presentation

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CHAPTER 3 Interpersonal and Gendered Communication

For the purpose of this text, we are going to use the following as working definitions:

■ Communication competence: the ability to effectively exchange and process information with others

■ Context: setting or situation

■ Empathic listening: letting speakers talk without interruption and demon- strating the listener’s support without evaluating the speaker or provid- ing instruction, instead encouraging the speaker to find a solution

■ Feedback: using statements or questions to demonstrate listening to a sender or to encourage clarification from a receiver

■ Gender: gender may not be constant or easily determined by others and is different from a person’s sex; it is demonstrated by how an individual chooses to behave/act, that is, masculine, feminine, or more likely some- where in between

■ Gender identity: a person’s perception of his or her masculinity or femininity

■ Goal competence: the capability to construct goals and choose a plan(s) to accomplish them

■ Interpersonal (also known as dyadic) communication: interactions between two people who know each other and share common goals (e.g., friends, lov- ers, family members, professionals, and a provider and a patient); it is not the same as an infrequent conversation between a customer and a store clerk or a restaurant waitperson

■ Interpersonal relationship: a bond between two people who share common goals requiring effective interpersonal communication for its develop- ment and/or maintainenance

C o p y r i g h t 2 0 1 7 . S p r i n g e r P u b l i s h i n g C o m p a n y .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 3/24/2022 11:36 AM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS AN: 1334772 ; Dr. Michael P. Pagano, PhD, PA-C.; Health Communication for Health Care Professionals : An Applied Approach Account: s4264928.main.eds

30 Health Communication for Health Care Professionals

■ Nonverbal communication: behaviors that are not word based; messages transmitted via observable or experienced actions (eye contact, touch, vocal volume, tone, etc.)

■ Role competence: the skill to assume various social/professional roles based on the context and communicators’ goals

■ Self-disclosure: sharing highly personal information with only a very limited number of most intimate friends/lovers

■ Sex: male or female, generally anatomically obvious to self and others; determined by presence of a vagina in a female or a penis in a male

■ Verbal communication: literally what you hear or say when in a conversa- tion with one or more interactants

■ I N T E R P E R S O N A L C O M M U N I C A T I O N A N D H E A L T H C A R E

As you may have surmised from the aforementioned definitions, interper- sonal communication is critical to our interactions with friends, family, and lovers, but it is also vital to successful outcomes in our professional lives. Perhaps no profession depends on the effective use of interpersonal com- munication exchanges more than health care. If you spend a minute to think of a recent visit to your own health care provider, or an interaction you had with a patient, you will likely understand that at the most basic level, almost all health communication is interpersonal. Health care providers and patients are constantly engaging in information sharing to assure effective diagno- sis, testing, treatment, and outcomes. But just as critical is the interpersonal communication between health care providers. Regardless of the channel (air waves, electronic, written, etc.), and whether it is verbal or nonverbal, providers needs to share information with other providers (intra- and inter- professionally) in order to achieve their patient goals, minimize risk, and attain successful outcomes.

Reflection 3.1. Thinking about a single interaction (with your provider, a colleague provider, or with a patient), how would you describe the communication exchange? Was it effective or problematic and why?

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3 Interpersonal and Gendered Communication 31

Understanding the role of interpersonal communication in health care is critical to the focus of this book. Once we recognize that almost all of our health care interactions are interpersonal, the value of understanding the the- ories and skills needed to be an effective communicator becomes glaringly obvious. And with that reality comes the recognition that for two people who share common goals (a patient’s health), the importance of developing and maintaining an interpersonal relationship becomes even more paramount. As we know from our personal lives, those friends, family members, lovers, and colleagues, with whom we have an interpersonal relationship are generally the people whom we trust, share information with, and value the most. Therefore, as a health care provider you will benefit greatly if you can strive to develop an interpersonal relationship with your patients, as well as your peers, colleagues, and superiors.

However, we cannot hope to accomplish effective interpersonal health communication and relationship development without a clear understand- ing of the impact of gendered behaviors on information exchanges, trust, collaboration, and goal planning/attainment. Therefore, this chapter explores how interpersonal and gendered communication in health care are so import- ant to interpersonal relationship development and maintenance. And, as pre- viously mentioned, in this culture we tend to share information more fully, listen to, collaborate with, and trust those with whom we have an effective interpersonal relationship.

■ B U I L D I N G R E L A T I O N S H I P S

For the purpose of this text, we are discussing professional relationships (provider–patient, provider–provider, provider–family member, etc.). As you know from your own relationships, they generally begin when one person becomes aware of another; in health care contexts, this may be the first time a patient goes to a provider, or the first time a provider begins working with another provider, and so forth. Based on the interpersonal communication

Reflection 3.2. Can you recall a situation in which you needed help from someone, or that person offered advice about something? Did/would your reactions to that offer change based on an interpersonal relationship with that person? If so, why? If not, why not?

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32 Health Communication for Health Care Professionals

of that initial contact, as well as the circumstances (patient’s wellness/illness, health care team, etc.), interactants will make decisions about the other per- son and future contact/communication. We need to constantly remind our- selves how different health care, as a profession/context, is from other areas of our lives. For example, we tend to have lots of everyday relationships. Some illustrations of these affiliations are the barista at the local coffee shop or the salesperson at the clothing store. While it may be nice to see a familiar face each time you visit, you will likely not change your behaviors if there is some- one else who replaces him or her. And although the person in these everyday roles may be friendly, remember your name, clothing size, drink order, and so forth, you do not share common goals. These everyday relationships gener- ally revolve around your desire/need for something versus the other person’s goal to sell something, keep his or her job, or influence the boss. As you can see, for most health care professionals, this is not the type of relationship that makes sense if you are trying to gather/share information. And while health care employees certainly want to keep their jobs and impress their superiors, generally speaking their primary goal is to help patients maintain or reestab- lish their wellness and achieve the best quality of life possible—which are almost always patients’ goals as well.

Based on this understanding of an interpersonal relationship with shared goal(s), provider–patient and provider–provider interactions need to have some common understandings:

1. There are expectations that each interactant agrees to adhere to

2. Rules are needed to assure both confidentiality and privacy, as well as trust and openness

3. An understanding that both provider and patient must be willing to do the work of not only maintaining the relationship, but attaining the shared goal(s)

In order for the relationship to develop and be most effective, both providers and patients have a right to expect that the information shared is accurate, complete, and effectively communicated. Therefore, if the patient refuses to discuss his or her prior drug use, it needs to be understood that the provid- er’s decisions, recommendations, and so forth may not be as effective as they would have been if the patient had been more communicative. Similarly, if the provider knows about risks or alternative outcomes, she or he would be expected to share those with the patient. One of the often nonverbalized rules in provider–patient health communication includes the need for patients to fully disclose their present, past, family, and social histories, but providers will not reciprocate. Another rule is that providers will not allow a conflict of interest (financial or professional) to negatively impact the patient’s care, wellness, or quality of life. Finally, the patient has a right to expect that the provider is not only qualified to offer care, but uses continuing education to update knowl- edge, decision making, information sharing, and so forth.

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3 Interpersonal and Gendered Communication 33

Now that we have discussed some of the important aspects of develop- ing and maintaining an interpersonal relationship in a health care context, we need to explore the communication competencies needed to help providers effectively exchange information, enhance trust, and encourage collaborative decision making with other interactants.

■ V E R B A L A N D N O N V E R B A L C O M P E T E N C I E S

Verbal Communication As you can imagine, being an effective interpersonal communicator relies on your verbal and nonverbal competencies. Let us first focus, however, on your understanding of verbal communication. It may seem like commonsense, but when we refer to verbal behaviors we are literally discussing the use of spoken symbols (language) to exchange information. The problem for many health care professionals is the difference in their perception of shared symbols and the reality for their patients and/or family members. We discuss the culture of health care in more detail in Chapter 5, but it helps if we recognize that provid- ers are assimilated into the health care culture (nursing, medicine, physician assistant, physical therapy, etc.) in part by learning a new shared language— medical terminology.

Because most health care providers have a bachelor’s degree at a minimum, their literacy level is already advanced beyond that of the average American. To further understand the problem, we should examine some statistics from U.S. Department of Education, National Institute of Literacy (2015) regarding adult Americans:

■ More than 30,000,000 cannot read

■ Nearly 50% cannot understand prescription labels

■ Nearly 50% are unable to read an eighth-grade-level book

■ Nearly 20% of high school graduates cannot read

Reflection 3.3. If you are in a relationship (platonic or romantic) and the other person self-discloses something very personal, what do you think that person expects in return? Why would that reality make it even harder for patients to self-disclose to providers?

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34 Health Communication for Health Care Professionals

Although these numbers seem difficult to comprehend, they have remained relatively unchanged for decades (U.S. Department of Education, National Center for Education Statistics, 2015). Therefore, based on these data, there is a high likelihood that many of your patients will have extremely low literacy levels and have difficulty even with everyday American English. As a conse- quence, health communication becomes even more problematic—patients have limited literacy and providers typically use terminology that is not even remotely part of the patient’s or family members’ vernacular.

