Teacher Immediacy for Effective Teaching in Medical Education

Abstract

This article introduces the concept of “teacher immediacy,” defined as the teacher’s communication behaviors that reduce the psychological distance between teacher and students. Though well investigated and recognized in the area of instructional communication, this concept is still new to the field of medical education. The authors first describe the origin, definition, and indicators of teacher immediacy, and then present empirical research findings on teacher immediacy’s positive associations with effective teaching. The authors also introduce findings of teacher immediacy research related to the online learning environment. They recommend medical educators adopt the term “teacher immediacy” and explore it in practice.

Introduction

Many useful strategies for effective teaching have been recommended to medical teachers. In the present article, we hope to contribute to this body of knowledge by introducing a concept that is still new to medical education, though it has been much researched and widely recognized in the field of instructional communication. This concept is “teacher immediacy” (also called instructor immediacy), which has been established by empirical research as an important factor influencing student motivation and learning as well as student ratings of instruction [1–3]. Although elements of teacher immediacy are discussed in medical education literature, they are referred to by various names, and investigation of teacher immediacy in medical education is still lacking. We propose that medical educators adopt the established term “teacher immediacy” as a common terminology and explore its roles in teaching and learning.

Definition of Teacher Immediacy

The notion of “immediacy” was originally put forward by Mehrabian, who conceptualized it as the extent to which the communicator’s behaviors enhance closeness to and interaction with the addressee [3]. Mehrabian [4] maintains that certain behaviors can reduce the perceived psychological distance between communicators, and that these behaviors—such as forward lean, eye contact, directness of body orientation, and smaller distances to the addressee—indicate communicator immediacy. The research of Mehrabian demonstrates that the major communicative function of immediacy behaviors is that they reflect a more positive attitude of the communicator to the receiver [5].

On the basis of Mehrabian’s notion, the concept of “teacher immediacy” was developed to refer to teacher verbal and nonverbal behaviors that decrease the perceived psychological distance between teacher and students [6]. Often-used and well-known scales for measuring teacher immediacy are those developed by Andersen [5] and Gorham [7]. Table 1 shows typical indicators of teacher immediacy.

Table 1.

Teacher immediacy behaviors (from Andersen [5], Gorham [7], and Freitas et al. [6])

Verbal	Nonverbal
• Addresses individual students by name • Asks questions • Gives feedback and praise • Uses humor • Gives personal examples • Encourages students to talk • Gets into discussion based on something a student brings up • Asks how students feel about an assignment • Solicits opinions • Refers to class as “our” class • Gets into conversations with individual students before or after class	• Eye contact (i.e., looking at class while talking) • Gestures • Positive head nods • Smiles • Vocal expressiveness (i.e., vocal variation as opposed to monotone when talking) • Facial expressions • Relaxed body position • Movement about the classroom • Forward leans • Appropriate touch • Close distance to students

Teacher Immediacy and Effective Teaching

Scholars have proposed some possible explanations for why teacher immediacy may be conducive to student learning. First, when a person communicates through words, facial expressions, tone of voice, body movements, and eye contact, multiple communication channels are utilized, hence generating greater immediacy than when he or she communicates only through words [5]. This greater immediacy indicates greater sensory stimulation [5]. Second, immediacy behaviors perceived by students may produce more liking (i.e., positive affect) toward the teacher and course content [3]. Third, a teacher exhibiting enthusiasm and trying to engage students in the classroom may enhance student involvement and enthusiasm for the material and the instruction [8].

Indeed, empirical research on teacher immediacy has established positive associations between teacher immediacy and effective teaching. Witt et al. [3] conducted a meta‐analysis of 81 studies (N=24,474) published from 1979 through 2001 that examined the relationship between teachers’ immediacy and students’ learning outcomes, indicating a positive and substantial relationship between overall teacher immediacy and overall learning. Three types of student learning were distinguished in their analysis: (a) affective learning, which refers to student attitudes toward the teacher and the course, and their intent to enroll in another course of the same type; (b) perceived learning, which is student self-reports of their learning in the course; and (c) cognitive learning, as objectively measured by test scores or course grades. Specifically, Witt et al.’s review reached the following main conclusions. First, teacher immediacy is positively associated with increases in each type of learning—affective learning, perceived learning, and cognitive learning. Second, nonverbal immediacy and verbal immediacy behaviors have similar effects. Third, across almost all of the nationalities and cultural groupings that were examined, positive correlations between teacher immediacy and affective and perceived learning are indicated.

