Review week 3 content for this weeks readings and answer the following questions. Include citations from the readings or other peer reviewed sources cited in APA format. Please provide 2 quality responses to peers
RESEARCH ARTICLE Open Access
Evidence of nonverbal communication between nurses and older adults: a scoping review Esther L. Wanko Keutchafo* , Jane Kerr and Mary Ann Jarvis
Background: Communication is an integral part of life and of nurse-patient relationships. Effective communication with patients can improve the quality of care. However, the specific communication needs of older adults can render communication between them and nurses as less effective with negative outcomes.
Methods: This scoping review aims at describing the type of nonverbal communication used by nurses to communicate with older adults. It also describes the older adults’ perceptions of nurses’ nonverbal communication behaviors. It followed (Int J Soc Res 8: 19-32, 2005) framework. Grey literature and 11 databases were systematically searched for studies published in English and French, using search terms synonymous with nonverbal communication between nurses and older adults for the period 2000 to 2019.
Results: The search revealed limited published research addressing nonverbal communication between older adults and nurses. The studies eligible for quality assessment were found to be of high quality. Twenty-two studies were included and highlighted haptics, kinesics, proxemics, and vocalics as most frequently used by nurses when communicating with older adults; while studies showed limited use of artefacts and chronemics. There was no mention of nurses’ use of silence as a nonverbal communication strategy. Additionally, there were both older adults’ positive and negative responses to nurses’ nonverbal communication behaviors.
Conclusion: Nurses should be self-aware of their nonverbal communication behaviors with older adults as well as the way in which the meanings of the messages might be misinterpreted. In addition, nurses should identify their own style of nonverbal communication and understand its modification as necessary in accordance with patient’s needs.
Keywords: Nonverbal communication, Nurses, Older adults
Background Communication is a multi-dimensional, multi-factorial phenomenon and a dynamic, complex process, closely re- lated to the environment in which an individual’s experiences are shared . Regardless of age, without communication, people would not be able to make their concerns known or make sense of what is happening to them . Communica- tion links each and every person to their environment ,
and it is an essential aspect of people’s lives . In healthcare settings, communication is essential in establishing nurse- patient relationships which contribute to meaningful engage- ment with patients, and the fulfilment of their care and social needs . Effective communication is a crucial aspect of nursing care and nurse-patient relationships [6–8]. In health- care encounters with older adults, communication is import- ant, in particular to understand each person’s needs and to support health and well-being . However, older adults may experience hearing deficits, changes in attention and coding of the information , and these communicative
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: [email protected] Discipline of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, 71 Manor Drive, Manor Gardens, Durban 4001, South Africa
Wanko Keutchafo et al. BMC Nursing (2020) 19:53 https://doi.org/10.1186/s12912-020-00443-9
disabilities may restrict their interaction, participation and ef- fective communication . Communication occurs through verbal or nonverbal
modalities [12, 13]. Nonverbal communication (NVC) is defined as a variety of communicative behaviors that do not carry linguistic content  and are the messages transmitted without using any words [15, 16]. NVC can act as a counter measure or an adjunct to verbal mes- sages, in that it is more reliable if there is inconsistency between verbal and nonverbal messages . Therefore, it is important that there is congruence between nonver- bal and verbal messages , with research showing that patients are particularly alert to nurses and nurse-aids nonverbal behaviors [17, 19–21], especially when they are anxious and feel uncertain . Despite the value of communication, it has been shown that healthcare workers spent very little time communicating with pa- tients not satisfied with the information they received and how it was communicated . Though verbal com- munication behaviors of healthcare providers have been extensively studied, their NVC behaviors have received less attention . Scholars have varied in their estimations of the pro-
portion of NVC in communication, with estimates as high as 93% , with other estimates of 60 to 90% . Moreover, scholars have described different modalities of NVC, including artefacts (presence of physical and environmental objects), chronemics (use and perception of time), haptics (use of touch), kinesics (form of move- ment of the body), physical appearance (body type and clothing), proxemics (use of space and distance), vocalics (aspects of the voice), and silences [23, 25–27]. Concern needs to be directed on NVC and its different
modalities as critical contributors to high quality care which plays a significant role in demonstrating respect for patients, fostering empathy and trusting provider- patient relationships . A significant relationship ex- ists between patient’s perceptions of empathy and eye contact and social touch , with touch, and gestures described as communication facilitators . Nurses' positive facial expressions demonstrate signs of bonding, respect and affection towards older patients  while voice tones have contributed decisively to the success of interactions with older adults . On the other hand, limited time has been reported by patients to have a negative impact on communication [31, 32], demon- strated in gestures of irritability which have caused em- barrassment in older patients , and speaking fast has been a further communication barrier between nurses and patients . The present review suggests the im- portance of understanding NVC between nurses and older adults, and underscores the need for focused re- search to address the gap in the knowledge of communi- cation in geriatric care. The primary aim of the study
was to identify the type of NVC strategies used by nurses to communicate with older adults in both acute care settings and long-term care settings.