The first step then in understanding verbal competency for a health care provider is to recognize the role symbol sharing plays in effective communica- tion. Next, it is critical to recognize the importance of context in communication exchanges. Perhaps if you think about a typical dinner with your family—in that context you communicate verbally using symbols that you know are most appropriate for such an audience. Suppose you go from dinner with your fam- ily, to a bar/club to relax with your friends, will your use of language/symbols change with the context? If you are like most Americans they will. Now what do you think will happen to your use of symbols when you enter a professional context? Again, they will likely change, perhaps drastically. As a health care provider, you will need to use the appropriate language/terminology with col- leagues and superiors, which requires symbols that are far different than those at your family dinner or your evening out with friends. Like many Americans, you will be able to subconsciously alter your symbol usage based on the con- text. However, health care is unlike almost any other context because providers must use the appropriate symbols/terminology with their peers and colleagues and a very different level of symbol sharing with patients and family members.

Reflection 3.4. Besides literacy, what do you think is another major obstacle in the health care context for effective interpersonal communication and informa- tion exchange?

When we think about the differences in health care communication and most other contexts, one major problem seems to transcend all others— patients’ emotional responses. In the current health care system, we tend to have an acute versus chronic care focus—both as providers and as patients. For the most part, adults are not seeking care unless they have a problem. Consequently, patients come to most health interactions with verbalized, or often nonverbalized, concerns (e.g., quality of life, financial implications, pain,

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3 Interpersonal and Gendered Communication 35

survival). These emotional issues may add an additional layer of difficulty to the provider–patient interaction.

Imagine if you will that you find a lump in your breast—male or female—what is likely the first thing you may assume that lump represents? Even if you are a seasoned health care provider, you are likely to be concerned that you could have cancer. Now, try to consider what it would be like not to be a health care provider with your knowledge of statistics for breast lumps for people of your age group and sex. Patients not only may be terrified that they have cancer, but some may be so concerned that they do not seek care immediately—too afraid to even tell anyone about it. Others may seek care, but not want to disclose all the information the provider is seeking in fear that by talking about a pos- itive family history, or other potential signs and symptoms, they will increase the chances that the lump is malignant. Therefore, one thing that the emo- tions associated with many health care contexts contribute to provider–patient interactions is a level of “noise” that jeopardizes effective interpersonal commu- nication and relationship development. Noise in this case is hindering the con- veyance of information that providers need to help accurately assess the problem/ situation. However, emotional issues in health care contexts create another type of noise that can be just as problematic for patients and providers—if not more so.

Another example of noise that interferes with effective information exchanges is the emotional concerns that distract a patient (or a provider) and decrease his or her ability to listen and assimilate what is being communicated. Think about your response to Reflection 3.5; haven’t we all experienced distractions from out- side events that made it very difficult to concentrate on what was happening in the present? Even if you cannot recall such a situation, you likely can understand how the death of a loved one, for example, might make it difficult to focus on a lecture, an exam, or a workplace assignment. Therefore, you should be able to see how a patient who thinks she or he has a serious illness, terminal condition, requires surgery, can no longer work, and so forth, would have a great deal of difficulty listening effectively to a provider who was trying to explain something, or seeking more information or shared decision making. Remember the possible breast lump? What if you’re sitting in the provider’s office and she or he says, “the

Reflection 3.5. Can you recall an exam or a lecture during which you had trouble concentrating because of something that had happened in your life? What was causing your distraction (a breakup with a lover, a death of a loved one, other unexpected joyous or sad news)?

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36 Health Communication for Health Care Professionals

biopsy shows that lump is a cancer”—what would you hypothesize occurs at that moment in the patient’s consciousness? Would it be surprising to learn that for many people the word cancer has terrifying connotations (relational meaning, e.g., that’s what killed grandma, or I won’t see my son get married) in addition to the denotative (dictionary) realities that overwhelm the brain’s ability to process incoming information?

In interpersonal communication, verbalized messages generally have two distinct types of meaning—denotative and connotative. The deno- tative meaning is literally the dictionary definition, cancer is a disease in which cells divide abnormally and can destroy other cells and/or organs. However, the connotative meaning of a message is much more personal, abstract, and/or subjective. So to one person cancer might have a con- notative meaning of death, that’s what killed Aunt Helen, or long-term sickness from the chemotherapy. The connotative meaning often has lit- tle to do with the denotative meaning—it is much more of an emotional response based on a person’s knowledge, experiences, hearsay, or myth. Thus, a provider may tell a patient that his or her breast tumor is a stage- zero carcinoma, noninvasive—compared to more advanced stages, this would be the best possible news for a patient. However, if the patient’s connotative interpretation of the message is terminal cancer, it is highly unlikely that the patient will hear little if any of the information the provider attempts to communicate about the disease, treatment plans, or prognosis. In this context, the connotative meaning and the patient’s emotional response have created so much noise in the interaction that she or he will not be able to process effectively the rest of the provider’s information.

Reflection 3.6. If you are delivering potentially emotionally charged news to a patient and/or family member, how might you try to overcome that person’s connotative response and obstructive noise in the interaction?

Once we recognize how problematic noise can be to effective inter- personal communication—especially from unrecognized connotative miscommunication—we can begin to find ways to help avoid or deal with the issue. For example, if you have to deliver news to a patient that you think could trigger a negative emotional response, you can either try to verbalize the message in a way that addresses the potential connotative meaning and minimize or eliminate it. Another way to help assure that the patient gets the information she or he needs in spite of the likely noise from the connota- tive meaning of the message is to ask the patient to bring a relative with him

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3 Interpersonal and Gendered Communication 37

or her to the interaction. The patient’s advocate is generally less emotionally impacted because it is not directly affecting him or her, and therefore can listen more effectively, take notes, ask questions, and share the information with the patient at a later time in a different, less emotional setting. Also, it is often very helpful to have a handout that is language specific (English, Spanish, etc.) and written at an appropriate patient reading level that can be taken home and easily understood by the patient and his or her family. The importance of rec- ognizing the potential negative impact of noise and connotative meanings on interactions will help you assess your patient/family member and determine the most effective way to communicate health information to help enhance the patient’s assimilation and decision making.

Listening Before we move to our discussion of nonverbal competencies, it is very import- ant that we highlight the critical role listening plays in effective interpersonal communication, but also in interpersonal relationships. Listening is different from hearing. Hearing is anatomical and physiological—if you have ears and they are working normally—you can hear. However, listening requires atten- tion and focus on the other communicator and the message. We’ve already discussed how emotional noise can interfere with patients’ abilities to listen. But too often providers do not listen as effectively as they could. Some pro- viders are so concerned with their needs to gather specific information and intrapersonally complete an algorithm based on the patient’s complaints that they do not listen to all that the patient/family member is trying to communi- cate. In addition, with the use of computers in health care contexts, providers are frequently so preoccupied with completing the electronic document that their focus is on the computer instead of listening to the patient. And, as briefly mentioned earlier, like patients, providers can have extra conversation issues impact their listening. Problems with family, friends, finances, even other patients who are not doing well, all can create noise that can interfere with a provider’s active listening. Finally, some providers may believe that the data they need to gather is more critical than the information the patient wants to share—in those cases the provider may minimize his or her listening and focus only on the responses that meet the provider’s information-seeking needs.

All of these issues are potential obstructions to patient and provider listen- ing and consequently effective interpersonal communication. Armed with this information, providers need to not only understand the importance of effective listening, but also to assure that they are doing all they can to enhance active listening. Some ways to improve your listening include:

■ Making the patient’s message your key focus

■ Trying not to make your information needs more important than the patient’s

■ Waiting to type/write/focus on your computer or paper until the patient has finished speaking

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38 Health Communication for Health Care Professionals

■ Using eye contact to demonstrate your listening

■ Providing feedback (restating what you heard or asking questions, even nodding or shaking your head) to demonstrate listening and/or understanding/confusion

The use of feedback is an important tool to assure that you have assimilated what was communicated correctly, but also to reinforce for the patient/family member that you were listening and want to clarify. Feedback can also be used to check that the patient understood what you told him or her. For example, you can ask the patient to restate what you just communicated. Try to avoid simply asking whether she or he has any questions—too often patients/family mem- bers didn’t understand what you said, or were unable to process the information because of noise, and they do not know what to ask, or want you to know that they didn’t assimilate what you communicated. As you can tell, the importance of verbally sharing easily understood symbols, recognizing the importance of denotative versus connotative meanings in interactions, and the critical nature of listening are all necessary for competent verbal communicators. However, as valuable as effective verbal communication is to information exchanges, inter- personal communication, and interpersonal relationships—in the U.S. culture, nonverbal competencies are even more critical.

Nonverbal Communication In American culture, nonverbal communication is extremely important to effective information exchange, interpersonal communication, and relation- ships. Nonverbal codes are used to express meaning, manage information flow, and contribute to or detract from verbal messages. As you know, we use non- verbal symbols to help receivers recognize whether we like or dislike something (e.g., smile, frown, thumbs-up), agree or disagree (e.g., head movement verti- cally versus horizontally), or are interested or disinterested in conversation (e.g., eye contact or body position/movements). Nonverbal behaviors also are used to illustrate power and status in this culture. For example, if you have a corner office at work or you are in a cubicle, your status in the organization is immediately recognized by your peers. In health care we use white coats, scrub clothes, and nametags to help patients and colleagues identify us as members of the pro- vider culture and our printed credentials, MD, DO (doctor of osteopathy), RN, physician assistant (PA), advanced practice registered nurse (APRN), physical therapist (PT), to provide nonverbal information about our organizational status.