More recent empirical studies support Witt et al.’s [3] conclusions regarding the relationship between teacher immediacy and student learning. For example, LeFebvre and Allen’s 2014 study [9] found that students who observed frequent instructor immediacy behaviors demonstrated higher cognitive and affective learning—that is, higher teacher immediacy correlated significantly with increased cognitive learning as evidenced by students’ letter grades in the course, and teacher immediacy also correlated positively with students’ affect toward the course content and instructor. Violanti et al.’s 2018 study [10] also confirmed the relationships among nonverbal and verbal immediacy, cognitive learning, and perceived learning.

Moreover, teacher immediacy’s connections with some other learner variables have been identified. Student motivation to learn is positively linked to teacher verbal and nonverbal immediacy [1, 8, 11], and such motivation increases the cognitive mastery of material [8]. Teachers who demonstrate more immediacy behaviors have both greater frequency and breadth of student participation in class [12], where participation is indicated by behaviors such as hand-raising with verbal response, calling out, asking questions, and engagement in group activities. Students who observe frequent verbal and nonverbal immediacy behaviors in their professors are more inclined to give high ratings to the quality of instruction [2, 9].

A word of caution is in order. How much teacher immediacy is optimal? The answer is probably not “the more the merrier,” since there seems to be an inverted U curvilinear relationship between teacher immediacy and student cognitive and affective learning [13]. Comstock et al.’s [13] experimental study manipulating three levels of teacher nonverbal immediacy found that moderately high teacher immediacy is more effective in helping students learn than either excessively high or low immediacy. Comstock et al. defined low nonverbal immediacy condition as indicated by the teacher’s reading from a script, using a flat tone, making no eye contact with students, standing immobile, and never smiling, nodding, or touching students. In the moderately high condition, the teacher glanced at notes from time to time, made eye contact 30% of the time, smiled 30% of the time, nodded, spoke with varied voice, walked across the floor in front of the class, did not touch students, and stayed 1.5 feet or more from students. In the excessively high condition, the teacher spoke without using notes, made eye contact 60% of the time, smiled 60% of the time, nodded, spoke with varied voice, roamed the aisles, touched a student’s shoulder from time to time, and approached some students at a distance of less than 1.5 feet. Though these operational definitions may seem rigid, they suggest that certain levels can give students too little or too much of a good thing. As with any good method, appropriate use and moderation are key to its effectiveness.

Online Immediacy Behaviors

A relatively new development in teacher immediacy research is with regard to the online learning environment. There is evidence that students in online courses regret the loss of face-to-face interactions afforded by the conventional classroom [14]. Studies have revealed that many students continue to voluntarily attend live lectures in the conventional classroom in spite of the fact that video recordings of the lectures are available to them online [15, 16]. It is possible that students value teacher immediacy which is made possible by the teacher’s physical presence. Carrell and Menzel’s [17] experimental study comparing three educational settings—a live classroom, a video classroom, and an audio with Powerpoint display classroom—found that perceived instructor immediacy was significantly higher for the live setting, and that motivation, perceived learning, affect toward the instructor, and willingness to enroll with the instructor were highest in the live setting.

Given the prevalence of online teaching, one must consider what teacher immediacy may look like in the online environment. Teachers can still ask questions, encourage discussion, invite students to ask questions, and use humor, as teachers do in the conventional classroom [18]. Arbaugh’s [18] study of web-based courses used verbal immediacy measures developed for conventional classroom teaching, and he found that those immediacy behaviors were positive predictors of student perceived learning and course satisfaction.

