of idealism during students’ socialization are given [ 56 ]. Positive role models and communication skills trainings with continuous student supervision with reflections and constructive feedback, which has been shown to have a positive influence on students’ performance, might help to prevent the decrease of empathy [ 55 ].
Strengths and weaknesses of this study
A strength of our study is the special format of a validated competency based assessment [ 37 ] with video material of 150 student-patient encounters. One weakness of this project is that only the CARE questionnaire is a validated instrument while the observation forms for signs of verbal and non-verbal communication were designed using aspects from the literature. Another weakness of our study is the large difference in numbers between male and female participants even though it resembles roughly the actual percentage of 60% female medical students in our cohorts. Another strength of this project is the external rating of the patient interviews with the CARE questionnaire, which is independent of the personal perception of empathy by the simulated patients. An additional weakness is the fact that the participant-patient encounters were only filmed with one camera, which does not allow for a very differentiated analysis of the facial mimic of participant and patient. Furthermore, the camera was visible and could have influenced the participants and the standardized patients in their reactions. However, a strength is that a similar format of videotaping is used in our communication course, which allows differentiated video feedback to the participants.
In conclusion, undergraduate medical students display differentiated communication behaviour with respect to verbal and non-verbal aspects and empathy in a competency-based assessment. While their verbal communication correlated significantly with their non-verbal communication but not with their empathy, their empathy correlated significantly with their non-verbal communication. Female students interrupted the simulated patients earlier than male students but showed in several cases significantly more signs of non-verbal communication. Since verbal and non-verbal aspects of communication are known to have an important impact on the physician-patient-encounter, the differences in communicatory aspects measured in our study suggest explicit teaching of verbal and non-verbal aspects of communication in communication classes during undergraduate training. Assessing different aspects of communication under simulated circumstances could be an important means for giving feedback to the students.
Consultation and Relational Empathy Questionnaire
Utrecht Hamburg Trainee Responsibility for Unfamiliar Situations Test
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We would like to thank all students who participated in this study.
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Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Universitätsklinikum Hamburg-Eppendorf III. Medizinische Klinik Martinistr. 52, D-20246, Hamburg, Germany
Daniela Vogel, Marco Meyer & Sigrid Harendza
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DV and SH designed the study. MM coordinated the study and the data acquisition. DV and MM performed the statistical analyses and interpreted the results with SH. DV and SH drafted the manuscript. All authors read and approved the final manuscript.
Correspondence to Sigrid Harendza .
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The study was performed in accordance with the Declaration of Helsinki and Ethics Committee of the Chamber of Physicians approval (PV3649). Participation was voluntary, anonymized and with written consent.
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Vogel, D., Meyer, M. & Harendza, S. Verbal and non-verbal communication skills including empathy during history taking of undergraduate medical students. BMC Med Educ 18 , 157 (2018). https://doi.org/10.1186/s12909-018-1260-9
Received : 03 January 2018
Accepted : 18 June 2018
Published : 03 July 2018
DOI : https://doi.org/10.1186/s12909-018-1260-9
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Developing Effective Communication Skills
A practicing oncologist likely uses just about every medium to communicate. They talk on the phone, send e-mail messages, converse one-on-one, participate in meetings, and give verbal and written orders. And they communicate with many audiences—patients and their families, referring physicians, and office staff.
But are you communicating effectively? How do you handle differing or challenging perspectives? Are you hesitant to disagree with others, especially those in authority? Do you find meetings are a waste of time? What impression does your communication style make on the members of your group?
Be an Active Listener
The starting place for effective communication is effective listening. “Active listening is listening with all of one's senses,” says physician communication expert Kenneth H. Cohn, MD, MBA, FACS. “It's listening with one's eyes as well as one's years. Only 8% of communication is related to content—the rest pertains to body language and tone of voice.” A practicing surgeon as well as a consultant, Cohn is the author of Better Communication for Better Care and Collaborate for Success!
Kenneth H. Cohn, MD, MBA, FACS
Cohn suggests creating a setting in which “listening can be accommodating.” For example, don't have a conversation when one person is standing and one person is sitting—make sure your eyes are at the same level. Eliminate physical barriers, such as a desk, between you and the other party. Acknowledge the speaker with your own body language: lean forward slightly and maintain eye contact. Avoid crossing your arms, which conveys a guarded stance and may suggest arrogance, dislike, or disagreement.
When someone is speaking, put a premium on “being present.” Take a deep breath (or drink some water to keep from speaking) and create a mental and emotional connection between you and the speaker. “This is not a time for multitasking, but to devote all the time to that one person,” Cohn advises. “If you are thinking about the next thing you have to do or, worse, the next thing you plan to say, you aren't actively listening.”
Suspending judgment is also part of active listening, according to Cohn. Encourage the speaker to fully express herself or himself—free of interruption, criticism, or direction. Show your interest by inviting the speaker to say more with expressions such as “Can you tell me more about it?” or “I'd like to hear about that.”
Finally, reflect back to the speaker your understanding of what has been said, and invite elaboration and clarification. Responding is an integral part of active listening and is especially important in situations involving conflict.
In active listening, through both words and nonverbal behavior, you convey these messages to the speaker:
- I understand your problem
- I know how you feel about it
- I am interested in what you are saying
- I am not judging you
Communication Is a Process
Effective communication requires paying attention to an entire process, not just the content of the message. When you are the messenger in this process, you should consider potential barriers at several stages that can keep your intended audience from receiving your message.
Be aware of how your own attitudes, emotions, knowledge, and credibility with the receiver might impede or alter whether and how your message is received. Be aware of your own body language when speaking. Consider the attitudes and knowledge of your intended audience as well. Diversity in age, sex, and ethnicity or race adds to the communication challenges, as do different training backgrounds.
Individuals from different cultures may assign very different meanings to facial expressions, use of space, and, especially, gestures. For example, in some Asian cultures women learn that it is disrespectful to look people in the eye and so they tend to have downcast eyes during a conversation. But in the United States, this body language could be misinterpreted as a lack of interest or a lack of attention.
Choose the right medium for the message you want to communicate. E-mail or phone call? Personal visit? Group discussion at a meeting? Notes in the margin or a typed review? Sometimes more than one medium is appropriate, such as when you give the patient written material to reinforce what you have said, or when you follow-up a telephone conversation with an e-mail beginning, “As we discussed.…”
For one-on-one communication, the setting and timing can be critical to communicating effectively. Is a chat in the corridor OK, or should this be a closed-door discussion? In your office or over lunch? Consider the mindset and milieu of the communication receiver. Defer giving complex information on someone's first day back from vacation or if you are aware of situations that may be anxiety-producing for that individual. Similarly, when calling someone on the phone, ask initially if this is a convenient time to talk. Offer to set a specific time to call back later.
Finally, organize content of the message you want to communicate. Make sure the information you are trying to convey is not too complex or lengthy for either the medium you are using or the audience. Use language appropriate for the audience. With patients, avoid medical jargon.
Be Attuned to Body Language—Your Own and Others
Many nonverbal cues such as laughing, gasping, shoulder shrugging, and scowling have meanings that are well understood in our culture. But the meaning of some of these other more subtle behaviors may not be as well known. 1
Hand movements. Our hands are our most expressive body parts, conveying even more than our faces. In a conversation, moving your hand behind your head usually reflects negative thoughts, feelings, and moods. It may be a sign of uncertainty, conflict, disagreement, frustration, anger, or dislike. Leaning back and clasping both hands behind the neck is often a sign of dominance.
Blank face. Though theoretically expressionless, a blank face sends a strong do not disturb message and is a subtle sign to others to keep a distance. Moreover, many faces have naturally down turned lips and creases of frown lines, making an otherwise blank face appear angry or disapproving.
Smiling. Although a smile may show happiness, it is subject to conscious control. In the United States and other societies, for example, we are taught to smile whether or not we actually feel happy, such as in giving a courteous greeting.
Tilting the head back. Lifting the chin and looking down the nose are used throughout the world as nonverbal signs of superiority, arrogance, and disdain.
Parting the lips. Suddenly parting one's lips signals mild surprise, uncertainty, or unvoiced disagreement.
Lip compression. Pressing the lips together into a thin line may signal the onset of anger, dislike, grief, sadness, or uncertainty.
Build a Team Culture
In oncology, as in most medical practices, much of the work is done by teams. Communication within a team calls for clarifying goals, structuring responsibilities, and giving and receiving credible feedback.
“Physicians in general are at a disadvantage because we haven't been trained in team communication,” says Cohn. He points out that when he was in business school, as much as 30% to 50% of a grade came from team projects. “But how much of my grade in medical school was from team projects? Zero.”
The lack of systematic education about how teams work is the biggest hurdle for physicians in building a team culture, according to Cohn. “We've learned team behaviors from our clinical mentors, who also had no formal team training. The styles we learn most in residency training are ‘command and control’ and the ‘pace setting approach,’ in which the leader doesn't specify what the expectations are, but just expects people to follow his or her example.”
Cohn says that both of those styles limit team cohesion. “Recognizing one's lack of training is the first step [in overcoming the hurdle], then understanding that one can learn these skills. Listening, showing sincere empathy, and being willing to experiment with new leadership styles, such as coaching and developing a shared vision for the future are key.”
Stated goals and team values. An effective team is one in which everyone works toward a common goal. This goal should be clearly articulated. In patient care, of course, the goal is the best patient outcomes. But a team approach is also highly effective in reaching other goals in a physician practice, such as decreasing patient waiting times, recruiting patients for a clinical trial, or developing a community education program. Every member of the team must be committed to the team's goal and objectives.
Effective teams have explicit and appropriate norms, such as when meetings will be held and keeping information confidential. Keep in mind that it takes time for teams to mature and develop a climate of trust and mutual respect. Groups do not progress from forming to performing without going through a storming phase in which team members negotiate assumptions and expectations for behavior. 2
Clear individual expectations. All the team members must be clear about what is expected of them individually and accept their responsibility for achieving the goal. They should also understand the roles of others. Some expectations may relate to their regular job duties; others may be one-time assignments specific to the team goal. Leadership of the team may rotate on the basis of expertise.
Members must have resources available to accomplish their tasks, including time, education and equipment needed to reach the goal. Openly discuss what is required to get the job done and find solutions together as a team.
Empowerment. Everyone on the team should be empowered to work toward the goal in his or her own job, in addition to contributing ideas for the team as a whole. Physicians' instinct and training have geared them to solve problems and give orders—so they often try to have all the answers. But in an effective team, each team member feels ownership in the outcome and has a sense of shared accountability. Cohn notes, “You get a tremendous amount of energy and buy-in when you ask ‘What do you think?’”
Team members must trust each other with important tasks. This requires accepting others for who they are, being creative, and taking prudent risks. Invite team members to indicate areas in which they would like to take initiative. Empower them by giving them the freedom to exercise their own discretion.
Feedback. Providing feedback on performance is a basic tenet of motivation. For some goals, daily or weekly results are wanted, while for others, such as a report of the number of medical records converted to a new system or the average patient waiting times, a monthly report might be appropriate. Decide together as a team what outcomes should be reported and how often.
Positive reinforcement. Team members should encourage one another. Take the lead and set an example by encouraging others when they are down and praising them when they do well. Thank individuals for their contributions, both one on one and with the team as a whole. Celebrate milestones as a way to sustain team communication and cohesion.
E-mail has numerous features that make it a wonderful tool for communicating with a team: it is immediate; it is automatically time-stamped; and filing and organizing are easy. (E-mail with patients is a more complex topic and is not addressed herein.)
