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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 264-269

Listening between the Lines: Introduction of a Module for Teaching Nonverbal Communication Skills to MBBS Students


1 Department of Microbiology, Janakpuri Super Speciality Hospital Society, Bathinda, Punjab, India
2 Department of General Medicine, All India Institute of Medical Sciences, Bathinda, Punjab, India
3 Department of General Medicine, Army College of Medical Sciences, New Delhi, India
4 Department of Anatomy, Army College of Medical Sciences, New Delhi, India
5 Department of Paediatrics, Army College of Medical Sciences, New Delhi, India
6 Department of Pathology, Army College of Medical Sciences, New Delhi, India

Date of Submission11-May-2021
Date of Decision24-Jul-2021
Date of Acceptance14-Aug-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Dr. Niket Verma
Department of General Medicine, All India Institute of Medical Sciences, Bathinda - 151 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_112_21

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  Abstract 


Background and Aim: Establishing good communication with patients is an essential component of good doctor–patient relationships and has a positive impact on health outcomes. A vital component of communication is nonverbal communication (NVC). NVC may reinforce or contradict our verbal comments, thereby altering the meaning of a message and its outcomes. Hence, it is imperative that medical students are made aware of NVC. The present study was undertaken to develop and implement a module for NVC skills and assess the perception of students and faculty. Materials and Methods: The study was conducted with students of 2nd professional MBBS. Participation was voluntary and approval was taken from the institutional ethical committee. All the contents of the module were jointly developed by the core faculty members. The module was conducted across three sessions and included role plays, exposure to simulated patients, an interactive lecture, and a focused small-group discussion. Feedback was obtained from students and faculty facilitators after conclusion of the third session. Results: Fifty-two students and seven faculty facilitators participated in the study. Fifty students (96%) agreed that the module was helpful in improving their NVC skills. All 52 students (100%) agreed that they felt more confident interacting with patients after attending the sessions. Forty-four students (84.6%) strongly agreed that they would attend such sessions in future also. The suitability of the module as a whole for inclusion in the curriculum was endorsed by all participants (100%). The faculty members felt that the most encouraging aspects of the module were its implementation in a nonthreatening environment, maintaining privacy during interactions with simulated patients, and self-assessment of the interaction. Conclusion: With regard to the feasibility and acceptability of the module, 100% of the participants and faculty facilitators agreed that the module should be included in the undergraduate curriculum.

Keywords: Curriculum, education, medical, nonverbal communication, students, undergraduate


How to cite this article:
Banerjee P, Verma N, Mohan C, Rustagi SM, Nair BT, Rautela A. Listening between the Lines: Introduction of a Module for Teaching Nonverbal Communication Skills to MBBS Students. Arch Med Health Sci 2021;9:264-9

How to cite this URL:
Banerjee P, Verma N, Mohan C, Rustagi SM, Nair BT, Rautela A. Listening between the Lines: Introduction of a Module for Teaching Nonverbal Communication Skills to MBBS Students. Arch Med Health Sci [serial online] 2021 [cited 2022 Jan 22];9:264-9. Available from: https://www.amhsjournal.org/text.asp?2021/9/2/264/333993




  Introduction Top


Communication in medical practice is well recognized as being important to the delivery of medical care. Effective communication between a health-care professional (HCP) not only results in better health outcomes, better compliance, higher satisfaction but also decreased litigation.[1],[2],[3] Communication largely can be described as being verbal and nonverbal. The verbal component is usually easy to interpret and analyze. It is discrete with clear endpoints; it is mostly under voluntary control and communicates our cognitive thoughts more than our emotions. In contrast, nonverbal communication (NVC) is less easy to interpret; it is continuous even in silence and operates at a less conscious level. NVC is more spontaneous and is mainly responsible for communicating attitudes and emotions.[4],[5] NVC has been defined as communication behavior without linguistic content.[6] It reinforces or may contradict our verbal comments, and thus has the potential to alter the meaning of a message and the following actions and outcomes.[7] In fact, Mehrabian and Ferris even developed a formula for verbal and nonverbal effects of a message stating a 7% impact of verbal, 38% of vocal tone, and 55% of facial expressions.[8] Thus, any HCP including medical students has to be well aware of this component of communication including its pitfalls.

