by Toni S. Adams, RDH, BA
Most of what we communicate isn't even spoken aloud. Just what message are you delivering?
Hans was the most extraordinary horse of his day. By tapping his hoof, he seemed able to do simple and complex math, even fractions; he could count people in a crowd; he could answer questions using an alphabet coded to use his taps; he even appeared to be able to read! He was nicknamed "Clever Hans" and became famous, even outside his home in Germany in 1900.
Of course, experts in several fields tried to disprove his abilities. All failed until 1911 when a researcher came up with the answer. Hans was unusually adept at reading nonverbal communication! Audience members would know the solution to a given problem and would tense up in anticipation of Hans' answer. When the correct number of taps was reached, they would relax and move their heads upward slightly, as little as one-fifth of a millimeter, raise their eyebrows, or dilate their nostrils. Each of these subtle cues told Hans that it was time to stop tapping.
We are all sensitive to the subtle and not-so-subtle nonverbal messages that continually bombard us. This article offers dental professionals an overview of the interesting field of nonverbal communication. I retired from a 26-year career as a dental hygienist and returned to school to earn a bachelor's degree in communication studies, which included the study of nonverbal communication.
What is nonverbal communication? According to communication scholars, it includes all behaviors that are not consciously verbal and that are assigned meaning by one or both of the parties in a communication interaction. The interesting part of this definition is that only one person must assign meaning to a behavior for it to be considered communication. We can receive messages that another person may not have meant to send and, conversely, we can send unintended messages.
Some researchers define the term even more broadly. They discuss the ways in which meaning also can be transferred by inanimate objects such as furniture and architecture, qualities such as color and temperature, and actions such as the use of time and space. It is easy to see that this is a broad area of study, which is one reason to become more familiar with it.
A more compelling reason is that, of the communication that individuals send, researchers tell us that up to 93 percent is nonverbal! That is a lot of information that can be sent, received, and misunderstood. In the rendering of health care we want to eliminate or, at the very least, minimize misunderstandings.
In dentistry, we learn the basics of plaque, caries, and periodontal disease; there are also basic principles in the field of nonverbal communication. First, this is a complex field that cannot be completely separated from verbal communication. Ray Birdwhistell, a pioneer in nonverbal research, reportedly said that studying nonverbal communication is like studying noncardiac physiology. Even so, there is much to learn from looking at this part of communication. Second, nonverbal messages are not absolutely consistent among people. Different cultures and different individuals vary in their use of nonverbal language just as they vary in their use of verbal language.
Third, all people are not equally able to understand nonverbal messages. Just as all horses are not as adept as "Clever Hans" was, so all of us have unique levels of ability in regard to "reading" nonverbal cues. Fourth, nonverbal messages can be used to complement verbal messages by repeating, contradicting, substituting, complementing, accenting and regulating them. Fifth, when the verbal and nonverbal messages are incongruent, we tend to believe the nonverbal rather than the verbal message. If someone is smiling as she or he says, "You're an idiot!" you take it as a joke. If the person says the same thing while wearing a serious expression, you would probably take offense.
A basic axiom of the communication studies field is, "One cannot not communicate." This means that we are constantly transferring meaning, no matter how hard we may try not to do so. Even the act of trying not to communicate communicates something, and the majority of that meaning is sent nonverbally. We give off messages by the way we move, by our attire, by our touch, by our facial expressions, by our eye contact, by how we use time and space, by how we listen, and by the way we say things.
We also derive meaning from the way a person surrounds herself or himself. Is an office tidy or messy, dirty, or clean? Is it decorated with bright or muted colors? What kinds of pictures hang on the walls? Do you hear classical, jazz, country, pop, or hip-hop music? Is the temperature tropical or frigid? Is the furniture arranged to invite conversation or to separate people? Is the lighting bright or dim? The questions could go on and on.
Now I will elaborate on some areas of nonverbal communication that I feel are especially important in dentistry: time, space, touch, paralanguage or expression, gesture, and listening.
Chronemics (the study of time)
In the United States, time is money; we earn it, spend it, save it, waste it, and never seem to have enough of it. The way we use time is often a function of our cultures. Edward T. Hall, another pioneering researcher in this field, made a distinction between monochronic and polychronic time. Monochronic time, used generally in Western cultures, is more linear. We want to be on time and do things one at a time. Polychronic time, more commonly seen in Eastern and native cultures, is more circular; several events can occur simultaneously and personal relationships come before schedules.
