Академический Документы
Профессиональный Документы
Культура Документы
By
____________________
Nursing
DECEMBER 2020
Approved by:
____________________________
Abstract
Culturally competent health care for the Deaf and Hard of Hearing is significantly understudied
within the United States. Limited knowledge is taught within healthcare programs for nurses,
doctors, pharmacists, and other professionals on how to bridge this existing communication
barrier. Within the Deaf community, this has led to a couple reoccurring issues. First, lack of
access to culturally competent care may make Deaf individuals may be more inclined to avoid
regular appointments with a primary care provider (PCP). Delaying regular assessments, health
education, and screenings can result in underlying and untreated health conditions worsening
over time. Second, Deaf individuals may frequent the emergency department more often for
minor issues due to both a lack of health education and education on appropriate healthcare
resources. The articles examined address existing barriers to health care and current interventions
focused on mitigating disparities for this population. This paper will address recommendations
for the nursing profession on how to strengthen trust, improve training, and enhance
communication with the Deaf population. In addition to the review of current literature, this
paper will identify best-practice recommendations, a plan proposal for implementing resources
and training among hospitals, and finally, a proposal to evaluate the implementation process.
2
CHAPTER 1
Introduction
Statement of Purpose
This thesis aims to develop evidence-based best practice recommendations for nursing,
community, and other health professionals when caring for patients and their loved ones who are
Deaf or hard of hearing. The best practice recommendations presented in this thesis are
supported by evidence-based research. Importance and relevance with respect to nursing will be
discussed, followed by a review of the current literature on the topic. Following this review of
literature, the evidence-based best practice will be presented, concluding with best practice
recommendations.
Deaf culture in the United States has a rich and diverse history. In the nineteenth century,
Laurent Clerc brought this visually expressive language over from Paris. Thomas Gallaudet, an
instructor of Deaf children at the time, opened the first of many U.S. schools for the Deaf in
1817 (Gallaudet, 2020). Thousands of deaf students came to these residential schools, and with
each generation came a slightly new set of stories, games, jokes, and rules of etiquette when it
came to communicate with American Sign Language (ASL). Currently, there are more than 20
million people in the United States with hearing loss (Ferguson & Shan, 2016). There is no way
to observe whether someone is Deaf with a capital ‘D’; rather, being culturally Deaf is an
identity and personal association with Deaf culture. Being deaf with a lowercase ‘d’ is the
medical definition for having profound hearing loss and inability to process sound and is not
necessarily a cultural identity (Yuksel & Unver, 2016). Many people born deaf do not think of
Aiding this demographic among various others, the Americans with Disabilities Act
(ADA) was created in 1990. The ADA specified in title III that it is illegal for any business,
building, or other place that is open to the public to discriminate against people with disabilities.
Said “public accommodations” include hospitals, pharmacies, and outpatient specialty clinics.
Providing equal access means providing auxiliary aids and services for those who are deaf and
hard of hearing. Auxiliary aids include ASL interpreters and written materials, depending on the
patient’s preferences. For example, at a standard check-up, a patient may only need notes and
gestures. However, with more severe medical emergencies requiring full exams and tests, a
qualified interpreter may be required to meet the needs of the more complicated situation. While
hospitals often decide what type of aid to give a patient, the Affordable Care Act requires that
hospitals give “primary consideration” to a patient’s choice. Many patients prefer interpreters for
optimal communication, though waiting for an available interpreter can take hours. Video remote
interpreting (VRI) is one option, though the obstacle of waiting for interpreter availability can
still remain. Additionally, VRI requires quality internet speed that may not be available in rural
Due to the language barrier, many deaf individuals avoid consulting their primary care
provider. Deaf women were reported to seek health information less, and instead seek advice
from her deaf peers as a first choice (Hubbard et. al, 2018). Communication is a vital component
of the discussion between a healthcare provider and the patient. Poor ability at relaying crucial
information to patients can lead to poor patient outcomes and diminished trust towards the
provider (Ferguson & Shan, 2016). This tendency leads to large portions of the deaf population
utilizing the emergency department when their medical conditions become problematic (Yuksel
& Unver, 2016). While deaf or hard of hearing healthcare providers would greatly help bridge
4
this healthcare gap, many programs unintentionally discourage deaf student from pursuing
Many healthcare professionals think deaf patients can read lips, though this is not common or
generally ever preferred among deaf patients (Yuksel & Unver, 2016). Common behavioral
norms within the Deaf community further establish this culture as organized and unique, though
are also sources of miscommunication. One major behavioral norm is eye contact. Although for
those of spoken language it may be common to perform other activities or look away while
talking, in Deaf culture, looking away communicates disinterest. Prolonged eye contact may be
uncomfortable at first for some, but this is a norm of Deaf culture (Hemberger & Morrow, n.d.).
