Sawada, N.O.; Mendes, I.A.C.; Galvão, C.M., Trevizan, M.A. The Importance of Nonverbal Communication During the Preanesthesia Period. Clinical Nursing Research, v.01, n.2, p.207-213, 1992. The Importance of Nonverbal Communication During the Preanesthesia Period Namie Okino Sawada, Isabel Amelia Costa Mendes*, Cristina Maria Galvão*, Maria Auxiliadora Trevizan* BRIEF This article discusses the phenomenon of nonverbal communication as evidenced between preoperative patients and the nurses attending them. Ten. such patients and the nursing group assigned to them were directly observed for frequency of nonverbal Interaction during the period immediately preceding surgery. Patients' nonverbal expressions of tension, fear, anxiety, and so on were noted, videotaped, and then analyzed according to three categories of interaction: positive, neutral, and negative. of 2,173 registered nonverbal interactions, 65.1% (1,416) were rated as negative, a finding that should alert nurses to the need to identify patients' manifestations of anxiety so as to provide assurance and a sense of courage preceding surgery. Positive means of communicating nonverbally are discussed. All authors are affiliated with the College of Nursing at the University of São Paulo in Brazil where Namie Okino Sawada and Cristina Maria Galvão are Assistant Professors. Maria Auxiliadora Trevizan is an Associate Professor, and Isabel Amelia Costa Mendes is an Associate Professor and Vice Dean.
Preoperative anxiety is a phenomenon and an emotional reality found in most patients. Several studies (Hathaway, 1986; Lindeman, 1972; Lindeman & Stetzer. 1973; Schmitt & Wooldridge, 1973; Ziemer, 1983) have indicated that anxiety can influence the patient's response to surgery and also have a negative effect on postoperative recovery. Operating room nurses therefore need to consider patient anxiety when they plan nursing care in the immediate preoperative period. Communication, one of the most important instruments used by the professional nurse, should be used to minimize preoperative anxiety in surgical patients. As cited by Lewis (1973), communication is a continuous process that involves perceptions of ourselves and perceptions of others as well as verbal and nonverbal messages. It includes the process by which one person can influence another through the transmission of content and feelings. Content is often transmitted by verbal messages and feelings by nonverbal messages. Myers and Myers (1972) emphasized that nonverbal communication is a means of expressing feelings and emotion. Through nonverbal communication, we can express love, desire, Interest, admiration, anxiety, acceptance, and other feelings that we do not express verbally. The presence of great anxiety and tension might not. therefore, be expressed verbally. For the purpose of investigating communication, Bales (1950) suggested a group of 12 categories that can be used to analyze the Interaction process. Interactions can be classified into four sections (positive reactions, attempted answers, questions, and negative reactions) encompassing three areas (emotional expressive, instrumental adaptive, and task). In addition, the identification of the sender and receiver are required. Another way of analyzing communications data is by grouping the sections into three areas categorized as positive, neutral, and negative (Bales. 1950, 1970; Jacobs, 1978). The positive and negative areas are related to the expression of emotional reactions and tension that indicate the needs of maintaining group integrity, whereas the neutral area is related to the execution of tasks. Nonverbal communication in the preoperative period is important for surgical patients. The objective of this study was to detect the frequency of nonverbal interaction between nursing staff and patients in the immediate preoperative situation. METHOD The subjects for the study were a sample of 10 patients who were in the hospital for surgical treatment and a nursing group that was assigned to them in the preanesthesia room of a Brazilian government teaching hospital. Direct observation of interactions between the patients and the nursing staff in the preanesthesia room was videotaped. Bales's (1950) categories were used for analyzing and classifying Interactions. The nonverbal Interactions categorized according to positive, neutral, and negative areas are shown in Table 1. The videotapes were analyzed by observers trained in the classification of interactions using Bales's criteria.
