Verbal And Nonverbal Communication

Communication is interacting with people (e.g. talking, body language, having relationships either in private life or work-related relationships…etc.).Its cycle involves the sending and receiving of messages, and it is a two-way process. Communication skills basically mean having the ability to process this cycle in the most effective way, which are the key features needed to build a strong and effective doctor-patient relationship and are needed to exchange information and feelings between physician and patients.

Generally, there are 2 types of communication:

• Verbal communication, which’s a commonality among linguists, and it’s all written and spoken communication. In this type, we communicate through words and their aspects, as we express our feelings through them.
• Nonverbal communication, It’s silent language. The information we get or perceive through facial expressions, body language, posture…etc., that hasn’t been written or expressed through words, are considered as nonverbal messages. It’s not a language that’s formally taught, but it’s a universal language with some exceptions in a few nonverbal cues or signals that are interpreted differently in different cultures.

The relationship between these two types of communication is fundamental in both everyday and clinical interactions because to build a strong relationship, understanding the message is essential, which depends on how well the information and emotions are expressed by the sender of the message, and how well they’re understood by the receiver of the message (e.g. how well the client can express his/her emotions, and how well the physician can understand them).

Verbal communication is communicating either orally or by written words. It’s the use of words and speech to express our message. There are some types of verbal communication such as ( face to face discussion, speeches, television & radio, telephone conversations, seminars, video, and written documents…etc.) all these can be considered as verbal communication, within two main types which are oral communication and writing.

Oral communication includes everyday conversations, speeches, and seminars. This type has a huge impact on communicating with others as well as it’s important in learning and teaching because we tend to remember and understand what’s spoken more than what’s written. And also written words are included in verbal communication. Written includes emails, books, letters, fax, notes, newspapers, commercials… etc. There’re three main aspects involved in effective communication: the words, the way you say them, and how you reinforce these words with nonverbal cues. All these aspects affect the sending and receiving (understanding) of the message. Appropriate words and appropriate ways of saying should be considered, for example talking with a friend is different than presenting at a conference. Reinforcement includes nonverbal signals needed to strengthen the verbal message, for example, a nodding head or maintaining eye contact shows interest in what others are saying. There are some basic elements of verbal communication, such as:

1. Voice: although voice is considered as a nonverbal cue, but without it there’ll be no verbal communication. Voice specificities such as voice tone, which’s very basic in communication, and changes the meaning of a word.
2. Language: language is an essential element in verbal communication. There are 6000-7000 known languages in the world, in order to communicate with others, and to avoid misunderstanding, you should be able to fully understand their language, otherwise it’ll be a barrier and may lead to misunderstanding. Language has some properties and principles such as:

• Language is symbolic; words we use have no meaning if they’re not representing something. For example, the word flower is not the flower itself, rather it’s just a symbol of a flower.
• It’s rule-governed; The three primary types of rules contained in language are:

1. Syntactic rule, which directs the arrangement of the words in a sentence.
2. Semantic rule, which guides the meaning of the words, and the way we interpret them. Without this rule of the shared meaning of words, communication would be impossible
3. Pragmatic rule helps us to understand and interpret the words more specifically, which helps us consider the context of the situation, as well as our relationship with the one we’re communicating with. For example, the statement “I killed it” can have a variety of meanings according to the context.

• It defines and limits the objects and what we want to say. Language defines the meaning of words, while simultaneously can limit the meaning. For example when someone asks you about a country, and you only talk about one feature of it, here you limit the understanding of that person about that country.
• Language lets us create and express our messages to others through words. Combinations of words can be used to transmit the message in a way that reflects your feelings, personality…etc.

Nonverbal Communication:

Nonverbal communication is interacting without writing and speech, such as your body posture, voice, facial expressions, gestures…etc. It is your use of distance, use of time, and the environment you create. Within any interaction between two people, over 90% of the communication that occurs is channeled through the nonverbal band, which has a great impact and influence on the receiver’s decoding or interpretation of any message. Nonverbal behaviors allow the observers to discern people‘s emotional state, e.g. happiness, anger, surprise, fear, disgust, sadness, etc. Different types of nonverbal communication such as:

Body movement: this is the way people use their bodies to communicate or enhance their verbal communication, and these are important forms of communication. Body movement includes posture, gestures, eye contact, and facial expression…

