Expressões corporais no cuidado : uma contribuição à Comunicação da Enfermagem Body language in health care : a contribution to nursing communication

Objective: to classify body language used in nursing care, and propose “Body language in nursing care” as an analytical category for nursing communication. Method: quantitative research with the systematic observation of 21:43 care situations, with 21 members representing the nursing teams of two hospitals. Empirical categories: sound, facial, eye and body expressions. Results: sound expressions emphasized laughter. Facial expressions communicated satisfaction and happiness. Eye contact with members stood out in visual expressions. The most frequent body expressions were head movements and indistinct touches. Conclusion: nursing care team members use body language to establish rapport with patients, clarify their needs and plan care. The study classifi ed body language characteristics of humanized care, which involves, in addition to technical, non-technical issues arising from nursing communication.


INTRODUCTION
This article presents some of the results of a master's thesis (1) that aimed to contribute to the development of the preliminary concept of nursing communication for the hospital environment.This thesis, based on a previous study (1) , used a table of analytical categories for verbal and non-verbal communication in nursing, which provide some denominations of the occupation linked to the bodies involved in nursing care, namely: body language in nursing care, nursing care body movements, body availability in nursing care, and body verbalization in nursing care.
In that thesis (1) , the results pointed to a categorical classification for nursing communication that was specific to the profession, and not derived from the field of communication: nursing communication.In this sense, the bodies that communicate, and the process of decoding patients' body signs by nursing professionals to guide their care, lay the foundation for this classification.This article broaches one of these categories, body language in nursing care, which aggregates body language during nursing care in various forms, including eye contact, verbal, facial and bodily expressions, and light touch, with no explicit purpose, all characteristics of nonverbal communication (1) .All these analytical categories were used to develop the preliminary concept of nursing communication (1) .
Communication is, by nature, interaction, and for this reason it was used as the basis to describe and classify non-verbal signs used by nursing staff and their patients in their health care encounters.Nursing communication facilitates the process of identifying and resolving problems in health care (1) .In this article, the term "nursing communication" is used because it is an essential element of care, without which nursing care ceases (1) .
Based on the above, this study aimed to include body language in nursing care.The main objectives of the research were: 1. Describe the body language used in nursing care; 2. Classify these expressions in the communication process; 3. On a preliminary basis, evaluate the categorical nature of body language in nursing care for nursing communication.

METHOD
The quantitative approach of this research enabled the observation, description and documentation of the aspects relating to the object of study.Two hospitals were selected for the collection of data: two cardiology units, one in a general hospital (GH) and the other in a specialized hospital (SH), both of which are part of the public health care network and located in Rio de Janeiro, Brazil.These two hospitals were selected because a diversity of care situations was sought in order to provide a consistent and adequate basis for better generalization, based on the results of the investigation.Inclusion criteria of the participants were availability during the research period, and acceptance to participate in the study.The exclusion criterion was the absence of interaction between team members and patients.The selection of cardiology units as the study scenario was based on prior knowledge of the type of patients admitted into these.
The research instruments and methods employed in data collection were: 1.A questionnaire containing sociodemographic data of the 21 study participants selected, according to the inclusion and exclusion criteria; 2. Systematic observation of nursing care situations (120 hours) in both hospitals, with the use of an observation form to document the body language and actions of members of the nursing teams and patients.In the SH, 43 care situations were observed, with participation of 2 nurses, 9 nursing technicians and 42 patients.In the GH, 21 care situations were observed, with participation of 3 nurses, 7 nursing technicians and 36 patients.
To begin data collection, preliminary contact was made with the nursing managers of the two cardiology units in the two hospitals.The study was submitted to the research ethics committees of both hospitals, the Anna Nery School of Nursing and São Francisco de Assis Hospital at the Federal University of Rio de Janeiro, and was approved under opinions nos.00133.288.226-11,0347/05-08-2011 and 035/2011, respectively.One of the researchers presented copies of the free and informed consent form (FICF), as established in resolution 196/96 of the National Health Council of the Brazilian Ministry of Health, which were subsequently signed by the participants of the study.Data were collected between August and September 2011.
The quantitative data produced from participants' sociodemographic data, and data obtained by means of systematic observation, were reviewed and processed using descriptive statistics.Based on these data, tables were created with frequencies and percentages for each hospital, in order to compare equalized raw data.
After treatment, classification and categorization of data, the following categories emerged: verbal expressions used in nursing care; facial expressions used in nursing care; eye expressions used in nursing care; and bodily expressions used in nursing care.Analysis and interpretation of the results were performed based on the literature regarding nursing communication adopted in the discussion phase of the results of this study.

