A review of immediacy and implications for provider-patient relationships to support medication management.

OBJECTIVES: This review is intended to 1) describe the construct of immediacy by analyzing how immediacy is used in social relational research and 2) discuss how immediacy behaviors can be incorporated into patient-provider interventions aimed at supporting patients' medication management.
METHODS: A literature search was conducted using Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, OVID, PubMed, and Education Resource Information Center (ERIC) EBSCO with the keyword "immediacy". The literature was reviewed and used to describe historical conceptualizations, identify attributes, examine boundaries, and identify antecedents and consequences of immediacy.
RESULTS: In total, 149 articles were reviewed, and six attributes of immediacy were identified. Immediacy is 1) reciprocal in nature and 2) reflected in the communicator's attitude toward the receiver and the message, 3) conveys approachability, 4) respectfulness, 5) and connectedness between communicators, and 6) promotes receiver engagement. Immediacy is associated with affective learning, cognitive learning, greater recall, enhanced relationships, satisfaction, motivation, sharing, and perceptions of mutual value in social relationships.
CONCLUSION: Immediacy should be further investigated as an intervention component of patient-provider relationships and shared decision making in medication management. PRACTICE IMPLICATIONS: In behavioral interventions involving relational interactions between interveners and participants, such as in medication management, the effects of communication behaviors and immediacy during intervention delivery should be investigated as an intervention component.

Introduction

Effective patient–provider communication contributes to patients’ understanding of their illnesses, treatment options, and adherence, which is imperative for disease management.1 Poor provider–patient communication often distances patients from participation in their care,2 which is associated with 1.5 times greater risk for treatment non-adherence,3 with medication non-adherence occurring in as many as 50% of patients. Patient factors, such as not understanding medications and instructions, can lead to unintentional non-adherence.4 In the USA, surveys of patients discharged from acute care hospitals have found that when a new medicine was being explained to them, only 65% reported that they had “always” been told what the medicine was for and what side-effects might be experienced.5 When patients do not adequately understand how to care for themselves after discharge, they are more likely to experience hospital re-admission. Avoidable hospital re-admission within 30 days of discharge occurs in as many as one in five elderly patients, and unnecessary re-admissions cost the federal government an additional $17 billion annually, because patients are not prepared to self-manage their illnesses after discharge.6 Active patient engagement in relationships with providers facilitates patient decision making, which is imperative in promoting effective medication management.

Interpersonal relationships can be enhanced through communication behaviors that convey a sense of interpersonal closeness, which is also known as immediacy. In learning situations, intervener immediacy is associated with certain learner attitudes and perceptions, such as interest in content and state motivation, in relation to learning.7 Understanding immediacy and how it can affect the provider–patient relationship can help inform self-management interventions; however, such studies of immediacy in health care are limited. The purpose of this article is twofold. The first purpose is to describe the concept of immediacy in communication and how it has been used in relational and educational research. The second purpose is to discuss how immediacy behaviors can be incorporated into patient–provider communication interventions aimed at supporting patients with medication management.

Defining immediacy

Immediacy is most often found in the field of communication research and has been less studied in the health care environment. Immediacy behaviors are “approach behaviors” conveying interpersonal closeness that increases sensory stimulation, which is perceived as warmth.8 The construct of immediacy refers to perceptions of physical and/or psychological closeness among individuals.9 These behaviors can include physically moving closer to someone during interaction, touching, using direct eye contact, smiling, having an open body posture, gesturing, and vocal expressiveness.10 While the study of nonverbal communication is not novel, immediacy encompasses more than just non-verbal behaviors. Immediacy is an affect-based construct, where communication behaviors reflect the underlying psychology between those communicating.

