How COVID-19 Is Testing and Evolving Our Communication Skills

Abstract

The COVID-19 pandemic forced us, as health care professionals and members of the general public, to adapt. Simple things we take for granted have become more difficult. As pressures increased for health care professionals, conversations and decisions have become tougher. This brought the need to adapt working practices and find ways to continue providing compassionate patient-centred care remotely. In UK radiotherapy departments, radiation therapist (review radiographer)–led clinics moved to telephone-based clinics to reduce the time spent by patients in a hospital environment. This required setting up a “virtual” clinic room with patients by removing distractions and setting boundaries for the conversation. We have had to adapt our communication skills quickly as picking up on nonverbal cues is not possible through the phone. It can be challenging to understand feelings through the tone of a patient's voice and empathise accordingly. The pandemic has forced patients to slow down and really focus on themselves which has led to picking up physical and mental health changes earlier. This is one of the many positive outcomes that can be drawn from the pandemic. Although we have changed how we work, ultimately we are still here to help our patients.

On March 23, 2020, the United Kingdom went into ‘lockdown’ in response to the COVID-19 pandemic. It forced all of us, as health care professionals and members of the general public, to change our ways in one way or another. Simple things such as the weekly food shop became more difficult. For health care professionals, conversations and decisions began to get tougher and pressures increased. We started to feel the effects of ‘moral injuries’ a form of psychological distress, from actions or lack of actions that violates a person's moral code and affects our mental health [1,2]. COVID-19 brought with it the need to adapt our working practices and adjust to the new needs of ourselves and our patients.

In the UK, radiotherapy patients are reviewed weekly by radiation oncologists and through radiation therapist (review radiographer)–led clinics. A review radiographer has advanced skills and qualifications in symptom management, triage, emotional support, and sign posting [3]. Most radiotherapy patients are reviewed on a weekly basis with input from radiation oncologist where required. As a radiation therapist (therapeutic radiographer) and member of the radiotherapy review team, I see patients throughout their radiotherapy treatments to address their physical and emotional side effects. At the core of our skill set as review radiographers are well-developed listening and interpersonal skills. Every review starts with the basics; making eye contact, smiling at the patient, listening and shaking their hand, to name a few…

“Hello, my name is Naman, I'm a member of our treatment review team, I'm just going to take you to one of our counselling rooms to check-in with you and have a discussion about treatment side effects. If you have come in with someone today, they are more than welcome to join us if you feel comfortable with this.” This was a normal prereview conversation in the waiting area, before COVID-19.

What Has Changed Since COVID-19?

Radiotherapy staff on treatment units began to work in personal protective equipment (PPE) such as masks and protective eyewear to minimise the risk of contracting or transmitting the virus. PPE is an uncomfortable, but necessary addition to our physical working environment that affects interactions with colleagues and patients. Communication with patients is much more difficult as voices behind masks are muffled. Patients who are hard of hearing or deaf are unable to read our lips. Interactions between team members are hampered, impeding workflow and adding to tensions. This literal barrier to effective communication is a moral injury we faced on a daily basis through this pandemic.

Those of us in the radiotherapy review team have changed to telephone appointments to minimise the time spent by patients in a hospital environment. Telephone reviews are not a new process within health care [4]; oncology teams use telephone triage when patients report treatment-related side effects. Triage calls need to be efficient in finding out the problem while providing reassurance—they have a standard narrative: what is going on and how long for, what needs to be done, refer on appropriately, document and reflect [5]. Radiotherapy reviews are usually face to face and are scheduled for each patient. They often cover much more than just physical side effects and help build up a rapport with the patient. They can cover healthy lifestyle advice, explore support networks, promote well-being and can help provide reassurance. Face-to-face reviews provide the opportunity to pick up on nonverbal communication cues that you would miss through a telephone. In my opinion, radiotherapy reviews are more in depth than triage calls as they cover all aspects of a patient's care and side effects to help them live with and beyond cancer.

Despite the obvious barriers of PPE or a telephone, effective communication is vital to deliver patient-centred care. Communication is the cornerstone of life. It helps us build relationships, to find problems, and find solutions. We learn how to communicate from what our parents or carers teach us. This develops as we experience the world socially and eventually through work. We all have unique journeys and experiences in life to make sense of an ever-changing world. We all have plans and ambitions for the future. COVID-19 is a unique experience for all of us: plans and ambitions on hold, an ever-changing environment and uncertain vision of the future. The daily uncertainty, fear, and changes have been exhausting. We do not know what tomorrow might bring.

People with cancer are dealing with all of these COVID-19 uncertainties on top of their diagnosis, treatments, side effects, and everything that goes along with that. To go one step further, patients with cancer can endure some form of lockdown during their cancer journey. The physical experience of lockdown to protect your health is nothing new to patients who have gone through systemic anticancer treatments that leave them with weakened immune systems. The experience of being locked down is new for other patients with cancer. The uncertainty of not knowing whether treatment will be successful or whether they will experience recurrence could be likened to the uncertainty surrounding a future coronavirus vaccine and effective treatments.

