Best Practices for Communication While Wearing Facemasks: A Scoping Review

Abstract

Introduction:

Facemasks are an important piece of personal protective equipment (PPE) to mitigate the spread of respiratory illnesses, but they can impede communication between patients and healthcare providers. The purpose of this scoping review is to identify effective communication practices while wearing facemasks.

Design:

Scoping review using a systematic search of articles from the PubMed, CINAHL, and Embase databases.

Methods:

The PEO (population, exposure, outcome) methodology was selected for this systematic scoping review. The population of interest (P) includes humans of all ages (children, adults, older adults); the exposure of interest (E) is PPE that covers the mouth (i.e., facemasks); and the outcome of interest (O) is successful or unsuccessful communication practices. The Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals appraisal guidelines were used to determine the level and quality of the research.

Results:

Thirty-nine articles met the inclusion criteria. Seventeen of these were high or good quality research studies, and the remaining twenty-two were non-research articles included with separate analysis as part of the scoping review. The seventeen articles encompassed 2656 participants. The highest quality evidence indicated that standard surgical masks have the least impact on speech perception compared to other non-transparent mask types, and that recognizing emotions is less accurate with facemasks, necessitating compensatory actions (i.e., reducing extraneous noise, using a microphone to amplify voice, and employing clear speech). Evidence was contradictory regarding the use of transparent masks. Evidence was of limited quality for other nonverbal and verbal communication strategies.

Conclusion:

Awareness of communication challenges is crucial when wearing facemasks. More high-quality studies are needed to evaluate communication techniques when speakers are wearing facemasks. Basic strategies such as selecting an appropriate mask type, reducing extraneous noise, using microphones, verbalizing emotions, and employing clear speech appear to be beneficial.

INTRODUCTION

Healthcare providers saw facemasks become the norm in healthcare during the COVID-19 pandemic. Wearing facemasks was an essential control measure to protect against the spread of COVID-19. Regardless of the specific infectious respiratory disease and facility requirements, facemasks have always been and will continue to be a component of patient care when limiting the spread of infectious respiratory diseases (Chow et al., 2023). Depending on the infection, these include standard surgical masks or N95 and higher-level respirators. Despite the benefits of facemasks in these care situations for preventing the spread of respiratory infections, wearing facemasks does alter communication between interlocutors (e.g., a healthcare provider and a patient) (Casey et al., 2021; Vitale et al., 2021).

Auditory speech and visual cues, such as lip movements and facial expressions, are critical in facilitating effective person-to-person communication (Riley, 2015). Facemasks are known to negatively impact both verbal and nonverbal communication through the degradation of sound (Goldin et al., 2020; Pörschmann et al., 2020) and visual obstruction (Casey et al., 2021; Saunders et al., 2021). In addition to hearing and comprehension difficulties, mask-wearing also interferes with empathic communication and relational care, as facemasks limit the ability to read facial expressions and to recognize care staff (Casey et al., 2021; Sugg et al., 2021).

Effective communication in healthcare is crucial to exchanging accurate information and establishing therapeutic relationships with patients. Poor communication with patients and families can result in a lack of understanding or misunderstanding, uncooperative care, lower patient satisfaction, and adverse health outcomes (Chan et al., 2018; Lotfi et al., 2019). In this regard, there is a need for healthcare providers to be aware of strategies to overcome the challenges of communication while wearing facemasks. Therefore, a systematic scoping review was completed to synthesize and describe effective communication practices with facemasks.

Objectives

The purpose of this scoping review was to identify effective communication practices while wearing facemasks. The PEO (population, exposure, outcome) methodology was selected, and the population of interest (P) was humans without limitations on age (adults, children, older adults), the exposure of interest (E) was PPE that covers the mouth (i.e., facemasks), and the outcome of interest (O) was successful or unsuccessful communication practices.

DESIGN

A scoping review was completed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology for reporting (Page et al., 2021). The research question was developed following the PEO—population, exposure, outcome—framework (Munn et al., 2018). The level and quality of the articles were determined using the Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals appraisal guidelines (Dang et al., 2022).

MATERIALS AND METHODS

Search Strategy

The systematic search was first conducted in August of 2021 and then repeated for new literature in February of 2022. The PubMed, CINAHL, and Embase databases were searched. The search consisted of keywords for the three major themes: (1) communication, (2) facemasks, and (3) effective practices. The keywords for each theme were connected by the Boolean operator OR, and the themes were then connected by the Boolean operator AND. No preset database filters were used. Results from each database were exported to EndNote and filtered for duplicates. A manual reference list search was completed on articles deemed eligible for inclusion.

