The Indian Journal of Pediatrics

https://doi.org/10.1007/s12098-018-2680-6

CLINICAL BRIEF

Non-verbal Communication in a Neonatal Intensive Care Unit: A Video

Audit Using Non-verbal Immediacy Scale (NIS-O)
Somashekhar Marutirao Nimbalkar 1,2 & Himalaya Raval 1 & Satvik Chaitanya Bansal 1 & Utkarsh Pandya 1 & Ajay Pathak 2

Received: 5 December 2017 / Accepted: 5 April 2018

# Dr. K C Chaudhuri Foundation 2018

Abstract
Effective communication with parents is a very important skill for pediatricians especially in a neonatal setup. The authors
analyzed non-verbal communication of medical caregivers during counseling sessions. Recorded videos of counseling sessions
from the months of March–April 2016 were audited. Counseling episodes were scored using Non-verbal Immediacy Scale
Observer Report (NIS-O). A total of 150 videos of counseling sessions were audited. The mean (SD) total score on (NIS-O)
was 78.96(7.07). Female counseled sessions had significantly higher proportion of low scores (p < 0.001). No video revealed
high score. Overall 67(44.67%) sessions revealed low total score. This reflects an urgent need to develop strategies to improve
communication skills in a neonatal unit. This study lays down a template on which other Neonatal intensive care units (NICUs)
can carry out gap defining audits.

Keywords Non-verbal immediacy scale observer report . Communication . Neonatal intensive care

Introduction Material and Methods

There has been a great advancement in the field of neonatol-
ogy as evident by the drop in Neonatal Mortality Rate (NMR)
of India to 29 in 2012 from 52 per 1000 live births in 1990 [1].
Most of the newborns surviving today require complex inter-
ventions, long duration of stay and prolonged ventilation.
Communicating information to parents thus is a critical skill
for healthcare providers. Empowered parents are an asset with
active and supportive involvement in newborn’s care. The
pediatricians need to address ethical issues, display empathy,
appear sensitive, support and guide parents, and also direct
relatives to sources of financial support. Nonverbal communi-
cation is interestingly a primary vehicle for expressing emo-
tion and can even contradict verbal communication. The au-
thors aimed to analyze non-verbal communication of medical
caregivers during counseling sessions in their unit.
This audit was conducted in the Level 3 NICU of a Medical
College in Central Gujarat. The counseling area in the unit is
under video surveillance. The recordings of the counseling
sessions for the months of March and April 2016 were extract-
ed and evaluated using Non-verbal Immediacy Scale
Observer Report (NIS-O). NIS-O has good face validity with
excellent predictive validity. It uses 5-point scale to assess 26
statements describing behavior of people while talking with
others. Different values are used as norms for evaluating
males and females (Table 1) [2]. Videos were analyzed by
the investigators, who did not work in the unit, during this
time using descriptive statistics and tool-based evaluations.
Institutional Ethics Committee (HREC) of HM Patel Center
for Medical Care and Education approved the study. Consent
was taken from the participants.

* Satvik Chaitanya Bansal

drsatvikbansal@gmail.com Results

1 A total of 150 videos of counseling sessions (65 by male and

Department of Pediatrics, Pramukhswami Medical College,
Karamsad, Gujarat 388325, India 85 by female physicians) were studied. The mean (SD) total
2 score on NIS-O was 78.96(7.07) [Range: 58, 94]. It was sig-
Central Research Services, Charutar Arogya Mandal,
Karamsad, Gujarat 388325, India nificantly higher for males [p = 0.003].
 Indian J Pediatr

Table 1 Performance of
counselors in non-verbal Male (n = 65) Female (n = 85) Combined (n = 150)
communication
Total Score Mean(SD) 80.91 (7.86) 77.47 (6.03) 78.96 (7.07)
Norm: Mean(SD) 91.6 (15.0) 96.7 (16.1) 94.2 (15.6)
Criteria High Score > 106 > 112 > 109
High Score n(%) 0 0 0
Criteria Low Score < 77 < 81 < 79
Low Score n(%) 14 (21.15) 59 (69.41) 67 (44.67)

