Communication is the exchange of information, ideas and feelings. There are three elements; verbal (written and spoken words), paraverbal (includes pitch, volume, intonation, emphasis, handwriting style) and non-verbal (includes facial expression, touch, body positioning, gestures, body adornment). Non-verbal communication (NVC) involves the exchange of ideas, feelings and information without the use of words; it provides clues to the attitude and feelings behind the words being spoken.
How important is the non-verbal element? Results from two studies conducted by Mehrabian (1971), suggested that the expression of attitudes and feelings comprised 55% NVC, with the verbal and paraverbal elements accounting for only 7% and 38% respectively of their overall communication (Figure 1). Navarro (2008) highlighted the importance of recognising people's non-verbal messages, as conveyed by their clothes, hairstyle, personal hygiene and general appearance, which imparts information about their personal and social identity. The need for a comprehensive understanding of and education in NVC skills is therefore important to help us better understand who we are talking to and how we can improve our ability to exchange ideas, information and feelings (Figures 2 and 3) (Hasson, 2012).
A growing number of studies looking at how NVC influences the clinician-patient relationship could give us some insight into the possible dynamic between veterinary surgeon and client. An observational study of patient behaviours in a GP consultation setting suggested that health professionals should pay attention to non-verbal aspects, such as slight forward lean and the use of gestures and to non-specific verbal elements, such as back-channelling (where feedback is given by the listener to show they are following and/or understanding the speaker) and social conversation, to increase favourable responses from patients (Little et al, 2015). A report that considered the impact of a nurse losing her ability to speak on her communication with patients showed, surprisingly, that the use of facial expressions and touch improved her development of empathy, intuition and active listening skills, leading to enhanced nurse-patient relationships (Kacperck, 1997). Stickley (2011) emphasised the importance of using touch and individual intuition, in addition to consideration of seating position, open posture (uncrossed legs and arms), slight lean towards the patient, eye contact and assuming a relaxed state during the consultation.
Several models for teaching NVC have been described in the medical literature; Mast (2007) and Ishikawa et al (2010) looked at the possible impact a greater awareness of NVC had on patient outcomes, such as patient satisfaction. It was suggested that training physicians and students about non-verbal behaviour can improve physician-patient communication and improve patient outcomes in the long term. NVC skills can be assessed (Collins et al, 2011); maintaining adequate facial expression, using affirmative gestures, and limiting unintended movements and hand gestures had a significant positive effect on perception of interview quality during a practical communication examination.
Physicians who express empathy in patient encounters by acting in a warm, friendly and reassuring way seem to be more effective, both in reaching patients' satisfaction and aiding recovery (Di Blasi et al, 2001). Empathy, defined as the ability to understand and share the feelings of another, is of great significance for better healthcare outcomes as part of a warm and friendly communication style (Mercer et al, 2002; 2007). In a study concerning history taking by medical students, NVC correlated significantly with verbal communication and with empathy, while verbal communication alone showed no significant correlation with empathy (Vogel et al, 2018).
Numerous studies also demonstrated that non-verbal immediacy behaviours (such as smiling, vocal variety and expressiveness, eye contact, gestures, touching and a relaxed body position, physical proximity, body orientation, body movements and gestures) are positively related to the effectiveness of teaching, student state motivation, and affective or cognitive learning outcomes. Interestingly, a recent study revealed subtle cultural differences regarding the non-verbal and verbal immediacy communication behaviours of agriculture professors in Austria, Slovenia and Albania (Klopčič et al, 2018). This was explained by noting that people in southern European countries are generally more non-verbally expressive in public than people from more northern European countries. With an international agricultural workforce in the UK this is worth reflecting on.
In social interactions, people naturally look at the person with whom they are interacting (Jakob, 1998). However, previous studies (Stivers, 1998; Roberts, 2004) have shown that veterinary surgeons tend to look at and talk to their patient rather than to the client (Figure 4).
Researchers have shown that non-verbal aspects of the physician-patient interaction, such as the physician's eye contact with the patient, are significantly related to patient satisfaction (Mast, 2007). There is evidence from psychological studies that another individual's direct gaze elicits brain activation that indicates a tendency to approach, whereas an averted gaze activates brain activation that indicates avoidance (Hietanen et al, 2008). There is also evidence that under mutual gaze conditions (i.e. direct gaze and body direction), emotional facial expressions result in more pronounced subjective experiences and physiologic responses than under averted gaze and body conditions (Schrammel et al, 2009).
What research has been conducted specifically in the veterinary field? In companion animal (CA) practice, communication strategies have been connected to specific outcomes, such as client satisfaction (Coe et al, 2010), veterinary trust (Grand et al, 2013) and veterinary satisfaction (Shaw et al, 2012). However, the existing research mainly focuses on verbal communication and excludes NVC.
