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Portraits on COVID-19 protective gear reveal human faces providing care

In an effort to humanize staff who are concealed during patient interactions, many were photographed so that patients could see their faces.

A comforting smile can make all the difference to an anxious patient. But when patients pull into one of Stanford Medicine's drive-through COVID-19 testing sites, they're met by a nurse or physician assistant concealed behind layers of personal protective equipment, to prevent transmission of the virus. Mask. Goggles. Face shield. Hair bonnet. Gloves. Gown.

As a researcher who has studied the role of compassion in medicine, Cati Brown-Johnson, PhD, thought patients would feel more at ease if they could see the faces of the people treating them.

Using a smart phone, a printer and some adhesive labels, she made disposable headshots that nurses could attach to their protective clothing.

"The circumstance is scary, and we want to shift the mindset towards warmth and caring and healing," Brown-Johnson said. "I felt we owed it to our own health care workers who might fall ill, and we owed it to our patients, and we owed it to the humanity of our health care workers who were underneath the full PPE, to try and bridge that gap."

Brown-Johnson, a research scientist in the school of medicine's division of primary care and population health, remembered seeing a documentary featuring Los Angeles-based artist Mary Beth Heffernan's PPE Portrait Project during the Ebola outbreak in Liberia. Heffernan encouraged Brown-Johnson to develop her own COVID-19 version and provided tips for setting up the portraits.

Studies of the placebo effect have shown that health care providers can help patients heal simply by interacting with them with competence and warmth. While protective gear during the coronavirus outbreak "signals competence," it also masks the facial cues that can be reassuring to a frightened patient, Brown-Johnson said.

In the pilot phase, she shot pictures of 13 health care workers at Stanford's Galvez Street testing site, prompting them to give a smile that they would want their patients to see. She produced enough labels for the nurses to apply a new one each time they swab-test a patient and change their PPE; and she told them to affix the stickers on their gowns at heart level, "because your care is coming from your heart."

Anna Chico, RN, was one of the nurses to try out the portraits.

"When they drove up to me, I would introduce myself and point to my picture saying, 'This is me under all this,'" she told me. "One patient actually said, 'I love your picture.' ... It enhanced my interaction with my patients, as they were able to see me and not just a full suit of PPE. It's so important to establish that human connection especially in these times of social distancing and isolation."

Brown-Johnson is now working with teams across Stanford Medicine and University HealthCare Alliance to roll out wearable portraits in all COVID-19 primary care and testing sites. She is also sharing the template with other health care groups and clinicians nationwide.

And it's not just a feel-good project. As a researcher who evaluates quality improvement initiatives in health care, Brown-Johnson wants to quantify whether the portraits are helping patients and providers. During the pilot, she had the nurses wear the stickers for one day on and one day off for six days.

She interviewed the providers and sent out a survey to all the patients who were seen that week. Patients were asked if they noticed the portraits, liked the portraits, and "most importantly, felt more caring warmth from providers on days with portraits compared to days without."

Cati Brown-Johnson made a portrait of her own to demonstrate.

Timothy Seay-Morrison, EdD, executive director of ambulatory care and service lines, said the portrait project adds to Stanford Health Care's continuing efforts to preserve the human connection between patients and clinicians.

"This experience has challenged us to concentrate even more on our electronic communication tone, adding video chat on mobile devices as a new standard for ambulatory and emergency visits, and now this beautiful PPE-portrait project," he told me.

As Brown-Johnson spearheads the project at Stanford, front line workers across the country are developing similar initiatives. Robertino Rodriguez, a respiratory therapist at Scripps Mercy Hospital San Diego, stuck a giant laminated badge on the front of his protective jacket to put worried patients at ease and shared a photo on Instagram, where it has inspired others to follow his example.

Cati Brown-Johnson's husband, filmmaker Arne Johnson, made this video about the COVID-19 PPE portrait project.

Brown-Johnson said she could see the concept of portraits catching on as mask wearing becomes more universal. The other day, she took a walk in her neighborhood wearing a mask for the first time, and a neighbor didn't recognize her right away. She spoke in a warm voice, but it took longer to connect.

"And she and I know each other already," Brown-Johnson said. "Imagine what happens when you don't know each other and you can't see their faces."

Photo by Cati Brown-Johnson

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