Literature review

A literature review was used to define immediacy by 1) examining conceptual boundaries, 2) identifying critical attributes, and 3) identifying antecedents and consequences. The literature was located thorough database search engines CINAHL, Google Scholar, OVID, PubMed, and ERIC EBSCO from 1968 to 2014 using the keyword “immediacy” in the title of articles. Searches were limited to English full-text articles. Based on the selection criteria, 404 articles were identified. Abstracts were reviewed to determine if the articles pertained to immediacy in interpersonal (relational) communication. Articles that did not pertain to this criterion (eg, reference to timing of events, alcohol drinking, reward, publishing, and Internet) were excluded.

Results

Historical views of immediacy

After removing duplicates and screening articles, 149 articles remained that met review criteria. Historically, immediacy was studied from the communication perspective. Immediacy in communication is attributed to Mehrabian,11 who described the concept as a directness and intensity in communication, known as the “immediacy principle”. From 1966 onward, scholars have increasingly studied verbal and non-verbal immediacy, as shown in Figure 1.

Figure 1

Number of studies included in this review and measures of immediacy.

Recent communication scholars have modified the original immediacy principle as the “principle of immediate communication”, suggesting “the more communicators employ immediate behaviors, the more others will like, evaluate highly, and prefer such communicators; and the less communicators employ immediate behaviors, the more others will dislike, evaluate negatively, and reject such communicators”.12 This suggests that individuals, who engage in immediacy behaviors, are more likely to be liked than individuals who do not engage in immediacy behaviors. These two principles suggest a reciprocal relationship between immediacy and liking, and over time, both have been supported and seen as correct.13

Dimensions (measures)

Measurement of immediacy was described as both subjective and objective across studies in this review. Immediacy measures included both self-report and observer rating scales. Verbal and non-verbal aspects of communication have been measured in studying immediacy. Regardless of whether immediacy was measured verbally or non-verbally, immediacy was described as a “perception of psychological closeness”,10,14–33 reflecting the underlying psychology of interpersonal communication. Both behaviors have been considered “artifacts of affect” and therefore have been used as surrogate/latent constructs to measure immediacy. In only one study, physiological dimensions were analyzed in relationship to anxiety and its effect on blood pressure ratings.34

Verbal immediacy

Mehrabian and Wiener’s early work examined linguistic features of communication.35 His approach considered that immediacy cues were encoded in the communicator’s word choices and reflected the communicator’s attitude toward the referent or object of communication, including their liking and preference toward such referents. Directness of the interaction and relationship between the communicator and referent could, therefore, be inferred from the communicator’s word choices. For example, a communicator’s word choices reflected the extent to which the receiver of the message was considered as a member of the communicator’s associated groups or was considered as an outsider. Early immediacy research focused on the communicators’ directness and intensity encoded in words.36–38 Gorham39 later approached verbal immediacy by asking students to describe their best teachers and specific behaviors that helped characterize them as such. This approach resulted in the construction of a measure of verbal immediacy, which is known as the verbal immediacy scale (VIS). Despite the VIS being widely used across studies included in our review,16,18,21–26,28,39–65 it has been criticized as being a measure of teaching effectiveness and not necessarily being a measure of immediacy.59,66

Further work to develop a measure of verbal immediacy was undertaken by Mottet and Richmond.67 Their work suggested that people use a variety of verbal strategies to pursue relationships that are not necessarily based on the linguistic code. They developed verbal typologies that represent strategies people employ to build or avoid relationships. Although verbal strategies are useful in making people appear more or less approachable, Mottet and Richmond67 contended that approach-avoidance strategies do not actually comprise verbal immediacy. Instead, they believed that VISs were measures of relational approach and avoidance.

Non-verbal immediacy

Non-verbal behaviors have long been studied in communication research; however, most studies of non-verbal behavior have assessed just one or two behaviors. Nonverbal behaviors as they naturally occur involve several behaviors that when combined are likely to reflect the communicator’s attitude. Non-verbal immediacy behaviors include observable objective behaviors such as touch, proximity, eye contact, verbal expressions, and tone of voice.

