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Listening Skills and Healthcare Research Paper


This study uses a quantitative survey technique, and summarized data collected is used to correlate results with listening skills as its fundamental principle (Punch, 1998). A survey was sent out on the Internet and yielded results from various gender, socioeconomic backgrounds and education levels. Communication issues have been maintained by employing a number of methods.

Pain faces scale training of participants and research assistants and maintaining good relationships with participants are used in our recruitment to further develop partnership between the study population and researchers and to maintain feedback.

Each step undertaken to gather and analyze data, validate findings and present research outcomes in which comprehensive and accessible findings will be used to facilitative growth and continued development. The purpose of this research is to develop a better understanding of listening skills and how better listening skills well as ability to recognize nonverbal expressions will assist the healthcare industry and its consumers.


The merriam-webster dictionary defines pain as “suffering or distress of body or mind”. It is argued that effective communication between healthcare provider and patient is an important element in improving treatment compliance. Holmes et al, (2007) on the other hand provides that pain interferes with person’s ability to communicate by altering normal patterns of verbal and nonverbal communication.

Listening skills is something that has been emphasized in the medical field for years. Professors in medical schools have been attempting to teach their students to be better listeners to their patients (Holmes at al, 2007).

As we seek to integrate effective communication skills in healthcare, the best question, and yet difficult to ask, is: does listening skills, as well as purposeful nonverbal communication, while being applied, more likely to improve the relationship between healthcare providers and patients?

Listening skills is something that has been emphasized in the medical field for around 2,500 years and the problem of communication challenges often leading to misdiagnosis has always been an issue. Frischenschlager and Pucher (2002) argue that describing pain to a physician falls solely on the patient. And in most cases, physicians often lack the skills to read patient’s nonverbal signs or even interpret the slang they use.

Therefore communication problems between providers and patients remain to be a major problem in the healthcare professional. The provider-patient as demonstrated by the pain scale (figure 1-Appendix) illustrates their interrelationships. The research conducted sought to answer the question, “Can pain faces be distinguished from other emotional expressions?”

Literature reviews on the ability to recognize facial expressions and listening skills issues facing both patients and health care providers in social dynamics of healthcare professional will be discussed. A thorough investigation on communication of health issues affecting these communities are illustrated which provides a synthesis of the existing problems.

This literature review is coined around personal and situational issues, as well as empirical research on the communication concerns with support of reviewed of population studies and themes are summarized. As the cultural context of health issues has a major influence on our communities, sociological literature on this pandemic is highlighted.

To affirm this analysis, researchers linked various responses to research from the related areas and concluded with references for future research on the health and sociological dimensions. The current literature was reviewed using Communication & Mass Media Complete database and searched online article using listening skills and facial expressions in healthcare as key words using Google.

The research concentrated on both young, middle and old age population as my headline and designed my research article around a pain face scales instruments to perform a thorough analysis on how participants can identify non-verbal signs to communicate their pain issues.

The finding being that if a “Lay” person could do it WELL then with a little training, a Healthcare Provider could do it as well. Training that included spending more time with their patients. Our careful analysis and research will then be used to identify the validity and applicable evidences that can be used in health care practices


This paper seeks to explore the relationship between healthcare provider and the patient, highlighting difficulties they experience when communicating to each other about pain issues. Our analysis aims at providing evidenced-based guidelines that will provide a set of recommendations that can improve listening skills on the patient and the service provider.

While much has been done to encourage physicians to improve their listening skills, research indicates that listening, as well as provider-patient interactions can improve with adequate training and follow-up. As the number of studies increases, the results, effects and outcomes of patient-provider communication, there is still a much research to be done in the field.


Questionnaires were designed and distributed over the internet. This environment allowed participants to freely and openly rate facial expressions as much as possible. Participants were well acquainted with internet and use of facial expressions in their day to day activities.

This equipped them with considerable knowledge of what was expected of them as many of the expressions such as anger, happiness, sadness, disgust, surprise, fear and pain in facial expressions related well with their personal experiences.

Literature Review


The most frequent complaint among patients is pain. According to Baird et al (2008), an estimation of 30 million people in the United States are suffering from chronic pain. It can not be assumed that the most prevalent pain always occur naturally. Acquiring effective communication skills requires the employment of observation and application practice of communication expressions.

According to the US Bureau of the Census (1995), nearly 7% of the US population deals with chronic pain every year making it a high priority concern within the healthcare community. Evidence from the US Department of Commerce shows that pain associated problems costs billions of dollars in the healthcare industry.

It adds that related problems such as chronic pain management and how to effectively deal with pain and cost management to be also of concern. The same studies also evidences high occurrence of opiate dependence among the mentioned group.

