Communication

RESEARCH ARTICLE Open Access

Evidence of nonverbal communication
between nurses and older adults: a scoping
review
Esther L. Wanko Keutchafo* , Jane Kerr and Mary Ann Jarvis

Abstract

Background: Communication is an integral part of life and of nurse-patient relationships. Effective communication
with patients can improve the quality of care. However, the specific communication needs of older adults can
render communication between them and nurses as less effective with negative outcomes.

Methods: This scoping review aims at describing the type of nonverbal communication used by nurses to
communicate with older adults. It also describes the older adults’ perceptions of nurses’ nonverbal communication
behaviors. It followed (Int J Soc Res 8: 19-32, 2005) framework. Grey literature and 11 databases were systematically
searched for studies published in English and French, using search terms synonymous with nonverbal
communication between nurses and older adults for the period 2000 to 2019.

Results: The search revealed limited published research addressing nonverbal communication between older
adults and nurses. The studies eligible for quality assessment were found to be of high quality. Twenty-two studies
were included and highlighted haptics, kinesics, proxemics, and vocalics as most frequently used by nurses when
communicating with older adults; while studies showed limited use of artefacts and chronemics. There was no
mention of nurses’ use of silence as a nonverbal communication strategy. Additionally, there were both older
adults’ positive and negative responses to nurses’ nonverbal communication behaviors.

Conclusion: Nurses should be self-aware of their nonverbal communication behaviors with older adults as well as the
way in which the meanings of the messages might be misinterpreted. In addition, nurses should identify their own
style of nonverbal communication and understand its modification as necessary in accordance with patient’s needs.

Keywords: Nonverbal communication, Nurses, Older adults

Background
Communication is a multi-dimensional, multi-factorial
phenomenon and a dynamic, complex process, closely re-
lated to the environment in which an individual’s experiences
are shared [1]. Regardless of age, without communication,
people would not be able to make their concerns known or
make sense of what is happening to them [2]. Communica-
tion links each and every person to their environment [3],

and it is an essential aspect of people’s lives [4]. In healthcare
settings, communication is essential in establishing nurse-
patient relationships which contribute to meaningful engage-
ment with patients, and the fulfilment of their care and social
needs [5]. Effective communication is a crucial aspect of
nursing care and nurse-patient relationships [6–8]. In health-
care encounters with older adults, communication is import-
ant, in particular to understand each person’s needs and to
support health and well-being [9]. However, older adults
may experience hearing deficits, changes in attention and
coding of the information [10], and these communicative

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* Correspondence: [email protected]
Discipline of Nursing, School of Nursing and Public Health, University of
KwaZulu-Natal, 71 Manor Drive, Manor Gardens, Durban 4001, South Africa

Wanko Keutchafo et al. BMC Nursing (2020) 19:53
https://doi.org/10.1186/s12912-020-00443-9

disabilities may restrict their interaction, participation and ef-
fective communication [11].
Communication occurs through verbal or nonverbal

modalities [12, 13]. Nonverbal communication (NVC) is
defined as a variety of communicative behaviors that do
not carry linguistic content [14] and are the messages
transmitted without using any words [15, 16]. NVC can
act as a counter measure or an adjunct to verbal mes-
sages, in that it is more reliable if there is inconsistency
between verbal and nonverbal messages [17]. Therefore,
it is important that there is congruence between nonver-
bal and verbal messages [18], with research showing that
patients are particularly alert to nurses and nurse-aids
nonverbal behaviors [17, 19–21], especially when they
are anxious and feel uncertain [14]. Despite the value of
communication, it has been shown that healthcare
workers spent very little time communicating with pa-
tients not satisfied with the information they received
and how it was communicated [22]. Though verbal com-
munication behaviors of healthcare providers have been
extensively studied, their NVC behaviors have received
less attention [17].
Scholars have varied in their estimations of the pro-

portion of NVC in communication, with estimates as
high as 93% [23], with other estimates of 60 to 90% [24].
Moreover, scholars have described different modalities
of NVC, including artefacts (presence of physical and
environmental objects), chronemics (use and perception
of time), haptics (use of touch), kinesics (form of move-
ment of the body), physical appearance (body type and
clothing), proxemics (use of space and distance), vocalics
(aspects of the voice), and silences [23, 25–27].
Concern needs to be directed on NVC and its different

modalities as critical contributors to high quality care
which plays a significant role in demonstrating respect
for patients, fostering empathy and trusting provider-
patient relationships [24]. A significant relationship ex-
ists between patient’s perceptions of empathy and eye
contact and social touch [28], with touch, and gestures
described as communication facilitators [27]. Nurses’
positive facial expressions demonstrate signs of bonding,
respect and affection towards older patients [29] while
voice tones have contributed decisively to the success of
interactions with older adults [30]. On the other hand,
limited time has been reported by patients to have a
negative impact on communication [31, 32], demon-
strated in gestures of irritability which have caused em-
barrassment in older patients [29], and speaking fast has
been a further communication barrier between nurses
and patients [32]. The present review suggests the im-
portance of understanding NVC between nurses and
older adults, and underscores the need for focused re-
search to address the gap in the knowledge of communi-
cation in geriatric care. The primary aim of the study

was to identify the type of NVC strategies used by
nurses to communicate with older adults in both acute
care settings and long-term care settings.