In terms of combined verbal and nonverbal messages together, interactants frequently use nonverbal codes to evaluate verbal messages. For example, if you are shaking your head from side to side, while you tell someone there is nothing to worry about—the other person is likely going to trust your nonver- bal message more than your verbal statement and be concerned. So nonver- bals can be used to reinforce verbal messages, contradict them, or highlight certain aspects of them. For example if you say “fire,” others may think it is not a major problem. But if you say “fire!” and your voice rises both in pitch

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3 Interpersonal and Gendered Communication 39

and volume, people are much more likely to not only perceive a problem, but respond immediately. The verbal symbol did not change, but the nonverbal cues, raising your voice and pitch, alerted listeners that this is not a typical use of the word fire. Be aware, however, that others can use your nonverbals in an interaction to also assess your credibility and interest. How would you feel if a health care provider, during an exam or discussion with a patient, goes to a closed exam room door and puts her or his hand on the knob while asking, “any questions”? In this culture, is there any reason to believe that this pro- vider really wants questions? In fact, most patients would likely assume just the opposite—the nonverbal cue, hand on doorknob, is what the provider intends to communicate—I am leaving; not the verbal message: seeking more conver- sation. As you can see, our nonverbal behaviors in this culture are extremely important to the effectiveness of an information exchange. But, before we dis- cuss nonverbals in more detail, there are two things that we absolutely need to be clear about:

1. Communication is about the receiver of the message, so it is not about what the sender of the message intends, it is about what the receiver understands. We can assume that in the previous example the provider did not intend to communicate that she or he was ready to close the conversation with no further dialogue, but, based on his or her nonverbal behavior, that is what the receiver (patient) perceived.

2. Everything we do communicates to others. Therefore, if you show up 5 minutes late for your first day of clinicals—whether you intended to or not—you have likely communicated to your superiors (and maybe even your peers) that you did not think it was worth your effort to get to the hospital/office on time.

The importance of these two realities is that a health care provider needs to be constantly aware of patients’ and peers’ perceptions of his or her message (ver- bal and nonverbal) and pay close attention to what is being communicated and how he or she intended the message to be interpreted.

Reflection 3.7. You are discussing a spinal tap procedure with a patient and she asks, “Does it hurt?” You respond, “Not really,” but your eyes are looking away from the patient and you bite your lower lip as you finish speaking. What would you hypothesize a patient in this culture would perceive the answer to her question to be and why?

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40 Health Communication for Health Care Professionals

In order to better understand nonverbal behaviors, it will be helpful to dis- cuss them in the categories in which they are commonly used:

■ Proxemics—related to the distance between interactants in a conversation

■ Haptics—how touch is used in nonverbal communication

■ Kinesics—the use of our bodies to communicate

■ Artifacts—accessories that contribute to the information exchanged in an interaction

■ Vocalics—the use of voice characteristics to alter message delivery

■ Chronemics—the impact of time on message exchanges

While entire books are dedicated to the discussion of these important non- verbal behaviors, we need to explore in some detail how each of these impact interpersonal communication and, therefore, interpersonal relationship devel- opment, maintenance, and/or dissolution.

Proxemics

Proxemics is an important nonverbal cue for health care providers to understand. In American cultural research, Hall (1959) has shown that we have communication expectations based on very specific distances between interactants. Think about your own conversations and try to recall how far apart you stand/sit from a friend/lover/colleague/professional when you are engaged in an interpersonal conversation. Generally, in this culture, we expect to have about 4 to 12 feet between ourselves and another person in a social situation: restaurant, class room, retail setting, and so forth. However, if we are talking with friends we are likely to be significantly closer, usually between 2 and 4 feet. Consequently, only our most intimate friends and lovers are gener- ally expected in our private space, between 0 and 18 inches.

Research Exercise 3a. You are a social scientist and you want to study proxemics. Go to a retail setting, not a bar or club. Find a stranger of the same sex (very important—do not attempt this with a stranger of the oppo- site sex) and start a conversation. As you two are talking, slowly inch closer to the other person (very slowly). How close were you able to get? What happened? How did this research project make you feel and why?

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3 Interpersonal and Gendered Communication 41

Proxemics, as you may have concluded, are extremely important nonverbal behaviors for health care providers to understand and utilize in interactions with patients. Think about your role in health care and how much of what you do involves “invading” a patient’s personal space. From taking vital signs (pulse, temperature, and blood pressure), to auscultating the chest, and exer- cising joints, almost everything health care providers do involves behaviors that are unacceptable in any other context. Supposing you were on a bus and you approached a stranger and suddenly grabbed his or her wrist and began feel- ing for a pulse. Or you started doing range -of-motion exercises with his or her knee—do you think that person would respond positively to these nonverbal behaviors? In all likelihood, the person would either scream and push you away, or try to punch you for invading his or her space. Clearly, these actions in the context of a bus, that are done constantly in a health care setting, are made even more unacceptable because they include the use of haptics (touch), which, combined with inappropriate proxemics, compound the miscommuni- cation and misperception of your actions. The question you need to ask your- self is: Do patients give up the right to expect input into this infringement on their personal space in a health care setting versus all other U.S. contexts (except prison)? This book is intended to help you assess the role of communi- cation in such situations, especially in a health care context.

Now, it should be understood that if we are discussing a life or death emergency situation, then the provider should do whatever is needed to aid the patient. However, in the overwhelming majority of health delivery scenarios, providers all too often assume that their needs (to gather data) supersede the patients’ perceptions of personal space and who can enter that domain without approval. In these instances, how much time would it take to acknowledge the patient’s right to his or her space and ask permission to enter it? For example, a simple query like, “Is it alright with you if I pull my chair up closer so I can examine you?” This one-sentence verbal message does much more than just communicate your recognition of the patient’s space. Such a question informs the patient that she or he has power in this interaction and that the two of you are collaborating in the process. When a provider invades a patient’s space without acknowledging the patient’s right to control his or her environment,

Reflection 3.8. As a health care provider, why would proxemics be important for you to understand? Have you thought about proximity in visits you have made to your own health care provider, or when you went to the emergency depart- ment (ED) or to a new provider? If so, what were your concerns?

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42 Health Communication for Health Care Professionals

the provider has nonverbally demonstrated his or her power as well as the patient’s loss of autonomy and decision making. This single act contributes to a patient’s assumption that the provider is taking an authoritarian role in the interaction and consequently is likely to be more paternalistic and declar- ative in his or her analysis, diagnosis, and treatment plan than informative, collaborative, and encouraging. Once a provider understands the importance of proxemics in this culture, she or he can make empowered decisions about how she or he wants, or does not want, to acknowledge the patient’s personal space and the provider’s need to access it. However, as noted earlier, proxe- mics is just one aspect of nonverbal behaviors—even more critical perhaps to patient– provider relationships and communication is the role of haptics.

Haptics

In the United States, touch (haptics) is generally reserved for close friends, family, and lovers. In fact, there are laws governing a person’s right to control who touches him or her socially and professionally. If you recall our example of the aforemen- tioned bus rider who is suddenly touched without his or her permission, you likely had an almost primal response to the thought of a stranger touching you with- out your permission. And yet, every day in this country health care providers do exactly that to patients. Think of the last time you took someone’s blood pressure or went to draw blood—consider especially this latter behavior—you are going to cause someone pain and yet, if you are like the majority of providers in this county, you didn’t ask to touch the person before you twisted a tourniquet around his or her arm tight enough to constrict the circulation and then inserted a needle into his or her vein (perhaps even without a warning that you were going to do that as well). Now, you can argue that a patient comes to see you for this very nonverbal behavior (to get his or her blood drawn), but does that mean she or he knowingly abdicated the right to say what happens to her or his body? If you recall the ear- lier discussion of all behaviors communicating—whether intended or not—what would you think a patient might perceive the message to be when a provider grabs his or her arm and performs a venipuncture without asking the patient’s permission to invade his or her space and touch the arm? It seems fairly clear that such a behavior would again communicate that a provider thinks his or her actions are more important than the patient’s autonomy. Once again, you as a provider have to make decisions about how you want to be perceived by patients, but if your actions (not seeking permission to touch) are so different from all other areas of American culture (except prison)—does it not seem wise to take a minute to explain to the patient that you need to draw blood, for example, and you would like his or her permission to touch the arm?

From a patient’s perspective, think about how important it is to have a health care professional acknowledge the right to control what happens to the patient’s body. Nonverbally it communicates the provider’s desire to collaborate, not dic- tate, to a patient about his or her health care. It is so important to understand how each communication behavior (verbal and nonverbal) can be cumulative in terms of how a patient perceives a provider’s empathy, compassion, and willingness

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3 Interpersonal and Gendered Communication 43

to share power. As you may have noted, proxemics and haptics are two very important nonverbal behaviors in provider–patient communication, but there are several more, especially kinesics.

