ACADEMIA Letters
MASKS IN PANDEMIC AND THE COURAGE OF
HEALTH PROFESSIONAL’S IN NON-VERBAL
COMMUNICATION
Cristina Vaz de Almeida
The pandemic crisis brought the globalization of mask use. Habits that seemed confined to
eastern countries and some Arab countries have spread across the globe since the beginning
of 2019 with coverage of almost the entire face (chin, mouth, and nose). In this process,
thousands of health professionals had to cover part of their faces with protective masks.
Considering that in Portugal there are 61,000 nurses (Order of Nurses, 2021) and 56200
doctors (Order of Physicians, 2021), not counting the other health professionals (Therapeutic professions) and those who support them every day (technical assistants) and for about
a year, more than 100,000health professionals wear masks in Portugal continuously in their
profession.
Mheidly, Mohamad, Fares et al., (2020) stress that protective measures, such as social
distancing and face masks, are essential to mitigate efforts against the virus, but present challenges in daily face-to-face communication, with a change in the communication paradigm.
According to these researchers (Mheidly et al., 2020),”Face masks mainly muffle sounds and
cover facial expressions that facilitate understanding during live communication”. For its
part, Carr (2020) argues that “through face masks, direct eye contact can still establish intent, clarity, connection, and compassion.” (p. 345). In an integrative view of the verbal and
nonverbal components of communication, DiMatteo et al.(2011) confirm that communication
can be verbal, supported by words, and not verbal, which uses gestures, posture, tone of voice,
proximity, among other elements of paralanguage (p.39). Knap, Hall and Horgan (2014) even
mention that it is “practically impossible to separate verbal and nonverbal behavior into two
separate and distinct categories”(p.8).
Academia Letters, April 2021
©2021 by the author — Open Access — Distributed under CC BY 4.0
Corresponding Author: Cristina Vaz de Almeida, vazdealmeidacristina@gmail.com
Citation: Vaz de Almeida, C. (2021). MASKS IN PANDEMIC AND THE COURAGE OF HEALTH
PROFESSIONAL’S IN NON-VERBAL COMMUNICATION. Academia Letters, Article 894.
https://doi.org/10.20935/AL894.
1
Verbal communication (including information-giving and positive discussion) and accurate nonverbal encoding (expression) and decoding (recognition) of emotion are also crucial
to the process of care, has been linked to numerous health outcomes (DiMatteo et al., 2011,
p. 9).
Health professionals were generally not accustomed to the continuous use of masks, except
for those very specific cases, such as intensive care, oncologic or surgery.
In this new communicational dynamic, a group of 40 Portuguese nurses, physicians and
psychologists answered a simple question: “ What facial expressions do you use to communicate with patients and their families when wearing masks, specifically when you want to: 1)
be assertive; 2) alert to the care to be taken in a situation; 3) demonstrate understanding / be
understanding?
The answers were diverse and point mainly to an experience made in the field to demonstrate the competencies of nonverbal communication, through the expressions of the rest of
the body and touch. The learning path of these ways of communicating is mainly based on
the enthusiastic acceptance of professionals by verbal and non-verbal communication, with an
increased effort to test what works and what does not work. Nonverbal communication is considered a good predictor of several measures of results, such as patient satisfaction, aptitude,
and clinical outcome (Vaz de Almeida, 2020, p.100).
Watzlawick et al. (1967) refer to the “complexity” of communication (p. 46), in which
language and behaviors are in and “we deal with a complex, fluid and multifaceted set of behaviors associated with verbalization, tones, postures and contexts, which together condition
the meaning of all other behaviors” (p. 46).
The Eyes Count, but Sometimes it’s a Conversation of the Blind
Among the results obtained by this simplified questionnaire survey, disseminated by sms and
e-mail to health professionals with a qualitative approach with a reduced sample (N=40), but
representative of the group of professionals who are operating in the field of the pandemic, in
hospitals, health centers. The research shows that all of the health professional, participants
in the online survey, give great importance to verbal communication, especially pointing out
the importance of the look and its movements not various emotional states. There are several
firms that “the eyes laugh now”. Among the health professionals are medical doctors, nurses,
psychologists, therapists, oral hygienists.
