COVID-19 Has Changed Patient-Clinician Communication: What Can Rehabilitation Professionals Do to Enhance It?

Introduction

Imagine yourself as a patient in the following three scenarios.

Scenario 1: You wake up in a noisy, bright room with a tube in your mouth and dozens of lines connecting you to various machines. You are terrified of the beings surrounding you, who look like aliens. What you do not remember is that you were admitted to an intensive care unit (ICU), that the “aliens” are healthcare providers in personal protective equipment (PPE), and that you are very ill with COVID-19. You desperately look around for your loved ones, but they are nowhere to be found.

Scenario 2: You underwent a total knee replacement on March 20, 2020, 2 days before the New York State shutdown in response to the COVID-19 pandemic. Having been discharged home, you are now eager to begin rehabilitation. Being post-operative, you are deemed an “essential” patient. The outcome of the surgery is highly dependent on early post-operative knee range of motion and swelling, and these are ideally assessed and treated during an in-person physical therapy session. After interrogating your physical therapist (PT) about the safety measures the hospital has undertaken, you decide to travel 90 min to your first appointment. When you arrive, you realize your extreme discomfort with the post-operative care that requires close proximity and physical touch by a stranger clearly not within current social distance guidance of 6 ft.

Scenario 3: You are working at home while being treated for back pain and you have scheduled a 30-min telehealth physical therapy visit on your lunch break during a hectic workday. Your husband is caring for your three school-age kids while acting as their teacher in your home. When first attempting to connect with the PT on your computer, you see only a blank screen. You phone the PT, who asks you to leave the session and reconnect; the PT’s face becomes visible, but she says that your screen keeps freezing. Frustrated and in pain, you leave the session and try to reconnect once more.

For public safety, rehabilitation has shifted to treating patients through telehealth or in person while wearing personal protective equipment (PPE). This allows a connection with patients but with several constraints. As the opening scenarios illustrate, the loss of non-verbal communication coupled with the heightened arousal states of fear, anxiety, and pain can interfere with the patient experience. With the limited amount of time clinicians have with patients, and the new barriers that are arising during the COVID-19 pandemic, the need for understanding and using the different components of language and communication effectively is essential. Keulan et al. reported that the amount of time spent with a clinician was not as important as the quality of the conversation they have with their therapist [10]. Patient satisfaction was not dictated by quantity of time, but rather the value they received from their time with the clinician [9, 12]. Similar to that of a placebo effect in medication trials, a clinician can influence an optimal therapeutic outcome regardless of biological changes by positively impacting a patient’s mind, cognition, and emotions [1].

Verbal communication employs words to convey information, while non-verbal communication includes multiple components such as gestures, tone, eye contact, facial expressions, touch, and body language (Table 1) [8]. Each component can be impacted differently depending on whether treatment is delivered in-person or through telehealth. Clinicians can make small but impactful modifications to enhance communication in patient care.

Table 1.

Components of non-verbal communication [2, 5–8, 11, 14]

Component	Definition	Examples	COVID-19 Modification-Live	COVID-19 Modification-Telehealth
Facial expression	Using the muscles of theface to display universalemotions	Smile, frown, grimace	Smile under a mask, lines inface and eyes willstill convey the expression	Remove mask for a telehealth visit
Gestures	Deliberate movements thatwe make	Pointing, waving, numeric	Use gestures for emphasis	Make sure gestures arevisible on screen
Paralinguistic	The way you choose to saysomething and the impressionit makes	Pitch, inflection, tone ofvoice, loudness	Reduce speed of speech Speak louder Enunciate	Be aware of delay fromcomputer connection Reduce speed of speech
Proxemics	How we maintain and perceivespace	Seating arrangements,personal space, businessinteractions	Read a patient’s comfort levelwith social distancing Be mindful of coming into thepersonal space Ask permission before enteringtheir space	n/a
Kinesics	Body language and posture Open postures: trunk of bodyopen/facing camera, relaxedappearance Closed postures: arms crossed	Maintain open postures	Expression of true feelingsthrough our body	Maintain open postures Position the device to make surebody is seen
Eye gaze	The use of our eyes forcommunication	Looking, staring, blinking	Maintain eye contact with patientthrough PPE	Focus attention on patient Know where the camerais on the device
Haptics	Communication through touch	Expression of sympathy,friendship, romance, status,power, dominance	Read a patient’s comfort levelwith breaking social distancing	n/a
Appearance	How you choose to presentyourself	Uniform, clothing, piercings, tattoos,nail polish, jewelry	Wear a laminated card with name,picture and job title Wear PPE appropriately	Wear professional attire, especiallyif conducting telehealth from home. Be mindful of visible background
Chronemics	How we use time tocommunicate	Schedules, appointments,waiting times	Instruct patients to arrive only a fewminutes before start time Start on time to reduce time in thewaiting room Walk patients out to avoid additionalpersonnel contact	End sessions on time Set up your space with appropriateequipment for efficiency before initiating the appointment
Artifacts	Tools that we use forcommunication	Physical objects usedduring a treatmentsession or in a clinic	Communication boards Tablets Safety signage Cleaning Supplies White boards to display person,place, timeand pertinent dates during currentepisode of care	Place all supplies, (e.g., tablet, bands, weights, towels)nearby for demonstration