Pain can be explained in different perspectives depending on individual experiences. Frischenschlager and Pucher (2002) provide that pain cannot be measured or quantified. Health care provider should in this case assess pain on individual perspectives. Therefore verbal and non-verbal description of their current health status depends solely on the patient.

This simply means that the overall communication context is influenced by the dynamic exchange of the service provider and patient interaction. However, this has never been the case. As Frischenschlager and Pucher (2002) state, “problems with the communication between doctor and patient are a frequent result (p.416).

Pain has often been defined as a warning sign indicating something wrong within the body. Pain is classified into two categories; acute and chronic pain. People in pain often undergo intense psychological experience. Acknowledging the importance of patients understanding how to respond to pain is important in communicating pain issues to the providers.

Issues associated with patient communication process are outside the scope of medical research. In this regard, Brannigan et al (2008) quotes, “pain should be looked at as a multi-dimensional affair and not just a one a warning sign” (p.12). Thus, being able to communicate effectively and knowing which messages to communicate are equally important.

Pain Theories

Frishenchlager and Pucher (2002) categorize pain theories into two groups; 1) the Frey theory and 2) the Goldscheider’s approach. Frey’s theory defines pain as special pain pathways that connect pain-specific nerve endings leading to the brain.

The Goldscheider’s approach states that nerve endings are not specific to any center of the brain and that pain can only be experienced when the level of pain reaches to an intense point that can not be tolerate leading a patient to expressing their discomfort.

Frishenchlager and Pucher (2002) links psychological factors such as distraction, relaxation, fear, depression, former pain experiences, family and cultural influences to be among factors that affect the way that people experience pain.

In their analysis, Frishenchlager and Pucher (2002) redefine pain as,”…………unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (p.419).Their definition gives equal weight to emotional and physical pain experience hence the rebirth of gateway theory that links emotions to physical pain, considered to be a breakthrough in theories of pain.

Effects of pain and patients’ inter-personal relationships are not only becoming important topics in research, the management of chronic and acute pain are also of paramount importance. In this regard, future research should take deeper studies in defining what chronic pain is and how it effects the population (Smith, 2008; GangHeong, 2000).

Pain is now being thought of as the Fifth Vital sign that offers way for physicians to assess overall health of an individual. Pain can be considered as chronic if the symptoms last up to three months. Walid et al (2008 argue that pronounced pain changes the behavior of an individual. They provide guidelines on how to determine levels of Chronic Pain as to include;

  • duration of illness;
  • number of treatments and consulted doctors;
  • psychological impairments such as depression, helplessness and loss of self-esteem;
  • social impairments such as social isolation, changes in the patient’s social role and position; and
  • Job-related impairments such as having to take days off because of being ill that can subsequently lead to dismissal.

Diagnostic classification of chronic pain

It presupposes:

  1. A continuous, torturing pain, which;
  2. Cannot be explained well by an organic damage; and
  3. Psychosocial problems or emotional conflicts are recognizable and can be brought into direct connection with the pain the patient experiences.

Gromala and Shaw (2004) define chronic pain as pain that lasts from one month to a year. Their analysis records a statistic of 57 million people in North America with majority being the disabled people. To this we come to the conclusion that pain is indeed a difficult problem for both physicians and patients (Bennett et al, 2009).

McCosker (2004) defines pain an “inner experience and others cannot truly observe its effects or share in its suffering” (p.62). Frischenschlager and Pucher (2002) links withdrawal symptoms as part of the psychological challenges a person undergoes when experiencing chronic pain.

They add that when someone isolates themselves from the society to heal results to withdrawal making the pain more intense. When a person life revolves around their illness, pain becomes part of their life.

Facial Action Coding System

The Facial Action Coding System (FACS) dates back in to the mid 19th century (Piderit, 1858). The most influential theorist was Charles Dawn in which he argues in his book ‘The Express of Emotions in Man and Animals” that facial expression is universal and innate characteristics. He further added that facial expressions played a crucial role in the experience of emotion (Darwin (1896).

FACS is defined by Ekman (1984) as “changes in the facial musculature comprised a large portion of emotional state” (p.319). He argues that the expressions were based on a “theoretical study designed to measure specific facial muscle movements believed to be associated with emotional expression” (p.321).

Ekman and Friesen (1978) further distinguish between two different types of judgments to include message judgments that refer to specific behavior and those made about behavior. They argue that facial expressions such as anger or happiness can clearly be distinguished from pain expressions, while to accurately measure the assumptions of psychological state, inferences about that which is being measured is required.

