Abstract
Purpose: The importance of immediacy and positive relationships between students and teachers is well-documented. Applying immediacy to the patient/provider model has not been sufficiently explored. The significance in creating a bond of trust between the patient/provider is vital to the diagnostic and therapeutic process. As outlined by the National Dental Hygiene Research Agenda, this literature review supports strategies for effective communication between the dental hygienist and client. It examines the relationship between oral health care providers and their patients and applies the verbal and nonverbal cues associated with immediacy to affirm their relevance and effectiveness in educating and motivating patients to achieve optimal oral and systemic health.
Introduction
“Immediacy is defined as the degree of perceived physical or psychological closeness between two people.”1 Social psychologist, Albert Mehrabian, is recognized for defining the concept of immediacy which states “people are drawn toward persons and things they like, evaluate highly, and prefer; and they avoid or move away from things they dislike, evaluate negatively, or do not prefer.”2 Immediacy encompasses verbal and nonverbal communication techniques that can be applied across multiple settings. Reducing stress and establishing a rapport with clients requires integrating the finesse of an educator and compassion of a quality clinician. Educators use immediacy techniques to educate their students; these same methods can be applied in a clinical setting. Like academicians, dental hygienists rely on finely honed verbal and nonverbal communication skills to impart health education information to motivate and educate patients in oral and systemic health. Dental hygienist, as skilled and knowledgeable clinicians must utilize communication skills that build patient trust and confidence and that convey their skills and knowledge. Desired traits associated with verbal immediacy include self-disclosure, humor, tone, reference to another's positive traits and discourse regarding commonalities. Principle nonverbal cues associated with immediacy include empathic listening, facial migration (showing expression), smiling, gaze orientation, physical appearance and touching.
By means of nonverbal and verbal communication strategies, a dental hygienist can enhance interactions and encourage clients to express their concerns. Nonverbal cues can be equally important, if not more important, than what is said. These cues may influence the outcomes of academic and clinical exchanges. Kearney et al found teacher immediacy was the most powerful predictor of students' reported willingness to comply with teacher requests.3
Consistent with the results of instructional communication, patients who view physicians as immediate report being less fearful and generally more satisfied with the medical care they receive.4 Interpersonal attractiveness, the degree to which others respond positively toward one another, can be improved by using immediacy behaviors. Clinicians wishing to employ the behaviors of immediacy should explore both verbal and nonverbal techniques and ways to ensure their congruence. Simple acts such as maintaining eye contact when communicating, gently patting a patient's arm for reinforcement and speaking with a gently non-threatening tone are some of the ways to achieve immediacy. Conscious application and diligent learning of both verbal and nonverbal communication strategies may help to improve health education outcomes.
Nonverbal Immediacy Behaviors
A part of all communication are nonverbal behaviors. These behaviors include kinesics, (the study of body movements when communicating), gestures and facial expressions, proxemics (the nature, degree and effect of the spatial separation individuals naturally maintain), olfaction, skin sensitivity, the use of artifacts, physical characteristics, eye movement, touching behavior, and environmental factors.5 Facial expressions and gestures include bodily contact, physical appearance, and the direction of gaze. Nonverbal behaviors include the paralinguistic variables of emotional tone, timing and accent. Teachers who convey verbal caring messages in combination with nonverbal caring cues are rated by their students as more credible.6 Some researchers believe that nonverbal behaviors are more effective at communicating immediacy than verbal behaviors. Approximately 93% of interpersonal attitude is communicated nonverbally.7 Nonverbal cues are often innate and may sometimes contradict a verbal message. One who has a proficient knowledge of nonverbal behaviors can effectively transmit a controlled nonverbal message.