Kinesics

Although the term kinesics may not be familiar to you, the nonverbal commu- nication behaviors it refers to will be. Some of the common actions included in kinesics include:

■ Body movements

• Gestures

• Gaze

• Facial expressions

• Arms crossed on chest

• Leaning back in a chair

• Sitting with legs spread out

Reflection 3.9. How would you feel if you were in a classroom or continuing- education conference and the professor/presenter came over to you and grabbed your hand and started helping you write notes? Were you not in that environment to learn? So how is that use of haptics different or similar to the previous blood-drawing example?

Research Exercise 3b. When you are in a meeting or in a classroom, put on your social scientist “hat” and observe how the speaker uses his or her kinesics to communicate with  the audience.  How do body movements and artifacts impact your perception of the speaker, the message, and the speaker’s credibility (be as specific and detailed as possible)?

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44 Health Communication for Health Care Professionals

Body Movements

Body movements refer to a person’s posture and gait. In this culture, we use body movements as one way to determine a communicator’s status, power, and interest. As mentioned previously, some people may not be consciously aware of these nonverbal behaviors, but their actions are nonetheless observed and assessed by others. Therefore, if you are in a meeting and you are sitting in a “closed” position (arms folded against your chest, legs crossed, pushed away from the table/desk), those body movements will likely be perceived as someone who is withdrawn or has little interest in what is being discussed. In contrast, if you are in a meeting and are leaning forward, with your arms and legs uncrossed, this “open” posture communicates your interest in the speaker and the topic and your attention to the material being presented. Similarly, if you are walking down the hall and moving slowly, your supervisor may perceive that you are bored or disinterested. How you move commu- nicates to others and the more you understand that, the easier it will be for you to make decisions about how you want your body movements and gait to be perceived by others.

Another form of body movement that is highly assessed and perceived as a key nonverbal cue in this culture is the handshake. Americans believe that a firm handshake is an expected nonverbal form of greeting, especially between two interpersonal communicators. In general, a handshake is an anticipated communication when meeting someone, either for the first time in a professional context or as a traditional greeting in many interactions with friends, colleagues, clients, or customers. It is in fact one person offer- ing another person the right to touch him or her (haptics). However, this aspect of kinesics is not just evaluated on whether it is communicated (an offer of a handshake or not), but equally for how strongly or weakly a person grips the other communicator if a handshake occurs. A weak handshake in this culture is often perceived as either a sign of disinterest, weakness, or diminished self-confidence.

Based on these expectations, you can not only observe how others use body movements in their interactions with you, but also be aware of how you use these forms of kinesics in your nonverbal communication. For health care profession- als, kinesics is especially important as you need to observe your patients’ body movements as part of your physical examination. You will want to determine, for example, whether a patient has a facial droop, or a limp, a weak grip, or an asym- metrical palpebral fissure (distance between eye lids). Although these kinesics may be signs of an illness or injury, they are also nonverbal behaviors that are communicating information about the patient. Therefore, you can use those same powers of health care observation to analyze kinesics (yours and others) during interpersonal interactions and evaluate what the body movements are commu- nicating about the sender and his or her or your nonverbal messages. In this cul- ture, another type of body movement that is perceived as having more credibility than others in the assessment of communication is one’s gaze.

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3 Interpersonal and Gendered Communication 45

Gaze

In American culture, we highly value a person’s gaze. This form of kinesics is generally theorized to communicate a person’s honesty and/or credibility based on whether that person is willing to make eye contact during an interpersonal interaction. Consider for a moment a male patient whom you are interviewing and he is complaining of dysuria (painful urination). To learn more about his problem, you ask him whether he previously had a sexually transmitted dis- ease (STD). As he starts to respond, you notice that his eyes are not looking at you, but instead, he is looking down at the floor, as he states, “Of course not!” This is an example of contradictory verbal and nonverbal cues. The patient has verbally denied any prior STD history, but his nonverbal kinesics (gaze), have suggested that he may not be telling the truth. Again, in this culture, we expect nonverbal behaviors to “complement” our verbal cues. Therefore, we expect peo- ple to look us in the eye when responding to questions—especially sensitive questions like the one in this scenario. When a person in a professional or per- sonal setting does not use his or her gaze as expected in this culture that indi- vidual’s communication is generally perceived negatively regardless of his or her verbal behaviors. Although body movements and gaze often work together to reinforce nonverbal messages, they also can be cumulative in connection with other forms of kinesics, for example, facial expressions.

Reflection 3.10. You have an interview for a job and go to greet the inter- viewer. Nonverbally, what are two of the most important kinesics you need to utilize to demonstrate your interest, sincerity, and recognition of cultural expec- tations for professional greetings?

Facial Expressions

Although in American culture there is an added emphasis placed on the assessment of nonverbal cues based on a communicator’s gaze, the impor- tance of a communicator’s facial expressions in transmitting his or her meaning is also very important to understand. Facial expressions are pow- erful nonverbal cues, especially in terms of communicating understanding, confusion, and emotions.

If you recall a recent conversation, professional or personal, you can likely remember how a colleague, supervisor/professor, friend, or lover responded during an interpersonal interaction. In this culture, we generally seek

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46 Health Communication for Health Care Professionals

nonverbal feedback in a conversation by observing the other communicator for a smile or a frown, a grimace, or raised eyebrows, and so forth. Similarly, we often assess a person’s facial expression to deduce whether she or he is happy, sad, angry, fearful, surprised, or disgusted. As an interpersonal communicator and a health care professional, you will want to utilize these various forms of nonverbal behaviors to help you better understand your patients’ and peers’ communication, but also to recognize how your own use of kinesics (facial expressions) are being analyzed by others. As mentioned previously, communicators use nonverbal cues to demonstrate and to analyze the assimilation of information, impact of the message on others, and/or the disconnect between a speaker’s verbal and nonverbal cues. A patient who has a pensive look on his or her face (wrinkled forehead, pursed lips, raised brows) may be trying to “unpack” the meaning of what was just heard. Or she or he may be confused about what was stated. In either case, a thought- ful interpersonal communicator might ignore the patient’s verbal ascent of understanding and use kinesics to determine that more clarity and content are needed to better assure effective assimilation of the message. Similar to body movements and gaze, facial expressions offer communicators both an opportunity to share information nonverbally, but also provide a feedback mechanism to help assess a person’s recognition and understanding of the message. However, not all nonverbal behaviors are feedback mechanisms. Specifically, artifacts are more (consciously and/or subconsciously) commu- nicator-centric forms of nonverbal communication.

Artifacts

Artifacts refer to a wide array of nonverbal cues, including body types, clothing, jewelry, and body adornments (tattoos, piercings, and so forth). By their very nature, artifacts tend to be a person’s communication about himself or herself to others (specific or in general). For example, a 20-year- old co-ed wearing bright-pink sweat pants with the word “Party” in big white letters across her butt probably did not consider how that would be perceived by a 60-year-old male professor walking up the stairs directly behind her. It is unlikely that this woman intended, when she got dressed that day, to either invite the professor to “party” or to make him aware of her extracurricular proclivities. And yet, that is exactly what her artifacts have communicated. Similarly, what about an emergency department (ED) provider who walks around in scrub clothes with his tattoos (neck and arms) and piercings (eyebrows, ears, and tongue) visible—do you think patients or even peers might perceive him as less credible a professional because of his body art? And what about the potential risk of hepatitis C from tattoos and piercings—might patients be somewhat concerned for their health? Although such an infection risk from tattoo needles, and so forth may be extremely low, it is a possibility and so is the perception of provider–patient transmission—which could be communicated nonverbally by the provider’s artifacts.

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3 Interpersonal and Gendered Communication 47

Unlike other forms of kinesics, artifacts are more subjective. For exam- ple, in this culture we have research that shows how people generally perceive limp handshakes, down-turned gazes, and frowns versus smiles, but artifacts are much more individualized. If a person is a fan of tattoos or piercings, then another person’s body art might very well be perceived as a positive nonverbal behavior. However, to a different person, who is not a fan of body art, tattoos, and piercings, they could be viewed as negative nonverbal messages. Therefore, health care professionals need to understand both what they are communicating with their artifacts and how they are assessing their patients’ and peers’ artifacts. It is important to not stereotype and certainly it would be a huge communication mistake to evaluate everyone who is obese as uncaring about his or her health. Or to categorize everyone who is thin as anorexic or bulimic. However, at the same time, it is important for providers to understand how patients, peers, fam- ily members, and/or organization administrators might perceive the providers’ artifacts. How do you think a 200-pound male patient might assess the verbal versus nonverbal (body type) artifact communication from a female provider who weighs 300 pounds and tells the patient that he needs to lose weight to stay healthy? As stated previously, it is impossible not to communicate (whether intended or not), so in order to be a skilled, thoughtful, interpersonal communi- cator—you need to understand how your nonverbal cues, including your artifacts, are impacting others’ perceptions and determine whether that is the message you want to be sending. However, not all nonverbal behaviors are silent, in fact, vocal- ics are an auditory form of nonverbal communication.

Vocalics

It may seem odd that there are sounds that are classified as nonverbal commu- nication; however, it really makes sense when you consider how we say things is sometimes more communicative than the verbal symbols we use. For exam- ple, “I need some help in here,” may be a simple request for some assistance by one provider to another, but the same symbols—when screamed at the highest volume a person can reach—communicate an emergent level of need. The various nonverbal characteristics (e.g., volume, pitch, and inflection) of our

Reflection 3.11. Why is it that health care organizations have certain dress codes regarding white coats, scrub clothes, uniforms, jewelry, and so forth? What is the organization trying to nonverbally communicate to its members and to its patients and their family members?