Another behavioral norm is getting someone’s attention by arm waving or physically tapping
them. To those only familiar with spoken language, these behaviors may come off as aggressive,
but this is normal behavior within the Deaf community due to the language’s highly visual and
tactile nature (Hemberger & Morrow, n.d.). Finally, a common behavioral norm among the Deaf
community is bluntness. Privacy looks different in Deaf culture, as American Sign Language is a
visible language. Conversations cannot change in volume to hide dialogue. Few topics are “off-
limits” for discussion, and blunt questions and statements seen as rude in English are acceptable
in Deaf culture (Hemberger & Morrow, n.d.). Without appropriate awareness, the issue of
impaired provider relationships is only anticipated to worsen over time as America’s population
Even with access to communication, such as that of an interpreter, deaf individuals often
have intersectional identities (e.g. gender, sex, race, class, religion, etc.). For example, deaf
patients who are lesbian, gay, bisexual, transgender, or queer or questioning (LGBTQ) may not
5
feel entirely comfortable disclosing their sexual orientation to a healthcare provider out of
concern for social stigmas (Miller et. al, 2019). Intimate medical procedures, like a
gynecological exam or pap smear, may leave deaf individuals more uncomfortable to have a
third party interpreter present (Miller, 2019). Deaf signers also experience greater rates of mental
disorders; compounded onto language and communication barriers between clinicians and
patients, deaf individuals are even more likely to be mis- and underdiagnosed. Only 2% of deaf
adults requiring mental health services actually receive appropriate mental health care (Pertz,
2018).
patients, compounded communication difficulties emerge among parents and newborn children
when both have different levels of hearing. In the West, 5-10% of children are raised in a deaf
family, and only 3% have two deaf parents (Beatrijs et. al, 2019). This indicates that most deaf
children grow up in hearing families; picking up the spoken language of the parents is nearly
impossible. Interestingly enough, some parents are preemptively learning ASL signs prior to
their child’s birth simply to have a means of communication while their child is still pre-verbal.
Numerous reasons exist to promote the learning of sign language and the cultural awareness of
the deaf community in order to help create a comfortable environment for these individuals
Significance to Nursing
Implications for nursing practice focus on the need for nurses to receive adequate training
during college on how to effectively interact with the Deaf population. More simulation
programs to help nurses experience the initial difficulties of caring for deaf patients can help
nurses learn how better to communicate before they are in an actual setting with a patient
6
(Yuksel & Unver, 2016). During simulation learning, students have not only the chance to play
the role of the nurse, but also the chance to play the role of the patient; with the latter role,
additional insight is gained by taking on the perspective of a deaf patient. With pharmacies, more
informational pamphlets, whether created by nurses or pharmacists, could greatly aid patient care
and understanding at the medication level (Ferguson & Unver, 2016). With the area of mental
health, deaf patients need to have special attention in screening processes (Pertz et. al, 2018).
With high rates of behavioral health diagnoses among patients, it is crucial to examine the social
determinants of health among this patient population. Low health and/or mental health literacy
means the Deaf community has less knowledge on mental illnesses and hot to get treatment.
Finally, general care of deaf pregnant women has shown that treatment for all deaf individuals
should prioritize patient preferences for communication (Hubbard et. al, 2018).
and suggesting possible options a Deaf person might choose, such as writing, reading lips, or
waiting for a translator (McKee et. al, 2018). Even more useful would be to train nurses and
other healthcare professionals on simple signs that are extremely common in the clinical setting,
such as allergy, hurt, where, or feel. There is an abundance of options for creating a safe and
accepting environment that genuinely focuses on Deaf patients as valued individuals, and
Summary
The purpose of this thesis is to create best practice recommendations for nurses in order
to better bridge the health care gap among minority populations such as those who are deaf. The
literature review that follows compiles research that supports the following methods for helping
deaf individuals receive optimum healthcare treatment. As discussed throughout the thesis, this
7
population require culturally competent care and the establishment of trust with their healthcare
provider. Often times, these individuals seek medical advice from alternative sources before
consulting healthcare systems that could lack culturally competent care. The objective for this
research review is to evaluate current provider training and where barriers to care still exist.
Additionally, an emphasis is placed on needs within the maternal and pediatric populations.
Finally, evidence-based recommendations in promoting optimum health outcomes for the deaf
Chapter 2
Review of Literature
Chapter two will address a series of compiled scientific literature that represent
the most recent findings regarding providing evidence-based care to Deaf individuals. The initial
search for literature for this thesis began through the PubMed database between the years of
2016 to 2028. To guide the literature search, the PICOT(S) question used was, “in deaf and hard
of hearing adults, how effective are non-technologically based interventions (such as writing and
lip reading) compared to no other interpreting options in improving patient satisfaction with
communication?” The databases used to search for existing research that may answer this
question were CINAHL and PubMed. All studies and reviews used were published between the
years of 2016 and 2018, and the search terms “deaf patients” and “communicating” were
utilized. After the initial literature review search, the search criteria years were broadened from
2010 to 2020, and the PICOT question was adjusted to, “for deaf and hard of hearing adults, does
providing nursing students and nurses with cultural competence training, simulations, and
appropriate visual aids enhance this population’s social determinants of health?” Enhanced social
determinants of health can be observed with more regular primary care provider visits, as well as
program for deaf signers. A secondary purpose included incorporating telemental health services
in order to assess its feasibility in addressing some of the mental health care gaps for deaf
patients. Telemental health is the use of telemedicine to provide mental health assessment and
treatment at a distance. Fifty deaf patients in Southeast Michigan aged 18 years and older who
9
utilized American Sign Language to communicate were screened and offered to participate in the
program. Deaf patients were screened for depression and/or anxiety, and if needs were identified,
deaf patients had the opportunity to work with an ASL-fluent clinical social worker to address
these concerns.
