Introduction
Imagine yourself as a patient in the following three scenarios.
Scenario 1: You wake up in a noisy, bright room with a tube in your mouth and dozens
of lines connecting you to various machines. You are terrified of the beings surrounding
you, who look like aliens. What you do not remember is that you were admitted to an
intensive care unit (ICU), that the “aliens” are healthcare providers in personal
protective equipment (PPE), and that you are very ill with COVID-19. You desperately
look around for your loved ones, but they are nowhere to be found.
Scenario 2: You underwent a total knee replacement on March 20, 2020, 2 days before
the New York State shutdown in response to the COVID-19 pandemic. Having been discharged
home, you are now eager to begin rehabilitation. Being post-operative, you are deemed
an “essential” patient. The outcome of the surgery is highly dependent on early post-operative
knee range of motion and swelling, and these are ideally assessed and treated during
an in-person physical therapy session. After interrogating your physical therapist
(PT) about the safety measures the hospital has undertaken, you decide to travel 90 min
to your first appointment. When you arrive, you realize your extreme discomfort with
the post-operative care that requires close proximity and physical touch by a stranger
clearly not within current social distance guidance of 6 ft.
Scenario 3: You are working at home while being treated for back pain and you have
scheduled a 30-min telehealth physical therapy visit on your lunch break during a
hectic workday. Your husband is caring for your three school-age kids while acting
as their teacher in your home. When first attempting to connect with the PT on your
computer, you see only a blank screen. You phone the PT, who asks you to leave the
session and reconnect; the PT’s face becomes visible, but she says that your screen
keeps freezing. Frustrated and in pain, you leave the session and try to reconnect
once more.
For public safety, rehabilitation has shifted to treating patients through telehealth
or in person while wearing personal protective equipment (PPE). This allows a connection
with patients but with several constraints. As the opening scenarios illustrate, the
loss of non-verbal communication coupled with the heightened arousal states of fear,
anxiety, and pain can interfere with the patient experience. With the limited amount
of time clinicians have with patients, and the new barriers that are arising during
the COVID-19 pandemic, the need for understanding and using the different components
of language and communication effectively is essential. Keulan et al. reported that
the amount of time spent with a clinician was not as important as the quality of the
conversation they have with their therapist [10]. Patient satisfaction was not dictated
by quantity of time, but rather the value they received from their time with the clinician
[9, 12]. Similar to that of a placebo effect in medication trials, a clinician can
influence an optimal therapeutic outcome regardless of biological changes by positively
impacting a patient’s mind, cognition, and emotions [1].
Verbal communication employs words to convey information, while non-verbal communication
includes multiple components such as gestures, tone, eye contact, facial expressions,
touch, and body language (Table 1) [8]. Each component can be impacted differently
depending on whether treatment is delivered in-person or through telehealth. Clinicians
can make small but impactful modifications to enhance communication in patient care.
Table 1
Components of non-verbal communication [2, 5–8, 11, 14]
Component
Definition
Examples
COVID-19Modification-Live
COVID-19Modification-Telehealth
Facial expression
Using the muscles of theface to display universalemotions
Smile, frown, grimace
Smile under a mask, lines inface and eyes willstill convey the expression
Remove mask for a telehealth visit
Gestures
Deliberate movements thatwe make
Pointing, waving, numeric
Use gestures for emphasis
Make sure gestures arevisible on screen
Paralinguistic
The way you choose to saysomething and the impressionit makes
Pitch, inflection, tone ofvoice, loudness
Reduce speed of speech
Speak louder
Enunciate
Be aware of delay fromcomputer connection
Reduce speed of speech
Proxemics
How we maintain and perceivespace
Seating arrangements,personal space, businessinteractions
Read a patient’s comfort levelwith social distancing
Be mindful of coming into thepersonal space
Ask permission before enteringtheir space
n/a
Kinesics
Body language and posture
Open postures: trunk of bodyopen/facing camera, relaxedappearance
Closed postures: arms crossed
Maintain open postures
Expression of true feelingsthrough our body
Maintain open postures
Position the device to make surebody is seen
Eye gaze
The use of our eyes forcommunication
Looking, staring, blinking
Maintain eye contact with patientthrough PPE
Focus attention on patient
Know where the camerais on the device
Haptics
Communication through touch
Expression of sympathy,friendship, romance, status,power, dominance
Read a patient’s comfort levelwith breaking social distancing
n/a
Appearance
How you choose to presentyourself
Uniform, clothing, piercings, tattoos,nail polish, jewelry
Wear a laminated card with name,picture and job title
Wear PPE appropriately
Wear professional attire, especiallyif conducting telehealth from home. Be mindful
of visible background
