Older Adults' Interpretation of Nurses' Nonverbal Communication in Cameroon: A Grounded Theory Inquiry.

Communication is central to nursing care. Yet, the nonverbal aspect of communication tends to be neglected or underestimated in nursing studies. Research has shown that older patients interpret nurses' communication messages during the clinical encounter. This article conceptualizes older adults' interpretation of and need for nonverbal communication (NVC) to enhance patient-centered communication advocated by the World Health Organization. The Corbin and Strauss (2015) inductive Grounded Theory approach was used to collect data from 3 hospital units in Cameroon using in-depth interviews with eight older adults, thirteen nurses, and four student nurses between July 2018 and January 2020. Open coding, axial coding, and selective coding were used for analysis, which reveals that interpretations of NVC can be positive or negative. It means that older adults view nurses either as angels or as difficult persons, depending on the nurses' positive or negative NVC and behaviors. These interpretations lead to consequences ranging from a preference for some nurses to noncompliance with care. The results further show that older adults need active listening, humor, and affection from nurses. Information regarding older adults' interpretation of and need for NVC can be used to improve curriculum content and to develop skills in and awareness of NVC with older adults. It is recommended that further research expand on effective nonverbal techniques during COVID-19 times where the meaning of facial expressions and voice inflection can be disrupted.

Questions and answers

Question 1: What do we already know about this topic?

Answer 1: Nonverbal communication is part of patient-centered care but it is under researched in nursing studies.

Question 2: How does your research contribute to the field?

Answer 2: The results show that older adults can interpret nurses’ nonverbal communication positively or negatively, with consequences attached to their interpretations.

Question 3: What are your research’s implications towards theory, practice, or policy?

Answer 3: The findings challenge nurses to look for ways to get messages across to older adults, considering their interpretation of and their needs for NVC. While there are possibilities of misinterpretations of NVC, our study suggests that older adults' interpretation of NVC guides better ways of communication with older adults. In times of COVID-19 where preventive measures such as social distancing and constant wearing of masks are emphasized, new norms regarding NVC should be explored.

Introduction

Worldwide, the aging population is growing, and people aged 60 years and older numbered 1 billion in the world, and 32 million in Africa in 2019. This rapid population growth requires prioritization of patient-centered care (PCC), which is a challenge in delivering quality care to older adults because of the complex healthcare needs and the communicative and cognitive impairments of older adults. Patient-centered care assumes that healthcare workers should communicate and interact with patients in a person-centered way. Person-centered communication (PCCom) is a set of skills demonstrated through verbal communication (VC) and nonverbal communication (NVC). It aims to ensure that healthcare workers attend to patients and their different needs and expectations. To be more person-centered, healthcare workers should promote PCCom with older adults.

Communication is more complicated than the mere transmission of information, and it includes verbal and nonverbal components. Yet, the nonverbal aspect of communication seems to be underestimated or neglected in nursing studies. Nonverbal communication is defined as “behavior of the face, body, or voice minus the linguistic content; everything but the words.” NVC remains a significant part of communication, and it has different modalities, including haptics (the use of touch), artifacts (the presence of physical and environmental objects), proxemics (the use of space and distance), chronemics (the use and perception of time), kinesics (forms of movement of the body), physical appearance (body type and clothing), silences, and vocalics (aspects of the voice).[12,13] Researchers use the terms “nonverbal communications (NVC)” and “nonverbal behaviors (NVBs)” interchangeably. We have done the same in this study.

Research has shown that people, including older adults, rely on verbal behavior (VB) or NVB to interpret a message communicated to them, based on distinct situational factors. This is called the decoding process. Research also suggests that people rapidly make judgments of others or their gestures, based on a brief excerpt of expressive behaviors sampled from any channel of communication. This means that a receiver interprets a sender’s cues or the absence thereof. Older adults can make rapid judgments on nurses based on a brief excerpt of nurses’ expressive NVB or the absence thereof. Although older adults may experience changes in the coding of information, they can interpret or misinterpret nurses’ NVBs.[18,19]

Focus needs to be directed toward NVC in hospital settings because with the rapid growth of the older population, nurses are expected to care for older adults more than any other patient. This implies that older adults are more likely to interpret nurses’ NVB more often than any other patient is. Additionally, studies conducted in Africa on communication between nurses and patients from 2000 to 2019 mostly focused on maternal and reproductive care, HIV, operative/postoperative care, intensive and palliative care, and primary healthcare settings. In a context where more data to understand the needs and the status of older adults in Africa are needed, it is crucial to understand how older adults from an African country interpret nurses’ NVC as well as their needs for NVC in hospital settings because older adults respond positively or negatively to nurses’ NVC. Additionally, negative experiences of interactions with nurses shape subsequent communication, which can impede the quality of care provided. Therefore, this paper aims at describing older adults’ interpretation of nurses’ NVC.

