Review of the Literature

Creating Immediacy Using Verbal and Nonverbal

Methods
Debra A. Dalonges, RDH; Jacquelyn L. Fried, RDH, BA, MS

Abstract
Purpose: The importance of immediacy and positive relationships between students and teachers is
well-documented. Applying immediacy to the patient/provider model has not been sufficiently explored.
The significance in creating a bond of trust between the patient/provider is vital to the diagnostic and
therapeutic process. As outlined by the National Dental Hygiene Research Agenda, this literature review
supports strategies for effective communication between the dental hygienist and client. It examines the
relationship between oral health care providers and their patients and applies the verbal and nonverbal
cues associated with immediacy to affirm their relevance and effectiveness in educating and motivating
patients to achieve optimal oral and systemic health.
Keywords: immediacy, teacher, verbal communication, nonverbal communication
This study supports the NDHRA priority area, Health Promotion/Disease Prevention: Assess strate-
gies for effective communication between the dental hygienist and client.

Introduction
“Immediacy is defined as the degree of perceived important, than what is said. These cues may influ-
physical or psychological closeness between two peo- ence the outcomes of academic and clinical exchanges.
ple.”1 Social psychologist, Albert Mehrabian, is rec- Kearney et al found teacher immediacy was the most
ognized for defining the concept of immediacy which powerful predictor of students’ reported willingness to
states “people are drawn toward persons and things comply with teacher requests.3
they like, evaluate highly, and prefer; and they avoid
or move away from things they dislike, evaluate nega- Consistent with the results of instructional commu-
tively, or do not prefer.”2 Immediacy encompasses ver- nication, patients who view physicians as immediate
bal and nonverbal communication techniques that can report being less fearful and generally more satisfied
be applied across multiple settings. Reducing stress with the medical care they receive.4 Interpersonal at-
and establishing a rapport with clients requires inte- tractiveness, the degree to which others respond posi-
grating the finesse of an educator and compassion of a tively toward one another, can be improved by using
quality clinician. Educators use immediacy techniques immediacy behaviors. Clinicians wishing to employ
to educate their students; these same methods can be the behaviors of immediacy should explore both ver-
applied in a clinical setting. Like academicians, den- bal and nonverbal techniques and ways to ensure their
tal hygienists rely on finely honed verbal and nonver- congruence. Simple acts such as maintaining eye con-
bal communication skills to impart health education tact when communicating, gently patting a patient’s
information to motivate and educate patients in oral arm for reinforcement and speaking with a gently non-
and systemic health. Dental hygienist, as skilled and threatening tone are some of the ways to achieve im-
knowledgeable clinicians must utilize communication mediacy. Conscious application and diligent learning of
skills that build patient trust and confidence and that both verbal and nonverbal communication strategies
convey their skills and knowledge. Desired traits as- may help to improve health education outcomes.
sociated with verbal immediacy include self-disclosure,
humor, tone, reference to another’s positive traits and Nonverbal Immediacy Behaviors
discourse regarding commonalities. Principle nonver-
bal cues associated with immediacy include empathic A part of all communication are nonverbal behaviors.
listening, facial migration (showing expression), smil- These behaviors include kinesics, (the study of body
ing, gaze orientation, physical appearance and touch- movements when communicating), gestures and facial
ing. expressions, proxemics (the nature, degree and effect
of the spatial separation individuals naturally main-
By means of nonverbal and verbal communication tain), olfaction, skin sensitivity, the use of artifacts,
strategies, a dental hygienist can enhance interac- physical characteristics, eye movement, touching be-
tions and encourage clients to express their concerns. havior, and environmental factors.5 Facial expressions
Nonverbal cues can be equally important, if not more and gestures include bodily contact, physical appear-
Vol. 90 • No. 4 • August 2016 The Journal of Dental Hygiene 221
ance, and the direction of gaze. Nonverbal behaviors Good communication is of paramount importance
include the paralinguistic variables of emotional tone, for effective patient outcomes. Smiling can enhance
timing and accent. Teachers who convey verbal caring interactions between patients and health care workers.
messages in combination with nonverbal caring cues A qualitative study explored oncology patients’ percep-
are rated by their students as more credible.6 Some tions of how healthcare providers conveyed positive
researchers believe that nonverbal behaviors are more communication. Characteristics deemed positive were
effective at communicating immediacy than verbal be- helpfulness, approachability and smiling.16
haviors. Approximately 93% of interpersonal attitude
is communicated nonverbally.7 Nonverbal cues are Gaze Orientation
often innate and may sometimes contradict a verbal
message. One who has a proficient knowledge of non- Every clinical encounter allows the possibility for eye
verbal behaviors can effectively transmit a controlled contact to build immediate rapport between the clini-