In sum, among the 50 deaf patients, there were 244 visits. Patient satisfaction with the
program overall was 86%. These findings were statistically significant. Patients described their
counselors as being some of the first to know ASL and being exactly what they needed. Sixty-
eight percent of deaf patients had some behavioral health diagnosis, additionally signifying the
need for mental health professionals versed in American Sign Language. One weakness of the
study was that 80% of the participants were white. More studies on the mental health of deaf
individuals who are African American, Asian American, etc. would be more beneficial in getting
a full visual of the deaf population’s mental health status. Additionally, the population was not
fully representative, as patients were not randomized, and they had the opportunity to decline
participating in the program. One strength of the study, however, was its innovative method. Few
studies report specific outcomes on an integrated mental health program tailored for deaf patients
The purpose of the Miller et. al (2019) study was to examine whether deaf LGBTQ
individuals’ comfort level with sharing health information in front of an interpreter affected their
ability to disclose sexual orientation to their provider. An online health survey in both English
and American Sign Language (ASL) was distributed to over 300 individuals. A binary logistic
Likelihood of coming out to providers was affected by acceptance of loved ones and
perceived patient centered communication from the provider. Chi-square tests were used to
describe the relationships among the variables within sexual orientation and gender identity
groups. A strength of this study was its ability to produce results with a demographic where 32%
were people of color (Miller et. al, 2019). However, potential negative aspects were minor
issues, such as face-to-face contact for consent forms could have resulted in fewer participants
The purpose of the Engelman & Deardorff (2016) study was to assess whether exposure
to a Deaf trainer, in addition to receiving training about working with the Deaf community, could
improve attitudes, knowledge, and skills among emergency responders. A total of 41 law
training for working with Deaf survivors. Survey results provided both qualitative insight and
quantitative results.
Overall, the training had a positive impact on perceived self-efficacy (p < .01) but no
recognized the benefits given by the training in eliminating misconceptions, though some were
still less than confident int heir abilities for a real life scenario involving a Deaf individual.
Strengths of this study included reliable and valid instruments that went through extensive pilot
testing and review by Deaf experts. Findings are additionally consistent with that of current
research on cultural competence. Some weaknesses of this study were that the results of initial
The research by Hubbard, D’Andrea, and Carman (2018) sought to share the results of a
pilot, descriptive study that explored the experiences of deaf women receiving perinatal care.
The purpose was also to offer multiple implications for nursing practice within the Quality and
Safety Education for Nurses (QSEN) framework. Five women from a deaf community in the
Southeastern United States were recruited by convenience and snowball sampling through flyers
and an interpreter at a local deaf organization. All participants were older than 18 years of age,
used ASL as their primary form of communication, and previously received obstetric care. A 20-
to 30- minute in-person interview was conducted with each participant. Interviews contained
Themes emerged related to: collaboration with ASL interpreters, missed opportunities for
safe and individualized care using technology, and potential quality improvement initiatives.
These findings were significant, as they provided useful insight into nursing practice. Ultimately,
a trusting relationship between nurses and deaf women is essential for risk reduction and
women’s empowerment as they navigate the health care system and adjust to motherhood. Trust
can be formed by having a small, consistent care team throughout pregnancy. Additionally,
providing resources such as childbirth educational videos with closed-captioning options greatly
enhances trust between the Deaf patient and prenatal clinic. Finally, providing culturally
competent care in language can determine provider trust. For instance, using culturally
insensitive language to announce to a mother that her baby can’t hear instead of simply sharing
that the baby is deaf. One weakness of the study was the lack of diversity in the respondent
population. If more case studies were conducted, or perhaps taken to the level of a survey, more
data could help identify more wide-reaching patterns. One strength of the study was the deep
insight obtained from the women regarding their care before, during, and after giving birth.
12
nurses to utilize when communicating with deaf patients. This descriptive qualitative research
(level VI) study took place in the emergency department of a university hospital in Turkey.
Twenty-two senior nursing students (SNSs) who were interns in this department, at the time,
volunteered to participate in the simulations, both serving as Deaf patients and as nurses. Faculty
developed scenarios based on literature and different factors that affect students’ ability to
communicate with deaf patients. Afterwards, five semi-structured items were used in the
debriefing session for the students to discuss the simulations. The discussions were transcribed
and analyzed.