Challenges to Communication with In-Person Treatment

Social Distancing

The need for social distancing can create a barrier to nonverbal communication that rehabilitation clinicians may find difficult to overcome. The nature of our profession requires close proximity to patients. Where distancing is required, rehabilitation professionals may struggle to provide comfort and support. Our use of proxemics (physical distance) and haptics (touch) has changed greatly, both between clinician and patient and among team members. Proxemics and haptics are important tools that rehabilitation staff use to communicate care, interest, and concern to patients. For instance, a hand placed on a patient’s shoulder can communicate support, but the close proximity in-person therapy entails may prompt verbal and non-verbal expressions of discomfort for patients during the pandemic. Empathetic speaking such as restating concerns, validating feelings, and asking permission to proceed with the treatment can help to ease a patient’s anxiety [11].

Personal Protective Equipment

Facial expressions are a part of how we communicate and interpret emotions [5]. Wearing masks, goggles, and splash shields allows only the eyes to be visible, but eye gaze with a patient can convey commitment and concern as a substitute for other facial expressions [5]. Paralinguistics (pitch, inflection, tone of voice) help put meaning and variability into speech, but N-95 masks attenuate sound, muffling, or amplifying speech [6, 7, 14]. The compensations made in paralinguistics such as speaking more loudly when wearing an N-95 can be misinterpreted as aggressiveness. Masks pose an even greater barrier for patients who are hearing impaired [7, 14]. Decreasing the speed of speech, increasing volume, and lowering pitch can be effective ways to compensate for the limitations of PPE [8].

Acute Care

In the acute care setting during the pandemic, clinicians are almost fully obscured under required PPE, making all hospital employees look the same. PPE can lessen the power of touch, and our proxemics may be particularly limited with patients in the ICU or with those who are coughing. Clinicians’ inadvertent body language due to discomfort in PPE may include posturing such as crossed arms or hands on hips. This can be misread by the patient as staff not being fully engaged or not wanting to be in a room. Clinicians can communicate interest when wearing PPE through open posturing, increasing eye contact, and being aware of their own body language [2, 3]. Clinicians can also verbally explain why they need to leave the room. Additionally, clinicians need to promote self-care by taking breaks after every two or three patients in order to remove masks due to discomfort and to rehydrate due to excessive perspiration. Current donning and doffing guidelines of PPE can add up to 15 min between each patient, causing a change in the accustomed chronemics (timing). To improve chronemics for staff and reduce exposure time to patients with COVID-19, clinicians now co-treat each session.

Other barriers to communication with COVID-19 patients include intubation, nasogastric and orogastric tubes, tracheostomies, and cognitive limitations due to post-ICU delirium. Such patients cannot clearly communicate their needs to staff. Clinicians can employ communication boards to serve as an artifact (tool) to assist these patients. However, careful consideration is needed when incorporating a communication aid; the patient must be alert and cognitively intact, and the communication board must be easy to interpret.

In our opening scenario, in which you are a COVID-19 patient in the ICU, your clinician could use a laminated card containing their name, picture, and job title to help you understand who is present in the room. The clinician should also utilize the white boards located in each hospital room. Writing the date, name of the hospital, and unit within the patient’s line of vision helps orient them.

Outpatient Care

Both the clinician’s and clinic’s appearance and use of artifacts have the ability to communicate certain messages to patients. Even though dress codes may not have changed, PPE has become an essential part of the clinician’s uniform. Appropriate wearing of PPE along with artifacts such as signage supporting social distancing and displaying/utilizing cleaning supplies communicates an environment of patient safety.

