Nursing Practices Within Telehealth Care: Communication Skills Re-Visited Amidst COVID-19 Pandemic and Beyond

Tayyib, N. A., Asfour, H. I., Lindsay, G. M.^*, Samb, C. & Ramaiah, P.

Faculty of Nursing, Umm Al-Qura University, Makkah, Saudi Arabia

*Correspondence to: Dr. Lindsay, G. M., Faculty of Nursing, Umm Al-Qura University, Makkah, Saudi Arabia.

Copyright © 2020 Dr. Tayyib, N. A., et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 27 June 2020
Published: 09 July 2020

Keywords: Telehealth; Communication Skills; Verbal and Non-Verbal Communication; COVID-19 Distance in Healthcare; Nursing Profession

Abstract
In nursing practices, effective communication is of the greatest importance to promote engagement with patients, playing a central role in enabling quality of healthcare interactions. However, problems raised by patients about their treatment are often found to be rooted in poor communication within their engagement with the healthcare system and healthcare professionals’ interactions. The safety need to minimise direct patient-practitioner contact in the light of COVID-19 has seen rapid growth in the prominence of telehealth care approaches such as video conferencing and greater use of video enhanced telephone calls. Consultations based on the use of these platforms alter the range and perspectives in communication processes taking place within this ‘virtual’ consultation setting. This new environment affects both verbal and non-verbal communication performance for practitioners and patients who may also have family members present during the consultation. This article revises established tenets for effective patient-practitioner communication within healthcare consultations, support from the nursing profession and provides guidance on dealing with challenges in effective communication posed within the telehealth environment. In the aftermath of the COVID-19 crisis many of these newer remote working practices are likely to continue to be part of healthcare practices and policy-makers are advocating that the nursing profession plays a more prominent role in leading policy and practice in future healthcare.

Introduction
The healthcare sector has been mobilised and re-positioned to avoid exposure to COVID-19 and deal with the enormous challenges of delivering effective care and simultaneously protecting staff, patients and their families. Services are being orientated towards new strategies of healthcare delivery based on minimising the risk of spreading infection and triaging medical care to those in most urgent need. These actions are responsive and are informed by strategies, actions and lessons learned from the management of unfolding events in previous crisis situations around the world [1]. The changes are organic and responsive to the nature of the threat as it unfolds.

Reports in the US indicate that usage of telehealth has experienced a massive growth of approximately 400% in response to cancelled healthcare visits and the re-design of existing services to remote mechanisms of delivery [2]. This crisis has accelerated the levels of digitization to help reduce avoidable physical interactions.

For example, the UK healthcare system has seen years of digital evolution take place within weeks. In 2019, less than 1 percent of appointments took place via video link, the vast majority being in person. In nonurgent care it is estimated that less than 10 percent of medical consultations are now proceeding to face-toface meetings. This shift has meant that clinicians must learn how to work effectively and safely in remote clinical practice, and the new normality is likely to retain a significant level of remote working practices [3].

The new normal comprises processes of imagination and reform and will build upon the successful innovations that have been rapidly introduced during the COVID-19 crisis in order to create new and more sustainable, patient-centred development paradigms [3]. Working practices that have been enabled with digital technologies and proven to be effective as ‘virtual’ services will likely continue in an evolving health care system capable of dealing with the new reality of ongoing COVID-19 preparedness. Consumers are interested in telehealth care with over 70% of people surveyed showing interest in using telehealth care in the future [4].

Telemedicine or virtual clinics that were planned for the distant future have now become something of the present, and will need to be incorporated into servicing current healthcare provision. The emergence of telemedicine and virtual clinics will change the milieu of healthcare with increasing numbers of the general public and patients interacting within ‘virtual space’ to manage and receive healthcare treatments. Moreover, the growing number of mobile health applications and wearable digital monitors are empowering individuals to engage in self-care health practices, which can when appropriate, interact and communicate with the other healthcare systems to provide more holistic representations of individuals’ health and health practices [5].

Telehealth Consultations: Nursing and Patient Perspectives
There are a number of definitions of “telehealth”, but the official website of the Office of the National Coordinator for Health Information Technology (ONC) defines telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration” [6]. Such technologies include video conferencing, the internet, the storage and making immediately available imaging data from the cloud, media streaming and various other electronic modes of communication. On the other hand, telemedicine is focussed on delivering remote clinical services but without the diversity of services provided by telehealth. Examples of telemedicine are remote consultations between expert and non-expert health professionals, procedures enabled by using AI technologies and consultations on basic health care using video and audio links.