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48 Health Communication for Health Care Professionals

voices allow us to alter the way in which our verbal messages are perceived. In addition, communicators can use laughing, crying, and whining as nonverbal behaviors to transmit both physical (tears) and/or emotional feelings. Health care providers need to be aware of how vocalics can be used to impact com- munication exchanges. Think about how your response to paralinguistic cues (screaming, crying, whining, laughing, and so forth) might impact your com- munication and/or your feedback to a sender’s message. Another unique form of nonverbal communication is related to the use of time—chronemics.

Reflection 3.12. How do you respond when you are in a conversation with a person who is crying? What if that person is a patient, would you respond differently? If so, how and why is the same nonverbal cue different?

Chronemics

In America, we have some very specific views on how we use time. For example, if you are expected to be at work or in class at 8:30 a.m., arriving at 8:45 a.m. is gener- ally viewed negatively and consequently may impact your pay, promotion, grade, and so forth. In health care, time can be a critical factor, for example, defibrillation that is delayed a few minutes could be the difference between life and death. Medication is usually most effective when provided on a set schedule and, sim- ilarly, the amount of radiation exposure is time dependent. However, although these are obvious impacts of time on treatment outcomes in health care delivery, chronemics refers to the use of time as a form of nonverbal communication.

One of the most frequent patient complaints in providers’ offices and hos- pital settings is related to chronemics. Patients and family members often per- ceive delayed appointments/visits with providers as nonverbal communication of the power and status differences in provider–patient interactions. Think about meetings or classes you attend, they generally do not begin until the leader/supervisor/professor arrives. Clearly, if she or he is leading the discus- sion or scheduled the gathering, then the perception is that nothing can take place until the person in charge arrives. Consequently, the audience in this case is aware of the leader’s/professor’s power and control over when things will begin and end. As a person who does not control the timing of these events, how do you feel when you arrive on time, but the featured speaker/ leader does not? Or you get summoned to your supervisor’s/professor’s office and when you arrive, you are asked to sit and wait until she or he is ready to see you—what do those nonverbal cues communicate to you (come to the office, wait till I am ready)? If you are like most Americans, and have been

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3 Interpersonal and Gendered Communication 49

summoned and told to wait until the other communicator is ready, you per- ceive these behaviors as an illustration of that person’s power and status.

From a nonverbal perspective, being a patient is even more difficult and frustrating. First, the patient is the person who is paying (insurance, copay, Medicare, etc.) for a service—which has its own set of expectations in this culture—but is unlike other contexts (e.g., a retail store where a sales person does not arrive in a timely manner to assist you). Second, the patient may be in pain, or anxious about the reason for the visit. Third, the patient is probably partially naked as she or he waits for the provider. Consequently, it is very difficult in such a scenario for a patient to walk out of an ED or a provider’s office because the patient is unhappy with the wait or being treated less than an equal. Therefore, through the use of chronemics, the provider has rein- forced his or her power and/or status vis-à-vis the nonverbal communication that her or his time is more valuable than the patient’s time. If you were in an interpersonal relationship (friend, lover, colleague) and the other person used chronemics to control the start and close of conversations, would you want to maintain or end that relationship?

As we have been discussing throughout this chapter, nonverbal com- munication is a powerful tool for enhancing or diminishing interpersonal relationships. A provider who schedules a patient visit every 10 minutes but knows that he or she will keep patients waiting is clearly more provider- centric than patient focused and communicates that reality to patients and staff through his or her use of chronemics. Clearly, verbal and nonverbal communica- tions are critically important for effective patient– provider interactions and rela- tionship development and maintenance. But interpersonal communication also relies on communicators understanding their roles, selves, and competencies.

■ R O L E , S E L F, A N D G O A L C O M P E T E N C I E S

Part of being an effective interpersonal communicator as well as a successful health care professional is possessing communication competence as demon- strated through your understanding of role, self, and goal proficiencies. Role

Research Exercise 3c. Ask three people (a  parent/grandparent, a peer, and a health care provider) the same question: “Why do doctors so often make patients wait before they see them?” and analyze their answers. What did you learn from the various audience responses/perceptions?

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50 Health Communication for Health Care Professionals

competence refers to a person’s ability to take on certain social roles (e.g., friend, parent, professional) and what the expected behaviors for each are, how to maintain them, and when it is okay to ignore those norms.

Think of your role as a health care provider, how does that shape your behavior—especially your interpersonal communication and relationship development? Do you use your role to highlight your status and power (verbally and nonverbally) or do you use your role to help you collaborate, empower, and educate patients? If you see your role as the person respon- sible for solving patient’s problems, making decisions for them, and being in control—you will likely assume a much more authoritarian position in your interactions with patients and family members. In contrast, if you see your role as participative you will be much more likely to take on a collaborative focus in your communication with patients and families. Therefore, the way you per- ceive your role in health care is going to have a direct impact on how you communicate. Providers have been often criticized for being disease focused and consequently seeing their role as more problem solving than informa- tion- and power-sharing collaborators. Just because you are licensed/certified to be a health care provider your role competency is going to be determined by how you choose to communicate that position to others. However, in addi- tion to your role impacting your interpersonal communication, so does your self-competence.

Self-competence is related to the self-image you choose to present to oth- ers. Based on your self-competence you can use interpersonal communication to determine how others perceive you. For example, in your health care pro- vider role, you can decide that you want to be seen as an intellectual, author- ity figure who knows more than patients and therefore you can unilaterally make decisions for them and share only the information you think is needed. Or you may want to present yourself as a patient-focused partner in health care delivery who encourages a dialogue, information and power sharing, as well as collaborative decision making. However, equally important as role and self-competence is goal competence.

Goal competence is knowing how to attain your communication goals. This means you are able to utilize both your American English-language literacy and your audience analysis to communicate effectively with the intended interactant. Therefore, you must rely on your interpersonal communication and relationship development skills, as well as your self- and role competen- cies to become goal competent. As this chapter has pointed out, being an effec- tive interpersonal communicator is much more than knowing about health care. Instead, to be successful when interacting with patients, family members, and peers it is critically important to not only assess their needs, literacy lev- els, and knowledge of the topic, but your own role and self-competence in order to attain your communication goals. However, in addition to assessing the other communicator from a content/capability focus, you also need to be able to determine how a person’s gender may impact his or her communica- tion behaviors.

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3 Interpersonal and Gendered Communication 51

■ S E X V E R S U S G E N D E R

In U.S. culture, we frequently confuse the terms sex and gender. However, from a social science and especially a communication perspective—these terms can be very different and yet critically important to effective interpersonal com- munication and relationship development. As Wood (2015) points out, “sex is a designation based on biology, whereas gender is socially constructed and expressed” (p. 19). This is truly important for health care providers. As you likely have seen, for nearly 100% of the population, sex can be determined based on the presence of a penis (male) or a vagina (female). For the very small minority of individuals who have unique genitalia, the older term hermaphrodite has been replaced with the current classification of intersexed. This text will not be exploring the social, psychological, and communication behaviors associated with being born intersexed. However, it is very important that health care pro- viders recognize that just because an individual has a penis, he may or may not communicate using masculine-gendered behaviors. And the same is true for a female, her sex does not define her gender—like males, her behaviors do.

And because gender is socially constructed, it can evolve and change as a person matures, has new experiences, and is more aware of his or her own feelings. Gender identity is an individual’s understanding of himself or herself. In our culture, we traditionally identify being masculine as strong, indepen- dent, aggressive, and unwilling to share many emotions, whereas being femi- nine is more about physical appearance, nurturing, showing emotions, and an interest in relationship development/maintenance. There are a number of the- ories regarding these gendered behaviors and how from infancy to adulthood we learn how to be masculine, feminine, or somewhere along that spectrum.

Some of the theories of gender, include:

■ Biological

■ Psychodynamic

Reflection 3.13. Think about your own gender identity. Do you perceive yourself as more masculine or feminine? What behaviors or feelings do you use to illustrate one gender over the other? Are there contexts in which you may need to behave the opposite of what you feel is the norm for you (more mas- culine if you see yourself as feminine, or vice versa)? If so, why? If not, why not?

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52 Health Communication for Health Care Professionals

■ Social learning

■ Cognitive development

These theories provide us with a breadth of views on how gender is developed, constructed, and evolves. Let’s examine the distinctions among them and how they can help you better understand your patients, peers, and others to be able to communicate more effectively with them.

Biological theory promotes the view that gender behaviors are the result of physiological processes (e.g., hormones, genetics). According to biologi- cal theory, hormones like testosterone and estrogen are responsible in part for gendered actions. So changes in testosterone levels, for example, could result in more or less aggression, nurturing, and so forth. But in addition, this theory also proposes that anatomy, specifically brain development, has a role in gender determination. As you may know, males tend to have bet- ter developed left lobes and therefore are often more linear, spatial, and abstract in their thinking. Females have increased right lobes, which control imagination and creativity among other cognitive functions. Clearly, there are some reasons to support biological theory, but it is also true that there are other theoretical possibilities for how gender behaviors are developed.