RESULTS
As for the study scenario, the cardiology unit of the GH treats preoperative and postoperative cardiac surgery patients, with 22 male and female beds.The SH treats preoperative and postoperative valvuloplasty patients and has 28 beds distributed into 14 wards with 2 beds each, distributed according to demand by gender.
The nursing staff of the GH unit comprised 5 nurses, including the head nurse, and 12 nursing technicians distributed into 2 shifts.The nursing staff of the GH unit comprised 3 nurses, including the head nurse, and 10 nursing technicians, distributed into 3 shifts.In comparison to the GH, the SH teams demonstrated greater availability of time to interact with patients and families, and thereby obtained more personal information from patients about their illnesses, in addition to clarifying questions about surgery and treatment, and informing about the care offered.
Body language in nursing care was detailed in four tables listing verbal, facial, eye and bodily expressions as facilitating and generating confidence in the development of the communication process between patients and members of the nursing staff.

Category 1. Verbal expressions used in nursing care
These expressions were the sounds emitted, use of a soft and caring tone of voice and the presence of laughter in times of relaxation between nursing staff and patients.These results are summarized in Table 1 below.
In both hospitals, the highest frequency was found in the absence of laughter in the interaction between patients and team members (28.6% and 33.9%).The presence of laughter between them was also present, but with less frequency (21.1% and 33.9%).Thus, it was found that patients laughed more than the nursing staff in both hospitals, given the larger number of patients.Reciprocity of laughter was observed between the patients and team members of the SH.These findings indicate that patients use laughter to express joy at the time of interaction.The responses of the nursing staff tended to be smaller because they sought to maintain a more professional demeanor when providing care.
A soft and caring tone of voice was more frequently used by the SH staff (11.3%) than that of the GH (0.7%).However, the absence of this manifestation by patients was greater in both hospitals (31.3%).The manifestation of other sounds (Ai! Ah! Oh! Eh! Psst!) in relation to other verbal expressions was lower (0.8% and 0.8%) in both hospitals.

Category 2 -Facial expressions used in nursing care
The data in this category indicate some of the facial expressions that were identified in team members and patients of both hospitals.Table 2 shows a summary of these expressions.In the data in this table, the types of facial expressions found (Figure 1) were used during interaction between nursing staff members and patients, so that the message would be conveyed to the receiver during the care process.These expressions are not only positive and negative, but also neutral.Few expressions showed correspondence between members and patients.The facial expression of happiness stood out for its high frequency both in the GH and the SH, despite it being an unusual expression in the hospital routine.Its prevalence remained in relation to other facial expressions observed.Facial expressions considered positive were happy, satisfied and confident.Neutral expressions were serious, indifferent, focused and curious.Negative expressions were worried, confused, tired, angry, embarrassed (awkward) and disappointed.Positive expressions by the nursing staff predominated (85.7%), whereas patients had a lower percentage (71.3%).Nursing staff members' neutral expressions reached 14.3% of the total.In contrast, patients' neutral expressions had a slightly higher Legend: GH: General Hospital; SH: Specialized Hospital.(86.7%).They kept their eyes focused directly on patients while providing direct care.In both hospitals, patients also had a high frequency of eye contact, but lower than that of the nursing staff (70.2%).In general, in both hospitals, patients also had higher frequencies of eye contact.
Possible reasons for such behavior may be related to embarrassment, inhibition or invasion of patients' physical and personal space, which was maintained, including refusal to watch common procedures such as hemoglucotest or dressing changes.Comparison of these findings with those of patients shows the therapeutic involvement of the nursing staff in the pursuit of quality care.