• Posture: This is how you position and move your body, which can communicate a great deal about you, for example, how much you’re interested in a conversation can be conveyed by your patient (audience) by the way you’re leaning towards or away from them, and turning your back or standing to leave can convey a lack of interest or signal to the end of the conversation.
• Gestures are any movement of the hands, and arms, which indicate different meanings. The way we wave, point, and use our hands when we’re speaking, we’re expressing ourselves with gestures. For example, open arms can sign honesty, hands held behind the back while speaking can communicate anxiety or reluctance, whereas expressive hand gestures can convey confidence, enthusiasm, and conviction. However, gestures are not universal and their interpretations are usually culturally based, for example, the “okay” gesture made with the thumb and the forefinger means “everything is all right” to an American. But in France, it means “You’re worth zero,” and in Japan, it means “money,” so a gesture can get you a smile or a slap depending on how it’s interpreted.
• Eye contact can also indicate several different types of messages, usually appropriate eye contact while speaking or listening is an expression of respect, interest, and confidence, and lack of eye contact is often a clue to the presence of anxiety, lack of confidence, as well as negligence and disrespect, however, prolonged eye contact or staring can be an expression of aggression. Like gestures, eye contact is also culturally based in interpretation, so we need to be aware and sensitive of the cultural differences in nonverbal signals, in order to avoid misinterpretation.
• Facial expression and our face are probably the most observed part and the most important conveyor of our emotions when we speak, it can express enthusiasm, approval, confusion or boredom…etc. Researchers have suggested that there are at least 640 different facial expressions when you take into account the different eyebrow/forehead, eyes/eyelid, and lower face expressions, which of them, can be used to make verbal messages seem smoother or assertive

Paralanguage: this is how we speak, it relates to all aspects of the voice which are not strictly a part of the verbal message, including the tone and pitch of the voice, speed, and volume, at which a message is delivered, and pauses and hesitations between words, aside from the actual words or contents of our message. These qualities of paralanguage enable the audience to fully understand what is being said.

• Pitch refers to the highness or lowness of our voice, and it’s determined by the physical length and thickness of our vocal cords, and most factual communications include changes in the pitch of your voice. It may rise when we are frightened, anxious, or excited, because the vocal cords tense and shorten, which causes the voice to get higher, and it can lower if we are attempting to sound more powerful or authoritative.
• The pace is the rate of speed at which we talk. Some speak fast, others slow, which is their own rate of speed. We tend to increase our pace of speech when we’re excited, or nervous, and a fast pace is often difficult to understand. Meanwhile, we tend to use a slow pace when we’re sad, and uncertain, which can be frustrating for the audience or the patients. In order to maintain interest during a speech or conversation, you should try to vary your pace.
• Volume is related to the loudness or softness of your voice. Without enough volume you cannot be heard, however, shouting or harsh sounding voice might be perceived as insulting. We can also adjust our volume to meet the requirements of the communication setting we are in. In a noisy, crowded room we raise our volume and speak above the other voices, whereas in a quiet place we tend to speak lower than normal volume. Sometimes lowering your voice almost to a whisper would help you make a point better than shouting.
• Quality refers to the overall sound of our voice. Each of us tends to have a distinctive tone. One’s voice can be loud and deep, while another voice is soft and high pitched.
• And the last aspect is articulation or pronunciation. Some people speak through clenched teeth with a little lip movement, which causes the sound to be trapped in the mouth and makes it hard for the audience to understand it. To avoid misunderstanding, and have good articulation, one should unclench the jaw, open mouth and properly enunciate each sound, and pay attention to the ends of words. This would help the listener as a certain lip-reading will be possible. And also mispronouncing words might be an indicator of ignorance or incompetence. So you must also use the correct sounds and emphasize each word, to make it easier for the listener to understand what has been said.

Personal presentation: this is the way you appear to others, which includes clothing, touching, and grooming.

• Clothing has an important role as it’s the most obvious display of who we are, because how we dress says a lot about us ( e.g. social class, beliefs, and attitudes…etc.), and it can also be a reflection of our mood and emotions. Researchers agree that clothing has the most effect on credibility.
• Grooming habits such as length and style of hair, makeup, perfume, and many other habits reflect a great message about who we are, and how we want to be perceived.
• Touching is the most intimate form of nonverbal communication. Touching behavior, or haptics (as it’s called by social scientists), can be used to reassure someone or express empathy, but you should be sensitive about the personal and cultural preference of the person you want to touch.

