Culture and Nonverbal Expressions of Empathy in Clinical Settings - A Systematic Review

Accepted Manuscript
Title: Culture and Nonverbal Expressions of Empathy in

Clinical Settings: A Systematic Review
Author: Aine
Lorie Diego A. Reinero Margot Phillips Linda
Zhang Helen Riess M.D.
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DOI:
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http://dx.doi.org/doi:10.1016/j.pec.2016.09.018
PEC 5466
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Patient Education and Counseling
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10-12-2015
22-7-2016
23-9-2016
Please cite this article as: Lorie Aine,

Reinero Diego A, Phillips Margot,
Zhang Linda, Riess Helen.Culture and Nonverbal Expressions of Empathy
in Clinical Settings: A Systematic Review.Patient Education and Counseling
http://dx.doi.org/10.1016/j.pec.2016.09.018
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Culture and Nonverbal Empathy in Clinical Settings
Culture and Nonverbal Expressions of Empathy in Clinical Settings:

A Systematic Review
ine Lori*1, Diego A. Reinero*1,2, Margot Phillips1, Linda Zhang1, Helen Riess1
Corresponding Author: Helen Riess, M.D., Empathy and Relational Science Program,
Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School. Wang
Ambulatory Care Center, Suite 812, 15 Parkman Street, Boston, MA 02114.
(hriess@mgh.harvard.edu) T: 617-724-5600. F: 617-726-7451
[* Equal author contribution]
1
Massachusetts General Hospital/Harvard Medical School, Empathy and Relational Science Program, Department of
Psychiatry, Boston, MA
2
New York University, Department of Psychology, New York, NY, USA

Highlights:
Nonverbal behaviors can convey culturally specific meaning in the clinical setting
Discordant patient-physician race is linked with impaired information exchange
Implicit bias emitted nonverbally negatively impacts communication and outcomes
Training in identifying culturally-specific nonverbal behavior is suggested

Abstract
Objective: To conduct a systematic review of studies examining how culture mediates nonverbal
expressions of empathy with the aim to improve clinician cross-cultural competency.
Methods: We searched three databases for studies of nonverbal expressions of empathy and
communication in cross-cultural clinical settings, yielding 16,143 articles. We examined peerreviewed, experimental or observational articles. Sixteen studies met inclusion criteria.
Results: Nonverbal expressions of empathy varied across cultural groups and impacted the
quality of communication and care. Some nonverbal behaviors appear universally desired and
others, culturally specific. Findings revealed the impact of nonverbal communication on patient
satisfaction, affective tone, information exchange, visit length, and expression decoding during
cross-cultural clinical encounters. Racial discordance, patients perception of physician racism,
and physician implicit bias are among factors that appear to influence information exchange in
clinical encounters.
Conclusion: Culture-based norms impact expectations for specific nonverbal expressions within
patient-clinician dyads. Nonverbal communication plays a significant role in fostering trusting
provider-patient relationships, and is critical to high quality care.
Practice Implications: Medical education should include training in interpretation of nonverbal
behavior to optimize empathic cross-cultural communication and training efforts should
accommodate norms of local patient populations. These efforts should reduce implicit biases in
providers and perceived prejudice in patients.

INTRODUCTION
There is critical need for health care providers to offer culturally competent empathic care [1-3].
Increasing diversity in patient populations and the healthcare workforce can generate crosscultural misunderstandings, contributing to increased medical errors, lack of trust and adherence
to treatment [4-7], and decreased patient satisfaction [8-10]. The U.S. confirms this multicultural
trend, reporting that by 2043, no individual racial group within the U.S. will make up a majority
[11]. In spite of increasing global diversification [12, 13], medical trainees are not adequately
prepared to provide cross-culturally competent care [14]. In-group biases (the effect wherein
people give preferential treatment to others who are perceived to be in the same group) arise in
cross-cultural contexts [15-18] and often disproportionally affect minorities, leading to
disparities in treatment, healthcare access, and health outcomes [19-23]. Indeed, a previous
literature review of cultural differences in medical communication found that clinicians are more
verbally dominant and behave less affectively (e.g., less rapport-building, friendly, or concerned)
when interacting with ethnic minority patients compared to White patients [24]. Therefore,
competence in cross cultural communication is becoming increasingly critical in practices and
policies of health services, with a corresponding need to train medical personnel in these skills to
improve the quality of care and patient outcomes [25].
Empathy, a capacity that includes cognitive and affective components enabling individuals to
perceive and respond to verbal and nonverbal emotional cues of others [26] is a key component
of effective cross-cultural care [9, 20, 26-38]. Empathy is expressed both through verbal and
nonverbal behavior [39], and nonverbal behavior (NVB) is estimated to account for 60%-90% of
communication [40]. The importance of nonverbal empathy in clinical encounters has been

highlighted in previous work [41-47], suggesting that clinician warmth and listening results in
greater patient satisfaction [48], and that specific NVBs, including head nodding, forward lean,
direct body orientation, uncrossed legs and arms, arm symmetry, and mutual gaze, are associated
with positive health outcomes [49]. Providers who are more sensitive to nonverbal cues reinforce
the perception of physician sincerity, dedication, and competence, which in turn improves
utilization of health services, functional status, and the overall provider-patient relationship [50].
Although existing medical, psychological, and sociological literature abounds with research that
examines gaps in cross-cultural communication, in-group bias, and the need for cultural
awareness and training [51-55], there is little research integrating cross-cultural differences and
patient-clinician NVB [56-61]. One study that focused on the verbal exchange between patients
and clinicians reported difficulty in reliably detecting NVB as such expressions can be
communicated vaguely, downplayed or masked, and veiled by language barriers [62].
Levine and Ambadys (2013) review examined the influence of nonverbal behavior on racial
disparities in healthcare. The findings suggest that through both historical minority group
derogation and clinician disengagement, patient distrust can arise. Moreover, negative
stereotyping, and culturally-bound nonverbal expectations obstruct nonverbal communication
and engagement in cross-racial patient-clinician encounters [61]. However, this previous review
was not systematic and focused primarily on White doctors and African American patients, thus
limiting the scope and generalizability of its findings. Our systematic review expands on Levine
and Ambadys work (2013) by broadening the cross-cultural context, and systematically
examining a wider range of groups that report culturally specific practices of NVB in healthcare.