After repeating the simulations three times, there was statistically significant
improvement in the students’ learning of communication skills to provide to deaf patients. Seven
main themes came out of the discussions, including: patient preferences, sitting position during
training, speech speed and content, body language, preparation, eye contact, and preparing a
pathway for communication with deaf patients. One weakness of the study was the lack of
diversity in participants. A very specific demographic of nursing students from one cohort was
studied, making it difficult to generalize the findings onto other populations of nursing students
and healthcare professionals. One strength of the study, however, was its consistency to other
research; numerous other pieces of literature support the idea that simulations work effectively,
Meeks et. al (2018) case study sought to gain insight into the individual experiences of a
deaf medical student in his emergency medicine (EM) rotation, and to determine challenges for
deaf students in an EM setting, find reasonable accommodations, and issue commentary on the
13
legal access required for deaf students. The various mechanisms for communicating with deaf or
The study found that some areas of difficulty that deaf medical students run into include
learning procedural skills, telephone calls, codes, and field experience. However, many solutions
were discussed. For instance, phone call difficulties can be avoided with adaptive headsets and
video relay services. With procedures, faculty could be encouraged to perform a procedure first
videos through online platforms can contain closed captioning to better prepare these individuals
for procedures. With emergencies, such as pulmonary resuscitations, the student’s designated
healthcare interpreter can play a strong role (Meeks et. al, 2018). Overall, this study was only
focused on one individual and not necessarily representative of the population, but the study
gave an in-depth look at the experience of a deaf individual from the perspective of a healthcare
student.
Mathews et. al (2011) sought to create role-reversal exercises for pharmacy students to
increase the awareness about barriers in the health care setting for deaf patients. Known as the
“Deaf Strong Hospital”, deaf volunteers from the community while students acted as patients. A
debriefing session followed for students to ask questions to a panel of the deaf volunteers. Not all
A total of 97% of the pharmacy students agreed or strongly agreed that the Deaf Strong
Hospital experience will likely impact their attitudes and behavior in future interactions with
patients who won’t speak English (Mathews et. al, 2011). Many expressed how the role reversal
helped them understand what it is like to have a communication barrier. A strength of this study
14
was that the program is easily transferable to another college or school of pharmacy. One
weakness reflected in the learning objectives was the low scores for Deafness as a culture.
The research by Ferguson and Shan (2016) sought to better understand pharmacists’
current means of communicating with deaf patients. Subjects 18 years of age and older who were
licensed as pharmacists and working in an area with a large deaf population were emailed or
given paper versions of a survey. This cross-sectional, survey-based study asked questions
relating to: the number of prescriptions filed daily, interactions with deaf patients per month,
comfort level in working with deaf patients, and methods pharmacists would or have used to
communicate with deaf patients. Of the 73 pharmacists who completed surveys, 50 (68.5%) of
them interact with at least 1 to 5 deaf patients monthly. Providing written material was found to
be the method used most often to communicate with deaf patients (98.6%). The second most
used was speaking so the patient could read lips (64.3%), and third was using a family member
to interpret information (54.8%). [It should be noted that written materials for deaf individuals
should be at about a 5th-6th grade reading level and contain visuals to enhance patient
There were several weaknesses acknowledged within the study. One weakness was that
the pharmacists’ responses may have been affected by the way the surveys were distributed. The
pharmacists who completed the survey online could have taken the survey at any time and not
have felt rushed. One the other hand, the pharmacists who completed the paper surveys were at
work when asked to take the survey, potentially adding pressure and skewing their answers. One
strength of the study, however, was the large amount of information that was able to be
15
collected. Pharmacists from chain retail pharmacies, independent retail pharmacies, and other
locations were all able to be included in the data, making the findings more generalizable.
In the 2011 study by Palese, Salvador, and Cozzi, the aim was to explore the preferred
pain evaluation scale when assessing deaf patients. The first phase of the qualitative study was to
obtain perceptions from nurses about their experience with pain scales for deaf persons, and the
second phase involved obtaining perceptions from deaf patients about their experiences and
preferences with pain scales. Four hour focus groups were held, audio recorded, and transcribed.
With the numeric rating scale, deaf patients stated that the scale must be adequately
explained before use, emphasizing that 9 or 10 are very strong pain. With the visual analogue
orientation holds different meaning in sign language. With the faces pain scale (FPS), the scale
was not easily understood, because facial expressions are common grammatical elements in sign
language that don’t necessarily correlate with pain. Finally, the Iowa pain thermometer (IPT)
scale was appreciated by participants, at least for intensity of pain, because of its simple format
and clearly vertical lines. Participants suggested using the same color throughout the
thermometer to avoid confusion. One strength of this study was that the findings were useful,
given that little has been researched on the preferences of the deaf population. One weakness of
this study in applying results to the United States is that the study took place in Italy. The study
Conclusion
Various factors contribute to culturally sensitive healthcare, or lack thereof, among the
Deaf and hard of hearing communities. The articles reviewed in this chapter identified common
barriers to this population, providing greater insight into both recommended practices and areas
16
for further research. These studies found that many providers are unaware of the legal
obligations to provide patients with interpreters; furthermore, divulging into more sensitive
topics like sexual identity and mental illness had profound impairment without adequate
Furthermore, research on larger populations of nurses and nursing students could provide
more concrete validation for encouraging more simulation training. The articles also pointed to
the general need for cultural competency training and accommodations for both deaf patients and
deaf students when providing educational materials. When nurses care for deaf patients,
assessment tools such as the Iowa pain thermometer scale are all the more important in providing
accurate assessments. Based on this review of existing literature, nurses and providers require a
series of clear, evidence-based recommendations in order to best support their Deaf and hard of
hearing patients.