Empathetic Listening
Listening effectively to others offers personal time, psychological presence, cognitive attention and emotional response, all valuable interpersonal resources. Expending the energy to listen to someone is theorized as an expression of affection. Empathic listening results in the receiver feeling validated and understood.8 Empathy is a required element in effective doctor-patient relationships.9 A study was performed analyzing empathy and clinical competency with 57 medical students. Clinical interactions and displays of empathy were rated by an independent observer. Results indicated that empathy can be related to high levels of clinical capability and favorable patient outcomes.10
Facial Expression
The human face is highly expressive and is often the object of attention.11 Mehrabian suggests that 55% of interpersonal communication occurs through facial expression alone.2 A dental hygiene clinician's expectations often are clearly communicated through facial expression. Through proper training and motivation, clinicians can effectively communicate sympathy and understanding, or a positive outlook and expectations.11
Smiling
Smiling, as a facial expression, has been studied extensively.12-14 Smiling is an important aspect of nonverbal communication and has been correlated with liking, affiliation an immediacy.1 A smiling person may be perceived as more trustworthy and honest. In a case of academic misconduct, students were given a summary of evidence and a photograph of the accused student displaying different facial expressions such as a neutral expression, a felt smile, a false smile or a miserable smile. Smiling targets although not seen as less guilty received more leniency than non-smiling targets. The study revealed that smiling targets are considered more likable, submissive, diplomatic and trustworthy. It appears that a smile can be an effective and positive immediacy tool for achieving leniency.15
Good communication is of paramount importance for effective patient outcomes. Smiling can enhance interactions between patients and health care workers. A qualitative study explored oncology patients' perceptions of how healthcare providers conveyed positive communication. Characteristics deemed positive were helpfulness, approachability and smiling.16
Gaze Orientation
Every clinical encounter allows the possibility for eye contact to build immediate rapport between the clinician and patient. A gaze may be comforting if it intensifies a pleasant situation, and it can open communication in an uncertain one. Conversely, failure to look a patient in the eye causes the patient to feel like a body and not a person, creating a process of dehumanization commonly seen in medical settings.11 Open-minded people face the person to whom they speak, stand close to the other person and maintain eye contact.5
Physical Appearance
The first form of nonverbal communication relates to physical appearance. Appearance can be used when developing judgements about people based on their looks, what they wear and their level of attractiveness.17 Physical appearance applies to attire, hairstyle, grooming and accessories. Perceived professionalism, including suitability, competence, ease of conversation and friendliness of professionals is suggestively influenced by the choice of dress style worn for work.18 Research suggests a patient's preference is for professional attire in dentistry. In one study of 586 subjects they experienced a greater willingness to share personal information with those who wear the identifiable and trusted white coat.19
Touch
Touch improves communication quality and demonstrates empathy. Touch is often culturally regulated in professional settings.17 A qualitative study of both patients and general practitioners (GPs) conducted in England showed the value that each of these groups attributed to touch. The study demonstrated that touch increases the warmth felt, and establishes the connection between doctor and patient. Touching provided the patient with a feeling of warmth increasing the connection to the doctor. GPs in the study stated that touching is “a human thing to do” and they felt that touch should be appropriate.20 Avoiding concerns about intimacy is critical but the patient responders felt touch on the hand or forearm was appropriate.20
Verbal Immediacy Behaviors
Verbal immediacy refers to the stylistic choice of verbal expressions that educators employ. Effective verbal communication helps receivers feel valued and important. Students may develop either a like or dislike for their teacher based on their display of immediacy during verbal communication.21 Oral health educators who use verbal behaviors to encourage immediacy may make their patients feel valued and important. Exceptional educators are not remembered because of an interesting lesson, but by how they made the student feel. Verbal immediacy tools like self-disclosure and using humor convey humanness. Verbal immediacy behaviors are displayed by signaling warmth and a willingness to connect to the receiver of a message. An example of effective verbal communication occurs when professionals urge patients to express their feelings about their oral health by simply encouraging their questions.
Self-Disclosure
Self-disclosure is deliberate sharing of personal information to help establish relationships of trust. Revealing motives, intentions, goals, values, and emotions, increases liking and feelings of immediacy.22 Skillful self-disclosure can humanize a person, creating connections that increase feelings of trust and intimacy. Disclosure can increase a readiness to work collaboratively to reach mutual goals. Students considered teachers effective when they displayed caring through self-disclosure.22
Humor
Considerable research examined an instructor's use of humor and resultant learning outcomes.23-25 The use of humor has been described as an important element for improving student interest and attention during the learning process. When students are interested, they enjoy the learning process.24 Humor can help students feel more comfortable, relaxed and more likely to learn and develop a bond with the teacher; however, if humor leads to sarcasm and criticism, intimidation may occur.25 In a classroom setting, humor can have both positive and negative effects.25
Humor, integrated into the clinical setting, creates a tone of openness and respect between clinician and patient. A study by Fovet states that the positive effects of humor include the release of endorphins and tension reduction during communication. Humor can have a holistic benefit by creating a natural connection with patients. Humor appears to promote an intimate connection between nurses and patients. This connection may result in more comforting and compassionate care.26
Vocal Behavior
Vocal cues convey certain personal characteristics and attitudes. Six specific vocal qualities may directly affect one's ability to be a persuasive speaker: volume control, rate of speech, use of pitch, articulation and fluency with effective pauses.27 Woolbert provided one of the earliest empirical studies of vocal communication showing that variety in tempo, force and pitch contribute to higher retention and learning of material.28 Imhof isolated vocal pitch to test how this variable impacts listeners' judgments of the people speaking.25 Results showed that low pitch makes a difference in the way a person is perceived.25 Negative teacher evaluations are closely related to teachers with a monotone voice, a speech pattern that works against a teacher's efforts to stimulate student attention.28 A monotone voice can reduce a patient's comprehension of material delivered orally.29 Full comprehension is especially important to motivate and help patients change behaviors to achieve optimal oral health.
