A qualitative study on non-verbal sensitivity in nursing students

EDUCATIONAL ISSUES IN NURSING PRACTICE

A qualitative study on non-verbal sensitivity in nursing students

Zenobia CY Chan

Aims and objectives. To explore nursing students’ perception of the meanings and roles of non-verbal communication and

sensitivity. It also attempts to understand how different factors influence their non-verbal communication style.

Background. The importance of non-verbal communication in the health arena lies in the need for good communication for

efficient healthcare delivery. Understanding nursing students’ non-verbal communication with patients and the influential

factors is essential to prepare them for field work in the future.

Design. Qualitative approach based on 16 in-depth interviews.

Methods. Sixteen nursing students from the Master of Nursing and the Year 3 Bachelor of Nursing program were

interviewed. Major points in the recorded interviews were marked down for content analysis.

Results. Three main themes were developed: (1) understanding students’ non-verbal communication, which shows how nursing

students value and experience non-verbal communication in the nursing context; (2) factors that influence the expression of

non-verbal cues, which reveals the effect of patients’ demographic background (gender, age, social status and educational level)

and participants’ characteristics (character, age, voice and appearance); and (3) metaphors of non-verbal communication,

which is further divided into four subthemes: providing assistance, individualisation, dropping hints and promoting interaction.

Conclusions. Learning about students’ non-verbal communication experiences in the clinical setting allowed us to under-

stand their use of non-verbal communication and sensitivity, as well as to understand areas that may need further improve-

ment.

Relevance to clinical practice. The experiences and perceptions revealed by the nursing students could provoke nurses to

reconsider the effects of the different factors suggested in this study. The results might also help students and nurses to learn

and ponder their missing gap, leading them to rethink, train and pay more attention to their non-verbal communication style

and sensitivity.

Key words: metaphor and qualitative, non-verbal communication, non-verbal cues, non-verbal sensitivity, nursing students

Accepted for publication: 4 July 2012

Introduction

Health care is a complex process, involving multiple

socially influenced concepts whose delivery and implemen-

tation rely heavily on communication. Health profession-

als usually have to obtain from their clients precise and

accurate information (their needs and pathological symp-

toms, their concerns regarding the illness, their feelings

about the treatments received and the frequency of their

health-relevant behaviours) to deliver the most appropriate

care services. In fact, patients are often unable to report the

required information in an accurate manner. In addition,

transactions in the healthcare setting are sometimes intimi-

dating from the patient’s perspective. It is especially true

that sometimes information given by healthcare providers

might confuse or overwhelm patients for various reasons

(e.g. technical language, jargon and the stress of the situa-

tion). Ameliorating patients’ health is indeed a mutual goal

Author: Zenobia CY Chan, MA, PhD, RN, MPHC, Assistant Pro-

fessor, School of Nursing, The Hong Kong Polytechnic University,

Hong Kong SAR, China

Correspondence: Zenobia CY Chan, Assistant Professor, FG421,

School of Nursing, The Hong Kong Polytechnic University, Hung

Hom, Kowloon, Hong Kong SAR, China. Telephone: +852 2766 6426.

E-mail: [email protected]

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 22, 1941–1950, doi: 10.1111/j.1365-2702.2012.04324.x 1941

of both patients and providers; however, the difference in

factors like communication styles, perspectives and bodies

of knowledge might impede the accomplishment of this

goal.

Undoubtedly, patients’ verbal complaints about their

problems are central to clinical diagnosis and treatment in

contemporary health care, but health professionals’ atten-

tion to patients’ non-verbal clues is also a sine qua non.

This was identified as early as in ancient Greece by Hippo-

crates, who urged healthcare practitioners to focus on

patients’ faces during clinical practice (Friedman 1982), and

was further supported by Donovan (2002)’s study which

explored how learning disability nurses handle patients

with potentially unrecognised pain. Donovan noted that

patients used a variety of non-verbal cues, facial expression

change, self-harming and aggressive behaviours, to express

their pain, corroborating the importance of paying atten-

tion. With the recognition of the significance of non-verbal

communication, endeavours to promote interactions

between healthcare providers and patients have improved

significantly in recent decades (Hall et al. 1995, Roter

2000).

