key: cord-0904403-tvq34lao
authors: Wittenberg, Elaine; Goldsmith, Joy V.; Chen, Chiahui; Prince-Paul, Maryjo; Johnson, Renee R.
title: Opportunities to improve COVID-19 provider communication resources: A systematic review
date: 2021-01-09
journal: Patient Educ Couns
DOI: 10.1016/j.pec.2020.12.031
sha: eeee080bf7c1c36fded574f669dc147e7c7bbf86
doc_id: 904403
cord_uid: tvq34lao

OBJECTIVE: Communication related to COVID-19 between provider and the patient/family is impacted by isolation requirements, time limitations, and lack of family/partner access. Our goal was to determine the content of provider communication resources and peer-reviewed articles on COVID-19 communication in order to identify opportunities for developing future COVID-19 communication curricula and support tools. METHODS: A systematic review was conducted using the UpToDate clinical decision support resource database, CINAHL, PubMed, PsycInfo, and Web of Science. The grey literature review was conducted in September 2020 and articles published between January-September 2020 written in English were included. RESULTS: A total of 89 sources were included in the review, (n = 36 provider communication resources, n = 53 peer-reviewed articles). Resources were available for all providers, mainly physicians, and consisted of general approaches to COVID-19 communication with care planning as the most common topic. Only four resources met best practices for patient-centered communication. All but three articles described physician communication where a general emphasis on patient communication was the most prevalent topic. Reduced communication channels, absence of family, time, burnout, telemedicine, and reduced patient-centered care were identified as communication barriers. Communication facilitators were team communication, time, patient-centered and family communication, and available training resources. CONCLUSIONS: Overall, resources lack content that address non-physician providers, communication with family, and strategies for telehealth communication to promote family engagement. The gaps identified in this review reveal a need to develop more materials on the following topics: provider moral distress, prevention communication, empathy and compassion, and grief and bereavement. An evidence-base and theoretical grounding in communication theory is also needed. PRACTICE IMPLICATIONS: Future development of COVID-19 communication resources for providers should address members of the interdisciplinary team, communication with family, engagement strategies for culturally-sensitive telehealth interactions, and support for provider moral distress.

Communication resources were included if they were published specifically as a COVID-19 resource, included communication with patient/family, and available as print material. Video and webinar links, connection/picture aids, decision-making tools, public message campaigns, letter to patients/residents, hospital communication checklists, phone scripts for assessing symptoms, and patient education materials were excluded from the review. Resources were entered and organized into Excel and were listed by title, the developing organization, communication topic or goal, and specific focus of the resource.

This review also aimed to explore peer-reviewed articles on COVID-19 communication. To capture this breadth of material the authors decided to include all primary research of any design (qualitative or quantitative or mixed methods), reviews and case studies, editorials, commentaries, and opinion pieces. Inclusion criteria included original articles in journals with a peer-reviewed process, published between January 1, 2020 -September 1, 2020 that specifically discussed COVID-19 communication including: Provider, Patient, and Family needs and issues for COVID-19 care and Provider, Patient, and Family views or experiences during COVID-19 care. The search was restricted to English language, studies involving adult patients and family members aged 18 and over and did not include studies from developing countries where care settings differ significantly from the US.

Two authors (EW and JVG) performed the grey literature search over a two-day period. These same researchers also conducted a screening of peer-reviewed articles by reviewing title and abstracts independently. Through open discussion, coders reviewed differences in coding to reach consensus. All disagreements were resolved with 100% agreement by both coders. Reasons for exclusion or ineligibility were recorded.

First, data from each provider communication resource were extracted into an Excel database. Items for each extraction included reference details (URL, name of organization creating resource), communication context (face-to-face, telehealth), resource type (conversation guide or summary document), communication approach (general or proactive planning before COVID-19 diagnosis), provider audience (physician, nurse, all healthcare providers), intended recipient (to improve communication with patient, family, or both), and whether or not the resource included example clinician statements and questions (yes or no), example questions asked by patient and family, and example responses to patient/family questions. Provider communication resources were assessed for quality using the six domains of best practices for patient-centered communication that identifies role and skills within each domain [14] . Total patient-centered communication scores were calculated based on whether or not best practices were present for role and skill. Two researchers (EW and JVG) independently assessed patient-centered communication domains and resolved differences through iterative discussions.

Second, data from peer-reviewed articles were extracted by one researcher (EW) and checked for accuracy and completeness by the second (JVG). The following information was extracted for each paper: author, journal, article type (summary, research study, or personal narrative), authors' primary clinical expertise (physician, nurse, social worker, other), whose experience was represented (patient, family, or healthcare provider). Quality was assessed by determining whether or not resources were provided (yes or no), recommendations were evidence-based, and whether or not a theoretical framework was referenced to support article content.