nonverbal message. cian and patient. A gaze may be comforting if it intensi-
fies a pleasant situation, and it can open communica-
Empathetic Listening tion in an uncertain one. Conversely, failure to look a
patient in the eye causes the patient to feel like a body
Listening effectively to others offers personal time, and not a person, creating a process of dehumaniza-
psychological presence, cognitive attention and emo- tion commonly seen in medical settings.11 Open-mind-
tional response, all valuable interpersonal resources. ed people face the person to whom they speak, stand
Expending the energy to listen to someone is theorized close to the other person and maintain eye contact.5
as an expression of affection. Empathic listening re-
sults in the receiver feeling validated and understood.8 Physical Appearance
Empathy is a required element in effective doctor-
patient relationships.9 A study was performed analyz- The first form of nonverbal communication relates
ing empathy and clinical competency with 57 medical to physical appearance. Appearance can be used when
students. Clinical interactions and displays of empathy developing judgements about people based on their
were rated by an independent observer. Results indi- looks, what they wear and their level of attractive-
cated that empathy can be related to high levels of ness.17 Physical appearance applies to attire, hairstyle,
clinical capability and favorable patient outcomes.10 grooming and accessories. Perceived professionalism,
including suitability, competence, ease of conversa-
Facial Expression tion and friendliness of professionals is suggestively
influenced by the choice of dress style worn for work.18
The human face is highly expressive and is often Research suggests a patient’s preference is for profes-
the object of attention.11 Mehrabian suggests that 55% sional attire in dentistry. In one study of 586 subjects
of interpersonal communication occurs through facial they experienced a greater willingness to share per-
expression alone.2 A dental hygiene clinician’s expec- sonal information with those who wear the identifiable
tations often are clearly communicated through facial and trusted white coat.19
expression. Through proper training and motivation,
clinicians can effectively communicate sympathy and Touch
understanding, or a positive outlook and expecta-
tions.11 Touch improves communication quality and dem-
onstrates empathy. Touch is often culturally regulated
Smiling in professional settings.17 A qualitative study of both
patients and general practitioners (GPs) conducted in
Smiling, as a facial expression, has been studied ex- England showed the value that each of these groups
tensively.12-14 Smiling is an important aspect of nonver- attributed to touch. The study demonstrated that
bal communication and has been correlated with lik- touch increases the warmth felt, and establishes the
ing, affiliation an immediacy.1 A smiling person may be connection between doctor and patient. Touching pro-
perceived as more trustworthy and honest. In a case of vided the patient with a feeling of warmth increasing
academic misconduct, students were given a summary the connection to the doctor. GPs in the study stated
of evidence and a photograph of the accused student that touching is “a human thing to do” and they felt
displaying different facial expressions such as a neutral that touch should be appropriate.20 Avoiding concerns
expression, a felt smile, a false smile or a miserable about intimacy is critical but the patient responders felt
smile. Smiling targets although not seen as less guilty touch on the hand or forearm was appropriate.20
received more leniency than non-smiling targets. The
study revealed that smiling targets are considered Verbal Immediacy Behaviors
more likable, submissive, diplomatic and trustworthy.
It appears that a smile can be an effective and positive Verbal immediacy refers to the stylistic choice of
immediacy tool for achieving leniency.15 verbal expressions that educators employ. Effective
verbal communication helps receivers feel valued and
222 The Journal of Dental Hygiene Vol. 90 • No. 4 • August 2016
important. Students may develop either a like or dis- fluency with effective pauses.27 Woolbert provided one
like for their teacher based on their display of immedi- of the earliest empirical studies of vocal communica-
acy during verbal communication.21 Oral health educa- tion showing that variety in tempo, force and pitch
tors who use verbal behaviors to encourage immediacy contribute to higher retention and learning of materi-
may make their patients feel valued and important. al.28 Imhof isolated vocal pitch to test how this variable
Exceptional educators are not remembered because of impacts listeners’ judgments of the people speaking.25
an interesting lesson, but by how they made the stu- Results showed that low pitch makes a difference in the
dent feel. Verbal immediacy tools like self-disclosure way a person is perceived.25 Negative teacher evalua-
and using humor convey humanness. Verbal immedi- tions are closely related to teachers with a monotone
acy behaviors are displayed by signaling warmth and voice, a speech pattern that works against a teacher’s
a willingness to connect to the receiver of a message. efforts to stimulate student attention.28 A monotone
An example of effective verbal communication occurs voice can reduce a patient’s comprehension of mate-
when professionals urge patients to express their feel- rial delivered orally.29 Full comprehension is especially
ings about their oral health by simply encouraging their important to motivate and help patients change be-
questions. haviors to achieve optimal oral health.