We often talk to patients about adjusting to a ‘new normal’ after their treatment ends, but patients going through cancer treatment during a pandemic face a whole new set of challenges. In switching to telephone reviews, we were concerned we would not pick up as much as an in-person review. Addressing concerns face to face or through telephone should not really be any different, should it?

How Have We Adapted?

The British Association for Counselling and Psychotherapy recently released a set of competencies on telephone and e-counselling [6]. Although not designed for use by radiographers, it has helped us transform how we approach telephone reviews.

We have been letting patients know a day in advance to expect a phone call from the review team. On the day of the review, after having read up on the patient's history and treatment plan, I then prepare to call the patient. While I'm pulling on my call centre–style headset, I like to take a moment to look at their ID photo so I have their face in mind when I call them.

“Hello …, my name is Naman, I am a member of the review team calling from … We're due to catch up for a treatment review over the phone this morning, is now a good time? Brilliant, this should take around 20–30 minutes. Before we get started, are you sitting comfortably or is there somewhere in your home you want to sit for the duration of this phone call? If you need a pen and paper to write down any notes or to grab a drink, then now would be the time to grab what you need too. … Is there anyone else with you joining in on this call that you feel comfortable having with you? Okay … let's continue …”

Our new normal includes setting appropriate boundaries with time, surroundings, who can listen in on the review and awareness. We have to remember to summarise after important aspects of the conversation and give the patient time to write some of the information down. It is important to wait for anyone else in the background to ask any questions. It can be a real flowing conversation over the phone perhaps easier than face-to-mask, but it's not without its challenges…

Some Challenges of Our New Practice

Keeping the conversation on track can be more difficult; for many patients who are isolating, we are tackling their loneliness as well as their treatment side effects. You might be the only person this patient has spoken to in a while. One patient I recall had no family in touch and no children. The only friends he had were the ones he would meet at the pub which was now off limits. During our chat he began to tell me about his garden. I remember thinking briefly, I have a long list of tasks to get through today and live in a flat with no garden but this is important to him. I think “should I quickly google something about gardening?” Then the patient says his wife used to love gardening and she made the garden look colourful and tidy when she was around…then I heard him crying through the phone. At this point it was difficult not to feel guilty that I could not do more. The use of silence and listening has become even more important; I wonder whether this patient could have opened up like this had we been speaking face to face? Grief is difficult to overcome and stereotypes challenge all of us. The stereotype is that men do not cry. Especially men of a certain generation and especially not to other men.

We are all having to live in the present, stop and notice what is around us. There are people like him everywhere, whether they have had cancer treatment or not. It is not my job to talk about a patient's garden but by not cutting him off, he got to talk about someone he loves and misses. It was sad and it upset me, but it was an absolute privilege that while he was in his safe space, at home, he trusted me enough to confide in me and cry over the phone. I'm very lucky to have at least one person in my phone book who would answer and listen to me.

The traditional view of face-to-face consultations by a health care professional has changed during this pandemic, potentially forever. Change is inevitable, however uninvited it is. We all have had to adapt at what feels like breakneck speed. Patients and staff have been forced to accept technology. Some of our more ‘mature’ staff have been looking to younger staff to guide them. For some patients, seeing someone “in person” is their way of feeling looked after. It gives them the space to open up and engage with you. Our new normal is a virtual review room where boundaries need to be drawn with the patient. Distractions need to be put aside. There are no more visual cues for you to pick up on and alter your approach. It is no longer eye contact and body language that we look for, but subtle changes in the tone of the patient's voice. It is difficult to empathise and console using just your voice. Use of silence and listening are really important. However, I found that being silent on the call for too long, waiting for the patient to answer a probing question, led a patient to think I was not there anymore and she hung up on me. This was embarrassing and amusing but at least I have learnt that on the phone you cannot be silent for too long. Sporadic murmurs of agreement or support are often just as important as a fully formed answer.

Lockdown has meant many of our patients are less busy and are being forced to slow down and refocus on themselves. There is more time to sit and talk. Perhaps the telephone helps erode some of the hesitancy and awkwardness of talking about openly themselves. For example, explaining how many times you open your bowels seems less intimate over the phone than face to face. I would argue we are uncovering more about side effects than we have before. Patients have more time to think about what they feel, what has changed, and what is on their mind.

As we navigate the moral injuries that this pandemic deals us, it is possible to also sense some of the positive outcomes. For me, the bond between patients with cancer and radiation therapists has grown stronger. Patients with cancer are risking their lives to come to our department, and when they arrive, they are treated by staff risking theirs. We have changed how we work, what skills we use to work, but behind a mask or telephone, we are still here to help our patients.