Culture has been defined as a learned system of knowledge, attitudes, beliefs, behaviors, values,
and norms that is shared by a group of people, community, kin, or nation [63]. Our systematic
review is guided by the following research questions: 1) Are nonverbal expressions in the
clinical setting culturally specific or universal? 2) If culturally specific, in what ways does
empathic NVB in the clinical setting differ cross-culturally? 3) What are the effects of empathic
cross-cultural NVB on patient outcomes? An examination of these questions will reveal some of
the complexities of cross-cultural nonverbal communication and empathy, and may subsequently
offer solutions to improve provider training, clinician cross-cultural competency, and the
reduction of disparities. Our systematic review will conclude with practice implications and
recommendations for future research.
METHODS
We searched MEDLINE, PsycINFO, and CINAHL from 1990 through September 18, 2014. An
example of our electronic search strategy (MEDLINE) is outlined in Appendix A (PsycINFO
and CINAHL search strategies available upon request). The electronic search strategy required
that articles: (1) be written in English and published in a peer-reviewed journal; (2) include in the
title or abstract at least one word related to culture (e.g., race, ethnicity, immigrant, crosscultural), clinician-patient communication (e.g., empathy, nonverbal, patient centered) and a
clinical setting (e.g., hospital, clinic, primary care). For the review by hand, the inclusion criteria
were: (1) experimental or observational studies with adults (age 18) and 10 subjects, written
in English and published in a peer-reviewed journal; (2) clinician-patient interactions addressing
health problems; (3) an analysis or discussion of cultural components; (4) an analysis or
discussion of clinician-patient NVB communication. Studies were excluded if: (1) not all four of

the inclusion criteria were met; (2) the patients had severe psychiatric, neurologic, or facial
impairments obstructing communication; (3) the health problems discussed were addressed
through non-traditional medical practice, (4) translators were the main focus of the study. For
full criteria, see Appendix B. Limitations are presented after the Discussion.
Our electronic search yielded 16,143 articles (MEDLINE: 8,709; PsycINFO: 3,079; CINAHL:
4,355). Removing duplicates yielded 16,025 articles. For the initial review, two pairs of authors
each independently reviewed half of the titles. A fifth author resolved disagreements between
reviewer-pairs (99% reviewer-pair agreement). Articles were included for the next round of
review if the title incorporated at least two of the three main content criteria (culture,
communication, clinical) and appeared relevant to the studys goal. This process yielded
1,040 articles.1 The second round of review examined the abstracts of these remaining articles,
again with two pairs of authors each reviewing one half of the results. Articles were included if
the abstract included all three content criteria. A fifth author resolved disagreements between
reviewer-pairs (95% reviewer-pair agreement). This yielded 116 articles. This new total included
two additional articles that were hand selected from the reference list of informative reviews.
The final round examined the full text of each article. Authors made independent judgments as to
whether the article met inclusion/exclusion criteria with particular focus on quality of nonverbal
communication measured. Disagreements were resolved by face-to-face discussion of four
Although this article selection process is common for systematic reviews, we nevertheless
performed a sensitivity check on 100 randomly selected results that had previously been
excluded (on the basis of the initial title review by two authors) and systematically reviewed the
abstracts of each of these articles. This sensitivity check confirmed that none of the 100 articles
met our inclusion criteria and provides evidence that our study selection process is indeed robust.
7

authors, leading to consensus judgment. Sixteen articles met our inclusion criteria. This selection
process adhered to PRISMA guidelines and is illustrated in Figure 1.
(Insert) Figure 1. Flow Chart of Study Selection Process.
RESULTS
The systematic review yielded 16 studies (Table 1). Eleven studies were conducted in the United
States; other locations included Canada, Slovenia, Sweden, Australia, and Trinidad and Tobago.
Six studies examined White Americans and African Americans [64-69]; other cultural groups
studied were Australian Aboriginals, Brazilians, Filipinos, South Asians, and Hispanics. Six
studies assessed scenarios in which the patients belonged to a minority culture and clinicians
belonged to the dominant culture [67, 68, 70-73] , and five studies examined combinations of
patients and providers in both majority and minority cultures [64-66, 69, 74]. By contrast,
four studies examined scenarios in which the providers belonged to a minority culture [75-78],
for example internationally educated nurses or physicians (from countries such as the Philippines
(39 total), India (11 total), China (5 total), Korea (3 total), Jordan (1 total), Lebanon (1 total),
Nigeria (1 total), and Kenya (1 total)). One study examined providers NVBs within the
majority culture [79].
The methods of data analysis varied across the included studies. There were nine quantitative
studies and seven qualitative studies. One study was a randomized controlled trial [68]; eight
were cross-sectional. Three studies used the Roter Interaction Analysis System (RIAS) to code

physician and patient behaviors during clinical encounters [67-69]. Seven studies reported
acceptable inter-rater reliability. Sample sizes of quantitative studies ranged from 52 to 458. The
seven qualitative studies were based on semi-structured interviews or focus groups, and their
sample sizes ranged from 10 to 48.
Patient and physician age and gender were reported in all of the quantitative studies. Factors
inconsistently reported were number of years in host country, level of education, language
proficiency, and use of interpreters. Mood or mental state was assessed in two studies [66, 68].
Clinical specialties included primary care clinics (5 studies), hospitals (5 studies), specialty
clinics (2 studies), nursing home (1 study), medical school (1 study), nursing school (1 study),
and community center (1 study). Care providers of different specialties and level of training were
studied, including: general providers (3 studies), physicians (8 studies), nurses (2 studies),
medical students (1 study), nursing students (1 study), and nursing home caregivers (1 study).
Main Findings
Findings of nonverbal behaviors influencing empathic cross-cultural care can be grouped into
two main categories (Table 2). We focus on quantitative studies demonstrating changes in
patient or clinician NVBs in cross-cultural clinical encounters and their outcomes. These include
patient satisfaction, affective tone, information exchange, visit length, and expression decoding.
Main findings and recommendations from qualitative studies that demonstrate cultural
preferences for specific NVBs as part of empathic care are presented in (Table 2).

Patient satisfaction. Physician concern, communicated nonverbally, correlated with patient
satisfaction in several studies [65, 66, 68, 72, 74]. Aruguete et al. showed that physician
nonverbal concern, irrespective of patient or physician race, was the best predictor of patient
satisfaction (p < .001) and positive physician recommendation from the participant (p < .001)
[65]. When the physician displayed positive emotion, made eye contact, and appeared attentive,
physician race was not correlated to participants' evaluations [65]. In another study, poorer
decoding of South Asian patients facial expressions (regardless of physician race) was
correlated with lower visit satisfaction and lower likelihood of adhering to a physicians
recommendations [74]. Similarly, high levels of perceived racism among AA patients interacting
with White physicians were associated with low patient ratings of warmth and respectfulness
(OR= 0.19, 95% CI= 0.05, 0.72) [67]. Cooper et al. showed that higher rates of physician
implicit race bias in racially discordant dyads were correlated with AA patients poorer ratings of
patient care (e.g., AA patients were less likely to feel that the doctor respects the patient (50.2%
vs 34.9%, p = 0.001), were less likely to report liking the physician (46.6% vs 32.7%, p < .001),
and less likely to recommend the physician (47.3% vs 34.4%, p = 0.001)). Values for trust,
feeling the physician likes him or her, and having confidence in the physician were not
significant [66].
Affective tone. Changes in the affective tone (tone of voice, warmth, or responsiveness) of
patients and clinicians during cross-cultural clinical encounters were found in several studies.
Johnson et al. found that both the patient and physician showed significantly less positive affect
during visits with AA patients as compared with White patients (patient positive affect: p < .001;
physician positive affect: p < .02) [69]. Stepanikova et al. found that nonverbal communication
10