Eligibility

Articles were eligible for inclusion if they were published in English, focused on humans, and evaluated successful or unsuccessful communication for a listener while a speaker was wearing a facemask. Studies were excluded if the population was not human, if the study did not focus on facemasks as the PPE (e.g., gloves and gowns), and if the outcome was not successful or unsuccessful communication. For example, studies that focused on comfort of facemasks for the speaker or the decision to wear a facemask were excluded because the outcome was not related to the success of communication for the listener. Conference abstracts were excluded, and grey literature was not searched and therefore not included. Non-research manuscripts (e.g., expert opinions) were included as part of the scoping review.

Data Extraction

All non-duplicate article citations were exported from EndNote into Microsoft Excel. Four reviewers first screened the titles and abstracts for eligibility. Following the initial screening, the full text articles were retrieved and screened by the same four reviewers for eligibility. Next, the first author, a doctoral trained nurse researcher, cross-checked and verified the eligibility of all full-text articles. Any disagreements were discussed between the reviewers and the first author in a consensus meeting.

All eligible articles were then reviewed and rated for level and quality of evidence by a nurse with graduate education. The data from research articles of high or good quality was then extracted into Microsoft Excel by the graduate nurse. The data from non-research articles of any quality or research articles of low quality was extracted by another reviewer into Microsoft Excel. All data extraction was verified by the first author, and any disagreements were discussed in a meeting to reach consensus. Data extraction included the study purpose, setting, sample description, sample size, design, and findings. If data was missing from the article, then the corresponding author of the included article was contacted for additional information.

Quality Assessment

Quality was assessed using the Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals appraisal guidelines. This appraisal process first involved determining the level of evidence, followed by the quality rating. There are five levels of evidence and three quality rating levels. Levels I through III encompass research studies, while levels IV and V incorporate non-research studies. Level I comprises experimental studies (randomized controlled trials) and systematic reviews of randomized controlled trials. Level II includes quasi-experimental studies and systematic reviews incorporating quasi-experimental studies. Level III features non-experimental and qualitative studies, as well as systematic reviews of non-experimental and qualitative studies. Level IV encompasses clinical practice guidelines, consensus panels, or position statements. Level V involves experiential and non-research evidence such as integrative reviews, case reports, and literature reviews. Within each level, there are distinct criteria for rating the article as high quality (Rating A), good quality (Rating B), or low quality/major flaws (Rating C) based on the study design.

The Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals appraisal guidelines include quality rating worksheets and algorithm to determine the level of evidence. A worksheet was completed for each eligible article by a nurse with graduate education. The first author reviewed these worksheets and the eligible articles and any disagreements were discussed between the appraiser and the first author in a consensus meeting. It was decided a priori to include non-research articles and include all articles meeting the PEO criteria regardless of the quality assessment, as this is a scoping review. However, non-research articles and/or articles of low quality would be appraised and analyzed separately. After appraisal, the articles were thus categorized into two groups: (1) research articles of high or good quality (Level I-III/Rating A or B), or (2) non-research articles of any quality or research articles of low quality (Level IV-V/Rating A-C and Level I-III/Rating C).

Analysis of Best Practices

All findings from the data extraction were reviewed and categorized by topic into the a priori categories of verbal, nonverbal, and other strategies. The initial categorization was performed by a nurse with graduate education. The specific findings within each of those categories was reviewed by the first author and in a consensus meeting with the article reviewers and the final strategy categories were made. The final groupings were presented to all authors for expert review and feedback until a consensus was reached.

RESULTS

Search and Study Characteristics

From 1,631 records initially identified in the three databases, 1,217 remained after the removal of duplicates (Figure 1). After title and abstract screening, 91 were selected for full-text review. After full-text assessment, 27 records were found to meet our inclusion criteria for analysis, and an additional 12 articles were identified from the manual reference list search. In total, 39 records were included in this review.

Figure 1.

PRISMA Flow Diagram of Literature Search and Selection.

Of the 39 included articles, most were published between the years 2020 and 2021 (n=34, 87.2%), largely in response to increased facemask use related to the COVID-19 pandemic. Seventeen articles (43.6%) were categorized as research articles of high or good quality, and the remaining twenty-two (56.4%) articles were categorized as non-research articles (Level IV), with most receiving a quality rating of B (n=14), followed by A (n=7) and C (n=1).

The 17 research articles represented a variety of research designs, including nine experimental, five survey, one quasi-experimental, one qualitative, and one randomized controlled trial (Table 1). The majority of these articles were rated as Level II (n=10), mostly as Rating B (n=8). Six articles were rated as Level III, mostly as Rating B (n=5), and one article was rated as Level I with Rating B. The majority were conducted in the US (n=10), followed by Europe (n=5), Australia (n=1), and India (n=1). The 17 research articles included 2,691 participants, with the sample size ranging from 1 to 1,168 participants (median 51 participants). The majority of the participants were adults with normal or unspecified hearing (n=1,661, 61.7%), followed by healthcare workers (n=585, 21.7%). Other participants included adults with moderate or severe hearing loss (n=304, 11.3%), parents of children with hearing loss (n=84, 3.1%), and healthy school-aged children (n=57, 2.1%).