Background

Over the years, the roles of non-verbal communication have

been extensively studied and discussed in the healthcare

arena (Cohen & Walco 1999, Sundin et al. 2001, Denison

2004, Barker & Buchanan-Barker 2006, Henry et al.

2012). Rintamaki et al. (2007) performed a study to exam-

ine male patients’ perceptions of human immunodeficiency

virus (HIV) stigma in healthcare contexts. They found that

a variety of healthcare providers’ behaviours, ranging from

equivocal non-verbal cues (such as evading eye contact or

maintaining interpersonal distance) to obvious discrimina-

tion (such as physical abuse), were perceived by HIV

patients as significant HIV stigma. The unpleasant experi-

ences revealed by the study suggest that healthcare provid-

ers should beware of their own behaviours and attitudes.

The relationship between the non-verbal behaviour of

health professionals and patient outcome is well supported

by the literature. Ambady et al. (2002a) noted that the lack

of eye contact and smiling of physical therapists might be

associated with a decline in their patients’ cognitive and

physical functioning. Other research also discovered that

physicians with better non-verbal skills in general not only

suffered less medical malpractice litigation (Ambady et al.

2002a,b), but might also be more successful at recognizing

psychological distress in patients (Robbins et al. 1994,

Bensing et al. 2005). Shapiro et al.’s study (1992) revealed

that oncologists’ apparent anxiety when communicating

their patients’ results also resulted in higher patient anxiety,

recall and perceptions of severity. This finding echoes

Beck et al.’s study (2002), which suggested that certain

healthcare providers’ non-verbal behaviours such as nod-

ding heads, leaning forward, and uncrossing legs and arms

may significantly enhance patients’ satisfaction with care,

understanding and psychological status. All these findings

suggest that proper non-verbal behaviour is a universal

requirement among different healthcare streams, implying

that awareness of this should be promoted in the medical

realm.

Non-verbal sensitivity is often known as decoding skill

which is the ability to recognise others’ emotion accurately

(Roter et al. 2006). When compared with health profession-

als who have less sensitivity, those who have superior skills

in reading and analysing patients’ non-verbal cues tend to

have more patients satisfy with quality of care and patient–

practitioner relationship and gain better health outcome.

(DiMatteo et al. 1980, 1986, Martin & Friedman 2005).

Observation of non-verbal cues is essential to diagnosis.

Non-verbal cues are an important indicator of problems

like Type A Behaviour Pattern, which characterised by

aggressiveness, sense of time urgency, explosive speech and

glaring facial expressions (Hall et al. 1986, Chesney et al.

1990). Reading facial expressions is a good approach to

obtain important information about patients’ innermost

physical or emotional state. However, it is possible that

patients’ facial expressions can appear either volitionally or

spontaneously (Rinn 1991). Patients’ behaviours may

include a particular non-verbal message that they would

like to deliver. For example, health professionals may

assume that the client wishes to get involved when showing

non-verbal cues like leaning towards the practitioner, smil-

ing and nodding (Coker & Burgoon 1987). In this way,

health professionals who are more sensitive to the non-ver-

bal cues of their patients will in general be able to gain a

more accurate view of their patients’ needs.

As evidenced by the literature, non-verbal behaviour

should be taken into consideration in communication train-

ing for health professionals. Understanding how healthcare

provision trainees’ perform non-verbal communication and

perceive non-verbal sensitivity is essential in preparing them

for field work. However, there has not been much discus-

sion so far to assess the non-verbal communication of nurs-

ing students and the influential factors, with a few studies

having focused on recognising cues and the non-verbal

communication process and effect between nurses/physi-

cians and patients (Mast 2007, Uitterhoeve et al. 2009,

Jansen et al. 2010).


