Although the guidelines for masking in hospitals and other health care settings have been revised and face masks are no longer mandatory, it is important to note that some patients and clinicians will choose to continue wearing masks for various personal or clinical reasons. While effective in reducing transmission of the coronavirus, masks have created challenges in assessing patients’ affective states, which impacts the accuracy of diagnosis and treatment. This article discusses strategies for assessing affect in patients wearing face masks.
How masks complicate assessing affect
One obvious challenge masks present is they prevent clinicians from seeing their patients’ facial expressions. Face masks cover the mouth, nose, and cheeks, all of which are involved in communicating emotions. As a result, clinicians may miss important cues that could inform their assessment of a patient’s affect. For example, when a masked patient is smiling, it is difficult to determine whether their smile is genuine or forced. A study that evaluated the interpretation of 6 emotions (angry, disgusted, fearful, happy, neutral, and sad) in masked patients found that emotion recognition was significantly reduced for all emotions except for fearful and neutral faces.1
Another challenge is the potential for misinterpretation. Health care professionals may rely more heavily on nonverbal cues, such as body language, to interpret a patient’s affect. However, these cues can be influenced by other factors, such as cultural differences and individual variations in communication style. Culture is a key component in assessing nonverbal emotion reading cues.2
Strategies to overcome these challenges
There are several strategies clinicians can use to overcome the difficulties of assessing affect while a patient is wearing a mask:
Focus on other nonverbal cues, such as a patient’s posture and hand gestures. Verbal cues—such as tone of voice, choice of words, and voice inflection—can also provide valuable insights. For example, a patient who speaks in a hesitant or monotone voice may be experiencing anxiety or depression. Clinicians can ask open-ended questions, encouraging patients to expand on their emotions and provide further information about their affect.
Maintain eye contact. Eye contact is an essential component of nonverbal communication. The eyes are “the window of the soul” and can convey various emotions including happiness, sadness, fear, anger, surprise, trust, interest, and empathy. Maintaining eye contact is crucial for building positive relationships with patients, and learning to smile with your eyes (smize) can help build rapport.
Take advantage of technology. Clinicians can leverage telemedicine to assess affect. Telemedicine platforms, which have become increasingly popular during the COVID-19 pandemic, allow clinicians to monitor patients remotely and observe nonverbal cues. Virtual reality technology can also help by documenting physiological responses such as heart rate and skin conductance.
Use standardized assessment tools, as these instruments can aid in assessing affect. For example, the Patient Health Questionnaire-9 and Generalized Anxiety Disorder 7-item scale are standardized questionnaires assessing depression and anxiety, respectively. Administering these tools to patients wearing a face mask can provide information about their affective state.