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Facing the challenge of masked communication

By: Fidelindo Lim, DNP, CCRN

“Can you hear me now?” was the byline of a popular TV ad in the early 2000s for a cell phone company, promising excellent cellular connectivity for life! (Can you imagine?) These days, I am overhearing, with effort, a variation on the theme of auditory loss in public in the advent of the public health mandated mask wearing. At checkout counters, one can see customers leaning an ear to the cashier, with a puzzled side glance, to hear what is being said. Perhaps it’s a minor inconvenience to repeat what was just said, and there is no doubt the plasticity of our brains will in no time adapt to communicating across a plexiglass barrier while wearing a mask. But I wonder how all this is affecting nurse-patient and staff interactions given that the tall order of therapeutic use of self rests heavily on old-fashioned communication sans facial covering?

Any nursing 101 textbook emphasizes the key elements of communication (sender, message, channel, receiver, environment, and feedback), and the importance of non-verbal cues (for example, facial expression) in patient interactions. The pandemic has made “quarantine” and “social distancing” the latest vogue words, but their literal implications have always posed novel challenges in face-to-face communication. Even before the COVID-19 pandemic, a hospitalized patient in airborne isolation was visited less frequently by the staff. The staff’s fear of contagion, the lack of adequate personal protective equipment (PPE), and the no-visitors-allowed policy at the height of the pandemic have greatly contributed to the “isolation” of the patient. From the patient’s perspective, it must be a terrifying experience to see healthcare workers suited in PPE, hear their muffled conversations from unseen lips, and vaguely guess the meaning of squinting or tearful eyes and furrowed brows. For the staff, infection control measures (for example, donning and doffing PPE and multiple hand hygiene practices before one can use a cellphone) have surely affected both the quality and frequency of communication.

Can you see me now?

The technology that allowed nurses and patients to maintain contact with their families during the fevered peak of the pandemic continues to be used today. Virtual visits, telemedicine, and the multitude of social media platforms give a modicum of what might have been in a face-to-face encounter. With continued mandatory masking of healthcare staff, we have somehow become unwitting subjects of an accidental social experiment on masked communication. How is masking going to affect the patient experience? How does it influence empathy? What is the impact of masking on teambuilding? Will masking improve our attention span?

In my role as a nursing faculty, remote teaching is made possible by technology that allows us to Zoom in and out of classes and endless faculty meetings. During Zoom classes, I typically scan the screen, purposely greet a student, and look them in the eye (or look them in the computer camera to be precise). But when the student’s video is disabled, the potential to communicate with our gaze, to connect, is nonexistent. In fact, when the camera is off and the participant does not speak, I am also denied the important social cues derived from the tone of someone’s voice. Teaching to a screen with blank squares with names requires more nervous energy. I tend to speak louder with the fear that my unseen audience might not hear me.

Since you (m)asked

So, how are we going to enhance patient communication in these masked times? The answers are found in the best practices we learned in nursing 101 (again). As every provider knows, at every encounter, always identify yourself while facing the person at eye level and introduce other staffers present. Staff can continue writing their names on the dry erase boards in the room. Some have written their names and role on their PPE, visible to the patient. Healthcare workers can remind themselves to speak clearly, naturally without overemphasis, and using shorter words. Even if your patients cannot see your lips, it’s important to smile as you greet them. Ask them how they feel and be genuinely interested in the answer you’ll hear.

In every encounter, address the patient directly and not their caregiver. Eliminate noise and other distractions and keep the room well lit. It’s best not to talk with the patient from another room. Let the patient use their eyeglasses and hearing aid as needed. A notepad and pen would also be helpful for patients who are mechanically ventilated or severely hard of hearing. For patients who are non-English speakers, optimize use of medical interpreters.

For pediatric patients, it’s suggested that nurses should make an effort to make their voices, eyes and gestures more expressive. It might also be helpful for children to identify their nurse if the nurse wears the same eyeglasses or personalized mask on top of the hospital issued mask.

The ongoing COVID-19 pandemic and its aftermath bring a host of mental health challenges, from new anxieties to exacerbation of depression. These require the staff to be intentional in listening as this is key in truly knowing the patient and in conveying empathy.

The talk of the town

The pandemic will indefinitely take the prime seat in everyday discourse, in and out the hospital. An often-heard conversation starters these days is “I didn’t recognize you with your mask.” In whatever medium, conversation will remain the essence of all human bonds and healthcare relationships, whether or not we are facing a public health crisis. When the mouth or most of the face is covered, it’s hoped that we might get better cues by looking into someone’s eyes. Maintaining meaningful eye contact in patient interaction is important, now more than ever. Masking should not preclude us from continuing to be creative and deliberate in promoting patient-centered communication. I’d like to imagine that years from now, patients and staff will talk about the pandemic, among its many life-altering consequences, as a time when we listened with our eyes and enhanced our emotional intelligence.

Fidelindo Lim is clinical associate professor at New York University – Rory Meyers College of Nursing.


The views and opinions expressed by My Nurse Influencer contributors are those of the author and do not necessarily reflect the opinions or recommendations of the American Nurses Association, the Editorial Advisory Board members, or the Publisher, Editors and staff of American Nurse Journal. These are opinion pieces and are not peer reviewed.

2 Comments. Leave new

  • Fidelindo Lim
    November 6, 2020 4:16 pm

    Thank you so much for reading Alex! Much appreciated!


  • Alex Mustachi
    October 18, 2020 3:29 am

    I wonder how your favorite phrase “Can you imagine?” Without a full face expression sounds like now?
    Great writing. Can you imagine otherwise anyway?

    Your old (very old) friend: mask of the day extravaganza


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