Methods

This study is part of a larger grounded theory study on NVC between nurses and hospitalized older adults.

Study Design

The chosen design was a grounded theory, which is an inductive systematic inquiry into empirical data and observations to explain a poorly understood phenomenon, such as NVC between nurses and hospitalized older adults. The study was underpinned by Symbolic Interactionism, which holds that human beings and shared meanings of reality are defined through interactions between and among the researcher and the participants.

Settings

The study was conducted in three wards in two public hospitals in the East Region and the Central Region of Cameroon. Data were collected in 2 medical units and 1 geriatric unit. Cameroon has a pyramidal public healthcare sector, with a centralized system of administration (a health ministry), an intermediate level (regional delegations), and a peripheral level (health districts). There is only 1 geriatric unit in Cameroon and no long-term care facilities. It is the reason why most of the older adults who need healthcare services are admitted in wards with younger adults and are categorized according to their illness.

Participants

Purposive sampling and then theoretical sampling were used to ensure selection of participants with rich data, which is required to understand the phenomenon of interest. Staff and student nurses were purposively selected due to their contact with older adults. The researcher started by purposefully sampling staff nurses with 2 years of experience, assuming that they will have enough significant interactions with older patients. After the first analyses, theoretical sampling was achieved when a nurse referred the researcher to other nurses that had previously worked in the chosen units, and when student nurses were also selected. Student nurses were included because older adults are cared for by both staff and student nurses. Criteria for including nursing students were experience in caring for an older adult during clinical placement and willingness to participate in the study. Four student nurses and thirteen nurses were interviewed.

Additionally, 47 patients were referred to the study. Thirteen patients were excluded from the study due to their being unable to speak and understand English or French, or because they had a critical illness. The researcher contacted suitable patients and their relatives to present the study and obtain their consent. Of those who met the inclusion criteria (n = 34), 2 patients declined to participate, 1 died, and 2 were discharged against medical advice. Eight older adults that gave their consent were interviewed.

Data Collection

Data were collected between July 2018 and January 2020 and consisted of 25 in-depth interviews conducted with older adults, students, and staff nurses until saturation was reached. The interview guides consisted of open-ended questions derived from observations of interactions between nurses, student nurses and older patients.

Ethical Considerations

Ethical clearance was obtained from the university ethics committee, and permission to conduct the study was given by the 2 hospitals. Participants were provided with information related to the purpose of the study, confidentiality, anonymity, and their right to withdraw from the study at any time without penalty. Participants signed consent forms and authorization for audio recording. Pseudonyms were used to ensure anonymity.

Data Analysis

The French interviews were translated into English by a certified translator, and a back translation was done to allow for peer review. The interviews were transcribed verbatim. Transcripts were checked against the audio recordings for accuracy. Data analysis started with the researcher reading each transcript to familiarize herself with the content. As suggested by Corbin and Strauss, questioning, making constant comparisons of incidents and categories, and thinking about the various meanings of a word were used throughout the analysis until data saturation was reached. The use of personal experiences was avoided to reduce bias and prevent the imposition of personal experiences on data. NVivo version 12 qualitative data analysis software facilitated the analysis. Open coding, where lower-level concepts were constructed, resulted in codes expressed in words similar to those used by the participants. Axial coding enabled collapsing the codes addressing similar phenomena into categories through constant comparison. Selective coding enabled relationship verification between categories.

Findings

All the participants reported on older adults’ interpretation of NVC and their need for NVC as described in Table 1. Five categories emerged from the data with regards to older adults’ interpretations of nurses’ NVC: (a) the core category, (b) the contextual conditions, (c) the actions/interactions, (d) the intervening conditions, and (e) the outcomes.

Table 1.

Categories and Codes Derived from the Data.

