CLINICAL
Non-verbal communication:
the importance of listening
Lynn Kacperek
ecently, I lost my voice as a result of
R ~on-infectious laryngitis. [ was work-
mg as a staff nurse in a private surgi-
cal hospital at the time and was concerned
whether it would be possible to practice effec-
tively while being unable to speak. My initial
reaction was that verbal communication was
essential for effective interaction. However, [
felt well and, following discussion with my
manager, a conscious decision was made that
this condition did not compromise my abiliry
to practice. It was agreed that telephone calls
would be answered by the other nurses and
that in cases of emergency the hospital's
nurse-call system could be utilized.
Interestingly, my initial reaction that speech
was essential for communication was quickly
challenged. Rather than having a detrimental
effect on my practice, the reverse was true. I
soon became aware that patients were
responding to me differently.
It would appear that minimal verbal inter-
vention, when combined with other aspects
of non-verbal communication, is effective in
conveying caring rather than relying solely
on verbal communication. Conversations did
not come to a halt as was initially supposed
and listening to patients without verbal inter-
ruption encouraged them to talk more. Also,
concentrating on what patients were saying
without interruption made it easier to gather
and synthe ize their message. It became
apparent that communicating non-verbally
was a quick and effective way of transcend-
ing other forms of communication.
REFLECTION ON PERSONAL
EXPERIENCE
Over a decade ago, Benner (1984) stated that:
'Knowledge will not expand or fully
develop unless nurses systematically
record what they learn from their own
experience.'
More recently, Johns (1995) explained that:
BRmSH J OURNAL O ~ N UR )l'C, 1997, VOL 6, N o
Abstract
This article presents the author's personal retrectlon on how her nursing
practice was enhanced as a result of losing her voice. Surprisingly, being
unable to speak appeared to Improve the nurse/patient relationship.
Patients responded positively to a quiet approach and silent
communication. Indeed, the skilled use of non-verbal communication
through silence, facial expression, touch and closer physical proximity
appeared to facilitate active listening, and helped to develop empathy,
Intuition and presence between the nurse and patient. Quietly 'being
with ' patients and communicating non-verbally was an effective form of
communication. It Is suggested that effective communication Is
dependent on the nurse's ability to listen and utilize non-verbal
communication skills. In addition, It Is clear that retrectlon on practical
experience can be an Important method of uncovering and exploring tacit
knowledge In nursing.
'Reflective personal knowledge is the
most substantive form of knowledge and
should properly constitute the body of
knowledge of a practice discipline.'
Recording personal reflections, therefore, is
a val uable method of describing, analysing,
evaluating and developing our understanding
of what we learn from practical experience.
Furthermore, when viewed within the context
of current literature and research, impressions
gained through reflection can be vindicated
and gaps in present knowledge uncovered.
Thus, the knowledge inherent in practical
nursing can be identified and made available
for theory development through the process of
reflection. Figure 1 outlines this approach.
PROBLEMS WITH COMMUNICATION
Communication is integral to effective nurs-
ing practice. Ley (1988) states that interper-
sonal communication is vita lly important to
Lynn Kacperck is Project
all caring professions. He suggests that many Nurse, IDdepeodent British
of the problems associated with patient non- Healtbcare, Fulwood Hall
Hospital, Preston,
compli ance could be avoided by improving
Lancashire. At the time of
health professionals' communication skills. writing sbe was a staff aune
The lack of effective communication is a con- at the above hospital
stant feature of complaints received by the
5 275
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CLINICAL
Hea lth ervlce Commissio ner; one th ird of
these a re related to communication problems
wi th nursing staff (Yo un g, 1995).
THE IMPORTANCE OF LISTENING
The UKCC's (1996) recent Guidelines for
Professional Practice devotes an entire section
to commu nicatio n. It highl ights the fac t that
effective commu nicati o n requ ires th e use of
many interpersona l sk ill s a nd emph asizes t he
importa nce of li stening to patient. T his per-
spective is re in fo rced by Adair (1994 ) who
. Experience is described
1 (words o nl y), 38% vocal o r pa ra lingui stic
Experience is analysed within the
conte xt of current re search
and literature
r by their clo thes, ma ke-up, perfume, hair tyle,
Expe rie nce is eva luated by
que stioning and challenging
• personal knowledge and
cu rrent theory
r interru pting the person who is co mmunicat-
New understanding is integrated
with existing knowledge
to inform pra ctice
To e xtend the boundaries of
nursi ng knowledge , gaps in present
knowle dge are identified for further
reflection , research and theory development
Figure 1. Outline of the reflection process.