RESULTS Of 2,173 registered nonverbal interactions, 468 (21.5%) were in the positive area, 289 (13.2%) were in the neutral area, and 1,416 (65.1%) were in the negative area (see Table 2). By grouping Bales's categories in positive area (Categories 1, 2, and 3), neutral area [Categories 4, 5. 6, 7, 8, and 9), and negative area (Categories 10, 11, and 12). the predominance of the negative area over the others was verified. DISCUSSION The result of this study is contrary to Mendes and colleagues' previous studies (Mendes. 1986; Mendes, Trevizan, Nogueira. & Okino, 1988; Mendes, Trevizan, Nogueira, Takakura, & Cardoso, 1988; Mendes, Trevizan, Takakura, & Nogueira, 1988) where the neutral area predominated. The situation showed more interactions linked to the execution of tasks, despite some leaning toward verbal communication, demonstrating a mechanized and depersonalized professional relationship. The predominance of the negative area was due to the high frequency of nonverbal interaction registered in Category 11 by the 10 patients who were observed. Category 11 is defined as manifestations of impatience, tension, agitation, nervousness, demonstration of anxiety, indications that the person is alarmed,
Table 2 Distribution of Interactions According to Patients and Areas of Bales's Categories Bales's categories of areas Patient POsitive Neutral Negative Total 1 13 (6.0) 34 (15.8) 168 (78.1) 215 (100) 2 6 (3.6) 24 (14.5) 135 (81.8) 165 (100) 3 20 (6.6) 54 (23.5) 155 (67.6) 229 (100) 4 71 (25.0) 24 (8.4) 188 (66.4) 283 (100) 5 22 (9.7) 22 (9.7) 181 (80.4) 225 (100) 6 36 (22.5) 29 (18.1) 95 (59.3) 160 (100) 7 211 (49.4) 27 (6.3) 189 (44.2) 427 (100) 8 16 (14,0) 14 (12.2) 84 (73.6) 114 (100) 9 30 (19.1) 21 (13.3) 106 (67.5) 157 (100) 10 43 (21.7) 40 (20.2) 115 (58.0) 198 (100) Total 468 (21.5) 289 (13.2) 1,416 (65.1) 2,173 (100) Note. The data and the numbers within parentheses correspond to observed frequency and percentage, respectively. disturbed, or worried about something that he or she has done or intends to do. All of the 10 patients studied demonstrated tension through disturbance, moving their heads up, constant movements of their limbs, or motionless positions associated with a look of sadness and fear. The nursing personnel, however, did not perceive this nonverbal communication, as there was a low frequency of interaction exchange between the studied patients and the nursing staff in the positive area. According to Bales's equilibrium theory (Bales, 1950, 1970; Jacobs, 1978), a reaction in the negative area must be followed by another reaction in the positive area, which in this case would be the nurse's reaction. Of the 2,173 recorded nonverbal interactions, only 468 (21.5%) were classified in the positive area; on the other hand, 1,416 (65.1%) were classified in the negative area. IMPLICATIONS FOR NURSING Because these results are related to a small sample, further studies are needed before results can be generalized. Some issues, nevertheless, need to be considered. This investigation showed that surgical nurses, who assist patients during the preanesthesia period, need to maximize their ability to identify nonverbal communicative activities. They need to be prepared to respond to patients' manifestations of fear, tension, and anxiety. Nonverbal communication is the behavior that speaks silently; through it, actions are transmitted as clearly as words and are understood as displayed (Blondis & Jackson, 1982). Nonverbal behavior transmits information about the patient to the nurse and the nurse's intentions of providing care to the patient. Nurses, therefore, have to develop abilities to recognize nonverbal communication, realizing that if verbal communication is received by hearing, nonverbal communication is directed to the other senses, namely, sight, touch, smell, and taste.
Previous studies (Heidt. 1981; Pearce. 1988; Weiss, 1979) have shown the effectiveness of using touch in the care of patients. Touch as a means of nonverbal communication can be most effective in the preoperative phase by relieving tension and providing assurance and courage that will lead to recuperation in the postoperative period. Nonverbal communication on the part of the surgical nurse is of extreme importance and a vital component of nursing. REFERENCES Bales. R.F.(1950). Interaction process analysis: A method for the study of small groups. Cambridge. MA: Addison-Wesley. Bales, R. F. (1970). Personality and interpersonal behavior. New York: Holt, Rinehart & Winston. Blondis, N. M.. & Jackson, B. E. (1982). Non-verbal communication with patients: Back to the human touch (2nd ed.). New York: Wiley. Hathaway, D. (1986). Effect of preoperative instruction on postoperative out-comes: A meta-analysls. Nursing Research, 35, 269-275. Heidt, P. (1981). Effect of therapeutic touch on anxiety level of hospitalized patients. Nursing Research. 30. 32-37. Jacobs, M. K. (1978). Equilibrium theory applied to small nurse group. In Aspon Systems (Ed.), Advances in nursing science. New York: Aspon Systems Corp. Lewis, G. K. (1973). Nurse-patient communication (2nd ed.). Dubuque. IA: William C. Brown. Lindeman. C. A. (1972). Nursing intervention with the presurgical patient. Nursing Research, 21, 196-209. Undeman. C. A., & Stetzer. S. L. (1973). Effect on preoperative visits by operating room nurses. Nursing Research, 22, 4-15. Mendes. I.A.C. (1986). Interacão verbal em situacões de enfermagen hospitalar: Enfoque humanístico. Unpublished doctoral dissertation, University of São Paulo, Brazil. Mendes, I.A.C.. Trevizan, M. A., Nogueira. M. S., & Okino. N. (1988). Matriz de interação: Auxiliar de enfermagem e paciente. Reuista Gaucha de Enfermagem. 9. 43-46.
Mendes. I.A.C.. Trevizan. M. A., Nogueira, M. S.. Takakura, M. S., & Cardoso, M. C. (1988). Perfil de interação: Atendente de enfermagem e paciente. In Simpósio Brasileiro de Comunicação. em Enfermagem. Anais. São Paulo: Ribeirão Preto. Universidade de São Paulo. Mendes. I.A.C.. Trevizan. M. A.. Takakura, M. S.. & Nogueira, M. S. (1988). 0 padrão de comunicação do enfermeiro com o paciente. Revista Paulista de Enfermagem, 8. 13-16. Myers. G. E.. & Myers, M. T. (1972). The dynamics of intrapersonal communication. New York: McGraw-Hill. Pearce, J. (1988). The power of touch. Nursing Times, 84. 26-29. Schmitt.F. E.. & Wooldridge, P.J. (1973). Psychological preparation of surgical patients. Nursing Research, 22, 108-116. Weiss. J. (1979). The language of touch. Nursing Research. 28. 76-80. Ziemer. M. M. (1983). Effects of information on postsurgical coping. Nursing Research. 32. 282-286.