Table 1.

Communication Strategy Summary

Communication Strategy	Level of Evidence	Citations
Be cognizant of facemask type on communication.
Transparent facemasks may improve communication compared to surgical masks although unclear.	Positive: 2B, 3B, 5A, 5B	Altschuler et al. (2021); Atcherson et al. (2017); Clancy (2021); Dehkordi and Ghiyasvandian (2021); Kilgore et al. (2021); Knollman-Porter and Burshnic (2020); McKee et al. (2020); Mehta et al. (2020); Mheidly et al. (2020); Mitchell and Hill (2020); Murphy et al. (2021); Saunders et al. (2021)
	Negative: 2B, 5B	Corey et al. (2020); Jarvis and Smith (2021)
	Unclear: 1B, 3B	Chu et al. (2021); Kratzke et al. (2021)
Standard surgical masks have the least impact on speech perception compared to other non-transparent mask types (e.g., N95s)	2B	Corey et al. (2020); Malin et al. (2021); Ritter et al. (2021)
Fabric masks have negative impact on speech perception compared to surgical masks.	2B	Corey et al. (2020)
Some N95s (i.e., cup-shaped and duckbill) may not have a negative impact on speech perception compared to surgical mask.	2B	Radonovich et al. (2010)
Acknowledge emotions because they are challenging to interpret with a facemask.
Recognize that some emotions cannot be accurately interpreted with facemasks.	2A, 3A, 3B,	Carbon (2020); Carbon and Serrano (2021); Chu et al. (2021); Godsell et al. (2013); Schlögl et al. (2021)
Emotions may need to be verbally stated while wearing facemask	5A, 5B	Houchens and Tipirneni (2020); Marler and Ditton (2021)
Compensatory actions are needed to help identify emotions.	2A, 3A, 3B, 5A, 5B	Carbon (2020); Carbon and Serrano (2021); Chu et al. (2021); Godsell et al. (2013); Houchens and Tipirneni (2020); Marler and Ditton (2021); Schlögl et al. (2021)
Ensure that the listener knows the other communication partner.
Consider use of PPE portraits.	Positive: 3B, 5B	Houchens and Tipirneni (2020); Knollman-Porter and Burshnic (2020); Marler and Ditton (2021); Murphy et al. (2021); Reidy et al. (2020)
	Unclear: 2B	George et al. (2021)
Always introduce self before further communication.	5A, 5B	Houchens and Tipirneni (2020); Marler and Ditton (2021); McCarthy et al. (2021)
Be cognizant of environment.
Reduce extraneous noise while wearing facemask.	2B, 5A, 5B	Armstrong et al. (2021); Jarvis and Smith (2021); Kilgore et al. (2021); Knollman-Porter and Burshnic (2020); Marler and Ditton (2021); Mehta et al. (2020); Mendel et al. (2008); Mheidly et al. (2020); Mitchell and Hill (2020); Vaidhyanathan et al. (2020)
Ensure adequate lighting and signage.	5B, 5C	Kilgore et al. (2021); Schroven (2021)
Use assistive technologies.
Use microphone to amplify voice.	2B, 5A, 5B	Altschuler et al. (2021); Corey et al. (2020); Dehkordi and Ghiyasvandian (2021); Schlosser et al. (2021)
Ensure listener is using prescribed sensory aids.	5A, 5B	Altschuler et al. (2021); Dehkordi and Ghiyasvandian (2021); McKee et al. (2020)
Use transcription apps.	3B, 5A, 5B	Carter (2020); Dehkordi and Ghiyasvandian (2021); Marler and Ditton (2021); McKee et al. (2020); Saunders et al. (2021)
Use thoughtful nonverbal communication.
Use visual aids such as written messages and communication boards.	3B, 5A, 5B	Altschuler et al. (2021); Champion and Holt (2000); Clancy (2021); Dehkordi and Ghiyasvandian (2021); Kilgore et al. (2021); Knollman-Porter and Burshnic (2020); Marler and Ditton (2021); McKee et al. (2020); Vaidhyanathan et al. (2020)
Be face to face when communicating.	3B, 5A, 5B	Champion and Holt (2000); Clancy (2021); McCarthy et al. (2021); Mheidly et al. (2020); Schlögl and C (2020); Schlögl et al. (2021); Zabukovic et al. (2021)
Make eye contact and be at same level while being mindful of cultural expectations surrounding eye contact.	3B, 5A, 5B, 5C	Armstrong et al. (2021); Jarvis and Smith (2021); Knollman-Porter and Burshnic (2020); McCarthy et al. (2021); Murphy et al. (2021); Schlögl and C (2020); Schlögl et al. (2021); Schroven (2021); Zabukovic et al. (2021)
Use gestures in non-distracting manner such as pantomiming actions, giving positive or negative affirmations, or suggesting direction.	5A, 5B	Armstrong et al. (2021); Jarvis and Smith (2021); Knollman-Porter and Burshnic (2020); Marler and Ditton (2021); McCarthy et al. (2021); Murphy et al. (2021); Zabukovic et al. (2021)
Use thoughtful verbal communication.
Use clear speech.	2B, 3B, 5B	Carter (2020); Clancy (2021); Cohn et al. (2021); Jarvis and Smith (2021); Kilgore et al. (2021); McCarthy et al. (2021); Saunders et al. (2021); Schlögl and C (2020); Schlögl et al. (2021); Vaidhyanathan et al. (2020)
Consider the balance between speaking loudly, slowly, and expressively without being patronizing.	5B	Carter (2020); Clancy (2021); Knollman-Porter and Burshnic (2020); Mehta et al. (2020)
Provide simple message with repetition and summary	3B, 5B, 5B	Kilgore et al. (2021); Mitchell and Hill (2020); Murphy et al. (2021); Saunders et al. (2021); Vaidhyanathan et al. (2020)
Verify that the listener correctly interpreted the message.	3B, 5B	Armstrong et al. (2021); Clancy (2021); Mitchell and Hill (2020); Schlögl et al. (2021); Schlosser et al. (2021); Vaidhyanathan et al. (2020)

