Implications of the current COVID-19 pandemic for communication in healthcare

The current COVID-19 pandemic has impacted all of us and will continue to do so for a long period of time. In the face of our constantly evolving knowledge of COVID-19 and its impacts, we are aware that even the relevance and accuracy of this statement may change by the time it is widely publicized. EACH: International Association for Communication in Healthcare, ACH: Academy of Communication in Healthcare and all of our stakeholders seek to learn from and support one other through community-building, investigation, and education, with the broader goal of improving the lives of our colleagues, healthcare professionals, patients, and families. As international organizations, we are uniquely positioned and hold the responsibility of contributing to the pandemic response not just from a local or national standpoint but with even greater inclusivity, inviting perspectives from different cultures, countries, health care systems and governments as they each have their own unique experience related to the pandemic and its myriad impacts.

Moreover, much work is needed to specifically address Covid19 related health disparities worldwide. Indeed, recent reports indicate that some communities have been disproportionately affected, including first responders, racial, ethnic and religious minorities, immigrant groups, the elderly, individuals with underlying health conditions, people who are incarcerated and others.

Below we briefly identify many, though not all, of the areas of communication in healthcare that are important to emphasize as we address the changing interactions with patients and families; between teachers and learners; between the media and the public and within healthcare teams. EACH and ACH are developing and also collecting resources to share with our professional community on many of these topics. Please visit our websites and consider sharing your resources and experiences with all of us.

1. Content of communication between health care providers and patients/families during the COVID-19 pandemic

1.1. Risk communication and uncertainty

When a new disease is spreading, epidemiologic data collection is ongoing. Especially in the initial phases of the spread of a disease and for many months afterward, there is a lack of comprehensive scientific evidence. Institutions engage in public risk communication, but the content of this communication can change daily with the increasing severity of the disease. This uncertainty can lead to a decline in people’s trust of institutions. Furthermore, marginalized communities are under-represented in science and healthcare, which reduces effectiveness in both composing and disseminating key messages about risk and risk mitigation. These communities understandably have low rates of trust in healthcare systems at baseline, making clear and equitable communication more difficult and even more important. This complexity occurs against a backdrop of collective fear, which influences not only the communication of risk but also its appraisal. Also, exposure to bad news and images of illness and death can increase anxiety and lack of confidence in the possibility of effectively managing the pandemic. One major aspect to consider is the negative impact of misinformation on behavior change by suggesting suboptimal actions or spreading information inconsistent with the views of health institutions.

1.2. Goals of care

While there has been an increasing push to have goals of care conversations with patients, particularly if they are perceived as being close to the end of life, the current crisis raises the importance of these discussions for anyone diagnosed with COVID-19 and in particular those needing hospital care. One size does not fit all. These discussions require a high degree of self-awareness and rapport building on the part of healthcare professionals, who are challenged to conduct these conversations effectively in “normal” times and in need of support as more people face potential mortality from the virus.

1.3. Shared decision making

Related to Goals of Care, communication in healthcare has emphasized the importance of patient centered care and shared decision making. While still promoting its importance, we also realize that in the context of severe resource limitations, such as those related to ventilators and ICU beds, these conversations shift from sharing decision making to bad news conversations where choices for care and preventing mortality are limited.

1.4. Breaking bad news

Healthcare providers need resources and support for effective bad news conversations. With COVID-19 the bad news can include seemingly less difficult news such as someone with a new symptom or chronic illnesses being told they are unable to access timely health care support or to receive a COVID-19 test or perhaps that they must self-quarantine for a period of time or cannot see their ill loved one. Of the utmost difficulty are conversations predicting imminent death, conveying a lack of care options, or informing someone of a loved one’s death.

1.5. Grief, loss and isolation

During the height of the pandemic and beyond, COVID-19 will continue to have a powerful impact. Conversations with patients and families will require listening, empathy, and responsive action to address loss of loved ones, income, and social contacts. Empathic discussions of how social determinants of health have real and sometimes tragic and fatal consequences can and should be broached.

1.6. Core communication skills

For even the most skillful practitioners of humanistic communication, the pressure of responding rapidly to public health, clinical, and teamwork crises can undermine communication performance. The communication skills that our professional community has identified through research evidence and disseminated through training of all levels of learners continue to be central to effective communication during this crisis and beyond. These include relationship and rapport building; assessing the patient’s/family’s full agenda and perspectives; recognizing emotional cues and responding empathically; sharing information and negotiating management in a way that includes the patient/family while also facilitating and assessing understanding. Furthermore, implicit bias, the common and unconscious assumptions based on social stereotypes, can interfere with effective clinician-patient communication. As you know, these skills are relevant to all conversations and especially the more difficult ones raised by COVID-19. We are curious to hear how you have found these skills particularly applicable during this time.