Proxemics: this is the study of using our space. As there are different levels of physical closeness appropriate to different types of relationships in different cultures and societies, people learn these different distances from the community they grow up in. Our personal space generally can be divided into four zones:

• Intimate distance ( 0 to 45 cm/ 0 to 18 inches) , this zone is classified as our own property, only our most intimate relationships and those who are emotionally close to us( e.g. family and close friends) are permitted into this area.
• Personal distance (45 cm to 1.2 m/ 18 inches to 4 feet), is the distance at which we interact at social events or in conversations with our family, friends, and relatives.
• Social distance (1.2 to 3.6 m/ 4 to 12 feet), is the distance we feel most comfortable when meeting new people, or sitting during committee meetings…etc.
• Public distance (3.7 to 4.5 m/ 12 to 25 feet), is used for public ceremonies, speeches, or it’s the distance to maintain between strangers in public. Often more than 25 feet is used in shouting or exaggerating nonverbal cues.

Correlation between verbal &nonverbal communication, and their importance in medicine and doctor-patient relationship:

Both verbal and non-verbal communication, individually take a huge part in the interaction between patients and doctors, and in expressing emotions. Proper communication between doctors with other colleagues or patients is essential to avoid errors in diagnoses and performing medical treatments. But in order to communicate and understand in the most effective way, both verbal and nonverbal techniques should be used together appropriately. To understand what we mean by this, we should consider these examples:

• Ali (yawning, and very pale, with dark pitches under his eyes): “I feel a little tired, but I’m ok.”
• Lily (to Lana, with a stern facial expression, in an angry tone of voice, and gesturing furiously): “You’re late!”
• Liam (faking a smile, and lying): “the cake was absolutely delicious! Really…”

In all these sentences, the non-verbal phenomena mentioned will affect the way the utterance is understood, for example, in the first sentence, the physical manifestation of Ali’s tiredness indicate to his audience that he’s absolutely tired and can’t pay enough attention to what they’re saying, however, he would like them to believe that he’s present. In the second one, Lily’s frown, her aggressive, high tone, and her gestures will determine the degree of anger in her, her audience. And in the last one, Liam fakes a smile, which indicates that he’s being ironic, and by this, he means the opposite of what he has said. Here we see the importance of using both techniques (verbal, and non-verbal) in an appropriate way because they can totally shift the meaning of a sentence. And this is the same in the medical field, in order to build a good physician-patient relationship, the physician should be efficient, and smart enough to read all the messages his/ her patient is expressing, either these messages are verbal ( what they say), or non-verbal. When speaking, try to match your voice, body, and gestures with the content of your verbal message.

The importance of using verbal communication in the care of patients has long been known. Both qualitative and quantitative studies have shown evidence of the benefits of effective communication in patients, a study was aimed to explore how much and what types of verbal communication nurses use when caring for unconscious or sedated patients. The findings of this study highlighted the need for formal support systems and continued education for medical staff about the benefits of verbal communication. Also, nonverbal communication has a huge role in medical examinations and doctor-patient relationships, as it’s an important method of exchanging information on the emotional status and contextualizing the meaning of verbal communication. . Patient‘s attempts to mask feelings can be detected by observing their body behavior, conversely, the physician can convey his/her attention and concern in the most effective manner possible.

In order to communicate verbally, show your interest and empathy for the patient, and transmit your message effectively, you should consider the process of it:

1. Preliminary communication: this usually involves the first impression and greeting with the patient. Appropriate greeting with a smiling face, and maintained eye contact, alongside handshake (if it was appropriate), while introducing yourself to the patient are important.
2. Reinforcement: encourage the patient to discuss, and talk about their illness and concerns, while maintaining eye contact, and nodding your head. While they’re talking show interest with a warm facial expression, to encourage them openly express him/ herself.
3. Effective listening: pay close attention to what the patient says, and avoid distractions.
4. Questioning: by asking questions you can further information to achieve diagnosis, and also you can obtain whether you’ve understood what they’re saying. There are 2 types of questions, open-ended question, which gives you more information and response from the patient. And close-ended question, which can beneficial for directing questions.
5. Reflecting and clarifying: you can summarize your patient’s message with your own words, this will convey the patient that you’re paying them attention and interest, as well as communicating your underestimating back to the patient.
6. Closing communication: at the end of the discussion, you should be able to diagnose the patient based on the information they’ve provided you. You have to ensure the patient has understood the condition and give them enough clarification to satisfy them with the information provided.

Conclusion

Communication is interacting with others. Its two types are verbal communication, which includes oral and written communication, and nonverbal communication, which’s using body language to interact with others and reinforcing our verbal messages, it includes body posters, gestures, facial expression, tone, and speed of voice…etc. Both verbal and nonverbal communions have a great role in interacting with others in our daily life, as well as in doctors interacting with their patients. In order to build a healthy, strong relation, we should use both verbal and nonverbal cues appropriately, considering personal and cultural boundaries.