The design of multimedia elements used in video for online courses can also contribute to instructor immediacy [19]. Ramlatchan and Watson’s [19] study comparing several online presentation designs revealed that the presentation with slides and audio only was the least preferred by students and its ability to convey instructor immediacy was rated significantly lower than presentations that showed both the instructor and the slides. That is, teacher immediacy was significantly enhanced when students were able to see the instructor on the screen. Ramlatchan and Watson suggest that, as in normal face-to-face communication, learners in online environments may be seeking some form of eye contact from the instructor, and that a blend of the human instructor and the graphics, animation, or textual content with narration can create an online environment that engages the learners.

According to Dixson et al. [20], recent research supports that the following behaviors are likely to have immediacy effects in online learning environments: tone, chronemics, and feedback. Dixson et al. explained these behaviors as follows. Tone allows for being expressive, and it can be created by the use of emoticons, figurative language, and aesthetics of course design. Emoticons are cues for expressing emotion, strengthening messages, and being inviting. Figurative language refers to such techniques as punctuation (e.g., Great idea!!!) and capitalization (GREAT IDEA) that help express attitude. Aesthetics includes the use of imagery (such as graphs and video), typographic design (e.g., “fun” fonts for relaxing a stringent tone), color (to convey emotion or to get attention), and overall cohesion of the presentation design. Chronemics concerns the aspects of time in communication, including response time, length of the message, and frequency of messages from the teacher. Teachers’ prompt responses can convey a positive perception of accessibility and maintenance of continuous interaction, while response delay or silence indicates unavailability or that message recipients are unimportant. Short messages from the teacher may be perceived by students as hurried. Frequency of responses is related to prompt feedback, which matters to students. Timeliness has been shown to be the most important aspect of feedback to some students. Also important are the types of feedback—students prefer written comments over grades without comments or computer generated grading. Dixson et al.’s [20] study concluded that student engagement levels were higher in courses with teacher’s more frequent use of tone, chronemics, and feedback to convey immediacy.

It is worth noting that almost all the studies of teacher immediacy cited in this article focused on college or university students, including a relatively small number of graduate students, and that the studies covered diverse disciplines, including sciences (such as physics and environmental sciences), communication, mathematics, business, engineering, general education, psychology, and nursing. It seems that teacher immediacy research has yet to turn attention to medical students and medical education. One study that involves medical students’ view on teacher immediacy was conducted by Knoster et al. [21]. It examined medical students’ preferences for 10 teacher behaviors or characteristics and found that students considered it essential for teachers to have subject matter expertise, present material clearly, and make material relevant to students’ needs. In contrast, students deemed teacher immediacy behaviors a luxury—desirable but nonessential. Knoster et al. proposed that the students emphasized the “essential” teacher characteristics probably because these characteristics directly facilitate course content learning which the students recognized as critical to their goals of obtaining medical licensure and having future career success. Knoster et al. also found that students in the clinical years attached more value to relational teaching behaviors (such as caring and immediacy) than students in nonclinical years. They postulated that teachers’ relational behaviors might arouse more positive affective states for students overwhelmed in clinical training. Though teacher immediacy was not the focus of Knoster et al.’s study, their findings suggest that medical students might have unique views of teacher immediacy due to the nature of their educational needs and experiences. Thus, it is important to explore teacher immediacy in the medical school context.

Implications for Medical Education

An abundance of scholarly literature sheds great light on what makes effective teaching in the college classroom. For example, Schonwetter [22] identified three most common lecture attributes that are highly correlated with student outcomes: organization of content, clarity of delivery, and teacher expressiveness. Expressiveness is operationally defined by behaviors such as movement while presenting material, gestures with hands and arms, eye contact with students, voice inflection, minimal reliance on lecture notes, and humor that is relevant to lecture content [22]. These “expressiveness” attributes are indicators of teacher immediacy.