Note. The level of evidence is listed from highest to lowest, refer to supplemental Table S1 to identify the individual level of evidence for each study included.

Findings

Detailed results from the 17 research articles are provided in Supplemental Table S1, and a summary of results from all 39 articles is provided in Table 1.

Type of Face Mask

Transparent Face Masks.

Five research articles of high or good quality evaluated transparent or clear facemasks, and eleven non-research articles discussed transparent or clear facemasks. The one randomized controlled trial (1B) randomly allocated patients to a surgeon who was wearing either a normal surgical facemask or a transparent facemask (Kratzke et al., 2021). Patients in the transparent mask group rated their interaction with the surgeon as superior, reporting a greater understanding of the provider’s explanations and expressing more trust in the provider. They also rated the surgeon higher in terms of demonstrating empathy and knowledge of their medical history.

The benefits of transparent masks for adults with hearing impairment were also demonstrated in an experimental study (2B) that evaluated transparent and surgical masks among adults with normal hearing and adults with moderate and severe hearing loss (Atcherson et al., 2017). There were no differences in speech perception in normal hearing adults across the surgical and transparent mask conditions. Adults with moderate and severe hearing loss performed the best with transparent masks when they could view the speaker compared to auditory only transparent mask and paper mask conditions. A mixed-methods online survey (3B) reported that patients felt communication with masks to be especially challenging in healthcare situations and that transparent masks may improve interactions (Saunders et al., 2021). Eleven non-research articles (5A & 5B) also suggested benefits of using transparent masks in order to preserve facial expressions and allow for lip reading (Altschuler et al., 2021; Clancy, 2021; Kilgore et al., 2021; Knollman-Porter & Burshnic, 2020; Leila Mardanian & Shahrzad, 2021; McKee et al., 2020; Mehta et al., 2020; Mheidly et al., 2020; Mitchell & Hill, 2020; Murphy et al., 2021).

In an online survey study (3B) of adults with normal hearing, healthcare providers with normal hearing, and healthcare providers with impaired hearing, both healthcare provider groups reported a preference for wearing a transparent mask and felt they could understand others better who also wore a transparent mask (Chu et al., 2021). However, the non-healthcare providers thought that they could understand people equally well with transparent versus non-transparent masks. The findings on the healthcare providers’ preferences contradict the randomized controlled trial in which the majority of surgeons reported that they were unlikely to choose a transparent mask over the standard surgical mask (Kratzke et al., 2021).

The findings on the benefits of transparent masks were not supported by one experimental study (2B) that evaluated the acoustic performance and sound degradation by the type of mask and found greater sound degradation with transparent masks compared to medical masks including N95s (Corey et al., 2020). However, in this study, the transparent mask piece was in a fabric mask rather than a surgical mask. Additionally, one non-research article (5B) expressed concern that transparent masks can fog, which equally obscures lip movements (Jarvis & Smith, 2021). The combination of these findings suggests that there are likely some modest benefits to transparent masks particularly related to speech perception. However, further research is needed on other benefits.

Other Face Mask Types.

Four research articles evaluated the impact of the type of mask on listener comprehension. In an experimental study (2B), the acoustic performance of 12 different types of masks was evaluated, including a standard surgical mask, a KN95 mask, an N95 respirator, six types of fabric masks, two transparent fabric masks, and one plastic shield (Corey et al., 2020). Acoustic performance was best with the KN95 mask, surgical mask, and jersey fabric mask, and worst with a denim fabric mask, bedsheet fabric mask, and plastic shield.