Ekman and Friesen (1978) define pain scale as a measurement that “identifies specific responses to specific stimuli, natural unfolding of specific behavior over time….which segment is likely to produce the most expressive behavior” (p.322). The intensity of facial expressions are measured at four (1=low, 2=medium, 3=high and; 4=very high).

The low ratings often display mild expressions such as smile with slightly raised corner of the mouth and corners of the eye without displaying the teeth. Medium rating expresses moderate expressions. This is often displayed like half smiling and half laughing, with eyebrows slightly raised and lips apart, exposing teeth.

High rating emotions are displayed such cry or laugh, with an open mouth, raised eyebrows and cheeks. Very high rating, display intense expressions when crying or laughing and lips are completely apart, teeth showing and cheeks substantially raised.

Nonverbal Communication

There are many ways a healthcare provider can look beyond what their patients are saying to what their patient’s body is telling them. Cooper (1979) gives several suggestions for what a healthcare provider can do to read some nonverbal clues that will help them better understand their patient’s pain.

Cooper (1979) suggests that many people talk without looking at the eyes of the other person, especially physicians; and this can suggest that one is not listening at all. Some patients, especially those in pain, have trouble articulating their feelings. Some signs that Cooper (1979) gives for a healthcare provider to look out for:

Facial Clues

  • In fear and pain the eyes open wide with the lower lid tensed. The eyebrows rise in a straight line and the mouth opens with the lips tense and drawn back
  • In sadness the eyes look downward with the lower lid raised

Cooper (1979) continues on stating that a person’s attempt to control their facial expressions, their nonverbal behaviors, gives away the fact that they are in pain and not able to tell their physician everything.

Use of non-Verbal Communication

Clinical spectrum of typhoid is broad, ranging from diarrhea, which may be fatal in a shorter incubation period of 48 hours or longer periods of up to 3 months, with an abrupt offset of headache, diarrhea and vomiting. The symptoms are often as a result of loss of large volumes of isotonic fluid.

Simple Explanation

Not all people who get typhoid look equally sick. Some patients may portray minor symptoms, while others look very ill. While looking at a patient, healthcare provider should be able to identify these symptoms from facial expressions by distinguishes between judgmental facial expressions such as anger or happiness and those made about behavior.

In this regard, proper training of facial coding aligned with a dimensional model of emotions should be encouraged in health professional along with spending more time with their patients to distinguish between their facial features.

Some symptoms such as diarrhea may be omitted by a patient since many may regard it as routine and unnecessary to mention it to the heath provider which may lead to misdiagnosis and improper treatment regimes. Therefore purposeful nonverbal communication and asking thoughtful questions is more likely to improve the relationship between healthcare providers and the patients.

Use of nonverbal communication such as body gestures, positions and facial expressions to convey information requires full attention and minimal distraction from the service provider, as reciprocate of showing caring and empathy to the patient.

It is proven that verbal communication builds relationship and enable people stay together longer. A patient may also gain a lot of knowledge about themselves that may improve interpersonal relationships. Talking to the healthcare provider about your health concerns, how you feel about yourself and how you feel about life, helps a patient heal and accept their condition.

Self disclosure puts someone in a position to see who they really are and binds people together. In addition, every person has their own beliefs, and they are able to reconcile their disagreements with a person they feel close to. Someone may feel unaccepted, your feelings may be hurt and you may feel your relationship is threatened.

To this reason, people need to make their feelings known by revealing and exposing themselves. Often, people who can not express themselves or rather shy individuals experience great anxiety in trying to express themselves.

Conclusively, communication is a complex and challenging process but is still absolutely essential asset for communication and building relationships. One progressively move from being a stranger to being close friends with healthcare providers is essential in improving patient’s health.

People may often feel that disclosing to much information may turn people away. They also have the perception that disclosing premature information to early, their intentions may be misread as an invasion and some may see it as an attack.

Patients often relate their past experiences of telling people very sensitive issues may lead to unfavorable impressions. One patient explained that a person may use information disclosed to them against the individual and we often take risks by sharing personal information with healthcare providers since information shared in a healthcare setting can not be used against them or for blackmail purposes.

Therefore, while self disclosure can be useful in helping patients relieve stress, patients should be educated on the importance of disclosing all their health issues and concerns, how to express their pain using facial expressions and the ability of healthcare providers to keep this information confidential (Donabedian 1988; Mechanic, 1998).

In “Healthcare and Listening: A relationship for Caring” by Brannigan et al, (2008) begin with the statement that the “optimal relationship between healthcare provider and patient is one of trust” (p.168). The authors continue on to explain that this trust relationship cannot exist without effective communication between the doctor and the patient.

Research is also found to support that effective communication practices are key in patient compliance with medical regimens, patient satisfaction, as well as decreasing malpractice lawsuits is found (Morlion et al, 2008).