Limited research into communication has been done in farm animal veterinary practice, on both verbal and NVC. The interaction in veterinary surgeon-farmer relationships may be different from CA practice; the less formal and more long-term vet-client relationships mean that certain aspects get condensed or skipped altogether in a conversation. For example, a seemingly simple question and answer can mean something more complex and gestures can replace words at times. Therefore, the farm animal consultation may have criteria that are different from small animal consultations, yet both have similar goals, such as client satisfaction and a good patient outcome.
How veterinary surgeons can use NVC in farm practice is currently not well described, yet it seems evident that there are opportunities to reflect on its use; client dissatisfaction claims often appear related to communication issues, of which NVC is likely to be a part.
GoPro camera recordings have been used to successfully record routine visits (Ritter et al, 2018) and may also provide footage which can be analysed for NVC characteristics, reflection and training. Research ongoing at the University of Nottingham and Bristol is aiming to establish a methodology to measure non-verbal parameters in the farmer-vet interaction using GoPro cameras.
To explore the use of NVC in current farm animal veterinary practice, we asked four farm veterinary surgeons, with a range of experience in farm animal practice, to reflect on their NVC and possible consequences in practice (Figure 5 and 6).
Thinking about your own use of non-verbal communication on farm, what do you think works well? How do you gauge this?
George Giles replies:
In my opinion eye contact is one of the most important forms of non-verbal communication. It enables me to gauge the meaning of a conversation and it also demonstrates that I am engaged with the topic of conversation. As farm vets we are often multi-tasking while having detailed discussions about the herd, for example discussing health issues while ultrasound scanning cows at a fertility visit. We often have our eyes obscured by ultrasound goggles, our eyes focused on scanning the image in front of us to achieve our diagnosis. Interestingly over the past year I have been using a tablet device strapped to my wrist to view my ultrasound image and often while my eyes are still fixed on the screen, I have made a conscious effort to make more eye contact and it has definitely made me more aware of non-verbal communication clues about the attitudes of people that I am interacting with. If the conversation moves to a delicate or detailed topic I will sometimes stop scanning and have a face to face conversation, it is difficult to assess whether this is due to me wanting to give my full attention to ensure that I do not misunderstand or misinterpret what information I am being given, or whether it is a subconscious way of me increasing my non-verbal communication. Either way, the most important aspect of this in my opinion is the eye contact.
Similarly our body position and stance frequently contradicts communication research which guides us to be facing and leaning into our client in a friendly manner while engaging in conversation. In my opinion a lot of non-verbal communication in farm animal practice is about being able to read the body language being shown by our clients.
More recently as a practice we have dedicated client reviews of farm performance, which is where we can utilise non-verbal communication more effectively and we see the benefit of this combined with not having to be distracted by performing other tasks at the same time. We do not routinely gauge our non-verbal communication individually, it will be based on general feedback about a vet from our clients. I think currently it would be very difficult to get a measure of this in isolation.
Owen Atkinson replies:
Well, this is something I have definitely been paying attention to in recent years. Number one, I really try and smile more. I also make sure I look at people when I talk to them, and importantly when I am listening to them. These are basics, and I believe they work well to help demonstrate that I am interested in them, and am there to listen to them and help them. I gauge success (or failure) by always reflecting on how my farm meetings have gone. This is a natural behaviour of mine now…but I know it didn't used to be.
Something I also do a lot is reaching out to touch someone on the arm or shoulder. It might be the briefest of touches (and it might be with the most initially unapproachable/guarded/aggressive person you could imagine). However, it is incredibly effective at showing that you care. This can make delivery of a hard-to-hear message much more successful. Maybe surprisingly, people don't flinch away, punch me in the face, or take the gesture in an unintended way. I find that it engenders more honest and trusting communication. I do, however, make sure that my hand is not caked in muck or bloody gunge before doing this.
Sarah Whittick replies:
The use of non-verbal communication on farm is not an area I have thought about in detail before and so a lot of the methods I currently employ will be subconscious. When reflecting about how I interact with a client on farm two main areas of non-verbal communication that I believe work well would be eye contact and body positioning.