1.7. Health care provider wellness and stress

Those providing care and support in the pandemic are experiencing overwhelming stress, difficulties managing uncertainty, and concern for their own health and the health of their families. All of these factors impact communication in healthcare, and therefore resources for managing these issues are of vital importance.

2. Processes of communication with patients and families during COVID19

In addition to the content of conversations changing, the process by which health care providers can and will communicate with patients and families has changed rapidly. Many health care providers with little experience using phones and particularly videoconferencing in patient communication are now having to more broadly implement these technologies. Health care providers and patients need support in adapting the core communication skills for in-person encounters to these virtual encounters, including effectively assessing patient’s non-verbal cues, emotional states and understanding. ACH and EACH have disseminated condensed guides for effectively communicating in different settings and via different methods. We are also collecting and sharing tools and resources on our website as guides for people who need support in health communication.

3. Teaching and assessing communication for health professional learners during the COVID-19 pandemic

With the necessity for physical distancing as a way to flatten the curve of COVID-19, opportunities for in-person educational and assessment sessions have been cancelled or postponed across the educational continuum for students, postgraduate learners, and practicing clinicians. This disruption raises several challenges and opportunities as we persist in our commitment to support ongoing development of communication skills.

Key considerations include:

3.1. Online communication skills teaching

While not necessarily the optimum way to strengthen communication skills, many teachers are learning and seeking to identify best practices for virtual communication skills teaching during the pandemic. Teachers need information on how best to employ videoconferencing platforms such as Zoom and WebX for experiential communication skills learning, which includes peer role play and practice with simulated patients.

3.2. Clinical learners not seeing patients

In many health professional schools around the world, many clinical rotations have been suspended. Sharing resources for continuing case-based and other forms of learning in the absence of direct patient encounters is another pressing need and opportunity.

3.3. Workplace-based learning

Not all learners have been removed from clinical settings during the pandemic and many, such as residents, are experiencing increased clinical obligations. It will be helpful to identify opportunities for continued emphasis on communication skills learning and development in the clinical setting. Innovations that adhere to the need for physical distancing and still emphasize communication content could include virtual rounding, video recording with asynchronous feedback of learner-patient encounters, and communication-focused debriefing of patient/family encounters.

3.4. Virtual communication assessments

In addition to in-person teaching, the pandemic has made in- person assessments such as OSCEs untenable. Many schools are developing successful and innovative ways to continue to conduct communication-focused performance based assessments, including involvement of simulated patients using videoconferencing platforms.

4. Research on communication in healthcare during the COVID-19 pandemic

4.1. Research focus

For research, the pandemic invites innovation while also presenting difficulties. Even before the crisis, evidence about what aspects of clinical communication improve outcomes for patients with less social privilege was sparse. That knowledge gap is now more important than ever and more challenging to measure during a global health crisis. Indeed, the COVID-19 outbreak is enriching the research agenda with new topics as critical healthcare provider-patient interactions and interactions with the families pose challenges to the applicability of standards of health communication developed over the past decades. A comprehensive understanding of what is happening currently as well as its future implications is needed, and new findings are expected to equip healthcare practice and education with strategies and tools to best respond to such an urgency.

4.2. Conducting research

Just as in-person clinical and educational interactions have been impacted, the ability to conduct in-person research is also being challenged. Some innovative approaches to collecting important data from learners, patients, families and health care providers include online surveys, phone or Zoom group and individual interviews, and support groups using social media applications.

4.3. Presenting research

The current pandemic has also changed the ways in which researchers are able to disseminate their findings. Graduate students and faculty traditional rely on professional conferences to present their work and invite feedback. Increasingly, other online initiatives/conferences will be needed to enable effective research exchanges and the enhancement of best practices in effectively sharing our research findings.

5. Policy implications for communication in healthcare during the COVID-19 pandemic

Policies need to be created to manage evolving scenarios at different levels of the health system and of society at large. Consensus over healthcare guidelines and protocols are created emergently and often without the possibility to meet face-to-face. Stakeholders are pressed to demonstrate flexibility as they adapt to different working scenarios. In the face of misinformation, which can negatively impact risk-appraisal and behaviors, institutions work to implement strategies for detecting and responding to inaccurate or conflicting messages. Also, in many countries, efforts are needed to reinforce hospitals and supply chains in the context of insufficient public health infrastructures. While this insufficiency presents a dire situation, especially for marginalized groups, it also presents an opportunity to redesign these structures with principles of equity and humanism at their core. In order to effectively navigate this challenge, individuals, teams, and systems will need to communicate effectively.

6. A call to contribute to communication in healthcare during the COVID-19 pandemic

We encourage all of you to join this conversation and related ones on the EACH and ACH websites, www.each.eu and www.achonline.org, to share your experiences and resources so that our collective wisdom can be used to support each other, our colleagues, and our communities as we continue to navigate this time of physical distancing/isolation, overburdened healthcare systems and healthcare workers, and significant loss of health, life and economic resources. Our lived commitment to relationship centered care could not be more critical.