Hurdles and solutions of communication in clinical practice amidst the COVID-19 pandemic: a cross-sectional study among Sri Lankan medical students

Abstract

Background

The COVID-19 pandemic disrupted communication for medical students, yet they adeptly adapted to the challenges, persevering with their clinical training. This study aimed to evaluate the various communication hurdles faced, adaptations practiced and how they correlate with patient-centeredness and stress due to the pandemic.

Method

A descriptive cross-sectional was done using a self-administered questionnaires among medical students in the final two years. A focus group discussion facilitated the questions to assess challenges and solutions. The Patient-Practitioner Orientation Scale (PPOS) and Coronavirus Pandemic Anxiety Scale (CPAS) were used to determine patient-centeredness and COVID-related anxiety. Independent sample t-tests and Pearson’s correlation coefficient done considering a statistical significance of p < 0.05.

Results

Female students and those without a previous communication skills training programme had greater communication difficulty. More adaptations were practiced among female students and final-year students. Overall, participants had high levels of patient-centeredness together with low levels of COVID-related anxiety. There was a significant relationship between students’ difficulty in communication and the adaptations practiced. COVID-related anxiety increased communication difficulty.

Conclusion

This study underscores the importance of addressing the barriers to effective communication to facilitate clinical training of medical students. Nurturing communication skills and encouraging positive coping strategies, would improve communication.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-026-07705-w.

Introduction

The coronavirus (COVID-19) pandemic proved to be a calamity in multiple ways to Sri Lanka [1]. While most professions adapted to ‘work from home’, medical education too had to reach a halt to curtail the spread of the disease leading to the adoption of ‘e-learning’ for medical students [2, 3].

However, with an effective surveillance and disease control system, Sri Lanka was able to contain the disease and revert to limited physical contact [4], with personal protective equipment, masks, and social distancing, which were all part of the ‘new normal’ [5, 6].

Communication in healthcare

Although limiting the duration of a conversation as a precautionary measure was feasible for other professions during the pandemic, it was an unfavourable task for healthcare professionals. A good doctor-patient relationship is based on good communication skills [7–9]. Communication in the context of healthcare encompasses a variety of qualities and abstract concepts, out of which patient-centeredness takes center stage [10, 11].

Medical students must communicate with patients as it forms the cornerstone of learning at a hospital, regardless of the number of books one may read [12, 13]. As William Osler once said, ‘He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all’ [14].

COVID-19 and anxiety

Despite the definite threat of COVID-19, medical students had to continuously engage in their work physically, facing an added risk of encountering a patient who was positive for the virus as they act as the point of first medical contact [15, 16].

Medical students, in particular, are vulnerable to various mental stressors and show a higher prevalence of mental disorders like depression and anxiety [17, 18]. The COVID-19 pandemic was taking a toll on the mental health of medical students, worldwide [19–21]. It was one of the foremost barriers that hindered an effective conversation as students tend to be hesitant to interact with patients in a time with record-high morbidity and mortality [22].

Challenges faced and adaptations undertaken during the pandemic

Communication during the pandemic was severely affected. Several new practices adopted to combat the transmission of COVID-19 [23]. A common practice of wearing face masks together with social distancing reduced the volume and clarity of speech, making it difficult for both parties to comprehend what is being said. Wearing a face mask also caused useful facial expressions to be lost, leading to the inability of medical students to recognize emotional cues which are useful in understanding what the patient is trying to communicate [23, 24].

Moreover, patients were not able to say if the medical student empathizes with him or her as all facial expressions are masked. Patients significantly perceive this as a lack of empathy which could potentially prevent patients from answering certain questions truthfully [25]. Furthermore, medical students were not able to use non-verbal cues such as a gentle touch of reassurance or a simple handshake to show appreciation for the patient’s time [23].

An aspect that is often under-recognized is the stigma towards healthcare personnel, and medical students [26]. It is only natural to associate any risk with those in its proximity. Hence, some patients tend to perceive medical students as a potential threat of virus transmission and prevent talking to them or talking only for a limited time [27].

In the background of such barriers to effective communication alongside a scarcity of studies conducted addressing the effect of patient-centeredness, this study would be a turning point in communication skills in clinical practice. The association of COVID-19 stress and patient-centeredness on the adaptations made to communicate will support to improve patient care strategies.

Methodology

Study design and setting

Ethical clearance for the study was obtained from the Ethics Review Committee of General Sir John Kotelawala Defence University, Ratmalana.