The new environment of conversation via video and/or voice calls with platforms such as Skype or Zoom rely on effective two-way communication skills encompassing verbal and non-verbal language. Even before the impact of COVID-19 on healthcare practices, training for effective communication skills was recognised as an important part of professional practice. However, ineffective and detrimental communication between staff and patients is still identified as one of the largest factors contributing to complaints raised by patients about poor health outcome experiences [7]. The potential for other confounding factors to interfere with effective communication seems even more likely in the context of tele-communication. Furthermore, the ability to pick up on non-verbal signals, particularly if these are subtle, may be muted or lost altogether.

The general population and future patients will also benefit from being more knowledgeable about health and its determinants in order to engage effectively with new systems of care. Health literacy and the notion of the expert patient are not new concepts, but they now take on a greater importance [8]. The effects are two-fold: first where the need for interaction via technology creates a potential barrier for engagement with health services and in communication between practitioners and patients, and second, being able to use remotely self-health assessments, sample collection or monitoring devices. In order for individuals to have greater insights into their health and effectively navigate, engage and interpret these systems they must have a sufficient level of understanding of fundamental human health and illness, health protection and disease prevention strategies in addition to the basic terminology. Information addressing these needs is widely available at sources such as “Healthline” and “WebMD” among many others applications in the self-help sector for the management of chronic diseases such as diabetes, heart disease, arthritis and the like [9,10]. Although such sources provide interpretation of complex medical issues in generally understandable terms for the lay person, they still require basic knowledge of medical physiology and treatment options and goals [11,12].

Nurses have an important role to play in expanding their health promotion activities more widely to educate patients in managing health and illness and new ways of navigating health services, sources of information and assistance in the use of supportive technologies. Documentation of patient nurse interactions and assessments of consultations will continue to be a component of practice and should be adjusted and streamlined according to the capabilities of the infrastructure facilitating virtual interactions. The management of video and audio data should be addressed as well as connectivity with the system of electronic health records. Some points for consideration in the use of digital health devices and ‘virtual’ communication in clinical practice are:

• System clinical governance, quality assurance, data protection, cyber security;
• Digital communication technology skills and supporting networks and websites;
• Scope of healthcare digital tools: biometrics; diagnostics; well-being assessments and monitoring; ‘wearable probes’ and communication with electronic medical records;
• Templates and protocols for structuring patient nurse consultations, e.g. pre-meeting information sharing; feedback and referral mechanisms;
• Health and digital literacy for users.

Patient Healthcare Feedback
Emphasis on patient-centred care has increased, as have calls for the transparency of data pertaining to patient satisfaction both of which are increasingly important components of risk management and patient safety programs [13]. One important route for patient feedback is through the patient complaints system. It provides a protected communication mechanism for patients and families to provide feedback and/or seek resolution on matters of unmet need or dissatisfaction. In the UK in 2017, National Health Services (hospital and community) received a total of 140,585 patient complaints involving healthcare professionals, with over half of these arising from a combination of general hospital in- and out-patient services [14]. Written complaints, when analysed by subject, revealed that the highest single cause of complaint concerned communication issues at 28,274 (20.1%). This was followed by patient care related to nutrition and hydration at 21,930 (15.6%) and third was ‘Values and Behaviours (staff)’ at 19,287 (13.7%). Therefore, in combination, approximately one third of complaints (33.8%) related to communication failures or discordant staff behaviours/values. These complaints were highest for medical staff (41.1%) and second highest for nursing staff (22.7%).

These findings were endorsed by the General Medical Council (GMC) who reported that the most commonly received complaints related to concerns with ‘investigations and treatment’, problems with ‘communication’, and a perceived ‘lack of respect’ for the patient [15]. Most complaints were noted to be secondary to poor communication [16]. There is increasing evidence beyond complaints themselves, that poor communication and lack of empathy are major causes of adverse events, patient dissatisfaction, and therefore, complaints [17]. Similar categories of healthcare complaints from patients are found across the developed world [18].

In a recent study examining 38 cases of negative patient feedback, a qualitative analysis of written reports identified four areas of communication shortcomings; namely for non-verbal issues: poor eye contact, discomforting facial expression, absence of active listening, lack of respect and empathy [19]. Kee et al. reported that issues arose within elements of verbal communication methods, inadequate quality and quantity of information, insensitive choice of words etc. Such issues are not new and continue to appear in patient complaints [19].

Effective communication is recognised as a vital attribute for healthcare professionals. This is important not only between doctors and patients, but also between doctors and other healthcare professionals. The move towards operating in a virtual clinic setting provides the opportunity to reflect on such weaknesses reported in traditional practice and to be more conscious of good communication practices, as it matters to patients and their perceptions of the quality of their care.

General Communication Goals
Effective new ways of communication in new and complex environments are likely to be one of the biggest challenges requiring the utmost attention because it is at the core of functioning healthcare and education systems. The following four sections outline components of good communication and its purpose.