Methods In order to map evidence-based knowledge and gaps [33–35] related to NVC between nurses and older adults, a systematic scoping review was conducted. Scop- ing reviews are useful to map the existing literature around a particular topic by charting findings and identi- fying research gaps , especially when the topic is complex or poorly reviewed . A scoping review was chosen over a systematic review because the purpose of the study was to identify knowledge gaps related to non- verbal communication, as opposed to confirming or re- futing the basis of current practice against relevant evidence . The study adopted the framework pro- posed by Arksey and O’Malley  and further refined by Levac et al. . The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist  was followed for this review (Additional file 1).
Research questions The main question for this review was: What is the evi- dence of NVC between nurses and older adults? The sub questions were: (i) What are the different modalities of NVC used in geriatric nursing care? (ii) What are the functions of using the different NVC modalities? (iii) How do older persons respond to different NVC modalities?
Eligibility criteria The JBI framework of Population, Concept, Context (PCC) was used to determine the eligibility of the re- search question for this review (Table 1).
Population Nurses including nursing students were considered in addition to qualified nurses and nurse aides because they are the largest population of healthcare workers .
Concept The focus was NVC between nurses and older adults (≥60 years). For the purpose of this review, the United Nations cut-off of 60 years and older referring to the older adult population in Africa  was considered; yet, most Upper Income Countries have accepted the chronological age of 65 years and older, the age of retire- ment, as a definition of an older adult . Socio- economic and disease reasons suggest that 65 years is not readily applicable to the African context . Older adults with dementia were excluded although
they are able to send and receive nonverbal information . Dementia care combines comorbidities, cognitive
Wanko Keutchafo et al. BMC Nursing (2020) 19:53 Page 2 of 13
and functional decline; leading to complex needs and ever-increasing difficulty for the patient in articulation , which is viewed as a challenging form of care.
Context Acute settings and nursing homes were included into the context. In nursing homes, care is usually carried out by nursing staff with different levels of education and training . Furthermore, community settings were excluded from the context because hospitalization is po- tentially stressful and involves unpleasant experiences for patients and their families , and thus offers a greater opportunity to identify the phenomenon under discussion.
Search strategy The search terms for this review originated from indexed subject headings, keywords of relevant studies, that recurred repetitively, and the Medical Subject Head- ings (MeSH) terms. The term ‘nonverbal communica- tion’ was used as a starting point to develop a search string and identified other keywords to refer to NVC. The string/Boolean search terms for this review in- cluded: Participants (“nurses” OR “registered nurse” OR “professional nurses” OR “students nurses” OR “nurse aides”) AND Concept (“nonverbal communication” OR “kinesics” OR “proxemics” OR “artefacts” OR “chrone- mics” OR “haptics” OR “vocalics” OR “physical appear- ance” OR “active listening” OR “silences”) AND Context (“old people” OR “elder” OR “elderly” OR “older people” OR “aged” OR “geriatrics”).
Database searching A range of sources were used to ensure a comprehensive coverage of the literature. An initial search was con- ducted in August 2017, repeated and finalized in No- vember 2019 The search made use of the following databases: Pubmed, Science Direct, Sabinet, Academic search complete, CINAHL with Full Text, Education Source, Health Source- Consumer Edition, Health Source: Nursing/Academic Edition, and MEDLINE.