If the goal of healthcare is what Brannigan et al, 2008) states as one that “…. prevents illness and injury, and help patients and their families manage medical conditions through counseling, medicine and therapeutic interventions” (p.168). Patients must trust their healthcare providers with sensitive, possibly life-threatening or life altering, information.

It is physician’s responsibility to use limited time that they have with the patient to listen and guide the conversation to get to, potentially, the most important information so that a correct diagnosis can be made. Communication becomes the most important element in the patient/doctor relationship (Eggly and Tzelepis, 2001)

A providers’ nonverbal behavior may provide subtle yet powerful messages concerning their perceived efficacy of pain management (Frantsve and Kerns, 2007). They continue that patients may respond to such unintentional “demand characteristics” that physicians may show; especially those patients who are in pain.

The research points out that within the last few decades the relationship between patient and physician has evolved from a parental relationship into a partnership (Eggly and Telesis, 2001). To address this shift, national medical organizations such as the “Accreditation Council for Graduate Medical Education” has put an emphasis on training physicians in more effective communication.


The design for the research study uses questionnaire posted over the internet to obtain raw data about listening skills facing young, middle and old aged patients and healthcare providers. Quantitative survey technique comprising of participant observation, and quantitative methods of randomly selecting participants were utilized because they were considered appropriate to the cultural and language differences that exists.

This research was designed in the quantitative genre of data collection as I believe this approach will allow us to obtain a more comprehensive understanding of health issues surrounding the selected group. Our research methodology of using questionnaire helped us gain better understanding on the complexities of social, economic and cultural factors impacting on them.

Quantitative approaches were believed to be appropriate as they are likely to yield more honest opinions in obtaining in-depth understanding of the meanings and events by obtaining raw data from participants. The participants were 108 comprising both male and female who ranged in age 18-60 years and were part of the large study of ability to recognize facial expressions.

Target Population

Target population consists of both male and female of ages 18 to 60. These samples group is aimed at educating the public, patients and healthcare providers (nurses, General practitioners and physiotherapists) dealing with patients with chronic pain on how to recognize facial expressions.

Participants were also selected with regards to; recent history of pain, structural deformity, thoracic pain, systematic unwell and constant progressive, non mechanical pain (chronic pain).

While the focus of this study was on adults alone, a participant of below 15 years was also included to obtain a holistic view of a Lay” person could do WELL in distinguishing facial expressions. The sampling techniques were randomized sampling (Polgar & Thomas, 2008), requesting participants to rate facial expressions and selecting samples to use in the study (Grove, 2007).


Pain scale seems like the most appropriate instruments a physician could use to assess patient’s pain. It is performed by having patients rate their pain on a scale of 1(being no pain) to 10 (being of severe pain) as demonstrated in the graphic rating scale in Appendices A.

Pain Scales

Pain scale instrument is commonly used by Healthcare Providers to assess patient’s pain. Brannigan and his colleagues (2008) article on ‘Healthcare and Listening’ stated that “the optimal relationship between the healthcare provider and the patient is one of trust” (p.170). It can not be assumed that effective communication always occurs naturally.

Acquiring effective interpersonal relationship between the service provider and the patient requires observation practice and interpersonal listening skills. This responsibility lies heavily on the healthcare provider. Their primary attribute to providing effective care requires being emphatic listeners as a strategy to understand patient’s nonverbal communication and take the time to observe their communication patterns.

Common problems often experienced in providing effective communication to patients is lack of empathy and understanding of nonverbal signals and communication apprehension on the part of the patient (Bundy, 2001; McCroskey et al,1998).

Testing and Evaluation

First of all, pain face scale should be tested to check the ability of patients learn the basics of the program. For the testing, patients should be invited in the survey room where a healthcare provider explains theoretical material and track the way students accept the information from the pilot training program.

Then, patients will be proposed to fulfill the assignment established by the program creators to check how they understand the facial expressions. Once the practical assignment is completed, patients should be offered to look through other options of the program.

Finally, a healthcare provider should provide with other helpful ideas that might be helpful for patients when living at home. The evaluation of the results should be based on the validity and reliability verification.

Project Location And Duration

The project implementation will be conducted with the help of the hospital facilities for the project managers to accurately test and evaluate the effectiveness of the pain scale instrument. More importantly, as face scale deals with exclusive evaluation of facial expressions, it has the correct training that can work out a consistent plan of publishing program implementation.

The project results are planned to be delivered in three weeks, as the pain scale should be properly tested and evaluated. The operation will be defined into three stages. First, the department should study the main difficulties in handling pain scale that may appear among the patients dealing with this program.