There are several distinct categories of NVC including kinesics (gestures, facial expressions, and gaze patterns), proxemics (body posture, position, territoriality, and personal space), and touch.[9] Teaching and assessing the affective domain is challenging enough and doing the same for all the above categories of NVC poses an even bigger challenge. Various researchers have adopted different methodologies for effectively teaching communication skills to undergraduate medical students. However, there are only a few studies in literature which have specifically explored the teaching–learning of NVC. A module for teaching NVC skills to MBBS students has especially become significant at this point of time because the newly introduced competency-based medical education curriculum lays great emphasis on communication skills and includes communication skills as a core competency for the Indian Medical Graduate (IMG).

The aim of the present study is to introduce a module for teaching NVC skills to undergraduate medical students and assess the perceptions of student learners and faculty facilitators regarding the feasibility, acceptability, and efficacy of the module.


  Materials and Methods Top


This study was conducted in the department of microbiology with students of 2nd professional MBBS, between October 2019 and February 2020, as part of the Advance Course of Medical Education being pursued by the primary author. Due permission was taken from the research committee and ethics committee of the institution before commencement of the project.

Faculty members of the college Medical Education Unit (MEU) were approached, and the study outline was shared. Interested faculty members filled a prevalidated consent form and were made part of the study as the core group. The Kern's six-step model of curriculum development was followed for development of the module.

Module development

Scripts for role plays

The module had five scripted role plays, individually addressing the five categories of NVC, namely gesture, gaze, facial expression, body posture/position, and touch.

Preparation of simulated patients

Nonteaching staff were requested to become simulated patients. They were briefed regarding the project, and thereafter, written informed consent was taken.

Resource articles

After a thorough literature search, five articles were shortlisted which highlighted the importance of NVC in a doctor–patient relationship and also gave an insight into the various components of NVC.

Resource videos

A YouTube search was conducted for relevant videos using the keywords “Non-verbal communication,” “communication skills for health care professionals,” and non-verbal communication in a doctor–patient interaction. Five appropriate videos were selected and archived in a folder.

Interactive lecture

An interactive lecture was prepared which covered the different components of communication skills and further described the various categories of NVC.

All the contents of the module were jointly developed by the core faculty members.

The module was validated by MEU members of our institute (other than the core faculty) and medical education experts from other institutes. A predesigned validation form was sent to them through e-mail. The experts were asked to rate the various components of the module on a three-point Likert scale regarding their adequacy (adequate/partially adequate/not adequate). The components were revised based on the suggestions received, and the module was finalized.

A brief interaction was held with the students to discuss the importance of NVC. They were also sensitized about the AETCOM module and the emphasis laid by the Medical Council of India on good communication skills for IMGs. The students were also made aware of the general plan of the study, so that they could make an informed decision before volunteering to participate. Students who volunteered for the study, filled a prevalidated consent form. The enrolled students and resource faculty were included in a WhatsApp group. The module was implemented in three sessions in a span of 1 week during regular college hours and attended by all core faculty members [Table 1].
Table 1: Details of the steps in which the three sessions of the module were implemented

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  1. Session 1 – day 1 duration: 75 min (venue: department of microbiology)
  2. Session 2 – day 3 duration: 75 min (venue: lecture hall)
  3. Session 3 – day 5 duration: 60 min (venue: lecture hall).


Feedback was obtained from students and faculty facilitators after conclusion of the third session. The student feedback questionnaire consisted of 13 closed-ended and 3 open-ended questions. The faculty feedback questionnaire consisted of 9 closed-ended and 3 open-ended questions.


  Results Top


Out of 100 2nd professional MBBS students, 52 volunteered to be part of the study. There was 100% attendance in all the sessions. Seven faculty members were part of the core group and were involved in the development and implementation of the module.

