“As humans, we like to think that we are in charge of our own space in the universe, every now and then, some microscopic entity reminds us that we are not”. Neil de Grasse Tyson(Astrophysicist)
Epidemic outbreaks are inevitable and often unpredictable. The environment around an outbreak is unique in all public health. Outbreaks are marked by uncertainty, confusion and a sense of urgency.
The World Health Organization (WHO) believes that it is now time to recognize that communication expertise has become as essential to the crisis as training in epidemiology and laboratory analysis.
The biggest communication challenge is crisis management. When companies and entities must manage these situations, with their reputation put to the test, communicating in the right way is vital, under pain of bearing damage that can extend for long periods. It is worth mentioning that communication plays a key role in times of crisis, being the tool that bridges institutions and all stakeholders, including health professionals who provide services.
To ensure that accurate and real information is shared, it is necessary for health services to structure, expand and strengthen their communication channels with different public in a proactive and immediate way, in order to minimize the risk of erroneous or distorted information being served.
Against pandemics, epidemics, outbreaks, etc., it is extremely important that health services identify all stakeholders in the business, in order to choose which tools should be used for horizontal and efficient communication. Below we list the five guidelines recommended by WHO for communicating with the public during epidemic outbreaks:
- Trust: The crucial objective of communication in an epidemic outbreak is to communicate with the public in order to create, maintain or restore trust.
- Immediate announcement: The trust parameters are established at the first official announcement. The opportunity, the frankness, and the breadth of this message can make the announcement the most important of all communication in an epidemic outbreak.
- Transparency: Transparency characterizes the relationship between crisis managers and the public. This allows the public to see the information collection, risk assessment and decision-making process associated with control in the event of a public health emergency.
- The public: Understanding the public profile is critical to effective communication.
- Planning: Risk communication should be incorporated into planning for serious events and in all aspects of responding to an epidemic.
Communication with internal public
The employees of an entity involved in a crisis, if well informed about the details of the situation, can help in spreading the institution’s strategies to other public, and people outside its limits.
Employees well informed about the real scenario the institution is going through, they feel psychologically safe, which impacts the reduction of absences in justification, absenteeism, dismissal requests, among others. During the crisis, it is not the time to pass vague information, make clear all the measures that the institution has been adopting to minimize, for example: the risk of lack of inputs, replacement of retired employees and open positions, acquisition of equipment.
It is important that the information is updated as new guidelines and events occur and is disseminated to all operational levels. Silence may seem negligent, both for the internal and external public, so both should be provided with information, so that they are sure that something is being done, and they have the perception of care of the entity.
For an effective communication with the internal public, below we list some channels that can be used:
- Perform daily quick meetings with the leadership;
- Use the shift change to inform relevant issues;
- Identify your best “unofficial spokespersons”, they can be excellent multipliers of information;
- Institute flow through communication boards, email, intranet, internal bulletins;
- Create a system by which internal public can ask questions and get quick answers.
In addition to the establishment of communication channels, closer monitoring of employees by other support departments may be necessary, such as people management, safety and occupational medicine. Below are some actions that these processes can promote during the crisis:
- Take responsibility for dealing with human resource issues that may arise to assist affected people, including helping the families of employees and third parties;
- Measure, monitor and report psychological impacts on employees, if applicable;
- Coordinate actions involving property security;
- Daily report of the number of employees on leave, number of suspected and confirmed cases, as well as the number of employees able to return to work activities;
- If an employee is confirmed with COVID-19, he or she and the other professionals who have had direct contact with him or her must be removed immediately. The other employees must be aware of the case to be aware of any symptoms, but the confidentiality of the infected person must be maintained;
- It is up to the employee to inform his employer about his health status. The Center for Disease Control and Prevention (CDC), the regulatory body in the USA, says it is important that employees with sick relatives inform their supervisors so they can take preventive measures.
Employee who becomes patient
In health units, it may happen that employees with COVID-19 are cared for inside the institution where they work. In these cases, employees must follow the flow established for patients, and the institution must take the measures determined by the Ministry of Health and Ministry of Labour, such as immediate removal of the employee and other professionals who had direct contact with him, compulsory notification, among others. Suspected cases must be reported immediately, that is, within twenty-four hours by the health professional responsible for the care.
In case of employee’s death, the employer must take the measures provided for by the Consolidation of Labor Laws (CLT), and other legislation.
Internally, with the team, there is no protocol to deal with this situation, but some guidelines can be followed:
- Make room for the team to recognize and validate their own feelings.
- Remind them that we can be brave and share our vulnerability at the same time.
- Help them to recover and reaffirm their purpose daily: they must be sure of the value of their presence on the front line, at this moment.
- Encourage them to seek help if their feelings affect their professional and human abilities.
- Promote hope in the team, this situation will pass.