The e-mail subject line is an especially useful feature that is typically underused. Make it your best friend. Use it like a newspaper headline, to draw the reader in and convey your main point or alert the reader to a deadline. In the examples given below, the person receiving an e-mail headed “HCC” is likely to scroll past it—planning to read it on the weekend. The more helpful subject line alerts the reader to be prepared to discuss the topic at an upcoming meeting:
- Vague Subject Line: HCC
- More Helpful Subject Line: HCC Plan to discuss the SHARP trial this Friday—Your comments due December 5 on attached new policies
As with all written communication, the most important aspect to consider is the audience. Consider the knowledge and biases of the person/people you are e-mailing. Where will the reader be when he or she receives your message? How important is your message to the reader?
The purpose of writing is to engage the reader. You want the reader to do something, to know something, or to feel something. Write it in a way that helps the reader. Put the most important information—the purpose of the email—in the first paragraph.
Except among friends who know you well, stay away from sarcasm in e-mail messages. The receiver does not have the benefit of your tone of voice and body language to help interpret your communication. When delivering comments that are even slightly critical, it's better to communicate in person or in a phone call than to do so in an e-mail. Something you wrote with good intentions and an open mind or even with humor can be interpreted as nitpicky, negative, and destructive, and can be forwarded to others.
Because we use e-mail for its speed, it's easy to get in the habit of dashing off a message and hitting the “send” button. We count on the automatic spell-check (and you should have it turned on as your default option) to catch your errors. But spelling typos are the least of the problems in communicating effectively.
Take the time to read through your message. Is it clear? Is it organized? Is it concise? See if there is anything that could be misinterpreted or raises unanswered questions. The very speed with which we dash off e-mail messages makes e-mail the place in which we are most likely to communicate poorly.
Finally, don't forget to supply appropriate contact information, including phone numbers or alternative e-mail addresses, for responses or questions.
Conflict is inevitable in times of rapid change. Effective communication helps one avoid conflict and minimize its adverse consequences when it does occur. The next issue of Strategies for Career Success will cover conflict management.
What Not to Do When Listening:
- Allow distractions
- Use clichéd phrases such as “I know exactly how you feel,” “It's not that bad,” or “You'll feel better tomorrow”
- Get pulled into responding emotionally
- Change the subject or move in a new direction
- Rehearse in your head what you plan to say next
- Give advice
Make Meetings Work for Your Team
A good meeting is one in which team goals are introduced or reinforced and solutions are generated. The first rule—meet in person only if it's the best format to accomplish what you want. You don't need a meeting just to report information. Here are tips for facilitating an effective meeting:
Don't meet just because it's scheduled. If there are no issues to discuss, don't hold the meeting just because it's Tuesday and that's when you always meet.
Use an agenda. Circulate a timed agenda beforehand and append useful background information. Participants should know what to expect. If it's a short meeting or quickly called, put the agenda on a flipchart or board before people arrive.
Structure input. Promote the team culture by making different individuals responsible for specific agenda items. Follow-up on previous task assignments as the first agenda item to hold group members accountable for the team's success.
Limit the meeting time. Use the timed agenda to stay on track. If the discussion goes off on a tangent, bring the group back to the objective of the topic at hand. If it becomes clear that a topic needs more time, delineate the issues and the involved parties and schedule a separate meeting.
Facilitate discussion. Be sure everyone's ideas are heard and that no one dominates the discussion. If two people seem to talk only to each other and not to the group as a whole, invite others to comment. If only two individuals need to pursue a topic, suggest that they continue to work on that topic outside the meeting.
Set ground rules up front. Keep meetings constructive, not a gripe session. Do not issue reprimands, and make it clear that the meeting is to be positive and intended for updates, analysis, problem solving, and decision making. Create an environment in which disagreement and offering alternative perspectives are acceptable. When individuals do offer opposing opinions, facilitate open discussion that focuses on issues and not personalities.
Circulate a meeting summary before the next meeting. Formal minutes are appropriate for some meetings. But in the very least, a brief summary of actions should be prepared. Include decisions reached and assignments made, with deadlines for follow-up at the next meeting.
Kenneth H. Cohn: Better Communication for Better Care: Mastering Physician-Administrator Collaboration. Chicago, IL, Health Administration Press, 2005, www.ache.org/pubs/redesign/productcatalog.cfm?pc=WWW1-2038
Kenneth H. Cohn: Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives. Chicago, IL, Health Administration Press, 2006, www.ache.org/hap.cfm
Suzette Haden Elgin: Genderspeak: Men, Women, and the Gentle Art of Verbal Self-Defense. Hoboken, NJ, Wiley, 1993
Jon R. Katzenbach, Douglas K. Smith: The Wisdom of Teams: Creating the High Performance Organization. New York, NY, Harper Business, 1994
Sharon Lippincott: Meetings: Do's, Don'ts, and Donuts. Pittsburgh, PA, Lighthouse Point Press, 1994
Kenneth W. Thomas: Intrinsic Motivation at Work: Building Energy and Commitment. San Francisco, CA, Berrett-Koehler Publishers, 2000
More Strategies for Career Success!
Deciding About Practice Options—J Oncol Pract 2:187-190, 2006
The Interview: Make it Work for You—J Oncol Pract 2:252-254, 2006
Employment Contracts: What to Look for—J Oncol Pract 2:308-311, 2006
Principles and Tactics of Negotiation—J Oncol Pract 3:102-105, 2007
Professional Advisors: They're Worth It—J Oncol Pract 3:162-166, 2007
Building and Maintaining a Referral Base—J Oncol Pract 3:227-230, 2007
Malpractice Insurance: What You Need to Know—J Oncol Pract 3:274-277, 2007
Joining a Practice As a Shareholder—J Oncol Pract 3:41-44, 2007.
verbal communication Recently Published Documents
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Speech Acts as a Variety of Verbal Communication
Real-time price discovery via verbal communication: method and application to fedspeak, patients’ and physicians’ experiences with remote consultations in primary care, during the covid-19 pandemic: a multi-method rapid review of the literature..
BackgroundDuring the COVID-19 pandemic, many countries implemented remote consultations in primary care to protect patients and staff from infection.AimThe aim of this review was to synthesise the literature exploring patients’ and physicians’ experiences with remote consultations in primary care, during the pandemic, with the further aim of informing their future delivery.Design & settingRapid literature review.MethodWe searched PubMed and PsychInfo for studies that explored patients’ and physicians’ experiences with remote consultations in primary care. To determine the eligibility of studies, we reviewed their titles and abstracts, prior to the full paper. We then extracted qualitative and quantitative data from those that were eligible, and synthesised the data using thematic and descriptive synthesis.ResultsA total of twenty-four studies were eligible for inclusion in the review. Most were performed in the United States of America (n=7, 29%) or Europe (n=7, 29%). Patient and physician experiences were categorised into perceived ‘advantages’ and ‘issues’. Key advantages experienced by patients and physicians included: ‘Reduced risk of COVID-19’ and ‘Increased convenience’, while key issues included: ‘a lack of confidence in / access to required technology’ and a ‘loss of non-verbal communication’, which exacerbated clinical decision making.ConclusionThis review identified a number of advantages and issues experienced by patients and physicians using remote consultations in primary care. The results suggest that, while remote consultations are more convenient, and protect patients and staff against COVID-19, they result in the loss of valuable non-verbal communication, and are not accessible to all.
Phonological Characteristics Shared By Questioner And Responder: A Comparison Between Individuals With And Without Autism Spectrum Disorder
How typically developed (TD) persons modulate their speech rhythm while talking to individuals with autism spectrum disorder (ASD) remains unclear. We aimed to elucidate the characteristics of phonological hierarchy in the verbal communication between ASD individuals and TD persons. TD and ASD respondents were asked by a TD questioner to share their recent experiences on 12 topics. We included 87 samples of ASD-directed speech (from TD questioner to ASD respondent), 72 of TD-directed speech (from TD questioner to TD respondent), 74 of ASD speech (from ASD respondent to TD questioner), and 55 of TD speech (from TD respondent to TD questioner). We analysed the amplitude modulation structures of speech waveforms using probabilistic amplitude demodulation based on Bayesian inference and found similarities between ASD speech and ASD-directed speech and between TD speech and TD-directed speech. Prosody and the interactions between prosodic, syllabic, and phonetic rhythms were significantly weaker in ASD-directed and ASD speech than those in TD-directed and TD speech, respectively. ASD speech showed weaker dynamic processing from higher to lower phonological bands (e.g. from prosody to syllable) than TD speech. The results indicate that TD individuals may spontaneously adapt their phonological characteristics to those of ASD speech.
RELATIONSHIP BETWEEN VERBAL AND NON-VERBAL COMMUNICATION OF NURSES WITH COMMUNICATION BARRIERS TO FAMILIES OF PRE-SURGERY PATIENTS IN THE INTENSIVE CARE ROOM AT THE ACEH GENERAL HOSPITAL IN 2020
Background: The nurse's verbal and non-verbal communication greatly affects the readiness of the patient and the patient's family to undergo surgery. Unclear communication causes misperceptions and the emergence of communication barriers in the nurse-client interaction process. The limited time and information provided are the causes of communication barriers in the client care process. This of course greatly affects patient care, especially in conditions that require intensive care. Methods: This study aims to determine the relationship between verbal and non-verbal communication between nurses and perceptions of communication barriers in families of pre-surgery patients in the intensive care unit, with a correlation design using a Cross Sectional study approach. The number of samples was 95 families of preoperative patients in the intensive care unit using purposive sampling technique. Results: 51.6% of nurses' verbal communication was good, and 50.5% of nurses' nonverbal communication was good, and there were no communication barriers between nurses and patients' families (54.7%). There was a significant relationship between nurses' verbal communication with perceptions of family communication barriers in pre-surgery patients in the intensive room (P=0.001) and there was a correlation between nurses' nonverbal communication with perceptions of family communication barriers in pre- surgery patients in the intensive room (P=0.002). Recommendation: Nurses are expected to continue to communicate effectively verbal and non-verbal with patients and families to prevent barriers in communication
Non-verbal communication online
Verbalizing spiritual needs in palliative care: a qualitative interview study on verbal and non-verbal communication in two danish hospices.
AbstractDenmark is considered one of the World’s most secular societies, and spiritual matters are rarely verbalized in public. Patients report that their spiritual needs are not cared for sufficiently. For studying spiritual care and communication, twelve patients admitted to two Danish hospices were interviewed. Verbal and non-verbal communication between patients and healthcare professionals were identified and analysed. Methodically, the Interpretative Phenomenological Analysis was used, and the findings were discussed through the lenses of existential psychology as well as philosophy and theory of caring sciences. Three themes were identified: 1. When death becomes present, 2. Direction of the initiative, and 3. Bodily presence and non-verbal communication. The encounter between patient and healthcare professional is greatly influenced by sensing, decoding, and interpretation. A perceived connection between the patient and the healthcare professional is of great importance as to how the patient experiences the relationship with the healthcare professional.The patient’s perception and the patient’s bodily experience of the healthcare professional are crucial to whether the patient opens up to the healthcare professional about thoughts and needs of a spiritual nature and initiates a conversation hereabout. In this way we found three dynamically connected movements toward spiritual care: 1. From secular to spiritual aspects of care 2. From bodily, sensory to verbal aspects of spiritual care and 3. From biomedical to spiritual communication and care. Thus, the non-verbal dimension becomes a prerequisite for the verbal dimension of spiritual communication to develop and unfold. The behaviour of the healthcare professionals, characterised by the way they move physically and the way they touch the patient, was found to be just as important as verbal conversation when it comes to spiritual care. The healthcare professional can create a connection to the patient through bodily and relational presence. Furthermore, the healthcare professionals should let their sensing and impressions guide them when meeting the patient in dialog about matters of a spiritual nature. Their perception of the patient and non-verbal communication are a prerequisite for being able to meet patient’s spiritual needs with care and verbal communication.
Verbal and Non-verbal Communication
Being present: is it the most important communication skill.
