Research
Nurses' nonverbal methods
of communicating with patients
in the terminal phase
Lena Kozlowska, Anna Doboszynska
Abstract
Aint: The aim of this study was to ascertain what methods of
communication nurses use during interactions with patients nearing
the end of their lives, with a particular focus on nonverbal
communication. Methodology: A questionnaire containing 24
questions was completed by 95 nurses working in one of five
hospices in Poland. Results: A total of 48% of the sample reported
frequently using nonverbal communication consciously and with a
certain aim, and a further 37 (39%) reported that they sometimes use
it. The sample's responses indicate that for patients the best form of
touch is holding hands. In addition, 63% of the respondents stated that
they had been educated in communicating with palliative care
patients, but only 56% thought that nurses' communication
knowledge and skills were satisfactory, and 50% would like to
undergo training in communication skills specific to palliative care.
Conclusion: Most nurses are aware of the importance of nonverbal
communication to their interactions with palliative care patients, but a
substantial proportion think that they need to be better educated in
theoretical and practical aspects of communication.
Key words: Non-verbal communication 9 Palliative care
# Education # Training
I
nterpersonal communicationtransmission
of signals from one person to another
(Gilbert and Hayes, 2009)is a very impor-
tant part of living in society. Proper expression
of our opinions, intentions, and feelings contrib-
utes to the formation of positive relationships
with other people in both our private and our
occupational lives. A good communicator
acquires skills not only in the sending of mes-
sages but also in receiving and interpreting what
Lena Kozlowska is
PhD student; Anna is being communicated. They have good listen-
Doboszynska is Head ing skills and are aware of and make allowances
of Department, Clinical
Nursing Department, for the individuality of each person. A good
Medical University of communicator is also able to cope with commu-
Warsaw, 27 Erazma
Ciolka Street, 01-445 nication barriers, such as cultural differences or
Warsaw, Poland cognitive and emotional states (Webb, 2011).
Correspondence to: Broadly, communication can be performed in
Lena Kozlowska two ways: verbally (with words) and non-
lenakozlowska@gmail.
verbally (without words). According to Pease
40
(2001), the vast majority of information
(approximately 93%) is passed on by nonverbal
cuesfacial expression, touch, eye contact, tone
of voice, dress, movement etc.
Both communication and interpersonal skills
are basic components of high quality nursing
care (Webb, 2011). Nurses are the members of
the interdisciplinary team who spend the most
time with patients, and hence communication
is of particular importance for nurses (Mojs
and Glowacka, 2009; Kim, 2011). Sometimes
communication can be difficult because of the
patient's age, education, culture, behaviour, or
social background, and poor communication
can be a barrier to good care (Webb, 2011).
However, proper communication in the nurse-
patient encounter can have a therapeutic influ-
ence on patients' health, allowing them to
express their emotional needs, ask questions,
resolve doubts, develop confidence and trust,
and obtain a sense of control over their health
condition and healing process (Webb, 2011). It
can also identify their expectations and
increase their satisfaction with their care (Ley,
1988). In addition, nurses often take on the
role of translator, for example by explaining
what was said by a doctor during a consulta-
tion and trying to help the patient handle the
situation (Hebert et al, 2011).
As many as 50% of family members do not
understand the patient's diagnosis and prognosis
(Jacobowski et al, 2010). This is a serious prob-
lem, especially in palliative care where the family
is often the main receiver of information about
the patient. Recently, a lot of attention has been
given to developing communication skills among
medical staff (Jarosz and Pozarowska, 2007).
Proper communication should be one of the
bases of nurses' occupational competence (Mojs
and Glowacka, 2009). Both competency and
skills are core elements of nurses' training, so
there is a need to identify diverse ways of
educating nurses to develop and improve their
competence and confidence in communication
International journal of Palliative Nursing 2012, Vol 18, No 1