Methods
In order to map evidence-based knowledge and gaps
[33–35] related to NVC between nurses and older
adults, a systematic scoping review was conducted. Scop-
ing reviews are useful to map the existing literature
around a particular topic by charting findings and identi-
fying research gaps [36], especially when the topic is
complex or poorly reviewed [37]. A scoping review was
chosen over a systematic review because the purpose of
the study was to identify knowledge gaps related to non-
verbal communication, as opposed to confirming or re-
futing the basis of current practice against relevant
evidence [38]. The study adopted the framework pro-
posed by Arksey and O’Malley [36] and further refined
by Levac et al. [39]. The Preferred Reporting Items for
Systematic reviews and Meta-Analyses extension for
Scoping Reviews (PRISMA-ScR) Checklist [34] was
followed for this review (Additional file 1).

Research questions
The main question for this review was: What is the evi-
dence of NVC between nurses and older adults? The sub
questions were: (i) What are the different modalities of
NVC used in geriatric nursing care? (ii) What are the
functions of using the different NVC modalities? (iii) How
do older persons respond to different NVC modalities?

Eligibility criteria
The JBI framework of Population, Concept, Context
(PCC) was used to determine the eligibility of the re-
search question for this review (Table 1).

Population
Nurses including nursing students were considered in
addition to qualified nurses and nurse aides because they
are the largest population of healthcare workers [40].

Concept
The focus was NVC between nurses and older adults
(≥60 years). For the purpose of this review, the United
Nations cut-off of 60 years and older referring to the
older adult population in Africa [41] was considered; yet,
most Upper Income Countries have accepted the
chronological age of 65 years and older, the age of retire-
ment, as a definition of an older adult [42]. Socio-
economic and disease reasons suggest that 65 years is
not readily applicable to the African context [43].
Older adults with dementia were excluded although

they are able to send and receive nonverbal information
[39]. Dementia care combines comorbidities, cognitive

Wanko Keutchafo et al. BMC Nursing (2020) 19:53 Page 2 of 13

and functional decline; leading to complex needs and
ever-increasing difficulty for the patient in articulation
[44], which is viewed as a challenging form of care.

Context
Acute settings and nursing homes were included into
the context. In nursing homes, care is usually carried
out by nursing staff with different levels of education
and training [45]. Furthermore, community settings were
excluded from the context because hospitalization is po-
tentially stressful and involves unpleasant experiences
for patients and their families [1], and thus offers a
greater opportunity to identify the phenomenon under
discussion.

Search strategy
The search terms for this review originated from
indexed subject headings, keywords of relevant studies,
that recurred repetitively, and the Medical Subject Head-
ings (MeSH) terms. The term ‘nonverbal communica-
tion’ was used as a starting point to develop a search
string and identified other keywords to refer to NVC.
The string/Boolean search terms for this review in-
cluded: Participants (“nurses” OR “registered nurse” OR
“professional nurses” OR “students nurses” OR “nurse
aides”) AND Concept (“nonverbal communication” OR
“kinesics” OR “proxemics” OR “artefacts” OR “chrone-
mics” OR “haptics” OR “vocalics” OR “physical appear-
ance” OR “active listening” OR “silences”) AND Context
(“old people” OR “elder” OR “elderly” OR “older people”
OR “aged” OR “geriatrics”).

Database searching
A range of sources were used to ensure a comprehensive
coverage of the literature. An initial search was con-
ducted in August 2017, repeated and finalized in No-
vember 2019 The search made use of the following
databases: Pubmed, Science Direct, Sabinet, Academic
search complete, CINAHL with Full Text, Education
Source, Health Source- Consumer Edition, Health
Source: Nursing/Academic Edition, and MEDLINE.

Google Scholar and Open Grey engines were also used
to source relevant literature. Additionally, the reference
lists of the included studies were used to search for add-
itional studies. Only studies written in either English or
French were retrieved.
Evidence of nurses’ NVC strategies while communicat-

ing with older adults, conducted in acute settings, and
published in English or in French between 2000 and
2019 were included. Quantitative, qualitative, mixed-
methods primary research studies, and reviews published
in peer-reviewed journals, and grey literature that ad-
dressed the research question such as book chapters,
thesis and reports were included. Evidence on communi-
cation with older adults suffering from communication
impairment or dementia, in psychiatric units or commu-
nities, published in languages other than English or
French were excluded. Evidence published before 2000
were excluded.

Study selection
The titles were reviewed against the eligibility criteria by
EW. This initial search was monitored, exported into
EndNote X9 reference manager, for abstract and full text
screening by EW. The duplicated studies were deleted,
followed by independent reviewing of the abstracts by
EW and JK. Studies deemed ‘unclear’ were advanced to
the subsequent screening stage. Assistance from the
study university library services was requested when full
texts could not be retrieved from the databases and five
full texts were provided. Full text of 75 eligible studies
were independently filtered by EW and JK using Google
forms. Additionally, a search of the reference list of all
identified reports and studies for additional studies was
performed by EW. MAJ pronounced on the discrepan-
cies that occurred during the abstract screening and the
full text screening until a consensus was reached.

Data extraction
Information relevant to the aim of this study were ex-
tracted independently by EW and JK. A data extraction
form was developed electronically using Google forms.

Table 1 PCC framework used to determine the eligibility of the research question

Criteria Inclusion Exclusion

Population Professional nurses, registered nurses, enrolled nurses, nurse
aides
Nursing students

Nurses working in community settings
All other healthcare workers
Informal geriatric care givers

Concept Nonverbal communication strategies and interpreted meaning
between nurses and older adults (≥60 years)

Verbal communication between nurses and older adults
Nonverbal communication strategies of older adults
Nonverbal communication with nurses and older adults with
communication impairments or disorders or dementia.

Context Acute settings, nursing homes, long-term care Acute hospital settings
End-of-life / Terminal care unit;
Psychiatric / mental health care unit;
Communities

Wanko Keutchafo et al. BMC Nursing (2020) 19:53 Page 3 of 13

Extracted data included bibliographic details, country
and setting, aim/objective, study design, targeted popula-
tion, nurses’ nonverbal strategies used while communi-
cating with older adults, older adults’ interpretation of
nurses’ nonverbal behaviors, and relevant outcomes of
interest. Discussions between EK and JK refined the
table of information extracted.