Using a three-stage thematic synthesis [15] , authors (EW, JVG) engaged a transparent summary of existing research. In this approach, we first implemented a line-by-line text coding per article, then developed descriptive themes, and ultimately generated analytical themes. The first stage included reading and re-reading the sample (EW, JVG) until article fluency was achieved. A line-by-line coding of the results sections completed the first stage. Moving into the second stage, we sought similarities and differences across line-by-line codes to group ideas and build descriptive themes. In the final stage of thematic synthesis, these descriptive themes were incorporated into synthesized findings that ultimately produced analytical themes. Analytical themes were determined based on the frequency and relevance of codes. Consensus on these generated themes was achieved via iterative discussions between authors. 

Thirty-six COVID-19 provider communication resources were located through the systematic search of grey literature. Documents originated from 22 organizations. Table 1 summarizes provider communication resources included in this review. The sample represented both conversation guides [16] [17] [18] 20, 21, [23] [24] [25] [26] 28, [30] [31] [32] [33] [34] [35] [36] 39, 42, 43] (n = 20) and summary documents [19, 22, 27, 29, 37, 38, 40, 41, [44] [45] [46] [47] [48] [49] [50] [51] (n = 16) and primarily provided information on face-to-face communication [16, 17, [19] [20] [21] [22] 24, 24, 25, 26, [28] [29] [30] 33, 35, 40, 45, 49, 50] (n = 18) or communication in either telehealth and face-to-face encounters [23, 32, 34, 36, 41, 44, 47, 48] (n = 8). Communication specific to telehealth encounters were also identified [18, 27, 31, 38, 51] (n = 5). The majority of resources targeted healthcare providers generally (n = 19), with nine resources specifically targeting physicians [16] [17] [18] 20, 22, 24, 26, 31, 33] and two resources specific to nurses [45, 48] . Among all resources the most common goal was to improve communication with patients [16] [17] [18] [19] 22, 23, 25, [27] [28] [29] [30] [31] [32] [33] [34] 43] (n = 17), followed by communication with both patient and family [20, 21, 24, 35, [31] [32] [33] [34] [35] [36] [38] [39] [40] [41] [42] [44] [45] [46] 48, 50, [45] [46] [47] [48] [49] [50] [51] (n = 16). Four resources [26, 37, 47, 49] were available for communication with families specifically.

Twenty-one resources provided a general approach to COVID-19 communication [ and fifteen resources provided a proactive approach aimed at addressing decision-making prior to a COVID-19 diagnosis [16, 17, [19] [20] [21] 23, 24, 26, 28, 31, 32, 34, 36, 43, 46] . Thirty resources included examples for clinicians and were most likely to provide example clinician statements [16,20,21,23-28,30-36, 38-46,50,48-51] . Three resources [37, 47, 49] did not provide example statements or questions and only two resources provided example questions asked by patients or family [44, 46] .

Sixteen resources focused communication on care planning. These resources included ways to elicit patient preferences [16, 17, 21, 32] and conversations to select treatment options [28, 29] . One resource addressed selecting options and patient well-being [19] . General goals of care discussions were addressed in three resources [26, 34, 36] ; two resources centered on choosing a proxy [39, 41] , advance care planning [23, 43] , and prognosis discussions in the intensive care unit [24] . One resource addressed discussing limited resources and treatment options with family [20] .

Seven resources included content that addressed working with families [44, 47] , including family assessment [48] , family meetings [45] , learning about family concerns [37] , and communicating policy changes and updates [22, 49] . Virtual communication in telehealth platforms was the primary emphasis in six resources which highlighted how to open and close telehealth visits [18, 51] , topics to discuss [27, 31] , and telehealth guide for tele-chaplaincy services [38] . Four resources emphasized general provider communication best practices [42] , including plain language materials [46], addressing racism [25] and cultural sensitivity [30] . Communicating about dying was present in four resources which focused on removing the ventilator [35] and what to say to a family when a patient is near death [33, 50] . One resource was a general COVID-19 communication summary document for chaplains [40] .

Content of each resource was compared against the six domains of patient-centered communication practices defined in terms of role and skill (Supplemental Table 1 ). Within the best practice definitions, only four resources scored 75% or higher [19, 31, 36, 42] , followed by 18 resources scored between 50-74%, and 12 resources scored 25% or less. The average score was 38%.