Application of Immediacy Principles
When applying the principles of immediacy, both verbal and nonverbal communication behaviors can be combined.21 Whether discussing an individual's health status or educating students, messages are transmitted via two types of communication: explicit and implicit. Explicit messages carry the content; implicit communication conveys emotions and feelings.21 Explicit messages are fundamentally verbal, while implicit communications are primarily nonverbal.21 Of the 7% of verbal communication, Mehrabian found that 38% happens through voice tone and 55% happens via general body language.2 When forming immediacy relationships with patients, clinicians must consider all acts of verbal and nonverbal communications.
Advantages of Immediacy
Immediacy displays warmth and improves interactions and relationships. Patient interactions are human experiences that create a relational link. Effective communication is a vehicle through which patients' involvement is optimized. A correlational study of nurses and patients revealed that the strength of their bond facilitated positive outcomes of care and enhanced patient satisfaction.30 Fostering and strengthening dental hygienists' bonds with their patients could produce similar results.
Relating educational principle of immediacy, Velez and Cano studied the association between student motivation and teacher immediacy. Their survey found that to increase student motivation via verbal and nonverbal cues, the instructor needs to exercise care and consistency. Exhibiting positive, encouraging gestures were recommended.5 Expectations for success are enhanced through a combination of constant, positive, and supportive verbal and nonverbal communication.20
Disadvantages of Immediacy
One distinct disadvantage of immediacy is that cues can be misinterpreted as intimate. Being warm and friendly in a social environment may be acceptable and encouraged. Similar communication traits may not be considered suitable in certain professional environments. The perception that one is not immediate has more dire consequences than counterproductive immediacy.1 With practice, one can become familiar with the immediacy degree necessary and appropriate for conveying professional messages required in the clinical setting.1
Conclusion
Communication skills, verbal and nonverbal, are essential to successful educator/clinician encounters with patients. As oral health professionals seek new and innovative ways to motivate and engage the dental patient in oral self-care, clinicians must consider the positive effects of immediacy. Successful and meaningful professional encounters require effective communication between the patient and the clinician. Developing approaches that improve communication allows the clinician to build trust, promote healing, and ultimately improve health outcomes. Specific communication skills to motivate patients to achieve optimal oral health are critical. Sending a supportive and caring message will contribute to the development of trust between the patient and the clinician, creating pathways conducive to learning and motivation. Oral health providers continually communicate to patients through body language, gaze, and facial expressions; therefore, care must be exercised to portray positive and caring gestures. A combination of productive verbal and non-verbal patterns will benefit educators, students, health care providers and patients. Although he concept of immediacy has been studied in education and nursing, further research relating to interactions between oral health care providers and patients is necessary.
Acknowledgments
I would like to thank Sheryl Syme, RDH, MS, Associate Professor and Director, Degree Completion Program of the University of Maryland for their integral roles and expert advice and encouragement throughout this project. A thank you to my friend, Wendy King-Herker, for her support and guidance.
Footnotes
Debra A. Dalonges, RDH, BS, is employed at Crosskeys Dental Associates in Baltimore, Maryland. Jacquelyn L. Fried, RDH, BA, MS, is an Associate Professor and Director of Interprofessional Initiatives, University of Maryland School of Dentistry.
This study supports the NDHRA priority area, Health Promotion/Disease Prevention: Assess strategies for effective communication between the dental hygienist and client.
- Copyright © 2016 The American Dental Hygienists’ Association