1942 Journal of Clinical Nursing, 22, 1941–1950

ZCY Chan

To further investigate participants’ perceptions of non-

verbal communications, they were encouraged to provide a

metaphor to describe their understanding. It is hoped that

the metaphoric language can enable us to gain a deeper

meaning from our participants regarding to non-verbal

communication. Metaphors can convey meanings and mes-

sages in a more implicit and safer manner, allowing them to

serve as a tool that enables one to describe and express

particularly sensitive phenomena, thoughts and feelings

(Froggatt 1998, Chan 2004). As suggested by Goodman

(2001), the metaphor also offers a mechanism that reveals

issues and incidents that are less known. The use of meta-

phor in Moss et al.’s (2003) study explored the relationships

between nurses and patients and helped nurses to overcome

barriers, which in turn enabled their grief and fear about

death to be heard and expressed. This research aims (1) to

explore the perceptions of nursing students towards the

meanings and roles of non-verbal communication and sensi-

tivity and (2) to discover the factors that affect nursing stu-

dents’ non-verbal communication with patients.

Methods

Design

This study used a qualitative approach to explore nursing

students’ perspective on non-verbal communicate and to dis-

cover the influential factors. Particularly in nursing, qualita-

tive research is adopted to comprehend or describe a

particular incident or phenomenon that is rarely explored. In

this study, in-depth interviews were adopted to explore how

nursing students perceive non-verbal sensitivity in relation to

patients and in the nursing profession. Interviews were

guided by an interview guideline consisting of nine questions.

Participants

Nursing students from the Master of Nursing and Year 3

of the Bachelor of Nursing were recruited through class,

e-mail and advertisements on campus to participate in a

study of communication skills. A total of 16 participants,

12 women and four men, agreed to participate in the study.

The selection criterion was participants had to have had the

experience of clinical placement for over one to three years

and of communication with patients.

Data collection

Two research assistants shared the interview tasks and

conducted a total of 16 in-depth interviews individually in

separate rooms. During the interviews, participants were

asked to respond to a number of questions about their per-

ceptions regarding non-verbal communication. Participants

were first asked to define non-verbal communication and

then to describe their expression of non-verbal cues when

facing patients of different age groups, gender roles, social

classes and educational levels. A question about how per-

sonal character, age, voice and appearance may have an

effect on non-verbal communication was asked as well.

Afterwards, they had to describe the main features of good

non-verbal communication. Lastly, they were asked to give

a metaphor to describe non-verbal communication in the

healthcare context. The interview length was generally

30 minutes to one hour and the interviews were conducted

in Cantonese and were audiotaped via mp3 recorder.

Data analysis

Content analysis was used to inspect, categorise, tabulate

or recombine the data to fulfill the initial suggestions of a

study (Yin 1994, Polit & Beck 2004). The research assis-

tant listened to the recordings a few times. Critical points

in the interview contents were marked down, reviewed and

analysed deliberately. Primary categories were developed by

linking relevant parts into significant themes (Philaretou &

Allen 2006). Afterwards, the data were fitted into the cate-

gories. Descriptive paragraphs about the categories were

written by the researcher, and the relationships between

categories were explored as well (Morse & Field 1995,

Polit & Beck 2004, Hipsky 2006, Philaretou & Allen

2006). Pairwise comparisons between categories and partic-

ipant responses were made to ensure that the ‘voice’ of each

participant was included and that data saturation was

achieved (Onwuegbuzie & Leech 2007). Once categories

were linked, the researcher went back to the original data

to search for any missing data and to ensure that all the

information had been analysed. Once the results had been

analysed, the interview records and results were sent to the

researcher for verification and counterchecking to ensure

validity.

Ethical consideration

All participants received an information sheet describing

the aims and objectives of the study. Signed consent forms

for audiotaping the interviews were obtained from the par-

ticipants. Participants had the right to stop or decline the

interview at any time. They were assured of dignity, pri-

vacy, confidentiality, and anonymity and that no potential

harm could come to them as a result of their involvement


Journal of Clinical Nursing, 22, 1941–1950 1943

Educational issues in nursing practice Non-verbal sensitivity in nursing students

in this study. Researchers observed participants’ psychologi-

cal responses closely to ensure that they were not affected

by psychological harm. All the research data were stored in

locked cabinets and then destroyed after the study had been

completed.