Communication Point One: General Communication Principles for Good Practice
Authentic meaningful and respectful ccommunication skills are recognised as being achieved when using guiding principles in verbal and written communications that convey truthfulness, credibility and build trust as outlined in the following points [20].

• Use clear, concise uncomplicated words.
• Focus on facts and be cautious with emotive issues.
• Be transparent and consistent with information.
• Genuine and authentic self.
• Relevant, fair and equitable across practice.
• Avoid minimising or speculating on issues.

These principles can guide the construction of clear messages that are not lost in extraneous material or misleading information. Whenever possible information should be framed in positive terms or instructions e.g. ‘dos’ rather than ‘don’ts’, and messages articulated in a steady and consistent manner.

Communication in Teleconference Consultations
Effective communication includes the ability to adapt, to be responsive, and to manage self-awareness during the process of talking and listening. Being an effective communicator in verbal and non-verbal processes is complex [21]. It includes the presence and timing of both verbal and nonverbal behaviours within the context of individual interactions with patients or families [22]. Effective communication includes the ability to adapt, to be responsive, and to manage self- and other awareness during the process of talking and active listening [23]. Additionally, effective communication is not only dependent on the observable behaviours of the practitioner, but also on the behaviours and perceptions of patients and the setting subject and context [24]. However, the essence of effective therapeutic communication should be as close to a face-to-face consultation as possible. Essential elements of effective communication in a patient-healthcare professional interaction are presented in Table 1.

Table 1: Essential Elements of Physician-Patient Communication [25].

Communication Point Two: Essential Elements in Healthcare Communication
It should be acknowledged that skills for operating the new digital video-conferencing platforms also need to be taken into account to ensure that all participants are able to operate compatible systems. Many people may need support and healthcare organisation should recognise potential training needs in digital device competencies. In the higher education sector, recent nursing undergraduate students rapidly transferred to a new virtual learning environment and reported effective engagement and were highly satisfied in the new learning environment (Personal Communication: Dr Nahla Tayyib and Dr Hayam Asfour, Umm Al-Qura University, 2020).

Non-Verbal Communication: Facial Expression
In the context of virtual clinics and/or teleconferences, the face is the main focus for visual communication although non-verbal signals with head movements, upper body and hands may be apparent. Recognition of facial expression is an essential ability for good interpersonal relations and a major subject of study in the fields of human development, psychological well-being, and social adjustment [26]. The recognition of emotion plays a pivotal role in the experience of empathy [27] in fear [28] and in the ability model of emotional intelligence [29]. Additionally, the literature demonstrates that impairments in the recognition of emotional expression are associated with several negative consequences, such as difficulties in identifying, differentiating, and describing feelings. Numerous studies have identified seven basic universally recognized emotions that can be expressed through facial expression. These are anger, disgust, fear, happiness, sadness, surprise and contempt [30]. These expressions are to a large extent under the influence of the voluntary nervous system so moderation of the expression is under the will of the individual. As such expression should be appropriate to situation in order to establish rapport and authenticity.

Non-Verbal Communication: Eye Contact
Eye contact is another major aspect of facial communication serving a variety of purposes. It can help regulate conversations for instance, turn taking, communicate involvement and show interest, manifest warmth and establish connections with others. Actual eye contact in combination with other facial expressions can be used to invite conversation. Lack of eye contact is usually perceived to be rude or inattentive [31]. However, it should be noted that there are cultural differences and norms, for example some Asian cultures can perceive direct eye contact as a way to signal competitiveness or fear [28], which in many situations may prove to be inappropriate. Others lower their eyes to signal respect, and similarly eye contact is avoided in some African countries. However, in western cultures this could be misinterpreted as lacking self-confidence [32,33]. Within a face-to-face consultation there needs to be awareness of the use of eye direction within consultation, and that a balance should be reached which is appropriate for the content and situation being discussed. Although eye contact is considered to be positive in engaging the other person, if too prolonged it can become uncomfortable. In addition, eye expression can communicate more data on mood and reactions to information being given or received, even although it may be changing at a sub-conscious level. So practitioners should try to be aware of their expressions to ensure that they are communicating what they intend and be clear on their interpretation of the expressions from those with whom they are consulting. The video analysis of emotions from facial expressions, eye movements and reactions is currently a developing field of research for the evaluation of non-verbal communication. In the future information of this type is likely to be incorporated in future healthcare records of some consultations and treatments [24,34].

Communication Point Three: Virtual Consultation
Non-verbal communication in terms of facial expression, eye contact and visible body movements have greater emphasis within a video conference setting. In combination with the components of a therapeutic consultation (Table 1), considerations for communications within a video teleconference [23] are outlined in Table 2.