Troubling results can occur when people with these two different orientations interact and do not understand the differences.
There is nothing more important in a dental office than time, where we earn our livings by appointments. We constantly live in the tension between our need to be on time, for both our patients and ourselves, and our ethical and legal obligations to provide excellent treatment. I cared for four sisters who were from the Philippines. These charming women became my personal friends - I even attended some of their family celebrations - but they were eternally late for their appointments. They would joke with me that they were on "Filipino time." I did not always appreciate the humor, especially when I was delayed in seeing my other patients.
However, by understanding the differences in perceptions of time, I lost a bit of my angst over the problem. I also found that as my friends became more acculturated to life in the United States, they began to understand my dilemma and to arrive more promptly for appointments. The patient's time is also valuable; dental professionals may give off unintended messages when we keep people waiting without at least acknowledging them.
Proxemics (the study of space)
People, like animals, maintain and defend certain areas of individual space around themselves. The amount of personal distance we require to feel comfortable is based upon many factors, primarily gender (men tend to use more space than women), age, cultural background, relationships with the people around us, our individual personalities, and the context of each situation. According to research, this distance can vary from 18 inches to four feet.
In dentistry, we routinely "invade" the most intimate personal spaces of our patients. This intrusion is one factor that likely contributes to discomfort in the dental chair. We place people on their backs, a vulnerable position, and then literally get in their faces. Even though such closeness is necessary to care for people, we are still "trespassing." I found that people often were too distracted to hear what I had to say when I was invading their spaces with pointy objects. I usually gained greater compliance with requests and suggestions if I made them while sitting face to face in a more equal relationship, outside of a person's personal space, rather than when he or she was in a vulnerable physical position.
Haptics (the study of touch)
Touch is an important way to communicate in all areas of life, as well as from the beginning of life. It is integral to a person's healthy physical and mental development. Lack of touching can cause young children to learn, walk, and talk later, or even to become mentally deficient.
Touch is important in dental care for two main reasons. First, touch can facilitate compliance. One communications researcher compiled results from 13 studies that investigated the relationship between touch and compliance.
In most cases a light touch on the upper arm or shoulder produced more compliance than no touch at all. Second, appropriate touch can communicate such positive feelings as friendship, reassurance, comfort, interest, concern, and care. Researchers have reported that there are positive effects when physicians and nurses touch hospitalized patients. It is easy to see that touch is an important part of creating a positive relationship through communication.
In dentistry, we must touch patients to care for them. Even though the touch of all health professionals today is attenuated by the required use of gloves to comply with infection control standards, we can still use touch in a positive way. We can shake hands, give a pat on the back or hand, or place a reassuring hand on a shoulder while we are ungloved.
During treatment, we can ask an ungloved staff person - preferably one who the patient knows - to hold the hand of an apprehensive person. I have both held the hand of a person receiving treatment from colleagues and asked other staff people to hold the hands of people who were in my care. Patients always responded positively. We can ask permission when we might need to touch a person in an unexpected place, such as when palpating the neck during an oral cancer screening.
One professor told me that, when she was looking for a new dentist, she eliminated the first three candidates in part because they did not shake her hand. While the appropriateness of who can touch whom under any given circumstance can vary among individuals and cultures, we must be sensitive to the patient's reaction to our touch and back off at the slightest sign of disapproval. (And you will sense that disapproval through ... guess what? Nonverbal communication!)
Paralanguage (the study of expression)
How many times have we heard, "It's not what you said, it's how you said it?" This quote refers to paralanguage, the study of the rate, volume, pitch, and quality of the voice. Researchers estimate that as much as 38 percent of the emotional meaning of a message is derived from vocal cues.
The classic example of paralanguage is sarcasm. Say, "You look wonderful today" both directly and sarcastically. The meaning is entirely different both times. You can give the same words many meanings by saying the phrase in other ways, such as emphasizing each different word, making it into a question, or varying the rate and volume of your voice.
The research on the relationship between certain vocal cues and persuasion can be applied to dentistry. A speaker's persuasiveness and credibility are enhanced when the speaker varies his or her pitch, speaks fluently and without hesitation, and responds promptly. People depend on paralanguage cues to interpret meaning when receiving dental treatment because their caregivers are covered in long jackets, gloves, masks, glasses, and face shields. We can transmit a sense of concern, liking, authority, humor, and a hundred other nuances of emotion. We can even "smile," by merely manipulating the rate, volume, pitch, and quality of our voices.