Fifty-three articles focusing on COVID communication were identified ( Table 2 ). The most common publication type was an article summary where communication was emphasized, defined, or discussed as a key element of the COVID-19 context. Five personal narratives were also included: one article summarized a doctor's experience as a COVID-19 patient [88] and four articles discussed the ways that physician communication with patients and families has changed pre-COVID to now [71, 76, 81, 96] . Finally, the sample included three research studies: an editorial included findings of a survey of 376 healthcare providers empathic attitudes and psychosomatic symptoms that concluded that clinician's higher empathy exposed them to more psychological suffering [56] ; qualitative interviews with 9 families about challenges in palliative care interventions [62] ; email or telephone interview with 8 physicians and 48 cancer patients that summarized 8 oncology-specific COVID-19 scenarios which patients responded to with anger, fear, and anxiety [68] .

The articles were published in the United States (n = 41), United Kingdom (n = 5), India (n = 2), Canada (n = 2), Singapore (n = 1), Australia (n = 1), and Israel (n = 1). The majority of authors were physicians (64%), followed by nurses (13%), research groups or multidisciplinary research teams (10%), social workers (5%), and other healthcare providers (8%). All but three articles described the communication experiences of physicians (94%). Communication resources or references to resources were provided in 58% of articles, with less than 13% providing an evidence-base or theoretical framework for recommended communication strategies.

A variety of communication topics were covered in the articles, with the most prevalent topic a general emphasis on patient communication (25%) where lessons learned were highlighted [59, 64, 71, 75, 80, 92] , barriers [96] and resources [58] shared culture humility [61] and equitable care [63] addressed, and communication in palliative care settings emphasized [62, 65, 101] . Goals of care discussions and telehealth were the next most common communication topics (13%, respectively). Recommendations for goals of care discussions were highlighted [52, 97, 77] and included end-of-life context [78] , dialysis decision-making [79] , family-centered care [70] , and diabetes [73] . Published articles about telehealth focused on use in the intensive care unit [83] , surgery [84] , cancer care [74, 76, 104] , and palliative care [77] and centered on social connectedness [57] .

Empathy and compassion were the next most common communication topic (11%) with an emphasis on staying connected to patients [81, 94, 102] by treating mind, body, and spirit [89] in response to the lack of nonverbal communication [93] . This challenge was underscored by one physician's personal experience [88] . Grief and bereavement were also a central communication topic in 10% of the sample, with articles addressing communication with family [72, 82] , bereavement risk factors [95] , types of grief [103] , and ways to mitigate fear and suffering [54] .

There were four articles each in the area of prevention, prognosis/end-of-life care, and moral distress. The clinician's communication role was described as part of prevention efforts to help the public manage the overflow of education [66, 99] , with a specific focus on the pharmacist's role ( [60] and cardiac care [98] . Barriers to end-of-life care [68, 58] were described, with one article addressing cancer care settings [99] and another offering a prognostic communication for clinicians [69] . Leadership [86] , ethics [53] , and interprofessional communication [91] were central to discussions about communication and ethics and how they influence symptoms of moral distress [56] . Finally, the sample included two articles on advance care planning [55, 67] .

Six analytical themes with corresponding subthemes identifying communication barriers were established: reduced communication channels, family/partner cannot be present, time, burnout for providers, telemedicine, and reduced patient-centered care. Subtheme frequencies were highest within themes of family/ partner cannot be present (23 articles), reduced patient-centered care (18 articles), and reduced communication channels (17 articles). Increased anxiety and fear for family made worse by isolation (7 articles) was the most frequent subtheme under the theme heading of family/partner cannot be present. Complementing that finding, isolation increasing fear and anxiety for patients (6 articles) was the most common subtheme under the reduced patient-centered care theme heading. Personal protective equipment interrupting verbal messages and nonverbal communication was the most frequent subtheme (10 articles) under the theme of reduced communication channels. Table 3 summarizes the six communication barriers. The most common communication barrier during COVID-19 pandemic is that patients and family members could not recognize the face and voice of their healthcare providers due to masking and the use of personal protective equipment (PPE) [59, 71, 75, 76, 80, 81, 84, 93, 96, 100, 101] . Frontline health workers in Italian emergency units in March 2020 experienced reduced communication channels resulting from masks, goggles, and face shields and struggled to recognize faces and voices [59] . Physicians in Switzerland interacted with elderly patients with hearing aids who had difficulty understanding masked voices [93] . A second communication barrier during the COVID-19 pandemic is that patients are anxious and fearful because they are left alone to face illness and their family cannot be physically present [52, 53, 58, 64, 73, 77, 79, 82, 83, 85, 88, 89] . For example, COVID-19 patients with a diagnosis of end stage renal failure were challenged to make dialysis decisions without their family members present to help comprehend language and provide emotional support [79] .