(Ronsen and Hanssen, 2009). Nurses need to be
aware that all behaviour (verbal or nonverbal;
intentional or unintentional) is a specific form of
communication. Moreover, caregivers should be
skilled in receiving messages from others. Care
recipients often focus on unintentional nonver-
bal signals, such as how nurses move, dress,
walk, or use touch (Webb, 2011). During com-
munication it is practically impossible to sepa-
rate verbal and nonverbal signals, and they are
both integral to any effective interaction (Knapp
and Hall, 1997).
In recognition of the significant influence of
communication, the American Association of
Colleges of Nursing identifies a competency for
end-of-life care that requires nurses to communi-
cate effectively and compassionately with
patients, families, and other members of the palli-
ative care team (Betcher, 2010). Nurses need to
be able to help patients understand their disease
state and health condition (Hebert, 2011), and
those who provide end-of-life care also need to
be able to initiate difficult conversations with
patients and families. The aim of this study was
to ascertain what methods of communication
nurses use with patients who are nearing the
end of their lives, with a particular focus on
nonverbal communication.
Methodology
Setting and participants
The study was concerned only with the hospice
setting, because of the profile of care that is pro-
vided in hospices. Although nurses in care homes
and hospitals do come into contact with people
nearing the end of life, the relationship between
nurses and patients in these settings is completely
different from that between nurses and patients
in hospices.
The study made use of a questionnaire, which
was sent to five different hospice facilities in
Poland after permission had been granted by the
hospice directors. To be eligibile to take part in
the study, the nurses also had to be fully qualified
and between 21 and 65 years of age. A total of
144 eligible nurses worked at these five hospices,
and all were asked to take part. Forty eight
nurses did not respond to the request, giving a
response rate of 66.7%. The breakdown of the
96-nurse sample was as follows:
27 of 29 nurses (28% of sample) working at
the 37-bed Oncology Hospice Foundation in
Warsaw
27 of 30 nurses (28% of sample) working at
the 25-bed House of Cod's Providence hospice
in Bialystok
17 of 34 nurses (18% of sample) working at
International journal of Palliative Nursing 2012, Vo! 18, No 1
Research
the 41-bed St Lasarus Hospice in Krakow *...proper
16 of 35 nurses (17% of sample) working at communication
the 24-bed Palliative Medicine and Hospice in the
Centre in Trzebnica
9 of 16 nurses (9% of sample) working at the nurse-patient
17-bed Caritas St Tarnw Hospice of Brother encounter
Albert in Dabrowa Tarnowska can have a
therapeutic
Data collection
The research was conducted from March to May
influence on
2011. A questionnaire was created for the pur- patients' health,
poses of the study {Box 1). The questions con- allowing them
cerned the nurses' behaviour and approach to to ... obtain
patients, their thoughts about different forms of
communication, their skills, and their education a sense of
in communication. The survey also collected control over
demographic data on the participants. A question- their health
naire was chosen as the data collection method to condition...*
enable collection from as many participants and
from as many settings as possible.
The majority of the hospices were sent the
questionnaire by post; in Warsaw only it was
handed in personally by the author. Each facility
had a person who took on responsibility for the
study and for asking the nurses whether they
wanted to take part. An introduction on the
questionnaire specified that participation in
the study was voluntary and anonymous. The
questionnaire also defined nonverbal communi-
cationfor the participants (as 'communication
performed by means other than words, e.g. the
tone of voice, body posture, smile, touch, ges-
ture'). The majority of the respondents returned
the questionnaire by post; in Warsaw only it was
collected by the author.
Data analysis
The results are presented as descriptive statistics.
Statistica software (version 9) was used for the
data analysis.
Results
The vast majority of the respondents were female
(91 nurses; 95%>) and most were younger than
50 years of age (81; 84%). Nearly half had
obtained at least a bachelor's degree (45; 47%),
although 34% had only a medical high school
education. The majority of the sample had been
in their jobs for at least 5 years: only 16 of the
nurses (17%) had not. The biggest group of
respondents were nurses who had worked in end-
of-life care from 2 to 5 years (37%); only 31%
had worked in palliative care longer than 10
years. Eighty one (84%) were educated in pallia-
tive care and 21 (22%) had obtained the title of
specialist in palliative care nursingthe highest
specialist nursing degree in Poland.
41
Research
^Nurses need Eighty nine of the respondents (93%) reported
to be aware that they were very or quite satisfied with their
that all jobs. Nearly all of them assessed their relation-
ships with patients positively: 89 (93%) said that