17
CHAPTER 3
Best Practice Recommendations: Providing Health Care to Deaf Populations
The purpose of this thesis was to create evidence-based recommendations for best
practice among nurses, health professionals, and parents when addressing the physical and
emotional needs of deaf and hard of hearing patients (see Table 1). This chapter outlines
suggestions that can be used to aid healthcare providers, programs, and facilities how best to
accommodate care for those who are deaf or hard of hearing. These recommendations are
Literature referenced in chapter two discussed the various ways in which access to
American Sign Language (ASL) interpreters is limited within the realm of healthcare (Pertz,
2018). Additionally, many repercussions exist for failing to provide proper interpretation,
whether in the acute care setting or with regards to mental health. For example, patients may not
disclose all relevant health history, or providers may not confirm patient understanding of their
medical treatment. However, if not possible for facilities to provide training or additional
compensation for learning common medical signs within American Sign Language, many areas
One focus is in encourage providers to actively seek to provide culturally competent care
to enhance provider trust. For instance, providers could benefit from understanding that a
characteristic of deaf culture is bluntness. Straightforward and honest dialogue is best, whereas a
phrase like, “it’s not important” can imply that information is being hidden (Hubbard et. al,
2018). Additionally, nurses must avoid language that implies deafness is unwanted, such as when
revealing the results of a newborn hearing screening (e.g. culturally sensitive language such as,
“your child is identified as deaf” instead of, “your child can’t hear”).
18
Table 1:
Pharmacists find Ferguson, M., & Shan, L. (2016). Survey Level III
accessibility to evaluation of pharmacy practice involving
interpreters the deaf patients. Journal of Pharmacy
most significant Practice, 29(5), 461-466. doi: 10.1177/
barrier to 0897190014568379
communication
Deaf patients with Miller, C. A., Biskupiak, A., & Kushalnagar, P. Level III
limited English (2019). Deaf LGBTQ patients' disclosure
Advocate for proficiency benefit of sexual orientation and gender identity
the prompt when credentialed to health care providers. Psychology of
provision of a sign language sexual orientation and gender
medical interpreters are diversity, 62(2), 194–203.
interpreter present https://doi.org/10.1037/sgd0000319
experience
Programs with deaf Level VI
medical students Meeks, L. M., Engelman, A., Booth, A., &
can only work if Argenyi, M. (2018). Deaf and hard-of-
interpreters are hearing learners in emergency
scheduled in medicine. The western journal of
advance for emergency medicine, 19(6), 1014–1018.
didactic and clinical https://doi.org/10.5811/westjem.2018.8.3
activities 8550
Not all nurses are Hubbard, L., D’Andrea, E. & Carman, L. (2018). Level VI
aware that they Promoting best practice for perinatal care
cannot assume a of deaf women. Nursing for Women’s
woman’s degree of Health, 22(2), 126-136.
Provide hearing based on https://doi.org/10.1016/
effective, her ability to j.nwh.2018.02.002
patient- vocalize sounds
centered
communication For those with Pertz, L., Plegue, M., Diehl, K., Zazove, P. & Level VI
and care language and McKee, M. (2018). Addressing mental
communication health needs for deaf patients through an
barriers, as well as integrated health care model. The Journal
social of Deaf Studies and Deaf Education,
marginalization, 23(3), 240-248.
patient centered https://doiorg.ezproxy4.library.arizona.ed
care ensures u/ 10.1093/deafed/eny002
diagnosis
For those with Pertz, L., Plegue, M., Diehl, K., Zazove, P. & Level VI
language and McKee, M. (2018). Addressing mental
communication health needs for deaf patients through an
Promote barriers, as well as integrated health care model. The Journal
cultural social of Deaf Studies and Deaf Education,
competency marginalization, 23(3), 240-248.
effective https://doiorg.ezproxy4.library.arizona.ed
communication u/ 10.1093/deafed/eny002
ensures accurate
history recording
Level III
Majority of law
enforcement Engelman, A., & Deardorff, J. (2016). Cultural
officers found Competence Training for Law
cultural competence Enforcement Responding to Domestic
training cleared up Violence Emergencies With the Deaf and
misconceptions Hard of Hearing: A Mixed-Methods
Evaluation. Health promotion
practice, 17(2), 177–185.
https://doi.org/10.1177/152483991562153
8
Utilize Use hearing status Level VI
culturally instead of saying Hubbard, L., D’Andrea, E. & Carman, L. (2018).
sensitive the child “passed” Promoting best practice for perinatal care
language or “failed” the of deaf women. Nursing for Women’s
hearing test Health, 22(2), 126-136.
https://doi.org/10.1016/
Medical programs Meeks, L. M., Engelman, A., Booth, A., & Level VI
Ensure closed with deaf students Argenyi, M. (2018). Deaf and hard-of-
captioning success by hearing learners in emergency
where captioning medicine. The western journal of
appropriate instructional videos emergency medicine, 19(6), 1014–1018.
