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Having to wear PPE creates a communication barrier that imposes a heavy burden on nurses. Patients look to nurses for information, help, and comfort, but now—at a time when they depend on nurses more than ever—you have to interact while swathed in protective gear. It is nice to be acknowledged as a “hero,” but being a masked hero makes the job a bit harder, doesn’t it?

What can you do to communicate more effectively and connect with patients while wearing PPE? DailyNurse sought guidance from patient-provider communication specialist Dr. Mary Beth Happ, PhD, RN, FAAN, FGSA.

Healthcare communication specialist Dr. Mary Beth Happ
Patient-Provider communication specialist Mary Beth Happ, PhD, RN, FAAN, FGSA

Dr. Happ outlined the problems: “[PPE can cause] muffled voice and conceals facial features, particularly the lips and mouth. We give each other important communication cues through facial expressions (such as smiling) as well as mouth and lip movement when talking. This is particularly important for patients who have any hearing impairment, delirium, or dementia. The patient may not realize that the nurse is speaking or may be confused by the sound of the nurse’s voice without seeing mouth movements. Another way that we communicate is through human touch. Unfortunately, reduced contact time and wearing protective gloves limits touch communication.” Here are Dr. Happ’s tips for nurses seeking ways to connect across the PPE barrier:

1. Use your eyes, your hands, and a notepad to communicate

“Getting and maintaining eye contact with the patient as much as possible is so important. ICU patient survivors have told us how frightening it is when the eyes are their only way to connect with the humans caring for them (due to intubation, physical restraints or weakness) and the nurse or therapist does not make eye contact.

Nurses can allay patient anxiety by using special communication tools and techniques to augment or assist a patient’s understanding of the nurse’s messages. For example, we recommend always keeping a notepad and felt tip pen or marker at the bedside. Write key words or phrases as you are speaking to reinforce and help the patient understand your message.  Use picture communication boards to emphasize your meaning if patients have low literacy or English proficiency. Also, gently touch the patient’s shoulder or arm when you speak to get their attention and connect.”

2. Make it easier to identify the person behind the mask

“Nurses and other health care team members caring for patients with COVID-19 have been very creative – some wear laminated photos of themselves smiling outside the PPE gowns. https://www.instagram.com/p/B-kH5YHDzBt/?igshid=18nqhn4wnwk00. Another option is the clear mask. There are several styles/manufacturers. This one fits snugly and is wipeable. https://www.theclearmask.com/updates/clearmask-receives-fda-clearance-first-fully-transparent-surgical-mask.

3. Adapt your speaking habits

“Over-enunciate, deliberately slow the pace of your speech, and keep each message short. Breathe in and out through your nose. Allow pause time for the patient to process what he/she thinks you said. Validate that they understand – ex: what did you hear me say? What do you understand will happen now? Try not to appear rushed. This is a good quick resource:  https://torontoadultspeechclinic.com/blog/2020/3/30/speaking-with-a-mask-on.”

4. Communicate with hand and arm gestures, or use a form of sign language to help convey your meaning

“We recommend simple but consistent (repeated) gestures and the use of referential pointing – that means pointing to objects or parts of the body that you are talking about. By consistent gestures, I mean that you should use the same gesture for particular words (such as, yes/no, okay, pain medicine, hot/cold, tired, turning/repositioning in bed) repeatedly to avoid confusion. We recommend posting a sign at the bedside with frequently used gestures and their meanings (sometimes patients have idiosyncratic gestures) so that others will use the same lexicon or “gesture dictionary.” Family members may be able to help identify meanings for individual gestures or expressions.”

5. Use audio and video technology to help patients stay connected with loved ones

“Make use of video conferencing and messaging with family members. Have families share photos or pre-recorded video messages. Make sure to speak to the patient about family, pet(s), and his/her interests outside of the ICU. Find the patient’s music preference and make use of patient-controlled music listening (see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683448/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3905330/).”

6. Follow some basic communication “dos and don’ts”

Dr. Happ’s list:

  • Do get the patient’s attention, make and maintain eye contact for as much of the interaction as possible.
  • Do establish a clear Yes-No signal with the patient (ex: head nods – shake; thumbs up – fist closed; eye blinks – eyes shut tight).
  • Do post the patient’s Yes-No signal and communication plan (tools, favorite topics, common gestures) at the bedside and pass this info on in shift handoffs and interdisciplinary rounds.
  • Do have communication supplies (paper, marker, clipboard, communication boards) ready at the bedside anticipating the need.
  • Do always confirm or validate your understanding of the patient’s message.
  • Don’t assume that patients who are quiet or have eyes closed have nothing to communicate. The eyes closed behavior may be their way of coping.
  • Don’t encourage patients who are orally intubated with an endotracheal tube to mouth words. This action is can cause bronchospasm and airway irritation.
  • Don’t assume that you can lip read a patient’s silently mouthed words with high accuracy. Lip reading is a difficult skill and prone to misinterpretation. For example, a request for “pants” was interpreted as “pain” and the patient received unnecessary sedating narcotics. A patient tried to tell his nurse about a problem with the “urinary bag” but the nurse walked away thinking he said, “you are bad.” The YouTube videos that replace nonsense words in politician’s speeches are evidence of the dangers of lip reading. If you must lip read, always confirm your understanding with the patient.

If you are working with COVID-19 patients, see this page on Patient-Provider Communication.org:  https://www.patientprovidercommunication.org/covid-19-tools/supporting-communication-with-patients-who-have-covid-19/.

Dr. Mary Beth Happ, PhD, RN, FAAN, FGSA, is the Nursing Distinguished Professor of Critical Care Research and Associate Dean for Research and Innovation at The Ohio State University College of Nursing. Dr. Happ’s research focuses on improving care and communication with communication-impaired patients.

Koren Thomas
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