Results

Communication exists in two major forms, verbal

and non-verbal. However, when compared with verbal,

non-verbal communication in nursing care seems to be

relatively less discussed in Asian countries. The following

sections reveal Hong Kong nursing students’ percep-

tions towards non-verbal communication and sensitivity.

Data collected from the 16 in-depth interviews were

categorised into three themes: (1) understanding students’

non-verbal communication, (2) factors that influence the

expression of non-verbal cues, and (3) metaphors of non-

verbal communication.

Understanding students’ non-verbal communication

All participants believed that as long as the message was

not communicated verbally or orally, the communication

process would be regarded as non-verbal communication.

They defined non-verbal communication as a kind of com-

munication method that expresses one’s thoughts and feel-

ings to another person through the use of body language,

touch, gestures, facial expressions or eye contact. In addi-

tion, merely by observing the behaviour of another party,

one may understand the meaning within it.

All participants experienced non-verbal communication

in the nursing context and found that it was necessary.

Compared with verbal communication, most of them

believed that non-verbal communication was superior in

delivering a sense of comfort, support and concern to

patients. Some believed that non-verbal communication

could be helpful to them in expressing their verbal message

better thus helping patients to understand the meaning

within. Especially when interacting with psychiatric, deaf

or mute patients, non-verbal communication plays a critical

role. They revealed that they need to observe carefully and

be conversant with patients’ facial expressions, gestures and

behaviours to address patients’ needs precisely. According

to participants’ opinions, positive eye contact, facial expres-

sions and presence can make patients feel more comfortable

and respected. Also, the speed and strength used in certain

services (wound cleaning and dressing procedures) were

perceived as non-verbal communications that could reflect

nurses’ warm-heartedness.

Participants suggested that to perform good non-verbal

communication, the non-verbal cues must be concise and

easily understood by the receivers. The meanings decoded

by the patients should be what the practitioners want to

express, otherwise misunderstandings might result. They

agreed that it is essential to learn and observe patients’ per-

ceptions of non-verbal cues, as everyone has different cul-

tural backgrounds, recognitions and demand concepts.

Therefore, non-verbal communication is tailor-made rather

than a formulistic practice. On some occasions, such as

showing emotional support and care to patients, non-verbal

communication ought to express a deeper meaning and the

messages within are strongly felt by the patients. Moreover,

non-verbal cues can assist patients to better understand ver-

bal messages or the content of the communication and thus

facilitate relationship development.

Factors that influence the expression of non-verbal cues

Most of the participants revealed that they expressed non-

verbal cues differently with different age groups. Participants

believed that many elderly people have hearing problems

and children are not interested in verbal instructions, and

therefore, a majority of participants would exaggerate their

facial expressions and actions to draw these patient groups’

attention and facilitate understanding. Also, more touching

is used to improve relationships with these age groups. One

participant expressed that he avoids touching the elderly

because he was warned by some Chinese elderly patients

who have superstitious beliefs, for example, old people who

straighten their legs on bed will have bad luck. Participants

used fewer gestures, body language and touching with adult

patients. They believed that adult patients usually preferred

more privacy and patients’ cues such as less eye contact and

a monotonous tone of voice were significant signals. As

adults and adolescents have better comprehension, verbal

communication is sufficient to deliver messages. Participants

might however use touching and a gentle voice tone when

patients in these two groups were depressed.

Patients’ gender does influence the expression of non-ver-

bal cues for most participants. However, the differences

only apply when patients’ age ranges from 11–70. The par-

ticipants tended to maintain a greater interpersonal distance

from patients of the opposite sex. They tried to avoid

touching as they did not want to embarrass and offend the

patients. Facial expression, gestures and body language

generally remained the same. Some female participants

revealed that female patients were more emotional and

expressed more non-verbal cues. The cues given by

female patients could be easily read and decoded; therefore,



ZCY Chan

female participants conducted relatively more non-verbal

communication with the female patients. On the other

hand, those participants revealed that male patients gener-

ally have a tougher image therefore participants preferred

asking male patients about their needs verbally. Also, some

participants agreed that wound dressing for female patients

were comparatively gentler than for male patients.