The COVID-19 pandemic has made people rely on the presence of the internet to run their business. Businesses, schools, retail, religious gatherings, and other components are all required to use an internet platform in some way. People can meet face-to-face and the feature of the contact is reinforced by both verbal and non-verbal communication prior to the viral eruption, making conversation much easier. The goal of this study is to emphasize the importance of being present during the COVID-19 Pandemic as well as the future projection of presence post-pandemic. Being present, as before the pandemic, comes effortlessly without conscious reflection because the interaction takes place offline without any restrictions. The result from this research that being present is the most crucial communication skill; it is the foundation of communication and can aid in more effective engagement on all levels (perception, comprehension, reasoning, memory, and production).
Communications Patterns in The Traditional Market “Pasar Sari Mulia” Kapuas City
Abstrak: Penelitian ini membahas tentang investigasi pola komunikasi di pasar tradisional “Pasar Sari Mulia” di Kota Kapuas. Masalah utama dalam penelitian ini adalah pola komunikasi yang digunakan di pasar tradisional. Selain itu, penelitian ini juga menemukan tentang bagaimana komunikasi nonverbal pembeli dan penjual di pasar tradisional. Dengan menggunakan pendekatan kualitatif dan data dianalisis tentang pengaruh budaya suatu bahasa dan bagaimana bahasa itu sendiri akan membentuk suatu budaya dalam suatu domain. Data diperoleh dari observasi dan menggunakan studi kepustakaan. Hasil penelitian menunjukkan bahwa bahasa Banjar merupakan bahasa yang umum digunakan di pasar tradisional. Alih kode dan kalimat persuasif biasa digunakan dalam melakukan transaksi. Pembeli dan penjual menggunakan pola komunikasi yang unik dan komunikasi non-verbal terutama dalam menarik, proses tawar-menawar dan ekspresi penutupan perdagangan. Namun bagi penjual, komunikasi yang digunakan cenderung membujuk pembeli untuk segera membeli barangnya. Abstract: This research deals with the investigation of communication patterns in the traditional market “Pasar Sari Mulia” in Kapuas City. The major issues in this research were the communication patterns which were used in the traditional market. Besides, this research also found about how are non-verbal communication of buyer and seller in the traditional market. Using qualitative approach and the data were analyzed about culture influences a language and how language itself will make a culture in a domain. The data were gotten from observation and used library research. The results showed that the Banjarese language was a common language which was used in the traditional market. Code switching and persuasive sentence were commonly used in doing transaction. The buyers and sellers used unique communication patterns and non-verbal communication especially in attracting, bargaining process and closing expression of trading. However, for the sellers, the communication used tends to persuade buyers to immediately buy their goods.
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This article is investigating verbal communication research in teaching the English language, its importance, and necessity in daily human life. The article shows how the teacher should help students to improve and develop their verbal communication skills. For this point, there are given some useful and effective techniques with methods in teaching the English language, which we have to use for developing students’ verbal communication skills and speech etiquette. The chosen topic is relevant to the fact that verbal communication and speech etiquette have a key place in a person’s successful life; therefore many researchers and article readers are interested in this topic. Speech etiquette is a component in the linguistic cultural picture of the world, as well as possessions and understanding of speech etiquette depends on the people behavior. Speech etiquette plays a special role in the foreign language study.
English Language , Verbal Communication , Skills , Language Teaching , Speech Etiquette , Learning , Ethics
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The relationship between language and its meaning is not straight forward (Søren- sen et al., 2019) , one reason for this is the complicated limitlessness of modern language semantics, including English (Wali et al., 2017) . Language is productive in the sense that there is an infinite number of words and phrases. There is no limit to a language’s vocabulary, as new words are introducing daily. Words are not the only things we need to communicate, although they are closely related to verbal and nonverbal (Parikh et al., 2014) symbols in terms of how we make the meaning of language. Every symbol represents some meaning related to a certain activity (Zhirenov et al., 2016) . Symbols can be used for communication verbally, for example, when spelling the word “winter”, in writing it is necessary to put the letters W-I-N-T-E-R together. Communication development is an effective teaching method in improving students technical communication skills as well as empathy (Vogel et al., 2018) .
Verbal communication helps express various needs, and in asking questions, that provide us with specific information. Verbal communication is also used in describing things, events, occasions, people, and ideas, by helping people to inform, persuade, and to take into consideration. In other words, verbal expressions help us to communicate with others in explaining our observations, thoughts, feelings, and needs.
Good communication skills are a self-confidence source, enabling a person to exert more control in their life by obtaining knowledge, research effectively, conceptualize, organize, and present ideas and arguments (Emanuel, 2011) . Verbal communication skills are a necessary tool for prospering in any subject; even learning these skills will take time, better practices can help students to learn quickly and apply knowledge in work. In addition, with improved communication skills, students will have the confidence and knowledge to not only get a good job but to perform well in interviews (Reith-Hall & Montgomery, 2019) . Communication skills are considered as an ability used to give and receive different kinds of information, similarly, in the development of personality throughout human being existence. During this period, communication becomes essential for personal growth, through which communicating people will find themselves, develop self-confidence, and define the relationship with the surrounding environment. The failure in building good communication skills will happen when people do not want to understand other’s opinions, thoughts, ideas, and feelings.
Particularly, there given methods to help students in improving their verbal communication skills and speech etiquette, by the following elements: how to choose words and vocabulary for this or that conversation topic, using key phrases through different dialogues; by watching movies students will be able to understand the language, eye contact, accents; and how to paraphrase and summarize the spoken language, and respond to different types of questions. This article has an actual place in linguistics because important role of verbal communication and speech etiquette in language learning and teaching process. The topic closely connected with methodology, owing to essential methods in teaching verbal com- munication skills and speech etiquette.
2. Communication Skills Importance
For teachers, it is highly important to have enough skills to communicate effectively, because they considered as one of the necessary determinants in teaching and learning success. In addition to transferring knowledge, the word “educate” is supposed to train learners verbal skills to develop themselves, the impact of higher education, the economy and the broader society transformed along time in various ways (Kromydas, 2017) .
In carrying out the learning process, teachers should combine their verbal and nonverbal communication skills; the ability of teachers in applying these types of communication can help improve both, teachers and students impressions in the process of teaching and learning. The teacher is the one who always explains and presents learning material to the class, for this purpose, the teacher should exhibit enough speaking with writing skills. The teacher is required to understand students’ verbal communication and be able to help students improve their verbal communication abilities. Verbal communication skills, either they are oral or written; involve vocabulary, mastering skills in choosing the right words to give meaning to the audience. Verbal abilities also concern with skills to organize the words logically.
More importantly, communication is the manifestation of accurate and open attitudes in information change between learners and students. Communication is closely related to culture (Piller, 2007) . Nevertheless, the culture itself can be a challenge in building interaction that potentially causes misunderstanding. Language problems can be associated with problems of hearing ability and pronunciation, speed, tone, and tune.
3. Developing Students Communication Skills
Participants in this study are teacher and students conducting education process. Students’ and teacher’s good and adequate communication shows their ethical level in the process of learning and teaching the language. Ethics is one of the most important things, which people need daily everywhere. Here we want to emphasize the regulation of ethical communication in foreign language teaching. Ethics is a branch of philosophy and it has been studied for thousands of years by many researchers.
In communication studies, curricula and ethics are often considered as a central place in service-learning courses, community-engaged activity, and communication activism where students come face-to-face with the harsh realities experienced by society. For some students, it may be the first time they witness and interact with people suffering from lack of basic resources, and sufficient educational opportunities, or subject to environmental hazards, to name just a few persistent inequities. These experiences lend themselves to a rich consideration of communication ethics situated at the individual, organizational, and systemic levels to understand how one voice intersects with others to affirm the dignity of all people as well as promoting learning and competence in everyday communication, as well as social changes through a broad and systemic transformation; ethical communication is necessary for social media, also impacting governmental regulation on ethics (Bowen, 2020) .
Competent and skilled communicators are ethical communicators who take responsibility for a message’s creation, impact, and effects in a diverse range of contexts, including mass media, interpersonal, intercultural, professional, and public areas. Stimulating the moral imagination is a key factor that helps students to recognize issues of communication ethics. They learn to weigh their self-interests relative to the self-interest of others, so their communication skills may construct the ethical dimension in the world they live in. In this regard, through the analysis of terminology the term speech etiquette is described in this article. Here we tried to give exact meaning and role of speech etiquette in foreign language learning and teaching.
Speech etiquette is included in the linguistic cultural picture of the world. Possession, understanding and choice of formulas of speech etiquette depends on the people behavior. The choice of speech etiquette formulas is playing a special role in the foreign language study. Without speech etiquette, it is impossible neither to enter the communication, nor to maintain communication, or to complete it. Speech etiquette is a set of requirements to the form, content, order, character and situational relevance of statements adopted in this culture. Speech etiquette, in particular, includes words and expressions used by people to say goodbye, requests, and apologies, accepted in various situations, forms of treatment, intonation features that characterize polite speech, etc. The study of speech etiquette occupies a special position at the junction of linguistics, theory and history of culture, ethnography, country studies, psychology and other humanities (Kereksha, 2019) . On the other hand, speech etiquette can be considered from the point of view of language norm. Thus, the idea of correct, cultural, normalized speech includes certain ideas about the norm in the field of speech etiquette (Ushakov, 2008) .
4. Ways to Obtain Good Communication Skills
There are some characteristics of effective verbal communicators which are very necessary, including active listening, adaptability, adapting one’s communication styles to support the situation, clarity, confidence and assertiveness, constructive feedback to giving and receiving it, emotional intelligence for identifying and managing teacher emotions, as well as students emotions, empathy, interpersonal skills as social skills which are especially useful in building strong arguments, interpretation of language, open-mindedness, patience, simplifying the complex, and storytelling.
The way to obtain a good proficiency in verbal communication is mention attributes concerning both the teacher and learners. Essentially, there are a lot of techniques and tools that teacher can use to improve students’ verbal communication skills ( Figure 1 ).
The useful thing here is to apply technology such as videos and audios, which are playing the most important role nowadays. Additionally, they will be in interesting and effective sense for students and learners.
Figure 1 . Techniques and tools for improving students’ verbal communication skills.
4.1. Watching Films That Model Conversation Skills
The conversation is one of the most basic and essential communication skills. It enables people to share thoughts, opinions, ideas, and receive information. Although it may appear simple on the surface, effective conversations include a give-and-take exchange that consists of elements such as language, eye contact, summarizing, paraphrasing, and responding.
Students can learn the fundamental elements of the conversation by watching films or videos about interactions taking place. The teacher can pause the video and ask questions such as, “What message is the listener sending by crossing his arms? What else can you tell by observing the language expressions in the conversation?”
4.2. Reinforce Active Listening
Communication is not just about speaking, but also about listening. The teacher can help their students to develop listening skills by reading a selection of text, and then having the class discussion and reflect the content by students explanations. Active listening also means listening to understand rather than a reply. Reinforce building good listening skills by encouraging students to practice asking clarifying questions to fully understand the speakers message.
4.3. Offer Group Presentations and Assignments
Team-building exercises can also help students sharpen both oral and written com- munication skills. Not only does it offer students the chance to work in small groups, thereby reducing some of the pressure, but it also allows them to debate their opinions, take turns, and work together towards a common goal.
4.4. Ask Open-Ended Questions
On the occasion where students require more than a one or two-word response, open-ended questions are vital for inspiring discussion and demonstrating that there are multiple ways to perceive and answer a question. A teacher might set a timer for students informal conversations and challenges to use open-ended questions. For example, teacher can show children the difference in how much more information they can obtain by asking, “What did you like best about the song?” rather than simply “Did you like the song?”