A descriptive cross-sectional study was conducted between December 2021 an January 2022 among a convenience sample of 334 fourth- and fifth-year medical students at the General Sir John Kotelawala Defence University, during a period when undergraduate clinical training was ongoing under COVID-19–related infection-control measures.

The study was conducted virtually through the use of anonymous self-administered online questionnaires via ‘Google Forms’.

Study population and inclusion criteria

The only inclusion criterion was the need for the completion of at least one clinical appointment physically.

Instrument development and study measures

Communication difficulties and adaptations practiced scale

Questions to identify the difficulties faced and adaptations practiced in clinical practice were incorporated after focus group discussions (FGD) with a set of representative students. These students were excluded from the final study to reduce bias.

Following the focus group discussions, a structured questionnaire was developed comprising two components: a Communication Difficulties subscale and an Adaptations Practiced subscale. The Communication Difficulties subscale consisted of 10 items assessing perceived barriers to effective clinical communication during the COVID-19 pandemic, including fear of infection, reduced audibility due to face masks, and limitations in non-verbal communication. The Adaptations Practiced subscale consisted of 8 items assessing strategies adopted to overcome these barriers, such as the use of gestures, repetition of information, and modification of communication style. All items were reviewed for clarity and relevance and the questionnaire was pilot-tested among a representative group of fourth- and final-year medical students prior to the main study.

Although derived from the same questionnaire, the Communication Difficulties and Adaptations Practiced subscales were scored and analyzed as independent variables, and no combined score was calculated.

The Communication Difficulties and Adaptations Practiced questionnaires were developed specifically for this study and has not been previously published.

The full questionnaire is provided as an English-language supplementary file (Additional file 3.

Communication difficulties subscale

The difficulties faced were formulated as statements marked on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) and a cumulative score was calculated at the end for each participant. Higher scores would mean greater difficulty in communicating during the pandemic.

Adaptations practiced subscale

The adaptations taken by students to overcome communication difficulties were marked on how often they adopt such practices using a Likert scale ranging from 1 (never) to 4 (always). A cumulative score was calculated at the end and higher scores would mean more adaptations practiced.

Patient-centeredness scale

For assessing patient-centeredness, the Patient-Practitioner Orientation Scale (PPOS), which is a validated tool was used [28] see “Additional file 1”]. It comprises 18 items, each marked on a Likert scale ranging from 1(strongly disagree) to 6 (strongly agree). These are summed up and a higher score indicates more patient-centeredness. The scale can also be broken into two distinct sub-scales: Sharing and Caring. The Sharing factor encompasses the extent to which the provider shares power with a patient in a medical-care relationship. The Caring factor reflects the belief that the provider is concerned about the patient and treats him or her as a whole [28].

COVID-related anxiety scale

The Coronavirus Pandemic Anxiety Scale (CPAS-11) was used to assess the level of anxiety due to the disease [29] see “Additional file 2”]. It is a validated tool and consists of 11 items that refer to various anxiety symptoms. Each item inquires the respondent how often he/she has experienced the respective item’s symptom in the last 2 weeks which is then scored on a scale of 0 (not at all) to 3 (nearly every day). The scores of the individual items are then summed up, with higher scores reflecting higher COVID-19-related anxiety.

Figure 1 illustrates the main variables used in this study

Fig. 1.

Conceptual framework illustrating the derivation of key study variables

Focus Group Discussions informed the development of the communication difficulty and adaptations practiced subscales and contributed to the overall conceptual framework. Patient-centeredness was assessed using the Patient–Practitioner Orientation Scale (PPOS), including sharing and caring dimensions, while COVID-19–related anxiety was measured using the Coronavirus Pandemic Anxiety Scale (CPAS-11).

Questionnaire language and pilot testing

In addition, socio-demographic data and details regarding attendance to a previous Communication Skills Training (CST) session were also recorded. Questionnaire was prepared only in English, owing to the fact that our study population consisted entirely of medical students whose main stream of study was in English with proficiency in the language. It was pre-tested on a representative sample of a set of fourth and final year medical students, in order to ensure its validity.

Statistical analysis

For the purpose of data analysis, the Statistical Package for Social Sciences (SPSS) software version 26 was used. Descriptive statistics were used to describe the data through frequency tables and cross-tabulations with measures of central tendency included where relevant. A sequential exploratory study design was utilized to explore the difficulties in communication encountered (“hurdles”) as well as the adaptations taken to overcome such difficulties (“solutions”) with other variables.

Hypotheses were then developed and inferential statistics were used to accept or reject them using a statistical significance of less than 0.05 probability at a 95% confidence interval.