Every professional must have an ethical attitude, keeping his company’s information confidential. Communications and data must be used for activities to achieve their results and should only be used internally.
Breaking professional secrecy may represent an offense, according to art. 154 of the Penal Code: “To reveal someone, without just cause, secret, that they have knowledge due to function, ministry, trade or profession, and whose disclosure may harm someone”. And, result in legal proceedings and detention.
Ordinance 356 of the Ministry of Health, which deals with Coping Measures to COVID-19, published on March 20, 2020, says in its first paragraph that “§ 1 The isolation measure can only be determined by medical prescription or recommendation of the epidemiological surveillance agent, for a maximum period of 14 (fourteen) days, which may extend for up to an equal period, according to laboratory results that prove the risk of transmission. ” And it adds that:
“Art. 3 The isolation measure aims at the separation of symptomatic or asymptomatic people, in clinical and laboratory investigation, in order to prevent the spread of infection and local transmission.”
“§ 4 The determination of the isolation measure by medical prescription must be accompanied by the patient’s free and informed consent form, according to the model set out in Annex I.”
“§ 7 The isolation measure by recommendation will be made through express notification to the contacting person, duly substantiated, observing the model provided for in Annex II.”
Technical Note 04/2020 of ANVISA, informs that all suspected cases must be “notified immediately, that is, within twenty-four hours by the health professional responsible for the care”, to the local epidemiological surveillance system.
In addition, patients who have a confirmed or suspected diagnosis of COVID-19, should be informed about the obligation to remain in isolation, either in the hospital or at home. In both cases, the patient or guardian must be asked to sign the Informed Consent Form on the need for isolation, according to the model presented in Annexes I and II of Ordinance 356 of the Ministry of Health.
Communication with patient, family and caregivers
Communication between health professionals and patients / relatives / caregivers is one of the crucial points for establishing a relationship of trust, identifying the preferences of those who will receive care and involving them in decision-making related to treatment. Communication is a skill that needs to be developed and performing it through a structured process can help the professional to be more assertive, especially in times of crisis.
Below, we list some recommendations found in the literature that can assist in assertive communication between health professionals and family members in times of crisis:
- At the time of diagnosis, be honest and make clear all the risks and possibilities of the course of the disease;
- Use simple, objective language, easy to understand, avoid technical terms;
- Always take time to clarify doubts;
- Always make sure that the information given is clear;
- Identify in the health team, who will be the facilitator of communication with the family, this reduces the risk of mismatch of information;
- Identify the primary caregiver;
- Explain the whole routine of the institution and the unit which the patient is allocated, how the flow of information will be, as well as the flow of notification of complications, if it occurs;
- Whenever possible, have other options for communication tools with families, and not just in person, for reporting newsletters;
- Do not delay the time for sharing information, this generates anguish, irritability and can give the impression of neglect;
- Think of alternative strategies to promote the visit to patients, such as the virtual visit for example, if there is not a high demand for inpatients and if the institution’s resources allow it;
- For patients who are going to be discharged, think about the possibility of creating, together with the crisis committee and communication team, informative materials in simple language, with the essential care at home.
Reporting laboratory test results
The demand for laboratory tests to detect SARS-CoV-2 will grow exponentially. As the response time for such an examination to be completed is often not fast, unfortunately many patients will be discharged from the hospital or even die, without the diagnosis of COVID-19 infection being confirmed or not. Although the health team’s priority is to provide assistance to those who remain in their care, we cannot “forget” patients who have already needed some intervention and are waiting for the diagnosis to be confirmed through laboratory tests.
Para que isso ocorra de maneira eficaz, e não gere uma percepção ruim na experiência do paciente, deixamos aqui, algumas recomendações para que seja organizado um fluxo de comunicação de resultados de exames laboratoriais nesse momento:
To occur effectively, and not generate a bad perception in the patient’s experience, here are some recommendations for organizing a flow of communication of laboratory test results currently:
- Check if this flow is already included in the actions of the Institutional Crisis Committee, if not, this is an important point to be discussed.
- Designate a professional to manage pending exams
- Set aside a daily period of the workday to survey the status of these exams.
- Reinforce with the teams in the service area the importance of keeping the patient’s record and another reference phone for contact updated.
- Give the result back to all patients, whenever possible.
- Prioritize positive results, but do not forget that the return of negative tests reduces the insecurity of the patient and family and improves their perception of the assistance provided.
- Do not forget to report the results of patients who died, this attitude is extremely important for closing the cycle of mourning and maintaining or suspending the isolation of family members.
- Evaluate the possibility of reporting the laboratory results to family members who have lost their loved ones, whether performed by a specialized professional.
- Structure an objective route for telephone contacts in order to optimize time.
- Always end the contact checking if the information provided is clear and take a moment to clarify doubts.
- Always list the difficulties encountered and the positive points and share with the Crisis Committee.