4.5. Use Tasks and Activities That Foster Critical Thinking
Another task-based method for improving student communication skills is through critical thinking exercises. These can be done verbally or through written assignments that give students the chance to answer questions creatively using their own words and expressions.
4.6. Offer Reflective Learning Opportunities
Recording students reading selected text or videotaping group presentations is an excellent method for assessing their communication strengths and weaknesses. Students can reflect on their oral performance in small groups. Then, ask each student to analyze the others so that they can get used to receiving constructive criticism. Besides these techniques and methods, there are other activities for improving students verbal communication skills, such as role-playing, which showed effective results from previous experiences.
Effective verbal communication skills include more abilities than just speech. Verbal communication encompasses both how to deliver messages and how to receive. Communication is a necessary skill, which is important to every student, teacher, and person, even to workers, who can convey information clearly and effectively to be highly valued by employers. Employees who can interpret messages and act appropriately on the information they receive have a better chance in their job excellence. Without speech etiquette, it is impossible to join and maintain the communication, or to complete it. Speech etiquette considered as a set of requirements to the certain form, content, order, character and situational relevance of statements adopted in this culture.
Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this paper.
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The Measurement of Eye Contact in Human Interactions: A Scoping Review
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- Published: 20 April 2020
- volume 44 , pages 363–389 ( 2020 )
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- Chiara Jongerius 1 ,
- Roy S. Hessels 2 , 3 ,
- Johannes A. Romijn 4 ,
- Ellen M. A. Smets 1 &
- Marij A. Hillen 1
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Cite this article
Eye contact is a fundamental aspect of nonverbal communication and therefore important for understanding human interaction. Eye contact has been the subject of research in many disciplines, including communication sciences, social psychology, and psychiatry, and a variety of techniques have been used to measure it. The choice of measurement method has consequences for research outcomes and their interpretation. To ensure that research findings align with study aims and populations, it is essential that methodological choices are well substantiated. Therefore, to enhance the effective examination of eye contact, we performed a literature review of the methods used to study eye contact. We searched Medline, PsycINFO and Web of Science for empirical peer-reviewed articles published in English that described quantitative studies on human eye contact and included a methodological description. The identified studies ( N = 109) used two approaches to assess eye contact: direct, i.e., assessing eye contact while it is occurring, and indirect, i.e., assessing eye contact retrospectively (e.g., from video recordings). Within these categories, eight specific techniques were distinguished. Variation was found regarding the reciprocity of eye contact between two individuals, the involvement of an assessor and the behavior of participants while being studied. Measures not involving the interactors in assessment of eye contact and have a higher spatial and temporal resolution, such as eye tracking, have gained popularity. Our results show wide methodological diversity regarding the measurement of eye contact. Although studies often define eye contact as gaze towards an exact location, this may not do justice to the subjective character of eye contact. The various methodologies have hardly ever been compared, limiting the ability to compare findings between studies. Future studies should take notice of the controversy surrounding eye contact measures.
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Eye contact is a fundamental aspect of nonverbal communication and social interaction from birth throughout adulthood (Kleinke 1986 ). Eye contact is an important indicator for healthy bonding between mother and child at early ages and for the diagnosis of psychiatric disorders later in life (Auyeung et al. 2015 ; Farroni et al. 2002 ). Furthermore, it is a fundamental factor in interpersonal relationship building (MacDonald 2009 ). Not surprisingly, eye contact has been the focus of research in various disciplines, such as communication sciences, social psychology, and psychiatry, and various approaches have been used to asses it.
Health communication research has, for example, focused on eye contact between patient and physician and on turn-taking in conversations. The focus of such research has been on the impact of eye contact on patients’ levels of trust, anxiety, and satisfaction (Farber et al. 2015 ; Hillen et al. 2015 ; Pieterse et al. 2007 ). Within this line of research, researchers have used video cameras to observe the gaze behavior of patients and physicians (Farber et al. 2015 ; Pieterse et al. 2007 ). Clinical consultations were filmed and, subsequently, physicians’ and patients’ gaze behaviors were coded by researchers using software for behavioral coding (Farber et al. 2015 ; Pieterse et al. 2007 ). As regards turn-taking, studies have observed people involved in a conversation and have, for example, related their amount of gaze to their proportion of speaking time to gain insight into the ‘smoothness’ of encounters (Kalma 1992 ; Kendon and Cook 1969 ). These studies have identified patterns of gaze in interactions indicating that someone is speaking, listening or inviting another interactor to take over.
In the field of social psychology, eye contact has, for example, been studied as a way for different individuals or groups to approach or deceive each other (Kleinke 1986 ). To understand how eye contact enables approaching behavior, eye contact is usually experimentally enhanced or obstructed during social encounters. Afterwards, effects are assessed on outcomes such as distance and affiliation (Argyle and Dean 1965 ; Knight et al. 1973 ). Studies focusing on deception and manipulation have compared the amount of eye contact between participants instructed to lie with a control group of truth-tellers (Jundi et al. 2013 ; Mann et al. 2013 ).
Research on eye contact within psychiatry often focuses on disturbed eye contact patterns as a potential indicator of psychiatric pathologies (Guillon et al. 2014 ; Papagiannopoulou et al. 2014 ; Schulze et al. 2013 ). Such studies have, for instance, found that individuals diagnosed with autism spectrum disorder tend to gaze less at the eye area compared to healthy individuals (Guillon et al. 2014 ; Papagiannopoulou et al. 2014 ; van der Geest et al. 2002 ). These studies generally use the amount of eye-directed gaze as a proxy for eye contact. For example, in a recent study, individuals diagnosed with autism spectrum disorder were instructed to look at the eye-region of faces in pictures. This allowed the researchers to examine the neurological effects of their gaze behavior in the subcortical system using fMRI (Hadjikhani et al. 2017 ). As illustrated, eye contact is central to research in various disciplines focused on understanding human interaction, using a variety of measurement strategies. As eye contact is such a crucial indicator of interpersonal relationships, clarity is needed about how it is defined. Moreover, valid and reliable methods should be chosen to assess it, appropriate for the specific research aim and population. If we want to aggregate and advance research on interpersonal eye contact, we need a clear overview of the different methodologies and their interpretations.
Several previous reviews have grouped the literature on eye contact. For example, the importance of eye contact in patient-physician communication was reviewed by MacDonald ( 2009 ). Furthermore, Senju and Johnson ( 2009a ) reviewed the effect of (perceived) eye contact on cognitive processing. More recently, Grossmann ( 2017 ) reviewed eye contact from an ontogenetic, phylogenetic, neurological, and neuro-hormonal perspective. These reviews have proposed multiple interpretations and models for understanding eye contact. However, they did not take into account the methodological variations in empirical studies on eye contact. A methodological review may provide insight into the implicit assumptions made by researchers about what eye contact is.
Although many researchers state they aim to investigate “eye contact”, variation in the methodologies to measure it complicates aggregation or comparison of study findings. Therefore, our aim was to provide an overview of the methods used to study eye contact across research disciplines. More specifically, we investigated how eye contact is defined and assessed in the empirical literature to uncover the specific techniques that have been used in eye contact research. To that end, we analyzed for individual studies general characteristics (study design, cohort, and field of study), operationalization of eye contact, and participant behavior under investigation. More generally, we analyzed the evolvement of eye contact measures over time, and the covariances between the operationalizations, age group of participants, field of study, and research question.
We conducted a bibliographic search in Medline, PsycINFO, and Web of Science, using the following terms: (eye contact) OR ((direct OR mutual OR dyadic OR eye) AND (gaze OR gazing)). For the exact search strings per database see “Appendix 1 ”. The search terms were refined beforehand based on the scope of our research question, literature, an initial exploratory search, and consultation with expert librarians. The search was limited to journal articles written in the English language. The last search date was February 8, 2018. The review was registered in the PROSPERO database, registration number: CRD42018094107. One study not identified in the initial search was added based on expert opinion of one of the reviewers.
Once the search was completed, two authors (CJ, MH) independently screened and discussed 100 articles based on their title and abstract to refine the inclusion criteria. Using these criteria, the same two authors independently screened 500 titles and abstracts to assess congruence and to refine exclusion and inclusion criteria. All further articles were screened by one author (CJ). We included only empirical journal articles. Since our main focus was on the measurement of eye contact in human–human interaction, we used the following inclusion criteria:
Authors described “eye contact” or mutual gaze behavior to be a part of the primary aim or research question of the study.
The study was focused on interaction between two real humans (i.e., no studies involving interaction between humans and animals or pictures).
Human eye contact was assessed using quantitative measures.
Methods to assess eye contact were specifically described in either the introduction, method, or results section.
We included studies on related concepts such as ‘interpersonal looking’ or ‘visual regard’ only if the authors additionally explicitly mentioned to focus on our focus of interest, i.e., ‘eye contact’. Therefore, if authors were clearly focusing on ‘eye contact’, but did not mention these exact words but related terminology such as ‘mutual gaze behavior between humans’ a study was included.
After the initial screening of titles and abstracts, final eligibility of the articles was determined based on the full-text. Two authors screened the full texts independently (CJ, RH). Any discordances were resolved through discussion. For all included articles, data were subsequently extracted according to a predefined extraction form. The extracted data included study aim, study design, field of study, participant age group and health status, and study methodology—i.e., the definition and the operationalization of eye contact, and measures and techniques. See “Appendix 2 ” for the complete extraction form.
The results of the search are summarized in Fig. 1 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search yielded a total of 5583 unique articles. After initial screening, 224 articles were assessed based on the full-text and 109 studies met the inclusion criteria.
PRISMA flowchart of included articles
Characteristics of the Included Studies
Study characteristics ( N = 109) are summarized in Table 1 . The studies were published between 1965 and 2017. Studies were performed mostly in the United States ( n = 60) and European countries ( n = 33). There were 80 experimental studies, one of which was a randomized controlled trial, and 29 were observational studies, of which 8 had a longitudinal design.
Studies included participants from various age groups: infants, children, adolescents, adults, and elderly; one study included a mixed cohort. Studies focused mostly on healthy participants. Other groups were patients with mental disorders, such as individuals diagnosed with autism spectrum disorder, or patients from specific patient populations, such as primary care patients.
The included studies focused on six sub-themes. The majority of studies assessed conversation dynamics , investigating the role of eye contact during conversations. Developmental studies focused on the role of eye contact during healthy infant and child development. Adult psychiatry studies assessed the role of eye contact in adult psychiatric disorders. Proximity studies examined its role in approaching or distancing behaviors. Studies in developmental psychopathology focused on the relationship between eye contact and the development of psychiatric disorders in infants and children. Lastly, group dynamics studies investigated the role of eye contact within groups.
Operationalization of Eye Contact in the Included Studies
Two main approaches to assess eye contact were found: direct (eye contact is assessed while it occurs and is not retrospectively verifiable) and indirect (eye contact is registered and assessed after it has occurred and is therefore verifiable retrospectively). Within these two categories, eight specific techniques to assess eye contact could be distinguished. A description of each category and technique, with examples illustrating the variety of methodologies, is provided in Table 2 .
There was wide variation across studies in how eye contact was defined, specifically regarding the reciprocity of eye contact. In studies using reciprocal measures ( n = 45 out of 109), eye contact was defined as situations in which one individual gazes at the other and vice versa simultaneously (i.e., two-way). In studies using non-reciprocal measures ( n = 43 out of 109), eye contact was defined as situations in which one individual gazes at the other, irrespective of the other’s gaze behavior (i.e., one-way). The remaining 21 studies did not specify the reciprocity of their measures.
Definitions additionally differed in the specific location to which gaze should be directed to be defined as eye contact. Twenty-nine studies specified that only gaze directed towards the eye-region was considered as eye contact. Twenty-six specified eye contact as gaze directed towards the face region. Nineteen defined eye contact more broadly as gaze directed towards another person. Two studies specified that gaze needed to be directed towards a general area, e.g., towards the interacting partner. Almost one third of the studies ( n = 33) did not specify any region.