Results

The sample size summed up to 334 students. The socio-demographic parameters and the characteristics of the study population are summarized in Table 1.

Table 1.

Socio-demographic data and characteristics

Gender
Male	119 (35.6%)
Female	215 (64.4%)
Age group
20–22y	15 (4.5%)
23–25y	154 (46.1%)
Above 26y	165 (49.4%)
Year of study
Fourth year	81 (24.3%)
Final year	253 (75.7%)
Nationality
Sri Lankan	289 (86.5%)
Other	45 (13.5%)
Would specialize in future
Yes	312 (93.4%)
No	22 (6.6%)
Attended CST sessions before
Yes	44 (13.2%)
No	290 (86.8%)

CST Communication Skills Training

Overall, majority of students faced difficulty in communicating with patients amidst the limitations posed by the pandemic (mean 36.41, SD 4.06). The responses to the individual statements on the difficulties on communication showed that the greatest difficulty was the fear of contracting COVID-19 while talking to patients in overcrowded places (mean 4.32). The difficulty that was next most encountered was the repetition of questions due to the reduced audibility of words through the face mask (mean 4.10).

The mean for adaptations practiced by students, in general was 22.39 (SD 2.57) and the responses to the individual statements on the adaptations in communication showed that the greatest adaptation practiced was using hand gestures and body language to convey a message (mean 2.97).

The mean PPOS score of the sample was 78.12 (SD 5.33) while the sharing and caring sub-scores were 38.0 (SD 3.28) and 40.1 (SD 3.44), respectively.

In general, most participants had low levels of COVID related anxiety with a mean of 6.09 (SD 2.27) on the scale. The highest score on the CPAS-11 scale was 17, which is just above the 50% mark of the maximum score obtainable on this scale. Responses to the individual items of the CPAS showed that the statement “Worried that I or someone in my family might get infected” carried the highest mean score of 2.35 (Table 2).

Table 2.

Overall scores of communication difficulty, adaptations practiced, patient-centeredness, and COVID-related anxiety among medical students (n = 334)

Variable	Mean	Standard deviation (SD)
Communication difficulty score	36.41	4.06
Adaptations practiced score	22.39	2.57
Overall patient-centeredness (PPOS total score)	78.12	5.33
Sharing factor (PPOS subscale)	38.0	3.28
Caring factor (PPOS subscale)	40.1	3.44
COVID-related anxiety score (CPAS-11)	6.09	2.27

The relationship between the adaptations undertaken, patient centeredness and COVID-related anxiety with other variables were analysed using independent sample t-tests. The results of this evaluation are shown in Table 3.

Table 3.

Association of adaptations practiced, patient-Centeredness and COVID-related anxiety with other variables

	Adaptations undertaken	Patient centerednessa	COVID-related anxietyb
Gender
Male	21.9 (2.49)	76.0 (4.85)	5.66 (2.21)
Female	22.7 (2.58)	79.3 (5.23)	6.30 (2.28)
	t = 2.58, p < 0.05	t = 5.66, p = 0.32	t = 2.46, p < 0.05
Year of study
Fourth	21.8 (2.19)	76.6 (4.30)	5.98 (1.98)
Fifth	22.6 (2.66)	78.6 (5.54)	6.10 (2.36)
	t = 2.28, p < 0.05	t = 2.90, p < 0.05	t = 0.44, p = 0.66
Prior attendance to a CST session
Yes	22.3 (2.53)	78.22 (5.41)	6.07 (2.18)
No	22.9 (2.78)	77.45 (4.74)	6.09 (2.86)
	t = 1.51, p = 0.38	t = 0.89, p = 0.35	t = 0.06, p = 0.69

Adaptations practiced represent scores from the Adaptations Practiced subscale only. Communication difficulty scores were analyzed separately and are not included in this table

^a As measured by the overall PPOS score

^b As measured by the CPAS score CST

CST Communication Skills Training

The distribution of communication difficulty with gender and year of study are illustrated in Figs. 2 and 3, respectively. The former had a significant difference between the 2 groups (p < 0.05) while the latter did not reflect such significance.

Fig. 2.

Relationship between gender and communication difficulty. This histogram shows the distribution of scores of communication difficulty between male and female students. The mean score for males was 35.2 (SD 3.44) and for females was 37.1 (SD 4.23)

Fig. 3.

Relationship between year of study and commuciation difficulty. This histogram shows the distribution of scores of communication difficulty between male and female students. The mean score for males was 363 (SD 3.05) and for females was 36.5 (SD 4.34)

Those students who had attended a previous CST session had a mean communication difficulty of 36.2 (SD 3.8) whereas those who didn’t had a mean of 38.1 (SD 5.21). An independent sample t-test done among these two groups revealed a significant association (p < 0.05).