Quality appraisal
The Mixed Methods Appraisal Tool (MMAT), version
2018 [46] was independently used by EW and JK to crit-
ically appraise the quality of the included primary stud-
ies. Discussion was used to resolve discrepancies. The
MMAT allowed for assessment of the appropriateness of
the aim of the study, adequacy and methodology, study
design, participant recruitment, data collection, data
analysis, and the presented findings [46]. The quality
of studies was graded with a quality score ranging
from ≤ 50% as low quality, 51–75% considered as an

average quality, and 76–100% considered as high
quality (Table 3).

Collating and summarizing the data
Content thematic analysis approach [64] was employed
to extract relevant data that answered the study ques-
tions. The results of the included studies were summa-
rized, manually coded, and presented using a narrative
approach. The nurses’ NVC behaviors were categorized
under nine items namely (i) artefacts; (ii) chronemics;
(iii) haptics; (iv) kinesics; (v) proxemics; (vi) vocalics;
(vii) physical appearance; (viii) active listening; and (ix)
silence.

Results
Two hundred and fifty-seven (257) studies met the eligi-
bility criteria following the deletion of 478 duplicates
from the 735 studies identified at the title screening
stage (Fig. 1).

Fig. 1 PRISMA 2009 Flow Diagram

Wanko Keutchafo et al. BMC Nursing (2020) 19:53 Page 4 of 13

Characteristics of included studies
Tables 2 and 3 summarize the characteristics of the 22
included studies. All included studies were published in
English and no eligible French studies were identified.

Study designs
Diverse research methods were employed within the 22
included studies. Thirteen studies were qualitative stud-
ies using individual interviews [19, 47, 55, 58, 60, 65],
focus groups [51, 65], participant observations including
video recordings [30, 47–49, 52, 57, 60], and participant

logs [54]. There were one survey [59], one randomized
controlled trial study [62] as well as one mixed methods
study [53]. The other studies were a review [50] and two
reflections [61, 63]. Three studies were related to con-
tinuous professional development [3, 4, 56].

Quality of evidence
Of the 22 included studies, 16 studies underwent meth-
odological quality assessment using the MMAT version
2018 [46]. The remaining six [3, 4, 50, 56, 61, 63] were
excluded from the quality appraisal because they were

Table 2 Characteristics of the included studies (1)

Author(s) and year Country Setting Design Sample sizes Quality
appraisal

Johnsson et al. 2018
[47]

Sweden Wards in a department of
medicine for older people

Qualitative: observations, field
conversations, and semi-structured
interviews

40 nurses and 40 older
adults

100%

Freitas 2016 [30] Brazil Family health unit Qualitative: video recording 32 nurses and 32 older
adults

100%

Small et al. 2015 [48] Canada Long term care Qualitative: observation (video recording)s 27 staff and 27 older
adults

100%

Freitas 2014 [49] Brazil Family health unit Qualitative: video recording 32 nurses and 32 older
adults

100%

Levy-Storms et al. 2011
[51]

USA Nursing home Qualitative: focus groups 17 nurse aides and 15
older adults

100%

Medvene and Lann-
Wolcott 2010 [19]

USA Assisted living facility and
nursing home

Qualitative: individual interviews 16 nurse aides 100%

Backhaus 2009 [52] Japan Nursing home Qualitative: observations 100 nurses and 57
older adults

100%

Gilbert and Hayes 2009
[53]

USA Nurse practitioners’ offices Mixed: observations (video recordings),
survey

31 nurse practitioners
and 155 older adults

100%

Sorensen 2009 [54] the
Balkans

Nursing home and
rehabilitation unit

Qualitative: nursing students’ logs 10 third-year nursing
students

100%

Williams and Warren
2009 [55]

USA Assisted living facility Qualitative: interviews and fieldwork 11 nursing assistants
and 39 older adults

100%

Carpiac-Claver and Levy-
Storms 2007 [57]

USA Nursing homes and assisted
living facilities in USA

Qualitative: observations (video
recordings)

17 nurse aides and 17
older adults

100%

Kaakinen et al. 2001 [65] USA Care facilities, clinics, and
private practice

Qualitative: one focus group and in-depth
interviews

12 nurse practitioners 100%

Jonas 2006 [58] Canada Long term care Qualitative: semi-structured interviews 19 older adults 100%

Tuohy 2003 [60] Ireland Continuing care unit Qualitative: participant observations and
eight semi-structured interviews

8 s year diploma
nursing students

100%

Butts 2001 [62] USA Two nursing homes Quantitative: randomized control trial 72 older adults 100%

Park and Song 2005 [59] Korea Medical, surgical, and
ophthalmology units

Quantitative: survey 136 nurses and 100
older adults

80%

Daly 2017 [4] Ireland Not reported Grey: Continuous Professional
Development

N/A N/A

Williams 2013 [50] USA Literature Review N/A N/A

Calcagno 2008 [56] USA Long-term care Grey: Continuous Professional
Development

N/A N/A

Linda 2002 [3] UK Not reported Grey: Continuous Professional
Development

N/A N/A

Bush 2001 [61] Germany Not reported Grey: author’ s reflection N/A N/A

Babikian 2000 [63] USA Long term care Grey: authors’ reflection N/A N/A

Wanko Keutchafo et al. BMC Nursing (2020) 19:53 Page 5 of 13

Table 3 Characteristics of the included studies (2)