Category	Codes
Core category	Nurses are angels
Contextual conditions	Older adults interpret nurses’ NVCOlder adults need nurses’ NVC
Actions/interactions strategies	Nurses show concern and interestNurses convey love or empathyNurses give hope to older adults
Intervening conditions (hinderers)	Nurses use a commanding toneNurses do not spend enough time with older adultsNurses convey anxietyNurses treat older adults as objectsNurses do not show respect to older adults
Consequences	Older adults comply with and accept careOlder adults do not avoid nursesOlder adults are satisfiedOlder adults feel at home

Core Category

The core category, nurses as angels, emerged from the data. An older woman viewed nurses as angels when nurses pat them while another one viewed them as nice when they did not shout. In the case below, a nurse’s non-procedural touch conveyed comfort to that old woman:

When I felt sad or cried, they would come and pat me and told me not to cry, because that situation wouldn’t last forever. They were angels, I am telling you. [P25, older woman, 70 years]

They are nice, because they don’t get angry nor shout. [P18, older woman, 78 years]

I see a staff that is close to patients. They want to understand exactly what our problems are. They come here regularly to check the IV. They ask me how I feel. The touch me. I tell you, they are like little angels... Anyway, I feel that they are very close to patients. [P19, older man, 65 years]

Contextual Conditions

Under contextual conditions, older adults’ interpretation of NVC and older adults’ needs for NVC were identified. Participants reported that older adults can interpret nurses’ NVC by interpreting nurses’ facial expressions, physical appearance, and gestures. It means that older adults watched nurses’ faces and gestures, and drew conclusions based on previous encounters with nurses or their personality. An older adult, a nurse, and a student nurse highlighted this point:

Yes, I do interpret their NVC. I watch a nurse’s expressions when I talk to her about this and that. I always watch their faces. [P25, older woman, 70 years]

I think “reading” is not the correct word. Older patients interpret our gestures. [P9, specialized nurse, 6 years of experience]

Because you can come in the morning, greet with your best smile, but the older patient reads on your face that you are not okay even if you are smiling. [P16, student nurse, 26-35 years].

Concerning the needs for NVC, only nurses and student nurses mostly reported on needs of NVC. Two categories emerged from the data related to the needs for NVC: needs related to NVC and other needs, which included love and affection, reassurance, and good communication with nurses. Participants mostly highlighted that older adults need to be touched. One nurse admitted that she touched an older man on his private parts to cheer him up:

Yes, he smiled. He was happy. I told him that he could still remarry even though he is a widower. Then I touched him, his beard, and his sex to cheer him up, to value him. I laughed with him throughout. [P6, diploma nurse, 11 years of experience]

However, another nurse emphasized that male older adults do not want to be touched on their private parts, as reflected in the following comment:

Yes, they don’t like it when we touch their private parts. It frustrates them when we touch their sex. Sometimes it even ruined the relationship established from the start. They don’t want you anymore because you saw their sex. [P7, diploma nurse, 9 years of experience]

Active listening, a modality of NVC, was reported to be needed by older adults. This subcategory stemmed mainly from nurses who view older adults as people who need to be confided in because they have secrets and stories to tell. Reminiscence seems to be common in older adults as they tried to remember their past. Therefore, they need people to listen to them. One student concluded that older adults need to be listened to:

Either it’s that attention because some older people just need someone to listen to them, and you gave them that attention. [P17, student nurse, 26–35 years old]

The use of hand gestures, another modality of NVC, was also mentioned by a nurse as an NVC need of older adults:

When I waved my hand, she also responded by waving and smiling. So, they need this communication with gestures. I don’t know if speaking is difficult or annoying but hand gestures work. [P7, diploma nurse, 9 years of experience]

Humor, often accompanied by laughter, was also mentioned as something older adults need:

Usually, I talk with older people with a slightly funny tone, because I know they miss it. I don’t make fun of them, but I know that they often need jokes. Just because someone is old doesn’t mean he doesn’t need jokes. [P11, diploma nurse, 13 years of experience]

Participants also reported on “other older adults” needs. The student nurses specially mentioned love or affection, which is viewed as empathy. In this study, most of the participants view older adults as children, and they concluded that older adults need affection as children do:

Older people are like children. They need affection just as we take care of newborns. If this communication does not exist, older patients might think they are mistreated because they are old. [P15, student nurse, 18–25 years old]

Yes, they need love. Everybody needs affection. I don't know anyone who lives without affection. We all need affection. [P17, student nurse, 26-35 years old].