Three other experimental studies (2B) evaluated word recognition between surgical masks and N95 masks (or FFP3 masks as the European equivalent to N95s). One study found that N95s resulted in less word recognition than surgical masks, which was significantly lower than a no-mask condition for N95s but not surgical masks (Ritter et al., 2021). A subgroup analysis indicated that hard-of-hearing participants had significantly worse hearing with surgical and N95 facemasks compared to normal-hearing participants and that female speakers in N95 masks resulted in significantly lower word recognition for both the normal- and hard-of-hearing groups. Similarly, the surgical mask, FFP3, and FFP3 masks plus face shield all significantly worsened speech intelligibility from the no-PPE condition and from each other (Malin et al., 2021).

Conversely, another study demonstrated that speech intelligibility did not differ between surgical masks, cup-shaped N95s, and duckbill N95s, which were also not significantly different from a no-mask condition (Radonovich et al., 2010). This study also identified that speech intelligibility significantly decreased for N95s plus a surgical mask, N95s with a filtering facepiece, and with PAPRs. The combination of these findings suggests that the type of mask does have an impact on acoustic performance and subsequent word recognition, meaning that speakers need to be cognizant of how each type of mask impacts listener comprehension. Surgical masks appear to have the least effect on listener comprehension of all types of masks, excluding transparent facemasks.

Acknowledging Emotions

Five research articles and two non-research articles explored the recognition of emotions while wearing facemasks. Two experimental studies (2A) determined that young to older adults could not adequately distinguish the emotions of anger, disgust, happiness, or sadness in adults wearing facemasks compared to no facemasks, and similarly, children could not adequately distinguish the emotions of disgust, fear, happiness, and sadness in adults wearing facemasks compared to no facemasks (Carbon, 2020; Carbon & Serrano, 2021). In addition to those emotions not being recognized by adults, the adult participants also rated themselves with lower confidence in identifying fear and neutral emotions in adults wearing facemasks compared to no facemasks. Adults completing an online survey (3B) more often identified happiness as the correct emotion in an adult wearing a transparent N95 compared to a non-transparent N95 (Chu et al., 2021). In a qualitative study (3A), healthcare providers reported that wearing a facemask impeded the therapeutic relationship with patients because they could not see facial expressions and emotions (Godsell et al., 2013). In an online survey (3B), healthcare providers were most likely to agree that acknowledging emotions was difficult while wearing facemasks (Schlögl et al., 2021).

The two non-research articles (5A & 5B) suggested that healthcare providers express emotion through verbal communication, for example, by stating, “I’m smiling back at you” (Houchens & Tipirneni, 2020; Marler & Ditton, 2021). The combination of these findings suggests that compensatory actions are needed to aid patients in identifying emotions while providers wear facemasks, such as verbally communicating the emotion, expressing the emotion through gestures and body language, and building a therapeutic relationship by spending more time with the patients (Carbon, 2020; Godsell et al., 2013).

Recognizing the Person Behind the Mask

Two research articles and six non-research articles examined ways to help recognize a healthcare provider wearing a mask. PPE portraits were discussed in two research articles. PPE portraits are large photos of the healthcare provider not wearing a facemask and smiling, which are either affixed to the healthcare provider or given to the patient. In a quasi-experimental study (2B), physicians reported significant improvement in communication between colleagues and perceived happiness by patients after implementing PPE portraits (George et al., 2021). However, patients did not report significant improvements in satisfaction, interaction, or communication with physicians following the implementation of PPE portraits. In a survey (3B), hospital providers had largely positive perceptions of PPE portraits (Reidy et al., 2020), although less than 10% of respondents actually had personal experience using PPE portraits. Four non-research articles (5B) also suggested benefits of using PPE portraits while wearing facemasks to build a connection with patients (Houchens & Tipirneni, 2020; Knollman-Porter & Burshnic, 2020; Marler & Ditton, 2021; Murphy et al., 2021).

Three narrative reviews (5A & 5B) also discussed the importance of the healthcare providers introducing themselves, asserting that introductions are essential for patients to know who is behind the facemask and what their role is (Houchens & Tipirneni, 2020; Marler & Ditton, 2021; Murphy et al., 2021). The quality of the evidence for recognizing the person behind the mask is insufficient to make strong evidence-based conclusions, so further research on PPE portraits and ways to help patients recognize the provider in a mask is needed. However, the suggestion to always introduce yourself to aid recognition is a low-risk and logical communication strategy.

Environmental Strategies

One research article and ten non-research articles discussed environmental strategies. In an experimental study (2B) evaluating the impact of dental office-related noise on speech perception with surgical mask use, both normal hearing- and hearing-impaired listeners had worse speech perception in the noisy environment compared to the quiet environment with a facemask (Mendel et al., 2008). Nine non-research articles (5A & 5B) also recommended reducing background and environmental noise by suggesting limiting distractions and noise by closing doors, turning off the televisions, and communicating one-on-one (Armstrong et al., 2021; Jarvis & Smith, 2021; Kilgore et al., 2021; Knollman-Porter & Burshnic, 2020; Marler & Ditton, 2021; Mehta et al., 2020; Mheidly et al., 2020; Mitchell & Hill, 2020; Vaidhyanathan et al., 2020). Other environmental modifications included ensuring adequate lighting (5B) (Kilgore et al., 2021) and having adequate signage (5C) (Schroven, 2021). Although only one research article provided evidence that reducing environmental noise while wearing facemasks is beneficial, this strategy is low-risk and logical.

