Running head: NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 1

Nonverbals in Medicine: Research Prospectus

Alexandria Baker, Grace Krueger, and Bennett Serchen

COM150: Research Methodology

Dr. Barbara King

24 April 2018
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 2

Introduction

Nonverbal communication is the act of sending and receiving messages in a variety of

ways without the use of verbal codes (Mast, 2007). It is both intentional and unintentional, and

most speakers are not conscious of these actions (Weisbuch & Ambady, 2009). These behaviors

include touch, eye contact, proximity, gestures, facial expression, dress, posture and vocal

inflection. The most important aspect of understanding nonverbal communication is the ability to

distinguish between verbal and nonverbal cues (Ledford, Canzona & Cafferty, 2015). For

example, if a verbal message is unclear, an individual can read the nonverbal behaviors to

interpret what has been said. The importance of nonverbal communication is demonstrated

within the patient-physician relationship in the medical field. While the verbal dialogue in the

medical field is important, there could be a number of nonverbal cues that can lead to the proper

diagnosis and overall satisfaction of the patient. The study reviews research related to nonverbal

behaviors in the medical field, then reflects on how these behaviors impact patient results and

satisfaction.

This study will refine and update extant scholarship on this subject by testing the

relationship between a physician’s eye contact and body orientation to overall patient

satisfaction. The practical significance of this study will apply to both physicians and patients. It

will help patients interpret their doctor’s nonverbal cues; therefore, they can form an opinion

about their doctor and develop a comfortability with disclosure. The study will also inform

doctors on how their nonverbal cues affect their relationships with their patients.
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 3

Literature Review

Nonverbal communication is imperative in the medical field. While verbal behavior

between physician and patient plays a large role in communication, it is beneficial to assess the

impact of nonverbal cues in the initial evaluation and treatment. The Expectancy Violations

Theory plays a role in the physician-patient interaction and analyzes how individuals respond to

unanticipated violations of social norms and expectations (Burgoon, 2016). The overall

satisfaction of a patient can be influenced by their expectation of the communication with the

physician.

The use of technology has become a beneficial tool in the medical field. McGrath, Arar,

and Pugh (2005) focused on the influence of the Electronic Medical Record (EMR) in the

patient-physician relationship. The EMR is a system that allows medical professionals to enter

and access data over the internet (McGrath et al., 2005). Since the release of the study in 2005,

there are more medical practices that utilize a similar system due to the rise of internet

capabilities and technology. McGrath and colleagues (2005) stated that physicians who accessed

the EMR and took “breakpoints” for eye contact used more nonverbal cues than physicians who

continuously worked on the computer while talking with their patients. It is interesting to

connect these findings to the study conducted by Mast (2007), who reported that there was a

positive correlation of gazing between physicians and patients, which means that the more a

physician made eye contact with a patient, the more the patient made eye contact with the

physician. Also, the same correlation occurred in terms of body orientation, leading to the

conclusion that both the physician and the patient mirror each other's behaviors (Mast, 2007).

One of the factors that contribute to a patient’s satisfaction with a physician is whether or

not he or she is benefiting from treatment. A study conducted by Coelho and Galan (2012) found
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 4

that patients had a better outcome if they rated their doctor high in nonverbal communication

skills. The doctor’s main attributes referenced were a warm tone of voice and good body

orientation, as well as sustained eye contact (Coelho & Galan, 2012). A similar finding from

Duggan and Bradshaw (2008) demonstrated how nonverbal communication impacts the

relationship between the patients and the doctors. When the doctors displayed positive nonverbal

communication, the patients were more comfortable and relaxed (Duggan and Bradshaw, 2008).

When a doctor displays warmth by using strong eye contact and friendly facial expressions, the

patient reports an overall higher satisfaction with the doctor (Henry, Fuhrel-Forbis, Rogers, &

Eggly, 2012). Overall, the patients who rated their doctor high in nonverbal skills felt their

relationships were better than the patients who rated their doctors poorly (Coelho & Galan,

2012). While positive nonverbal communication allows a patient to feel more comfortable, there

are other benefits to a physician displaying positive nonverbal signals.

Ruben and Hall (2016) hypothesized that patients would display nonverbal behaviors that

were indicative of their pain with physicians who were nonverbally competent, as opposed to the

patients paired with nonverbally unsupportive physicians. The researchers found that the

patient's assigned with the nonverbally supportive physicians more accurately displayed their

pain (Ruben & Hall, 2016). A different study found a significant correlation between the honesty

of their patients and the nonverbal skills of the physician. Patients were more likely to be more

honest the better the physicians’ skills (Smith, Heisel, & McCroskey, 2009).

Research supports the importance of eye contact in the patient-physician relationship.