Andersen et al8 combined several different non-verbal behaviors to operationalize non-verbal immediacy. Andersen et al’s work resulted in the simultaneous development of three instruments: 1) generalized immediacy scale, 2) behavioral indicants of immediacy scale, and 3) trained rater’s perception of immediacy scale.8 These scales were developed to address measurement concerns in establishing both subjective and objective measures, as well as a means to establish construct validity. The behavioral indicants of immediacy scale has been considered problematic because learners are asked to compare their teacher against another teacher and the scale has item redundancy.68 Building on these limitations, Gorham and Zakahi51 generated a 14-item instrument combining items from Andersen’s early work and researcher-generated items to balance positively and negatively worded items. This revised instrument, nonverbal immediacy measure, was later reduced to ten items69 and was used primarily across the last decade. Use of these instruments indicated some potential reliability problems, with reliability estimates ranging from 0.67 to 0.89. As a result, the non-verbal immediacy scale was constructed.70 This newer scale includes a self-report and observer versions and has since been used in communication research, with reliability estimates of 0.90.70

Given the literature included in this review, immediacy can best be conceptualized and measured as a multi-dimensional construct consisting of both verbal and non-verbal components. Non-verbal and verbal immediacy components are outlined in Table 1.

Table 1

Examples of non-verbal and verbal immediacy behaviors

Non-verbal immediacy behaviors	Verbal immediacy behaviors
Touch	Use of pronouns such as “you” and “we”
Proximity	Use of personal names
Eye contact	Verbal empathy
Tone of voice
Hand gestures
Facial expressions

Contextual influences

Immediacy has been studied mainly in a few different disciplines including psychotherapy, linguistics, and predominately, in education. In studies reviewed, the core of immediacy is the “interpersonal relationship”. The types of relationships examined are shown in Table 2. Immediacy was primarily limited to adults or college-aged students.

Table 2

Contextual influences (not mutually exclusive)

Type of relationship	Number of studies
Student–teacher8,14,16–19,21,23–31,33,38–46,49–57,60,62,63,65–70,72,73,75,76,84–141	106
Online/web-based16,19,40,41,56,72,87,93,95,109,126,127,130,142	14
Graduate student; teacher or advisee19,40,41,56,87,127,130,143	8
Powerful; authority42,75,97,98,108,140,141	7
Social, peer (roommate and student inter-relationships)32,38,144–147	6
Counselor–client74,77,80,148,149	5
Supervisor–subordinate10,12,70,141,150	5
Intimate partner32,34,70,151	4
Teacher assistant/student tutors58,73,139,152	4
Human–computer interaction126,130,138,153	4
Provider/physician–patient20,154	2
Military student–teacher93	1
Coach–athlete61	1
Librarian–library users37	1

In all studies, communication occurred either face-to-face or online; in most cases, the interpersonal relationship was between one and many, such as in the classroom. In a number of articles,40,41,44,52,71–74 immediacy was related to the “here and now” meaning both parties’ communication behaviors conveyed involvement and engagement in the present conversation. When those behaviors were utilized, there were descriptions of “presence”. Focus on affect in the relationship influenced immediacy, whereas distancing behaviors were described as more information seeking/gathering with no affect. Because of the context studied, including classroom and psychotherapy, immediacy was studied in the context of powerful relationships. One additional study investigated source immediacy in the context of authority. In this study, immediacy was studied in relation to the actual presence of the authority figure and behavioral responses depended on presence.75 Certain types of relationships (eg, teacher/student and therapist/client) create power differentials.76

While immediacy was studied in communication studies, psychotherapy researchers also investigated immediacy as an intervention in client and psychotherapist relationships. Collingwood and Renz,77 for example, evaluated the therapeutic interaction between a counselor and his/her client. Expressed in these relationships were communications that conveyed empathy and respect, as well as communication that focused on the “here and now” of the relationship. For example, if the client talked about the counselor and their relationship or if the counselor related the content of client discussions to the relevant content at hand, this was considered indicative of immediacy. The study of immediacy and specific types of immediacy were further developed from interaction analysis in case studies across time78,79 and then from more generalized, descriptive, and longitudinal studies of immediacy.80 More recent literature defines immediacy as observable events between a patient and psychotherapist that includes disclosure of the here-and-now, expressed by either the client or the psychotherapist71 and is a part of the therapeutic process.81