Google Scholar and Open Grey engines were also used to source relevant literature. Additionally, the reference lists of the included studies were used to search for add- itional studies. Only studies written in either English or French were retrieved. Evidence of nurses’ NVC strategies while communicat-
ing with older adults, conducted in acute settings, and published in English or in French between 2000 and 2019 were included. Quantitative, qualitative, mixed- methods primary research studies, and reviews published in peer-reviewed journals, and grey literature that ad- dressed the research question such as book chapters, thesis and reports were included. Evidence on communi- cation with older adults suffering from communication impairment or dementia, in psychiatric units or commu- nities, published in languages other than English or French were excluded. Evidence published before 2000 were excluded.
Study selection The titles were reviewed against the eligibility criteria by EW. This initial search was monitored, exported into EndNote X9 reference manager, for abstract and full text screening by EW. The duplicated studies were deleted, followed by independent reviewing of the abstracts by EW and JK. Studies deemed ‘unclear’ were advanced to the subsequent screening stage. Assistance from the study university library services was requested when full texts could not be retrieved from the databases and five full texts were provided. Full text of 75 eligible studies were independently filtered by EW and JK using Google forms. Additionally, a search of the reference list of all identified reports and studies for additional studies was performed by EW. MAJ pronounced on the discrepan- cies that occurred during the abstract screening and the full text screening until a consensus was reached.
Data extraction Information relevant to the aim of this study were ex- tracted independently by EW and JK. A data extraction form was developed electronically using Google forms.
Table 1 PCC framework used to determine the eligibility of the research question
Criteria Inclusion Exclusion
Population Professional nurses, registered nurses, enrolled nurses, nurse aides Nursing students
Nurses working in community settings All other healthcare workers Informal geriatric care givers
Concept Nonverbal communication strategies and interpreted meaning between nurses and older adults (≥60 years)
Verbal communication between nurses and older adults Nonverbal communication strategies of older adults Nonverbal communication with nurses and older adults with communication impairments or disorders or dementia.
Context Acute settings, nursing homes, long-term care Acute hospital settings End-of-life / Terminal care unit; Psychiatric / mental health care unit; Communities
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Extracted data included bibliographic details, country and setting, aim/objective, study design, targeted popula- tion, nurses’ nonverbal strategies used while communi- cating with older adults, older adults’ interpretation of nurses’ nonverbal behaviors, and relevant outcomes of interest. Discussions between EK and JK refined the table of information extracted.
Quality appraisal The Mixed Methods Appraisal Tool (MMAT), version 2018  was independently used by EW and JK to crit- ically appraise the quality of the included primary stud- ies. Discussion was used to resolve discrepancies. The MMAT allowed for assessment of the appropriateness of the aim of the study, adequacy and methodology, study design, participant recruitment, data collection, data analysis, and the presented findings . The quality of studies was graded with a quality score ranging from ≤ 50% as low quality, 51–75% considered as an
average quality, and 76–100% considered as high quality (Table 3).
Collating and summarizing the data Content thematic analysis approach  was employed to extract relevant data that answered the study ques- tions. The results of the included studies were summa- rized, manually coded, and presented using a narrative approach. The nurses’ NVC behaviors were categorized under nine items namely (i) artefacts; (ii) chronemics; (iii) haptics; (iv) kinesics; (v) proxemics; (vi) vocalics; (vii) physical appearance; (viii) active listening; and (ix) silence.
Results Two hundred and fifty-seven (257) studies met the eligi- bility criteria following the deletion of 478 duplicates from the 735 studies identified at the title screening stage (Fig. 1).
Fig. 1 PRISMA 2009 Flow Diagram
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Characteristics of included studies Tables 2 and 3 summarize the characteristics of the 22 included studies. All included studies were published in English and no eligible French studies were identified.
Study designs Diverse research methods were employed within the 22 included studies. Thirteen studies were qualitative stud- ies using individual interviews [19, 47, 55, 58, 60, 65], focus groups [51, 65], participant observations including video recordings [30, 47–49, 52, 57, 60], and participant
logs . There were one survey , one randomized controlled trial study  as well as one mixed methods study . The other studies were a review  and two reflections [61, 63]. Three studies were related to con- tinuous professional development [3, 4, 56].