Student feedback

  1. Forty-three respondents (82.6%) strongly agreed that the module was delivered effectively whereas 42 (80.8%) strongly agreed that the sessions were conducted within the stipulated time [Figure 1].
  2. An overwhelming 50 respondents (96.1%) strongly agreed with the statement that the module was conducted in a nonthreatening environment. Fifty-one respondents (98%) expressed agreement (marking either agree or strongly agree) with the statement that the format of the whole module enhanced their learning
  3. The module employed role plays, simulated patients, resource videos, and resource reading material. The number of respondents who strongly agreed with the effectiveness of these tools was 43 (82.7%) for interaction with simulated patients, followed closely by 41 (78.8%) for role plays, 29 (55.7%) for videos, and 27 (51.9%) for the resource reading material
  4. Fifty respondents (96%) expressed agreement (marking either agree or strongly agree) with the statement that the module was helpful in improving their NVC skills
  5. All 52 respondents (100%) expressed agreement (marking either agree or strongly agree) that they felt more confident interacting with patients after attending the sessions
  6. Forty-four respondents (84.6%) strongly agreed that they would attend such sessions in future also
  7. The only statement which elicited a response of “disagree” by 3 (6.3%) respondents was regarding the adequacy of prior sensitization
  8. The open-ended questions in the feedback questionnaire enquired about the factors that encouraged or discouraged learning, whether such a module should be incorporated in the curriculum and any further suggestions for improvement of the module. The questions elicited a positive response from all the participants, and some responses are mentioned verbatim in [Table 2]
  9. At the end of the third session, the participants were asked to pen down their reflections. The reflections were analyzed for affirming the feasibility, acceptability, and efficacy of the module. Some excerpts from the reflections are presented in [Table 3].
Table 2: Student responses to open-ended questions in the feedback form

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Table 3: Excerpts from the reflections by students

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Figure 1: Student responses to the close-ended questions of the feedback questionnaire (based on a five-point Likert scale)

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Faculty feedback

  1. Faculty members agreed that the module was effective for teaching NVC skills to undergraduate medical students. All seven faculty members (100%) agreed that the module was implemented effectively, conducted within the stipulated time, and generated interest in the topic. The exact number of responses for each statement of the feedback form is presented in [Figure 2]
  2. The open-ended questions were similar to the student feedback form. In the opinion of the faculty facilitators, the most encouraging aspect of the module was its implementation in a nonthreatening environment. Maintaining privacy during interactions with simulated patients and self-assessment of the interaction also encouraged the students. Simulated patients and role plays enhanced the learning and gave a fair insight to the students on the nuances of NVC and its importance in doctor–patient interaction. There was absolute consensus that the module should be made part of the curriculum for teaching communication skills.
Figure 2: Faculty responses to the close-ended questions of the feedback questionnaire (based on a five-point Likert scale)

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  Discussion Top


Larsen and Smith in their study as far back as 1981 had concluded that nonverbal behavior of the physician in the patient–physician interview is important in determining patient satisfaction and understanding.[10] The need for teaching NVC to students was felt by other researchers too, and a recent study concluded that a training module for communication skills including NVC is beneficial and should be made part of the curriculum.[11] Another study by Vogel et al. assessed the skills of final-year students for verbal and nonverbal communication and concluded that there is differentiated communication behavior of undergraduate medical students with respect to verbal and nonverbal aspects of communication. They suggested that explicit communication training and feedback might be necessary to raise students' awareness for the different aspects of communication including empathy. Thus, the need of the hour is to have a formal and systematic training of undergraduate students for NVC along with other components of communication skills.

The present study was conducted with 2nd professional MBBS students because (as per the previous MBBS curriculum) clinical postings begin from this phase and this involves direct interaction with patients and their families in wards and outpatient departments.

As per the feedback given by the participants, majority (82.6%) of them believed that the use of simulated patients is a very effective teaching–learning method, and in their own words, the students described that they “felt like a doctor” during the interaction. The experience allowed them to realize their own strengths and weakness. This finding collaborates with the review done by Williams and Song, where they have illustrated the effectiveness of simulated patients in improving student's clinical skills.[12] Recording of interaction with simulated patients has been previously used as an assessment tool,[13] but in our study, we utilized the recording for self-assessment, which was much appreciated by the students and enhanced the acceptability of the module. A recent study by Nair discussed role play as an effective tool for teaching communication skills to undergraduate students. In our study too, role plays were appreciated by all the participants. Role plays turned out to be a versatile and effective tool as every individual component of NVC could be displayed and discussed and the participants could appreciate the impact of NVC on patients. The other teaching tools used were resource videos and reading material shared on the WhatsApp group. In our study, we used this e-learning platform only to disseminate the resource videos and reading material. Role plays and recorded videos are efficacious teaching tools for students to experience and understand complex scenarios of doctor–patient interaction and give them a perspective from both the doctors' and the patients' side.[14],[15]

The perception of the core faculty members toward the module was very positive and they approved of all the components of the module. The acceptance of the module as a whole was very encouraging as evident by the comments given by students in their reflection writing. The fact that 100% of the participants and faculty facilitators agreed that the module should be included in the undergraduate curriculum is testament to the feasibility and acceptability of the module.

