By Dr. Seleem R. Choudhury

Interpreting facial cues is a central component of effective communication. In his 1865 book, Expression of Emotions in Man and Animals, Charles Darwin argued that our brains are able to extract a tremendous amount of subtle detail from just a glance. Our fascination with the face begins at birth, and as adults we remember faces better than any other object (Darwin & Prodger, 1998).

In the healthcare field, clinicians use facial expressions as a part of good therapeutic communication to show empathy, create understanding, and alleviate anxiety (Kujala, Somppi, Jokela, Vainio, & Parkkonen, 2017).  But in a time where face masks are the requirement for clinicians and patients alike, our reliance on facial cues to communicate well can be a hindrance. It is difficult to be certain you are communicating effectively and picking up on facial expressions that indicate a patient’s well-being while wearing a face mask. Yet, clinical staff are discovering ways to maintain connection with patients and create understanding to continue to provide compassionate care.

Challenges to facial communication while wearing a face mask 

Building trust.

Patients share honest, confidential information about their health, well-being, and environment because they believe healthcare professionals are trustworthy. In fact, recent surveys consistently show that nurses are the most trusted profession.  That trust is based on how authentic and present we are to the patient, and we communicate that presence and attention through our facial expressions (Nuttall & Pezaro, 2020).

A 2013 study found that when doctors wear a face mask during consultations, this has a significant negative impact on the patient’s perception of the doctor’s empathy and diminishes the positive effects of relational continuity.  Establishing trust between medical staff and patients is more challenging if they can’t see our faces.

Determining patient well-being.

When you are working in the Emergency Department (ED), you have to be mindful of the fact that while you were planning to be in the ED that day, the patients you are treating did not plan to be there. They have an acute need, and that will ramp up their anxiety level.  As care providers, we discern the measure of a patient’s anxiety through facial cues (Wenze, Gunthert, & German, 2012), and then take steps to relieve it. Face masks hide these expressions and create difficulties in recognizing and addressing fear or anxiety.

Furthermore, we are asking many questions about our patients’ lives at home from suicidality, alcohol, drug use to if they feel safe at home, as a matter of course in our ED.  We ask these simple questions to understand whether someone is being abused or trafficked, whether they’re able to pay their rent, or if they’re having mental health issues, to list a few examples.  These are essential components of a patient’s well-being, and we rely on their body language and facial expressions to pick up on cues that go beyond their verbal response (Fischer & Manstead, 2008).  If a patient is wearing a face mask, however, nurses and providers are limited to observations of patients’ eyes, eyebrows, and forehead.

Creating understanding.

Face masks can create a breakdown in communication and significantly impair social relations (Chung et al., 2016; Hung, 2018; Wong et al., 2013).  Our brains are designed to use visual cues, including watching the speaker’s lips move, to understand speech (Blanch-Hartigan, Ruben, Hall, & Mast, 2018). This visual information is unavailable while wearing a mask. 

Issues also emerge for those who have hearing impairments or hearing loss, as face masks affect the clarity and volume of speech (Iezzoni, O'Day, Killeen, & Harker, 2004).  As healthcare providers, we have to ensure that we are heard and understood for the health and safety of the patient, and face masks present a challenge to that goal. 

Medical staff well-being.

While essential for preventing the spread of disease to clinicians, the constant use of face masks by healthcare professionals can negatively impact their well-being (Johnson, 2016).  A 2016 study found that while “respirators may appear to be rather simple, they can interfere with respiration, vision, communications, feelings of well-being, personal procedures such as eating and sneezing, and [the proper use of] other equipment.”

Face masks and other facial PPE create a buildup of lactic acid, which generates extra carbon dioxide that can be exhaled. This build-up of carbon dioxide acts as a respiratory stimulant that leads to hyperventilation, or harder and deeper breathing.  Additionally, the inability to eat or drink to prevent self-contamination while wearing the face mask can lead to dehydration. Wearing the N95 is also very harsh and unforgiving on the face and will often leave the wearer with heavy indentations and skin breakdowns.

Communicating effectively while wearing a face mask

Unquestionably, wearing a facial personal protection N95, face mask, glasses and hair covering thus revealing only the eyes, eye brows and a sliver of forehead presents challenges to communication and developing a relationship with patients (Braga, 2018), but medical staff can employ several strategies to continue to offer compassionate care—even with facial PPE.

Make eye contact.

ED workflow moves pretty swiftly. Under normal conditions, I can be making notes on the computer while facing away from the patient, but still ask questions and communicate through my facial expressions.  While wearing a face mask, though, eye contact becomes more important than ever for building trust, discerning patient well-being, and communicating effectively.