behaviour their relationships were good or very good, and
(verbal or the remaining 6 (6%) said that their relationships
nonverbal; were satisfactory. The majority of the nurses (84;
intentional or 88%) also declared that they did not have any
problems in communication. However, when
unintentional) they were asked who they found it most difficult
is a specific to work with, 24 (25%) replied people who they
form of had met only recently, 25 (26%) said strangers,
and 21 (22%) said patients' families.
communication. '
When asked what percentage of information
is passed on by nonverbal cues, 39 (41%) said
over 50%, which best corresponds to Pease's
(2001) estimation. Almost half of the respondents
(46; 48%) reported that they very often use non-
verbal communication for a definite purpose in
their contact with patients; a further 37 (39%)
reported that they sometimes use it. The forms of
deliberate nonverbal communication that the
sample reported using most frequently were
touch, facial expression, and eye contact.
Eighty nine of the nurses (93%) stated that
they express compassion for their patients in
their everyday nursing practice. The majority said
that they did this through nonverbal cues: 20
(21%) by the holding patient's hand, 20 (21%)
by silently keeping the patient company, 18
(19%) by smiling at the patient, and 9 (9%) by
sustaining eye contact with the patient. Only 22
(23%) expressed compassion for their patients
through verbal contact. In response to the ques-
tion, 'How do you express your anger to
patients?', 62 of the nurses (65%) declared that
they never expressed their anger at work. For
those who did express their anger, avoidance of
eye contact (14 nurses; 15%) and general avoid-
ance of contact with patients (7 nurses; 7%) were
the most common methods.
When asked about the meaning of touch for
the relationship with the patient, the majority of
the participants (74; 77%) chose the option
'holding the patient's hand is helpful in express-
ing emotion'. Almost half thought that the form
of touch that patients appreciate most was hold-
ing hands, one quarter thought that it was shak-
ing hand in greeting, and 17% (16 nurses)
thought that it was stroking.
In the respondents' opinion, nurses smiling has
a very positive influence on patients. It gives
them relief and contentment (33 nurses; 34%),
relieves tension in difficult moments (34 nurses;
35%), and makes them more inclined to hold
conversations (23 nurses; 24%). The respond-
ents reported that the most common patient
42
reaction to seeing nurses smiling was return of
the smile (56 nurses; 58%). With respect to
appearance, over half of the respondents (60
nurses; 63%) claimed that nurses have to care
about the neatness of their uniforms because
patients pay attention to such matters.
Sixty four of the nurses (67%) stated that they
had been educated in communication, and 60
(63%) said that this was specific to communica-
tion in palliative nursing care. Furthermore, 50%
of the nurses (48) would like to attend training
about communication in palliative care. Almost
all of the nurses (90; 94%) felt that such training
was necessary, and only 56% (54 nurses) thought
that nurses' communication knowledge and skills
are satisfactory.
Discussion
The participants being predominantly female and
under 50 years of age is representative of the hos-
pice nurse population in Poland. Similar results
have previously been obtained in a survey of pal-
liative care nurses conducted in Belgium,
Switzerland, and France (Levorato et al, 2001):
in this survey the average age of the participants
was 43 and over 95% were female. In the present
study, 34% of the participants reported having
only a medical high school education. This is not
surprising, as in Poland a university education
has only been compulsory for nurses since 2005.
Over 90% of the respondents claimed to be
satisfied with their job. Job satisfaction is an
important part of any work and has a direct influ-
ence on nurses' relationships with patients and
other members of the multidisciplinary team. In a
survey conducted by the Podhale State Higher
Vocational School in Nowy Targ, and the
Orthopedic-Rehabilitation University Hospital in
Zakopane, among nurses who work with incura-
ble patients the most important factors influenc-
ing job satisfaction were relations with the patient
and their family, and eliminating unpleasant
symptoms of disease (Lyzniecka et al, 2007).
Nurses are the members of the palliative care
team that tend to spend the most time with
patients (Mojs and Glowacka, 2009; Kim, 2011).
Almost every nursing procedure requires that the
nurse make some form of contact with the
patient. According to Moore (2005), successful
communication is indispensable in the provision
of high-quality care at the end of life. The major-
ity of the respondents here reported that they
have no problem communicating with patients.
These results differ substantially from those of a
Brazilian study by Trovo de Araujo and da Silva
(2004), which surveyed nurses who worked with
dying patients in intensive care units. These
International Journal of Palliative Nursing 2012, Vol 18, No 1
 Research