in concordant AAAA dyads was more positive, as indicated by more smile, touch, and open
body position, compared to communication in any other racial combination [64].
Cooper et al. found a significant association between physician implicit bias as measured on an
Implicit Attitude Test (IAT) and patient positive affect, where AA patients were less likely to
demonstrate positive affect (as observed by coders) as compared to encounters with physicians
without implicit race bias (p = .04). Higher levels of physician implicit race bias were
significantly associated with greater clinician verbal dominance, lower patient positive affect,
and poorer ratings of interpersonal care among AA patients [66]. Implicit bias also correlated
with significantly higher ratings of physician positive affect during visits with White patients, but
there was no significant change in positive affect among White patients. Similarly, Hausmann et
al. found that encounters in which patients reported high levels of perceived racism had a
significant negative association with coder ratings of nonverbal provider positive affect (B = 0.34, 95% CI= -0.66, -0.01) and with patient positive affect (B= -0.41, 95% CI= -0.073, -0.09)
[67].
Havranek et al. [68] further explored how race influences communication in race-discordant
clinical encounters. In a randomized controlled trial of the effects of a values affirmation
exercise (validation of patient self-worth and concerns) given prior to clinic visits, coder ratings
of warmth/friendliness and interactivity were significantly higher in the intervention group,
whereas ratings of depression/sadness and distress were significantly higher in the control groups.
Information exchange. Racial discordance, patients perception of physician racism, and
11

physician implicit bias are among factors that appear to influence information exchange in
clinical encounters. In Havranek et al., AA patients randomized to receive values-affirmation
training prior to their clinic visit gave and asked for significantly more information about their
medical condition than the control group (p = .03) [68].
In racially discordant dyads, physicians were more verbally dominant (p < .001) and less patientcentered (p < .05) with AA patients than with White patients [69]. Physicians with higher rates of
implicit bias predicted significantly more clinician-dominated exchanges irrespective of patient
race: (p < 0.05, and p < 0.01) [66, 69]. High levels of perceived racism among AA patients were
negatively associated with patient ratings of ease of communication (OR= 0.22, 95% CI=0.07,
0.67) [67]. Perceived racism among White patients was negatively associated with patient ratings
of visit informativeness (OR= 0.4, 95% CI= 0.23, 0.71), but not among AAs [67].
Visit length. Findings for visit length varied. Visit length remained the same despite significant
improvements of information exchange after patients received values affirmation training in
Havranek et al. Ratings of physicians rate of speech, verbal dominance, and patient centeredness
did not differ significantly between the intervention and control groups [68]. In another study,
higher levels of physician compliance stereotyping (a measure of the implicit association
between race and the concept of the compliant patient) were associated with longer visits,
slower speech, less patient centeredness, poorer ratings of interpersonal care and lower ratings of
patient positive affect among AA patients [66]. In contrast, Johnson et al. showed no difference
in speech speed or visit duration when medical visits between AA or White patients were
compared [69].
12
Expression decoding. One study of physicians ability to identify nonverbal emotional cues
across races was included in our review [74]. South Asian physicians were no better at decoding
facial expressions or vocal tones of South Asian or Caucasian patients than Caucasian physicians.
Physicians, regardless of their ethnicity, were more accurate at rating Caucasian patients facial
expressions and vocal tones than South Asian faces and voice tones. Therefore, assumptions
cannot be made regarding greater attunement to NVB between similar groups, as the accuracy in
NVB decoding appears to be related more to the influence of the dominant culture.
Cultural preferences for NVBs: qualitative studies. The qualitative studies included in our
review revealed explicit patient preferences and expectations for certain NVBs as part of
empathic care. [70-73, 76-78]. They are summarized in Table 2.
DISCUSSION
Our systematic review results indicate that nonverbal expressions of empathy are essential
components of cross-cultural clinical competency and quality care. However, optimal expression
of empathic NVB can vary across cultural groups, especially in culturally diverse clinical
settings. It appears that culture mediates nonverbal empathic expression on several levels,
including race, nationality, gender, and occupation [64, 66, 67, 69, 71, 74, 79]. Greater attention
to and skill with interpreting and expressing NVB across such cultural groups can improve the
provider-patient relationship and help to diminish disparities in quality of care. Several theories
inform the interpretation of our findings, discussed below.
13

Emotion expression: Cultural equivalence or cultural advantage model?
Extensive research suggests that the expressions of six basic emotions (happiness, sadness, anger,
fear, disgust, and surprise) are universal [80]2, though members of the same national or ethnic
group may be more able to identify these facially-expressed emotions [82]. There has also been
debate as to whether empathy, which encompasses the detection and expression of a broad range
of emotions, is a capacity that can be expressed and understood universally (cultural equivalence
model) or is subject to cultural norms (cultural advantage model) [58]. This raises the concern of
whether specific nonverbal expressions of empathy may be universally interpreted or culturally
dependent. For example, culturally determined power and status dynamics may drive certain
expectations of nonverbal deference to authority figures, such as reduced or avoidance of direct
eye contact with physicians. Such culturally dependent expectations of behavior, as revealed
through NVB, may become more pronounced in cross-cultural patient-clinician encounters,
risking further miscommunication within and between different cultural groups. These
communication missteps may discourage patient participation, reduce shared decision-making
and diminish patient-centered care, which could negatively impact the quality of care and
ultimately, healthcare outcomes.
Cross-cultural considerations of nonverbal empathy

1) Race
Whereas this reviews search terms aimed to capture a broad representation of cultural groups
our search yielded a predominance of American reports that focused on race as the cultural
variable of interest in the patient-clinician encounter. This emphasis on race may reflect
Also see [81] Barrett LF. Are emotions natural kinds? Perspect Psychol Sci. 2006;1:28-58.
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perceived racial bias in the U.S., belying a lengthy historical context of minority group
oppression. Nonetheless, cross-racial communication issues may also extend to other crosscultural communication contexts, particularly those focusing on group prejudices.
Race plays a role in physicians NVB and its influence is best understood when physician race
and patient race are considered jointly [64]. One study showed that AA physicians exhibited
more positive NVB with AA patients than White physicians, in contrast to mixed positive and
negative signals found between AA physicians interacting with White patients [64]. These
findings suggest that NVB exists at both conscious and unconscious levels of awareness. In
another study, high levels of perceived past discrimination by AA patients were correlated with a
perceived lack of White physicians positive affective tone and overall worse care [67]. This
implies that clinicians working with discordant groups should be especially aware that past
experiences of discrimination could influence how patients perceive the clinicians nonverbal
displays.
2) Nationality
Differences in empathic nonverbal expressions were shown across cultural groups [64-68, 73, 74,
79, 83]; however, each cultural group valued and/or employed positive nonverbal signals. Some
studies indicated that particular cultural groups have preferences for specific nonverbal
expressions (e.g., gaze and proximity) that are context dependent [70, 72, 73, 77]. Western
physicians must take caution in cross-cultural contexts not to misinterpret acts of nodding or
silence as signs of mutual understanding as these patient expressions could instead be masking
confusion or suppressing emotions [71]. Missing or inaccurately decoding such NVB in a cross-
15