According to participants’ opinions, social class and edu-

cational level of patients seemed to have less influence on

the expression of non-verbal cues. The reactions towards

different social classes varied among participants. Around

50% of them believed that all patients should receive equal

professional expert care as discriminating against certain

social classes was unethical. The participants would not

know or try to explore patients’ background. Some partici-

pants who had experience working in both private and pub-

lic hospitals revealed that they were more aware of their

own performance when caring patients from higher social

classes and would, for example, stand straighter, smile

more, touch less and adopt an even stricter attitude. This is

because they believed that these patients usually have higher

standards and make more complaints. Similar phenomenon

was found in Findik et al. (2010) and Yan et al. (2011)

study, showing that patients with higher income and educa-

tion level have lower satisfaction with health care when

compared to patients with lower income and education

level. In public hospitals, they felt more relaxed. One partic-

ipant revealed that patients in private hospitals voice their

problems more actively, while patients in public hospitals

give more non-verbal cues. Her speculation was that even if

a patient verbally expressed an issue, they might not receive

an immediate response from the busy practitioners. Few

participants regarded personal characteristics as the factor

that influenced their balance of verbal and non-verbal cues.

Participants who did not consider patients’ education

level as an influential factor revealed that they would use

simpler sentences or wording to facilitate patients’ under-

standing. A few participants had previously been chal-

lenged by highly educated patients and therefore tried not

to have too much contact, expressing fewer non-verbal and

verbal cues. Some participants perceived that certain nurs-

ing terms might not be well understood by patients with

low educational levels. They tried to use more non-verbal

cues such as actions, gestures and demonstrations to

express their thoughts. They also felt that less educated

patients were more intimate, as these patients seemed to

have more faith in them. There are studies revealed that

less educated patients tend to have more trust on healthcare

practitioners than highly educated patients because less

educated patients were lack of knowledge and therefore

may rely more on practitioners (Beaver et al. 2009,

Haywood et al. 2010).

Other than considering patients’ background as an influ-

ential factor, participants’ character, age, voice, and appear-

ance were also explored. According to participants’ own

reflection, more outgoing participants were more willing to

approach and talk to patients. Some participants who were

a bit timid would use smiles and eye contact to test whether

the patient was approachable. After gaining more experi-

ence, participants felt more confident and were willing to

use more non-verbal communication or to actively approach

patients. Some found that their awareness and understand-

ing of patients’ non-verbal cues and needs improved as well.

On the other hand, some participants revealed that once

they got used to certain incidents, they would show less of

their emotions and express fewer non-verbal cues. Voice

was not considered as an influencing factor by most partici-

pants. They also did not think their appearance had an effect

on communication, as they had to wear masks while working.

Metaphors of non-verbal communication

Table 1 summarises all the 16 metaphors related to partici-

pants’ perceptions of non-verbal communication. According

to the descriptions of the 16 metaphors, participants’ ideas

could be categorised into four themes: (1) providing

assistance, (2) individualisation, (3) dropping hints, and (4)

promoting interaction.

Subtheme 1: providing assistance

Five metaphors indicated that non-verbal communication

plays a pivotal role in providing assistance. Participant 1

described the relationship between nursing services and

non-verbal communication as a tablet and water. She

explained that nursing services and medicine have similar

functions and purposes, namely to help patients to recover

from sickness. When taking a tablet, water is consumed as

well so that the medicine can be swallowed easily. As non-

verbal communication helps nurses to deliver better nursing

services and support to their patients, its supportive role

plays the same role as water. Participant 3 said that teach-

ers use many different kinds of chalk to write down teach-

ing content on the blackboard and emphasise different key

ideas. Nursing services consist of different tools and skills,

and non-verbal communication is a kind of important

communication tool. It helps nurses to express their

thoughts and feelings to patients or reinforce the message

contents and ideas. Participant 8 described non-verbal

communication as a good quality pen: ‘Communication is

just like a pen: any pen can write something, but whether




the words are pretty or the writing speed is fast are another

matter. A pen that does not leak ink allows a writer to

write faster and prettier’. This indicates that every nurse

has opportunities to communicate with patients, but the

communication experience depends on the skills. Good

non-verbal cues facilitate better communication and enable

nursing services to be delivered faster. Participant 9 viewed

non-verbal communication as a form of emotional support.