When explaining to the client the differential diagnosis for a case I think it important to have direct eye contact and not have any equipment or animal standing in-between. While I do discuss what I am finding during the clinical examination I also find it effective to summarise the findings after the initial examination and use this to link on to the differentials list. This is done standing face to face with the farmer using direct eye contact. This enables me to gauge when more explanation is required or when they may disagree with my point as I am able to view their body language and facial expressions in response to my comments. If signs are noticed that the client disagrees with some of the explanation this enables me to rephrase my point. I aim to deliver the plan confidently and assertively and so I imagine my body language will reflect this
Jonathan Mayer replies:
In my experience, I've found simple things such as a handshake and smile while meeting clients establishes a professional rapport. I've found that eye contact and posture whether it's standing up straight or unintentional postural mimicry of the client during conversations helps as well. Assessing the outcome on any conversation on the farm can be difficult, depending on how you look at the outcome, whether it is a client requesting you back or implementation of changes you've suggested, success can be difficult to ascertain.
How important is learning about this part of communication? How could vets improve their understanding of and skill development in non-verbal communication?
George Giles replies:
I think communication skills training has improved in vet schools in recent years, however the use of non-verbal communication is not to my knowledge taught separately. Communication skill training should reflect positively with clients; we often hear from clients that they struggled with previous vets because they were ‘too academic’ or didn't understand their business, I think that often this is an issue with communication rather than a true misunderstanding of their business. The type of person that is attracted to apply to vet school will often be focused on the detailed science and facts rather than striving to become a well rounded communicator. Getting vets or vet practices to encourage feedback from clients could be a way to improve non-verbal communication, however it may be difficult to establish specific deficits in non-verbal communication as clients may not associate the acts of non-verbal communication as the limiting or most important factor.
Owen Atkinson replies:
Massively important. There are few easily accessible resources available to us, or directed at us (vets), I think, to help us improve here. Our own experiences and upbringing naturally mean we all have different levels of non-verbal communications skills. I would say I was not gifted at all in this respect, so it is something I have needed to work on. For me, my skills development probably began when I first did CowSignals training, which included some communication skills. From there, my interest was piqued, and I have since tended to gravitate towards anything which might help my communication skills. There are a lot of books out there, and we are all surrounded by opportunities to practice (my poor kids!)
Sarah Whittick replies:
The importance on non-verbal communication is likely underestimated by graduates and veterinary students and more information in the area is required to prove its value. The main area of non-verbal communication that often has guidance provided by an employer would be body adornment. Often vets are provided with a uniform and are made aware of any areas that are considered inappropriate such as certain clothing or piercings. Personal presentation is an important part of any job and will form the basis of a client's first impression about a vet. It is important that we are aware of any areas of communication that could be negatively affecting client satisfaction and clinical outcomes as they will be harmful to the client-vet relationship.
As farm vets mostly work alone, they rarely get to see how their colleagues may handle clinical scenarios differently. To understand and develop non-verbal communication it would be a useful exercise for vets to be able to observe their colleagues communicating with clients and then be able to critique what works well/not so well.
Jonathan Mayer replies:
As a significant part of communication is non-verbal and there is such little understood about the importance within a farm setting, I think it is important that more research is done, so as clinicians we can become more aware of how we can communicate better. With the increased difficulty in staffing leading farmers to hiring from a wider pool, often cultural and linguistic backgrounds may not be shared, which means a greater understanding of non-verbal communication may be required to communicate more effectively. Improving veterinarian's knowledge could come through CPD where actors could be used. This would allow an external audit of what non-verbal tools you use. The downside being this is an artificial environment, and it may be hard to audit how you use non-verbal communication on farm.
How do you think farm animal vets compare to other farmrelated stakeholders (foot trimmer, AI tech, nutritionist, accountant) regarding the way we use non-verbal communication?
George Giles replies:
I believe that often vets would compare comparatively with other farm technicians such as AI technician or foot trimmer in their approach to non-verbal communication. The reality often being that little if any thought is given to non-verbal communication on a day to day basis. The practical task presented in front of them is the priority and therefore non-verbal communication is low down on their priority list. I think that advisors and even sales people have much more training in non-verbal communication and can often have an easier platform to implement NVC as they are able to offer their full attention to the farmer without having a patient in front of them and a farmer expecting them to multi task. I think that there is currently a huge variation between farm animal vets and their ability to use NVC, research has shown repeatedly that farmers class their vet as one of their most trusted advisors and this gives farm animal vets a huge opportunity to maximise the benefit of NVC.
Owen Atkinson replies:
I'm not sure we are any different. I think there is a wide range of skills within all of those aforementioned fields. Successful consultants tend to have good communication skills because the relationship part of their work is arguably more essential than for some of the other professionals. In other words, a vet, AI technician or foot trimmer with appalling communication skills can perhaps get away with it more as they can to some degree compensate by being technically excellent.
