The Use of Empathic Communication During the COVID-19 Outbreak

Abstract

As of May 13, 2020, the number of confirmed SARS-CoV-2 (novel corona virus, COVID-19) infections has risen to 4 300 000 worldwide, with over 1 300 000 confirmed cases in the United States. Various prediction models of spread indicate more hospitalization, increased ventilator use, and the shifting of medical resources to most efficiently serve the patient’s needs. Additionally, mitigation strategies such as monitoring for symptoms, social distancing, safer at home, and the wearing of masks caused our institution to implement significant operational changes to our usual practice. This included screening patients and staff for symptoms, rescheduling routine medical visits, postponing procedures, converting face-to-face visits to telephone or video visits, and changing visitor visit policies. In this article, we describe the various ways we deployed empathic communication messaging and resources across the institution during the COVID-19 pandemic.

Introduction

Our institution is a not-for-profit academic medical center with almost 5000 physicians and scientists and over 60 000 allied health and administrative staff. Based in the midwestern United States, our institution has several medical centers and regional health systems across several states.

Our communication training unit, Experience Training, Education, & Coaching (XTEC) was created in response to a critical need for enhanced communication skills to improve the patient experience across all our sites. Experience Training, Education, & Coaching’s mission is to inspire and unleash the very best in those we serve by (1) training that is compelling and of the highest quality aligned with our institution’s core values, (2) education which advances others’ knowledge of communication tools and strategies, and (3) coaching to enhance interpersonal skills. Experience Training, Education, & Coaching consists of 13 individuals, most who have extensively studied communication in health care, are certified coaches, and have taught communication strategies at colleges, universities, and other health care organizations around the world. Our team members provide resources to assist our institution’s staff with interpersonal communication strategies both internally with their colleagues and externally with patients, families, and visitors. Experience Training, Education, & Coaching activities include group training in empathic communication across all roles, scripting of empathy-oriented communication, individual communication coaching, and curbside connections for navigating challenging conversations.

Empathic Communication

The abilities of health care professionals to demonstrate empathy and trusting communication in human interactions are essential to complete the health care interaction to the fullest potential. An empathic approach involves health care staff demonstrating skills of a therapeutic relationship involving open, honest, trusting communication with empathy and warmth (1). Empathy is defined as understanding the patient’s experience, communicating one’s understanding, and supporting the relationship by moving forward in a helpful style. Empathy is a skill that can be grown in professionals and developed as a key competency in health care (2).

Seeking to better connect with our patients, our institution embarked upon wide scale training of empathic communication skills in 2016. Staff from XTEC recognized that care providers had empathy for their patients, but communicating that sense of empathy back to the patient was often lacking. In response, XTEC created 60- to 90-minute face-to-face training sessions with a 6-month sustainment curriculum customized to the various roles across our institution. The cognitive component of empathy is perspective-taking (3), and this was paired with contrasting courtesy and empathy and empathic reflective listening statements. Reflective listening involves mindfully paying attention to what the communicator feels and believes, so that an empathic reflective response can be formulated, allowing the speaker to feel understood. The efforts that began in 2016 laid the foundation for our response to the COVID-19 pandemic.

Emergence of COIVD-19 and Its Impact on Clinical Operations

On March 23, 2020, our institution introduced significant practice changes in response to community spread of COVID-19. This included screening patients and staff for symptoms, rescheduling routine medical visits, postponing elective procedures, and converting face-to-face visits to telephone or video visits. Other changes included the visitor policy, limiting the number of guests, and guidelines for managing possible staff exposure to COVID-19.

The COVID-19 crisis also has a significant financial impact on the organization. Due to projected revenue loss from canceling office visits and procedures, our institution implemented mitigation strategies including painful furloughs, salary decreases, and work-hour reductions. Such significant changes required coordinated actions and consistent messaging to over 60 000 staff. Below, we describe several specific examples of infusing empathic communication into our messaging to staff and patients during the COVD-19 crisis.