Non-verbal communication acts like a fulcrum, assisting

nurses in the delivery of psychological intervention. When

non-verbal communication is performed well, patients may

eventually suffer less. Participant 12 thought that non-ver-

bal communication could make nursing care more perfect,

just like a decorative flower makes things look prettier. She

believed that not everything could be expressed verbally

and gave an example of how non-verbal cues could rein-

force verbal messages: ‘I could verbally tell a patient that I

care about her, but by holding her hand at the same time,

the feeling of my care for her is emphasised’.

Subtheme 2: individualisation

Four metaphors showed that non-verbal communication is

individualised, often influenced by different factors. Partici-

pant 2 recognised that her pattern of conducting non-

verbal communication depends on patients’ situations and

her relationship with the patient. She wore different masks

when facing different patients. She had more patience and

contact with familiar patients, as well as giving more non-

verbal emotional support to patients in unpleasant condi-

tions. A durian is a kind of fruit that has a strong smell

and taste. Some people love it, while others may feel sick

at even the slightest taste of it. As stated by participant 5,

the acceptance of non-verbal communication and the

durian depends on people’s preferences and perceptions.

She gave the following example: ‘An expression can be

decoded into two different meanings. For example, a

smile: some people may consider it as a friendly greeting,

while others may think it is a sneer’. Patients come from

all walks of life, and their background, age, educational

Table 1 Metaphors given by the participants

Metaphors related to

non-verbal communication Descriptions

Subtheme 1: providing assistance

Participant 1 Tablet and water If nursing service is the pill, then non-verbal communication is the

water that helps practitioners deliver service and support to patients

Participant 3 Chalk An important tool that helps nurses to deliver messages or reinforce

meanings

Participant 8 Good quality pen Allows nurses to deliver messages faster and in a better manner

Participant 9 Fulcrum Helps nurses deliver psychological intervention more easily

Participant 12 Decorative flower With non-verbal communication, nursing care could be more perfect

Subtheme 2: individualisation

Participant 2 Mask The way of communicating non-verbally depends on the situation:

I wear different masks when facing different patients

Participant 5 Durian Non-verbal communication is just like a durian; it really depends on

people’s preferences and perceptions

Participant 7 Water Has to able to fit into containers with different shapes

Participant 15 Walking stick Not every patient values non-verbal communication, just as not

everyone needs to hold a walking stick

Subtheme 3: dropping hints

Participant 10 Pioneer Using and reading non-verbal cues allows me to know if a patient is

approachable

Participant 13 Detective case Through reading the non-verbal cues, I can guess the patients’

feelings and thoughts

Subtheme 4: promoting interaction

Participant 4 Bridge A bridge that allow one to have a connection with others

Participant 6 Two-way bridge Provides connections between nurses and patients

Participant 11 Playing ping-pong If I show more care, such as smiling and touching, the patients

might respond in a nicer way

Participant 14 Any ball gameplayed by

two people

When I use more non-verbal cues, patients might be attracted by me

and thus show me some response

Participant 16 Playing basketball Having interactions with patients, passing messages back and forth



ZCY Chan

and social levels influence their demand and understanding

of different non-verbal cues. A similar concept was con-

cluded by participant 7, who suggested that non-verbal

communication should be as flexible as water. Nurses

should consider different influencing factors and adopt dif-

ferent non-verbal communication patterns with different

patients. According to participant 15, non-verbal commu-

nication may not be highly valued by every patient. She

said, ‘Some patients like verbal and some would prefer

more non-verbal. Like a walking stick, it is very important

when it is needed, otherwise it is unimportant if one

thinks he can survive without it’. Holding an elderly hand

is very important, as this action could guide the elderly

person to walk properly and confirm the presence of the

nurse.