Sarah Whittick replies:
Farm animal vets will have more direct contact with the farmer than some other stake holders such as the foot trimmer and AI tech as often they perform the work without the farmer being present. Other stake holders which act in more of a consultancy role, such as nutritionists, may well perform better than vets as their visits on farm are solely based on communication and ensuring they convey the correct message. They will likely have better exposure to different non-verbal communication tools and will be presented with less distraction on their farm visits in comparison to vets who may have to be examining a number of animals while discussing an unrelated topic. As discussed above, non-verbal communication is likely undervalued and therefore under used by farm vets who may rely on other areas of communication they deem more important.
Jonathan Mayer replies:
It is hard to compare how other stakeholders communicate on farm, often the relationship is different, so potentially a different style of communication is needed. I'd hope that through training at universities and CPD veterinarians are more aware of communicative tools and the importance of it, though equally some people may be naturally better communicators than others.
Do you think the role of non-verbal communication will be more or less important in the future and why?
George Giles replies:
I think it will be more important. As we continue to have more information at our fingertips the role of the farm vet in my opinion will be to facilitate clients to make more informed decisions about the variety of sometimes conflicting information in front of them. NVC is a core requirement for a successful facilitator.
Owen Atkinson replies:
In the future? It is and has been important for always. It might continue to be neglected, but that is not what I hope for.
Sarah Whittick replies:
Non-verbal cues will likely remain just as important in the future as at the present time but potentially their value will be better understood. Effective communication is key for a good vetfarmer relationship and poor communication is frequently the source of discontent. Therefore any tools that increase the effectiveness of communication, whether that be verbal or non-verbal, should be capitalised on by the profession to improve the vet-farmer interaction.
Jonathan Mayer replies:
An argument for the importance is that despite a large proportion of communication with farm clients occurring over the phone, when on farm it is important to communicate effectively.
On the other hand, with the increasing use of technology it would be interesting to see if videocalls are used more for advice where non-verbal communication would be important. With the increased use of technology people may also start to de-skill with communication whether it is in a verbal or non-verbal sense.
What aspects of non-verbal communication would you like to learn more about?
George Giles replies:
I would like to understand more about some of the subtle aspects to NVC and to learn more about the signals that I am giving out. I sometimes find myself with my arms folded when talking to farmers and realise that this could be seen as a negative form of NVC.
Owen Atkinson replies:
I'm a sucker for any opportunity to learn and experience better communication. There are surely things which I am unknowingly unknowing about and so these are the aspects I would most welcome to be brought into my sphere.
Sarah Whittick replies:
Currently there appears to be little known as to how important non-verbal communication is when used by farm vets. Although this has been explored and demonstrated in similar professions the vet-farmer relationship is very different to client relationships in the small animal sector. Often the vet can visit the farm weekly and so has much more exposure to a client resulting in better understanding as to what types of communication are effective on particular farms.
Any techniques that help gain trust with the client, improve client satisfaction and result in successful clinical outcomes should be explored and utilised.
Jonathan Mayer replies:
I feel that I would like to improve my knowledge on all aspects of non-verbal communication but specifically, I would be interesting in learning about which non-verbal tools could be used to improve communication with people that have a difficult linguistic and cultural background to my own.
What would you recommend academic research could do/not do to support this?
George Giles replies:
The starting point for academic research would be to assess the current levels of NVC of farm animal vets and to then gain an understanding of what ‘good’ looks like. This could then be trialled and once significant findings are sought it could be fed back to the profession.
Owen Atkinson replies:
Anything. For example, even the most simply designed observational study could help hold a mirror up to ourselves, and this could help us self-improve. There might be some vets who need to see an evidence base for a certain intervention or communication style before having their interest stimulated, or to gain sufficient confidence to pursue a specific methodology. It would be interesting to know how many readers have skipped this article in preference for more ‘scientific’ items, or how many have been drawn to this article to read first. That in itself could be telling. It might be a reflection point for the individual too. Why did they make the choice they did? Research possibilities are endless. However, what might be more useful is sharing experiences; encouraging more mentoring within the profession and opening ourselves up to non-veterinary personal development. It is fantastic that this article has been written and I wish the authors a lot of success in developing as wide a reach as possible in this important aspect of our veterinary work.
Sarah Whittick replies:
Academic research would need to clearly demonstrate the importance of non-verbal communication on farm in order for it to be integrated into training of farm vets. A lot of non-verbal communication happens without either party realising it and therefore it is difficult to measure its effectiveness if people aren't even aware it's happening. It is also harder as farm vets to deliver effective non-verbal communication as often there is not a direct line of sight between the farmer and the vet during communication and so the job is heavily reliant on verbal communication in these instances. Equally lots of instances involve delivery of advice by telephone and so verbal communication still has to be heavily relied upon in the profession.
Jonathan Mayer replies:
It would be interesting for research to look at non-verbal communication between people from different linguistic and cultural backgrounds within a farm setting.