Author(s) and
year

Objective Outcomes reported Conclusions

2018 Johnsson
et al. 2018
[47]

To describe how nurses communicate with older
patients and their relatives in a department of
medicine for older people in western Sweden

Nurses’ nonverbal communication strategies:
standing position, eye gaze, speaking faster,
speaking louder, speaking with a friendly tone,
kneeling down, closing the door, smiling, facial
expressions, smiling

Proxemics, kinesics,
vocalics

2017 Daly 2017 [4] To explore communication between nurses and
older adults, with an emphasis on promoting
effective communication in practice

Nurses’ nonverbal communication strategies:
considering the environment, using touch
appropriately, positioning oneself at the same
level, active and compassionate listening

Artefacts, haptics,
proxemics, active
listening

2016 Freitas 2016
[30]

To assess proxemics communication between
nurse and elderly in nursing consultation

Nurses’ nonverbal communication strategies:
posture-Sex, sociofugo-sociopeto axis, distance
evaluation, kinaesthetic, contact behaviour, visual
code, thermal code, olfactory code, voice Volume

kinesics, vocalics,
haptics, proxemics,
artefacts

2015 Small et al.
2015 [48]

To explore the nature of communication between
care staff and residents when they do not share
the same language and ethno cultural
backgrounds

Nurses’ nonverbal communication strategies:
pointing, touching, eye gazing, smiling, sitting
next, head nodding, playful gestures

kinesics, proxemics,
haptics

2014 Freitas 2014
[49]

To analyse the performance of nurses in nursing
consultation for the elderly based on the
theoretical framework of Hall

Nurses’ nonverbal communication strategies:
posture-sex, sociofugo-Sociopeto axis, distance
evaluation, kinaesthetic, contact behaviour, visual
code, thermal code, olfactory code, voice Volume

kinesics, vocalics,
haptics, proxemics

2013 Williams 2013
[50]

To review evidence-based strategies for effective
communication with older adults across long-term
care settings

Nurses’ nonverbal communication strategies: eye
contact, facial expressions, singing, humming,
touching.
Patients’ responses of nurses’ nonverbal
communication strategies: dominance, disinterest

kinesics, haptics
negative responses

2011 Levy-Storms
et al. 2011
[51]

To characterise the meaning of and experiences
with individualized care from the perspectives of
both nursing aides and nursing-home residents

Nurses’ nonverbal communication strategies:
listening, touching the shoulder
Patients’ responses of nurses’ nonverbal
communication strategies: respect, favouritism

haptics, active
listening
Mixed responses

2010 Medvene and
Lann-Wolcott
2010 [19]

To identify the communication behaviours and
strategies used by socially skilled geriatric nurse
aides working with residents in long term care
facilities

Nurses’ nonverbal communication strategies:
touching, smiling, spending time with, observing
body posture;

haptics, kinesics,
chronemics

2009 Backhaus
2009 [52]

To examine the special nature of communication
between residents and staff in a Japanese elderly
care institution by taking a cross-cultural
perspective

Nurses’ nonverbal communication strategies: kiss,
hand shake, military tone

haptics, vocalics

2009 Gilbert and
Hayes 2009
[53]

To examine contributions of older patients’ and
nurse practioners’ characteristics and the content
and relationship components of their
communication to patients’ proximal outcomes
and longer-term outcomes, and contributions of
proximal outcomes to longer-term outcomes

Nurses’ nonverbal communication strategies: gaze,
nod or shake of the head, eyebrow movement,
smile, touch

kinesics, haptics

2009 Sorensen
2009 [54]

To demonstrate and discuss how personal
competence, with emphasis on communication
and empathy, can be developed by nursing
students through international clinical practice

Nurses’ nonverbal communication strategies: body
contact, pointing, nodding, smiling, laughing,
active listening, voice pitch, thumbs up,

kinesics, vocalics,
active listening,
haptics

2009 Williams and
Warren 2009
[55]

To explore how communication affects issues
relating to residents maintaining cognitive and
physical functioning so that they are able to
remain in residence

Nurses’ nonverbal communication strategies: talk
louder.
Patients’ responses of nurses’ nonverbal
communication strategies: rudeness; disinterest in;
disdain for; perceived hypocrisy; threats to
noncompliance; infantilization of residents;
adultification of residents;

Vocalics
Negative responses

2008 Calcagno
2008 [56]

To provide pointers to help clinicians listen to the
needs and concerns of their clients

Nurses’ nonverbal communication strategies:
greeting with a smile and handshake, sitting face-
to-face, leaning forward, sitting close enough, lis-
tening, having an open posture

active listening,
kinesics, proxemics

2007 Carpiac- To identify types and examples of nurse aide- Nurses’ nonverbal communication strategies: kinesics, haptics,

Wanko Keutchafo et al. BMC Nursing (2020) 19:53 Page 6 of 13

not primary studies. The 16 studies which underwent
methodological quality assessment showed high meth-
odological quality and scored between 80 and 100%. Of
these studies, 15 studies [19, 30, 47–49, 51–55, 57, 58,
60, 62, 65] scored 100%, and one [59] scored 80%.

Study results
Three outcomes were reported in the studies: the NVC
behaviors of nurses, the functions of those behaviors and
the responses of older adults to the NVC behaviors.

Nurses’ NVC behaviors and their functions
Of the 22 included studies, 20 reported on nurses’ NVC
behaviors including haptics, kinesics, proxemics, vo-
calics, active listening, artefacts, and chronemics. There
was no mention of physical appearance nor silences in
all the included studies.