Chronemics
How we use time tocommunicate
Schedules, appointments,waiting times
Instruct patients to arrive only a fewminutes before start time
Start on time to reduce time in thewaiting room
Walk patients out to avoid additionalpersonnel contact
End sessions on time
Set up your space with appropriateequipment for efficiency before initiating the appointment
Artifacts
Tools that we use forcommunication
Physical objects usedduring a treatmentsession or in a clinic
Communication boards
Tablets
Safety signage
Cleaning Supplies
White boards to display person,place, timeand pertinent dates during currentepisode
of care
Place all supplies,
(e.g., tablet, bands, weights, towels)nearby for demonstration
Challenges to Communication with In-Person Treatment
Social Distancing
The need for social distancing can create a barrier to nonverbal communication that
rehabilitation clinicians may find difficult to overcome. The nature of our profession
requires close proximity to patients. Where distancing is required, rehabilitation
professionals may struggle to provide comfort and support. Our use of proxemics (physical
distance) and haptics (touch) has changed greatly, both between clinician and patient
and among team members. Proxemics and haptics are important tools that rehabilitation
staff use to communicate care, interest, and concern to patients. For instance, a
hand placed on a patient’s shoulder can communicate support, but the close proximity
in-person therapy entails may prompt verbal and non-verbal expressions of discomfort
for patients during the pandemic. Empathetic speaking such as restating concerns,
validating feelings, and asking permission to proceed with the treatment can help
to ease a patient’s anxiety [11].
Personal Protective Equipment
Facial expressions are a part of how we communicate and interpret emotions [5]. Wearing
masks, goggles, and splash shields allows only the eyes to be visible, but eye gaze
with a patient can convey commitment and concern as a substitute for other facial
expressions [5]. Paralinguistics (pitch, inflection, tone of voice) help put meaning
and variability into speech, but N-95 masks attenuate sound, muffling, or amplifying
speech [6, 7, 14]. The compensations made in paralinguistics such as speaking more
loudly when wearing an N-95 can be misinterpreted as aggressiveness. Masks pose an
even greater barrier for patients who are hearing impaired [7, 14]. Decreasing the
speed of speech, increasing volume, and lowering pitch can be effective ways to compensate
for the limitations of PPE [8].
Acute Care
In the acute care setting during the pandemic, clinicians are almost fully obscured
under required PPE, making all hospital employees look the same. PPE can lessen the
power of touch, and our proxemics may be particularly limited with patients in the
ICU or with those who are coughing. Clinicians’ inadvertent body language due to discomfort
in PPE may include posturing such as crossed arms or hands on hips. This can be misread
by the patient as staff not being fully engaged or not wanting to be in a room. Clinicians
can communicate interest when wearing PPE through open posturing, increasing eye contact,
and being aware of their own body language [2, 3]. Clinicians can also verbally explain
why they need to leave the room. Additionally, clinicians need to promote self-care
by taking breaks after every two or three patients in order to remove masks due to
discomfort and to rehydrate due to excessive perspiration. Current donning and doffing
guidelines of PPE can add up to 15 min between each patient, causing a change in the
accustomed chronemics (timing). To improve chronemics for staff and reduce exposure
time to patients with COVID-19, clinicians now co-treat each session.
Other barriers to communication with COVID-19 patients include intubation, nasogastric
and orogastric tubes, tracheostomies, and cognitive limitations due to post-ICU delirium.
Such patients cannot clearly communicate their needs to staff. Clinicians can employ
communication boards to serve as an artifact (tool) to assist these patients. However,
careful consideration is needed when incorporating a communication aid; the patient
must be alert and cognitively intact, and the communication board must be easy to
interpret.
In our opening scenario, in which you are a COVID-19 patient in the ICU, your clinician
could use a laminated card containing their name, picture, and job title to help you
understand who is present in the room. The clinician should also utilize the white
boards located in each hospital room. Writing the date, name of the hospital, and
unit within the patient’s line of vision helps orient them.
Outpatient Care
Both the clinician’s and clinic’s appearance and use of artifacts have the ability
to communicate certain messages to patients. Even though dress codes may not have
changed, PPE has become an essential part of the clinician’s uniform. Appropriate
wearing of PPE along with artifacts such as signage supporting social distancing and
displaying/utilizing cleaning supplies communicates an environment of patient safety.
Manual therapy, a typical treatment modality, requires clinicians to be in a patient’s
personal space. Social distancing guidelines may make patients more uncomfortable
even though they have chosen to attend a live session. Health care practitioners must
read body language and verbal cues from patients to understand his/her comfort level.