Participants expressed that older adults need reassurance from nurses when they are hospitalized because they are anxious:

Every sickness itself makes older patients feel diminished. They need us to keep their spirits up. [P3, diploma nurse, 23 years of experience]

Finally, a nurse reported that older adults need good communication with nurses, although they do not always speak or understand French:

I have to use another method that is not verbal. Even if I speak in French and they don’t understand, they must feel that there is communication going on. [P8, specialized nurse, 3 years of experience]

Actions/Interactions Strategies

Usually, angels are seen are doers of good things or protectors. This category describes what nurses did in order to be seen as angels. In this study, being an angel had different meanings for older adults. For some, it means that nurses showed concern and interest in older adults being healed. For others, being an angel means standing or sitting close to older adults, being kind and not irritating, or not having negative NVB. Negative NVBs in this study include frowning, not smiling, sighing, nodding the head, standing far from, looming over, having the back toward the patient, or talking on the phone. In the quote below, a positive look or eye gaze is highlighted:

They don’t look at me badly. They look at me with kindness. All of them are kind. [P18, older woman, 78 years]

A further positive interpretation of NVC was love or affection. Older adults could watch nurses’ NVBs and discerned that they conveyed love. One older adult mentioned that listening (active listening), sitting next to (physical proximity), smiling (kinesics), and touching (haptics) conveyed love as seen below:

When a person loves you, it means that she can even sit next to you to listen to what you have to say. [P21, older woman, 82 years]

When she sees me smiling or touching her, she feels valued, accepted, and not rejected. She feels that she is loved. [P3, diploma nurse, 23 years of experience]

Not only do older adults feel loved, they also feel at home when nurses use affective touch. Yet the hospital environment is very different from one’s home but in this study, feeling at home includes a sense of belonging to a family:

When I touch him without gloves, it reassures him. I massage him, and he feels good, confident. He feels at home, like amid his family. [P10, nurse aid, 14 years of experience]

Patients are always concerned about their condition, and they look for reassurance from nurses, especially if their condition is critical. As angels, nurses give hope to older adults. In this study, older adults concluded that if nurses smile or come closer to them, it means that their condition is not that bad. If their condition is critical and they are about to die, nurses will avoid coming closer to them or caring for them. They assumed that if they still receive care, there is still hope for them:

When a nurse smiled at me, it conveyed that she wanted me to be at peace and know that it is not that bad and they’ve got it under control. It assured me. [P25, older woman, 70 years]

When they look at you, they change their thoughts because you smiled. Even if they didn't get what you said, they saw your smile. What is certain, he knows that his sickness is not that bad. [P16, student nurse, 26-35 years old]

Intervening Conditions (Hinderers)

In this study, the intervening conditions were described as what nurses should not do in order to be seen as angels. They emerged from the negative interpretations of nurses’ NVC and included not smiling, using a commanding tone, frowning, and being silent for too long. One nurse highlighted that nurses are difficult if they do not smile in contrast to being angels:

Nurses should always smile because older patients read us. They can pick up that we don’t love them, that we are difficult. [P7, diploma nurse, 9 years of experience]

Nurses are not angels when they use a commanding tone or when they do not spend enough time with older adults, as reported by a nurse and a student nurse:

For instance, some nurses cannot speak in a soft tone. In that case, older patients think that we only shout and don’t take good care of them. [P3, diploma nurse, 23 years of experience]

Maybe because he had issues at home, he comes and talks to the patients with a commanding tone. It appears as if he does not even have time to waste. [P15, student nurse, 18-25 years old]

The results also show that nurses are not angels when they conveyed anxiety. For instance, when nurses have negative facial expressions, such as frowning or having a sad face, the condition of older adults is perceived as critical:

When you make gestures, he feels that there is nothing serious. If you are rude, or if you frown when reading his report, the person will think that his situation is critical; his time to die has come. [P11, diploma nurse, 13 years of experience]

Patient-centered care includes the idea that patients should be “treated as persons.” For nurses to be angels, they should not treat older patients as objects. One nurse said that older adults understand that they are being treated as objects when nurses are silent and do not say anything for an extended period:

In the case where you observed a nurse dressing a wound without saying anything for more than 30 minutes, the patient could think that she didn’t want to communicate with him because he’s an object. He would not accept her, because it might say that she took him as an object. [P2, middle unit manager, 32 years of experience]

Lastly, nurses are not angels when they are not showing respect to older adults. In this study, older adults feel unimportant or despised when nurses are cold or when they stand at a distance as reported by an older adult and a nurse:

When you are a cold nurse, I feel sad and unimportant. [P25, older woman, 70 years]

Older patients, as I said, are people who are one-step ahead of us. So, they can see how you stand by them, and they conclude that you esteem or despise them. [P8, specialized nurse, 3 years of experience]

Outcomes

The fact that nurses are seen as angels leads to consequences, where participants highlighted that older adults comply with and accept care, they are happy, and they do not avoid some nurses. Additionally, older adults feel loved and at home, and they have hope when nurses are angels. A preference for some nurses was mentioned by a nurse when nurses display negative NVBs, which leads to a relationship breakdown with the less appreciated nurses:

When you walk in with a stoned face, they know that you don’t love them, and they, too, won’t cooperate. They will instead wait for your nicer colleague. [P7, diploma nurse, 9 years of experience]

Compliance with and acceptance of care and treatment were also mentioned as consequences:

They may not accept the care offered by a nurse whose NVC doesn’t favor them. For instance, an older patient receiving an injection may not cooperate with someone who doesn’t usually smile. When the person that generally smiles with them comes, they accept the care easily. [P13, middle unit manager, 10 years of experience]

In addition, older adults appreciate it and are happy when nurses display positive NVBs, such as sitting close to them and smiling. Patient satisfaction is one of the desired outcomes of nursing care:

I like it when they sit close to me and smile with me. I am happy. [P20, older woman, 64 years old]

When nurses are angels, older adults feel at home, especially when nurses use affective touch. Yet the hospital environment is very different from one’s home but in this study, feeling at home includes a sense of belonging to a family:

When I touch him without gloves, it reassures him. I massage him, and he feels good, confident. He feels at home, like amid his family. [P10, nurse aid, 14 years of experience]

Discussion

This study aimed to conceptualize older adults’ interpretation of and need for NVC in 2 hospital settings. All the participants, mostly nurses, highlighted issues about older adults’ interpretation of NVC. The core concept that emerged from the data is nurses as angels. In the context of the study where older adults interpret nurses’ NVC and have needs for NVC, nurses are seen as angels when they are concerned and interested in older adults, they are kind and close to older adults, and when they convey empathy. On the other hand, nurses are seen as angels when they do not use a commanding tone nor display negative facial expressions. Consequently, older adults do not avoid them, but rather comply with and accept the care offered. They also feel that they belong to a family and they have hope. This study contributes to responding to the call for more data on older adults in African countries. The findings of our study also add to the existing empirical studies showing that older adults interpret nurses’ NVC messages.[18,28]

Action/Interaction Strategies

This study found that nurses are described as angels when they sit close to older adults, touch them affectionately, or do not shout at them. This is consistent with previous research conducted in the USA, where affective touch was interpreted as a sign of respect, and comfort touch was associated with improved faith and belief in older adults. However, in Japan, a handshake and a kiss on the forehead were inappropriate for older adults and a touch on the buttocks was perceived as if nurses were dominating older adults in USA. This confirms what one of the participants said about avoiding touching older adults inappropriately. It is true that nurses not only touch patients for vital signs checking or medication administration, but they also have countless physical contacts with patients that occur within the social context and everyday interactions. This means that touch is instrumental or affective in healthcare encounters. Yet, affective touch can serve as one resource to display empathy to older adults. In this light, nurses should first build a relationship of trust with older adults before engaging in affective touch, they should adjust their NVC techniques to each patient, and they should not impose touch on older adults.

In this study, older adults reported that they feel at home and loved when nurses touch them and sit close to them to listen to them. This is consistent with a study conducted in Canada where older adults expressed the need to be listened to by healthcare workers. Older adults in the Balkans described their relationship with the nurses that listened to them as that of friends or family members. According to Peplau (1952), nurses are expected to play six main roles, namely, stranger, teacher, resource person, counselor, surrogate, and leader. Although older adults and nurses are strangers when older adults are admitted, their evolving relationship should change from that of strangers to that of companions. Nurses should ensure a friendly, sincere and respectful relationship with older adults, to prevent noncompliance with care.