Haptics
Haptics were reported in 17 studies [3, 4, 19, 30, 48–54,
57, 60–63, 65] of which 12 studies, which underwent

quality appraisal, were of high quality. Haptics were
identified when nurses shook hands with older adults,
held their hands, stroked or touched their hands. Nurses
also kissed older adults, hugged them or gave them a pat
on the shoulder.
In a study aiming at examining the special nature of

communication between residents and staff in a Japanese
elderly care institution, haptics were referred to as a
handshake given by a member of staff against one older
adults will [52]. This type of touch was used in a joking
manner in Japan, where handshakes are uncommon, but
was imposed on the older adult who did not appreciate
it [52]. In another study conducted on types and exam-
ples of nurse aides-initiated communication with long-
term care residents during mealtime assistance, haptics
referred to a handshake when staff praised the older
adults for eating all their food or to a touch on the arm
for raising attention [57]. Stroking older adults’ hands
were reported to be a means of conveying attention or
affection while holding one older adult’s head back was
used by a nurse to appease a negative response from the

Table 3 Characteristics of the included studies (2) (Continued)

Author(s) and
year

Objective Outcomes reported Conclusions

Claver and
Levy-Storms
2007 [57]

initiated communication with long-term care resi-
dents during mealtime assistance in the context of
residents’ responses

smiling, touching, laughing, singing, eye gazing,
leaning forward, nodding, shaking hands, high
pitch, soft tone

vocalics

2001 Kaakinen
et al. 2001
[65]

To describe communication between nurse
practitioners and elderly clients

Nurses’ nonverbal communication strategies:
touch, time, flyers, listening, drawings, pamphlets,
written instructions; books; education files

artefacts, chronemics,
haptics, active
listening

2006 Jonas 2006
[58]

To explore the experience of being listened to for
older adults living in long-term care facilities

Patients’ responses of nurses’ nonverbal
communication strategies: nurturing contentment,
vital genuine connections, respect and benefit

Active listening
Positive responses

2005 Park and
Song 2005
[59]

To determine and compare the communication
barriers perceived by older inpatients and nurses
caring for them, with the aim of identifying the
disparities between the perceptions of the two
parties

Nurses’ nonverbal communication strategies:
speaking far away, without eye contact, with mask
on, too loudly, too fast.
Patients’ responses of nurses’ nonverbal
communication strategies: working without a
sincere attitude, being unfriendly, showing no
respect

proxemics, kinesics,
artefacts, vocalics
negative responses

2003 Tuohy 2003
[60]

To ascertain how student nurses communicate
with older people

Nurses’ nonverbal communication strategies:
talking louder and slower, eye contact, facial
expressions, appropriate touch

vocalics, kinesics,
haptics

2002 Linda 2002
[3]

To explore the skills that are required for effective
communication with older people

Nurses’ nonverbal communication strategies: body
movements, postures, gestures, touch, proximity,
pace of approach, eye contact, demeaning tone,
speaking too quickly

kinesics, vocalics,
haptics, proxemics

2001 Bush 2001
[61]

Author’s reflection on active listening Nurses’ nonverbal communication strategies:
leaning over, holding hand, active listening, eye
contact, spending more time, notes, learning
tools, posture, physical proximity

haptics, kinesics,
active listening,
chronemic, artefacts,
proxemics

2001 Butts 2001
[62]

To examine whether comfort touch improved the
perceptions of self-esteem, well-being and social
processes, health status, life satisfaction and self-
actualization, and faith or belief and self-
responsibility

Patients’ responses to nurses’ nonverbal
communication strategies: improved perception of
self-esteem, well-being, social processes, health
status, life satisfaction, self-actualisation, and faith
or belief

Haptics
Positive responses

2000 Babikian 2000
[63]

Author’s reflection on her encounter with an old
person

Nurses’ nonverbal communication strategies:
holding of hand, sitting next to

proxemics, haptics

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older adult in a study exploring the nature of communi-
cation between care staff and residents who did not
share the same languages and ethno-cultural back-
grounds [48].
Hugs were mentioned as a deliberate communication

strategy used by a nurse practitioner to meet the unique
needs of older adults in a study aimed at describing
communication between nurse practitioners and older
adults [65]. Hugs were also reported by nurses as a con-
scious NVC strategy specific to each older adult to es-
tablish rapport and prevent communication breakdowns
between nurses and older adults [48]. An example was
demonstrated through staff rubbing the sleepy older adult
under the chin as a form of stimulus [48]. Additionally, a
pat on the shoulder was mentioned as a caring gesture in
a study aimed at characterizing the meaning of and expe-
riences with individualized care from the perspectives of
both nursing aides and nursing home residents [51].
However, a kiss on an older adult male’s forehead was
described as inappropriate conduct [52].

Kinesics
Kinesics was reported in 14 studies [19, 30, 48–50, 53,
54, 56, 57, 59–61] of which 8 studies, which underwent
quality appraisal, were of high quality. Nursing students
developing personal competence in international clinical
practice, used pointing and thumbs up, as movements of
the hands, to communicate nonverbally when words
were in short supply [54]. Further, a Swedish study de-
scribed nurses’ use of pointing to communicate with
older adults and their relatives in a department of
medicine for older adults [47].
Kinesics also referred to as movements of the head,

included facial expressions, movements of the eyes, and
head nods. Student nurses’ use of facial expressions and
eye contact were described as components of effective
communication with older adults [60]. While facial
expressions such as a smile and laugher were reported
to both quickly and amicably resolve disagreements
between staff and older adults, smiles were seen as
enhancers of the communication in a study where staff
occasionally engaged in smiling with older adults [48]. A
nurses’ smile was also seen as a way to either convey the
message [54], to initiate communication [57] or an
attempt to create a positive atmosphere during the
meeting with older adults [47].
Student nurses described head nodding as a means to

convey their message nonverbally when communicating
with older adults [54]. Nodding was also used to convey
communicative intent nonverbally, to indicate acceptance
or rejection of staff’s actions [48], and to address or to
praise the older adult [57]. Additionally, nodding was used
by nurses to show that they had understood what older
adults and their relatives had said [47].