cultural context may overlook patients physiological and psychological distress and could also
decrease clinicians diagnostic acumen.
Specific NVBs, such as eye contact, may also have various meanings. For example, a Filipino
Canadian community voiced preference for more direct eye contact from providers, especially if
the provider is giving instructions [73]. This same group also cautioned against the use of
lowered eye contact, which can symbolize respect or shame depending on the context, as well as
head-to-foot gaze, which could be interpreted as demeaning [73]. However, in direct contrast, a
study with Caribbean medical students cautioned against the use of direct eye contact with some
Caribbean elderly as this could be interpreted as a sign of disrespect [77].
In multiple studies, open body posture was assessed [64, 65, 75, 77, 79] and associated with
patient ratings of clinician warmth and overall care. Proximity to the patient was generally
viewed as empathic (e.g., Brazilians preferred closer proximity and warmth), although Williams
et al. noted certain constraints by gender and age in Caribbean cultures (Table 2). These nuanced
results further highlight that although training is often shaped by the dominant culture, it should
actually be tailored to the norms of the local population. Therefore, a providers use and
awareness of specific NVB should be aligned with the specific cultural norms of patients to
enhance both information exchange and patient satisfaction.
3) Gender and occupation

NVB can vary according to gender and profession of the provider, however differences in NVB
by gender and occupation are largely unexamined variables in the cross-cultural clinical context,
16

and here we report preliminary findings. Zaletel et al. examined the frequency of NVBs in
Slovenian nursing homes and found that male caregivers3 exhibited more negative NVBs
(e.g., dropping the eyes, refusing by head shaking, frowning, staring, making grimaces)
than female caregivers. Non-physician professional staff exhibited positive NVBs (e.g.,
making eye contact, smiling, raising the eyebrows, nodding) significantly more frequently
than non-professional helpers [79]. Additionally, gender differences were noted in which
female caregivers demonstrated mixed nonverbal patterns with their male patients [79].
Stepanikova et al. found that female physicians delivered highly positive nonverbal messages
using smile and gaze but at the same time, their body position was more closed, suggesting a
lack of social ease [64].
Studies of internationally educated nurses and physicians found that NVBs served both as
barriers and compensatory strategies for empathic clinical care. Xu et al. [75] found that
internationally educated nurses in the U.S. used therapeutic touch less frequently and were
perceived as less warm by U.S. raters. The cultural norms regarding touch are particularly
important to understand, as touch could be perceived as dominating or controlling, or as an
expression of warmth and caring depending on the cultural group or cross-cultural context. In
contrast, studies of internationally educated clinicians [76, 78] reported that clinicians attempted
to compensate for language gaps by using more touch and emphasizing gestures, eye contact,
smile, and friendliness to convey care.
The group of 267 caregivers (27 men, 240 women) consisted of three groups: nursing staff
(graduate nurses and nurse assistants), social helpers (auxiliary personnel), and other nonphysician professionals (physiotherapists, occupational therapists, social workers).
17

Intergroup and implicit bias
In addition to racial and ethnic differences, the patient-clinician relationship may be regarded as
an intergroup interaction as there is an inherent power differential in the patient-clinician
relationship due to the clinicians medical knowledge and experience, and the patients
subordinate role of seeking medical advice. The power differential within the patient-clinician
relationship or the concept of professional dominance [84] can also be affected by various
cultural factors, including nationality, socio-economic status, race, gender, and age. Current
intergroup research indicates that prejudice toward different cultural groups often stems from
implicit in-group biases, which results in favoring or being selective towards members that share
the same group identity [85-88]. Our findings indicate that implicit bias can leak out through
inadvertent negative nonverbal expressions and can be detected in the form of verbal dominance
and lower patient positive affective tone [66]. Implicit biases could likewise be revealed in other
inadvertent nonverbal expressions, such as closed body position or reduced eye contact [64].
Such culturally determined dynamics can seriously compromise successful clinical care and
therefore require greater awareness of these NVBs to advance and strengthen cross-cultural
competency [24].
LIMITATIONS
This systematic review has several limitations. First, examining the provider-patient relationship,
cultural dynamics, and NVB is a complex undertaking and definitions and naming conventions
are heterogeneous. Second, we were limited to reviewing full-text articles in English after 1990,
thereby potentially excluding relevant studies published pre-1990 or those published in other
languages. Pragmatically, we were limited to English-only papers as we did not have ready
18

access to translators or multilingual authors. Although this presents a serious limitation in crosscultural research, one key area of interest is how other cultures convey and perceive empathy via
NVB as it relates to interactions with U.S.-based clinicians. As noted in our introduction, the US
is becoming more racially diverse and cross-cultural clinical encounters are on the rise. This is of
particular interest as our systematic review allows us to make more concrete recommendations
for our U.S.-based clinicians. The recent publication dates of many of the cited studies confirm
intensified research and clinical interest in this topic due to rapidly changing demographics.
Additionally, there were methodological limitations of several studies we examined. Two studies
[65, 75] included simulated patients, and although this design increases internal validity, it limits
external validity. One study used a facial expression computer program to test provider
facial expression decoding in lieu of direct clinical observation [74]. The sample sizes of our
studies were generally small and insufficiently powered to assess confounding variables such as
age, gender, socioeconomic status, clinical setting, language fluency or degree of acculturation.
Most studies used convenience samples rather than randomized samples, and most were Western
and Eurocentric-based. Furthermore, because members of the dominant culture typically code
studies, additional coder bias may have been introduced. Together, these methodological
limitations suggest cultural NVB is an important area for further research with larger patient and
clinician samples that follow rigorous research methodologies, both in qualitative and
quantitative investigations.
PRACTICE IMPLICATIONS
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Nonverbal communication is a critical component of cross-cultural competency, which includes
demonstrating respect for patients and fostering empathy and trust. While these competencies
appear to be universally valued, there are cultural differences in how they are expressed and
reciprocated. Clinicians cultural competence can improve by learning the nonverbal norms of
the various cultural backgrounds that they serve. There are cross-cultural nonverbal practices that
appear to be widely desired, such as open body posture, smile, and demonstrations of warmth by
facial expression. There are also reports of NVBs that convey culturally different meanings, such
as length and directness of eye gaze, meaning of hand gestures, and touch, and these must be
used judiciously. This review summarized specific and generally desired NVBs in the cultural
studies that met our inclusion criteria (Appendix B). Specific techniques for training in cultural
competency are described below.
Empathy is a process that involves both receptive and expressive capacities [26], and clinicians
in cross-cultural encounters require skills to perceive patient cues and express culturally sensitive
nonverbal behaviors. This can be achieved by promoting clinician awareness of implicit race bias
[66, 67] and teaching appropriate responses. Specific techniques may include role-playing,
imagery, mindfulness training [67] and nonverbal skills training [26]. Values affirmation
exercises prior to race-discordant clinical encounters can also enhance information exchange and
perception of providers NVBs displays of warmth and respect [68]. Providers more skilled at
cross-cultural NVB will also strengthen their perceived dedication and competency amongst
patients, as well help improve their diagnostic abilities by eliciting affective cues and
establishing rapport with the patient [89]. These techniques are similar to the empathy training
for medical trainees, previously reported, [26], which can be applied to cross-cultural
20