Second, the project team should conduct a research in the field and define what listening skills and technologies will fit best. This stage will take the most of the time allocated for the scheme. Finally, it is necessary to conduct pilot implementation in order to eliminate all possible drawbacks of the program.

Data collection

Participants were required to read the questionnaire carefully and select the picture of the facial expression such as happiness, pain, disgust, fear, anger and sadness that best described the picture provided. Below is a sample of the data collected over the internet.

Respondent IP Address Response for facial Expression (Happiness, Fear, anger, sadness, surprise, pain, disgust Gender Ethnicity/Race Household Income Highest educational level Are you currently a student Specify education level Age
Male White/Caucasian $40,000 – $59,999 Masters No 25-30 -Happiness
Female White/Caucasian $40,000 – $59,999 Masters Yes 25-30 -Happiness
Female White/Caucasian $60,000 – $79,999 Bachelors Yes Masters 36-40 Happiness Female Asian $40,000 – $59,999 Masters Yes Masters 22-24 Happiness
Female Black/African American $60,000 – $79,999 Bachelors No Masters 22-24 Happiness
Female White/Caucasian $60,000 – $79,999 High School/GED Yes 31-35 Happiness
Female White/Caucasian Bachelors No Masters 22-24 Happiness
Female White/Caucasian $40,000 – $59,999 Bachelors Yes 25-30 Happiness
Female White/Caucasian $60,000 – $79,999 High School/GED Yes Bachelors 18-21 Happiness
Female White/Caucasian Less than $20,000 High School/GED No Bachelors 25-30 Happiness
White/Caucasian $60,000 – $79,999 Bachelors Yes 31-35 Happiness
Male White/Caucasian Less than $20,000 Masters PhD 51-55 Happiness
Female White/Caucasian Yes Happiness
Female White/Caucasian Less than $20,000 Bachelors Yes Masters 25-30 Happiness
Male White/Caucasian Less than $20,000 Bachelors No Masters 25-30 Happiness
Female White/Caucasian $40,000 – $59,999 High School/GED No 31-35 Happiness
Female White/Caucasian $40,000 – $59,999 Bachelors No 31-35 Happiness
Female White/Caucasian $20,000 – $39,999 High School/GED Yes High School/GED 22-24 Happiness
Female White/Caucasian Less than $20,000 Associates No Bachelors 22-24 Happiness Female White/Caucasian $20,000 – $39,999 Bachelors Yes 25-30 Happiness
Female White/Caucasian Less than $20,000 Associates Yes Bachelors 22-24 Happiness
Female Asian Less than $20,000 High School/GED No Bachelors 22-24 Happiness
Female White/Caucasian Less than $20,000 Bachelors No 22-24 Happiness
Female Asian $60,000 – $79,999 High School/GED No 41-45 Happiness
Male Asian $40,000 – $59,999 Bachelors Yes 22-24 Happiness
Female White/Caucasian $100,000 or more Bachelors No PhD 25-30 Happiness
Male White/Caucasian $80,000 – $99,999 Bachelors No 25-30 Happiness
Female White/Caucasian $20,000 – $39,999 High School/GED No 31-35 -Happiness
Female White/Caucasian $40,000 – $59,999 Masters Yes 25-30 Happiness
Female White/Caucasian $40,000 – $59,999 Masters Yes 25-30 Happiness
Female White/Caucasian $60,000 – $79,999 Bachelors Yes Masters 36-40

Limitations of the study

There are many different pain scales used; however, it is the general consensus that none of them are an adequate source of determining ones “true” pain level.

When pain levels are described to medical professionals they are usually assigned meaning by using verbal descriptors such as “excruciating, unbearable, etc.” At times doctors give examples and patients are asked to choose from those descriptors such as the McGill Pain Questionnaire.

While there are an abundance of appropriate words to describe pain they are not words we use. Therefore it is important that patients and physician’s come to a mutual understand and achieve shared meaning when communicating about pain (Faunce et al, 2006).

Although pain is the most common medical complaint most patients seeking treatment for pain are not chronic pain patients. Chronic pain patients develop a pain vocabulary that is influenced by medical specialist treatment and by exposure to repeated pain assessment measures (GangHeong, 2000).

When dealing with pain it is of vital importance that the provider and patient develop a “shared meaning” of pain descriptors since the medications that are given to deal with pain are very potent and therefore it is important to get a correct diagnosis and for the patient to have a good relationship with their health care provider (Roberts and Bucksey, 2007).

According to Butler and his colleagues (2009) both the VAS and VRS (in appendices) are based on the assumption that people have a “shared” meaning or understanding of pain and its descriptors.