Subtheme 3: dropping a hint

Two participants suggested that non-verbal cues are

like hints. Participant 10 offered the pioneer as a meta-

phor because nonverbal cues are signals that allow him

to explore patients’ readiness to communicate. He said,

‘Sometimes, when I nod and make eye contact with

patients, patients who do not want to chat with me may

ignore me. Through such responses I know when I

shouldn’t interrupt them’. Participant 13 perceived read-

ing and guessing the meaning of non-verbal cues as a

detective case. He often finds and analyses non-verbal

cues given by patients to understand and address their

needs and thoughts. However, he seemed to have reserva-

tions regarding non-verbal communication: ‘The patients

and I have to guess each others’ cues. Non-verbal commu-

nication is not as clear as verbal because it can cause

misunderstandings’.

Subtheme 4: promoting interaction

Five metaphors represented the nurse–patient interactive

process. Participants 4 and 6 imagined non-verbal commu-

nication as a bridge that connected them with patients. Via

the bridge, messages could flow freely between nurses and

patients. Participant 6 further pointed out that confusing

non-verbal cues could obstruct the bridge. Participant 11

suggested that the communication process was like playing

ping-pong. The process is reciprocal: ‘When I show more

care and smiles to my patients, they may eventually show

more respect and concern for me as well’. Participants 14

and 16 gave similar metaphors, namely any ballgame

played by two people and basketball respectively. Their

descriptions were very alike, because they believed that

giving friendly non-verbal cues to patients could attract

their attention and elicit a better response from them. The

process allows them to interact with patients and build

closer relationships.

Discussion

Communication is undoubtedly highly valued in the health-

care context, as it is a crucial tool that connects patients and

practitioners (McCabe 2004). As suggested by DiMatteo

et al. (1980), patients are more satisfied with practitioners

with higher non-verbal communication skills. Our partici-

pants also perceived the importance of non-verbal communi-

cation and sensitivity because it facilitates the delivery of

services and uplifts service quality. It widens expression

opportunities, as well as developing a closer link between

patients and practitioners, allowing better interaction and

collaboration (Chambers 2003). However, as revealed by

some participants, non-verbal communication should be tai-

lor-made and conversant because the perspectives, needs

and behaviour of different patients vary.

Meeting patients’ physical and psychological needs is

often viewed as the primary task. In fact, during the deliv-

ery of services, nurses must consider patients’ demographic

background, as this is a factor that plays a part in patients’

satisfaction with nursing care and practitioners. Although

our participants have limited clinical experience, they expe-

rienced different non-verbal communication styles when

dealing with patients from different walks of life. Patients’

gender influenced our participants’ expression of non-verbal

cues; however, they might not know that patients actually

have different expectations of practitioners of different gen-

ders. Mast et al. (2008) discovered that patients expected

female practitioners, while maintaining a professional

image, to show more feminine characteristics as well,

including using more eye contact and a gentle tone of voice,

talking less and maintaining closer interpersonal distance.

Male practitioners can perform a wider range of behav-

iours, but patients expected them to be more masculine,

such as having a louder voice, acting more expansively and

maintaining more interpersonal distance. Some of our par-

ticipants believed that adult patients prefer to enjoy more

privacy and therefore might communicate less with them. A

similar phenomenon was found in Devoe et al. (2009)

study, showing that practitioners were less likely to com-

municate with patients aged 18–64. This might be because

younger patients prefer more expedient, fast and potent

treatments and would love to have more control over their

own health care (Jung et al. 2003). On the other hand,

elderly aged over 65 prefer practitioners provide them with

healthcare decisions and continuity of care (Jung et al.

2003). Some participants revealed that they were more




aware of their behaviours when dealing with higher social

class patients, and that they would behave more naturally

in public hospitals. In fact patients from lower social classes

are actually more passive and less prone to voicing their

thoughts and questions (Willems et al. 2005). Observing

the non-verbal cues of patients from lower social classes

and communicating with them actively should be emphas-

ised, rather than passively knowing patients’ needs. Our

findings revealed that traditional superstitious beliefs of

Chinese patients may influence practitioners’ non-verbal

communication; therefore, practitioners should consider

cultural beliefs as well. As described by Furnham and

Wong (2007), Chinese have more superstitious and

religious belief, whereas British look more into biological,

psychological and societal factors.