Table 2: Virtual clinic Additional Practice Points in Tele-Conference Communication

As mentioned previously, communication is a two-way process and the patient is usually less practised in the art of communication than the health care practitioner. Moreover, unfamiliarity with the engagement with technology on both the patient and healthcare professional could hamper effective communication or foster misinterpretations. Some guidance has been suggested that can assist patients to effectively participate in health care consultations are presented below.

Strategies to Help Patients Engage in Health Care Consultation
Patients are often not clear on what questions to ask or how to focus their concerns, particularly after much information searching which may have contributed to additional confusion before interacting with a healthcare professional. Designed by health literacy experts, an initiative called ‘Ask Me 3’ has been designed with the intention of helping patients become more participatory when consulting with a healthcare professional. The authors suggest that their simple guidelines provide a critical platform to improve communications between patients, families and health care professionals.

Communication Point Four: Facilitation of Patient Engagement
Ask Me 3^® is an educational program that encourages patients and families to ask three specific questions of their providers to better understand their health conditions and what they need to do to stay healthy.

• What is my main problem?
• What do I need to do?
• Why is it important for me to do this?

By creating an environment in which questions are encouraged from patients, it is more likely for them to become active participants in their health care. Such engagement has been linked to making less mistakes when caring for themselves, positive outcomes and increased patient satisfaction [35]. More information on assisting patients to understand healthcare processes, medical terminology and engagement with services can be provided and an accessible source for further explanation is available at URL https://wiki2.org/en/Health_literacy.

Nurses can help facilitate communication within their consultations with patients through the adoption of practices associated with effective communication as just outlined within a structured framework that includes the four areas of communication considerations outlined in previous sections [36]. The completion process for a meeting is important to allow for any overlooked issues to be raised, future plans confirmed and create a sense of curtsey for the time spent [37]. The usual subtle social cues like closing a notebook or standing up may be missed on screen or appear too abrupt. Becoming more common in larger meeting settings is the use of a hand wave to signal closure in virtual consultations by way of ‘softening’ an awkwardness or abruptness in the closure point [38], and in ‘moderate form’ viewed as a positive body language signal for closure [39].

Nursing Engagement in Emerging Healthcare
Mastery in communication is recognised as a defining quality in the nursing profession [40,41] and consists of dynamic skills sets that allows nurses to successfully enact traditional patient-focussed communication processes (e.g., education, empathy, counselling) while acquiring new communicative skills (e.g., technology, conflict resolution, change management) when interacting both with colleagues and patients [42]. Effective communications skills have long been valued and will continue to be central to professional nursing practice as healthcare evolves in the post COVID-19 era. In recent times, nurses, midwifes and advanced practice nurses have rapidly expanded their practice to lead in COVID-19 response in a wide variety of roles: first responders, teachers and researchers, community and intensive care experts, healthcare coordinators, managers, and mobilizers of resources. Occurring across acute care and community-based healthcare settings and higher education digital technologies to fulfil safe ‘distancing’ guidelines were frequently employed. It has been suggested that there is a need to build on these current new services to develop further, innovative services that maximize the contribution made by nurses and midwives within healthcare and to enable them to work at the ‘top of their license’ [20]. The authors conclude that by leveraging the skills of the global nursing workforce, gaps in public healthcare policy can be addressed and future humanitarian crises predicted and managed in the most effective manner [20]. Therefore, a priority for politicians and global health care leaders is to raise the profile and status of nursing and midwifery and ensure expanded scope of practice in clinical practice, education, research and policy decision-making remain priority target areas [43-45].

Operating within a developing digitally-enhanced health care system will continue to present new learning and practice challenges where refined and relevant communication skills will be of the upmost importance. Effective communication remains a central component of clinical practice using video conferencing as the environment to provide care for patients. The COVID-19 crisis has raised the visibility of nurses’ contributions to the global public [2]. It is hoped that in the aftermath of COVID-19 healthcare nursing will continue to develop its professional scope to meet the emerging health needs of the population and embrace new technologies as a means of providing safety and effectiveness for staff, patients and the general population at large.

Conclusion
A central challenge in delivering safe and effective care to patients amid the COVID-19 crisis necessitated minimising direct patient-practitioner contact. Where possible non-urgent healthcare was deferred and when appropriate consultative care (in some cases diagnostic) was delivered remotely by telephone and video conferencing for non-emergency health care management. In addition to IT proficiency, core skills in communication were fundamental to the effective conduct of these ‘virtual’ healthcare interactions. Key tenets of good communication have been summarised with emphasis on specific challenges when care is being delivered within the context of an electronic digital video platform. Practice delivery should continue to provide recognised patient-professional communication standards and adapt care delivery in the new context.

Bibliography