276
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fo und th at interviewing pa tients and listening
to th eir experi ences of ca re provided va lu able
in fo rm ati o n w hi ch could be utili zed to
imp rove the qua lity o f care. Thi s tud y
empha ized the impo rtance of listening as a
va lua ble ski ll fo r nu rse researchers. In add i-
tio n, Bu rnard (1992) states th at listening and
attend ing are the twO most impo rtant ele-
ments of thera peutic communica ti on and
'over-ta lking' is the least productive.
NON-VERBAL COMMUNICATION
on-verba l com mun ica ti on is the term u ed
to describe a ll fo rms of human communica-
tion not contro lled by speech. Mehra bi an
(1971) fo und that the tota l impact of a mes-
sage could be broken down to 7% ve rba l
as pects (tone of voice, silence, inflecti on,
other sounds) and 55 % non-verba l. Argy le
(1988) sugge ts that th e no n-verba l compo-
nent of communica tion is fi ve times mo re
in fl uentia l t han t he ver ba l as pect . Pease
(1985) highlights the impo rta nce of recogni z-
ing peop le's non-ve rba l messages as conveyed
personal hygie ne and genera l appea rance.
THE EXPERIENCE OF LISTENING TO
PATIENTS
Li stening and attending invo lves heari ng and
understanding the ve rba l, non-verba l and
paralinguistic as pects of the message. This is
best ach ieved by re mai ning quiet and no t
ing except to exchange sho rt encourage ment
such as 'yes', 'I ee' a nd 'go on '. It is often dif-
fi cult to keep qu iet. I remember feeling the
urge to as k questions a nd to add my own
opinio ns as soon a they came into my mind.
However, beca use I had lost my voice [ was
una ble to interrupt a nd therefore interactions
fo llowed the patient' age nda; this seemed to
ma ke it much ea ier to esta bli sh a rap port.
on-verba l encourage ment and re-assura nce
was effecti ve a nd eve ra l pa ti ent sa id
how peaceful it wa to be listened to and
nursed q uietl y.
LOSi ng my voice made me a ware of the
complexity of the communicati on proce
a nd how words ca n block optima l interac-
tio n. Using fac ia l expression and movement
such as nodding my hea d, tilting it slightl y to
BRm H J OUR Al OF N UR ING, 1997, V Ol 6, No 5

one side, smiling gently ai'ld eye contact
helped to reinforce and encourage patients to
talk. Keeping a relaxed and open body pos-
ture and mirroring the patient'S body position
and body language helped demonstrate inter-
est and involvement. Also, by being in tune
with my own non-verbal behaviour it was
easier to react to patients' non-verbal cues.
One patient's non-verbal cues were communi-
cating anxiety, i.e. he was wringing his hands,
putting his fingers up to his mouth and wrin-
kling his forehead, but he was actually saying
that everything was fine. By changing my
body position, i.e. moving to sit closer to him,
he gradually began to express his concerns.
Faulkner (1992) reinforces the notion that
patients often give non-verbal cues as to how
they are feeling and states that nurses should
be receptive to this as these cues frequently
lead to valuable opportunities for communi-
cation. Thus, being unable to speak encour-
aged me to be more receptive to patients'
non-verbal communication.
SILENCE
Silence that is coupled with a relaxed
approach gives patients time and space to
think. However, Davidhizar and Newman-
Giger (1994) point out that many nurses are
uncomfortable with silence during their inter-
actions and interrupt the silence by talking.
The authors recommend that nurses should
make use of silence in order to promote com-
munication and not be intimidated by it.
They also note that cultural differences may
alter the meaning of silence.
Porritt (1990) explains that silence often
causes the listener to feel anxious; the patient,
however, will usually signal (non-verbally)
when he/she wants verbal interaction, e.g. by
making eye contact.