Assistive Technologies

Three research articles and nine non-research articles recommended using assistive technologies to improve communication while wearing facemasks. Two online surveys (3B), which included both closed- and open-ended questions, collected information on strategies to aid communication while wearing facemasks. Parents of hearing-impaired children suggested using assistive devices and interpreters during dental visits with the provider in a facemask (Champion & Holt, 2000). Adults with normal hearing and adults with hearing impairments recommended assistive devices, including the use of transcription apps when communicating with facemasks (Saunders et al., 2021). The use of transcription apps that convert spoken words into written text in real-time was also suggested by three non-research articles (5B & 5A) (Carter, 2020; Dehkordi & Ghiyasvandian, 2021; Marler & Ditton, 2021; McKee et al., 2020), and general assistive technologies were suggested by an additional two non-research articles (5B) (Houchens & Tipirneni, 2020; Mehta et al., 2020).

An experimental study (2B) determined that the addition of a lapel microphone improved the acoustic performance of 10 mask types (Corey et al., 2020). Performance did not improve with a face shield and one type of transparent mask, where there was further distortion of the speech. Three non-research articles also suggested the use of microphone devices, including speakers in patient rooms (5B) (Schlosser et al., 2021), pocket talkers (5B) (Dehkordi & Ghiyasvandian, 2021), and lapel microphones (5A) (Altschuler et al., 2021). Lastly, three non-research articles (5A & 5B) suggested always ensuring that a patient is wearing their prescribed sensory aid (i.e., hearing aids, glasses) (Altschuler et al., 2021; Dehkordi & Ghiyasvandian, 2021; McKee et al., 2020). The use of a lapel microphone appears to be a successful strategy and although the quality of the other evidence is not compelling, it provides future directions for research and practical tips that are low-risk and logical.

Nonverbal Strategies

Three research articles and seventeen non-research articles discussed nonverbal communication strategies while wearing facemasks. The recommendations focused on visual aids, positioning and body language, gestures, facial expressions, and removing the face covering when struggling.

Visual aids.

Visual aids such as explanatory books and videos, written messages, and communication boards were recommended by eight non-research studies (5A & 5B) (Altschuler et al., 2021; Clancy, 2021; Dehkordi & Ghiyasvandian, 2021; Kilgore et al., 2021; Knollman-Porter & Burshnic, 2020; Marler & Ditton, 2021; McKee et al., 2020; Vaidhyanathan et al., 2020). The one research study (3B) of communication strategies recommended by parents of hearing-impaired children during dental visits also provided these suggestions (Champion & Holt, 2000). Thus, the quality of evidence is limited on the benefits of visual aids while wearing facemasks.

Positioning and body language.

Recommendations on positioning and body language ranged from ambiguous to specific. Vague recommendations (5B) included being mindful of body language and posture (Carter, 2020; Mehta et al., 2020; Vaidhyanathan et al., 2020). More specific recommendations included being face-to-face with the person (3B, 5A, 5B) (Champion & Holt, 2000; Clancy, 2021; McCarthy et al., 2021; Mheidly et al., 2020; Schlögl & C, 2020; Schlögl et al., 2021; Zabukovic et al., 2021), making eye contact and being at the same level (3B, 5A, 5B, 5C) (Armstrong et al., 2021; Knollman-Porter & Burshnic, 2020; McCarthy et al., 2021; Murphy et al., 2021; Schlögl & C, 2020; Schlögl et al., 2021; Schroven, 2021; Zabukovic et al., 2021), getting the patients’ attention before speaking (5B) (Dehkordi & Ghiyasvandian, 2021; Kilgore et al., 2021; Knollman-Porter & Burshnic, 2020; Mitchell & Hill, 2020), and using touch (5B) (Rushton & Edvardsson, 2021). One non-research article also suggested being mindful of eye contact based on the cultural expectations (5B) (Jarvis & Smith, 2021). Thus, the quality of evidence is limited on positioning strategies while wearing facemasks.

Gestures.