Scripting for Frontline Staff Required to Manage Appointment Cancelations and Deferrals

Our first task was to craft scripting for frontline employees responsible for contacting patients to cancel appointments, procedures, or deny their initial appointment. Patients may have waited weeks or months for appointment confirmations and have significant emotional, financial, and time invested into their scheduled visits, and there existed significant uncertainty of when these appointments would be rescheduled. Our scripting team employed perspective taking by placing themselves into the shoes of the patient. Recognizing emotions such as confusion, anger, disappointment, and fear, they reflected those emotions in scripting for frontline staff. An example is below:

Hello, my name is ______. I am calling from __________. Is patient _______available? We are reviewing all upcoming scheduled appointments to support ongoing efforts for social distancing in response to the COVID-19 pandemic. This has been a distressing time for our community and our goal is to keep everyone safe.

At this time, we need to delay your upcoming appointment. We value you as a patient and appreciate your understanding. We will contact you as we are able to resume our normal operations.

Thank you for your time today. This has been a very difficult situation and certainly not what anyone would have expected; we truly appreciate your understanding. I would like to ensure that we have your most up-to-date contact information. (Review contact information) Thank you again, and please refer to the ___________.com website for ongoing updates.

Proactively Equipping Service Recovery Staff With Letters and Messaging for Anticipated Complaints

Given the substantial changes to patient scheduling, we anticipated an increase in formal complaints lodged with the Office of Patient Experience. We outlined 4 likely scenarios for our service recovery staff. These included complaints from (1) patients who received cancelation notices for their appointments/procedures, (2) patients who were seeking an appointment in which access was denied, (3) patients who wanted COVID-19 testing, but didn’t meet testing criteria, and (4) visitors who expressed concerns about the “no-visitor policy.” Built upon empathic communication training, we recommend service recovery employees respond to complaints by reflecting the patient’s concern and then reiterating that this is a difficult time filled with questions and worries from many. In most situations, we recommend a legitimization statement such as “anyone in your situation would feel the same way” to follow. We suggest closing by providing a reassurance statement (Online Appendix A). “Our institution’s perspective is” should never be stated before the patient’s perspective is taken into consideration.

Providing Nurses and Physicians With Empathic Messaging

Under normal circumstances, many different staff may respond to call lights (visual and auditory notification system) in response to a patient need. In order to ensure the adequate supply of personal protective equipment (PPE) such as masks and gowns, only one designated care team member was authorized to enter a patient’s room using PPE. Because this can lead to patients feeling isolated, XTEC created empathic responses for other staff to utilize when they were not able to enter a patient’s room (Online Appendix B).

Scripting for Visitors Not Able to Be With Their Loved Ones—Finding the Right Words

A universal struggle in health care through COVID-19 is helping patients and families through challenging times when they cannot be physically present with each other. To support both staff and patients, XTEC created a “Finding the Right Words” online module and supporting resource. The tools are based in the foundational empathic reflective listening statement and enhanced with contrasting “hope/worry,” “This is a time,” and “I wish” statements (4). These guiding statements are used to help initiate difficult conversations while maintaining compassion and empathy. Examples include:

It’s evident how much you care for your loved one. My hope is that our treatments will help her. My worry is that the virus has greater impact on those with underlying conditions.

Normally we would continue to weigh out our options, but given our circumstances and the progression, this is a time where we have to refocus from treatment to planning end-of-life care.

Right now, we are asking you to ______. I wish things could be different. This must be so difficult to hear when you love someone. Examples could include leave personal items at home, use the telephone to stay in contact, or updates to policies to share.

Communication Guidelines for Telemedicine Visit

The COVID-19 crisis caused the organization to accelerate virtual visits at an unprecedented pace, converting many face-to-face visits to telephone or video visits. Different communication skills are needed to establish rapport, build trust, and support the relationship in these non-face-to-face interactions. To help fill this gap, XTEC created the webside manner series of resources focused on adding a human touch to digital experiences. The inaugural issue emphasized the following points:

• Recognize the patient is inviting you into their home.

  • ∘ Thank you for welcoming me into your household today.

• Empathic statements are often less present in video visits (5); therefore the use of perspective taking is of utmost importance.

  • ∘ From your perspective, addressing this symptom should be our top priority.

• Over 50% of the communication is conveyed by body language.

  • ∘ Pay attention to nonverbal gestures, maintain eye contact into the camera, and nod your head to show listening.