Participant Behavior in the Included Studies
Across included studies, eye contact was measured in relation to various behaviors and/or tasks, i.e.:
Natural behavior the participants carried out their regular activities as they would have done, had they not been involved in the research, usually in a familiar setting (e.g., at home). Their behaviors were observed and their amount of eye contact while doing so was measured. Examples of natural behavior in the included studies are mothers breastfeeding their children (Arco et al. 1979 ); patients visiting their physicians for a medical consultation (Asan et al. 2013 ); waiting room behavior (Cary 1978 ); and musicians performing at a concert (Biasutti et al. 2016 ).
Interview participants responded to a set of questions asked by an interviewer, researcher, or confederate. An example is a study in which frequency of eye gaze while being interviewed was compared between anorexic young women and a control group (Cipolli et al. 1989 ).
Assigned task participants were assigned a specific task, usually in an experimental setting. The most prevalent task was conducting a conversation on a topic specified by the researcher, e.g., self-disclosure (Amerikaner 1980 ). Examples of other tasks are: a bowling game (Iizuka 1994 ); a role play (Breed and Porter 1972 ); looking at one another (Hessels et al. 2017 ); and participating in a training (Hurley and Marsh 1986 ).
Other studies measured eye contact during behaviors that fit into several of the categories. Examples are studies where participants had to participate in an interview while performing a specific task, e.g., providing false answers (Jundi et al. 2013 ; Mann et al. 2013 ).
Remarkably, participants were rarely made aware of the fact that their gaze behavior was being observed; the majority of the studies included covertly measured eye contact.
Operationalization of Eye Contact over Time
Figure 2 documents changes in the use of methodologies over time. The most frequently used method from 1965 to 1978 was the event recorder. The use of video camera(s) became more frequent between 1978 and 1991, and was still the most common method between 2004 and 2017. Recently, new techniques using camera on glasses and eye tracking have emerged. Between 2004 and 2017 coding sheets were used more frequently to assess eye contact compared to earlier time periods.
Use of various techniques over different time periods
Over time, technical advances have resulted in eye contact measures that have become increasingly precise and accurate. Higher resolution has enabled more temporal and spatial precision. For instance, when estimating the total duration of eye contact based on observer judgment, one may estimate in minutes or perhaps seconds. Eye-tracking techniques enable estimates of eye contact duration in milliseconds (Hessels et al. 2017 ; Hurley and Marsh 1986 ). The same accounts for spatial resolution. A coding sheet may capture whether someone gazes towards the general face region, whereas eye tracking enables researchers to distinguish between gaze towards the right vs. the left eye (Hessels et al. 2017 ; Phillips et al. 1992 ).
Studies also differed regarding the involvement of the assessor in the actual eye contact. In 15 studies, the assessor was directly involved in establishing eye contact. For example, in multiple studies, the assessor served as interviewer and pressed a button on an event recorder whenever the interviewee looked them in the eyes. In the remaining 94 studies, assessors were not involved in the eye contact. For example, in multiple studies, independent assessors retrospectively scored the occurrence of eye contact based on video recordings of an interaction.
Figure 3 shows that the involvement of assessors in assessing eye contact has decreased over the years.
Decrease of assessor involvement in eye contact registration
Covariance Between Operationalization and Study Characteristics
A frequency analysis of co-occurrences between participant age groups (adolescents; adults; children; elderly; infant; mixed) and operationalizations (study design; technique; moment of assessment; reciprocity; gaze location; involvement of the assessor) was performed (see “Appendix 3 ”). Few distinct patterns of co-occurrence were found, except for one: most observational studies were done with infants and children (18 out of 30) and most experimental studies were done with adults (56 out of 78). Next, a frequency analysis on co-occurrence of study field (approach-proximity; conversation; development; developmental psychiatry; group dynamics; psychiatry) with operationalizations was performed. Results again yielded few patterns, except that almost half of the observational studies (14 out of 30) were focused on (child) development whereas most experimental studies (39 out of 78) were focused on conversations.
It was not possible to quantitatively examine co-occurrence of research questions with methodology of the included studies, because of their high diversity.
To create an overview of the various ways in which eye contact has been measured across disciplines we explored the assessment of eye contact in empirical studies. We identified 109 studies measuring eye-contact starting from 1965. We distinguished two categories of assessment, i.e., direct and indirect, and eight specific assessment techniques used within six different research disciplines. The identified techniques varied in spatial and temporal specificity, and in their reliance on human judgment.
Our results demonstrate a wide variety of methods to assess eye contact. Specifically, the eight identified techniques produce different outcomes. Estimation by a participant or observer yields a single indicator of eye contact occurrence. A coding sheet gives an assessor’s estimation of the level of eye contact on a predefined scale. A timer provides a (cumulative) amount of duration, and an event recorder both frequency and duration of the level of eye contact. Video camera(s) yield any of the aforementioned outcomes and can additionally be used for retrospective assessment. A camera on glasses can additionally provide a mobile perspective. Head-mounted and desk-mounted eye-tracking techniques assess (mobile) time and frequency of fixations within a certain area of interest. These different techniques have evolved over time, increasing in temporal and spatial resolution. Eye-tracking yields more precise measurements than estimation or coding sheet techniques. Eye-tracking techniques also enable researchers to operationalize eye contact with more refined criteria, thereby facilitating replication studies.
Yet, the more novel techniques may not necessarily be the preferred techniques—they are often more expensive, require a different set of skills and have so far been time-intensive, limiting sample sizes (Franchak et al. 2017 ; Honma 2013 ). Yet, due to fast technological advances, eye tracking analysis is now becoming less time intensive, enabling larger sample sizes. Additionally, not every research question requires the precision that eye-tracking enables. In Table 3 , we provide an overview of the possibilities offered by the various techniques, to provide some guidance in choosing the right technology for different types of research questions. Our recommendations are not definite. Researchers should choose what best suits their research question, population, and task. In their decisions, they can take into account factors such as obtrusiveness, interest in subjective experience or gaze location, and the required temporal and spatial resolution. For example, if the aim is to understand the gaze behavior of individuals diagnosed with autism spectrum and/or social anxiety disorders, researchers might want to take into account both frequency and duration of gaze towards the eye region, as these people may differ from healthy controls in dwell times and frequency of looking at the eyes (Auyeung et al. 2015 ; Hessels et al. 2018a ). In people with social anxiety disorder, one might additionally want to assess their estimation of the level of eye contact in comparison to healthy controls, since their interpretation of eye contact might differ (Honma 2013 ). If the aim is to understand gaze behavior of healthy neonates, observation with video cameras or coding sheets may be appropriate, as these are the least intrusive (Harel et al. 2011 ).
Our results show that the use of measures in which the assessor of the eye contact is involved as an interactor in the eye contact, which therefore cannot be verified afterwards, has decreased over time. Although their relative subjectivity may make these measures less reliable, they do justice to the definition of eye contact as a subjective perception of perceiving another person’s gaze (Gamer and Hecht 2007 ).
People’s experience of eye contact can be influenced by many factors, such as the presence of a third person, the distance from the other persons’ face, or the perceiver’s visual acuity (Gamer and Hecht 2007 ). We found that researchers often operationalize eye contact as being tied to a specific gaze location. Yet, this may not do justice to the personal experience of eye contact. It is known that humans are not always capable of judging when they are being looked at in the eyes. Particularly downward directions (i.e., towards the mouth) often still elicit the experience of eye contact (see Gamer and Hecht 2007 ). However, in specific cases, it could be relevant to focus on specific gaze locations such as the eye region, for example, when using the amount of eye contact as a diagnostic criterion for pathologies such as autism spectrum disorder. Whereas humans are usually unable to assess whether gaze is directed towards specific facial regions, novel measurement techniques like eye tracking are capable of doing so (Auyeung et al. 2015 ; Gamer and Hecht 2007 ).
If possible, future studies should combine measures that rely on personal experience of eye contact with techniques without the assessor’s involvement in the eye contact registration, to determine (dis)congruence between their results. Such studies could, for example, investigate to what extent gaze location reflects people’s subjective experience of eye contact.
When investigating eye contact, researchers should choose their methods based on what best fits their research aim and population. For example, the subjective experiences of neonates are obviously impossible to assess, whereas in psychiatric populations it may be very insightful to measure people’s personal experience of eye contact. This aligns with our finding that studies involving infants and children were almost always observational, whereas the experimental studies more often included adult populations.
Our results demonstrate that studies assessing eye contact are heterogeneous, not only in measurement methods, but also regarding study populations and the behaviors that were studied. Such behaviors ranged from naturally occurring conduct, through being interviewed, to assigned tasks such as conversation, games, or trainings. The most coherent group of behavioral tasks studied was identified in developmental psychology and involved observational, naturally occurring behavior of infants. Overall, however, the wide heterogeneity in tasks, outcomes and operationalizations prevents researchers from comparing findings regarding eye contact across studies.
To our knowledge, only two studies have compared eye-contact measures, examining the differences between observer and participant rating (Edmunds et al. 2017 ; Shaw et al. 1971 ). One of these found weaker correlations between observer and participant eye contact ratings, than between multiple observer ratings (Shaw et al. 1971 ). The other study found that using a standing video camera was less reliable than using camera on glasses (Edmunds et al. 2017 ). Other studies evaluated the reliability and validity of measuring eye contact using either observer ratings (Knight et al. 1973 ) or video coding (Beattie and Bogle 1982 ). All of those concluded that there were methodological issues with the studied techniques. For example, when using observer ratings, the distance between observer and participants was found to affect the rating reliability (Knight et al. 1973 ). When using video cameras, using two cameras (each focused on one of the interactors’ faces), combined in a split-screen was found to be more reliable than using one camera only or two cameras with greater distance (Beattie and Bogle 1982 ). More studies comparing multiple measures to assess eye contact are needed to provide researchers with guidance in choosing optimal measures for their particular study aim. Furthermore, such comparative research would provide insight into the interpretability of eye contact measures, facilitating the interpretation of both previous and future studies. In addition to choosing between measurement techniques, researchers also need to decide on their specific outcome operationalization. For example, when using eye-tracking, both frequency and duration of eye contact have been used. How precisely to interpret the associated outcomes is not clear yet. For example, a person who makes very frequent, brief eye contact may either be perceived as attentive or as restless. How frequency and duration relate to each other, remains to be determined in methodological research.
A surprising finding is that only a few studies include a detailed description of their methods for assessing eye contact. We excluded studies that did not explicitly describe their measures. Still, 31% of the included studies lacked a specific description of the target gaze region of the supposed eye contact. Moreover, in 19% of the studies, it was unclear whether eye contact was operationalized as reciprocal or not. As a consequence, we cannot assess the comparability of studies aiming to measure eye contact. The use of different measures could signify that different studies are investigating different things. For instance, a study measuring unidirectional eye contact using a scale might yield completely different results than a study measuring reciprocal eye contact with desk-mounted eye tracking.
The issue of comparability may, in reality, be even more profound than identified in our review. We included only research focused on ‘eye contact’, not on related phenomena, and excluded any research on eye contact that did not involve (at least) two human beings. In the research we excluded, even more ways to measure eye contact may have been employed. An example is research instructing individuals to make eye contact with an experimenter in an experimental condition, after which researchers make inferences about whether eye contact has taken place, albeit without formal measurement: (Ponkanen and Hietanen 2012 ). Other studies outside of the current review’s scope have, for example, instructed participants to look at pictures of faces, using their gaze behavior as a model system for studying human social interaction (Senju and Johnson 2009b ). This even greater heterogeneity in measurement could lead to incoherent research findings and conclusions. Future studies should precisely define and operationalize eye contact to enhance interpretation and comparability across studies.