Eye gaze was seen as nurses’ willingness to be engaged
in conversation in a review on evidence-based strategies
for effective communication with older adults across
long-term care settings [50]. Eye gaze was also used to
gain older adults’ attention, or as means to both connect
relationally and instrumentally [48]. Additionally, eye
gazing was used to gain older adults’ attention, when the
nature of communication between care staff and resi-
dents using different languages and having ethno-
cultural backgrounds was explored [48]. Eye contact was
suggested as advice to effectively communicate with
older adults [3], or a means of improving communication
skills [61]. However, Visual Code factor was among the
factors that received the lowest scores in a study analyzing
the performance of nurses in nursing consultation for the
older adults based on the theoretical framework of Hall
[49]. The low score was justified by the unpreparedness of
nurses about the aging process [49].
Movements of the body included leaning over older

adults to assess their progress [61] or to check on them
in a study conducted on types and examples of nurse
aide-initiated communication with long-term care resi-
dents during mealtime assistance [57]. Additionally,
leaning forward was a means to indicate the nurses’
eagerness and readiness to listen to the older adults’
stories, in a study providing pointers to help clinicians
listen to the needs and concerns of older adults [56].

Proxemics
Proxemics, defined as the social meaning of space and
interactive field, which determines how relationships
occur [115] were reported in 10 studies [3, 4, 30, 47, 49,
56, 59, 61, 63], and included physical proximity and
physical distance. Of these studies, eight were of high
quality based on the MMAT assessment.
Speaking far away was mentioned as a nurse-related

communication barrier perceived by both older adults
and nurses [59]. Additionally, a Swedish study noted that
nurses remained standing while using a medical voice to
communicate with older adults, [47]. In contrast, nurses
positioning themselves at the same level as older adults
was a strategy to support their communication with
older adults [4]. Sitting next to older adults was part of
the playful gestures nurses engaged in, in a study which
explored the nature of communication between care
staff and residents with different languages and ethno-
cultural backgrounds [48]. Likewise, pointers to help cli-
nicians listen to the needs and concerns of older persons
included physical presence to enhance the ability to
listen and show interest [46], sitting by the older adult’s
side to hold their hand [63], sitting face to face to indi-
cate presence and the readiness to listen [56]. On the
contrary to the literature supporting engagement on the
same plane, kneeling down was also used by nurses to

Wanko Keutchafo et al. BMC Nursing (2020) 19:53 Page 8 of 13

make eye contact with older adults and seen in the
instance of planning a good home return [47].

Vocalics
Vocalics were reported in nine studies [30, 47, 49, 52,
54, 55, 57, 59, 60] where they described different aspects
of the voice tone and sense of calm. All the eight studies
that underwent quality appraisal were of high quality.
A military tone with endearment used to address an

older adult, in a Japanese elderly care institution, was not
appreciated even though used in jest [52]. Conversely, al-
though to no avail, a soft tone was used by a nurse to en-
courage an older adult to eat her food [57]. Additionally,
speaking too quickly and in a demeaning tone were re-
ported as barriers to effective communication [3]. Likewise,
speaking too loudly and speaking too fast were nurse-
related communication barriers as perceived by nurses and
older adults [59]. Speaking faster and with a monotonous
tone were reported when nurses used a medical voice to
communicate with older adults as well as speaking louder
and with great emphasis on selected words were reported
when nurses used a power voice [47].
Conversely, speaking calmly contributed to create mu-

tual trust in the student nurse-older adult relationships
in a study demonstrating that communication and em-
pathy can be developed by student nurses through clin-
ical practice [54]. Speaking slower was a means for
student nurses to be understood by older adults [60],
and speaking with a friendly tone was used by nurses to
increase the knowledge of older adults [47]. Additionally,
the tone used by nurses favored communication with
older adults and made possible the understanding of
what was being expressed in a study aimed at assessing
proxemics communication between nurse and elderly in
nursing consultation [30].

Listening
Listening was reported in seven studies [4, 51, 54, 56, 58,
61, 65] of which four studies were eligible for quality
appraisal and scored 100% on the MMAT assessment.
In one instance, listening was reported as a means to

help nurses assess older adults’ physical condition more
effectively [61]. Active listening coupled with compas-
sionate listening was a strategy to support nurses’ com-
munication with older adults [4], and proven to be
helpful [65]. Emphatic, non-judgmental listening, while
being aware of the body language of the older adults,
provided pointers to help nurses listen to the needs and
concerns of their clients [56].
Actively listening to older adults’ verbal and NVC be-

haviors was seen as leading to individualized care and a
sign of respect to older adults in a study characterizing
the meaning of and experiences with individualized care
from the perspectives of both nursing aides and nursing-

home residents [51]. Nursing students, associated active
listening in relation to NVC as an empathic response
and an open – minded attitude [54].

Artefacts
Artefacts were reported in five of the 22 included studies
[4, 30, 59, 61, 65] of which three studies eligible for
quality appraisal were of high quality.
Artefacts were communication supports and aids that

can support nurses’ communication with older adults
[4]. Artefacts included notes and hands-on learning tools
as strategies to improve communication [61] as well as
flyers, pamphlets, written instructions, books and educa-
tion files [65].
When promoting effective communication in practice,

it was advised that nurses should be mindful of the phys-
ical environment that can affect interactions between
them and older adults [4]. The results show that nurses
closed the door of an older adult’s room to avoid any
disturbance of the communication exchange in Sweden
[47], while nurses performed their service with the door
opened and allowed excessive entry of others into the
room while consulting older adults in Brazil [30]. Nurses
should guarantee privacy and should avoid speaking
while wearing a mask as it is considered as an impedi-
ment to effective communication [59].