interactions. Finally, how we train medical students and clinicians should reflect the diversity of
the populations they serve, rather than the norms of the dominant culture in order to promote
diagnostic accuracy, mutual respect and trust.
CONCLUSION
Nonverbal communication and culture permeate virtually every aspect of health care delivery,
and this review demonstrates that additional research is needed. Some cultural groups have
context-dependent preferences for certain NVBs [70, 73, 77]. This complicates detection and
delivery of nonverbal signals among culturally discordant groups. Though culturally specific
NVBs of empathy exist, we recognize that culture is dynamic and constantly changing,
particularly in cross-cultural environments [90]. Our review of the literature highlights that
culture not only shapes norms for NVB in medical encounters, but it also appears to mediate
communication itself [64, 66, 67, 71, 74, 79]. Therefore, greater training efforts are needed to
improve perception and interpretation of patients NVB, and to enhance clinicians awareness of
their own displays of empathic NVB. Both undergraduate and graduate medical education
initiatives could encourage focus groups and specific training in this emerging area. Medical
trainees increasingly represent multinational and multiracial backgrounds, or have worked in
medical settings all over the world. Such trainees could be invited to share cultural norms from
diverse backgrounds in experiential learning settings to inform traditional patient-doctor courses.
Training programs in empathic behavior with patients from all backgrounds are needed.
Further research in empathic NVB is critical to the global health conversation. Currents in
todays world political landscape are creating additional urgency for training in cross-cultural
21

competence. With massive shifts of minority groups into racially and ethnically dominant
cultures, the misinterpretation of cultural norms and NVB can have dire consequences if cultural
competence is not made a top priority consequences not only for individuals and patients, but
for populations as a whole. This review serves as a springboard to develop training programs
that focus on empathic NVB with special attention to cross-cultural communication. Such
training is urgently needed at the undergraduate and graduate level to improve cultural
competency nationally and internationally in our increasingly diverse world.
Acknowledgments/Funding:
All authors gratefully acknowledge that this project was made possible with a grant from The
Arnold P. Gold Foundation and the David Judah Fund. The Arnold P. Gold Foundation and the
David Judah Fund had no role in study design, collection, analysis, interpretation of data, writing
the report, nor in the decision to submit the report for publication. The authors would also like to
thank Carole Foxman, Martha Stone, Lidia Schapira, M.D., and Arielle Gordon-Rowe for their
invaluable assistance.
Authors Contact Information:

1. in Lori, Ph.D., Empathy and Relational Science Program, Department of Psychiatry,
Massachusetts General Hospital/Harvard Medical School. Wang Ambulatory Care Center,
Suite 812, 15 Parkman Street, Boston, MA 02114. (alorie@mgh.harvard.edu) T: 617721-9961
22

2. Diego A. Reinero, B.S., Department of Psychology, New York University. 6 Washington
Place, New York, NY 10003. (diego.reinero@nyu.edu)
3. Margot Phillips, M.D., Empathy and Relational Science Program, Department of
Psychiatry, Massachusetts General Hospital/Harvard Medical School. Wang Ambulatory
Care Center, Suite 812, 15 Parkman Street, Boston, MA 02114.
(maphillips1@partners.org)
4. Linda Zhang, Empathy and Relational Science Program, Department of Psychiatry,
Suite 812, 15 Parkman Street, Boston, MA 02114. (xzhang02@college.harvard.edu)
5. Helen Riess, M.D., Empathy and Relational Science Program, Department of Psychiatry,
Suite 812, 15 Parkman Street, Boston, MA 02114. (hriess@mgh.harvard.edu) T: 617724-5600. F: 617-726-7451
Author Contributions:
Helen Riess had full access to all of the data in the study and takes responsibility for the integrity
of the data and the accuracy of the review.
Study concept and design: Lori, Phillips, Zhang, Riess
Acquisition of data: Lori, Reinero, Phillips, Zhang, Riess
Analysis and interpretation of data: Lori, Reinero, Phillips, Riess
Drafting of the manuscript: Lori, Reinero, Phillips, Riess
Critical revision of the manuscript for intellectual content: Lori, Reinero, Phillips, Riess
Obtained funding: Riess
23

Administrative, technical, or material support: Reinero
Study supervision: Riess
All authors gave final approval to the submitted paper.
Ethical Approval:
No ethical approval was required for the systematic review.
Conflict of Interest Disclosures:

Dr. Riess reports a financial interest in Empathetics, Inc. No other disclosures were reported.
24

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Figure 1. Flow Chart of Study Selection Process.
34

Appendix A. MEDLINE Electronic Search Strategy
Database: Ovid MEDLINE(R) 1946 to Present
-------------------------------------------------------------------------------1 Empathy/ or empath*.ti,ab. (16415)
2 compassion*.ti,ab. (4567)
3 affect/ (24011)
4 eye contact.ti,ab. or Eye Movements/ (23679)
5 (gaze* or gazing).ti,ab. (9762)
6 kinesics/ or gestures/ or (gesture* or body language).ti,ab. (4209)
7 nonverbal communication/ or (non-verbal or nonverbal).ti,ab. (9773)
8 facial expression/ or facial.ti,ab. (83410)
9 Voice Quality/ or voice.ti,ab. (19708)
10 Touch/ or touch*.ti,ab. (28443)
11 smiling/ or (smile* or smiling).ti,ab. (3742)
12 (handshake* or shake hand* or hand shake*).ti,ab. (183)
13 lean*.ti,ab. (25884)
14 Posture/ or postur*.ti,ab. (75225)
15 or/1-14 (311111)
16 Physician-Patient Relations/ (59545)
17 Interpersonal Relations/ (54776)
18 "Attitude of Health Personnel"/ (90992)
19 Attitude/ or additude*.ti,ab. (38762)
20 Trust/ or trust.ti,ab. (20571)
21 stereotyping/ or stereotyp*.ti,ab. (22961)
22 Personal Satisfaction/ or satisf*.ti,ab. (198602)
23 communication barriers/ or barrier*.ti,ab. (143193)
24 (doctor patient or patient doctor).ti,ab. (4900)
25 communication/ or communicat*.ti,ab. (191659)
26 clinician*.ti,ab. (114903)
27 (patient adj1 physician).ti. (1816)
28 relations*.ti. (181398)
29 Primary Health Care/ (53504)
30 medicine/ or general practice/ or family practice/ (88263)
31 or/16-30 (1113105)
32 15 and 31 (37998)
33 exp Ethnic Groups/ or ethnic*.ti,ab. (159069)
34 "Minority Groups"/ or minorit*.ti,ab. (43777)
35 refugees/ or "transients and migrants"/ (14289)
36 Racism/ or (race* or racial or racism or biracial).ti,ab. (94970)
37 Prejudice/ or prejudic*.ti,ab. (24724)
38 Healthcare Disparities/ or disparit*.ti,ab. (34508)
39 attitude to health/ (72138)
40 health knowledge, attitudes, practice/ (71692)
41 (culture* or cultural).ti,ab. (784151)
42 cross-cultural comparison/ or cultural characteristics/ or cultural competency/ or cultural
35