Attributes

In reviewing the literature, we have postulated six specific attributes of immediacy: respectfulness, approachability, connectedness, attitude, engagement, and reciprocity. These attributes are not mutually exclusive. Immediacy attributes were identified based on authors’ descriptions of immediacy and measures of immediacy. Definitions of immediacy most often referenced Mehrabian82 and Andersen et al.83 The term immediacy is often used interchangeably with “immediacy cues”; however, immediacy is the affective response, whereas immediacy cues are the specific behaviors that lead to immediacy perceptions.84

Immediacy is reflected in the communicator’s attitude toward the receiver and the message, conveys approachability, stimulates interest in the receiver, conveys connectedness between communicators, and promotes receiver engagement in communication; therefore, it is reciprocal in nature.

Antecedents

Antecedents of immediacy were rarely explicitly described; two broad antecedents were implied based on definitions of immediacy and contexts within which immediacy was studied. The first antecedent is proximity. Any situation that places people in proximity to one another presents the opportunity for people to interact. For example, in educational research, the classroom was the context that permitted interaction. Web-based environments, though they do not involve face-to-face interaction, were also important contexts that led to interaction.16,19,40,41,47,56,72,87,93,109,126,127,130,142

The second antecedent is the use of verbal and non-verbal immediacy cues that signal “liking”. This antecedent is derived from studies that based their immediacy definition on Mehrabian’s work,11 which considers immediacy as a manifestation of liking.14,16,37,50,96,101,144,155 Implied in this definition is that when a person likes another person, he or she will engage in more immediacy behaviors. Andersen et al8 described this as engagement in non-verbal communication behaviors that signal approach, availability, and openness and signal the beginning of a relationship.

Consequences

Immediacy is associated with affective learning, cognitive learning, greater recall, enhanced relationships, satisfaction, motivation, sharing, and perceptions of mutual value in the relationship (Table 3). These outcomes were evaluated by both correlational descriptive and experimental designs. Those who are more immediate are considered more assertive and responsive to others’ needs than those who are less immediate.66 This likely has to do with the fact that immediate individuals are considered communicatively competent,66 meaning that they can effectively and appropriately communicate with a variety of individuals in different situations and contexts.

Table 3

Consequences of immediacy

Consequences
Affective learning14,17,23,24,30,31,39–42,51,52,55,58,60,69,76,86,90,91,105–107,121,125,128,129,131,134,136–138
Cognitive learning24,31,39,40,42,51,53,55,56,58,60,64,86,90,91,93,101,103,104,107,109–111,121–123,128,131, 134,136,152
Behavioral learning18,51,55,57,60,86
Motivation12,21,23,30,40,43,44,63,65,84,90,91,93,110,119,131,136
Recall33,91,99,103,118,121
Satisfaction12,20,28,29,31,32,37,38,40,52–54,56–58,61,64,65,73,85,88,90,91,108,116,141
Self-efficacy37,46,62,93

Interactive communication is indicative of greater collaboration and shared decision making.17 In the few studies that focused on health care, including the physician and psychotherapist relationships, use of immediate behaviors was associated with patient satisfaction, increased attention, and more sharing, as well as medical competence, humility, and access.20,148 Immediacy has also been associated with one’s ability to elicit emotional sharing, including interpersonal connection, trust, and caring.16,20,34,77,141,154

Immediacy behaviors, in general, are positively related to cognitive learning, but not all immediacy behaviors have the same effect. Specifically, vocal expressiveness, smiling, and relaxed body posture had the greatest effect on cognitive learning, whereas touch had the least effect.111 This suggests that as individuals try to increase cognitive learning, regardless of the context, it may behoove them to concentrate on improving specific immediacy behaviors, rather than trying to improve all immediacy behaviors. In general, those viewed as immediate were considered approachable, encouraging, and effective.

