Strategies to Enhance Provider Communication During the COVID-19 Experience

For the past month, I’ve had to face COVID-19 from a very personal vantage point. Having two family members, each in separate hospitals in my community, and both on ventilators, each day has brought tremendous challenges. Since visiting hospitalized patients is not an option, I’ve had to rely on daily phone calls from two different healthcare teams. As “the nurse in the family,” I’m charged with passing along information to the family in order to minimize multiple calls into the ICU.

What has really become apparent to me over the past few weeks is the wide variation in communication styles from nurses and medical providers. Some communications are detailed and thorough, with a calmness that invites questions and the ability to connect, while many others are short and sparse; leaving me with the impression that I was clearly an interruption to their day.

I have no doubt that these front-line providers are fatigued and even frightened about their own well-being and that of their families. In some cases, providers are overwhelmed with feelings of personal responsibility. My guess is many have begun second guessing their clinical skills as they face a new disease where rapidly emerging treatments and care guidelines are being shared in the annuls of social media rather than traditionally trusted peer-reviewed literature.

I started to put myself in their shoes, imagining what it would be like to return to critical care nursing after being away from bedside care for over 10 years. Would I be any better in terms of empathy and compassion over the telephone? I had to be honest with myself and admit that I probably wouldn’t be much different. I knew I would certainly be sympathetic, but empathy and sympathy are two separate ways of listening and responding.   

Does that make me a bad nurse I thought? I came to the conclusion that no, it doesn’t. Critical care workers are trained to be “fixers.” We see a problem, and race to solution. In our traditional forms of education and training, there isn’t a lot of time spent on developing empathetic listening skills.

That’s why I was so happy to learn about Empathetic Communication Training for healthcare professionals using a model called CANDOR (Communication and Optimal Resolution), developed in 2009 under a grant from AHRQ.

CANDOR Model 

The CANDOR model was initially developed under the Patient Safety and Risk Management domain to encourage clinicians to break down the “wall of silence” due to fears of shame and blame and potential litigation when a patient safety event or medical error occurs. It has been adapted for the COVID-19 pandemic to help clinicians sharpen their skills in open and honest communications with patients and their family members when faced with the trauma and tragedy brought on the by COVID-19 virus.

More importantly perhaps is that the model supports peer-to-peer connection, which is vital to help front line care providers deal with the extreme stress that they are facing daily. The CANDOR model training begins with an exercise on sympathy versus empathy.

The Problem with Sympathy

Sympathy, which is based on feelings of care and support whenever others are in pain or suffering, is often accompanied by platitudes and “silver lining” phrases, such as saying to someone who just lost their spouse “well at least you had 30 great years together.”

Sympathy, particularly among healthcare providers is often accompanied by “one upper” comments, such as saying to a colleague who is describing the horrible shift they just had, “well you think that’s bad, at least you didn’t have to intubate eight patients in a row this morning.”

The problem is that sympathy paradoxically drives disconnection between two people and rarely results in feeling better when under stress.

The Difficulty of Empathy

In contrast, empathy depicts the understanding of the feelings of others in the absence of judgement or placation. Empathy, or “feeling with others” creates connection, which has been shown to make people feel better when they know their feelings are unconditionally acknowledged and understood.

Empathetic listening is often difficult for many healthcare providers. It requires the courage to be vulnerable, without rushing to fix the problem directly, which is something we’re hardwired to do. Rather it requires that we come from a stance of solidarity, curiosity and support.

Techniques such as reflective listening, acknowledging and naming the feelings, and an expression of regret about the situation are challenging when having to deliver bad news to a family and even more challenging over the telephone, but will go a long way in helping ease the trauma for a patient or family member.

For a short and humorous illustration of sympathy vs. empathy see Its Not About the Nail. 

Three Tiers of Empathetic Communication

The training model supports three tiers of empathetic communication for healthcare workers.

Tier 1

The first is at the local or unit level. This is practiced by colleagues during a daily huddle, or in a one-on-one with a trusted colleague. Informal peer-to-peer support when dealing with the stress of losing a patient or the fear of bringing this disease home to your kids, for example, can be more effective with empathetic listening.

Tier 2

The second is trained peer-to-peer support by Patient Safety, Risk Management officers and other trained individuals to provide one-on-one crisis intervention, group facilitation and investigation of the event if indicated.

Tier 3

The third tier is an expedited referral network, with referrals to chaplain services, psychologists, social workers or employer assistance programs. In times of the COVID-19 pandemic, all three levels of support can even be provided via remote viewing, such as Zoom or Webex when face to face interaction isn’t possible.

CANDOR Resources

I leave you now with some resources that may be of interest to you and your teams. First, I hope you’ll find a few minutes to review the presentation by Timothy McDonald MD, JD and Andrew Furman, MD, MMM, FACEP recently provided in a free webinar sponsored by ECRI. Click here to watch the presentation. For more information about CANDOR, click here.

Whether you are providing direct patient care, or supporting those that do, I thank you for the work you are doing. If you, like me, are supporting others stricken by this horrible virus, you might find this information helpful in your own communications with friends and family. I know I did. Stay strong. Stay healthy. Stay connected.