Intervening Conditions

Research has shown that limited time has been reported by patients to have a negative impact on communication. In this study, it was found that nurses are seen as difficult when they do not spend time with older adults or do not speak to them. Likewise, in Israel, nurses who removed a catheter without looking at or talking to older adults were treated as absent, and glancing at a watch to indicate being in a hurry was perceived as disinterest by older adults. Yet, the healthcare professionals’ ability to communicate that they have time to listen is of great importance for patients. It has been shown to express older adults’ feelings of being confirmed and being cared for in Denmark. Therefore, nurses are encouraged to spend enough time with older adults.

In this study, nurses were deemed difficult when they used a commanding tone. Likewise, the use of a high-pitched tone of voice was viewed as commanding and disrespectful, and speaking loudly was perceived as unfriendly and disrespectful. The tone of speech could create a positive or a negative atmosphere in the ward and can be associated with elderspeak or baby talk, a form of patronizing communication, which should be avoided in healthcare interactions. Nurses are encouraged to adopt a person-centered tone and to be caring, polite, respectful, and supportive while avoiding a controlling tone, which is bossy, controlling, directive, and domineering. However, in pandemics, where masks and physical distance are required, the meaning of a high-pitched tone can be different from nurses’ perspective and older adults’ perspective in the sense that nurses will be more likely to speak loudly to be understood.

Needs for NVC

An alternative to a controlling tone can be humor, which was reported by nurses as one of the needs for NVC. Having a sense of humor can reduce older adults’ boredom and help them feel accepted. Humor is an indirect communication strategy that needs to be increased in clinical settings. Another need expressed by the participants was affection. “Affection” is another word for empathy, which has been studied in healthcare encounters. Conveying empathy is an essential ethical aspect, which contributes to the quality of nursing practice and helps one to understand the concerns, experiences, and perspectives of older adults better, to take appropriate empathy-driven actions. Although the hospital stay in acute settings is often shorter than in long-term care settings, nurses can still show affection to older adults through their positive NVBs.

Consequences of Interpretations

This study shows that there could be consequences of older adults’ interpretation of nurses’ NVC. Participants reported that older adults prefer nurses whose NVC favors them to nurses whose NVC does not, which leads to relationship breakdowns with some nurses. Likewise, in Pakistan patients expressed that they will avoid nurses that speak in a loud voice. Another consequence reported was noncompliance with or resistance to care or treatment. Likewise, missed opportunities for PCCom and the use of elderspeak have been found to increase resistiveness to care. Because nursing care is significantly positively related to medication communication, nurses should ensure that older adults comply with care and treatment.

Limitations

Although the intent of this study was not to conceptualize the interrelationships of NVC and geriatric care, 1 limitation in this study was that there was no equal participation of nurses and older adults about interpretations of and needs for NVC. Almost of the older adults were reluctant to express their opinions related to negative interpretations of NVC, which made the analysis of negative interpretations mostly stem from nurses’ perceptions. Additionally, it could have been more interesting to describe the nurses’ NVC across the different phases of the nurse-patient relationship described by Peplau, which are orientation, identification, exploitation, resolution, and termination.

Future Recommendations

The findings challenge nurses to look for ways to get messages across while delivering PCC, and that they should consider older adults’ interpretation of and need for NVC. With increased NVC awareness, nurses can learn to modify their NVB to better meet older adults’ psychosocial needs. While there are possibilities of misinterpretation of NVC, our study suggests that older adults’ interpretation of NVC guides better ways of communicating with them. Because today’s student nurses will become tomorrow’s nurses providing geriatric care, evidence-based information regarding older adults’ interpretation of and need for NVC should be available in nursing curricula. Healthcare institutions are encouraged to provide ongoing professional development programs for nurses to develop and deepen effective NVC skills with older adults in acute settings. Future researchers are invited to expand on both VC and NVC to understand PCCom in clinical settings. In times of COVID-19, norms regarding NVC might be disrupted. For instance, when faces are covered, facial expressions are not as visible. In any nursing situation needing mask wearing, it will be difficult to see the facial expressions of nurses when covered by masks. Therefore, researchers are encouraged to explore the interpretation of NVC across preventive measures, such as social distancing and constant wearing of masks.