In the COVID-19 environment, wearing personal protective equipment (PPE) is the norm for clinicians. Monthly, U.S. health care workers use 89 million masks. While these masks help prevent the spread of disease, PPE creates barriers to effective communication that is requiring clinicians to learn new techniques for interacting with patients. Learning new verbal and non-verbal techniques to overcome PPE communication barriers is especially important for conveying compassionate communication essential for building trust and rapport with patients and improving health outcomes.

Health care workers in patient-facing roles are struggling with communication barriers created by PPE. A study cited by the Postgraduate Medical Journal found that 90.3 percent of health care professionals who use enhanced PPE were perceived as having communication difficulties.

As clinicians grapple with communicating through the mask, patients are also struggling in these interactions, feeling a lack of empathy and connection with their doctors.

According to research cited in the Journal of Hospital Medicine, a study of over 1,000 patients randomized to mask-wearing and non–mask-wearing physicians revealed a significant and negative effect on patient perception of physician empathy in consultations performed by mask-wearing physicians. Another study found that participants, with very few exceptions, reported that face coverings negatively affected feelings of connection with the speaker and hearing and understanding.

Compassionate communication skills are critical for clinicians under normal circumstances but are now vital to caring for patients who are feeling scared, anxious, and overwhelmed during the pandemic. A combination of verbal and nonverbal techniques can help clinicians convey compassion despite the communication challenges of PPE that muffles voices and conceals facial features.

To help build trust and rapport with patients in this environment of PPE and social distancing, clinicians should consider the following:

It’s a dialogue not a monologue

Establishing a dialogue with patients starts by sitting down and facing the patient while speaking. Many doctors tend to multi-task, but especially with the communication barriers PPE causes, sitting at eye level and making good eye contact goes even further to show the patient they have your full attention.

Active listening is also part of an effective dialogue with patients, helping clinicians understand how the patient is feeling. This is especially important considering that PPE obscures some of the non-verbal cues clinicians have traditionally relied on for information on how the patient feels. Asking open-ended questions and paying attention to what patients are saying and how they are saying it will help the patient open up about their needs.

Addressing patient emotions is another important part of creating a compassionate dialogue. Saying something like “thank you for sharing your anxiety – it is natural to feel that way and I am glad you shared this with me” can help create a sense of connection by using verbal empathy that legitimizes and validates the patient’s feelings.

The power of a smile

Patients can’t see the smile behind the mask, but they will notice a smile reaching the eyes. Smiling with the eyes is often referred to as a Duchenne smile named after neurologist Guillaume Duchenne who observed that sincere smiles rely not only on the movements of the mouth but on the cheeks and the eyes.  A Duchenne smile is characterized not only by the corners of the lips turning up but also by the happy crinkles around the eyes created when the orbicularis oculi muscles (a muscle in the face that closes the eyelids) lifts cheeks and crinkles eyes at the corners.

Elevating brows, nodding the head, or tilting the head can also help create the impression of smiling with the eyes. When masks obscure the face, smiling with the eyes can make patients feel more at ease. Don’t forget about other gestures to convey compassion or understanding. For example, a simple thumbs-up or head nod are other ways to convey positive feelings toward the patient when the smile is hidden.

Keep calm and carry on

A calm tone and demeanor can go a long way in decreasing patient anxiety. Clinicians should be mindful of the tone, cadence, and inflection of spoken words in order to help put patients at ease. It is important to keep the tone of voice even and avoid a rapid cadence, which is often interpreted as rushing. Proper use of pauses can transmit feelings of compassion and sensitivity toward the patient. Slowing down speech, elevating volume, and lowering pitch are other means for improving communication while wearing PPE.

The language of posture

Maintaining a relaxed posture can help reduce patient anxiety and communicate understanding and compassion.

Avoid a closed posture, which non-verbally communicates disinterest and is characterized by arms folded, hands in pockets, legs crossed and/or sitting at an angle from the patient. By contrast, an open posture, directly facing the patient and leaning forward communicates interest and caring non-verbally and expresses a high engagement level that can foster a better connection.

While masks are essential to stopping the spread of disease and ensuring patient and staff safety, the barriers to communication and disconnection created by PPE adds complexity to clinician/patient communication. To overcome these barriers and communicate compassionately with patients through the mask, clinicians will need to double-down on learning communication techniques that build trust and rapport. Optimizing verbal and non-verbal techniques will help convey compassionate communication and facilitate a supportive relationship that enhances the patient experience and leads to better clinical outcomes.

Anthony Orsini is neonatologist and founder, The Orsini Way. He is the author of It’s All In The Delivery: Improving Healthcare Starting With A Single Conversation.

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