Manual therapy, a typical treatment modality, requires clinicians to be in a patient’s personal space. Social distancing guidelines may make patients more uncomfortable even though they have chosen to attend a live session. Health care practitioners must read body language and verbal cues from patients to understand his/her comfort level. Hands crossed over the chest or leaning away suggest a person is not ready for someone to enter their personal space. Obtaining consent allows a patient to safely invite the clinician to perform the chosen modality.

Challenges to Communication with Telehealth Treatment

There is a learning curve for both clinicians and patients in telemedicine. The telehealth model requires clinicians to adjust verbal and non-verbal communication. A clinician arriving late to a session due to technological difficulties may inadvertently communicate disrespect for the patient’s time (chronemics). Frustrations with connectivity in telehealth may increase both clinicians’ and patients’ sympathetic nervous system responses. Clinicians and patients can take a deep breath together to access the parasympathetic nervous system and reset, much like an internet connection, to promote healing. Tone of voice can be used to heighten someone who is demonstrating signs of apathy or sadness. Alternatively, tone can be used to de-escalate someone who seems to be stuck in a hyper-aroused state. As in the third scenario described above, both the patient and clinician are experiencing difficulty linking via telehealth. The clinician can first use breathing to engage the parasympathetic system to manage their own frustration in establishing a telehealth connection, use a calming tone to de-escalate the patient’s frustration, and convey respect for their time by asking the patient to determine whether they prefer to continue the session or reschedule for a time that works better for them.

Telehealth alters our usual understanding of proxemics and haptics. Increased attention to factors such as auditory cues and kinesics (body language/posture) will signal whether patients are receptive to a clinician virtually entering their home. Family members can be involved during sessions to deliver manual therapy after clinician education, move the camera around for optimal visualization, or motivate the patient to participate. Inviting family into the treatment session might ease anxiety of our patients through co-experience and proximity. Facial expressions and eye gaze are powerful non-verbal communication tools during telemedicine treatments. Understanding where the camera is located on the device will help simulate eye contact between clinician and patient. Even though telehealth limits clinicians to treating in two dimensions, facial expressions and gestures can still be clearly communicated and identified. Clinicians should be mindful of setting up in a location where their body can be visible so nothing is left questionable regarding the clinician’s engagement. All possible distractions should be removed from the space, and e-mail notifications should be silenced to devote attention to the session.

The Role of Stress and Empathy in Communication

During the COVID-19 pandemic, stress on staff can become a major barrier to effective and efficient communication due to overwhelming fatigue, emotions, and social isolation. Communicators may become impatient, use aggressive tones or words, finish the communication partner’s sentence, or be blinded to the other individual’s point of view [4, 11].

For example, a therapist may say to a patient, “I told you to stop running. No wonder you aren’t better.” A more neutral statement, such as “modifying your activity can have a big effect on your ability to heal,” may be more effective [11].

Empathy, the ability to see the world from another’s perspective, holds the key to non-verbal communication barriers. During the COVID-19 pandemic, it is crucial that clinicians bear in mind that the patient, regardless of diagnosis, is likely feeling scared, isolated, helpless, or overwhelmed. Tone of voice can enhance optimal healing potential [13]. Empathetic listening requires us to remove distractions and also involves maintaining a quiet space, being mindful of word choices [16], giving patients the opportunity to speak, and trying not to finish their sentences. Empathetic speaking requires taking a reflective pause, gathering thoughts in order to be clear and concise, and being mindful of tone [15]. Patients should be given time to express how they feel when given feedback or new information [3]. As clinicians, part of our role is to create a space in which our patients can feel safe and where vulnerability is supported. In order to do this, it is vital for clinicians to participate in self-care practices in any way that is meaningful and personal (e.g., prayer, meditation, routine, activity). We can serve as a role model and be a calming presence.

The COVID-19 pandemic has forced clinicians to change the way they communicate with patients. Use of PPE, social distancing, and telemedicine have been able to decrease community spread of COVID-19, while enabling clinicians to deliver quality care. Given the success of treatment under these circumstances, clinicians need to prepare for protective measures continuing for an indeterminate amount of time and be aware of how they impact communication with patients. Clinicians should be educated on how to increase utilization of available non-verbal communication techniques.

This is a unique and stressful time for clinicians and patients alike. Regardless, a clinician’s primary role is to be a care provider for all patients. Open communication with patients relies on the clinician’s acknowledgment of his/her own feelings and ability to engage in empathetic speaking and listening to promote a healing environment. Providers can continue be effective in their roles as caretakers by being mindful of utilizing the optimal combination of verbal and non-verbal communication strategies.

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The authors declare that they have no conflicts of interest.

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