within online https://doi.org/10.5811/westjem.2018.8.3
21
None of the Ferguson, M., & Shan, L. (2016). Survey Level III
surveyed evaluation of pharmacy practice involving
pharmacists knew deaf patients. Journal of Pharmacy
they were required Practice, 29(5), 461-466. doi: 10.1177/
to provide and pay 0897190014568379
for an interpreter
Adhere to legal
provider The Americans Hubbard, L., D’Andrea, E. & Carman, L. (2018). Level VI
obligations with Disabilities Promoting best practice for perinatal care
Act (ADA) of deaf women. Nursing for Women’s
encourages a Health, 22(2), 126-136.
discussion at the https://doi.org/10.1016/
first prenatal visit j.nwh.2018.02.002
on the preferred
aids and services,
even if a walk-in
visit
22
Utilize printed The average McKee, M. M., Paasche-Orlow, M. K., Winters, Level VI
visuals to aid reading level of a P. C., Fiscella, K., Zazove, P., Sen, A., &
in patient care. deaf patient is 5th-6th Pearson, T. (2015). Assessing Health
grade Literacy in Deaf American Sign Language
Users. Journal of health
communication, 20 Suppl 2(0 2), 92–100.
https://doi.org/10.1080/10810730.2015.10
66468
Utilize printed A vertical Palese, A., Salvador, L., and Cozzi, D. (2011). Level VI
Iowa pain thermometer is One-dimensional scales for pain
thermometer simple and well- evaluation adopted in italian nursing
(IPT) scale received among practice: Giving preference to deaf
deaf patients for patients. Journal of Nursing
measuring pain Measurement, 19(2), 91-104.
intensity doi:http://dx.doi.org.ezproxy4.library.ariz
ona.edu/10.1891/1061-3749.19.2.91
23
A variety of potential interventions were discussed in this chapter and listed within Table
1. Many recommended interventions can be completed independently by the nurse, providing all
the more reason for nurses to utilize these methods in their care of Deaf and hard of hearing
populations. Some elements of nursing care simply involve enhancing trust by advocating for the
presence of a medical interpreter (Miller et. al, 2019; Hubbard et. al, 2018). Nurses can enhance
contact and respectfully engaged body language (Yuksel & Unver, 2016). While in college or
working, students and nurses can gain more insight into caring for those with language barriers
medical information, facilities already providing educational videos need merely closed
captioning (Meeks et. al, 2018; Hubbard et. al, 2018). With assessing patients, medical scales
like the Iowa pain thermometer (IPT) show to be best for determining pain intensity over
numeric scales. Above all, establishing patient trust is a large element of providing optimal care
nursing care of deaf and hard of hearing patients. These suggestions allow for nurses to improve
practice both in acute settings and outpatient mental health settings where care for these
populations is often lacking. Utilizing these recommendations, nurses can better develop trust
24
with patients and overall empower patients in their plan of care. Further logistics of
CHAPTER 4
hospital and outpatient specialty clinic protocol for providing care for deaf individuals. The
presented will be used by health care providers to ensure staff members are fully supported with
the resources and training to best care for deaf patients. The protocol will include a prompt
within the electronic medical record (EMR), a cultural competency educational model, and
When an individual is admitted to the unit, if they state they have hearing loss, appear to
have hearing loss, or their medical history shows a potential for hearing loss, a decision tree will
automatically appear to prompt the provider to follow the interventions listed in the protocol. For
example, the provider will follow the decision tree and confirm with the patient their hearing
status and whether they identify as Deaf. The provider will ask the patient for their preferred
communication modality. If the patient is unsure, the decision tree will list options, such as
handouts with visuals, pen and paper, an ASL interpreter, and more. The number for the facilities
on-call ASL interpreter could be made available in the system, as well. The decision tree should
also prompt nurses to update the patient’s preferences and any accommodations provided in the
EMR to ensure future health visits run even more smoothly. Within the EMR, there should also
25
be an option for the nurse to chart the patient’s assessment utilizing the Iowa temperature pain
scale.
With the release of the protocol, an educational program for staff will be initiated. The
first component will be a flexible, online module required for staff. The module will focus on
cultural competency within the Deaf population. The course will educate nurses and other
providers on various identities within the Deaf community, such as what it means to be deaf
versus culturally Deaf. Lessons will remind learners of the importance in advocating for a
patient’s preference, including the need for an interpreter if requested. Additionally, the
Americans with Disabilities Act (ADA), title III, will be emphasized, reminding everyone of the
provided and explained, teaching staff the need to ensure deaf patients communicate in a space
with optimal lighting, fully face patients, and maintain eye-contact and lip visibility as much as
possible. Staff should also be direct with deaf patients, use clear and appropriate facial
expressions for the emotions conveyed, and ensure the patient comprehends any information
given.
The second element of the staff education will include in-person training for all staff
members. Training will be either annually or during orientation, depending on the employees’
time of hiring. The primary objective of this in-person training is to simulate caring for a deaf
patient. Depending on the facility’s decision in coordination with the nurse educator, the role of
the deaf patient can either be filled by those attending the training in order to gain additional
perspective, or deaf volunteers from the community can partake in the training. Additional
training could include teachings from the facility’s ASL interpreter(s) on common signs to know,
such as allergy, hurt, where, feel, and more. Utilizing the ASL interpreter can also familiarize
26
staff with one another, and potentially clear up any confusion that may exist, such as how to
operate video remote interpreting (VRI) devices. In-person training would also be helpful to
clarify any confusion on the new EMR protocols for deaf patients.