Category 4. Bodily expressions used in nursing care
Bodily expressions used in communication between nursing staff and patients included head movements, touch, and physical closeness when speaking.Table 4 summarizes these expressions.
In both the GH and the SH, head movements represented agreement or disagreement in the context of conversation between nursing staff and patients, which exhibited reciprocity.At times, these head movements were adopted by team members to confirm or deny without speaking, in response to questions from patients.There were also reciprocal manifestations of patients in relation to nursing staff.Data on the expressions between nursing staff and patients had differing percentages (64.3% and 39.4%, respectively).Head movements were more frequent for patients, and light touch was more present among the nursing staff.In general, adding the percentages of nursing staff and patients, and considering the presence and absence of expression, light touch had percentages (65.7%) close to those of excessive closeness (65.1%), more by the absence of closeness.
Indifferent touch, defined as touch involved in technical procedures, was also present in interactions between nursing staff and patients.This type of touch was more frequent among Most expressions were spontaneously directed by patients to nursing staff because there were more of them and expressed themselves based on their communication needs.Interaction was initiated on technical procedures, generating positive, neutral or negative facial expressions.However, these expressions served to identify reactions, questions and needs that patients were experiencing at certain times, complementing the sent message, which facilitated their understanding.These expressions were also used as a basis for responses by the nursing staff, often without words.

Category 3. Eye expressions used in nursing care
This category listed eye expressions, including eye contact and typology at the time of dialog between nursing staff and patients.Table 3 presents a summary of these expressions.
Members of the nursing staff had higher frequencies of eye contact, with and without dialog, in both the GH and in the SH Legend: GH: General Hospital; SH: Specialized Hospital.
nursing staff were five and three, respectively.The facial expressions of patients in both hospitals were eleven and eight types for the GH and the SH, respectively.However, in both hospitals, facial expressions were positive (happiness and satisfaction) for both nursing staff and patients.
Thus, expressions of happiness and satisfaction became signs for both parties in the interaction of care.Perhaps they emerged because the patients relied on the work of the nursing staff, their members and experience.However, the closeness of nursing staff was implicitly based on receiving the confidence of patients, minimizing the period of treatment and hospitalization, and providing quality care.This finding is corroborated by the literature, which indicates that the establishment of trust between the nursing staff and patients needs time for the interpersonal relationship to generate a bond during communication (4,(6)(7) .
The most common facial expressions of happiness and satisfaction could be a consequence of both the patients' confidence in the nursing team, and the significant experience of the professionals (most with two years of care practice).The use of communication as a way to stimulate trust, improve the quality of care provided to patients, and establish interaction with them, is highlighted by the literature confirming these findings (8) .
The facial expressions found emerged as non-verbal communication that helped both the nursing staff and patients to identify some obscure content of verbal communication.The literature confirms this analysis when it highlights that the manifestations of bodily expressions reveal the permission that patients give staff, and what are their reactions in certain moments of interaction in the care (3) .On the other hand, these expressions are present in daily care routine because they are signs that can denote commitment, availability and interest of professionals with patients (3,6) .The data presented in Table 2 confirm this analysis by showing the facial expressions of happiness and satisfaction from both nursing staff and patients, which have a greater variety.
In category 3, eye contact and the specifics of the look, the possible reasons for the most common behaviors of patients and nursing staff to keep visual contact with or without dialogue, may be related to a strategy for establishment of greater closeness and trust in a relationship of care.The literature confirms this finding, indicating that eye contact is a way of demonstrating attention and facilitating the exchange of information during the interaction (9) .On the other hand, the behavior of looking away and breaking eye contact, which was higher for patients, the team members (29.7%) than by the patients (9.9%).This bodily language manifested several times when the members used touch in their actions and acts of care, more for nursing techniques such as checking blood pressure, pulse and capillary blood glucose, applying dressings or offering meals to patients, at the proper time, requiring the staff to touch the patients.Patients responded less to touch perhaps because they understood there was no need for reciprocity, given the therapeutic purpose of touch by the nursing staff.
Excessive closeness among team members and patients was present in both hospitals, although with very low frequency (2.5% GH and 1.2% SH) showing that, for the most part, the nursing staff were removed during the conversation, maybe because of embarrassment, because the excessive proximity had already occurred before care, especially the procedures.Therefore, to avoid exceeding the limit of socially tolerable physical space in an interaction, nursing staff preferred to keep a certain distance when speaking with patients.

