Review articleCulture and nonverbal expressions of empathy in clinical settings: A systematic review
Introduction
There is a critical need for health care providers to offer culturally competent empathic care [1], [2], [3]. Increasing diversity in patient populations and the healthcare workforce can generate cross-cultural misunderstandings, contributing to medical errors, lack of trust and adherence to treatment [4], [5], [6], [7], and decreased patient satisfaction [8], [9], [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], [16], [17], [18] and often disproportionally affect minorities, leading to disparities in treatment, healthcare access, and health outcomes [19], [20], [21], [22], [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], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [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], [42], [43], [44], [45], [46], [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], [52], [53], [54], [55], there is little research integrating cross-cultural differences and patient-clinician NVB [56], [57], [58], [59], [60], [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 Ambady’s [61] 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 Ambady’s work [61] 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, how 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.
Section snippets
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, cross-cultural), clinician-patient
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], [65], [66], [67], [68], [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
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
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 access to translators or
Practice implications
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
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
Conflict of interest disclosures
Dr. Riess reports a financial interest in Empathetics, Inc. No other disclosures were reported.
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: Lorié, Phillips, Zhang, Riess
Acquisition of data: Lorié, Reinero, Phillips, Zhang, Riess
Analysis and interpretation of data: Lorié, Reinero, Phillips, Riess
Drafting of the manuscript: Lorié, Reinero, Phillips, Riess
Critical revision of the manuscript for intellectual content: Lorié, Reinero, Phillips, Riess
Obtained funding:
Ethical approval
No ethical approval was required for the systematic review.
Acknowledgments
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.
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Equal author contribution.