Findings suggest that physicians lose important information while inputting notes into the EMR

system (McGrath et al., 2005). If a physician is focused on the computer, rather than the patient,

it is likely that there will be nonverbal cues that are lost that could contribute to understanding a
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 5

patient’s condition. When the nonverbal cues are negative, the effects can be harmful to the

patient-physician relationship (Duggan & Bradshaw, 2008). A lack of nonverbal cues displayed

by the doctor can result in an inability to understand the patient’s concerns, resulting in lower

patient satisfaction (Duggan & Bradshaw, 2008). The more information that a doctor can retrieve

from a patient can lead to a better diagnoses, which will lead to improved patient care and

improved patient satisfaction.

While most studies show that there is a positive correlation between nonverbal

communication and patient satisfaction, there is a study that claims a limitation of the

relationship. According to Henry and colleagues (2012), negative nonverbal communication did

not decrease patient’s satisfaction with their doctor. Although the study found that using

nonverbal communication to display warmth had positive effects, there was no difference in

satisfaction when the nonverbal cues were negative (Henry et al, 2012). However, several studies

have refuted this claim. Negative nonverbal communication can have negative consequences on

the doctor-patient relationship such as when the doctor displays a less direct body orientation

(Ledford et al, 2015). The results of a less direct body orientation are lower patient satisfaction

with their doctor and the patient feeling misunderstood (Ledford et al, 2015).

In a considerable portion of the extant literature on patient-physician communication, the

independent variable being tested was broad. Rather than focusing on one particular area of

nonverbal communication, the studies looked at eye contact, posture, body orientation, vocal

tone, among others. Additionally, the studies are relatively outdated, many of which were

conducted five or more years ago. Since the release of McGrath and colleagues study in 2005,

there have been more practices that utilize a similar system due to the rise of internet capabilities

and technology. The current study will analyze both eye contact and body orientation, as well as
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 6

provide an up-to-date source of the impact of nonverbal communication on patient satisfaction.

The following hypotheses are proposed:

H1: Physicians who display high amounts of eye contact have a higher level of patient

satisfaction than physicians who do not.

H2: Physicians who use direct body orientation with patients have a higher level of patient

satisfaction than physicians who do not.

Methodology

The study administered a lab experiment with a post-test to examine whether physicians

who display high amounts of eye contact have a higher level of patient satisfaction than

physicians who do not. The post-test will also examine if physicians who use direct body

orientation with patients have a higher level of patient satisfaction than physicians who do not.

The scale allows researchers to reach a large sample and protect the privacy of the respondents.

This will eliminate a small sample size as a confounding variable. It also eliminates a threat to

internal validity since the scale will remain the same for each respondent; therefore, the

procedure remains constant. The study will observe the relationship between nonverbal

communication and patient satisfaction with their physician.

Subjects and Sampling

The population for the present study is willing adult participants obtained from personal

contacts found through the researchers’ social media outlets. The individuals who demonstrate

interest will be placed on a list, with adults between the ages of 18 and 65 selected for this study.

According to Multack and Noel-Miller (2012), most beneficiaries of Medicare are between the

ages of 65 and 67, so the age cutoff was 65 to avoid changes that occur with individuals

requiring specific Medicare physicians. The final sample size will be 200 people, with 50
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 7

individuals randomly assigned into four groups: one that receives positive eye contact stimulus,

one that receives negative eye contact stimulus, one that receives positive body orientation

stimulus, and one that receives negative body orientation stimulus.

Measurement of Variables

The measurement instrument that will be used to conduct this study is a post-test with

seven Likert-scale items and one open-ended question (see Appendix A). The post-test will be

accompanied by a cover letter (see Appendix B). The scale displays the degree that the

respondents agree or disagree with a certain question or statement. It will contain five different

options per statement: strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly

agree (5). The measurement instrument was modified from the Hailey, Willoughby, Butler &

Miller (1998) that studied the effects of communication style on women’s satisfaction with

physicians. This post-test measurement tool was validated from the study and modified by the

researchers to measure patient satisfaction based on a physician's nonverbal communication.