The survey is anonymous and serves exclusively for scientific ainns, therefore I am kindly asking for honest ansv^ers.
The results v^ill help to investigate the use of nonverbal nneans of connmunication between the nursing staff of the
hospice and patients in the terminal phase of disease.

Sex: D Female D Male

Age: D 21-34 years old D 35-49 years old D >50 years old
Education: Q Medical high school D A-level Undergraduate degree D Masters degree
Work-experience: D <S years D 5-10 years D 11-20 years D >20 years
Work-experience in hospice: D < 2 years Q 2-5 years 05-10 years D > 10 years
Palliative care training: Specialist training D Qualification course D Specialist course
Training course G None

1. Are you satisfied with your job?

D Completely Q Fairly satisfied D Fairly unsatisfied D Completely unsatisfied D I don't knov^
2. How do you evaluate your relationship with patients?
D Very good D Good D Satisfactory D Poor D Very poor D Other
3. How much information is transferred via nonverbal means of communication?
D < 10 % D Around 20% D Around 35% D >50% D I don't knov/
4. Do you face any difficulty in interpersonal communication on a daily basis?
D Yes, a lot D Some difficulty D Little difficulty D No difficulty D I don't know
5. Do you have any difficulty connmunicating with patients during your work?
D Yes, a lot D Some difficulty D Little difficulty D No difficulty D I don't know
6. With whom do you find it most difficult to communicate? (Up to three answers, numbered in order of importance)
D Closest relatives D Those recently met D Strangers D Co-workers D Patients
Q Patients' families Q Other
7. What emotions and feelings are nnost often transferred by nonverbal means of communication?
D Positive ones D Negative ones D Neutral D All of the above D None of these D I don't know
8. Have you ever consciously used nonverbal communication for any specific purpose with a patient?
G Yes, very often (what elements?) G Yes, sometimes (what elements?) G Never G Other
9. What kind of information can a nurse communicate to a patient via body posture?
G Willingness or reluctance to approach G Mood G Both of the above G No information
G Body posture has some significance, but only in connection with verbal communication G Other
10. Do you think a nurse should care about looking neat while working?
G Absolutely yes, patients pay great attention to this G Yes, but not by all means
G Not necessarily, patients in hospice have more serious problems than how people look
G No, at work there are no conditions for this G I don't know G Other
11. How do you express your sympathy toward patients most often?
G I stay silent in patient's presence G I talk to them
G I don't show excessive interest because patients do not like it G I hold their hand G I smile at them
G I keep eye contact with them G ' do not show any sympathy G Other
12. How do you show your anger towards patients most often?
G I neither talk to them nor answer any questions G I avoid eye contact G I do things to spite them
G I avoid any contact with them G I pay more attention to other patients G I do not express any anger
G Other...

International Journal of Palliative Nursing 2012, Vo! 18, No 1 43

Research

Box I (part 2). Study questionnaire

13. Have you noticed any changes in patients' approach while raising your voice?
D Yes, information transmitted in this way gets to a patient more easily Yes, the patient is more humble
D The patient gets nervous D The patient gets closed up and is reluctant to talk
D I don't know, I have never tried Other
14.What does touch mean in the relationship between patient and nurse;
D It is only therapeutic (hygiene, injections, changing dressings) D Holding a hand helps to express emotions
Stroking, tapping is a kind of reward for a patient D Slight slapping is a good punishment
I don't know D Other
I S.What form of touch do patients appreciate most?
' D Shaking one's hand good morning D Holding one's hand Stroking D Tapping one's shoulder
D Patients do not like any form of touch D Other
: 16. Do patients with terminal diseases like being held by hand while talking?
D Yes, very much Q Quite a lot D Not much D Not at all Q I don't know D Other
i 17.What does a nurse's smile mean in communication with a palliative care patient?
! n It gives relief and contentment D It releases tension D It makes patient more willing to talk
; n It embarrasses the patient D It offends the patient D It has no meaning D Other
; 18.What are the most common reactions to nurses smiling?
D The patient smiles too Q The patient is more confident D The patient is embarrassed
' D The patient feels offended D The patient doesn't react D Other
19.What kind of company is most demanded by a terminal patient from the nursing staff?
; D Being with the patient D Being with the patient and holding their hand
D Coming round to see and talk to the patient for a while D Frequent conversations and eye contact
D Patients do not like presence of other people D Other
20. Have you ever been trained in interpersonal communication?
n Yes n No n I don't know
21. Have you ever been trained in communication with a patient who is at the end of their life?
D Yes D No D I don't know
22.Would you like to take part in training about communication with terminal-phase patients?
; D Very much so D Quite like to D Rather not D Not at all D I don't know
23. Do you think that such training for nurses is necessary?
' Very much so Quite necessary Not really Not at all I don't know
24. Do you think that nurses have satisfactory knowledge about interpersonal communication?
: n Absolutely yes D Quite satisfactory D Not really D Not at all I don't know

I Thank you very much for completing the survey.

nurses reported that they had difficulties in com-
municating with their patients despite being
aware of the therapeutic benefit of doing so.
Some of them even avoided making contact with
terminally ill patients and their families. The
results of the present study are more in line with
those of Emold et al (2011), who found that the
majority of the oncology nurses they surveyed
reported a high level of self-confidence in their
ability to initiate discussions with patients.
Many of the participants in the present study
reported that they very often use nonverbal com-
munication for a definite purpose in their contact
with patients. Nonverbal communication cues
are an integral part of the patient interaction, and
are often used for making initial contact. They