Quality of evidence Of the 22 included studies, 16 studies underwent meth- odological quality assessment using the MMAT version 2018 . The remaining six [3, 4, 50, 56, 61, 63] were excluded from the quality appraisal because they were
Table 2 Characteristics of the included studies (1)
Author(s) and year Country Setting Design Sample sizes Quality appraisal
Johnsson et al. 2018 
Sweden Wards in a department of medicine for older people
Qualitative: observations, field conversations, and semi-structured interviews
40 nurses and 40 older adults
Freitas 2016  Brazil Family health unit Qualitative: video recording 32 nurses and 32 older adults
Small et al. 2015  Canada Long term care Qualitative: observation (video recording)s 27 staff and 27 older adults
Freitas 2014  Brazil Family health unit Qualitative: video recording 32 nurses and 32 older adults
Levy-Storms et al. 2011 
USA Nursing home Qualitative: focus groups 17 nurse aides and 15 older adults
Medvene and Lann- Wolcott 2010 
USA Assisted living facility and nursing home
Qualitative: individual interviews 16 nurse aides 100%
Backhaus 2009  Japan Nursing home Qualitative: observations 100 nurses and 57 older adults
Gilbert and Hayes 2009 
USA Nurse practitioners’ offices Mixed: observations (video recordings), survey
31 nurse practitioners and 155 older adults
Sorensen 2009  the Balkans
Nursing home and rehabilitation unit
Qualitative: nursing students’ logs 10 third-year nursing students
Williams and Warren 2009 
USA Assisted living facility Qualitative: interviews and fieldwork 11 nursing assistants and 39 older adults
Carpiac-Claver and Levy- Storms 2007 
USA Nursing homes and assisted living facilities in USA
Qualitative: observations (video recordings)
17 nurse aides and 17 older adults
Kaakinen et al. 2001  USA Care facilities, clinics, and private practice
Qualitative: one focus group and in-depth interviews
12 nurse practitioners 100%
Jonas 2006  Canada Long term care Qualitative: semi-structured interviews 19 older adults 100%
Tuohy 2003  Ireland Continuing care unit Qualitative: participant observations and eight semi-structured interviews
8 s year diploma nursing students
Butts 2001  USA Two nursing homes Quantitative: randomized control trial 72 older adults 100%
Park and Song 2005  Korea Medical, surgical, and ophthalmology units
Quantitative: survey 136 nurses and 100 older adults
Daly 2017  Ireland Not reported Grey: Continuous Professional Development
Williams 2013  USA Literature Review N/A N/A
Calcagno 2008  USA Long-term care Grey: Continuous Professional Development
Linda 2002  UK Not reported Grey: Continuous Professional Development
Bush 2001  Germany Not reported Grey: author’ s reflection N/A N/A
Babikian 2000  USA Long term care Grey: authors’ reflection N/A N/A
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Table 3 Characteristics of the included studies (2)
Author(s) and year
Objective Outcomes reported Conclusions
2018 Johnsson et al. 2018 
To describe how nurses communicate with older patients and their relatives in a department of medicine for older people in western Sweden
Nurses’ nonverbal communication strategies: standing position, eye gaze, speaking faster, speaking louder, speaking with a friendly tone, kneeling down, closing the door, smiling, facial expressions, smiling
Proxemics, kinesics, vocalics
2017 Daly 2017  To explore communication between nurses and older adults, with an emphasis on promoting effective communication in practice
Nurses’ nonverbal communication strategies: considering the environment, using touch appropriately, positioning oneself at the same level, active and compassionate listening
Artefacts, haptics, proxemics, active listening
2016 Freitas 2016 
To assess proxemics communication between nurse and elderly in nursing consultation
Nurses’ nonverbal communication strategies: posture-Sex, sociofugo-sociopeto axis, distance evaluation, kinaesthetic, contact behaviour, visual code, thermal code, olfactory code, voice Volume
kinesics, vocalics, haptics, proxemics, artefacts
2015 Small et al. 2015 
To explore the nature of communication between care staff and residents when they do not share the same language and ethno cultural backgrounds
Nurses’ nonverbal communication strategies: pointing, touching, eye gazing, smiling, sitting next, head nodding, playful gestures
kinesics, proxemics, haptics
2014 Freitas 2014 
To analyse the performance of nurses in nursing consultation for the elderly based on the theoretical framework of Hall