These questions were modified by replacing “surgeon” with “physician” to better relate to the

study. The updated post-test was validated by both a panel of communication scholars and a pilot

study of 25 subjects that provided feedback of this instrument. The self-report questions for the

survey are the same and it is given to every participant in the study for consistency. The self-

report questions included seven closed-ended questions and one open-ended question that allows

the participant to answer freely. This open ended question will allow participants to express their

opinions toward the physician. The open-ended data can be used to show a correlation between

positive words associated with positive nonverbal communication, and vice versa.
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 8

Procedure

Once the sample is drawn, the volunteers will be randomly assigned one of four videos,

as explained in the “Subjects and Sampling” section. These videos will be sent via email. The

subjects watch their assigned videos alone. The four videos will show a middle-aged female

physician interacting with a patient who is not shown on screen. Since the patient is not shown,

this allows the participants of the experiment to visualize themselves in the situation. The patient

has a checkup at the same doctor’s office in each of the videos. The videos are consistent with

variables such as physician’s sex and age, setting, and appointment type. This consistency will

eliminate these factors as being confounding variables. Once the assigned video is complete, the

participants answer the attached post-test. The video and questionnaire will be completed

individually, which prevents intersubject bias. Each respondent will be given the same set of

instructions about watching the video and completing the questionnaire. This will prevent a lack

of procedure reliability since each participant will receive one of the four videos with the same

questionnaire.

In this study, the participants are not told about the varying displays of nonverbal

communication. This allows subjects to form their own opinions about the physician without

question bias. The questions and statements administered on the post-test do not directly ask

about nonverbal communication, but asks if the subject would trust this physician or return to the

physician in the future. The data will give reliable answers about how nonverbal communication

impacts the subject’s feelings of satisfaction toward the physician without them being aware of

the positive or negative nonverbal signals displayed by the physician.

NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 9

Data Analysis

The Likert scale is based on a number scale with possible scores from 1-5 that range from

strongly disagree to strongly agree. The questions that reflected negatively upon the physician

will be reverse coded to reflect positively. The highest possible score that can be obtained is a 35

and the lowest score is a 7. The study examines the difference of patient satisfaction based on the

nonverbal communication of the physician; therefore, an analysis of variance will be conducted

to examine the difference in mean scores on Likert-scale items among the four groups. The final

question asks the participant to list three to five words used to describe the physician, and these

words will be coded as either positive or negative. The relationship between a physician's

nonverbal communication and the words used to describe their character will be analyzed using a

Chi-square analysis to establish whether the differences are statistically significant.

Conclusion

The hypotheses that the study was based on: H1: Physicians who display high amounts of

eye contact have a higher level of patient satisfaction than physicians who do not, and

H2: Physicians who use direct body orientation with patients have a higher level of patient

satisfaction than physicians who do not. The data that will be collected from the participants are

expected to exceed the 0.05 confidence level and the null hypothesis will be rejected. Therefore,

the results would be statistically significant.

The results from this study can validate that physician’s high levels of eye contact and the

use of direct body orientation can promote higher patient satisfaction. These results can be

applied to physicians who wants to improve patient satisfaction and increase retention rate. If a

patient is not satisfied with the physician, the patient will more than likely not return. The results

can conclude that high levels of nonverbal communication could increase patient satisfaction.
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 10

Overall, the patient will be satisfied with their physician and the physician will be satisfied to

have returning patients.

The study was intended to measure the influence of nonverbal communication, but it is

not possible to encompass all aspects of nonverbal communication. The methodology used for

this study targeted a variety of individuals, but it was limited in that aspect. Due to the limited

individuals accessible through the researchers’ social media outlets, there is a greater population

that could have been researched. Additionally, the study was unable to target the older

population given the means of communication that was used to obtain the participants. The older

generation does not have a significant presence on social media and would be unable to

demonstrate interest in the study. Another limitation of the study was the inability to account for

the presence of a male physician since the study used a female physician. It is possible that

individuals would react differently to an opposite sex physician. The study was limited since it

was conducted in a controlled setting. If the study happened in real-time, there would be more

emotion and reaction to a physician's nonverbal communication; however, this change would

results in more variability of the procedure. There were a number of variables the researchers

needed to consider to limit variance, but it is not possible to encompass every variable.

Due to the limitations of the study, it would be beneficial to repeat the study with a

broader population. It is likely that the contacts from the researchers’ social media accounts will

be from a similar geographic location; therefore share a similar communication style. The

updated study will lead to the information whether nonverbal communication interpretation

changes with a different demographic. Another area of interest would be whether individuals

from the same race/ethnicity would have similar results. It would be interesting to see how this

factor would influence the patient’s satisfaction with the physician based on nonverbal
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 11

communication. Also, it would be relevant to study how the results would change with a male

physician as opposed to a female physician. Additionally, future research could examine the

impact of education level on patient satisfaction. If an individual learned skills to analyze

nonverbal communication, it is likely these individuals would realize several aspects of the

physician’s communication style. These factors would be possible avenues for future

communication research.
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 12

References

Burgoon, K. J. (2016). Expectancy violations theory. In C. R. Berger & M. E. Roloff (Eds.), The

international encyclopedia of interpersonal communication (pp. 1-9). Hoboken, NJ: John

Wiley & Sons, Inc.