Chronemics
There was lesser reporting of chronemics and NVC, de-
scribed in only three studies [19, 61, 65] and only one study
eligible for quality assessment was of good quality [19].
In a study aimed at identifying the communication be-

haviors and strategies used by socially skilled geriatric
nurse aides working with residents in long term care fa-
cilities, spending time with older adults was described by
the nurses as giving them positive regard, explained as
being respectful, acknowledging and showing interest
and approval [19]. In a reflection on active listening,
spending more time with older patients was mentioned
as a means to promote feelings of acceptance, and exer-
cising patience as the most challenging part of the com-
munication process [61]. Likewise, time was found to
positively affect nurse practitioners-older adults relation-
ships [65].

Old adults’ responses to nurses’ NVC behaviors
Six studies [50, 51, 55, 58, 59, 62] reported on the older
adults’ responses to nurses’ NVC behaviors. The responses
were either positive or negative.

Positive responses
Positive responses to nurses’ NVC behaviors were re-
ported in three studies [51, 58, 62]. Comfort touch from

Wanko Keutchafo et al. BMC Nursing (2020) 19:53 Page 9 of 13

nurses was shown to improve the perceptions of self-
esteem, well-being, social processes, health status, life
satisfaction, self-actualization, and faith or belief [62]
while a pat on the shoulder was perceived as a sign of
respect [51]. In a study exploring the experience of being
listened to, for older adults living in long-term care facil-
ities, results showed they expressed their satisfaction,
gratification, and unburdening and described their rela-
tionships with the nurses who listened to them as being
close like friends or family [58].

Negative responses
Negative responses to nurses’ NVC behaviors were re-
ported in four studies [50, 51, 55, 59]. In a study aimed
at exploring how communication affects issues relating
to residents maintaining cognitive and physical function-
ing in order to remain in the residence, vocalics were
perceived by the nurses as rudeness, disinterest, “infant-
ilisation” and “adultification” [55]. In a study with the
aim to determine and compare the communication bar-
riers perceived by older adults and nurses caring for
them, speaking far away, without eye contact, wearing a
mask and too loud was perceived as being unfriendly,
working without a sincere attitude, and showing no re-
spect [59]. In a review of evidence-based strategies for
effective communication with older adults across long-
term care settings, touching their buttocks or looming
over them were perceived by older adults as dominance,
while glancing at their watch or down the hall was
perceived as a sign of disinterest [50].

Discussion
This systematic scoping review explored evidence on
NVC between nurses and older adults, focusing on cog-
nitively intact older adults with no mental illness nor
communication impairment. A total of 22 studies were
included. Haptics, kinesics, proxemics, and vocalics were
the most frequently used NVC strategies by nurses when
communicating with older adults, of which 15 scored
100% on MATT. This study’s findings further demon-
strate a limited use of artefacts and chronemics as forms
of NVC. Physical appearance regarding NVC was not
mentioned in any of the included studies nor was si-
lence. The results evidenced limited published research
in the select topic and in particular for studies located in
Asia and Africa, as well as for quantitative studies.
Though the majority of studies were qualitative designs,
which do not allow generalization of findings, the quality
of the included studies ensures credibility.
The majority of the studies included in this review

illustrate the different modalities of nurses’ NVC behaviors
in geriatric nursing care. The most cited NVC behaviors
were haptics perhaps because touch is an essential and
often unavoidable part of nursing care [66]. Haptics or

communication by touch [67] can include aggressive touch,
accidental touch, playful touch, task related touch [68] or
task-oriented touch, touch promoting physical comfort,
and touch providing emotional containment [66, 68]. In the
included studies, touch was used to joke, to praise, to get
attention, to convey attention, to stimulate, and to show
care. In one instance, touch was not appreciated by the
older adult [52], which highlights that touch can lead to
either positive or negative outcomes, depending on the
nurses’ awareness and intention [69]. Touch can be a nurs-
ing tool [70], but nurses need to use touch appropriately,
taking into consideration preferences and avoiding its
imposition on older adults.
Kinesics are different from haptics in the sense that

there is no contact with a person, and only movements
of the hands, head, and the body are used. Kinesics were
used when words were in short supply, to convey mes-
sages, to indicate acceptance or rejection by either party,
to resolve disagreements amicably and with speed, to
initiate communication, to get attention, and lastly to
praise. Gesturing with a meaning of rejection or disap-
proval as well as abrupt gestures interrupt the exchange
of messages [71], highlighting the need for nurses to en-
sure correct decoding of kinesics [71]. Also, it is import-
ant that nurses keep eye contact with older adults
during interactions, keeping in mind that the permission
of this contact may vary depending on culture [30].
Proxemics included personal space and territoriality

[72] and included sitting next to, face-to-face, beside the
person, kneeling, looming over, and speaking far away
from the person. Proximity can therefore indicate pres-
ence, readiness to listen, and a sign of interest in the
older adult. Distance can be seen as a barrier to effective
communication with older adults. There should be a bal-
ance between distance and proximity, with nurses mind-
ful of the often-invasive nature of nursing, and the need
to create a therapeutic space where older adults’ privacy
is not violated.
Vocalics are often associated with “elderspeak”, which

in addition includes oversimplifying the language, speak-
ing at a slow rate, loud, and with a demeaning tone [73].
In this study, vocalics included speaking with a military
or a demeaning tone, speaking too fast or too loud,
which led to negative outcomes while speaking calmly or
slower led to positive outcomes. Conversely, speaking
with a soft tone also led to a negative outcome [57]. In
light of the importance of nurses developing self-
awareness of the tone that they use to communicate, an
opportunity exists for them to use audio recordings to
reflect on their tone [3].
Physical appearance was not mentioned in any of the

included studies; yet, the clothing worn in nursing is a
form of NVC that frequently shapes people’s judgments
about others, regardless of whether or not the