Recommendations on gestures varied from ambiguous to specific. Vague recommendations (3B, 5A, 5B) suggested using gestures to ensure nonverbal communication matched verbal communication (Altschuler et al., 2021; Mehta et al., 2020; Schlögl & C, 2020; Schlögl et al., 2021; Vaidhyanathan et al., 2020). More specific recommendations gave examples of helpful gestures (5A & 5B) that fall within three categories: 1) pantomime (e.g., gesturing toothbrushing to signify it’s time to brush teeth), 2) emblems (e.g., thumbs up or down), and 3) deictic (e.g., pointing) (Armstrong et al., 2021; Knollman-Porter & Burshnic, 2020; Marler & Ditton, 2021; Murphy et al., 2021; Zabukovic et al., 2021). Two non-research articles (5A, 5B) commented that gestures need to be conducive to communication (McCarthy et al., 2021) rather than distracting (Jarvis & Smith, 2021). Thus, the quality of evidence is limited on gesturing while wearing facemasks.

Facial expressions.

Recommendations also focused on using positive (3B, 5A, 5B, 5C) or exaggerated facial expressions (5A, 5B) despite nearly half of the face being covered by a facemask (Armstrong et al., 2021; Champion & Holt, 2000; Clancy, 2021; Mehta et al., 2020; Mheidly et al., 2020; Schroven, 2021; Zabukovic et al., 2021). Although this recommendation is limited by the quality of evidence, higher quality evidence presented in the “Acknowledging Emotions” section above confirms that some facial expressions can be accurately captured with the use of a facemask despite the challenges posed by the mask.

Removing the facemask.

Two research articles (3B) also reported that participants suggested pulling the mask down to allow lip reading when communication challenges could not be overcome. These survey studies included parents of hearing-impaired children receiving dental visits prior to the COVID-19 pandemic (Champion & Holt, 2000) and both normal hearing and hard-of-hearing adults during the COVID-19 pandemic (Saunders et al., 2021). The authors of neither article endorsed these recommendations by participants, although there may be specific clinical scenarios where the benefit of improved communication from temporary mask removal may outweigh the risks of disease transmission between the patient and healthcare personnel.

Verbal Strategies

Vocal strategies.

Three research studies explored voice strategies, one of which was an experimental study (2B) that identified the impact of fabric facemasks on speech comprehension using three speech conditions (Cohn et al., 2021). Comprehension was greatest for adults with no hearing impairment when the speaker used clear speech compared to casual speech and positive-emotional speech. Clear speech was defined as speaking to someone who may have trouble understanding you, causal speech as speaking in a natural and casual manner, and positive-emotional speech was defined as smiling and expressing positive emotions while speaking. The strategy to speak “clearly” was also suggested by in a survey (3B) of adults with and without hearing impairment (Saunders et al., 2021) and was confirmed to be a beneficial strategy in a survey (3B) completed by healthcare providers (Schlögl et al., 2021). Seven non-research articles (5B) also provided this suggestion (Carter, 2020; Clancy, 2021; Jarvis & Smith, 2021; Kilgore et al., 2021; McCarthy et al., 2021; Schlögl & C, 2020; Vaidhyanathan et al., 2020).

In addition, thirteen non-research articles (5A, 5B, 5C) suggested to speak loudly, slowly, and expressively while enunciating and stressing important words (Armstrong et al., 2021; Clancy, 2021; Houchens & Tipirneni, 2020; Jarvis & Smith, 2021; Kilgore et al., 2021; Knollman-Porter & Burshnic, 2020; McCarthy et al., 2021; Mheidly et al., 2020; Mitchell & Hill, 2020; Murphy et al., 2021; Schroven, 2021; Vaidhyanathan et al., 2020; Zabukovic et al., 2021). However, depending on how extremely the speaker adopts these tips, they may fall into the positive-emotional category of speech. In contrast, four non-research articles (5B) discussed the balance of adopting clear speech without falling into patronizing speech. These articles suggested that shouting can be interpreted as patronizing (Carter, 2020); when increasing volume, speakers need to ensure not to increase pitch (Clancy, 2021; Knollman-Porter & Burshnic, 2020) and to consult an expert such as a speech-language pathologist to ensure the correct balance of pitch and prosody (Mehta et al., 2020). The combination of these findings, although limited in quality, suggests that speaking “clearly” is beneficial; however, finding a balance between pitch, rate, and amplitude is important to ensure respectful communication.

Messaging.

Providing a simpler message was suggested in the survey (3B) of adults with and without hearing impairment (Saunders et al., 2021) and by three non-research articles (5B) (Kilgore et al., 2021; Mitchell & Hill, 2020; Murphy et al., 2021). Repeating, summarizing, or paraphrasing the message was also suggested by three non-research articles (5B) (Kilgore et al., 2021; Mitchell & Hill, 2020; Vaidhyanathan et al., 2020). Although the quality of evidence is limited for these recommendations, the tips on messaging are practical and low-risk.

Verifying comprehension.

Verifying that the patient can understand and hear the speaker was confirmed as a useful communication strategy in a survey (3B) of healthcare providers (Schlögl et al., 2021). This strategy of confirming that the listener hears and comprehends what the speaker is saying was also described in four non-research articles (5B) (Armstrong et al., 2021; Clancy, 2021; Mitchell & Hill, 2020; Vaidhyanathan et al., 2020). A strategy suggested in one non-research article (5B) for communication between healthcare providers is a common tool used in healthcare called “closing the loop” in which the receiver of the message confirms and verifies understanding before more communication occurs (Schlosser et al., 2021). Although the quality of evidence is limited for these recommendations with facemasks, the tips on verifying comprehension are logical and low-risk.

