Today, the world is a strange place. The COVID-19 pandemic has likely changed the way you work with clients, particularly as you glove up and use protective face masks.

And, as clinicians well know, patients with a diagnosis of stroke, brain injury, or hearing loss already have communication difficulties. Now they face the additional challenge of trying to communicate with people who are wearing varying levels of face masks and personal protective equipment just to be in the same room as them. These patients will find it harder than ever to hear or understand clinicians through their protective barriers. They’re already anxious and worried about the virus, even if they are not ill. 

With more people wearing masks, and not just in health care settings, we can help our clients overcome this new obstacle by giving them strategies to use when they communicate with people with covered faces.

The problem

During this pandemic, we know we need to maintain “clean hands” by washing and sanitizing. But what about maintaining “clean communication”? Our use of language and gestures requires cleaning as well. Face masks can alter communication by reducing overall speech loudness, muffling speech, and obstructing facial expression. They especially block access to facial features we rely on most for communication—lips, teeth, and tongue—leaving us with only half the picture when we try to piece together a person’s facial expression (see sources). 

With additional background noise—already problematic in various communication settings— speech loudness through face masks only worsens signal-to-noise ratios (see sources). 

We generally provide clinical services without barriers to the face. When face masks obstruct visual cues, we may likely see increased communication stress, fatigue, and anxiety, especially for children, older clients with hearing loss and/or cognitive decline, and many people with hearing loss, generally. 

Children, with or without hearing loss, need good signal-to-noise ratios compared to adults. Older clients with hearing loss and/or cognitive challenges have been shown to require higher signal-to-noise ratios to perform as well as their younger counterparts, and audiovisual information has been demonstrated to be especially helpful as well (see sources). People with hearing loss make up a diverse group, with some wearing personal hearing devices and some using sign language. Obscuring facial expressions and lip-reading cues can only make communication more difficult, even blocking a simple, reassuring smile—a small gesture that can go a long way.

Communication tips

To help ease communication difficulties posed by face masks, here are some ways we can help our patients and clients.

  • Check any devices. If the client has hearing aids or a cochlear implant, make sure the device is in good working order so the client receives the maximum benefit.
  • Use clear speech. Fully form every word and sentence precisely and accurately. Don’t exaggerate or shout words.
  • Use gestures along with verbal expression. For example, hand gestures and other nonverbal movements can accentuate your verbal message.
  • Ask the client how they prefer to communicate, especially if you notice that the mask is already posing difficulty for the patient. Use pen and paper to supplement communication, if necessary. 
  • Wear gloves if the client requires touch as part of their communication. Appeal to other senses that are intact. You may want the client to wear gloves as well.
  • Reduce background noise sources. Because face masks can reduce overall amplitude and attenuate and/or distort certain speech frequencies, reduce competing noise during client sessions.
  • Use personal amplifiers and assistive listening devices to improve signal-to-noise ratio. You can buy an inexpensive device or use a pair of headphones with one of several amplifier apps on a smartphone. 
  • Consider using an automatic speech-to-text app (such as Otter, Live Transcribe, or Ava) in an internet browser or on a smartphone so the client can read what you’re saying. The communicator should speak directly into the provided microphone (no more than six inches away) for maximum accuracy. Adding an external directional microphone to the smartphone can help improve transcription by reducing extraneous noise. The apps may struggle with some accents or speech impairments, but they could also be used as an objective treatment tool for some clients.
  • Wear a transparent face mask, with or without a face shield. As early as 2016, there has been an FDA-approved transparent surgical face mask (The Communicator from Safe ‘N’ Clear). Or, consider having a washable fabric mask made with a transparent window. Use this type of mask if a client with hearing loss is a skilled lip-reader and needs to be able to see your mouth.

Face masks offer an important protective barrier in the attempt to slow the spread of COVID-19, but they also create new communication obstacles. We can adopt many accommodations and compensatory strategies to maintain accessibility when working with clients of all ages who have communication disorders. Let’s continue to be amazing communication professionals and adapt! 

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