Independent sample t-tests were done to find the association between the PPPOS sub-scores with other variables. There was a significant association (p < 0.05) between the sharing score and gender with females scoring more (mean 4.29) than males (mean 4.11). A similar significance (p < 0.05) was associated with the caring score where females and males had means of 4.53 and 4.33, respectively. Although there was no significance between the sharing scores and year of study, fifth year students significantly scored more (mean 4.49) than the fourth year students (mean 4.34) in their caring scores.

Pearson’s correlation analysis was conducted to examine inter-variable relationships (Table 4). Notably, COVID-related anxiety demonstrated a significant negative correlation with the sharing dimension of patient-centeredness, indicating that higher levels of pandemic-related anxiety were associated with lower sharing scores. Communication difficulty showed a significant positive correlation with both adaptations practiced and COVID-related anxiety.

Table 4.

Inter-variable correlations between communication difficulty score, adaptations practiced score, patient-centeredness, and COVID-related anxiety (Pearson’s correlation coefficients)

Communication difficulty score (subscale)
Adaptations undertaken	0.191*
Patient-centeredness	0.039
Sharing factor	– 0.045
Caring factor	0.102
COVID-related anxiety	0.251*
Adaptations undertaken score (subscale)
Patient-centeredness	− 0.001
Sharing factor	− 0.044
Caring factor	0.040
COVID-related anxiety	0.107
Patient-centeredness
Sharing factor	0.781*
Caring factor	0.804*
COVID-related anxiety	– 0.067
COVID-related anxiety
Sharing factor	– 0.154*
Caring factor	0.042

*Correlation significant at p < 0.05 (2-tailed)

Communication difficulty and adaptations practiced represent independent subscale scores derived from the same questionnaire and were analyzed separately

Only the significant associations are highlighted with the p-value, to facilitate interpretation.

Discussion

Our study revealed several interesting relationships between the parameters evaluated.

It showed that students had low levels of anxiety due to the pandemic, which is similar to findings from another Asian study [30]. However, this contrasts findings from certain other studies, where the prevalence of anxiety was higher [19, 31]. The reason for a dissimilarity in findings could be the use of tools with different cut-offs to measure anxiety. Female students depicted higher levels of anxiety compared to males as seen in several other studies [20, 21]. There was an absence of a significant difference between anxiety levels and year of study. Nevertheless, there are studies to show that with increasing seniority, anxiety levels tend to increase [19, 32].

Patient-centeredness, as measured by the PPOS scale, was not significantly different between males and females. However, females have portrayed higher levels in other studies [33–36]. To account for this dissimilarity, the sharing and caring sub-scores were higher in females.

As reflected in other studies [33, 36], patient-centeredness was higher in final year students compared to their juniors. However, a few other studies [35, 37, 38] have found an inverse relationship between seniority and patient-centeredness.

The difference in the sharing score between senior and junior students remained to be insignificant. However, senior students scored significantly higher on the caring score compared to their juniors; as was the case for another study [33]. Students, as they meet more patients during training, would understand the importance of incorporating the patient’s perspective into decision-making and hence score more on the sharing scale. The reason for an almost similar caring score could be due to the fact that students, irrespective of year of study, focus more on taking a detailed history from the patient rather than engaging in formulating a management plan.

Importantly, our findings demonstrated a significant negative association between COVID-related anxiety and the sharing dimension of patient-centeredness. This suggests that heightened pandemic-related anxiety may adversely influence students’ willingness or ability to engage patients in shared decision-making during clinical encounters. Increased anxiety may prompt students to prioritise task completion, limit interaction time, or adopt more clinician-directed communication styles as coping mechanisms in perceived high-risk environments. This highlights the psychological dimension of patient-centered communication, indicating that elevated anxiety may subtly undermine collaborative aspects of the doctor–patient relationship even when technical communication skills are preserved.

Our findings portray a wide spectrum of difficulties which medical undergraduates had to face during the COVID-19 pandemic. The most commonly encountered difficulty of being afraid of contracting the disease during a conversation aligns with the concerns related to infection transmission during the pandemic. It further implies that most students had a subjective hurdle to overcome rather than an objective one. Barriers to effective communication such as facemasks masking facial expressions and muffling the volume of speech are findings that are reported elsewhere, as well [39–41].