The #1 thing I try to do is be present with the patient. I maintain eye contact to indicate that I am listening and understand what they’re saying, and pay attention to facial expressions. Though most of the face is covered by a mask, the eyebrows and forehead can still be very expressive, showing concern or confusion when knit together, or surprise when raised. Tears in the eyes or the inability to maintain eye contact can indicate anxiety. 

Exaggerate hand gestures.

In addition to making eye contact, I’ve also become more exaggerated with my hands when speaking to a patient.  If I’m trying to be open, I face my hands upward. If I’m speaking more authoritatively, I put my hands downward.  Expressing yourself with body language can help create understanding even in the absence of full facial cues. 

Re-introduce yourself.

With masks, headbands to cover our hair, glasses, N95s, face shields, gloves, and gowns covering our IDs, we all look the same. Re-introduce yourself with name and title each time you enter a patient’s room. Some facilities have staff write their names on their headband, or display pictures of themselves (while smiling) outside their PPE to help differentiate themselves and feel more human to the patient. 

Smile.

Some people hide behind their face masks, thinking the patient can’t see their face, so there is no need to smile.  But there are all kinds of studies showing that patients become more anxious when their healthcare providers don’t smile or look away from them.  And these studies were done when patients could see their providers’ entire face! 

Your patients can absolutely tell when you are smiling by your eyes and tone of voice. Your whole mask moves up with your cheeks when you smile.  One provider I work with will even verbalize “I’m smiling.” While that may not be necessary, the extra effort to smile and use humor and conversation to add an element of normalcy will help put the patient at ease.

Check for understanding.

It is essential for Nurses and other clinical staff to ensure that they are understood by their patients, even with the challenges that face masks present to clear communication.  It can be helpful to speak louder or more slowly, but a more effective approach is to focus on greater enunciation.  It’s important that you give plenty of time for the patient to respond. This pause and attentiveness will convey listening but it will also help you to determine if the patient has understood what has been said. 

Additionally, use the marker boards in the patient rooms as a tool to help both you and the patient. Keep the board updated with the names of their nurses or doctors. Write out or demonstrate your instructions, what’s going on in their bodies or with their treatment, or why certain tests are important. Include discharge instructions with details.  Written communication (or drawings) can help medical staff and patients remain on the same page and increase understanding. 

Face masks are a crucial part of preventing the spread of disease, and will be a part of providing and receiving care for the foreseeable future.  While this presents challenges to clear communication and building trust with patients, healthcare professionals can still find ways to communicate effectively and provide compassionate care to those they serve.

References

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Braga, A. R. G. R. (2018). The Impact of the Surgical Mask on the Relationship Between Patient and Family Nurse in Primary Care.

Caissie, R., McNuttn Campbell, M., Frenette, W. L., Scott, L., Howell, I., & Roy, A. (2005). Clear speech for adults with a hearing loss: does intervention with communication partners make a difference? Journal of the American Academy of Audiology, 16(3), 157-171.

Chung, V. C., Yip, B. H., Yu, E. L., Liu, S., Ho, R. S., Sit, R. W., . . . Wong, S. Y. (2016). Patient Perceptions of Expression of Empathy From Chinese Medicine Clinicians in a Chinese Population: A Cross-Sectional Study. Medicine, 95(17).

Darwin, C., & Prodger, P. (1998). The expression of the emotions in man and animals: Oxford University Press, USA.

Fischer, A. H., & Manstead, A. S. (2008). Social functions of emotion. Handbook of emotions, 3, 456-468.

Hawkley, L. C., & Cacioppo, J. T. (2007). Aging and loneliness: Downhill quickly? Current Directions in Psychological Science, 16(4), 187-191.

Hung, Y.-w. (2018). A Study of Barriers to the Wearing of Face Masks by Adults in the US to Prevent the Spread of Influenza: Arizona State University.

Iezzoni, L. I., O'Day, B. L., Killeen, M., & Harker, H. (2004). Communicating about health care: observations from persons who are deaf or hard of hearing. Annals of Internal Medicine, 140(5), 356-362.

Johnson, A. T. (2016). Respirator masks protect health but impact performance: a review. Journal of biological engineering, 10(1), 4.

Kujala, M. V., Somppi, S., Jokela, M., Vainio, O., & Parkkonen, L. (2017). Human empathy, personality and experience affect the emotion ratings of dog and human facial expressions. PloS one, 12(1).

LeMoult, J., Joormann, J., Sherdell, L., Wright, Y., & Gotlib, I. H. (2009). Identification of emotional facial expressions following recovery from depression. Journal of Abnormal Psychology, 118(4), 828.

Nuttall, S., & Pezaro, S. (2020). The value nurses and midwives hold. British Journal of Midwifery, 28(1), 22-22.

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Wong, C. K. M., Yip, B. H. K., Mercer, S., Griffiths, S., Kung, K., Wong, M. C.-s., . . . Wong, S. Y.-s. (2013). Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care. BMC family practice, 14(1), 200.