Our conclusions should be interpreted in light of some limitations. First, we did not assess the quality of the included studies, given that our primary focus was to analyze the methodology used to assess eye contact. It is thus possible that the quality of the included studies varies, especially taking into account they date back as far as 1965. However, we believe that giving a broad and historical perspective on the methodologies used to study eye contact justifies our choice. Second, we selected peer-reviewed articles in English only and therefore excluded published articles in other languages.
In this review, we have highlighted the methodological diversity of measures to asses eye contact between two human beings. Of particular importance for future work is how various operationalizations of eye contact—such as the personal experience of eye contact or the more precise measures assessing gaze location—can be used to better understand the phenomenon of eye contact and its consequences for human interaction. To do this, research is needed that captures both the first-person experience of eye contact and the more objective outsiders’ perspective. Researchers need to make their choices for specific definitions and operationalizations of eye contact well-founded, based on evidence or theory. Future studies would benefit from specific descriptions of which techniques were used, the direction of gaze (reciprocal or not), the area of interest of the gaze direction (eyes, face, body or person), and the participant behavior. Moreover, a more meticulous investigation of the comparability of measures is needed before conclusions can be drawn and theories formed about the workings of eye contact.
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Department of Medical Psychology, Amsterdam Public Health Research Institute, Academic Medical Center, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands
Chiara Jongerius, Ellen M. A. Smets & Marij A. Hillen
Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, The Netherlands
Roy S. Hessels
Developmental Psychology, Utrecht University, Utrecht, The Netherlands
Department of Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
Johannes A. Romijn
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Jongerius, C., Hessels, R.S., Romijn, J.A. et al. The Measurement of Eye Contact in Human Interactions: A Scoping Review. J Nonverbal Behav 44 , 363–389 (2020). https://doi.org/10.1007/s10919-020-00333-3
Published : 20 April 2020
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DOI : https://doi.org/10.1007/s10919-020-00333-3
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Imagine listening to a computer-generated voice that pronounces each word perfectly but without any inflection or variety. Such a voice would be devoid of the rich sounds of nonverbal communication, which include pitch, volume, accent, and all the other qualities that characterize voices. Now, think about an e-mail exchange. Sometimes, the words people type are all that is needed. Other times, the words themselves are not enough, so people embellish them by adding bold typeface, italics, or extra punctuation marks such as ellipses or exclamation points. People also insert emoticons, which are symbols such as smiling or frowning faces, to add a nonverbal dimension to e-mail.
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Conversely, it is difficult for humans to imagine a world that is completely nonverbal. When people visit foreign countries where they do not speak the language, they may try to use nonverbal communication such as pointing and facial expressions to get their message across, but without a common language to speak, interaction can be frustrating and counterproductive. As another example, think of the joy parents experience when their baby first starts to speak. Although children could previously communicate with their parents nonverbally, language opens up a whole new avenue of communication, allowing for more precise and intricate exchanges of information.
As these examples illustrate, verbal and nonverbal forms of communication are both essential parts of human interaction. Although both forms of communication can be used alone, they are more frequently used together. In this research paper, the interplay between nonverbal and verbal communication is explored. First, a brief history of the emergence of nonverbal communication as an area of research is reviewed. Next, nonverbal and verbal forms of communication are conceptualized and distinguished from one another, followed by a discussion of what constitutes verbal and nonverbal codes. This research paper ends with a brief section on future directions for research.
History and Foundations
Various forms of nonverbal communication have been studied throughout the ages. The ancient Greeks and Romans studied how to use nonverbal behaviors to be more persuasive. During the 18th century, many Europeans were educated in the art of elocution—how to use gestures, posture, dress, and proper diction to make speeches more dramatic and emotional. The first social scientific perspectives on nonverbal communication emerged in the 19th century. Most notably, in his book The Expression of Emotion in Man and Animals, Charles Darwin (1872/1904) examined how nonverbal behaviors communicate emotion in socially adaptive ways. In the latter half of the 20th century, psychologists and communication researchers began focusing more attention on nonverbal aspects of the communication process.
Ekman and Friesen’s Early Contributions
Paul Ekman and Wallace Friesen were among the first to examine how nonverbal and verbal codes work together. They described five relationships between nonverbal and verbal communication: repetition, substitution, complementation, contradiction, and emphasis (Ekman & Friesen, 1969). Repetition occurs when the verbal and nonverbal message communicates the same thing. Saying “No” while shaking one’s head or “Stop!” while putting one’s hand out are examples of this. Substitution occurs when nonverbal behavior takes the place of a word or words.A nod may be used rather thantheword“Yes,”or a high-five may say “Congratulations!”
Complementation takes place when the nonverbal and verbal messages add to one another, sometimes to create a clearer meaning. For example, smiling while looking into a spouse’s eyes and saying “I love you” communicates an especially high level of warmth and affection. Contradiction is at work when the verbal and nonverbal messages are at odds with one another, such as saying “I’mnot mad” whilelooking away and making a surly face or being sarcastic, which occurs when speakers use vocal tone to indicate that they mean the opposite of what they are saying. Finally, emphasis involves using nonverbal communication to underscore what is being said. Yelling while saying “Watch out!” emphasizes the urgency of a dangerous situation, just as a hand gesture might indicate that a point someone is making is especially important.
Ekman and Friesen’s (1969) early work also examined the following five types of kinesic behavior that help describe how body movement functions within the total communication process: emblems, illustrators, affect displays, adaptors, and regulators. Emblems refer to a set of body movements that “have a direct verbal translation” (Ekman & Friesen, 1969, p. 63). They can stand in for words entirely and often do so when verbal communication is difficult or inappropriate (Ekman & Friesen, 1969; see also Burgoon, Buller, & Woodall, 1996; Streek & Knapp, 1992). Therefore, they are often used strategically. Emblems have a common verbal meaning within a given culture or social group. For instance, in U.S. culture, there are emblems that mean “Good luck!” (crossing one’s fingers), “Way to go!” (giving a thumbs up), and “Stop!” (putting one hand up with the palm facing away from the face). Emblems are typically so well understood within cultural or social groups that they “are virtually independent of linguistic context” (Bavelas & Chovil, 2006, p. 100). However, when used outside one’s own cultural or social group, emblems are frequently misunderstood. Giving a thumbs up is translated as “Way to go!” or “Congratulations!” in the United States, but in many places around the world, including Iran, the thumbs up is a rude, offensive gesture.
Affect displays are body movements that transmit internal emotional states (Ekman & Friesen, 1969), such as clenching one’s fists to display anger or smiling to exhibit happiness (see Andersen & Guerrero, 1998, for a review).
These body movements sometimes accompany speech and have the ability to replicate, say the opposite of, or qualify verbal communication (Ekman & Friesen, 1969). For example, a person might say, “I’m so angry with you,” while displaying a furrowed eyebrow and showing his or her teeth (Shaver, Schwartz, Kirson, & O’Connor, 1987), whereas another person might say, “I’m not jealous,” while displaying a cold look. Some facial expressions of emotion need to be interpreted within the context of accompanying speech (Mead, as cited in Jones & LeBaron, 2002). Speech, however, is not a necessary component for the communication of affect (Bavelas & Chovil, 2006; Burgoon et al., 1996). People recognize stereotypic, universal facial displays of sadness, such as frowning and downcast eyes, in the absence of verbal communication (Bavelas & Chovil, 2006). When affect displays become easily recognized without speech, they may be classified as emblems because they are so easily interpretable (Ekman & Friesen, 1969).
Illustrators help describe, clarify, or emphasize something. Examples include drawing a declining line in the air when talking about a dropping number of car sales, pretending to kick a ball, drawing the shape of an A-line skirt in the air when describing it, pointing to a star in the sky while saying “That star,” and using hand gestures to indicate the speed of a song when conducting a symphony (Andersen, 2008).
Sometimes emblematic behaviors function as illustrators. For instance, a person might make a circle around her or his ear to indicate that someone is crazy while saying “psycho” (Ekman & Friesen, 1969, 1972). In this case, the emblematic behavior emphasizes and clarifies the meaning of the term psycho.
As the above examples suggest, illustrators are “movements which are directly tied to speech” (Ekman & Friesen, 1969, p. 68). Although illustrators sometimes repeat verbal communication (Burgoon et al., 1996; Ekman & Friesen, 1969), as much as 80% of gestures in some research on faceto-face interaction involve “nonredundant information” (see Bavelas & Chovil, 2006, for a review). In fact, gestures that fall under the illustrator category may complement, emphasize, and sometimes even disagree with the spoken word (Burgoon et al., 1996; Ekman & Friesen, 1969). Some illustrators, such as batons and ideographs (Ekman & Friesen, 1969), are highly related to linguistic context, as “their meanings depend on the ‘talk thus-far’ and are worked out in the talk that succeeds them” (Streek & Knapp, 1992, p. 13; see also Bavelas & Chovil, 2006). For example, a person must rely on linguistic cues to determine the meaning of a raised eyebrow, which could be used to emphasize a word, show one’s surprise or confusion, or flirt with someone, among other possibilities (Bavelas & Chovil, 2006).
Adaptors, or actions of the body used to “satisfy self or bodily needs,” have no special connection to speech (Ekman & Friesen, 1969). Most adaptors are directed toward the self, such as moistening one’s dry lips with a tongue, scratching one’s arm, biting one’s nails, twisting the ring on one’s finger, or chewing on a pen. Some adaptors are directed at other people, such as tucking a strand of hair behind a friend’s ear or wiping the dirt off a child’s face. Adaptors are often enacted without intention or conscious awareness, although object adaptors may be used to intentionally communicate. Self-directed adaptors are used most frequently when people are alone or do not think that others are watching them (Ekman & Friesen, 1972).
The last set of kinesic behaviors, regulators, are body movements that are connected to verbal communication in a distinct way. Although they “carry no message content in themselves,” they “convey information necessary to the pacing of the conversation” (Ekman & Friesen, 1969, p. 82). For example, a person may nod his or her head to encourage another person to continue speaking. Other regulators, such as eye contact or lack thereof, raising of an eyebrow, and shifts in posture, may indicate to a speaker to stop talking altogether, to repeat a message, and/or to let another person speak. Ekman and Friesen (1969) note that adaptors and affect displays can perform regulative functions in a conversation.
Watzlawick, Beavin, and Jackson’s Early Contributions
At around the same time that Ekman and Friesen’s classic work was published, Watzlawick, Beavin, and Jackson’s (1967) groundbreaking book, Pragmatics of Human Communication, brought nonverbal messages to the forefront of the communication field. Prior to the 1960s, communication scholars tended to examine verbal messages related to persuasion, self-disclosure, and power without considering nonverbal messages. Two propositions from Watzlawick and colleagues’ (1997) book changed this. Specifically, the authors advanced the famous propositions that one cannot not communicate and that every message has a content and relational level. According to the “one cannot not communicate” proposition, it is impossible for people to avoid communicating with others. Even when people do not speak, nonverbal behaviors such as posture, gestures, physical appearance, and facial expressions communicate messages.
In terms of the distinction between the content and relational level of messages, the content level refers to literal meaning, whereas the relational level refers to how a message is interpreted within a given context. On a relational level, a message is interpreted on the basis of the situation, the relationship people share, and the nonverbal behaviors people display. For example, imagine that Maria and Jake are sitting on opposite ends of a couch watching a movie. Maria says, “I’m cold.” Her statement has a literal meaning, but it also has several potential relational meanings. If Jake interprets Maria to mean “Do something so I’m not so cold,” he might rearrange the blanket on his lap so that it covers both of them or he might get up and switch the heat on. Perhaps Maria and Jake have been arguing and Maria’s comment means that she is feeling cold toward him. Or perhaps saying “I’m cold” is a signal that she wants Jake to put his arm around her so that they can make up. The way Jake determines the relational meaning behind Maria’s words would partially depend on her nonverbal communication. Did she smile and sound wistful when she said “I’m cold,” or did she look away from Jake and sound tense? Understanding that every message has a content and relational level helps highlight how verbal and nonverbal communication work in concert to create meaning.