In order to implement the hospital protocol and supporting educational programs, the
Plan-Do-Study-Act (PDSA) cycle will be used. PDSA cycle will offer a framework for the
implementation of the protocol within one facility. The PDSA cycle is often used as a tool to
incorporate evidence-based research into the clinical setting (Institute for Healthcare
Improvement, 2020). In addition to implementation, this chapter will also highlight the
evaluation of the suggested protocol. The ‘plan’ and ‘do’ sections of the PDSA cycle will be the
framework for the implementation section, and the ‘study’ and ‘act’ sections of the PDSA cycle
The PDSA cycle elements will begin with ‘plan’, which states the objective of the
protocol and develops the plan to test the change, asking what data needs to be collected and
what predictions are being made. The ‘do’ step is when the protocol is tested out on a small scale
and documented for any problems or unexpected outcomes. The ‘study’ step is the period for
analyzing results and comparing data to predictions, summarizing what was learned. Finally, the
‘act’ step determines what modifications must be made in order to prepare for the next test on a
Implementation
Research has demonstrated that decision trees can be an effective method for enabling
providers with a visual reminder of the necessary steps and viable options for a particular
27
situation (Bae, 2014). Furthermore, previous studies mentioned within prior chapters have shown
the effectiveness of simulations in training staff members to care for deaf patients (Mathews et.
al, 2011; Yuksel & Unver, 2016). Providing staff resources, teaching cultural competence, and
utilizing a training program with ASL interpreters and potentially deaf volunteers is a promising
implementation for integrating evidence-based practices into clinical practice. The approach will
be discussed theoretically with the PDSA cycle outline. After implementation and evaluation on
a smaller scale, adjustments can be made for a larger scale, such as at clinics or other hospitals.
Plan. The first step of the PDSA cycle involves a planning process to go over all the
implementation process is to both create the committee in charge of the pilot, and have this
committee decide on the details of the project. The committee would likely consist of the nurse
educator, nurse manager, ASL interpreter, Information Technology (IT) technicians, and
whomever else could provide optimal insight, such as a Deaf member of the community. The
committee will decide how the resources and training will be distributed. The IT technician(s)
will fine-tune the EMR protocol to ensure user-friendliness with the pop-up suggestions and
embedded links. The facility’s resources will also affect the content of the decision tree (e.g.
what will be written about how to reach the ASL interpreter). All involved will determine which
module to require, and all involved will decide on a time and date for the in-person trainings.
Do. The second step of the PDSA cycle involves actually implementing the resources and
training on an initially small scale. Data collection during this time will contribute to later
adjustments of the program. The implementation pilot will be conducted within a single hospital
facility. After creating the decision tree and trainings among the committee members, the
hospital board will be consulted for approval and any necessary editing. When the program is
28
initiated, nurses will fill out online pre-tests on both their knowledge of Deaf culture and
etiquette, as well as survey questions on how comfortable they feel with caring for deaf patients.
Nurses will be required to complete the cultural competency models before attending the
in-person session. In-person sessions can also highlight the new EMR protocol within the unit so
that nurses are familiar with the new resource. Nurses will break into groups and go through
simulations; receive training from the direction of the ASL interpreter; and gain instruction from
the nurse educator on how to operate a VRI device and chart pain for the Iowa temperature pain
scale. At the conclusion, the nurses will have a week to fill out the online post-test and survey
Summary
setting was developed based on research evidence. Previous literature has shown the
effectiveness from simulations with educating and preparing health care providers to care for
deaf patients. For example, the Deaf Strong Hospital, which allowed pharmacy students to gain a
patient perspective on having a communication barrier, received positive feedback from 97% of
participants (Mathews et. al, 2011). Cultural competency trainings have been shown to clear up
misconceptions about the Deaf community and their communication preferences (Engelman &
Deardoff, 2016). Overall, the PDSA model offers a clear outline to implement new programs in
practice, as established with the ‘plan’ and ‘do’ steps (Institute for Healthcare Improvement,
2020). The following section will discuss the ‘study’ and act’ steps of the PDSA cycle.
29
Evaluation
The final portions of the theoretical study involve the ‘study’ and ‘act’ steps of the PDSA
cycle. These steps focus on analysis and improvement based on what was learned from the
implementation of the program. After the evaluation stage, the next step in the future would be to
continue planning another PDSA cycle refined and adjusted to fit a slightly larger scale.
Study. The third step of the PDSA cycle involves analyze the data and results of the
implementation portion of the program. Observations during training sessions from committee
members, results from pre- and post-tests, and comments made within survey sections can all be
taken into account. Any misconceptions with the EMR protocol’s prompts would be taken into
account. Data can also be pulled from the EMR to audit and evaluate how often providers are
documenting the implementation of suggested interventions per the number of deaf patients
admitted. Test results can show whether the modules and in-person sessions enhanced the
knowledge of nurses regarding culturally competent care of deaf patients. The surveys will
provide both guided and open-ended options to allow nurses to report their confidence in their
knowledge and abilities to care for deaf patients. Among the various areas, a large amount of
information is being given: how to ask for a patient’s preferences, how to obtain an interpreter,
how to maintain proper body language, how to use basic ASL signs, how to use and record pain
with the Iowa temperature pain scale, and how to operate VRI. There are numerous resources
and trainings, so running the pilot study is crucial for determining where confusion may emerge.