The conclusion of all participants reveals that the “eyes actually count”, but the communication argument must also go through the communication of the body, cinesthesia, proximity
(Proxemia), tone of voice and touch (Knapp, 1972).
Academia Letters, April 2021
©2021 by the author — Open Access — Distributed under CC BY 4.0
Corresponding Author: Cristina Vaz de Almeida, vazdealmeidacristina@gmail.com
Citation: Vaz de Almeida, C. (2021). MASKS IN PANDEMIC AND THE COURAGE OF HEALTH
PROFESSIONAL’S IN NON-VERBAL COMMUNICATION. Academia Letters, Article 894.
https://doi.org/10.20935/AL894.
2
An intensive care nurse, from a huge portuguese hospital, reveals that sometimes these
encounters, in which everyone wears masks is similar to a “blind talk”, that is, “often not
even the eyes are used, because they are all hidden through the glasses blurred by the steam
of breath, and both I and the family member I am contacting have the glasses blurred”. The
answer highlights the need for touch: “it is the touch that allows me to speak better with family
members, as well as some gestures with the head”. This touch is preferably a touch as hygienic
as possible (with hand washing care before and after contact).
Four nurses from the community area reveal that eye movement and nonverbal communication are being used and reused in the face of circumstances.
If you want to “smile with your eyes” they have softened their eyes, and move their heads
back and forth.
To be assertive, “they open their eyes well and fix the person, and at the same time move
their heads to the frentand back inagreement”.
As for the indication of care, they report that “they open their eyes a lot and raise the
eyebrows and if there are any objects or instruments related to the care they should have, they
look and point to what should be taken into account while explaining.
The key to correctly interpreting facial expressions is to study body posture, body movement and context (BBC, 2020).
A doctor from a large hospital Portuguese stresses: “We express ourselves orally, but we
really speak with the eyes, through nonverbal language”. This doctor points out that “nonverbal communication can probably establish more communication and truth than what we
say.”
Compared to a teacher who has to have certain requirements to make himself understood
(Council of Europe, 2015, p. 33), and in analogy, also the quality of the presentation of the
health professional depends on the clarity of articulation, flow, variations in rhythm and tone,
gestures, among others.
But understanding the other through the mask needs time and continuity of the relationship. She also points out that “often when you hear someone’s voice, who is our true friend,
we know that the person is not well even if he says otherwise.”
The Mask and its Identities
The mask reveals identities, so there is a need to show images of that identity through the
mask itself. For example, masks with drawings of smiles, animal faces, artists, heroes of
drawn stall, or as fashion prop (Viva, 2021).
Academia Letters, April 2021
©2021 by the author — Open Access — Distributed under CC BY 4.0
Corresponding Author: Cristina Vaz de Almeida, vazdealmeidacristina@gmail.com
Citation: Vaz de Almeida, C. (2021). MASKS IN PANDEMIC AND THE COURAGE OF HEALTH
PROFESSIONAL’S IN NON-VERBAL COMMUNICATION. Academia Letters, Article 894.
https://doi.org/10.20935/AL894.
3
According to Höijer (2011), social representations are about processes of collective significance, resulting in common cognitions that produce social bonds that unite societies, organizations, and groups (p.3).
WHO (2020) states that “non-medical tissue masks can be worn by the general public
under the age of 60 and that they do not have underlying health problems.” This opening for
community masks quickly praised the most creative, even generating a style of mask design
(Reuters, 2020).
In Japan, people have been used to wearing masks for many years and the diversity found
in this social representation is even more fruitful. Thus, there are masks that cut off ultraviolet
rays and prevent glasses from embouring, which make the face look thinner (The japan Times,
2021). According to a credible source (Japan Times, 2021), there is even a term for women
who look good in masks - masuku bijin (masked beauty), and contests are held to decide
which one is most attractive with masks. As mentioned, (Japan Times, 2021), “the key to this
attraction, is eye enhancement.”