DISCUSSION

This review aimed to identify best practices for overcoming communication barriers inherent in facemask usage by healthcare providers. Effective communication is essential for ensuring safe patient care and for meeting patients’ psychoemotional needs. Determining these best practices is necessary when anticipating the need for ongoing use of facemasks during the care of persons with respiratory illnesses in healthcare settings. Although the quality of evidence was limited in this scoping review, our results provide valuable insights and practical recommendations for healthcare providers.

Despite the limited evidence, surgical masks were consistently found to have minimal impact on communication, while the acoustic performance of KN95, N95, and fabric masks varied. Transparent facemasks offered some advantages in terms of speech perception and patient-provider interactions, particularly for individuals with hearing impairment. However, further research is needed to better understand the benefits of transparent masks, as well as to determine the most effective designs that minimize sound degradation and fogging issues. Healthcare organizations may require specific mask types based on their protective qualities, and future research is needed to determine the most effective mask types for communication while maintaining adequate protection levels.

The recommendations from this scoping review included verbal and non-verbal strategies, environmental modifications, and assistive technologies to enhance communication and understanding. The ability to recognize and acknowledge emotions is essential in healthcare settings. While wearing facemasks, providers need to rely on alternative communication strategies such as verbalizing their emotions, using gestures and body language, and investing more time in building therapeutic relationships with patients. Environmental strategies, such as reducing background noise and ensuring adequate lighting, may also improve communication in healthcare settings when facemasks are worn. Assistive technologies, including transcription apps, lapel microphones, and other communication devices, were also recommended. Although the evidence for these strategies is limited, they offer potential future research directions and practical tips for healthcare providers.

Verifying comprehension is another key aspect of effective communication in healthcare settings when facemasks are worn. One communication strategy that has been widely used in healthcare is “closing the loop,” which involves the receiver of a message confirming and verifying their understanding before continuing the conversation. This approach ensures that both parties understand and minimizes the misinterpretations that can occur when wearing facemasks.

This review included research, literature, and editorials focused on both the hearing-impaired and non-hearing-impaired population. A systematic review focused solely on the impact of the COVID-19 pandemic on the hearing-impaired population suggested that use of facemasks when communicating with this population leaves them especially vulnerable (Mansutti et al., 2023). Similar to this review, the authors identified that many of the recommend strategies for effective communication are not supported by robust research evidence and urge continued research on mask modification and effective communication skills, and call for increased use of sign-language interpreters in the healthcare setting.

This scoping review was limited by quality of evidence. Future research should focus on generating more robust evidence to better understand the effectiveness of these strategies and explore novel approaches to improve communication while wearing facemasks. Moreover, the generalizability of our findings may be limited, and additional studies should investigate the applicability of these strategies in different settings and populations. Future research should consider cultural aspects and linguistic differences in language to provide a more comprehensive understanding of communication challenges with facemasks. The populations included in this review were primarily children, healthcare workers, and older adults with varied levels of hearing competency. Results should be interpreted within their population since communication needs are inherently different across these groups. Additional research should address communication issues with facemasks for other populations, such as persons living with dementia, which present further communication challenges.

Interdisciplinary collaboration is essential to advance research on promoting communication to overcome communication barriers. Teams might include clinician providers, patients, and families, as well as speech and audiology professionals, linguists, and materials and sound engineers. Ideally, such interdisciplinary teams can work synergistically to address communication barriers during PPE use, identify best practices, and promote successful communication outcomes. Using an interdisciplinary person-centered communication approach will be essential to success because all patients will have individual communication needs that require individualized assessment.

CONCLUSION

The use of facemasks in healthcare settings has highlighted the importance of effective communication. This scoping review provides an overview of the current evidence and strategies for improving communication while wearing facemasks. While more research is needed to strengthen the evidence base, the findings provide valuable guidance for healthcare providers seeking to optimize patient-provider interactions. As we move forward in the context of pandemics and other public health emergencies, it is crucial to acknowledge that communication challenges related to facemask use will likely persist. Therefore, continuing research efforts to develop and refine strategies to address these challenges is essential. By extending our understanding of the communication barriers associated with facemasks and identifying best practices to overcome them, we can help to improve communication in a variety of situations where protection is necessary.

Clinical Relevance:

The findings of this scoping review highlight the importance of considering communication challenges while wearing facemasks in the healthcare settings. The review suggests that selecting an appropriate mask type, reducing extraneous noise, verbalizing emotions, and employing clear speech are some strategies that may be effective in mitigating the impact of facemasks on communication between patients and healthcare providers.