Psychodynamic theory centers around the importance of the mother– child relationship in the child’s gender development. This theory proposes that female children are able to identify more closely anatomically with their mother and therefore tend to identify with their mother’s gendered behaviors. Conversely, boys do not identify as closely with mom and therefore seek a father or other male figure as a guide. However, this theory also suggests that mothers realize the differences in gender and what is expected of males and encourage boys to behave differently than females. For example, boys are sent outside by their mother to play alone or with friends, whereas girls are encour- aged to stay inside and help cook. But psychodynamic theory is not the only nonbiologic approach to gender development.

Social learning theory postulates that humans learn how to be masculine or feminine by watching others as children and then, using the feedback they receive for those behaviors to determine whether or not to adopt them. For example, a young boy might see his father watching a football game and enjoy- ing it. Consequently, if he starts throwing a football or tackling his brother or friends and he gets positive feedback from his parents, friends, and siblings, according to this theory, he will likely see those behaviors as being appro- priate for his gender. Conversely, if a girl sees a woman on TV fighting and she starts to fight with her sibling, she might get reprimanded by her parents, friends, and/or siblings for not being feminine and decide that those behaviors are incorrect for her gender. Although biological, psychodynamic, and social learning theories all suggest that outside forces are in large part responsible for the development of gendered behaviors, cognitive development theory is more person-centric.

Cognitive development theory suggests that children are not just responding to hormones and/or the directives or rewards of others, but

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3 Interpersonal and Gendered Communication 53

actively developing their own gender identities. According to this theory, children listen and observe how others communicate with them and then pick which behaviors to continue in order to get the responses they desire (e.g., “a good little boy,” or “a smart little girl”). According to this theory, children develop a sense of their gender very early, before they start kin- dergarten or first grade at the latest. However, regardless of which gender theory you support, the important aspect for those in health care is that gender shapes our lives, communication, and decision making and it can- not be deduced by merely observing a person’s sex. Therefore, it is very important for you as a health care professional to understand differences in masculine- and feminine-gendered behaviors and not stereotype all males as masculine or all females as feminine.

■ M A S C U L I N E - V E R S U S F E M I N I N E - G E N D E R E D C O M M U N I C A T I O N

Although it is crucial for providers to understand the differences between gender and sex, as well as the theories of gender development, it is equally if not more essential that health care professionals recognize the distinctions between femi- nine and masculine communication behaviors. By doing so, providers can assess how those actions might impact patient information exchange, collaboration, trust, and/or decision making. In America, feminine communication is typically used to nurture and develop relationships (familial, platonic, and/or romantic), whereas masculine communication refers to behaviors that generally support the speaker’s independence, control, goals, and status. One of the key masculine behaviors that demonstrate control is how often masculine- gendered individu- als interrupt others. Also, masculine speech is more often to the point and more forceful than feminine-gendered communication. Conversely, feminine-behav- iors are more typically cultivating, collaborative, and encourage participation. Once health care providers begin to assess an individual’s communication behav- iors, not merely based on his or her sex, they can begin to better determine how to share information, power, and decision making.

By evaluating a patient’s or peer’s gender, vis-à-vis her or his communica- tion, health care providers can determine the most effective communication style needed to meet the patient’s expectations and desires. For example, if a provider is having a conversation with a feminine-gendered individual (female or male), the professional would want to understand the importance of building a relationship from the patient’s perspective: having a provider who listens and offers feedback and is more interested in collaboration than an authoritative style. Similarly, if the provider determines that a patient is masculine gendered, regardless of his or her sex, then the professional would want to encourage more discussion, ask more questions, as well as enhance the patient’s feeling of independence and control.

As we have been discussing, interpersonal communication is intended not just to build relationships, exchange information, and help interactants attain

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54 Health Communication for Health Care Professionals

shared goals—it is also an opportunity to develop trust, promote credibility, and highlight similarities. The more your patients can feel that you are com- municating interpersonally with them as individuals (based on their educa- tion, health literacy, age, and gender), the more likely it is that you can develop a trusting, collaborative relationship that will allow for the open exchange of information, power, control, and decision making.

It is important to recognize that one of the key aspects of developing and maintaining an interpersonal relationship is the use of self- disclosure. Communicators tend to use self-disclosure (of their most personal information) only with the most trusted people in their lives. Generally speaking, Americans self-disclose their most intimate life stories with a very few (one or two) extremely selective (platonically related, but more frequently romantically related) individuals. In fact, self-disclosure is one way of assessing how an interpersonal relationship is evolving. When one communicator chooses to self-disclose (e.g., I had an abortion or I was arrested, or I love you) in a bur- geoning relationship—it is expected to help the relationship continue to grow. However, that expectation is dependent on the other interactant reciprocating with his or her own self-disclosure (building trust and helping ensure confi- dentiality). This is one of the tools we use in relationships to build reliance— sharing our most intimate feelings and/or experiences.

Reflection 3.14. Think of a relationship you have been in, either platonic or romantic. Can you recall when you or the other person made a self-disclosure and how it impacted the relationship (positively or negatively)? Was there a reciprocal self-disclosure? If so, did the presence or absence of a reciprocal response enhance the relationship or jeopardize it, and why?

If self-disclosure is so key to developing and maintaining interpersonal relationships in the larger U.S. culture, then how does that impact your use of interpersonal communication in health care contexts? As should be somewhat obvious, health care providers do not just need a patient to self-disclose his or her most intimate experiences, they actually seek that information. Therefore, in a culture in which self-disclosure is limited to a communicator’s closest friends and/ or lovers, health care expects patients to communicate completely differently— telling providers (often strangers or near strangers), the most intimate details of a person’s life (medical, sexual, psychological, family, etc.). No one in this culture, except health care professionals, routinely asks a person how many people she or he had sex with, if the patient has or had an STD or abortion, how much alcohol she or he consumes, or whether there is a present or past history of drug abuse

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or addiction by the patient or his or her family. But unlike every other interper- sonal relationship in American culture, a unilateral self-disclosure by the patient is not only expected but professionally mandated. Therefore, think about how you might help maintain the relationship by explaining briefly the need for such pri- vate information, or assuring the patient that you will keep his or her disclosure confidential (keeping in mind that your records will be reviewed by the patient’s insurance carrier, so there is only so much confidentiality possible). The point of this discussion is to remind you that health care occurs in a totally different con- text and requires much different interpersonal communication for patients than all other experiences in their lives (except perhaps jail).

Interpersonally, health care providers not only ask but expect patients to get naked, or nearly naked, allow themselves to be touched in areas usually restricted to a person’s most intimate lovers, and self-disclose their most pri- vate experiences. However, at the same time the provider is trying to encour- age the patient to develop/maintain a relationship with a communicator who is fully clothed, not touched by the patient (except perhaps for a handshake), and not reciprocating with her or his intimate personal data. Armed with these major deviations from expected interpersonal communication and relation- ship development in this culture, it should not be too surprising that there are not only health literacy issues that constrain provider–patient information exchanges and relationship development, but interpersonal communication expectations and experiences as well. As you work to become more effective interpersonal communicators and health care providers, try to remind your- selves of the importance of verbal and nonverbal cues, as well as gendered behaviors in not only assessing your patients’ communication, but your own. In order to enhance patient outcomes and provide a context in which information is exchanged, provider–patient interactions are collaborative and informative and based on power equality and shared decision making, providers need to recognize their key role in assuring that messages are clear, complete, and effectively communicated based on the patient’s health and language literacy, and assimilated appropriately. With such efforts, patients and providers have a much greater potential for attaining shared outcomes (e.g., wellness, and/or illness/injury treatment, goals).

R e f l e c t i o n s ( a m o n g t h e p o s s i b l e r e s p o n s e s )

3.1. Thinking about a single interaction (with your provider, a colleague provider, or with a patient), how would you describe the communication exchange? Was it effective or problematic and why?

When you considered your prior interaction, if you looked at it as a patient, you likely had a completely different response than if you examined the conversa- tion from a provider’s perspective. That is why it is important to think about provider–patient communication from an interpersonal, not strictly diagnostic or treatment, perspective. The more you can attempt to find an equal power/

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56 Health Communication for Health Care Professionals

control viewpoint for your patient interactions the more the interpersonal communication becomes about exchanging information and accomplishing patient-centered goals. The problem with provider-focused communication is that the conversation is not about sharing, but about getting the data the provider needs so she or he can make a diagnosis, determine a treatment plan, and so forth and, therefore, collaborative and participative decision making is hardly possible.

3.2. Can you recall a situation in which you needed help from someone, or that person offered advice about something? Did/would your reactions to that offer change based on an interpersonal relationship with that person? If so, why? If not, why not?

Interpersonal communication research has shown that people are more likely to trust someone they have an interpersonal relationship with and therefore are more likely to carefully consider any recommendations or information from that person. Also, the more we like someone, the more we see that person as similar to ourselves and the more likely we are to share information and decision making with him or her. If a stranger spends 5 minutes with you and then tells you to take a pill and you will be better— are you not less likely to trust that recommendation than if you hear similar suggestions from a provider you have known for a longer period of time, who you like, who cares about you, and has your best interests in mind? If the stranger is seen as just another provider and not someone who cares about the uniqueness of the patient and his or her complaints, it is unlikely the patient is going to value highly, or even follow the provider-stranger’s recommendation/advice. Using interpersonal communication (verbal and nonverbal) to develop and maintain a relationship has the most potential for accomplishing both your and the patient’s shared health/wellness goals.