Running out of time was the third most common communication barrier during the pandemic [55, 59, 69, 70, 95, 97] . Even for providers who have a deep understanding and experience of communication with the patient/family, they are overworked and lack the time to talk to the patient/family in new situations presented by the pandemic [55, 59] . During the pandemic, less completion of advance care planning (ACP) prior to hospital admission was identified and resulted in prolonged grief because families were not allowed to see their loved ones in the midst of active dying or upon post-mortem [95] . The fourth communication barrier is an intense emotional impact on patient/family and providers [56, 80, 86, 87, 91, 99, 100, 103] . Witnessing high numbers of suffering/deaths in a short period of time brought complicated grief for providers during COVID-19 pandemic [103] . Prestia (2020) suggests truthful, mindful and relevant communication for nurses [86] Nurse Leader, Summary Nurse

Moral distress Offers suggestions on staying resilient and upholding one's moral obligations during COVID- 19 Raftery, Lewis, Cardona [87] Gerontology, Summary Nurse Provider Advance care planning Proposes nurse-led and allied health-led ACP discussions to ensure patient and family inclusion and understanding of the disease prognosis, prevention of overtreatment, and potential out comes in crisis times Ramachandran [88] Anesthesia Reports, Personal Narrative Physician Patient Empathy and compassion To present a junior doctor's view of how COVID-19 was managed by the health system and a personal view of his COVID-19 experience Rathore, Puneet, et al [89] Indian [91] Headache, Summary with scenarios Physician Provider Moral distress To describe 11 scenarios of unhelpful and dysfunctional messages heard by the authors and their colleagues during the COVID-19 pandemic when they talk with COVID-19 patients and their families to minimize the negative impact of moral distress [86] .

Telehealth offers a pathway to connect COVID-19 patients and their family members, especially when social distancing and isolation are barriers to care delivery. However, telehealth itself can become a communication barrier [57, 70, 74, 82, 100, 104] , and providers should not solely rely on telehealth when communicating to patient/family. For example, for patients and their family members who live in rural areas without reliable internet access, providers should prioritize patient/family's needs and enhance engagement during communication in each encounter [70] . Telehealth created an extra layer of barriers when communicating with family members regarding medical interventions, the consequences of those decisions, and subsequent transition to end-of-life care because families needed constant and continual real-time discussions in order to comprehend unfolding medical information [82] .

The last communication barrier was decreased patient-centered care [62] [63] [64] [65] [66] 78, 79, 81, 85, 89, 94, 98, 100] . Due to resource strain and the need to protect society from the impact of COVID-19, providers may not be able to provide patient-centered care [65] . For example, in addition to information of COVID-19 treatment, providers should provide COVID-19 patients and their families with clear and culturally sensitive information about how to take care of themselves to quarantine or self-isolate [63] . Table 4 summarizes communication facilitators.

In this review, peer-reviewed articles and provider resources were limited to information about face-to-face interactions and focused primarily on physician-patient communication. Articles predominantly highlighted the connection between physician and patient and resources were primarily for physician audiences. However, patient communication is often compromised or not at all possible due to advanced COVID-19 disease processes and findings from this study demonstrate that COVID-19 communication barriers pertain more to communication with family. Few provider resources reviewed in this study focused on communication with families, with even less content available for telehealth interactions.

Despite the missing content in provider resources to support family communication, family-centered communication was empirical evaluation [114] . Resources and tools are needed to address provider stress from overloaded work and exposure to COVID-19 without PPE. Research has shown that there are no major differences in the prevalence of burnout between physicians and nurses and improving communication skills is one way to reduce symptoms of burnout [115] . Findings here highlight team communication as a communication facilitator. Notably, physicians play an important role in patient care and establishing organizational culture for collaboration with other physicians and team members [116] . Finally, the amount of materials available in the grey literature demonstrates the immense need for COVID-19 resources for healthcare providers which was further evidenced by details of the communication barriers in peer-reviewed articles. However, there remains a lack of evidence-base or theoretical framework for communication resources and information summarized in peerreviewed articles. Best practices for patient-centered communication were primarily missing in communication resource content and peer-reviewed articles rarely included a summary of evidencebased work for communication recommendations or reference a theoretical framework. As we continue to learn more about COVID-19 and adjust to communication changes in the clinical setting, future work on understanding interactions about COVID-19 should be grounded in communication theory.