The results of this study did not support this, as hypothesized participants were personalized in their use of pain descriptors and presumably in their understanding of the word as well. Butler et al, (2009) have shown that a valid assessment for pain cannot be developed if people in pain do not have a shared perception of the dimension.

Butler et al (2009) go on to state that caution should be used when relying on the use of word to convey pain intensity. Also words meant to describe only the most acute pain have little understanding when brought together with other pain assessments. When attempting to clarify pain levels in a medical setting more than just relying on VAS or VRS is needed.

Butler and his colleagues (2009)continues to addresses the idea that language and pain are interrelated and that pain can be better understood by the understanding of the language. Since patients and doctors use different descriptors for pain it is difficult to reconcile the descriptors.

Also, since the descriptors for the illness and pain given by the doctors are at times so grave the patient’s initial reaction is not a favorable one. Also it is found that since language descriptors for pain differ from person to person, it is difficult to assign a value to each descriptor.

It is understood that pain caries from person to person so the terminology differs from person to person (GangHeong, 2000; Darmohray et al, 2008; Beckett et al, 2009).

Pain face scales as well as other scales are still under scrutiny for their lack of patient interaction, the scale does not take into account the fact that pain is a very personable experience and must be treated as such (Crichton, 2001).

Future Research and the required Changes in Healthcare

According to Roberts and Bucksey (2007), there have been two significant social changes that have helped put emphasis on the importance of effective communication for healthcare providers:

The first came in 1999 when the Institute of Medicine announced that medical mistakes are not unusual or isolated, rather that they happen everywhere and often. Also they concluded that these mistakes were not minor but deadly.

They went on to say that the disclosed mistakes were only a small sampling handpicked to be given to the public, while the real bulk of the incidents were never disclosed to the general public. Healthcare providers were outrage to have to admit their mistakes and patients were fearful as safety became a national priority.

After panels were put together to as quoted by Brannigan et al, (2008) to “set standards, address safety issues, and review medical errors; it became apparent from the research conducted that poor communication and concealing mistakes were two significant factors that ultimately led to legal recourse” (p.170).

The second problem was the public’s loss of trust, high profile scandals by individuals or groups in power caused the public to be critical to those who were in a profession that was perceived as prestigious (Brannigan et al, 2008.)

In recent years various medical organizations (such as the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education) have begun to emphasize improved training and demonstration of competence in communication skills.

The nursing profession is also beginning to advocate good listening and communication as a quality needed to be a good nurse; skills which one must possess to demonstrate caring to a patient.

The idea that listening is important to be a well rounded medical professional is not a new concept but it is just being framed as a skill and an expectation of a skill that all medical professionals should have the basic concept of(Bundy, 2001; Bennett et al, 2009).

Brannigan et al,(2008) proceeds to say that methods to improve communication and effective listening on the part of the physician have been studied since the 70’s, however the early research focused mainly on the physician’s communication skills, medical skill training communication skills and how the physician performed in clinical encounters.

As studies become more recent they include the elements of empathy, time, trust, malpractice, and patient satisfaction.

The patient can benefit in positive ways from a healthcare provider who is an effective communicator such as the patient’s improvement in emotional health, functional status, and a change in physiological measures, particularly in patients with chronic conditions (Morlion et al, 2008).

Considering the risks involved for both the patient and the physician the importance of effective, thorough, and willing communication and listening goes beyond just a “courtesy” and on to an ethical obligation (Castro-Lopes et al, 2008).

Listening and the sensitivity associated with communication are required by both parties: from patients to provider and from provider to patient. This is an underdeveloped area of communication, according to McCroskey et al (1998), and needs to incorporate considerations of communication and listening is required.


Communication Apprehension and Healthcare

In some cases, lack of good communication relationship between the healthcare provider/patient relationships relies on the patient. The patient can experience what is called Communication Apprehension also known as “CA”. CA is “an individual’s level of fear or anxiety associated with either real or anticipated communication with another person or person’s” (McCroskey et al, 1998).

This is the definition that has been used to describe people who have “CA”, people who are anxious about real or upcoming communication situations. It is clear that this anxiety or “discomfort” caused by the “CA” can cause very real physical effects to the person suffering from the ‘disorder’ (McCroskey et al, 1998).

There are clear indicators if a person is “high CA”. A “High CA” when presented with a situation where they have to communicate will experience the fight or flight syndrome. These are the people that would rather die than speak in public.

These types of people may even have problems with their speech or they may use a high amount of vocal pauses (uum, ya know, ahhh). Others may have a negative perception of these people because of their lack of communication skills.