Wanko Keutchafo et al. BMC Nursing (2020) 19:53 Page 10 of 13

perceptions are true [74]. Therefore, nurses should be
aware that the way they present themselves through
their uniforms might indirectly communicate something
about the care they render.
Positive responses to nurses’ NVC behaviors included

improved perceptions of self-esteem, well-being, health
status, and faith as well as expressed satisfaction and
gratification when being listened to by nurses. On the
other hand, older adults viewed vocalics used by nurses
as a sign of rudeness and disinterest, while nurses who
used proxemics were perceived as being unfriendly,
working without a sincere attitude, and showing no re-
spect. In order to avoid negative responses from older
adults, a level of trust between nurses and older adults
needs to precede touch [75]. Though nurses–patients’
communication is influenced by conditions that arise in
hospital settings, [76], nurses need to adjust their com-
munication style to each situation and each patient [77].

Implications for practice
Awareness of NVC will lead to a greater understanding
of the messages exchanged [74]. When the essence of
nursing care falls short, all other initiatives are more
likely to fail as well [78], implying that if communication
with older adults is hindered or tampered with, every-
thing else nurses engage in is likely to fail. Nurses need
to be self-aware of their NVC as well as the way in
which the meanings of the messages might be misinter-
preted, highlighting a need for interventions to aid
nurses to interact and communicate holistically with
older adults [79]. Additionally, when nurses are aware
that older adults are not a homogenous group subject to
general assumptions of care [4], communication barriers
created by nurses create barriers [61] would be avoided.

Implications for education
An emphasis should be placed on teaching effective
communication to prepare future healthcare providers
to minimize miscommunication, deliver safe, quality
care, and contribute to anti-ageism measures. Also, the
training of nurse on NVC will enable the establishment
of bonds with older adults and culminate in effective
care [49]. Preparation of the neophytes will ensure a sus-
tainable, older-person centered and appropriately trained
workforce as advocated by the WHO (2016) [43].

Implications for research
This scoping review draws attention to the limited evi-
dence, specific to NVC between nurses and older adults
without mental illness, or communication impairment,
indicating a gap in literature, in particular in Asian and
African countries. In addition, this review highlights the
need for further research to provide an African insight
into NVC to answer the WHO call for more data to

understand the needs and the status of older adults in
Africa [80]. We further recommend a study to determine
the impact of nurses’ NVC behaviors on older adults’
satisfaction and safety of care. Though time constraints
can sometimes prevent nurses from providing the atten-
tive communication older adults seek, it is important
that nurses identify their own style of NVC and under-
stand how to modify, when necessary, their interactions
with patients, in particular older persons.

Strengths and limitations
Strengths
This study is possibly the first scoping review to map
evidence on NVC between nurses and older adults with
neither mental illness nor communication impairment.
This study demonstrated a substantial gap in the NVC
literature to guide future research on older adults with
no mental illness or communication impairment. The
study’s methodology also allowed the inclusion of differ-
ent study designs, and the identification of relevant stud-
ies methodically charting, and analyzing the outcomes.

Limitations
Despite the inclusion of MeSH terms, it is possible that
research on NVC existed under different terminologies,
which were not captured in this review. As only
abstracts written in English and French were included,
some relevant studies may have been missed. Several
studies of NVC between nurses and older adults may
have been reported only in contexts of mental illnesses
or communication deficiencies, leading to their exclu-
sion from this review. Additionally, studies on NVC be-
tween other healthcare workers and older adults have
not been reviewed.

Conclusions
This study explored evidence on NVC between nurses
and older adults with no mental illness nor communica-
tion impairment. The results revealed that haptics, kin-
esics, proxemics, and vocalics were the most frequently
used NVC strategies by nurses while there was a limited
use of artefacts and chronemics as forms of NVC. Fur-
thermore, physical appearance and silence were not
mentioned in any of the 22 included studies. Nurses
used NVC strategies to joke, to praise, to get or convey
attention, to stimulate, to show care, to indicate accept-
ance or rejection, to resolve disagreements amicably, to
initiate communication, to indicate presence, readiness
to listen, and a sign of interest in the older adults. Lastly,
older adults responded to nurses’ NVC behaviors either
in a positive way or in a negative way.

Wanko Keutchafo et al. BMC Nursing (2020) 19:53 Page 11 of 13

Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s12912-020-00443-9.

Additional file 1.

Additional file 2.

Abbreviations
MMAT: Mixed Methods Appraisal Tool; MeSH: Medical Subject Headings;
NVC: Nonverbal Communication; PCC: Population, Concept, Context; PRISMA-
ScR: Preferred Reporting Items for Systematic Reviews and Meta-Analyses ex-
tension for Scoping Reviews; WHO: World Health organization

Acknowledgements
The authors acknowledge the systematic reviews workshops organized by
the School of Nursing and Public Health of University of KwaZulu-Natal for
the provision of resources towards this review.

Authors’ contributions
EW conceptualized the study under the supervision of JK, and designed the
methodology. EW, JK, and MAJ contributed to writing the manuscript. MAJ
critically reviewed the manuscript. All authors read and approved the
manuscript.

Funding
(Not applicable).

Availability of data and materials
Data sharing is not applicable to this article.

Ethics approval and consent to participate
(Not applicable).

Consent for publication
(Not applicable).

Competing interests
The authors declare that they have no competing interests.

Received: 9 December 2019 Accepted: 4 June 2020

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