diversity/ (44690)
43 exp geographic locations/ (3206192)
44 exp Continental Population Groups/ (152589)
45 or/33-44 (4116502)
46 32 and 45 (10064)
47 limit 46 to english language (9382)
48 limit 47 to yr="1990 - 2014" (8719)
49 animal/ (5256927)
50 48 not 49 (8586)
51 humans/ and 48 (8330)
52 50 or 51 (8653)
NOTE: A second search was run using these same search terms but adding the search statement:
cues/ or (cue*1 or clue*1).ti,ab. to the top of list, and identifying any new results as a
consequence of this addition.
Appendix B. Inclusion and Exclusion Criteria

Inclusion Criteria:
Experimental or observational studies examining each of the following:
1) Communication, for example, empathy, compassion, affective relationship,
nonverbal, gaze, patient satisfaction)
2) Cultural groups, for example, cross-cultural, socio-cultural, various ethnic, racial, and
country groups, cultural competence;
3) Clinician-patient interactions addressing health problems.
4) Studies reported in English, peer-reviewed papers, subjects > 18 years old, N > 10.
Exclusion Criteria:
Commentaries, reviews, dissertations, replies, and book chapters
Studies on theoretical, hermeneutics, and concept analysis
Studies on patients with severe neurologic impairment and disorders of face and neck that
interfere communication
Studies on patients with active psychosis or developmental disorders
Studies on nonverbal healing through massage or dance therapy
Studies on sex therapy/ relationship counseling
Studies on mother-infant bonding
Studies on infants
Studies on children
Studies on auditory disorders
Studies on pharmacy
Studies on translator communication
36
TABLE 1. Overview of studies: sample, setting, methods, and nonverbal behaviors studied
(studies are organized in reverse chronological order within study design)
Patient
sample, total
n
(n of each
culture)
Author
Study
Design
Havranek, E.
P., et al.
(2012)
Randomiz
ed control
trial
USA
Primary care
99
(99 AA)
Coelho, K.
R. & Galan,
C. (2012)
Crosssectional
USA
Hospitals
and clinics
Cooper, L.
A., et al.
(2012)
Cross
sectional
USA
2 Primary
care clinics
Country
Practice
Clinician
sample,
total n
(n of each
culture)
Inte
rrate
r
relia
bilit
y
Nonverbal
behavior
studied
Observatio
n Strategy
Instruments
7
(7 non-AA
physicians)
Audiotaped
clinic visits
RIAS, patient
questionnaire
0.98
Emotional tone
of patient and
physician
Patient satisfaction
and provider
satisfaction, physician
verbal dominance,
patient centeredness,
visit duration,
information exchange
60
(30 South
Asian, 30
WA)
30
(16 South
Asian, 14
WA
physicians)
Computerize
d tests of
physicians'
ability to
decode
facial
expressions
and vocal
tones
1) Facial
expression
coding
system, 2)
Vocal tone
assessment, 3)
Patient
satisfaction
survey, 4)
authordeveloped
Patient
Adherence
survey
NR
Facial
expression
decoding
accuracy and
vocal tones
decoding
accuracy
Patient satisfaction,
self-reported patient
adherence
269
(213 AA, 56
WA)
40
(9 AA, 12
Asian, 19
WA
physicians)
Audiotaped
clinic visits;
Implicit
Association
Tests (IAT)
for clinicians
Two IATs for

measuring
racial
attitudes and
stereotypes,
and patient
questionnaire
0.861
Patient and
physician
positive affect
Implicit race bias and

compliance bias of
physicians, patient
satisfaction, visit
length, speech speed,
clinician verbal
dominance, patient
Outcomes
37

centeredness
Stepanikova,
I., et al.
(2012)
Crosssectional
USA
3 Primary
care clinics
209
(29 nonWhite, 190
WA)
30
(3 nonwhite, 27
WA
physicians)
Videotaped
clinic visits
Adaption of
the Nonverbal
Communicati
on in Doctor
Elderly
Patient
Transactions
(NDEPT)
0.830.96
Open body
position, eye
contact, smile,
touch
Patient ease,
physicians mixed
signals
Xu, Y., et al.

(2012)
Crosssectional
USA
2 Hospitals
1
(1
standardized
patient)
52
(IENs: 38
Philippines,
5 India, 3
Korea, 3
China, 1
Kenya, 2
NR)
Videotaped
encounter of
nursing
intake of a
standardized
patient
Authordeveloped
scales
0.82
Eye contact,
smile, body
position,
nodding,
gesture,
hugging,
interpersonal
space, and
therapeutic
touch
Global assessment of
communication
Hausmann,
L. R., et al.
(2011)
Crosssectional
USA
Veterans
Affairs
Hospitals
353
(100 AA, 253
WA)
63
(63
Orthopedic
surgeons)
Audiotaped
clinic visits
RIAS, patient
questionnaire
0.680.92
Provider
warmth/respect
fulness
Patient-rated visit
informativeness, and
ease of
communicating with
the provider
Zaletel, M.,
et al. (2012)
Crosssectional
Slovenia
27 Nursing
homes
267
(267
Slovenians)
267
(267
Slovenian
care givers)
Direct
clinical
observation
by pairs of
trained
observers
Kovacev
Non-Verbal
Expression
Checklist
NR
Provider facial
expressions,
head
movements,
gestures, body
position,
silence
Distribution of
nonverbal behaviors
by gender and
professional type
38

Johnson R.
L., et al.
(2004)
Crosssectional
USA
General
clinics
458
(256 AA, 202
WA)
61
(21 AA, 9
Asian, 30
WA, 1 Other
physicians)
Audiotaped
clinic visits
RIAS, patient
questionnaires
0.880.79
Patient and
physician
positive affect
score:
dominance/ass
ertiveness
(patient only),
interest/attenti
veness (both),
friendliness/wa
rmth (both),
responsiveness
/engagement
(both), and
sympathy/emp
athy (both)
Patient positive affect,

physician positive
affect, verbal
dominance, patientcentered orientation,
visit duration and
speech speed
Aruguete,
M. S. &
Roberts, C.
A. (2002)
Crosssectional
USA
Student
health clinic
116
(97 AA, 19
WA)
2
(1 AA, 1
WA
physician in
a simulated
video)
Participants
watched 1 of
4 videos
Patient
questionnaires
NR
Physician
facial
expression,
distance from
patient,
concern for
patient,
understanding
of patient
Patient-rated
satisfaction, trust,
self-disclosure,
recommendation,
recall, compliance
Bergman, A.
A. &
Connaughto
n, S. L.
(2013)
Qualitativ
e
USA
Prenatal
clinic
48
(48 Hispanic)
NR
(American
providers)
Semistructured
interviews
Qualitative
NR
Physician
warmth,
friendliness,
smile, eye
contact,
patience,
formal
greetings
Patient centered care

approaches, patient
trust, provider
credibility
Williams, S.,
et al. (2013)
Qualitativ
e
Trinidad
and
Tobago
Medical
School
N/A
36
(36 medical
students)
Videotaped
focus groups
Qualitative
NR
Eye contact,
personal space,
body
movements,
touch, vocal
tone
Provider perceptions
of patient
expectations
39