3.3. If you are in a relationship (platonic or romantic) and the other person self-discloses something very personal, what do you think that person expects in return? Why would that reality make it even harder for patients to self-disclose to providers?

In American culture, we expect the other person in a romantic or platonic rela- tionship with us to reciprocate when we self-disclose. And yet, in health care contexts for a number of personal, psychological, and organizational reasons, providers are taught not to reciprocate, but instead make sure they get their patients to self-disclose information that no one else save maybe one or two other people even know. Once again, assume the role of patient, if a provider whom you do not know well, or who does not communicate any interest in forming an interpersonal relationship with you, asks you to disclose details of your sex life, alcohol and/or drug use, and will not be reciprocating, would you be as likely to share that information with him or her as you would with a provider you felt you had a trusting/caring relationship with? In most cases,

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3 Interpersonal and Gendered Communication 57

having an emotional connection enhances trust and encourages information sharing—even when the provider cannot reciprocate.

3.4. Besides literacy, what do you think is another major obstacle in the health care context for effective interpersonal communication and information exchange?

There are many obstacles to effective interpersonal communication and information exchange in health care settings; among the most obvious are the patient’s perceived loss of power and control. Patients often experience a diminished sense of autonomy based on a number of verbal and nonverbal factors in many health communication contexts. First and foremost is the issue of a clothed provider and a nearly naked patient. Second is the fact that many providers choose to stand over a patient (seated or reclining) clearly demonstrating the provider’s power/control. Third, many providers use closed- ended questions to control the conversation—the provider determines what is important information and seeks to minimize any emotional or relational aspects not directly related to the provider’s data-gathering needs. Fourth, pro- viders frequently interrupt patients in order to control the conversation, time, and demonstrate nonverbally/verbally their power in the interaction. Finally, more often than not providers control both the openings (they almost always show up to the conversation after the patient has arrived) and closings—pro- viders decide when their information-seeking/sharing needs are met and decide it is time to close the interaction (e.g., “any more questions?” with a hand on the door knob—mismatched verbal/nonverbal behaviors). Therefore, although health literacy is extremely important to effective provider–patient interactions, the impact of the provider’s communication of power and control can be equally as obstructive to effective information-sharing and collaborative decision making.

3.5. Can you recall an exam or a lecture during which you had trouble concentrating because of something that had happened in your life? What was causing your dis- traction (a breakup with a lover, a death of a loved one, other unexpected joyous or sad news)?

Most of us have been in situations in which we had trouble concentrating on what was going on around us because of intrapersonal communication— usually unspoken dialogue with ourselves. Therefore, we can understand how difficult it is to listen and assimilate information when we are distracted by these emo- tional or physical interferences (noise). Consequently, as a health care provider it should not be surprising that many patients, even family members, have sim- ilar difficulties concentrating and understanding information presented along with a perceived or real life-threatening or life-changing diagnosis, prognosis, and/or treatment plan. If you are taking a test or listening to a lecture and you get distracted by some emotional or physical event in your life, it is problematic but far less serious than the reality for patients who are told they have a tumor,

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cancer, heart attack, and so forth. If you have difficulty concentrating because your significant other wants out of a relationship—imagine what it must be like for a patient who is just told she or he has a malignancy or his or her death is imminent? Health communication differs from all other forms of communi- cation because of the emotional aspects of the context and content. Therefore, providers need to fully consider how to deliver “bad news” or potentially bad news to patients. Perhaps the provider will need to ask the patient to bring an advocate (spouse/family member/friend) to listen, take notes, and/or ask questions. Or the provider will decide to share the news, but request a second meeting the following day to assure the patient not only heard the message but also assimilated it correctly and has a chance to ask his or her questions and gather more information. One thing the provider should try to avoid is giving bad news and expecting the patient to make a carefully considered deci- sion immediately thereafter. Unless the problem is a life or death situation, the provider would be wise to separate the information about the illness or injury from a detailed discussion about possible next steps and/or treatment options. The impact of “noise” in a communication channel, for example, the emotional fears attached to hearing certain words: tumor, cancer, malignancy, heart attack, stroke, and so forth—should suggest to providers the need to reassess how much information to provide at one time, the need for a patient advocate, the value of a repeat visit and further information sharing, and/or the value of lit- eracy/language-appropriate handouts. The obfuscation created by potentially life-altering diagnoses, prognoses, and treatment options should suggest to providers the need to find alternative ways to communicate with patients and/ or family members/advocates. Just being correct in a diagnosis should not be sufficient for a provider—the patient needs to be able to understand what has been determined, assimilate the facts and the options, and make an informed decision. However, without adequate time and appropriate contexts, patients cannot be expected to quickly overcome their initial reactions/fears/uncertain- ties and address important decision-making options while they are still unable to fully process information and respond appropriately to it.

3.6. If you are delivering potentially emotionally charged news to a patient and/or family member, how might you try to overcome that person’s connotative response and obstructive noise in the interaction?

In such a scenario, a health care provider would be wise to recognize the risk of emotional noise and/or fear in the conversation and do all she or he can to minimize that possibility. As mentioned earlier, you could encourage the patient to bring an advocate (spouse, life partner, friend, etc.) to listen, take notes, and discuss with the patient what had been discussed with the pro- vider at a later time in a different setting. And you might ask yourself whether you are doing all you can to encourage assimilation of information. For exam- ple, did you schedule the time to talk about the emotionally charged news when you have time to sit and answer all the patient’s/family’s questions

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and provide feedback to determine what the patient/family member heard, understood, and/or had questions about? Are you attentive to your language choices and use verbal messages that are both literacy and language appro- priate? Do you need a professional translator? Be sure to pay close attention to your nonverbal behaviors so you are communicating more collaboratively and less authoritatively/paternalistically—sit, maintain eye contact, encour- age questions, make sure your nonverbal behaviors are complementary, not contradictory, communicate your empathic listening by allowing the patient/family member to fully express his or her feelings, concerns, and questions. Provide further information in print for later reading, again based on the educational, language, and literacy levels of the patient/family. Offer to answer questions at a later time by phone or in person. Be careful not to provide unrealistic hope or expectations, but focus on quality-of-life issues and empowering the patient to aid him or her in making informed decisions.

3.7. You are discussing a spinal tap procedure with a patient and she asks, “Does it hurt?” You respond, “Not really,” but your eyes are looking away from the patient and you bite your lower lip as you finish speaking. What would you hypothesize a patient in this culture would perceive the answer to her question to be and why?

As discussed earlier, nonverbal communication/behavior in U.S. culture is perceived as more accurate than verbal messages. Therefore, a provider who says one thing, but nonverbally contradicts the statement is most likely com- municating the opposite of what she or he said. Consequently, providers need to be keenly aware of the importance of complementing their verbal messages with appropriate nonverbal cues. In the context described in this question it is likely that the provider did not want to scare the patient by honestly com- municating the reality: “There will be some pain, discomfort, and/or pressure, but I will inject some medicine under your skin to make the pain less and I will tell you everything I am doing, before I do it.” By communicating what you will be doing and what should be expected, both verbally and nonver- bally, not only can the patient increase his or her trust in you, but he or she will be adequately informed of what is about to happen. Providers must resist the impulse to hide facts from patients, verbally or nonverbally, and instead find a way to empower the patient with information that can be understood, assimilated, and assessed. You may not be able to eliminate all pain in health care procedures and diagnostic tests, but you can make sure your patient is properly informed and prepared without having to interpret conflicting verbal and nonverbal messages.

3.8. As a health care provider, why would proxemics be important for you to under- stand? Have you thought about proximity in visits you have made to your own health care provider, or when you went to the emergency department (ED) or to a new provider? If so, what were your concerns?

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60 Health Communication for Health Care Professionals

Proxemics or the space between communicators is very important to provider–patient communication and relationship development. As dis- cussed earlier, providers—in order to do their work—need to use haptics and proxemics to assess patients’ vital signs, breath and heart sounds, abdomen, skin, and so forth. However, providers can either nonverbally demonstrate their power and control by touching the patient and altering the expected distances between communicators without asking the patient’s permission, or providers can ask to infringe on the patient’s personal space in order to do their exams. Taking a few seconds to illustrate providers’ recognition of patients’ proxemics and their expectations by asking permission to touch prior to doing so, is one small step in affording patients a bit of social/cultural normalcy and control.

3.9. How would you feel if you were in a classroom or continuing-education confer- ence and the professor/presenter came over to you and grabbed your hand and started helping you write notes? Were you not in that environment to learn? So how is that use of haptics different or similar to the previous blood-drawing example?

Not unlike Reflection 3.8, this example seeks to help health care providers understand how touching someone, even if they have chosen to put them- selves in the context, can be perceived and treated by the person in charge as a nonverbal permission to touch without asking. However, the act of acknowledging the patients’ rights to control who touches their bodies, just as they do in all other aspects of their lives, demonstrate providers’ recognition of power- and control-sharing in the provider–patient interaction.

3.10. You have an interview for a job and go to greet the interviewer. Nonverbally, what are two of the most important kinesics you need to utilize to demonstrate your interest, sincerity, and recognition of cultural expectations for professional greetings?