TOUCH
Touch was another powerful non-verbal
method of responding to the patient. I fre-
quently used light touch on the hand or arm
and this seemed to bring comfort and enrich
the meaning of my communication. Fry
(1994) found that the careful use of touch
when relating to people with visual disabili-
ties had a therapeutic effect.
Tutton (1991) states that touch is an inte-
gral part of nursing care and may have many
BRITISH JOURNAL OF NURSING, 1997, VOL 6, No
NON-VERBAL COMMUNICATION: THE IMPORTANCE OF LISTENING
potential benefits for patients. The subtle use ... touch is an
of gentle touch was a potent and effective way ,
integral part of
of communicating. It signified a depth of feel-
ing and understanding which words could not nursing care and
so easily convey. I remember sitting quietly may have many
with a patient who had returned to the ward potential benefits
immediately after surgery. No words were
spoken, but as I gently stroked the back of her for patients. The
hand she relaxed, later commenting that this subtle use of
was precisely what she had needed. gentle touch was
PRESENCE, INTUITION AND EMPATHY: a potent and
TOWARDS HOLISTIC PRACTICE effective way of
communicating
At this time] used all my resources of mind,
body and spirit to communicate with patients with patients. It
and, as a result, an intangible quality natural- signified a depth
ly emerged within the nurse/patient relation- of feeling and
ship. Benner and Wrubel (1989) describe this
as 'present tense concern' or 'being there', understanding
stating: which words
' ... the ability to presence oneself, to be could not so ,
with a patient in a way that easily convey.
acknowledges your shared humanity, is
the base of much of nursing as a caring
practice.. .'
Gardner (1992) refers to this intuitive under-
standing (which is expressed mainly through
non-verbal communication) as 'presence' and
believes that:
'Presence is the gift of the self, verified
by the nurse and the patient .. .'
Being more sensitive to the message I was
conveying enabled me to create and adapt this
in a more caring and personal way.
Interestingly, however, Burnard and Morrison
(1991) suggest that nurses perceived their
interpersonal style as tending to be authorita-
tive rather than facilitative. Perhaps my inter-
personal style was normally more authorita-
tive; however, by ada pting and expanding the
non-verbal aspects of my communication it
had become facilitative. Moreover, by aban-
doning professional detachment in favour of
closeness between myself and the patients,
empathic relationships developed.
Morse et al (1992) explored the use of
empathy in nursing, believing empathy to be
the essence of the nurse/patient relationship.
Non-verbal behaviours were considered
important in communicating empathy, and
were expressed through moderate head nod-
ding and gesturing, a steady gaze and the min-
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CLINICAL
Interpersonal imum of acti vity or bo dy movement. In addi-
ti on, Pease (198 5 ) believes that intuiti o n is
skills, o ften grounded in an a bility to correctl y inter-
particularly pret no n- verba l co mmunicati on a nd pa ra lan-
'non-verbal guage. Indeed , wh en o ne listens and pays
attentio n, the right res po nse occurs natural-
communication, ly. Develo ping listening and non-verb al com-
must not suffer municati on skill s a ppeared to increase my
lack of attention in a bility to utili ze the inta ngible qua lities of
presence, intuiti on and empath y.
nursing literature,
education and DIFFICULTIES WITH RESEARCH
research or lose
J ones (1994 ), when reviewing recent research
significance simply o n nu rses' interpersona l skill s, fo und inherent
,
because they are difficul t ies in empl oying empirica l methods o f
difficult to enqu iry. Thi s may have been du e, in part, to
the intangibility o f the subj ect matter. H e
define and
a rgued that interpersonal skill s are a phe-
evaluate. nomeno n whi ch do no t fit eas il y into reduc-
ti oni st resea rch method s. Ackn owledging this
d ilemma, it ap pea rs th at deve loping funda-
menta l understa nding within nu rs ing is just
as impo rtant as esta bli shing ca use/effect rela-
ti onshi ps .
Refl ectio n is an idea l sta rting po int fo r
developing this understanding. The practice
o f kee ping re fl ecti ve diaries a nd logs could
help to develop the resea rch skills necessa ry
to record ri goro us fi eld notes a nd di aries.