Hands crossed over the chest or leaning away suggest a person is not ready for someone
to enter their personal space. Obtaining consent allows a patient to safely invite
the clinician to perform the chosen modality.
Challenges to Communication with Telehealth Treatment
There is a learning curve for both clinicians and patients in telemedicine. The telehealth
model requires clinicians to adjust verbal and non-verbal communication. A clinician
arriving late to a session due to technological difficulties may inadvertently communicate
disrespect for the patient’s time (chronemics). Frustrations with connectivity in
telehealth may increase both clinicians’ and patients’ sympathetic nervous system
responses. Clinicians and patients can take a deep breath together to access the parasympathetic
nervous system and reset, much like an internet connection, to promote healing. Tone
of voice can be used to heighten someone who is demonstrating signs of apathy or sadness.
Alternatively, tone can be used to de-escalate someone who seems to be stuck in a
hyper-aroused state. As in the third scenario described above, both the patient and
clinician are experiencing difficulty linking via telehealth. The clinician can first
use breathing to engage the parasympathetic system to manage their own frustration
in establishing a telehealth connection, use a calming tone to de-escalate the patient’s
frustration, and convey respect for their time by asking the patient to determine
whether they prefer to continue the session or reschedule for a time that works better
for them.
Telehealth alters our usual understanding of proxemics and haptics. Increased attention
to factors such as auditory cues and kinesics (body language/posture) will signal
whether patients are receptive to a clinician virtually entering their home. Family
members can be involved during sessions to deliver manual therapy after clinician
education, move the camera around for optimal visualization, or motivate the patient
to participate. Inviting family into the treatment session might ease anxiety of our
patients through co-experience and proximity. Facial expressions and eye gaze are
powerful non-verbal communication tools during telemedicine treatments. Understanding
where the camera is located on the device will help simulate eye contact between clinician
and patient. Even though telehealth limits clinicians to treating in two dimensions,
facial expressions and gestures can still be clearly communicated and identified.
Clinicians should be mindful of setting up in a location where their body can be visible
so nothing is left questionable regarding the clinician’s engagement. All possible
distractions should be removed from the space, and e-mail notifications should be
silenced to devote attention to the session.
The Role of Stress and Empathy in Communication
During the COVID-19 pandemic, stress on staff can become a major barrier to effective
and efficient communication due to overwhelming fatigue, emotions, and social isolation.
Communicators may become impatient, use aggressive tones or words, finish the communication
partner’s sentence, or be blinded to the other individual’s point of view [4, 11].
For example, a therapist may say to a patient, “I told you to stop running. No wonder
you aren’t better.” A more neutral statement, such as “modifying your activity can
have a big effect on your ability to heal,” may be more effective [11].
Empathy, the ability to see the world from another’s perspective, holds the key to
non-verbal communication barriers. During the COVID-19 pandemic, it is crucial that
clinicians bear in mind that the patient, regardless of diagnosis, is likely feeling
scared, isolated, helpless, or overwhelmed. Tone of voice can enhance optimal healing
potential [13]. Empathetic listening requires us to remove distractions and also involves
maintaining a quiet space, being mindful of word choices [16], giving patients the
opportunity to speak, and trying not to finish their sentences. Empathetic speaking
requires taking a reflective pause, gathering thoughts in order to be clear and concise,
and being mindful of tone [15]. Patients should be given time to express how they
feel when given feedback or new information [3]. As clinicians, part of our role is
to create a space in which our patients can feel safe and where vulnerability is supported.
In order to do this, it is vital for clinicians to participate in self-care practices
in any way that is meaningful and personal (e.g., prayer, meditation, routine, activity).
We can serve as a role model and be a calming presence.
The COVID-19 pandemic has forced clinicians to change the way they communicate with
patients. Use of PPE, social distancing, and telemedicine have been able to decrease
community spread of COVID-19, while enabling clinicians to deliver quality care. Given
the success of treatment under these circumstances, clinicians need to prepare for
protective measures continuing for an indeterminate amount of time and be aware of
how they impact communication with patients. Clinicians should be educated on how
to increase utilization of available non-verbal communication techniques.
This is a unique and stressful time for clinicians and patients alike. Regardless,
a clinician’s primary role is to be a care provider for all patients. Open communication
with patients relies on the clinician’s acknowledgment of his/her own feelings and
ability to engage in empathetic speaking and listening to promote a healing environment.
Providers can continue be effective in their roles as caretakers by being mindful
of utilizing the optimal combination of verbal and non-verbal communication strategies.
Supplementary information
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