Watzlawick et al. (1967), associating verbal and nonverbal communication, refers to the
“complexity” of communication (p. 46), in which language and behaviors are in and “we deal
with a complex, fluid and multifaceted set of behaviors associated with verbalization, tones,
postures and contexts, which together condition the meaning of all other behaviors” (p. 46).
So, everything seems to count in communication and, even if a nose, mouth, or chin is
not seen, the human body communicates, even without wanting to communicate. The topic
addresses a longstanding question and debate in the field. We can see people wearing face
masks, and of course, this will raise many questions that need answers, i.e., for how long will
we continue like this? And how can we express ourselves when wearing a face mask?
Conclusions and Open Doors
New openness arises to train health professionals and other crucial actors in society, being
useful, we believe, that giving the voice to mime artists will be a good way to support culture
and better learn nonverbal communication without words. As Carr (2020) says : the actor’s
toolbox of communication techniques, especially the act of listening, is not that much different
from the clinician’s toolbox (p. 345).
The central question is that, regardless of the artifact used, (protective masks that may hinder communication), “patients must be able to adhere. They must have the tools and strategies
necessary and must have the capacity to overcome any barriers to adherence that stand in their
way” (DiMatteo et al., 2011, p. 11).
And in fact, all this relates to health literacy, which it intends to do as a determinant of
Academia Letters, April 2021
©2021 by the author — Open Access — Distributed under CC BY 4.0
Corresponding Author: Cristina Vaz de Almeida, vazdealmeidacristina@gmail.com
Citation: Vaz de Almeida, C. (2021). MASKS IN PANDEMIC AND THE COURAGE OF HEALTH
PROFESSIONAL’S IN NON-VERBAL COMMUNICATION. Academia Letters, Article 894.
https://doi.org/10.20935/AL894.
4
health, that people can better access services and professionals, understand them, and then
use health information in correct decisions for their lives. We highlight how adaptations in
communication have been made by health care professionals in Portugal, and importance of
health literacy, in the access, understanding and use of health information, strengthened by
verbal and nonverbal communication
The present paper also presents the new challenges related to COVID-19 pandemic that the
mankind experienced in 2020: healthcare professionals found new solutions to communicate
and to keep in touch with their patients using different means.
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Academia Letters, April 2021
©2021 by the author — Open Access — Distributed under CC BY 4.0
Corresponding Author: Cristina Vaz de Almeida, vazdealmeidacristina@gmail.com
Citation: Vaz de Almeida, C. (2021). MASKS IN PANDEMIC AND THE COURAGE OF HEALTH
PROFESSIONAL’S IN NON-VERBAL COMMUNICATION. Academia Letters, Article 894.
https://doi.org/10.20935/AL894.
5
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Academia Letters, April 2021
©2021 by the author — Open Access — Distributed under CC BY 4.0
Corresponding Author: Cristina Vaz de Almeida, vazdealmeidacristina@gmail.com
Citation: Vaz de Almeida, C. (2021). MASKS IN PANDEMIC AND THE COURAGE OF HEALTH
PROFESSIONAL’S IN NON-VERBAL COMMUNICATION. Academia Letters, Article 894.
https://doi.org/10.20935/AL894.
6
nurses to health literacy: The ACP AssertiveNess Model (A), Clarity (C) And Positivity (P) In the Therapeutic Relationship. Zenodo. DOI( https://zenodo.org/badge/DOI/10.
5281/zenodo.4495585.svg)] (https://doi.org/10.5281/zenodo.4495585
Viva (2021). The Local Fashion Brands Making Face Masks [online]
Retrieved on: https://www.viva.co.nz/article/fashion/new-zealand-fashion-designers-face-masks/
Academia Letters, April 2021
©2021 by the author — Open Access — Distributed under CC BY 4.0
Corresponding Author: Cristina Vaz de Almeida, vazdealmeidacristina@gmail.com
Citation: Vaz de Almeida, C. (2021). MASKS IN PANDEMIC AND THE COURAGE OF HEALTH
PROFESSIONAL’S IN NON-VERBAL COMMUNICATION. Academia Letters, Article 894.
https://doi.org/10.20935/AL894.
7