Because “more talk” is better in the United States, someone with High CA is likely to be considered as a less attractive socially and may seem less desirable to be around just because of their unwillingness to speak up. These kinds of self-crown perceptions tend to affect the patient/doctor relationships.

In some cases, people with high CA may still be apprehensive to speak up when in pain or in the presence of a Healthcare Providers (McCroskey et al, 1998). When the person is having trouble speaking up they can often leave out details that are important to a potential diagnosis or frustrate the physician leading to a breakdown in communication (Bundy, 2001).

McCroskey et al (1998) revealed that trait CA had a small relationship with patient question asking and information seeking. Sate CA had a strong relationship with patient question asking and information seeking. In the health care environment High CA’s are going to ask fewer questions, start fewer conversations, and avoid communicating with their physician whenever possible.

Because in other contexts High CA’s should have more state anxiety when communicating with someone of elevated status such as their physician five more research questions were formed to flesh out the patients fear of communicating with the doctor and the trait and state CA.

A patients fear or anxiety related to communicating with their physician is consistent with the theory that patient apprehension can seriously interfere with the physician/patient communicative relationship and be associated with negative outcomes for the patient.

There are many elements which factor into communicating with the physician, such as disconfirmation communication, language usage, controlling interaction, nonverbal communication, apprehension, trust, and willingness to discuss personal issues. Butler et al, (2009) found that “individuals, who are apprehensive about communicating with a particular person, do not normally initiate interactions with that person” (p.56).

So if you are uncomfortable with your doctor you would not initiate a conversation with him/her about an intimate problem (Eggly and Tzelepis, 2001).

The most effective way to treat chronic pain is through an ongoing, collaborative relationship with a primary care provider or pain specialist. According to Frantsve and Kerns (2007) giving providers communication training can lead to positive outcomes, including greater satisfaction ratings by individuals with chronic pain.

Most patients indicated that they believed that their relationships with providers were better when their providers spend more time with them, at least twenty minutes or more, and displayed a greater amount of interest in their life and issues (Darmohray et al, 2008).

McCroskey and his colleagues (1998) article on effective physician-patient communication identified four communication relationship to include; 1) engagement 2) empathy 3) education and 4) enlisting the patient in the doctor – patient relationship.

They mention communication skills required by doctors to include: 1) active listening 2) eliciting patients’ perspective on illness 3) decoding and responding to patient emotions 4) negotiating treatment plans more effectively

It is clear that communication is a necessity in a good doctor-patient relationship.

The process of communication requires encouraging two way dialogue and establishing partnership between two parties; the patient and the service provider-that creates an atmosphere of caring. This bridges the social gap between the provider and the patient, effectively uses verbal and non-verbal communication and creates a friendly atmosphere that allows a patient to tell his or her story and ask questions.

Pain face scales should be personalized in relation to patient’s educational level and their ability to express their pain and treatment instructions. This can first start by asking a patient to recall or to repeat instructions given to them. This is one way of ensuring effective communication by enabling patients understand their health conditions and available treatment options (Curtin, 1987; DiMatteo, 1994; Hal 1988; Ong, 1995).

The relationship between a patient and a client is one important way of ensuring healthcare providers communicate the outcomes of the patient’s illness. Important aspects to consider when determining communication inter-relationships are educational background, sex, age and ethnicity as earlier stated by McCroskey and his colleagues (1998).

Others factors such as ample time allocated to patient-provider personal contact and privacy should also be considered when identifying characteristics that can improve communication relationships between the two parties. Also, service providers should improve practices in their own settings by adopting behaviors and techniques that could result to increased patient knowledge and effective communication.

It is evidenced that establishing good relationship between healthcare provider and the patient creates an atmosphere of caring and bridges the gap between them. This means that facial expression should be personalized in accordance to the patient’s educational level and ability to understand the technical information.

In this regard, patients and health providers should be able to 1).establish and maintain rapport and trust (care), 2). Diagnose communication and problem solving skills to determine diagnosis and treatment (solve) and; 3).counseling and education (education) (Fallowfield, 1998; Kopp,1989; Levinson, 1995; Roter & Hall, 1991).

The following table provides examples of responsibilities required from both service providers and patients in exchanging factual communication.

Share facts Share feelings
Service provider Communicate clearly and accurately on diagnosis and help patient apply the treatment to their own life Show care by understanding and respecting them
Patient’s responsibility Clearly description health condition and ask questions where needed Be honest by expressing expectations and concerns

Two-Way dialogue

Both speak and listen without interruption. Both ask questions, exchange information and express opinions to fully understand the other party. Both relationships should be regarded as partnerships in which both parties strive to maximize the results. The patient should also realize that both parties are responsible for the outcome and their cooperation is highly required.