Nurses’ nonverbal communication strategies: posture-sex, sociofugo-Sociopeto axis, distance evaluation, kinaesthetic, contact behaviour, visual code, thermal code, olfactory code, voice Volume
kinesics, vocalics, haptics, proxemics
2013 Williams 2013 
To review evidence-based strategies for effective communication with older adults across long-term care settings
Nurses’ nonverbal communication strategies: eye contact, facial expressions, singing, humming, touching. Patients’ responses of nurses’ nonverbal communication strategies: dominance, disinterest
kinesics, haptics negative responses
2011 Levy-Storms et al. 2011 
To characterise the meaning of and experiences with individualized care from the perspectives of both nursing aides and nursing-home residents
Nurses’ nonverbal communication strategies: listening, touching the shoulder Patients’ responses of nurses’ nonverbal communication strategies: respect, favouritism
haptics, active listening Mixed responses
2010 Medvene and Lann-Wolcott 2010 
To identify the communication behaviours and strategies used by socially skilled geriatric nurse aides working with residents in long term care facilities
Nurses’ nonverbal communication strategies: touching, smiling, spending time with, observing body posture;
haptics, kinesics, chronemics
2009 Backhaus 2009 
To examine the special nature of communication between residents and staff in a Japanese elderly care institution by taking a cross-cultural perspective
Nurses’ nonverbal communication strategies: kiss, hand shake, military tone
2009 Gilbert and Hayes 2009 
To examine contributions of older patients’ and nurse practioners’ characteristics and the content and relationship components of their communication to patients’ proximal outcomes and longer-term outcomes, and contributions of proximal outcomes to longer-term outcomes
Nurses’ nonverbal communication strategies: gaze, nod or shake of the head, eyebrow movement, smile, touch
2009 Sorensen 2009 
To demonstrate and discuss how personal competence, with emphasis on communication and empathy, can be developed by nursing students through international clinical practice
Nurses’ nonverbal communication strategies: body contact, pointing, nodding, smiling, laughing, active listening, voice pitch, thumbs up,
kinesics, vocalics, active listening, haptics
2009 Williams and Warren 2009 
To explore how communication affects issues relating to residents maintaining cognitive and physical functioning so that they are able to remain in residence
Nurses’ nonverbal communication strategies: talk louder. Patients’ responses of nurses’ nonverbal communication strategies: rudeness; disinterest in; disdain for; perceived hypocrisy; threats to noncompliance; infantilization of residents; adultification of residents;
Vocalics Negative responses
2008 Calcagno 2008 
To provide pointers to help clinicians listen to the needs and concerns of their clients
Nurses’ nonverbal communication strategies: greeting with a smile and handshake, sitting face- to-face, leaning forward, sitting close enough, lis- tening, having an open posture
active listening, kinesics, proxemics
2007 Carpiac- To identify types and examples of nurse aide- Nurses’ nonverbal communication strategies: kinesics, haptics,
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not primary studies. The 16 studies which underwent methodological quality assessment showed high meth- odological quality and scored between 80 and 100%. Of these studies, 15 studies [19, 30, 47–49, 51–55, 57, 58, 60, 62, 65] scored 100%, and one  scored 80%.
Study results Three outcomes were reported in the studies: the NVC behaviors of nurses, the functions of those behaviors and the responses of older adults to the NVC behaviors.
Nurses’ NVC behaviors and their functions Of the 22 included studies, 20 reported on nurses’ NVC behaviors including haptics, kinesics, proxemics, vo- calics, active listening, artefacts, and chronemics. There was no mention of physical appearance nor silences in all the included studies.
Haptics Haptics were reported in 17 studies [3, 4, 19, 30, 48–54, 57, 60–63, 65] of which 12 studies, which underwent
quality appraisal, were of high quality. Haptics were identified when nurses shook hands with older adults, held their hands, stroked or touched their hands. Nurses also kissed older adults, hugged them or gave them a pat on the
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