DISCUSSION
To analyze the results and compare the two hospitals in this study, the findings concerning manifestations of bodily expressions proved to be quite close, despite the difference between the numbers of participants (76 patients and 21 members of the nursing staff).
The presence of sounds produced by team members and patients in category 1 may indicate that the patient had a problem, the reason for interaction at the time of the conversation, or acting as a stimulus for more intimate contact between the two.This finding is supported in the literature when the sounds collaborate for the judgment of emotions that are being presented by patients when they speak (3)(4) .
One possible explanation for the laughter of the nursing staff may be found in their good adjustment and job satisfaction.This finding is confirmed by the literature when it highlights that job satisfaction is also associated with the people's emotions, work and organization of the work environment, which generate positive responses from the professionals when providing care (5) .
In category 2, the difference in results was greater expressiveness and variety in facial expressions during nursing care.In the GH and the SH, the type of facial expressions of the may be related to embarrassment, inhibition or invasion of their personal and physical space, evident even in refusal to look at nursing technical procedures that were being carried out.The literature emphasizes how personal body space is fundamental in the hospital environment.The exposure of the patient to invasive procedures performed by strangers, in moments of great emotional and physical fragility, causes different reactions in each patient.It also emphasizes that nursing professionals should touch people consciously, aware of the potential effect of this act (6) .
The results showed that the look of the nursing staff was related to the establishment of eye contact, both at the time of interaction, in which speech and physical contact could be present, as well when the care was finished.In this sense, the nursing staff used this bodily expression to reaffirm the bond of trust established between them and the patients.
Eye expressions are related to body closeness or distance of nursing staff during care, which is confirmed in the literature when affirming that physical positioning in relation to the other person can encourage their collaboration, and the maintenance of personal distance facilitates identification of facial expressions (3) .On the other hand, the literature indicates that during communication, knowledge of who is caring, by their body signs or those of the other, can help in the identification of a specific need, in addition to bringing the nursing professional closer or further way from interaction with their patient (6,(9)(10)(11) .
In category 4, on bodily expressions, body language was predictably present both among nursing staff and patients, to aid the communication of reactions, feelings and messages beyond verbal communication.Similarly, the expressions found in this study could enable the development of greater understanding of the interpersonal relationship, and more qualified professionals in patient care (11) .Nonetheless, despite touch being a way to examine, administer and teach in an instrumental dimension, comfort and humanization within the scope of care were maintained.This result confirms the position that, in general, touch is essential to nursing care (6,12) .Thus, the indiscriminate use of light touch by team members disregarded the broader impact that it might have for patients, with the risk of dehumanizing care, which was emphasized by the predominant facial expressions of satisfaction and happiness found in category 2. Nurses must establish a form of contact with their patients that goes beyond touch for performing techniques, and seek other ways to establish relationships of empathy with patients.The use of affection during touch in moments of health care shows the patient's feelings related to human comfort (6,14) .

CONCLUSION
Confirmation of the findings of this study by the literature was greater than its contradiction.Therefore, nursing communication was confirmed as possible and essential to more qualified, specialized and humanized nursing care.Thus, the objectives of this study were achieved, because the nursing staff used their bodies to communicate during care, both in a more traditional and expected manner, as well as unexpectedly.In this sense, body language in nursing care features a categorical nature compatible with nursing communication.
The nursing care situations in the study involved facial expressions, eye contact, touch, head movements, voice, physical closeness and looks.These forms of body language were present in contact between the nursing staff and patients, in moments of interaction for more qualified and humanized care.On the other hand, body language in nursing care showed a sufficient set of results to indicate its applicability in nursing.Thus, these expressions can be configured based on their suitability and appropriateness to compose an analytical category for nursing communication.
In this study, the body was the basis for classification of non-verbal communication, because it is the means by which communication is established, independent of words, between those who provide care and those who receive it.In nursing, bodies incorporate a consensual invasion by the other, socially sanctioned to carry out techniques and other approaches adopted by the nursing staff.Furthermore, the professional bodies involved with the bodies of other professionals to generate collective work, with the purpose of caring for the patient and contributing to the formation of a knowledge linked to actions and acts of caring.
Another aspect implied by this classification for non-verbal communication involves the use of body language both for embracing and rejecting the other.According to the results of this study, the nursing staff tended to use their body language to get closer to their patients.Moreover, they adopted an instinctive decoding of their body language, that is natural to any human being.Therefore, they gained knowledge of the patients' needs and planned interventions specific to each situation.

0. 8 Figure 1 -
Figure 1 -Facial expressions adapted from the "Essential Expression Challenge" and found in this investigation, Rio de Janeiro, 2013 Legend: GH: General Hospital; SH: Specialized Hospital.

Table 1 -
Verbal expressions in nursing care, Rio de Janeiro, 2012

Table 3 -
Eye expressions in nursing care, Rio de Janeiro, 2012 value (16.7%), yet still less than positive expressions.Negative expressions were unique to patients and had a low value (12%).

Table 4 -
Bodily expressions in nursing care, Rio de Janeiro, 2012