Jain, P. &
Krieger, J. L.
(2011)
Qualitativ
e
USA
Hospital
N/A
12
(Internationa
lly educated
resident
physicians: 6
India, 2
China, 1
Jordan, 1
Lebanon, 1
Nigeria, 1
Philippines)
Semistructured
audiorecorded
interviews
Qualitative
NR
Eye contact,
touch,
gestures,
warmth
Internationally
educated resident
physicians crosscultural strategies
Jirwe, M., et
al. (2010)
Qualitativ
e
Sweden
Nursing
school
N/A
10
(5 Swedish
student
nurses, 5
immigrant
student
nurses)
Semistructured
audiorecorded
interviews
Qualitative
NR
Eye contact,
smile, gestures,
warmth
Swedish and nonSwedish student nurse

strategies and
difficulties in crosscultural encounters
Shahid, S., et
al. (2009)
Qualitativ
e
Australia
Varied:
recruited
from
oncology
centers
30
(30 Australian
Aborigines)
NR
Australian
providers
Semistructured
audiorecorded
interviews
Qualitative
NR
Patient
nodding and
silence,
physician
friendliness
Trust, patient
perception of
physician knowledge
and competence
Roberts, T.
E. (2007)
Qualitativ
e
USA
Community
centers
42
(42
Brazilians)
NR
American
providers
Semistructured
interviews
Qualitative
NR
Perception of
physician
warmth, touch
Patient satisfaction,
patient trust
Pasco, A. C.,
et al. (2004)
Qualitativ
e
Canada
Hospital
24
(24 Filipinos)
NR
Canadian
nurses
Semistructured
interviews
Qualitative
NR
Touch, eye
contact and
gaze
Patient trust
NOTES: AA = African American, WA = White Americans, IEN = Internationally educated nurse, MD = physician, RN = Registered nurse, N/A = Not applicable, NR = not reported, NVB = Nonverbal
behavior, RIAS = Roter Interaction Analysis System, USA = United States of America
40
TABLE 2. Studies' Main

Nonverbal Findings (Studies
are organized in reverse
chronological order within study
design)
Study
Havranek, E. P., et
al. (2012)
Coelho, KR., and

Galan, C. (2012)
Refer
ence
#
68
74
Study
Design
Research
aims
Main nonverbal
findings
Implications
Randomi
zed
control
trial
To test the effect

of a values
affirmation
intervention
given to AA
patients prior to
their clinic visit
with a non-AA
primary care
physician
Affective tone: overall

communication in the
intervention group was
significantly more
friendly, interactive, and
respectful (p=0.02).
Patients were rated as
less distressed and less
depressed (p=.03)
Information exchange:
patients in the
intervention group
requested and provided
more information about
their medical condition
(p =.03).
Visit length: no
significant difference
Patient satisfaction: no
Patient trust: no
Values affirmation exercise can improve the experience of

AA patients in primary care visits with non- AA physicians
To examine
physicians
abilities to
decode nonverbal
emotions of
Caucasian and
South Asian
patients, and to
test the
hypothesis that
this ability
correlates with
patient
satisfaction and
Facial and vocal tone

decoding accuracy:
South Asian physicians
were no better at
decoding the facial
expressions or vocal
tones of South Asian
patients, and both South
Asian and Caucasian
physicians were better
at decoding Caucasian
nonverbal stimuli (p
< .0001)
Patient satisfaction:
Physicians can have difficulty interpreting South Asian

nonverbal cues which is correlated with poorer patient
satisfaction and poorer patient adherence
Crosssectional
Greater exchange of medical information is achieved

without increasing visit length, and overall positive affective
tone of patients and physicians is significantly greater
Physicians should be aware that their affective tone may
be influenced by the patient's level of comfort and
monitoring cues such as instructiveness and friendliness may
influence patients' affective tone and exchange of medical
information
Physicians should be trained to improve awareness of

differences in South Asian facial and vocal tone expression
41
Cooper, L. A., et al.

(2012)
66
Crosssectional
patient adherence
South Asian patients

were more likely to be
dissatisfied with the
quality of care provided
by their physician (p
= .032)
Patient adherence:
South Asian patients
reported they were less
likely to adhere to
recommendations (p
< .001)
To examine
associations of
clinicians
implicit attitudes
about race with
visit
communication
and patient
ratings of care
Positive Affect:
clinician race bias was
associated with lower
patient positive affect
among Black patients
and higher physician
positive affect among
White patients
Physician verbal
dominance: clinician
race bias was associated
with greater physician
verbal dominance
and White patients
Visit length and speech
speed: clinician race
compliance bias was
associated with longer
visits and slower speech
and faster visits and
faster speech among
White patients
Patient Satisfaction:
greater clinician race
bias was associated with
lower Black patient
ratings of clinician
respect, liking, (p
< .001) or
recommending
physician (p = .001)
Training to improve clinician awareness of implicit race

bias.
Physician self-awareness can reduce implicit race and
compliance bias, with improvements in overall
communication and patient ratings of care, particularly
42

Stepanikova, I., et
al. (2012)
64
Crosssectional
To examine the
influence of race
of physicians
with patients
who are over 65
years old, on
nonverbal
communication
during medical
interviews
Open body posture,

smile and touch:
Concordant race
resulted in high use of
smile, touch, and open
body position for both
AA and White
physicians, and was
highest in AAAA
dyads compared to the
average across other
dyads (open body
posture: p < 0.001;
smile: p = 0.048; touch:
p < 0.001). Discordant
race in AA physicians
with White patients
resulted in highest use
of smile and gaze with
lowest use of open body
position.
Eye contact: White
physicians made more
eye contact with White
patients as compared to
their AA patients but it
was only marginally
significant (p = .08)
Training in nonverbal behavior across all races with

specific focus on open body posture and awareness to avoid
sending mixed nonverbal messages, especially in race
discordant visits
Xu, Y., et al. (2012)
75
Crosssectional
To evaluate
nonverbal
communication
behaviors of
internationally
educated nurses
(IENs) in the
United States
Therapeutic touch (p
< .01), interpersonal
space ( p < .01), and eye
contact (p<.05) were
positively correlated to
overall global
impression score
Provide targeted communication training to newly

arrived/hired IENs with focus on therapeutic touch,
interpersonal space, and eye contact to improve patient
rating of overall clinical care
43

Hausmann, L. R., et
al. (2011)
67
Zaletel, M., et al.