44 International Jounml of Palliative Nursing 2012, Vol 18, No 1


can come in the form of various modalities, such
as auditory cues, visual cues, touch, and so on.
According to Pease (2001) only 7% of all com-
munication is expressed through words.
Therefore, even if nurses do not talk to terminal
patients they are still communicating with them
through nonverbal cues such as their body pos-
ture, appearance, presence or absence, and their
glance (Trovo de Araujo and da Silva, 2004).
Nonverbal messages can convey both positive
and negative information. The majority of the
nurses questioned here were aware of the types
of information that can be sent by nonverbal
cues, although a substantial percentage (41%)
did not know that research has estimated that
more than 50% of information is transmitted by
nonverbal signals (Pease, 2001).
Over half of the participants claimed that the
appearance of nurses (especially their uniform)
is important because patients pay attention to
what the medical staff look like. A study by
Marc (2000), which was conducted with the
parents of children being cared for on paediatric
wards, offers confirmation of this, as it also
found that the appearance of a nurse has an
influence on the relationship with patients.
Hence, nurses' appearance is a very important
nonverbal cue. Marcinowicz et al's (2010) study
revealed that younger patients and those with
higher education most frequently perceived non-
verbal cues from their GPs during doctor-
patient encounters, and this pattern may also be
true for nurse-patient encounters.
Touch is an indispensable component of the
nursing profession (Michalko, 1996). In the
present study, the participants reported that
the best form of touch from the patients' point of
view is the nurse holding their hand. Sieminska et
al (2003), in their study conducted among patients
on surgical, dermatological, ophthalmic, and gen-
eral wards, revealed that over 80% of the patients
surveyed thought that touch was an important
part of diagnosis, and the majority also thought
that it was an important part of providing sup-
port. The form of touch that the patients most fre-
quently looked forward to was shaking hands. In
Walewska and Klapa's (2003) study among nurses
working in intensive care units, the results showed
that touch mainly has a role in support. Together,
these findings indicate that patients appreciate the
value of touch as a part of supportive care no
matter where they are receiving their care.
According to Jarosz and Pozarowska (2007),
everyone can learn how to communicate. Half of
the respondents in the present study reported a
desire to attend communication training, and
around the same proportion thought that nurses
International Journal of Palliative Nursing 2012, Vol 18, No 1
Research
currently have insufficient communication ^Halfofthe
knowledge and skills. Proper communication respondents
skills are an essential part of nursing (Mojs and reported a
Glowacka, 2009), and in everyday practice they
should be used in interactions with both patients
desire to
and their families as well as the other members of attend
the multidisciplinary team. Furthermore, communication
Fallowfield and Jankins (1999) found that com- training,
munication skills are a significant factor in medi-
cal clinicians' stress, emotional burnout, and lack and around
of job satisfaction. the same
proportion
Limitations
thought
As the respondents were aware that the study
that nurses
was being conducted anonymously, there is no
reason to suspect that the results are not a true currently have
representation of the opinions of the sample. insufficient
Furthermore, a sample size of 96 nurses equating communication
to a response rate of 66.7% means that there is
good reason to think that the results are repre-
knowledge
sentative of the nursing population of the five and skills.*
hospices surveyed. Nevertheless, it is not possible
to state whether the nurses who did not respond
would have shared the opinions of the partici-
pants, and nor can the results be extrapolated to
other hospices within or outside Poland. In addi-
tion, the questionnaire was created for the pur-
poses of the study and has not been validated,
and this will be needed if further studies are to be
undertaken. The presented results only provide
an indication of nurses' opinions about commu-
nication, and it will be important to compare
these with patient assessments of nurses' commu-
nication skills in future studies to confirm the
level of requirement for nursing education in this
area. Finally, it would be necessary to conduct
before-and-after or two-group comparison stud-
ies in order to assess the effectiveness of any
communication training.
Conclusion
Among nonverbal means of communication in
everyday practice, the nursing staff who partici-
pated in the present study most frequently used
touch, facial expression, and visual contact in a
conscious way. They thought that patients most
appreciated having their hand held at difficult
moments. However, although 88% of the sam-
ple reported having no problems communicat-
ing with patients, around half felt that nurses'
communication skills and knowledge were
insufficient and would welcome the opportunity
for further training. Hence, the study findings
indicate that nurses who work with patients
who are at the decline of their lives need to be
better educated in theoretical and practical
aspects of communication. i@i
45
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Correspondence
International Journal of Palliative Nursing welcomes correspondence relating to any of its content,
whether for the Editor's attention only or for publication in the journal.
We also encourage letters on any relevant aspects of palliative care from authors who would like
to communicate with the readership without necessarily wanting to publish a full-length article.
To submit correspondence or discuss the publication potential of a piece, please contact the
Editor, Craig Nicholson: craig.nicholson(markallengroup.com
46
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