Insights and ideas un covered by reflecti on
could be explo red furth er throu gh qua litati ve
research meth o ds such as pa rti cipant o bser-
va ti o n, ca se studi es and bi ogra phica l
acco unts. Interpersonal skills, pa rticul a rl y
non- verba l communication, must no t suffer
from lack o f attention in the nursing litera -
ture, edu cation and resea rch or lose signifi -
cance simply beca use they a re difficult to
define and eva luate.
EDUCATION IN NON-VERBAL
COMMUNICATION
Fo r co mmuni ca ti o n to be effecti ve, the
non-verba l aspects of nurse/patient intera c-
ti on must be understood. This issue wa
explored by D avi s (1994 ), who concluded
th a t mi sunderst andin gs occur a nd ma ny
opportuniti es fo r effecti ve communication a re
lost beca use o f insufficient kn owledge . H e
beli eves th a t pati ents wo uld benefit a nd
become mo re coopera ti ve and compliant if
nurses had a better understa nding o f non-
verba l behavio ur.
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SUPPORT FOR NURSES
N urses need to understa nd the psychologica l,
emoti onal a nd spiritual needs of patients if
the concept o f holism is to have value in nurs-
ing. It wo uld appea r from my personal reflec-
tio n that patients often express these needs
non-verba ll y. I fo und it ea sier to ga ther infor-
matio n a nd to und erstand patients' needs
w hen I acti vely listened and responded using
no n-verba l communication.
H o wever, the needs of nurses are equally
impo rtant. Although this personal reflection
has been va luable in developing my knowl-
edge, self-awa reness and practical skills, it has
been cha llenging and difficult. When entering
into meaningful refl ectio n on practica l experi-
ence, it is vital that support and encourage-
ment are ava ilable as the process of reflectio n
can be uncomfortable as well as rewarding. As
stated in a recent Government document
(Department of Health, 1993), clinical super-
vision ca n provide an ideal environment in
w hich to explore reflecti ve practice. Indeed,
J o hn s (1995) ad vocates guided refl ection,
through clinica l supervision, as a structured
way of enabling and suppo rtin g nurses to
reflect and lea rn from their experiences.
CONCLUSION
There a re pertinent messages to be learn ed
from this personal account. If learning from
practice is to occur then refl ection on experi-
ence is vita l. In additi on, refl ectio n is a valu -
a ble meth od of un covering tacit kn owledge,
which sho uld be exa mined w ithin the context
of current research and literature, in order to
a na lyse findings critica ll y, develop knowl edge
a nd stimulate further inquiry.
Explicit within thi s re fl ection is confirma-
ti o n that nursing is dependent on effecti ve
huma n interactio n within the context o f care.
Acti ve listening ap pears to be demonstrated
ma inly th ro ugh no n-verbal communicatio n.
Th erefore, the need fo r a comprehensive
understanding of and education in non-verba l
communicati on skills is reinforced. It is rec-
ogni zed th at nurses need to give info rmation
and negotiate ca re ve rball y with patients.
H owever, the importa nce of fa cilitating effec-
ti ve communication through active listening
a nd the sk illed use of non-ver ba l communica-
tio n is clea r and sho uld not be underestimat-
ed in the prac tice setting. IDD
BRmSH J OURNAL OF URSI G, 1997, V Ol 6, No 5
 NON-VERBAL COMMUNICATION: THE IMPORTANCE OF LISTENING

Adair L (1994) The patienr's agenda. Nurs Stand
9(9}: 20-3
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Excellence and Power in Clinical Nursing
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Benner P, Wrubel J (1989) The Primacy of Caring:
Stress and Coping in Health and [l/ness.
Addison-Wesley, California
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Health Professionals. Chapman and Hall, London
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KEY POINTS
• Reflection is a valuable method of uncovering and exploring tacit
knowledge in nursing.
• Nursing is dependent on effective communication; however, words
can often prevent optimal interaction_
• Communicating non-verbally is a quick and effective way of
transcending other forms of communication_
• Listening is often demonstrated through non-verbal communication.
• The skilled use of non-verbal communication can develop the
intangible qualities of presence. intuition and empathy.
• The document Guidelines for Professional Practice (UKCC. 1996)
states that effective communication requires all the nurses' skills and
places strong emphasis on the importance of listening to patients.

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