Similar recommendations are found in medical education literature. In her step-by-step guide for preparing and implementing lectures, De Golia [23] provides, among other excellent strategies, tips for what she calls “presentation behaviors” of the teacher, including the following: establish rapport with students by creating a conversational relationship and using eye contact; avoid reading from lecture notes; show enthusiasm by looking at students, using their names, inviting them to ask questions, and using humor; use vocal variety and verbal pauses; and look relaxed by occasionally moving about the room and using gestures. All these behaviors fall under the category of “teacher immediacy.” Similarly, Brown and Manogue [24] point out that a lecturer sends to students nonverbal messages consisting primarily of eye contact, gestures, and body movements, and that these messages may be used to establish rapport, monitor student reactions, convey meaning and attitudes, or emphasize a point. They also used the term “expressiveness” to refer to teacher’s enthusiasm, friendliness, humor, use of a conversational style, facial expression, and vocal inflection. Furthermore, Brown and Manogue propose that medical teachers make lectures interactive, allow students to think, and give students feedback. In short, their recommendations for lecturing include elements of teacher nonverbal and verbal immediacy. De Golia [23] also suggests that medical teachers use interactive techniques (such as questioning and small-group discussions) during presentations to raise students’ interest and motivation, enhance student interactions with the teacher and with peers, give students feedback, and get feedback from students.

The above qualities of good teaching—expressiveness, presentation behaviors, nonverbal messages, and interactivity—are covered by the concept of teacher immediacy: expressiveness, presentation behaviors, or nonverbal messages can be summarized as nonverbal immediacy, and the verbal elements that encourage interactivity are consistent with verbal immediacy behaviors. Thus, “teacher immediacy” is useful as a unifying concept that musters the above lists of somewhat discrete characteristics of good lecturing. It is worth noting that, although much of teacher immediacy research has been carried out in classroom settings where the teacher gives lectures and leads discussions, use of teacher immediacy is not restricted to the large-group lecture format. Witt et al.’s review [3] covered empirical studies that involved “a teaching–learning context where instruction was delivered to a learner or learners” (p. 191). Thus immediacy behaviors may be applied in all medical education settings where the medical teacher delivers instruction to learners.

The concept of teacher immediacy may be useful to medical educators in several ways. First, it gives medical teachers a common language to talk about certain qualities of good teaching already discussed but variedly named or listed in literature, including smile, eye contact, movement, enthusiasm, verbal encouragement, feedback, and interactions with students. Second, knowing immediacy behaviors’ role may encourage teachers to try to use immediacy to better their teaching, both in conventional venues such as lectures and in online courses. The use of immediacy will also benefit teachers themselves, since they are likely to receive more positive ratings from students, which may lead to greater career satisfaction and advancements. In addition, immediacy behaviors help teachers develop positive relationships with students [21]. Third, faculty development can give attention to teacher immediacy, for research has shown that teachers trained on a set of immediacy behaviors demonstrated significant gains in student ratings from pre- to post-test [22]. Fourth, for the assessment of teaching, rating forms can assess specific immediacy behaviors, rather than evaluate only global dimensions such as teachers’ “communication skills,” so that teachers would benefit from specific ratings of actual behaviors that they can monitor and adjust [2]. Finally, medical education researchers can study the role of immediacy in the classroom and in online instructional environments. Though teacher immediacy has been well researched elsewhere, its role in medical education is yet to be explored. Various methods can be used in this exploration, but perhaps a direction that medical education scholars can focus on is experimental research. According to reviews by Witt et al. [3] and Liu [1], a relatively small number of studies of teacher immediacy used experimental (or quasi experimental) designs, while the majority of studies used survey methods which indicated correlations rather than causal relationships. As scholars continue to stress the importance of verbal and nonverbal immediacy because it is associated with positive learning outcomes and student participation and motivation [25], the need for more experimental studies presents an opportunity for medical education scholars to make important contributions to teacher immediacy research.

Conclusion

Teacher immediacy is a proven means for enhancing teaching effectiveness. Medical educators can use it in various instructional settings to promote student motivation, interest, participation, positive attitude toward instruction, and, ultimately, learning.

Declarations

Competing Interests

The authors declare no competing interests.