The relationship between anxiety and the level of difficulty students showed a direct association which was as expected. Anxiety would make students to focus more on the negative consequences of having a conversation with a patient. This finding suggests that as the level of pandemic-related stress increased, so did the perceived communication challenges faced by the students. It sheds light on the fact that an interplay between psychological factors and communication barriers within the context of healthcare does exist during a global health crisis. However, the suboptimal communication in this case would not necessarily mean that students are only afraid of disease transmission. This is due to the fact that the score calculated comprises of several other items that concern more with objective obstacles to having a conversation such as reduced volume (masks) and blurred vision (eyewear). These findings are quite novel as existing literature lacks findings to relate the anxiety due to the pandemic with communication difficulty.

As far as the gender is concerned, female students had more difficulty in communicating effectively during the pandemic. This suggests potential gender-related differences in the perception and experience of communication challenges. Gender being a driver for communication difficulty during the COVID-19 pandemic is an aspect rarely studied upon.

The year of study did not play a significant role in determining the level of communication difficulty, indicating that students across different stages of their education faced similar hurdles. This was an expected finding as the extent of academic knowledge does not change the existing barriers to communication in this pandemic.

Students who had attended a previous CST session had lesser difficulty in communicating than those who hadn’t, reflecting the importance of educating students on these essential soft skills. This would not only improve the overall quality of a conversation with a patient, but also enable the student to tackle the novel obstacles in communication imposed by the pandemic.

Finding solutions to the problems faced was an aspect that had not been evaluated in depth in other studies [41–43]. However, our study was able to produce a list of solutions, in keeping with our study objectives, and their relationship to other variables were studied. The use of body language to convey messages, being the most commonly practiced adaptation highlights the importance of non-verbal communication strategies in maintaining effective communication amidst social distancing measures and usage of personal protective equipment.

Interestingly, communication difficulty and adaptations practiced shared a significant positive correlation. This underlines the resilience of students to converse with a patient amidst the various challenges put in their way. Our findings also showed that gender and year of study were insignificant to the number of adaptations one may practice. This reflects that students employed similar strategies to cope with communication difficulties, highlighting the universality of certain adaptation techniques. Students in general overcame communication difficulties with the use of such adaptations, a positive message to take back from this study.

Strengths of this study were the sample size of 334 students, making a representative proportion of students. In addition, we were able to come up with a list of ‘solutions’ to the ‘hurdles’ found during communication during COVID-19, a less studied area in terms of communication among medical students.

Limitations of this study would include the self-report of adaptations rather than an observational study. Also, the self-grading of anxiety could have been dependent on how the participant felt at that particular situation. Furthermore, the adaptations practiced could have been a normal practice for certain students even prior to the pandemic and would not reflect the actual impact of COVID-19 on such approaches.

Future research could explore additional factors contributing to communication difficulties during the pandemic, such as patient perspectives and the impact of specific communication training programs. By understanding these factors, targeted interventions could be developed to mitigate the challenges posed by future crises of similar nature.

Conclusion

This study demonstrates that medical students experienced substantial communication challenges during the COVID-19 pandemic, driven by both infection-related fears and objective barriers such as personal protective equipment. COVID-related anxiety was positively associated with communication difficulty and negatively associated with the sharing component of patient-centeredness, indicating that heightened psychological stress may undermine collaborative communication during clinical encounters.

Importantly, prior communication skills training was associated with lower perceived communication difficulty, and students demonstrated resilience by adopting adaptive communication strategies despite prevailing challenges. These findings highlight the need for undergraduate medical curricula to integrate structured communication skills training alongside psychological support mechanisms, particularly during public health emergencies. Strengthening these domains may help sustain patient-centered communication and clinical learning during future healthcare crises.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Abbreviations

CPAS-11

Coronavirus Pandemic Anxiety Scale

COVID-19

Coronavirus-19

CST

Communication skills training

FGD

Focus group discussion

PPOS

Patient-Practitioner Orientation Scale

Author contributions

Dalpatadu SAC: Conceptualization (Lead), Methodology (Lead), Formal analysis (equal), Writing - review and editing (lead)Dalpatadu KCS: Conceptualization (Supportive), Formal analysis (equal), Writing - review and editing (equal)Amaratunga LTDS: Formal analysis (equal), Investigation, Writing - original draft, review and editing.

Funding

No funds or grants was received for this study.

Data availability

The dataset analysed during the current study is available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Approval was obtained from the Ethics Review Committee of General Sir John Kotelawala Defence University. Informed consent was obtained from all individual participants included in the study.Refernce RP/2021/66.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.