• Technical processes can take focus away from the patient. Acknowledge that video visits may be a new experience.

  • ∘ These video visits are new. I appreciate you giving them a try.

• Narration and explanation are key.

  • ∘ Is it OK if I type while we talk? I want to make sure that I capture everything.

Experience Training, Education, & Coaching continues to build out resources that will define the way we communicate via digital experiences to ensure the human connection is not lost.

Frontline Messaging for Rescheduling Appointments That Were Canceled Due to the COVID-19 Crisis

As our institution plans its return to scheduling outpatient appointments, rescheduling previously deferred appointments requires specialized communication. Experience Training, Education, & Coaching created resources and scripting for the allied health staff responsible for rescheduling appointments. An example follows:

It’s natural to be concerned with all that is happening. Anyone would be. If it’s okay, I’d like to share some information with you. (brief pause) We put your appointment(s) on hold out of an abundance of caution and are now ready to put them back on the schedule, because we believe that appropriate steps have been taken to assure your safety.

Scripting Created for Supervisors to Manage Expense Reduction Conversations

Experience Training, Education, & Coaching created guides for supervisors who need to have challenging conversations with their staff regarding furloughs or salary reductions. The guide offered skills that align with perspective-taking strategies, such as keeping the focus on the recipient of bad news rather than the deliverer. Supervisors were counseled to avoid statements such as “This is hard on me too,” or “I hate having to give you this news.” The 6 main steps in the document were:

• 1. Begin with a short, simple gratitude statement

  • Thank you for meeting with me today…

• 2. Follow with a legitimization statement

  • This is something that you hoped wouldn’t have to happen…

• 3. Reiterate that this will impact good people. Do not use the word “unfair,” because negative outcomes are much more easily accepted when it is communicated that fair practices were utilized in decision-making.

  • Mary, our leaders have put so much thought into this to make it as fair as possible, and yet good people are still going to be affected.

• 4. Avoid jumping to the “silver lining,” such as, “You can always enjoy the summer…” “Look at the bright side…”. Instead, allow a moment to process, feel, and express. Whatever is said, do not argue their point until first empathically reflecting. If something irrational is said that needs correction, empathically reflect what was said first, then ask permission before you give your perspective.

Example: Reflecting and asking permission

This is total garbage. This wasn’t done fairly at all. CEOs should be reducing their pay.

• Incorrect: As a matter of fact, they are reducing their pay…

• Correct: Reflect: It feels unfair to you. From your perspective, it seems like others, specifically our top leaders should take a bigger hit. Ask Permission: Would you mind if I shared what I know?

• 5. Offer more time for questions. Answer questions directly, honestly, and appropriately. Have prepared answers to the most common questions prior to your meeting. Also be ready for reactions that could range from shutting down to high emotional behavior. Praise any graciousness that you can find in their responses.

• 6. Offer support and resources. Convey the message, “I’m here for you.”

The guide also emphasizes the importance of the bearer of the news to practice good self-care during this unprecedented time.

Discussion

In 2016, a renewed emphasis on connecting with our patients in a way that makes them feel understood led to organization wide training in empathic communication. We have described several specific ways empathic communication has been infused into communication as a result of COVID-19. These ranged from outpatient appointment cancelation and rescheduling, inpatient practice, non-face-to-face visits, and communication with our own staff in relation to and staff and salary reduction.

In order to ensure consistency and a fast response time, an agile team was created to respond to the communication needs of the organization. Experience Training, Education, & Coaching was able to respond to practice needs with coaching, scripting, and curbside consults. Our institution set up a Hospital Incident Command System (HICS) to oversee COVID-19 efforts. All of the resources our unit created were vetted through HICS. We created a template with consistent components that incorporated key messages, tips, and scripting language for each request. The consistency and continuity of utilizing the template allowed HICS to quickly recognize that the initiatives were coming from XTEC. Our response time to get final documents to HICS was less than 24 hours for each request from various units. Finally, it was vital to have a very structured tracking process. We met daily to debrief learnings, track requests, and craft a summary report to senior leadership.