Communication of Death by COVID-19
Death during the Covid-19 pandemic has some important characteristics: it can be very frequent; must be communicated remotely; it is considered acute, that is, with little significant previous history; has particularities regarding the funeral. There is no single protocol for communicating a patient’s death to family members, but there are some practical recommendations:
- Check the patient record, observe if there is any more detail that is important to be said, check correct data of the patient and caregiver.
- Make a call to the primary caregiver listed on the record. Check if he is in the place and conditions for this conversation.
- Perform more objective listening but let him speak what he knows or feels.
- Provide the news clearly and objectively, in a warm and gentle tone.
- Allow time for emotions: try to empathize at a distance, donate silence and respect, wait for a manifestation of him to follow.
- Request and activate support networks. Request support from someone for documentation and funeral procedures, the person will not always be able to.
- Record phone call in patient record.
Any death confirmed for COVID-19 by the Death Verification Service, must be notified immediately to the local surveillance system. The local epidemiological surveillance system should also be aware when the cause of death is inconclusive or ruled out for COVID-19. It is recommended that public and private health services do NOT send suspected or confirmed cases of COVID-19 to the Death Verification Service (SVO). If the collection of biological material has not been carried out while still alive, post-mortem collection should be performed at the health service, using a swab in the nasal cavity and oropharynx, for further investigation by the local surveillance team. It is necessary for each location to define a flow of collection and processing of these samples.
Communication with the External Public
In order for the institution not to disclose mismatched information, in case of any situation involving media intervention, it is important that external communication is planned and centralized:
- One must choose the person to speak for the entity, the organization’s spokesperson.
- Define media strategies: assess which media is most appropriate to act, according to the crisis demand.
- Think like journalists: evaluate / investigate what they want / expect as information, attitude and actions.
- Speak directly with those affected: time to show genuine concern for those involved, listen to complaints, clarify doubts, show what is being done to solve the problem.
- When it is essential to grant interviews, the communication area needs to train who will be interviewed.
- Managers and employees should be guided to direct external demands to the press / communication department, without providing prior information.
- Professionals responsible for communication must centralize all actions in crisis management with the press.
- Crisis management must be supported by the preparation of official notes.
Attention: Only employees of the institution should not be considered as internal public. Other professionals with direct action must also be taken into account, they are: interns, third parties, consultants and large suppliers, who can be questioned by the external public, including reporters, when they try to surround the entity in a time of crisis, about “what is happening? “.
The problem should be less if this public is well informed and knows who to direct all external demands to.
The Covid-19 pandemic has a load of situations which effective communication can guarantee the best care for patients, families and professionals. In crisis situations, we must focus, in addition to combat measures, on prevention and planning measures.
All the measures exposed were based on the evidence available at the time and may be changed in the face of new evidence. It is recommended that additional strategies be based on epidemiological information periodically released by federal, state or municipal authorities.
- Comunicação eficaz com a mídia durante emergências de saúde pública – Um manual da OMS – 2009.
- Manual de gestão de crise e imagem. ABRAPP – Associação Brasileira das Entidades Fechadas de Previdência Complementar – 2015.
- Manual de Gestão de Crises para Relações com Investidores – Deloitte – 2015.
- PORTARIA Nº 356, DE 20 DE MARÇO DE 2020 do Ministério da Saúde – Dispõe sobre a atuação dos alunos dos cursos da área de saúde no combate à pandemia do COVID-19 (coronavírus) – https://brasilsus.com.br/index.php/pdf/portaria-no-356/
- Douglas Crispim, Maria Júlia Paes da Silva, Walmir Cedotti, Millena Câmara, Sarah Ananda Gomes – COMUNICAÇÃO DIFÍCIL E COVID – 19 – Recomendações práticas para comunicação e acolhimento em diferentes cenários da pandemia, 2020. https://ammg.org.br/wp-content/uploads/comunica%C3%A7%C3%A3o-COVID-19.pdf.pdf
- NOTA TÉCNICA GVIMS/GGTES/ANVISA Nº 04/2020 – ORIENTAÇÕES PARA SERVIÇOS DE SAÚDE: MEDIDAS DE PREVENÇÃO E CONTROLE QUE DEVEM SER ADOTADAS DURANTE A ASSISTÊNCIA AOS CASOS SUSPEITOS OU CONFIRMADOS DE INFECÇÃO PELO NOVO CORONAVÍRUS (SARS-cov-2).
- Código Penal brasileiro – Lei nº 13.964, de 2019.
- Comunicando más notícias: o protocolo SPIKES. Carolina de Oliveira Cruz, Rachel RieraII. Diagn Tratamento. 2016;21(3):106-8.
- FARRA, Sharon L. et al. Disaster management: Communication up, across, and down. Nursing management, v. 48, n. 7, p. 51-54, 2017.