(2012)
79
Crosssectional
To examine the
relationship
between AA and
White patients
perceptions of
discrimination
from past
healthcare
encounters and
patient-provider
communication
during a
subsequent
medical visit
Listening: Feeling that

a physician did not
listen was the most
common form of
perceived racism
expressed by both races
Affective tone: less
positive nonverbal
affect among patients
(Beta = -0.41, 95% CI=
-.73, -0.09) and
providers (Beta = -0.34,
95% CI= -0.66,-0.01)
was associated with
high levels of perceived
racism among AA
patients
Warmth/respectfulnes
s: high levels of
perceived racism was
associated with low
patient ratings of
provider
warmth/respectfulness
(OR=0.19, 95%
CI=0.05, 0.72) and ease
of communication (OR
=0.22, 95% CI=0.07,
0.67). Perceived
classism yielded similar
results
Increase physician awareness of unintentional biases
Crosssectional
To quantify
nonverbal
communication
of caregivers in
Slovenian
nursing homes
Smile: No significant
difference in rates of
smiling between gender
or type of caregiver
Eye contact: No
significant difference in
rates of eye contact
between gender or type
of caregiver
Gestures: associated
with gender and type of
caregiver, with nurses
and females manifesting
fewer negative
expressions (p = 0.034)
Training to improve rates of positive nonverbal

communication
Training to improve positive affective tone, listening, and

how to counter negative emotion states through role-playing
or mindfulness
44

Johnson R.L., et al.
(2004)
69
Crosssectional
To examine the
association
between patient
race/ethnicity
and patientphysician
communication
Affective tone: overall

physician affective tone
was less positive with
AA compared with
White patients, and AA
patient affective tone
was less positive
compared with White
patients (p = .02)
Verbal dominance:
physicians were 23%
more verbally dominant
with AA patients than
with White patients (p
< .001)
Patient-centeredness:
content was 33% less
patient-centered with
AA patients (p < 0.5)
Training to improve clinician communication skills

including affective communication (e.g., rapport-building,
minimizing verbal dominance), and empowering minorities
for active participation in health care
Aruguete, M. S. and
C. A. Roberts
(2002)
65
Crosssectional
To examine the
impact of race
(AA vs. White)
and nonverbal
communication
on patient
evaluations
Smile, facial
expression, eye
contact, attentiveness,
personal space (sitting
< 2 feet from patient),
and posture (forward
lean): physician display
of nonverbal concern
via these behaviors was
the best predictor of
patient satisfaction (p
< .001) and positive
physician
recommendation (p
< .001), regardless of
physician race
Increase nonverbal skills training for students and

practitioners in same and discordant race encounters, with
focus on behaviors that communicate nonverbal concern
Bergman, A. A. and
S. L. Connaughton
(2013)
70
Qualitati
ve
To understand
the experience
and expectations
of Hispanic
women in
prenatal clinics
Friendliness: Patients
expressed preference for
friendly ("amable")
providers
Smile: a smile may
convey warmth,
professionalism, and
confidence that the
provider was competent
Eye contact: patients
sought sustained eye
contact together with a
Training to improve awareness of local cultures'

expectations for patient-centered communication: e.g.,
Hispanic women in prenatal clinic visits expressed
preferences for physician friendliness, attentiveness, and
patience/not rushing
45

smile as signs of
provider
professionalism and
warmth
Williams, S., et al.

(2013)
Jain, P. and J. L.
Krieger (2011)
77
76
Qualitati
ve
Qualitati
ve
To understand
the challenges of
teaching
nonverbal
communication
skills in a
Caribbean
medical school
Eye Contact: in
Tobago, it is considered
disrespectful to look
into the eyes of an elder
Personal Space: in the
Bahamas and Jamaica,
closer proximities are
considered invasive
rather than reassuring
Traditional (Western) teaching of physician nonverbal

behavior did not reflect the diversity of patient preferences in
Caribbean cultures
To understand
the
communication
strategies
international
medical
graduates use in
medical
interactions to
overcome
language and
cultural barriers
Internationally educated
physicians expressed
difficulty knowing how
to respond to patients'
emotions after giving
bad news because in
their culture physicians
disclose medical
information to family
members rather than to
the patient directly.
They may compensate
for intercultural
differences and
language barriers with
several strategies,
including repeating
information using nonverbal communication
such as eye contact,
friendliness, smile,
vocally conveying
warmth and care,
respectful silence, and
supportive touch
Training to improve communication strategies of

internationally educated physicians early in their career, with
focus on disclosure of medical information and addressing
patients' negative emotions when giving bad news
Medical education should address culturally specific

norms for nonverbal communication
46

Jirwe, M., et al.
(2010)
78
Qualitati
ve
To understand
the experiences
of student nurses'
cross-cultural
communication
with patients
Lack of skills and

language barriers can
result in patient and
nurse dissatisfaction.
Communication
strategies included
mirroring the patients
emotions, using pictures
and using body
language (smile, eye
contact, touch). Nurses
who had immigrated to
Sweden expressed more
confidence
communicating in crosscultural encounters than
Swedish nurses
Training to improve nursing skills, confidence, and

satisfaction, including use of smile, touch, eye contact, and
mirroring patient expressions
Shahid, S., et al.

(2009)
71
Qualitati
ve
To report
Aboriginal
patients' views
about effective
communication
between
Aboriginal
people and
cancer providers
in Australia
Warmth: Aboriginal
patients tended to act
reserved and viewed
many physicians as
lacking compassion and
warmth
Silence: Aboriginal
patients expressed
reluctance to admit to
difficulty understanding
their physicians and
lacked the confidence to
ask questions
Head Nod: Aboriginal
patients may nod rather
than admit lack of
understanding
Improve awareness of meaning of Aboriginal patients'

silence and nodding, and further integrate Aboriginal clinical
support and interpreters in cancer care
Roberts, T. E.
(2007)
72
Qualitati
ve
To understand
what health
practices and
beliefs are
common among
Brazilian
immigrant
patients
Warmth: Brazilian
immigrants experienced
U.S. clinicians as
lacking warmth and
desired more personal
warmth from their
providers ("carinho")
Personal space:
preference for more
physical closeness from
providers
Touch: preference for a
hug or a kiss over a
Lengthen clinical encounters and consider if the patient

expects or desires more warmth in nonverbal and verbal
behavior from clinicians
47

handshake
Smile and eye contact:
can convey warmth.
Clinician "coldness" can
be interpreted by
absence of a smile or
eye contact
Pasco, A. C., et al.

(2004)
73
Qualitati
ve
To identify
FilipinoCanadian values
that impact
patient-nurse
interactions
Touch by nurses helps

develop trust in
hospitalized Filipino
patients. Patients
experience a nurses'
touch as conveying
respect for the patient
Eye contact: direct eye
contact is valued;
lowered eyes may mean
respect or shame and is
context-dependent. A
head-to-toe gaze by a
nurse can be perceived
as demeaning
Improve nurse awareness of use of gaze and touch to

build relationships with hospitalized Filipino patients
NOTES: AA = African American, IEN = Internationally educated

nurse, vs. = versus
48

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