Two of the most important kinesics for greeting a stranger, or anyone for that matter, would be eye contact and a smile. Clearly, an applicant for a job wants to demonstrate his or her interest in the position, friendly/positive attitude, and honesty vis-à-vis his or her nonverbal behaviors. In U.S. culture, eye contact is perceived as critical to a communicator’s assessment of the other person’s interest, honesty, and credibility. A person’s smile, or lack thereof, is assumed to reflect the individual’s attitude and enthusiasm. Therefore, if these kinesic behaviors are recognized as being so vital to communicating these nonverbal messages in other aspects of a provider’s life, why would she or he not want to use them also in his or her interactions with patients—both strangers and those who are well known? Try to find a way to use normative communication behaviors of the larger American culture in your microlevel interactions with patients—regardless of the context (ED, office, hospital, etc.)—and patients will likely appreciate your efforts to normalize the interaction.

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3 Interpersonal and Gendered Communication 61

3.11. Why is it that health care organizations have certain dress codes regarding white coats, scrub clothes, uniforms, jewelry, and so forth? What is the organization trying to nonverbally communicate to its members and to its patients and their fam- ily members?

Health care organizations are trying to establish the values, beliefs, and goals for their members, customers, and vendors, as well as meet regulatory require- ments. Consequently, many institutions want to assure that their employees’ artifacts: clothes, hair, jewelry, body art, and so forth meet the organization’s, regulators’, and patients’ expectations. The need to find nonverbal ways to build credibility with customers is also a concern. Having standardized artifacts helps to both brand the organization and minimize employees’ and customers’/ patients’ distractions. Finally, the more employees/providers appear profes- sional, the more likely the perception that they are knowledgeable, well trained, and dedicated to the organization’s values and goals.

3.12. How do you respond when you are in a conversation with a person who is cry- ing? What if that person is a patient, would you respond differently? If so, how and why is the same nonverbal cue different?

One of the things a health care provider, or anyone for that matter, can do when a person is crying is acknowledge the person’s sadness and encour- age him or her to talk about what is causing the feelings. Or, in the case of a patient or a patient’s family member, the provider knows why the person is crying—the provider can acknowledge the cause (fear, sorrow, pain, loss, etc.). Empathic listening allows providers to communicate their understanding of the patient’s situation and feelings. Many times when someone is crying she or he just wants to be able to talk about his or her concerns with someone. The patient does not necessarily expect the other person to fix the problem/situa- tion, but just to allow him or her to verbalize what is causing the feelings and tears. Clearly, if the patient is crying because of pain or a misunderstanding, a provider who listens can provide relief (medication and/or communication/ education); however, providers need to be willing to ask questions when they are faced with a crying patient and/or family member and not ignore or avoid him or her. Building an interpersonal relationship in provider–patient interac- tions is no different from the nonverbal and verbal interpersonal communica- tion required among friends, family, and/or lovers. Providers need to listen and offer patients an opportunity to discuss their situations/problems/concerns.

3.13. Think about your own gender identity. Do you perceive yourself as more mascu- line or feminine? What behaviors or feelings do you use to illustrate one gender over the other? Are there contexts in which you may need to behave the opposite of what you feel is the norm for you (more masculine if you see yourself as feminine, or vice versa)? If so, why? If not, why not?

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62 Health Communication for Health Care Professionals

In terms of how you think of your gender, do you see yourself as more competitive or collaborative? Are you more independent or participative? Do you strive to be more aggressive or nurturing? These are just some of the behaviors that distinguish masculine- from feminine-gendered individuals. However, as discussed earlier, you likely use a mixture of gendered behaviors and can position yourself somewhere along the gendered communication spectrum from über masculine to über feminine. Nonetheless, there are con- texts when more masculine-gendered behaviors (regardless of a person’s sex) may be the most appropriate—for example, in a crisis. If there is a fire and you need everyone to evacuate, you likely will want a more masculine-gendered communication style to assure that whoever is in the dwelling understands that they need to leave immediately and aggressively help anyone who may have difficulty getting out. Or if you are trying to encourage maximum participation in a team that you are leading, you may want to use a more feminine-gendered approach (regardless of your sex) and encourage collaboration and participa- tion instead of using an authoritarian/paternalistic style. These same consider- ations can be applied to provider–patient and provider–provider interactions. There may be certain contexts in which it is important for you to assume a more masculine-gendered communication style, but in general, a more feminine approach allows for more collaboration, nurturing of the provider–patient rela- tionship, and mutual participation in information sharing and decision making.

3.14. Think of a relationship you have been in, either platonic or romantic. Can you recall when you or the other person made a self-disclosure and how it impacted the relationship (positively or negatively)? Was there a reciprocal self-disclosure? If so, did the presence or absence of a reciprocal response enhance the relationship or jeop- ardize it, and why?

In most interpersonal communication/relationship scenarios, when one per- son chooses to self-disclose, the other party in the dyad is expected to recipro- cate. However, in health care, patients are asked to self-disclose as part of the information seeking in almost every provider–patient interaction. However, although patients are expected to self-disclose, providers are discouraged from reciprocating. This is antithetical to the norm in our culture and what is expected in all other aspects of interpersonal communication/relationships. As a consequence, it is important for providers to understand how unique this situation is for patients and to use empathic listening to be supportive of patients when they self-disclose difficult or painful information and not just treat the situation as if it is normative for the patient.

S k i l l s E x e r c i s e

Talk with someone you know well and stand up to talk when she or he is sitting. How does it make you feel not being at eye level? Next, with a different friend or loved one, have a pad of paper or a smartphone or electronic tablet, and while

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talking to the person, start looking at and/or writing/typing on the paper or e-de- vice. How does that impact your ability to focus on what the other person is say- ing? Ask the person how he or she perceived the communication based on your behaviors?

Video Discussion Exercise Analyze the video

■ The Doctor (1991)

Role-Play Using These Interactive Simulation Exercises Pagano, M. (2015). Communication case studies for health care professionals: An

applied approach (2nd ed.). New York, NY: Springer Publishing Company.

■ Chapter 5, “Autonomy Is a Myth” (pp. 45–54)

■ Chapter 7, “Closings” (pp. 67–78)

■ Chapter 20, “The Nurses Paid More Attention to the Computer Than They Did to Me” (pp. 201–208)

Health Care Issues in the Media A doctor’s story http://well.blogs.nytimes.com/2015/06/25/sharing-my-story-with-patients/? smid=nytcore-ipad-share&smprod=nytcore-ipad

A nurse’s story http://well.blogs.nytimes.com/2013/09/13/when-nurses-bond-with-their- patients

H e a l t h C o m m u n i c a t i o n O u t c o m e s

Provider health communication at its most basic level is interpersonal. It is fundamentally diverse, dyadic interaction between providers and patients and/ or providers and providers. However, interpersonal communication is generally, in American culture, intended to help develop and/or maintain interpersonal relationships. In health care, however, because of the scientific/biomedical approach of many providers, interpersonal communication becomes more monologue-like, with a paternalistic and authoritarian style that includes health care jargon/terminology, a detective-like inquisition during which patients are peppered with closed-ended questions that serve to verbally and nonverbally demonstrate the provider-centered nature of the interaction. This unique communication style used by many health care professionals is intended to primarily gather the material the provider needs and/or share

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64 Health Communication for Health Care Professionals

information that the provider controls. These verbal and nonverbal behaviors also serve to reinforce the provider’s role and goals, frequently without any effort to assure that these are shared or mutually constructed patient-centered goals. Furthermore, with a disease-focused approach, it becomes even easier for many providers to neglect the impact that gender, not just sex, has on both communication and health care issues. The importance of assessing a patient’s gendered communication preferences, as well as offering carefully considered verbal and nonverbal provider behaviors, can help health care professionals be more effective in their interactions based on the patient’s messages and mas- culine- versus feminine-gendered communication behaviors.

■ R E F E R E N C E S

Hall, E. (1959). The silent language. New York, NY: Random House. U.S. Department of Education, National Center for Education Statistics. (2015).

National assessment of adult literacy. Retrieved from http://nces.ed.gov/naal/ kf_demographics.asp

U.S. Department of Education, National Institute on Literacy. (2015). U.S. Illiteracy statistics. Retrieved from http://www.statisticbrain.com/ number-of-american-adults-who-cant-read

Wood, J. T. (2015). Gendered lives: Communication, gender, and culture (11th ed.). Stamford, CT: Cengage Learning.

■ B I B L I O G R A P H Y

Korsch, B., & Negrete, V. (1972). Doctor-patient communication. Scientific American, 227, 66–74.

Lederman, L. (2008). Beyond these walls: Readings in health communication. New York, NY: Oxford University Press.

Ratzan, S. (1994). Health communication as negotiation: The Healthy America Act. American Behavioral Scientist, 38, 224–247.

Servellen, G. (2009). Communication skills for the health care professional: Concepts, practice, and evidence (2nd ed.). Sudbury, MA: Jones & Bartlett.

Tongue, J., Epps, H., & Forese, L. (2005). Communication skills for patient- centered care. Journal of Bone and Joint Surgery, 87, 652–658.

Trenholm, S., & Jensen, A. (2013). Interpersonal communication (7th ed.). New York, NY: Oxford University Press.

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