Disclosing all required information from a patient to determine proper diagnosis and treatment is also of paramount. The service provider on the other hand should have the required skills that will enable him interpret and analyze information received effectively to explain the condition and treatment to the patient.

Bias and Confounding

The problems in collecting data over the internet were summarized as follows; communication issues in the around the world have not been adequately addressed, despite best efforts of number of researchers dedicated to the health and welfare issues of these people.

The quality of the data collected here can not serve as conclusive, this is because a relative small portion of the population was used, and the research used different definitions for pain. There was also a problem in assessing remote indigenous population, hence compromising the results of the study (Valance, 2001, p.1). Therefore, little data collected here can not be relied on for future research.

Since communication issues in respect of listening skills such as engagement, empathy, education and enlisting the patient in the doctor care are increasing at an alarming rate, Valance (2001) suggests that studying the problem more closely with the affected people of the relevant communities is likely to address the problem adequately.

Validity of the Research

This research conducted sought to answer the question, “Can pain faces be distinguished from other emotional expressions-such as happiness, disgust, fear, sadness, surprised and anger?” This research principle is founded on two principles;

  1. Patients people have different cultural and language background—which required the researcher to develop models of inquiry
  2. Any attempt to solve problems on middle-aged population will be done in partnership with the consent of the communities surrounding them.

Quantitative research methodology used in this research provided a better chance of identifying the nature of the problem because the sampling strategies are better suited in dealing with small samples.

It also equipped the researcher with considerable knowledge of the population to be studied contributing to the validity of the results. Internet questionnaire were well guided, informed and driven by personal experiences. Also, the time allocated before the study commenced helped the researcher gain more understanding of health problems facing the world at large.

To ensure the middle aged and the old population are able to have a say, equal opportunity in the research study and design was responsive to the needs of the population under study.

The need for ongoing health campaigns of the communication skills should be provided and extended to the community, schools and preschools. Health related promotional activities should be encouraged to minimize occurrence of pain complains.


The systematic reviews were identified using the internet and survey monkey database. Pain scales used the grading was simple and easy to apply and showed a large degree of consistency between the grading of the patient that of the health provider, diagnosis and treatment.

Patients of ages 51 to 60 of Caucasian, Black/African American decent and Asian origins with average income mostly identified the same facial expression with regards to happiness, sadness, surprise, anger, disgust, disgust and pain. Also, participants of ages 28 to 30 with high income responded well to nonverbal communication signs compared to those of below 15 years.

A set of questions were drawn in English language to guide participants and to ensure consistent information was gathered. The iquestionnaire protocol covered the key information area (facial expressions), including opinions on intervention services of the same to uncover their thoughts, perceptions and feelings.

The questions were structured in a culturally sensitive manner, using their own language to obtain raw data from participants. In a research sought to measure the occurrence facial expressions on day to day activities, as a strategy to identigy the service gaps regarding health issues within the healthcare profession.


It is clear that understanding and further research in listening skills knowledge will assist in the communication of pain descriptors and putting at ease the patient in the treatment of pain. What is most needed is for all those involved in Healthcare to understand the listening process as well as having a basic understanding of how to read nonverbal signals.

Having this skills along with that of empathy, will empower the healthcare provider to offer a more complete treatment plan to those who they treat and will allow them to see those that are in pain more clearly.

This research has provided a set of principles that should be used in the training course to improve listening skills. The three process of communication; caring, diagnosis and problem solving and education of patient-provider provide attention to the most important aspects of healthcare.

These processes combined with proficiency in providing health services and appropriate diagnosis and treatment when effectively applied results to better outcomes for the two parties. Emphasizing listening skills, nonverbal aptitude, and empathy, is not a new attitude in the healthcare setting but as seen it is one that is still lacking emphasis.

It is proven that verbal communication builds relationship and enable people stay together longer and improves interpersonal relationships. Patients should be educated that by talking to healthcare providers about your health concerns, how they feel about yourself and how they feel about life, helps them heal and accept their condition. Self disclosure puts someone in a position to see who they really are.

Healthcare providers should on the other hand learn and understand each patient’s beliefs and cultures. As the objective of this paper strives to improve listening skills and the facial exercises, references used here will provide opportunities to accomplish these goals.

Healthcare providers have their own clinical language that requires use of technical words that enable them communicate to each other which may be complex when used with patients.

In some instances patients can also speak in their own dialects and slang, which makes it difficult for a health provider to comprehend. But with a little training a Healthcare Provider could be able to distinguish distinguishes between two different types of judgments; pain expressions and emotional expressions.


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Taraji Michael studied at San Francisco State University, USA, with average GPA 3.31 out of 4.0.

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