Kinesics (the study of gesture)
One of the most difficult skills to acquire when learning a foreign language is to understand a telephone conversation because the conversant's body language cannot be seen. We depend a great deal on facial expression and gestures to complete the meaning attached to the words that are uttered. This complex area of nonverbal communication studies eye contact, facial expression, posture, arm and hand motions, and general body language.
Gestures can replace, regulate, and add emphasis to an interaction. A wink, a raised hand to indicate "stop," a shrug of the shoulders, and a studied stare all convey meanings both on their own and in conjunction with verbal messages. Gestures generally foreshadow verbal communication, giving us a literal "heads up," so that we are aware that a message is coming. Remember that Clever Hans was able to read minuscule head movements.
In dentistry, we can use gestures to enhance our patient education efforts. I am grateful to my friend and colleague, Mary Sheehan, RDH, for teaching me a technique that was consistently effective in explaining the progress of periodontal disease. Hold your left forearm vertically and make a fist with the same hand, then wrap the fingers of the right hand around the left wrist. The fist represents the tooth, the wrist and arm represent the root, and the fingers represent the bone and gingiva. Move the fingers of the right hand toward your elbow as you explain that gum disease causes the bone to move away from the teeth. Then open up those fingers and move them away from your arm as you say that gum disease also causes the gums and the bone to separate from the teeth.
These three-dimensional, nonverbal gestures, when combined with a verbal explanation, always elicited an "ah-ha" reaction, which a spoken explanation or even a two-dimensional picture alone did not.
Most of us have learned about the importance of being a good listener at some time in our lives - either in school, parent training, or in continuing education classes. But I refer here to much more than just the well-known concept of "active listening." Until I took some communication studies classes, I never thought of this as a form of nonverbal communication. We can use all of the areas of nonverbal communication (posture, gesture, facial expression, and so forth) that I have discussed to create a receptive, listening climate.
Yes, it takes more time to listen. Yes, we are always pressed for time. But consider the consequences if we don't listen. We may miss a crucial bit of information that could ultimately cost time, health and money for both our patients and ourselves.
The executives of many Fortune 500 corporations, who know that business people can spend up to 42 percent of their time listening, also are concerned about the ability of management and staff to listen well. More than one-fourth of these companies provide listening training for their staffs - some of them provide it annually. Fortune 500 executives consider poor listening to be one of the most important problems facing them. They state that a lack of listening skills in employees and managers can negatively affect organizational success. Furthermore, their research has found that listening training improves employees' listening skills.
Dental offices are businesses that provide health care services. If listening is so important to the executives of many Fortune 500 corporations, then it should be even more important to us. The following incident made the point for me. An elderly woman arrived 15 minutes late for her appointment. She was also in a hurry, so, when I asked her to update her health history, she merely scanned it, making no changes. I was almost ready to treat her, when I heard her mutter under her breath, something about not wanting to miss this appointment after all she had gone through to get here. I questioned her about it. She had to ask her son to take time off work to bring her. She couldn't drive because she had just been released from the hospital after having a pacemaker implanted.
Of course, I had to tell her that for her own well-being, we would need to reschedule her appointment until we could consult with her cardiologist. She was not happy. But I was so glad that I took a moment to listen; otherwise the consequences could have been dire. I am sure many readers can recall similar stories.
It is enough to just become aware of the importance of listening, and to pay attention to how you listen. Do you give a person your full attention, or do you multitask? Do you interrupt an answer before the whole thought is uttered? Does your body language indicate openness and acceptance, or do you display a lack of attention and a feeling of being rushed?
The time you devote to updating the health history is perfect for "hearing" what someone has to say. I suggest that we can all improve both our personal and office skills by taking the next available continuing education course on listening.
We can become better clinicians by training ourselves to be more aware of both the nonverbal messages sent to us by our patients, and those we send to them.
Remember, we cannot not communicate. As Emerson wrote, "What you do speaks so loud that I cannot hear what you say." When we "listen" to the nonverbals, we can read as much from a person's posture, movement, expression and demeanor as we can from looking at her or his gingivae. These skills can serve us in all areas of life as well as at work. We certainly can do even better than Clever Hans!
Toni S. Adams, RDH, BA, resides in San Jose, Calif. She earned an associate's degree in dental hygiene from Foothill College in Los Altos Hills, Calif., in 1973 and practiced until 1999. She earned a bachelor's in communication studies from San Jose State University with a minor in health professions. She can be contacted at [email protected].