Some studies have suggested the beneficial functions of

using metaphors as a data collection tool in qualitative

studies. Metaphors can act as a powerful expressive lan-

guage which in turn forms pictures in readers’ minds, clari-

fying and deepening meanings and making data highly

conceptual (Levitt et al. 2000, Bonner & Greenwood

2005). The metaphor approach in this study organised our

data, making it more condensed and enabling us to build

up themes. It also helped us to understand familiar experi-

ences and thoughts and reflected underlying needs and

thoughts, which allowed us to suggest proper interventions

and prompted our emotions (Carpenter 2008). However,

Carpenter (2008) pointed out that the approach should be

used appropriately to avoid confusing readers, and Schmitt

(2005) suggested that cultural aspects must be considered

as they can influence metaphor analysis and alter meanings.

For example, readers in some countries might not be famil-

iar with the durian metaphor in our study. If the metaphor

is used appropriately, it is certainly a useful and creative

method and can shed light on qualitative data collection

and analysis.

Limitations and recommendations

The participants in this study were all nursing students who

had limited clinical experience. Their experiences and views

of non-verbal communication were comparatively less than

those of registered nurses. A study should be conducted to

explore the perceptions of non-verbal communication in

registered nurses so as to determine whether they hold dif-

ferent values and experiences. In addition, this study mainly

focused on nurses’ perceptions of their own non-verbal

behaviour instead of that of patients’ non-verbal behaviour.

Also patients’ perceptions were not examined. Most of

the patients’ ‘thoughts’ and ‘experiences’ revealed in the

interviews actually consisted of participants’ assumptions.

It is crucial to explore patients’ perceptions so as to facili-

tate and clarify the cognition of both parties and thereby

enable non-verbal communication to be more effective and

interaction quality uplifted. The data collection method

applied in this study was based on in-depth interviews.

Our data were lack quantitative data support, such as

performing an interpersonal sensitivity test that could

examine participants’ ability to decode and encode non-ver-

bal cues in real practice. A study observing the correlation

of non-verbal cues to participants’ and patients’ characteris-

tics could provide us with a deeper insight into the use

and perception of non-verbal cues in the healthcare con-

text. This study is a pioneer study in Hong Kong. It is

suggested that non-verbal communication should be fur-

ther investigated within other Asian countries so as to

draw comparison between Eastern and Western countries,

as well as further enhance our nursing knowledge and

clinical practice.

Conclusions

The results showed nursing students’ non-verbal communi-

cation experiences in the current Hong Kong clinical set-

ting, which reflected their strengths and areas that may be

in need of further improvement, as well as the importance

of non-verbal communication in the nursing context. This

study seemed to be a preliminary clinical study in Chinese

societies, as nursing students’ non-verbal communication

and sensitivity are rarely discussed in the Chinese health-

care context. It is hoped that it will pave the way for clini-

cal nursing development, especially non-verbal sensitivity

between nurses and patients. Last but not least, adopting

the metaphor as a data collection and analysis tool should

be further encouraged, as it can add colour and social

cultural elements into nursing literature.

Relevance to clinical practice

Through understanding nursing students’ experience and

perspective on non-verbal communication, we can under-

stand the knowledge that they lack of. For example, many

participants do not consider voice and appearance as influ-

ential factors; however, as suggested by some literature,

patients do value voice and professional image. These

results could provoke students and nurses to rethink,

train and pay more attention to their non-verbal communi-

cation style and sensitivity, thus helping them to facilitate

the communication process and service delivery in their

future career path.



ZCY Chan

Funding

This study was financially supported by The Family and

Community Health Division at School of Nursing, The

Hong Kong Polytechnic University.

Contributions

Study design: ZC; data analysis: ZC and manuscript pre-

paration: ZC.

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A qualitative study on non-verbal sensitivity in nursing students