Gaps exist within provider communication resources and peerreviewed accounts of the COVID-19 communication context. A comparison of topics addressed in provider resources and peerreviewed articles demonstrates a need to develop more materials on provider moral distress, prevention communication, empathy and compassion, and grief and bereavement. Of significance is the lack of content (research or resource) that addresses nurse experiences and needs, communication with family, and telehealth interactions that promote family engagement and cultural sensitivity.

Three important findings shape future development of communication support for frontline providers working in any health crises (e.g., COVID-19, Ebola, SARS). First, the majority of sources in this review were physician-centered. Communication strategies demonstrated a specific focus on topics typically discussed and initiated by the physician and did not always include ways to respond when topics are initiated by patient/family, which is a more common communicative role for nurses, social workers, and other healthcare team members. Second, there continues to be a Table 4 Facilitators for COVID-19 communication identified from peer-reviewed articles.

Main themes Subthemes lack of evidence-base for communication support materials. Both provider communication resources and peer-reviewed articles focused the majority of content on care planning, goals of care, and general communication practices from personal and institutional experiences. More research is needed to evaluate whether these 'best practices' are also effective for patients and families; current materials reflect only the voice of the provider (namely the physician) and there is a need to learn more about what is comforting for patients and families. Finally, it is evident that telehealth interactions will continue to be more widespread. As providers utilize new technology, more work is needed to determine best ways to engage patient and family in virtual environments.

Research reported in this publication was supported by the Archstone Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Archstone Foundation.

The authors report no declarations of interest.

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Stage Protocol for goals of care [79] Checklist for video calls

PPERV (Preparation, professionalism, empathy, respect, virtual physical exam) [84] "Trustful, mindful, relevant, sensitive communication

ABC (Attend mindfully, Behave Calmly, Communicate Clearly)

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Crisis symptom management and patient communication protocols are important tools for all clinicians responding to COVID-19

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Three reasons to focus on patient and family engagement during the COVID-19 pandemic

Family-centered care during the COVID-19 era

The role and response of palliative care and hospice services in epidemics and pandemics: a rapid review to inform practice during the COVID-19 pandemic

What should palliative care's response be to the COVID-19 pandemic?

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Nursing patients with chronic critical illness and their families: a qualitative study

Oncology nurses' communication challenges with patients and families: a qualitative study

National Institutes of Health COVID-19 Treatment Guidelines Panel, Coronavirus Disease, (COVID-19) Treatment Guidelines

What is health systems responsiveness? Review of existing knowledge and proposed conceptual framework

Best practice" for patient-centered communication: a narrative review

Methods for the thematic synthesis of qualitative research in systematic reviews

COVID-19 Conversation Guide for Inpatient Care

COVID-19 Conversation Guide for Outpatient Care

COVID-19 Telehealth Communication Tips

COVID-19 Recommendation AId

COVID-19 Conversation Guide for Crisis Standards

COVID-19 Conversation Guide for Long-Term Care

A Physician's Guide to COVID-19

Advance Care Planning Script

Communication Skills for Bridging Inequity v2

Goals of Care COVID Script

Patient Priorities Care in an Age-Friendly Health System Telehealth Guidance for COVID19 Communications

Honoring Previously Determined Preferences for Medical Care

Medical Priorities for Treatment Options

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Proactive Call to Patients With COVID at Home Script

Proactive Care Planning for COVID-19

Saying Goodbye to a Dying Familiy Member Over the Phone: Conversation Script

Respecting Choices, Introducing and Scheduling Proactive Care Planning

Communication Skills for COVID-19: Patient Dying Despite Critical Care Support

COVID Ready Communication Playbook

Social Work Hospice & Palliative Care Network, Working With Families Facing Undesired Outcomes During the COVID19 Crisis

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CALMER Goals of Care: A Discussion Guide

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Academy of Communication in Healthcare, COVID-19 Communication: Quick Tips to Connect

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Communication Guide for Nurses and Others During COVID-19

Person-centered Guidelines for Preserving Family Presence in Challenging Times

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Communication strategies to mitigate fear and suffering among COVID-19 patients isolated in the ICU and their families

Communication skills in the age of COVID-19

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Physical distancing with social connectedness

Crisis symptom management and patient communication protocols are important tools for all clinicians responding to COVID-19

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Introducing the Video call to facilitate the communication between health care providers and families of patients in the intensive care unit during COVID-19 pandemia

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Competencies to promote collaboration between primary and secondary care doctors: an integrative review

We thank Adele Dobry and Jennifer Masunaga, Librarians at California State University Los Angeles, who assisted in designing the literature search strategy.