Distinguishing Nonverbal and Verbal Communication
To fully understand the interplay of nonverbal and verbal communication, it is essential to conceptualize these terms and distinguish them from one another, especially since there is controversy in the scholarly community regarding where the line between verbal and nonverbal falls. For early nonverbal scholars, the issue was fairly simple: Words constituted verbal communication, and everything other than words constituted nonverbal communication (Burgoon & Saine, 1978; Eisenberg & Smith, 1971; Knapp, 1978; Mehrabian, 1972). Since then, however, researchers have argued that this definition is too broad and that it does not help people understand the qualities that distinguish verbal and nonverbal communication. For instance, if nonverbal communication is everything but words, does it include body movements such as involuntary blinking, which no one pays attention to? Most contemporary researchers would say “No” and argue that involuntary displays of behavior should not be studied as communication (e.g., Bavelas, 1990; Burgoon et al., 1996; Guerrero, Hecht, & DeVito, 2008).What about sign language or Braille? In these cases, the channel is nonverbal (gestures or touch), but the message is made up of words.
Analogic Versus Digital Processing
A more contemporary conceptualization of the distinction between nonverbal and verbal communication rests on whether the message is processed digitally or analogically (Andersen, 2008; Gudykunst, Ting-Toomey, & Chua, 1988). When a message is processed analogically, people consider the whole message rather than dissecting it into smaller parts. In contrast, when a message is processed digitally, people make sense of it by looking at all the parts that make up the whole. Think about how children learn the alphabet. Often, they learn to sing theirABCs before they learn to say them.To a 3-year-old, “LMNOP” is usually a sound, not five distinct letters.This is because they havelearned theABCs bysinging, which is an analogic activity.When they learn to say (and later write) each letter of the alphabet, they will be processing the information digitally. Analogic information, such as songs, artwork, facial expressions, and body movement, is processed primarily in the right side of the brain. Digital information, such as numbers, letters, and distinct words, is processed primarily in the left side of the brain (Andersen, 2008).
Some scholars have argued that communication is only nonverbal if it is processed analogically (Andersen, 2008). According to this view, nonverbal communication is continuous and holistic and as such is processed as a gestalt. This means that people see the “big picture” when processing nonverbal communication, just as young children see “LMNOP” as something bigger than each individual letter. Verbal communication, on the other hand, involves linguistic information that is processed digitally (Andersen, 2008). Verbal information consists of discrete units that are highly notational and logical, such as the individual letters of the alphabet or individual words in a sentence. (See Table 1 for the key characteristics distinguishing verbal and nonverbal communication.)
Table 1. Key Distinguishing Features of Verbal and Ninverbal Communication
Iconic Versus Symbolic Communication
Most verbal communication is symbolic and culturally specific. When communication is symbolic, there is an arbitrary relationship between the word (or behavior) and what it means. For example, in English, the word tree came to refer to something that grows up from the ground and has a trunk and (usually) branches. However, people could have easily chosen another word to represent tree (e.g., maybe “huckily”). Indeed, in other cultures, there are many different words for “tree.” These words do not resemble or relate to the trunk with the branches growing out of it in any real way; the association is arbitrary. People who do not know English would not connect the word tree to the image of the trunk with branches.
In contrast, many forms of nonverbal communication are iconic or intrinsic. Iconic messages resemble what they stand for. Examples of iconic messages include using one’s hands to show how big, tall, thin, or short someone is; pretending to kick a ball or swing a bat; or pointing to show direction. Intrinsic behaviors are actions that show a person’s internal state or constitute behavior in and of themselves. Examples include smiling, crying, hitting, and kissing. These types of behaviors tend to be understood across cultures, although there may be differences in the cultural rules that govern them. As a case in point, kissing is universally understood as an affectionate action, but the rules for kissing vary by culture (e.g., kissing both sides of the face to greet someone is more appropriate in some parts of the world than others).
Although it is tempting to classify words as symbolic and behaviors other than words as iconic or intrinsic, the distinction is not quite so simple. Onomatopoeia words, such as “buzz,” “flush,” and “tap,” are iconic and may be understood across cultures. Similarly, although many body movements and vocalizations are iconic or intrinsic, others are symbolic. For instance, emblems can be translated into words and have various symbolic meanings in different cultures. Crossing one’s middle finger and forefinger have different referents depending on one’s culture. In the United States, this gesture commonly means “good luck” if held up in front of one’s face and “I’m lying” if held behind one’s back. In other cultures, this gesture is a sexual symbol, a symbol of friendship, or an obscene gesture. Although gestures such as the U.S. “good luck” gesture often have iconic roots (“I’m with you” in the case of the good luck meaning; “We’re close” in the case of the friendship gesture; one person on top of another in the case of the sexual symbol), they evolve so that they become synonymous with a particular meaning, thus functioning as a symbol.
Overall then, the relationships between most verbal communication and their referents are arbitrary and culturally specific. In contrast, a considerable portion of nonverbal communication is iconic or intrinsic and therefore understood (at least sometimes) across cultures. There is a gray area between these two positions. This gray area is occupied by onomatopoeia words and emblems. Some scholars consider emblems to be a form of nonverbal communication, and other scholars consider them to be a form of verbal communication. Those endorsing emblems as nonverbal communication cite their iconic roots (Guerrero & Floyd, 2006), whereas those endorsing emblems as verbal communication cite their verbal translation and constancy (Andersen, 2008).
Multimodal Versus Unimodal
In face-to-face contexts, one key distinction between nonverbal and verbal communication is that the former is multimodal or multichanneled whereas the latter is unimodal or unichanneled (Andersen, 2008; Burgoon, Guerrero, & Floyd, in press). This means that people can send various nonverbal messages at the same time. A person can simultaneously smile while leaning forward and gesturing, but a person can only say one word at a time.
The multimodal nature of nonverbal communication separates it from verbal communication while also making it an especially complex and sometimes ambiguous form of communication. If a person engages in multiple nonverbal cues at the same time, which behavior should a receiver focus on most? A receiver may not even pick up on all the different nonverbal cues that are occurring. This is why people often process nonverbal communication as a gestalt—in other words, they create a global image of the person’s behavior in their mind rather than trying to interpret each behavior separately (Andersen, 2008). Obviously, however, there is considerable room for misinterpretation, especially if the receiver ignores or downplays some potentially meaningful behaviors.Although verbal communication can also be misinterpreted (and often is), the unimodal nature of verbal messages leaves less room for ambiguity.
Spontaneity Versus Intentionality
The term communication itself is defined differently by various scholars. Some scholars believe that for communication— either verbal or nonverbal—to occur, a sender must direct a message to another person or persons (Motley, 1990, 1991). Other scholars believe that communication occurs whenever a receiver attaches meaning to another person’s words or behavior (Andersen, 1991). Still others contend that communication occurs under either of these conditions (Guerrero & Floyd, 2006). The most common conceptualization of nonverbal communication is in line with the latter perspective, with nonverbal communication defined as nonlinguistic behaviors (body movement, vocal tone, facial expressions, etc.) that are either sent with intent or interpreted as meaningful by a receiver. This definition is appropriate for nonverbal communication because many forms of nonverbal communication occur spontaneously (Andersen, 1991). This is especially true of intrinsic nonverbal behaviors, such as crying, smiling, sighing, or speaking in a nervous voice. Such behaviors are often spontaneous expressions of a person’s internal feelings. People tend to trust spontaneous nonverbal cues more than they trust words (Burgoon et al., 1996).
Verbal communication, in contrast, tends to be sent with intent. Sometimes, verbal communication is highly strategic; people purposely say things a certain way to try to reach a particular goal. Other times, verbal communication is intentional insofar as it is directed toward another person (Motley, 1990). Although people can botch up what they mean to say, they still have a choice as to whether to utter the words or not. Some nonverbal behaviors are harder to control. People have difficulty controlling tears in their eyes, fleeting facial expressions of emotion, and vocal anxiety because such behaviors are highly spontaneous.
Of course, some nonverbal communication is strategic.A person might fake a yawn as an excuse to leave a social gathering early or smile as a means of trying to manipulate someone or create a good impression. To further complicate matters, the line between spontaneity and strategy can be blurry. Take the case of emblems. Emblems such as the hitchhiker’s thumb or the “OK” gesture are used like words and are therefore strategic. But many facial emblems (see Ekman & Friesen, 1969), such as a sad or a happy face, can be spontaneous or strategic, depending on the situation. In general, however, verbal communication tends to be more strategic, whereas nonverbal communication tends to be more spontaneous.
Displacement and Reflexivity
While nonverbal communication is unique in terms of its iconicity, multimodal nature, and spontaneity, verbal communication has the unique qualities of displacement and reflexivity (Burgoon et al., 1996). Displacement refers to the ability to refer to things that are removed in time and space. For example, people can talk about how they felt last week compared with this week or how they would like things to change in the future. Nonverbal communication, in contrast, occurs in the here and now. Displacement is also related to being able to talk about things that are absent or nonexistent through the use of the negative. A daughter can tell her mother how she does not feel (“My throat doesn’t hurt”) as well as how she feels (“but my nose is really stuffed up”). It is more difficult to indicate negative states with nonverbal communication. The daughter could point to her throat and shake her head, but this could be interpreted in multiple ways (i.e., as indicating that her throat feels bad rather than that it does not hurt). Thus, verbal communication has a much greater ability for displacement than nonverbal communication.
Similarly, verbal communication has the special quality of reflexivity (Burgoon et al., 1996), which means that language can reflect on itself. A son might tell his father, “I didn’t mean to sound so sassy,” and his dad might reply, “I didn’t mean to sound so harsh.” People also make statements such as “I wish I hadn’t said that,” “I’m not doing a good job telling you how I feel,” “I think you misunderstood what I was trying to say,” and so forth. Words allow people to refine and reconstruct the meanings of other words that were previously uttered in a way that nonverbal communication cannot.
Nonverbal and Verbal Codes
Thus far, nonverbal communication has been conceptualized as analogic behavior that is multimodal, is usually iconic or intrinsic, and tends to be more universal and spontaneous than verbal communication.Verbal communication, in contrast, has been conceptualized as digital, symbolic, unimodal, and culturally specific. Displacement and reflexivity are two unique characteristics of verbal communication. Next, this research paper examines the various codes that constitute both nonverbal and verbal communication (see Table 2). A “code is a set of signals” that is associated with a unique message channel (Burgoon et al., 1996, p. 18). A channel is the mode of transmission, such as the voice, the body, or the environment. Within most channels, some messages are communicated nonverbally, whereas others are communicated verbally.
Table 2. Nonverbal and Verbal Codes
Within the area of nonverbal communication, proxemics and haptics are both contact-related codes. Proxemics refers to messages communicated through the channel of space (Smeltzer, Waltman, & Leonard, 2008). For example, a nonverbal scholar studying proxemics might be interested in the fact that romantic partners generally sit closer to one another than friends (Guerrero, 1997) or that employees sometimes position their belongings in a particular way to show their cubicle space or their “territory” on the lunchroom table (Smeltzer et al., 2008). Haptics, or tactile communication, refers to messages communicated through human touch, which may span from intimate touch, such as hugging and holding hands, to nonintimate and even aggressive touch, such as punching and kicking (Guerrero et al., 2008).