Implications

This module can be included as an integral part of the AETCOM training. Such modules will make the students aware of NVC and its importance in developing good doctor–patient relationship. Improved communication skills in HCPs can improve patient outcomes and reduce violence against health-care staff.

Limitations of the study

Due to paucity of time, the study did not assess the effectiveness of the module in improving NVC skills in the participants during their interactions with actual patients and attendants.


  Conclusion Top


The module after due validation was perceived by both students and faculty as feasible and acceptable for enhancing NVC skills in undergraduate medical students. The various components of the module were deemed effective, and the impact of the module as a whole for teaching NVC was positively established. The module, therefore, is suitable to be included in the teaching curriculum for communication skills.

Acknowledgments

We would like to thank the faculty at the NMC Nodal Centre, CMC, Ludhiana, and the faculty, students, and staff of the Army College of Medical Sciences.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rider EA, Hinrichs MM, Lown BA. A model for communication skills assessment across the undergraduate curriculum. Med Teach 2006;28:e127-34.  Back to cited text no. 1
    
2.
Laidlaw A, Hart J. Communication skills: An essential component of medical curricula. Part I: Assessment of clinical communication: AMEE guide No. 51. Med Teach 2011;33:6-8.  Back to cited text no. 2
    
3.
Tamblyn R, Abrahamowicz M, Dauphinee D, Wenghofer E, Jacques A, Klass D, et al. Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. JAMA 2007;298:993-1001.  Back to cited text no. 3
    
4.
Verderber RF, Verderber KS. Inter-act: Using Interpersonal Communication Skills. Belmont CA. 1st ed. Boston: Wadsworth Publishing; 1980.  Back to cited text no. 4
    
5.
DiMatteo MR, Taranta A, Friedman HS, Prince LM. Predicting patient satisfaction from physicians' nonverbal communication skills. Med Care 1980;18:376-87.  Back to cited text no. 5
    
6.
Knapp ML, Hall JA. Nonverbal Communication in Human Interaction. 7th ed. Boston: Wadsworth Publishing; 2010.  Back to cited text no. 6
    
7.
Burleson, B. Interview during the annual meeting of the National Communication Association, Miami Beach, November, 2003.  Back to cited text no. 7
    
8.
Mehrabian A, Ferris SR. Inference of attitudes from nonverbal communication in two channels. J Consult Psychol 1967;31:248-52.  Back to cited text no. 8
    
9.
McCorry LK. Communication Skills for Health Care Professionals. 1st ed. Wolter and Kluwer Publishing; 2011.  Back to cited text no. 9
    
10.
Larsen KM, Smith CK. Assessment of nonverbal communication in the patient-physician interview. J Fam Pract 1981;12:481-8.  Back to cited text no. 10
    
11.
Tanwani R, Chandki R, Joshi A, Arora VK, Nyati P, Sutay S. Perception and attitude of medical students towards communication skills lab and teaching module. J Clin Diagn Res 2017;11:C12-4.  Back to cited text no. 11
    
12.
Williams B, Song JJ. Are simulated patients effective in facilitating development of clinical competence of health care students? A scope review. Adv Simul (Lond) 2016;1:6.  Back to cited text no. 12
    
13.
Ishikawa H, Hashimoto H, Kinoshita M, Fujimori S, Shimizu T, Yano E. Evaluating medical students' non-verbal communication during the objective structured clinical examination. Med Educ 2006;40:1180-7.  Back to cited text no. 13
    
14.
Modi JN, Anshu, Chhatwal J, Gupta P, Singh T. Teaching and assessing communication skills in medical undergraduate training. Indian Pediatr 2016;53:497-504.  Back to cited text no. 14
    
15.
Nair BT. Role play – An effective tool to teach communication skills in pediatrics to medical undergraduates. J Educ Health Promot 2019;8:18.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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