Through our various activities and initiatives, XTEC developed stronger partnerships with other internal units. The patient experience, public affairs, information technology, practice operations, nursing, human resources, and quality management services all strongly advocated for incorporating empathy into the messaging to both patients and employees. These groups were crucial in the distribution of XTEC’s documents to ensure that the scripts reached the appropriate audiences and supported staff in having challenging conversations.

We were able to identify opportunities for improvement. First, the initial requests for communication support were very vague. Inbound requests did not provide supporting policy language or rational for changes being made in the practice. This delayed scripting and resulted in many different iterations of the document. Another opportunity we identified was to have resources posted to our institution’s internal COVID-19 website, which was the point of information sharing for all things COVID-19 related. Often the resources developed were not easily accessible or were not able to be posted to the website at all because of competing priorities. The final opportunity was our lack of ability to track how often our scripts were utilized. Although we believe the resources are excellent and helpful to staff and patients, we were not able to develop a tracking system for their use due to the rapidity of implementation of COVID-19-related practice changes.

Overall, we believe that empathic communication is an impactful and vital communication skill for almost any interaction, and we demonstrated that this type of communication can be infused into diverse communications including crisis situations such as the COVID-19 pandemic.

Author Biographies

Sheila K Stevens is a quality administrator at Mayo Clinic, an Instructor in the Mayo Clinic Alix School of Medicine, and member of Motivational Interviewing Network of Trainers. She is a certified coach and has a background in counseling, education, and patient experience.

Rebecca Brustad is the patient experience training, education and coaching manager for Mayo Clinic. Over her 11 year career with Mayo Clinic, Rebecca has grown from a one-person Patient Experience department in a small community hospital to the manager of a national team of communication experts. She is a faculty member for the Mayo Clinic Communication in Healthcare and a Silver Quality Fellow.

Lena Gilbert is an advisor in The Office of Mayo Clinic Experience, and member of the Training, Education & Coaching team. She has an extensive background in education and curriculum development in the fields of education and health care. She is currently pursuing a PhD in Occupational and Technical Studies with a concentration in Training.

Benjamin Houge is a senior advisor in The Office of Mayo Clinic Experience, and member of the Training, Education, and Coaching team. He is the primary author of Cognitive-Emotion Communication for Pain and holds a position at Viterbo University in the College of Nursing, Health, and Human Behavior. A certified change management practitioner and a counselor by training, Ben brings extensive experience in Motivational Interviewing, counseling, and behavior change to interventions targeting interpersonal effectiveness.

Timothy Milbrandt is an advisor in The Office of Mayo Clinic Experience, and member of the Training, Education & Coaching team. He has worked in the medical field for over twenty years, and has served as an adjunct faculty member in higher education. Tim has received basic and advanced training in Motivational Interviewing, and is a member of the Motivational Interviewing Network of Trainers. He is certified as both a Tobacco Treatment Specialist and as a Wellness Coach, and is a licensed mental health professional.

Karee Munson is an advisor in The Office of Mayo Clinic Experience, and member of the Training, Education and Coaching team at Mayo Clinic. She is a faulty member for the Mayo Clinic Communication in Healthcare, Certified Change Management Practitioner and a Silver Quality Fellow. She has over twenty years of experience in healthcare and has a background in community health, coaching and patient experience.

Jennifer Packard is a senior advisor in The Office of Mayo Clinic Experience, and member of the Training, Education and Coaching (XTEC) team providing communication training and coaching to Mayo Clinic staff. With a background in counseling psychology, she has more than twenty years of clinical experience in the fields of addictions and health behavior change. National Board Certified Health and Wellness Coach, a member of the Motivational Interviewing Network of Trainers (MINT).

Brooke Werneburg is an advisor in The Office of Mayo Clinic Experience, and member of the Training, Education and Coaching team. She is an assistant professor of Medicine and a National Board Certified Health and Wellness Coach. She has background in patient experience, health promotion, and marketing.

Mustaqeem A Siddiqui, MD, MBA, is an enterprise medical director for Mayo Clinic Experience Training, Education and Coaching. He is a member of the Mayo Clinic Patient Experience Leadership Committee and an assistant professor of Medicine within the College of Medicine at Mayo Clinic.