There are also verbal cues related to space and touch. For example, people regulate space using devises such as welcome signs, keep-out signs, and bumper stickers with sayings such as “If you can read this you’re too close” (Andersen, 2008). Public territory and traffic are also governed by signs that tell people when and for how long they can park, when they can turn left or right, and whether a beach or park is public or private. At the haptic level, Braille is an excellent example of a tactile language that is processed digitally rather than analogically (Andersen, 2008). Braille is a language system complete with all the letters of the alphabet and punctuation necessary to string letters together to make words and to string words together to make sentences.
When most people think about nonverbal communication, they think about body language. The formal name for body language is kinesics . Nonverbally, kinesic codes involve actions of the body that communicate signals without using touch or physical contact with another person (Burgoon et al., 1996). For example, posture, eye behavior, facial expressions, body movements (such as pointing or scratching one’s arm), and most gestures fall under the nonverbal code of kinesics (Burgoon et al., in press; Guerrero et al., 2008). These types of kinesic cues can vary in terms of degree and intensity. A person can use demure eye contact to flirt or steady eye contact to intimidate. Similarly, a person’s posture can vary from extremely relaxed to extremely tense.
Verbal kinesic cues, in contrast, tend to be more constant. In other words, there is much less variability in how people express verbal cues communicated through the kinesic channel. American Sign Language is a good example of a system of verbal communication that involves body movement. Like Braille, sign language includes behaviors that stand for words as well as letters that are strung together in logical ways that allow people to make sense of them. Similarly, lip reading is a form of verbal communication that involves being able to decode kinesic behaviors into words (Andersen, 2008).
While certain gestures, such as using one’s hands to show how tall or short someone is, fall neatly into the category of nonverbal communication, others do not. Andersen (2008) argued that emblems such as the “good luck” gesture and “the finger” are actually forms of verbal communication because they are processed digitally like language and tend to be constant rather than variable. However, other scholars include emblems as a form of nonverbal communication (e.g., Burgoon et al., 1996; Knapp & Hall, 2006). Guerrero and Floyd (2006) considered emblems to be a form of nonverbal communication because such gestures nearly always share a resemblance to the words or ideas they communicate. Thus, their origins are iconic even though they become symbolic once they are universally understood within a given culture or social group. Moreover, gestural and vocal emblems (e.g., putting one’s index finger over one’s mouth and saying “shhh” to signal that someone should be quiet) tend to be used strategically, whereas facial emblems (e.g., smiling or rolling one’s eyes) tend to be much more spontaneous.
Physical Appearance Codes
Fair or not, the way people look creates impressions. For instance, considerable research has demonstrated that there is often a halo effect for good-looking people. People assume that a person who is beautiful on the outside also has positive internal traits, such as being more sociable, honest, and socially skilled (Dion, 1986). There are numerous nonverbal cues related to physical appearance. Some of these cues involve signals sent from the way a person’s body looks, such as hair color, skin color, size of body, and facial features. Other cues involve what a person wears, including clothing and accessories such as jewelry, ties, and scarves.
Although most physical appearances are nonverbal, some are verbal. People often wear T-shirts or jackets with slogans on them. In fact, some schools even have rules about what can and cannot be verbally represented on student clothing. Verbal cues on clothing can also show group membership.A baseball or dance team jacket, for example, might be emblazoned with both the individual’s and the group’s name.
Many people think of the voice as part of the verbal code rather than the nonverbal code. Yet the way people say words communicates important messages. Within the area of nonverbal communication, the terms vocalics and paralanguage are used to describe the part of spoken language that is nonverbal. Vocalics includes all the signals other than the words themselves that are sent through a person’s voice. These include voice qualities such as pitch, accent, speaking rate (i.e., how fast or slow someone speaks), volume, and level of expressiveness, among numerous qualities of the voice (Burgoon et al., in press). Vocalics also includes how people say words—are they singing, shouting, or whispering? Pauses and silence are also part of the vocalic code. For example, the amount of time it takes for someone to respond to another person’s question is a silence that can send a message, as are the silences that convey a cozy level of comfort between two people or an angry grudge.
Verbally, spoken words are part of the voice code. The ability to speak and to construct sentences in ways that make sense to others who speak the same language are essential skills for being able to communicate verbally. Thus, the ability to speak is not enough, nor is the ability to say words. Famous case studies of children who were raised in isolation or with animals have shown that there is a developmental window for learning how to encode language (e.g., Rymer, 1994). Specifically, children need to be exposed to language before puberty if they hope to be able to acquire the language skills necessary to communicate. Although children who were isolated during their childhood often learn hundreds or thousands of words, they do not understand grammar or syntax, and they, therefore, cannot put discrete words together in ways that communicate broader messages.
Environmental and Artifactual Codes
Messages are also communicated via the environment and the objects within that environment. On the nonverbal side, there are myriad environmental cues, such as building design, color, furniture arrangement, noise, temperature, and artifacts (e.g., paintings, flowers). These types of environmental cues often frame communication by encouraging or discouraging social interaction (Guerrero et al., 2008). The objects people carry with them, such as purses, backpacks, briefcases, and cell phones, can also influence communication.
On the verbal side, signs that identify the names of buildings on college campuses, the office of the CEO, or the name of a street are all examples of verbal environmental cues. Room and house numbers can also be considered a form of verbal communication because numbers are processed digitally, as are letters and words. Some artifacts within environments also contain verbal communication. For example, some schools have a copy of the constitution posted on the wall. In museums and zoos, there are often placards that explain an exhibit or give facts about an animal. Personal artifacts, such as diplomas or awards hanging in one’s office, contain verbal information that can enhance a person’s credibility and status.
Researchers studying nonverbal communication use the term chronemics to refer to the ways people “use and perceive time” (Guerrero et al., 2008, p. 10). The way people use time is most closely related to communication. For example, being early or late communicates messages to others, as does the amount of time people are willing to wait for someone and the extent to which a person focuses on one versus multiple tasks at a time. Some people are oriented more toward the present, whereas others are focused on the future (Gonzales & Zimbardo, 2008). In the workplace, people are more likely to be satisfied with their jobs when they have a future time focus and less likely to be satisfied with their jobs when they feel pressured to work at a fast pace (Ballard, 2008). Nonverbal cues related to a fast-paced environment can contribute to feelings of pressure at work.
Time is also communicated through digital, verbal channels. The clock itself constitutes a highly digital mode of communication. In the United States, people frequently wear watches. Clocks are often on walls, computers, cell phones, and palm pilots. Verbally, people talk about “not having enough time to chat” or “having to go so I won’t be late.” Thus, talk about time often serves to help people regulate their communication with others. As mentioned earlier, verbal communication is also unique in that people can refer to things in the present, past, and future by using language. Nonverbal communication only occurs in the present.
Interestingly, people from different cultures may vary in the extent to which they communicate about time using analogic versus digital cues. In some cultures, people view time precisely; in other cultures, people view time as loose and approximate (Hall, 1984). In the United States, people see time as fixed. When asked what time it is, people give the exact (or close to the exact) time. They also keep tight schedules and closely follow rules that regulate time. For individuals in this type of culture, digital forms of chronemic communication, such as watches and calendars, are especially important. In other cultures, such as Brazil and Southern Italy, time is treated more loosely; people are freer to be late or early for meetings; and analogic cues, such as how high the sun is in the sky and how dark it’s getting, carry more meaning.
The Olfactic Code
In contrast to the other codes discussed so far, olfactics is a code that is almost exclusively nonverbal. Nonverbal researchers use the term olfactics to refer to the use and perception of smell as related to communication (Burgoon et al., in press). Although people can talk about something smelling good or bad (just as we can talk about the time), smells are almost always processed in a holistic fashion. The study of olfactics includes research on how people adorn themselves with smells such as perfume (Aune & Aune, 2008). In many places around the world, and particularly in the United States, people use perfume, soap, and body deodorant to convey a particular image to others or to cover up odor. Natural odors related to hormones and DNA structures are also part of the olfactic code (Furlow, 1996), as are smells within the environment.
Although scholars have made much progress in understanding the interplay between verbal and nonverbal codes of communication, much work remains to be done. One of the key issues relates to how much of the meaning associated with an interaction is derived from verbal versus nonverbal cues. Early estimates put the influence of nonverbal communication as high as 93%, but more recent studies suggest that nonverbal cues generally contribute about 65% of meaning, whereas verbal cues contribute about 35% (Burgoon et al., 1996). These percentages change depending on the task. When people are interpreting emotional cues, nonverbal communication is even more important. However, when people are trying to digest information, verbal communication is particularly critical. Future research should continue to explore how verbal and nonverbal cues contribute separately and in concert to create meaning.
Another important issue for future research is cultural differences. As discussed earlier in this research paper, some codes of communication are more easily understood across cultures than others. Researchers have also uncovered a number of cultural differences in the way people communicate nonverbally (for reviews, see Andersen, 2008; Burgoon et al., in press). Yet little is known about the interplay of verbal and nonverbal cues across cultures. Scholars have determined that some countries, such as the United States and Germany, are characterized as low context, which means that people rely more on precise information from verbal communication (Hall, 1984). Other cultures, such as those in Asia, are characterized as high context, which means that people rely more on subtle information from contextual and nonverbal cues. For instance, the Chinese system of writing is filled with intricacies that are rich in meaning. Similarly, the meaning of some Vietnamese words change based on how they are said. In high-context cultures, analogic codes reflected in writing and speaking style appear to fuse with digital codes related to written and spoken words in ways that people in low-context cultures may not understand. There may well be other differences in how verbal and nonverbal codes relate to each other across various cultures, so this is an important area of future research.
Another recommendation for future research is to examine how verbal and nonverbal communication work together to create patterns of reciprocity and compensation. Reciprocity occurs when people display behaviors that have similar meanings (Burgoon et al., 1996). So one person might smile, and the other person might say “I love you.” Compensation occurs when people display behaviors that have opposite or very different meanings, such as one person looking away when another person stands too close to her or him. Thus far, most of the work on reciprocity and compensation has focused almost exclusively on nonverbal communication. Yet these codes could play off each other. For example, people might avert eye contact when conversation gets highly intimate or hug someone after receiving a compliment. Guerrero, Jones, and Burgoon (2000) demonstrated that people sometimes compensate verbally when their romantic partner acts avoidant (by saying things like “What’s wrong?), even though they reciprocate nonverbally by showing more negative affect. A better understanding of these types of patterns will bring scholars one step closer to understanding the intricacies of the interplay between verbal and nonverbal codes.
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- 1 Department of Psychology, Northeastern University, Boston, Massachusetts 02115, USA; email: [email protected].
- 2 Department of Psychology, University of Michigan, Flint, Michigan 48502, USA; email: [email protected].
- 3 Department of Psychology, Loyola Marymount University, Los Angeles, California 90045, USA; email: [email protected].
- PMID: 30256720
- DOI: 10.1146/annurev-psych-010418-103145
The field of nonverbal communication (NVC) has a long history involving many cue modalities, including face, voice, body, touch, and interpersonal space; different levels of analysis, including normative, group, and individual differences; and many substantive themes that cross from psychology into other disciplines. In this review, we focus on NVC as it pertains to individuals and social interaction. We concentrate specifically on ( a) the meanings and correlates of cues that are enacted (sent) by encoders and ( b) the perception of nonverbal cues and the accuracy of such perception. Frameworks are presented for conceptualizing and understanding the process of sending and receiving nonverbal cues. Measurement issues are discussed, and theoretical issues and new developments are covered briefly. Although our review is primarily oriented within social and personality psychology, the interdisciplinary nature of NVC is evident in the growing body of research on NVC across many areas of scientific inquiry.
Keywords: decoding; encoding; interpersonal accuracy; nonverbal behavior; nonverbal communication.
- Interpersonal Relations*
- Nonverbal Communication* / psychology
- Social Perception*