The mean total score was significantly less in males as well
as females as compared to norms [p < 0.001]. Not a single
video revealed High Score (>109) – neither in males (>106)
nor in females (>112) as per the norms. Female counselors had
significantly higher proportion of low scores (<81) as com-
pared to male counselors (<77) as per the norms (69.41% vs.
21.15%; p < 0.001). Overall 67(44.67%) sessions revealed
low total score (Table 1).
Discussion
Parents of a premature or critically ill newborn go through
significant emotional distress [3]. This stress may be amelio-
rated if the medical team provides contextual information and
support for parents. Moreover, the medical team is almost
always the source of information to the parents, and they
spend very little time searching internet and medical books
[4, 5]. This is especially important in the current study where
majority of parents are the rural poor. Caregiver-parent com-
munication also determines the degree of satisfaction, which
the parents feel. Professionalism, which includes information
being provided and explained to the parents in a calm, confi-
dent and controlled manner, and empathy, which includes be-
ing caring and providing emotional support, encouragement
and reassurance, are crucial determinants of parental satisfac-
tion with neonatal intensive care unit (NICU) care [6]. In a
South African setting [7], only slightly more than half (57%)
of interviewed parents were satisfied with overall communi-
cation during NICU care. Another cross-cultural study of nine
NICUs characterized that the discussions of morbidity and
mortality adequately addressed the information needs of the
majority of parents in only 5 of 9 centers [8]. The present audit
also shows unsatisfactory non-verbal communication by the
caregivers in just under half of all the counseling sessions. The
scores were worse for female-counselled sessions, but this
observation may be biased as only a single female caregiver
was audited.
The blame for poor communication skills can be laid at the
feet of the Medical Council of India, which has neglected the
push for development of crucial areas such as medical ethics,
problem solving skills, behavior science and communication
skills, since the stress is mostly on acquisition of knowledge
[9]. We need to move away from the knowledge dominated
examinations to more skill-oriented examinations [10].
Retrospective feedback trials regarding parents’ expecta-
tions from counseling are needed. Specific tools are being
studied, such as using communicative algorithms and commu-
nicative case sheets for common NICU problems [11]. The
authors suggest the use of simulation along with case histories
from recorded videos to be studied as a strategy to improve
communication.
The authors accept the limitations in the current study –
small sample size, the tool being subjective and not validated
for the Indian population.
Conclusions
Communication has cultural connotations and in India with its
varied culture and language, such studies should be carried
across various centers. This study lays down a template on
which other NICUs can carry out gap defining audits. It is
also imperative to individual NICUs and the current NICU
where the study has been carried out, to ferret out solutions
to improve communication.
Contributions SCB: Designed the study, collected the data, wrote the
paper, and approved the final manuscript; SMN: Conceived the study,
designed the study, wrote the paper, and approved the final manuscript;
UP: Collected the data, gave inputs to the paper, and approved the final
manuscript; HR: Designed the study, collected the data, analyzed the data,
wrote the first draft and approved the final manuscript; AP: Designed the
study, analyzed and interpreted the data, gave important intellectual in-
puts to the manuscript and approved the final manuscript. SMN will be
the guarantor for the paper.
Compliance with Ethical Standards
Conflict of Interest None.
Source of Funding None.
Indian J Pediatr
References
1. Zodpey S, Paul VK. PHFI, AIIMS, and SC- State of India’s
Newborns (SOIN) 2014- a report. New Delhi, India: All India
Institute of Medical Sciences and Save the Children, Public
Health Foundation of India; 2014.
2. Richmond VP, McCroskey JC, Johnson AE. Development of the
nonverbal immediacy scale (NIS): measures of self- and other-
perceived nonverbal immediacy. Commun Q. 2003;51:504–17.
3. Yee W, Ross S. Communicating with parents of high-risk infants in
neonatal intensive care. Paediatr Child Health. 2006;11:291–4.
4. Dhillon AS, Albersheim SG, Alsaad S, Pargass NS, Zupancic JA.
Internet use and perceptions of information reliability by parents in
a neonatal intensive care unit. J Perinatol. 2003;23:420–4.
5. Kowalski WJ, Leef KH, Mackley A, Spear ML, Paul DA.
Communicating with parents of premature infants: who is the in-
formant? J Perinatol. 2006;26:44–8.
6. Sawyer A, Rabe H, Abbott J, Gyte G, Duley L, Ayers S. Parents'
experiences and satisfaction with care during the birth of their very
preterm baby: a qualitative study. BJOG. 2013;120:637–43.
7. Ranchod TM, Ballot DE, Martinez AM, Cory BJ, Davies VA,
Partridge JC. Parental perception of neonatal intensive care in pub-
lic sector hospitals in South Africa. S Afr Med J. 2004;94:913–6.
8. Partridge JC, Martinez AM, Nishida H, et al. International compar-
ison of care for very low birth weight infants: parents' perceptions of
counseling and decision-making. Pediatrics. 2005;116:e263–71.
9. Verma K, Monte BD, Adkoli BV, Nayer U, Kacker SK. Inquiry-
driven strategies for innovation in medical education: experiences
in India. Indian J Pediatr. 1993;60:739–49.
10. Sood R, Adkoli BV. Medical education in India – problems and
prospects. J Indian Acad Clin Med. 2000;1:210–2.
11. Biasini A, Fantini F, Neri E, Stella M, Arcangeli T. Communication
in the neonatal intensive care unit: a continuous challenge. J Matern
Fetal Neonatal Med. 2012;25:2126–9.