Discussion of immediacy in medication management intervention

Immediacy is a relationship-based construct that encompasses both verbal and non-verbal communicative behaviors in a way that increases attention and psychological closeness among individuals. In the educational contexts studied, immediacy has been associated with affective learning, increased motivation to learn, and increased cognitive mastery. In the few health care-related contexts that have been studied, immediacy resulted in greater personal reflection,156 as well as greater connection among providers and patients, with patients working more closely to achieve important health goals.154 Although the educational context is different from the health care context, both education and health care environments involve relationships between people, who support others’ learning and skill acquisition. Health care providers often assume instructional teaching roles in providing patient education. In these teaching roles, the health care provider must engage the patient in learning; this includes using strategies to enhance affect toward learning and motivation. Given that there is a cumulative body of evidence suggesting that immediacy has been effective in enhancing these very outcomes, it is likely to have the same effect in the context of patient education. If medical providers employ immediacy behaviors, then it is more likely to engage the patient, leading to shared decision making and then better preparation for self-management of prescribed medications.

Increased attention is being paid to shared decision making in the health care context; yet, inclusion of immediacy in this relationship is yet to be explored. Furthermore, in behavioral interventions involving relationships between interveners and participants, the effects of the perceived immediate behaviors by research participants of the interveners delivering interventions are yet to be investigated. For example, intervener immediacy may be just as important as intervention fidelity for interventions involving interpersonal communication with patients. This means that patients’ perceptions derived from provider use of high or low immediate behaviors may interact with behavior change efforts, such as medication management. If there is an interaction between participant perception of intervener immediacy and the outcome, results of interventions delivered in the social relational context may be stronger or weaker than what is actually reported.

The concept of provider immediacy may be useful in designing interventions to support medication management. To date, several different approaches to enhance adherence and medication management have been studied. These interventions have focused on patient education, counseling, and post-discharge follow-up to assess adherence.157 In studies investigating patient–provider relationships, patient perception of provider communication has correlated with medication adherence. Liu et al158 studied hormone treatment therapy following breast cancer diagnoses in low-income women and found that communication perception was linked with adherence to medication treatment. Furthermore, the oncologist’s patient-centered communication was an independent predictor of sustained adherence at 36 months after diagnosis. Providing patient education and counseling at discharge with improved health care provider communication has been shown to reduce patients’ risk for adverse medication problems and re-admissions.159 Though interventions have targeted enhanced communication with patients, most studies have been of poor quality or were underpowered159 and lacked focus on the relational communication aspects of immediate communication behaviors.

Conclusion

By employing immediacy behaviors, health care providers are more likely to draw patients’ attention to important educational points. More importantly, when providers employ immediacy behaviors, they are more likely to engage patients in a dialogue that will enhance the provider–patient relationship. This enhanced relationship is likely to assist patients in feeling more comfortable while discussing their plans of care and what is most meaningful for them in the context of their own lives. Thus, by enhancing relationships with patients, providers can enhance shared decision making and patients’ self-management behaviors. Incorporating personalized components of communication and immediacy in interventions is needed in medication management research and practice.

Implications for research and practice

Researchers and practitioners should consider the potential immediacy effects on targeted outcomes. It is hypothesized that non-verbal behaviors account for 80% of communication between individuals.160 Interveners, who interact with patients, may use behaviors that increase immediacy or distance the patient from communication. These behaviors may alter the patient’s attention to important educational messages, beliefs in the content, and trust in the relationship, all of which may modify the outcome of interest (eg, medication management and adherence). Therefore, as interventions are designed to support medication management, incorporating communication behaviors known to enhance immediacy should be considered in intervention design, intervener selection, and intervention fidelity. Including patients’ self-report of immediacy as well as objective measurement of immediacy can inform how immediacy may affect medication adherence interventions. Immediacy measures can be useful in understanding patient perceptions of the communication behaviors used in delivering interpersonally based interventions.