Coelho, K. R., & Galan, C. (2012). Physician cross-cultural nonverbal communication skills,

patient satisfaction and health outcomes in the physician-patient relationship.

International Journal of Family Medicine, 2012, 1-5. doi:10.1155/2012/376907

Duggan, A. P., & Bradshaw, Y. (2008). Mutual influence processes in physician-patient

communication: An interaction adaptation perspective. Communication Research

Reports, 25(3), 211-226. doi: 10.1080/08824090802237618

Hailey, B.J., Willoughby, S. G., Butler, M. N. & Miller, L. (1998). Effects of

communication style on women’s satisfaction with physicians. Psychology, Health &

Medicine, 3(4), 435.

Henry, S. G., Fuhrel-Forbis, A., Rogers, M., & Eggly S. (2012). Association between nonverbal

communication during clinical interactions and outcomes: A systematic review and

meta-analysis. Patient Education & Counseling, 86(3), 297-315. doi: 10.1016/

j.pec.2011.07.006

Ledford, C. J., Canzona M., & Cafferty L. (2015). Clinical communication in context: Applying

cognitive role theory in a study of physician non-verbals. Florida Communication

Journal, 43(1), 29-40. Retrieved from http://web.a.ebscohost.com.pioproxy.carrollu.edu/

Mast, M. S. (2007). On the importance of nonverbal communication in the physician-patient

interaction. Patient Education and Counseling, 67(3), 315-318. Retrieved from

https://www-clinicalkey-com.pioproxy.carrollu.edu/
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 13

McGrath, J. M., Arar N. H., & Pugh J. A. (2005). Doctor-patient communication: The influence

of electronic medical record usage on nonverbal communication in the medical

interview. Paper presented at the annual meeting of International Communication

Association. New York, NY.

Multack, M., & Noel-Miller, C. (2012, June). Who relies on medicare? Retrieved from

https://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/who-

relies-on-medicare-factsheet-AARP-ppi-health.pdf

Ruben, M., & Hall, J. (2016). Healthcare providers’ nonverbal behavior can lead patients to

show their pain more accurately: An analogue study. Journal of Nonverbal Behavior,

40(3), 221-234. doi: 10.1007/s10919-016-0230-3

Smith, R.S., Heisel, A.D., & McCroskey, J.C. (2009). Nonverbal immediacy in the

physician/patient relationship. Communication Research Reports, 18(3), 211-217.

doi:10.1080108824090109384800

Weisbuch, M., & Ambady, N. (2009). Unspoken cultural influence: Exposure to and influence of

nonverbal bias. Journal of Personality and Social Psychology, 96(6), 1104-1119. doi:

10.1037/a0015642
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 14

Appendix A
Gender:
Male ______ Female ______
Other (If so, please list) ________________________________ Prefer not to say ______

Age:
18-28____ 29-39____ 40-50____ 51-61____ 62-72____

1 - Strongly disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly agree

1) How confident are you about the physician's knowledge?
1____ 2____ 3____ 4____ 5____

2) How nervous are you feeling in this situation?

1____ 2____ 3____ 4____ 5____

3) How likely will you be to seek out another physician?

1____ 2____ 3____ 4____ 5____

4) How much do you like this physician?

1____ 2____ 3____ 4____ 5____

5) How confident are you that you will get the right treatment?
1____ 2____ 3____ 4____ 5____

6) Was the physician actively involved in your treatment?

1____ 2____ 3____ 4____ 5____

7) How satisfied are you with the level of care?

1____ 2____ 3____ 4____ 5____

8) Please list three to five words that could be used to describe the physician:
_____________________________________________________________________________
_________________________________________________________________________

The questions in bold were adapted from the Haley et al. study. The format of the remaining
questions were adjusted to resemble the adapted study.
NONVERBALS IN MEDICINE: RESEARCH PROSPECTUS 15

Appendix B
Thank you for volunteering to participate in this confidential study. The study is looking at the
patient-physician relationship. If at any point during the study you have questions or need
assistance, we can be reached by email at aabaker@pio.carrollu.edu. Once you are added to the
study, you will receive an email that contains a video. It is important that this video is watched in
its entirety and that it is watched alone. When the video has ended, click the link that is provided
under the video. This should be done directly after the video has been watched. The link will
direct you to a website called Survey Monkey. These questions should be answered honestly and
to the best of your knowledge. Make sure all the questions have been answered before the submit
button has been pressed. The entire process should take no more than twenty minutes to
complete. At any point during the study, you have the option to withdraw and your results will
be omitted from the study. You may exit out of the survey once all the questions have been
answered and submitted. Thank you for taking the time and being a part of this study.
- Alex, Grace, and Bennett