Self-Disclosure Application of Immediacy Principles

Self-disclosure is deliberate sharing of personal in- When applying the principles of immediacy, both
formation to help establish relationships of trust. Re- verbal and nonverbal communication behaviors can be
vealing motives, intentions, goals, values, and emo- combined.21 Whether discussing an individual’s health
tions, increases liking and feelings of immediacy.22 status or educating students, messages are trans-
Skillful self-disclosure can humanize a person, creating mitted via two types of communication: explicit and
connections that increase feelings of trust and intima- implicit. Explicit messages carry the content; implicit
cy. Disclosure can increase a readiness to work collab- communication conveys emotions and feelings.21 Ex-
oratively to reach mutual goals. Students considered plicit messages are fundamentally verbal, while implicit
teachers effective when they displayed caring through communications are primarily nonverbal.21 Of the 7%
self-disclosure.22 of verbal communication, Mehrabian found that 38%
happens through voice tone and 55% happens via
Humor general body language.2 When forming immediacy re-
lationships with patients, clinicians must consider all
Considerable research examined an instructor’s use acts of verbal and nonverbal communications.
of humor and resultant learning outcomes.23-25 The use
of humor has been described as an important element Advantages of Immediacy
for improving student interest and attention during the
learning process. When students are interested, they Immediacy displays warmth and improves interac-
enjoy the learning process.24 Humor can help students tions and relationships. Patient interactions are hu-
feel more comfortable, relaxed and more likely to learn man experiences that create a relational link. Effective
and develop a bond with the teacher; however, if hu- communication is a vehicle through which patients’ in-
mor leads to sarcasm and criticism, intimidation may volvement is optimized. A correlational study of nurses
occur.25 In a classroom setting, humor can have both and patients revealed that the strength of their bond
positive and negative effects.25 facilitated positive outcomes of care and enhanced pa-
tient satisfaction.30 Fostering and strengthening den-
Humor, integrated into the clinical setting, creates tal hygienists’ bonds with their patients could produce
a tone of openness and respect between clinician and similar results.
patient. A study by Fovet states that the positive ef-
fects of humor include the release of endorphins and Relating educational principle of immediacy, Velez
tension reduction during communication. Humor can and Cano studied the association between student
have a holistic benefit by creating a natural connection motivation and teacher immediacy. Their survey found
with patients. Humor appears to promote an intimate that to increase student motivation via verbal and non-
connection between nurses and patients. This connec- verbal cues, the instructor needs to exercise care and
tion may result in more comforting and compassionate consistency. Exhibiting positive, encouraging gestures
care.26 were recommended.5 Expectations for success are en-
hanced through a combination of constant, positive,
Vocal Behavior and supportive verbal and nonverbal communication.20

Vocal cues convey certain personal characteristics Disadvantages of Immediacy

and attitudes. Six specific vocal qualities may directly
affect one’s ability to be a persuasive speaker: volume One distinct disadvantage of immediacy is that cues
control, rate of speech, use of pitch, articulation and can be misinterpreted as intimate. Being warm and
Vol. 90 • No. 4 • August 2016 The Journal of Dental Hygiene 223
friendly in a social environment may be acceptable the development of trust between the patient and
and encouraged. Similar communication traits may not the clinician, creating pathways conducive to learn-
be considered suitable in certain professional environ- ing and motivation. Oral health providers continually
ments. The perception that one is not immediate has communicate to patients through body language,
more dire consequences than counterproductive im- gaze, and facial expressions; therefore, care must
mediacy.1 With practice, one can become familiar with be exercised to portray positive and caring gestures.
the immediacy degree necessary and appropriate for A combination of productive verbal and non-verbal
conveying professional messages required in the clini- patterns will benefit educators, students, health care
cal setting.1 providers and patients. Although he concept of im-
mediacy has been studied in education and nursing,
Conclusion further research relating to interactions between oral
health care providers and patients is necessary.
Communication skills, verbal and nonverbal, are
essential to successful educator/clinician encounters Debra A. Dalonges, RDH, BS, is employed at
with patients. As oral health professionals seek new Crosskeys Dental Associates in Baltimore, Maryland.
and innovative ways to motivate and engage the Jacquelyn L. Fried, RDH, BA, MS, is an Associate Pro-
dental patient in oral self-care, clinicians must con- fessor and Director of Interprofessional Initiatives,
sider the positive effects of immediacy. Successful University of Maryland School of Dentistry.
and meaningful professional encounters require ef- Acknowledgments
fective communication between the patient and the
clinician. Developing approaches that improve com- I would like to thank Sheryl Syme, RDH, MS, As-
munication allows the clinician to build trust, promote sociate Professor and Director, Degree Completion
healing, and ultimately improve health outcomes. Program of the University of Maryland for their in-
Specific communication skills to motivate patients tegral roles and expert advice and encouragement
to achieve optimal oral health are critical. Sending throughout this project. A thank you to my friend,
a supportive and caring message will contribute to Wendy King-Herker, for her support and guidance.

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