Act. The fourth and final step of the PDSA cycle involves the chance to modify any
elements of the program that could be improved. If any areas produced low test scores or
confusion within the surveys or observations, these areas would receive additional focus in the
next PDSA cycle. Methods of teaching may require breaking information down more in order to
30
provide optimal clarity. Perhaps certain information taught will be taken out of the program
altogether in order to prevent information overload among the nurses. Once the necessary
changes are determined and implementing, the next PDSA cycle can begin again, this time with
detailed literature review, covering a variety of topics on how health care providers can improve
the social determinants of health for the Deaf and Hard of Hearing populations within the United
States. The literature review highlighted common barriers, such as a lack of interpreters, limited
cultural competency, minimal provider training, and inappropriate pain assessment tools. The
thesis further revealed and highlighted health disparities among this minority group. Though the
thesis was focused on deaf individuals, the thesis captured other disparities among groups such
approach at reaching this target population. The programs suggested could further be
implemented at other hospitals and clinics on a broader scale. By improving the social
determinants of health for the deaf population and creating greater trust between this group and
healthcare providers, improve health outcomes and fewer emergency department visits can be
predicted to result.
The thesis project is primary limited by the amount of existing research available on Deaf
populations. Though many research studies were recent, a large amount of research required
broadening the timeframe as much as ten or more years in order to find useful information.
Existing studies often had lower than desirable levels of evidence, as many were qualitative
31
and/or case studies. Few studies utilized dependent variables and controls that could allow for
generalizations. With the suggested implementation itself, the ability to create cultural
competency modules, if none already exist, could be costly and time-consuming. If a hospital
chooses to run simulations with volunteers from the Deaf community, finding available
individuals annually and with every new nurse orientation could be difficult. Finally, assessment
pieces, such as how well the trainings improve the experience of a deaf patient, or the rates of
deaf patient admittance to the emergency department, could take a long period of time to acquire.
The frequency with which deaf individuals admit to the facility could be low, depending on the
hospital’s size and proximity to deaf populations. In essence, the facility has little control over
the amount of deaf patients who use the hospital, making it uncertain whether nurses will have
the opportunity to care for a deaf individual and evaluate the usefulness of the program.
32
Summary
The following thesis was created to compile best practice recommendations aimed at
significant health disparities among deaf individuals as compared with the general United States
population. Even with the Americans with Disabilities Act, several studies show that not all
providers are aware of the need to provide patients with an interpreter. Many healthcare
providers hold misconceptions about the deaf population, assuming all deaf individuals can read
lips and understand English. When misconceptions and failure to check for comprehension
occur, patients are unaware of the present situation. The negative aspects of uncomfortable
procedures or difficult news become magnified when not respectfully communicated. Even
elements like pain measurement with numeric scale or horizontal scales can be misinterpreted by
the Deaf community because of their associations and understanding of said scales. For many
deaf individuals, Deaf culture is an identity that requires empathy and understanding just as
much as any other culture. Thus, it is crucial that nurses and other healthcare workers strive to
provide this population with intentionally patient-centered care. Nursing programs and hospital
training programs must emphasize the nee for culturally competent care.
comprehensive in-person trainings to target health disparities among deaf populations. This
intervention can be implemented and evaluated using the Plan-Do-Study-Act (PDSA) cycle
framework, giving the opportunity from the nurses and other members involved. Subsequently,
the learning environment allows for identification of necessary improvements in order to ensure
optimal adjustments before expansion to other hospitals and outpatient facilities. Overall,
33
implementing this hospital program, rooted in current evidence-based research, will better equip
nurses and other healthcare workers to build trust and communicate with the deaf community.
34
References
Bae J. M. (2014). The clinical decision analysis using decision tree. Epidemiology and
Engelman, A., & Deardorff, J. (2016). Cultural competence training for law enforcement
responding to domestic violence emergencies with the deaf and hard of hearing: A
https://doi.org/10.1177/1524839915621538
Ferguson, M., & Shan, L. (2016). Survey evaluation of pharmacy practice involving deaf
0897190014568379
https://www.gallaudet.edu/history-through-deaf-eyes/online-exhibition/formation-of-a-
community
Hemberger, L. & Morrow, K. (n.d.) Respecting the deaf community. Retrieved from
https://sites.trinity.edu/sensoryimpariment/respecting-deaf-community
Hubbard, L., D’Andrea, E. & Carman, L. (2018). Promoting best practice for perinatal care of
j.nwh.2018.02.002
Retrieved from:
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChang
es.aspx
35
Mathews, J. L., Parkhill, A. L., Schlehofer, D. A., Starr, M. J., & Barnett, S. (2011). Role-
reversal exercise with deaf strong hospital to teach communication competency and
McKee, M. M., Paasche-Orlow, M. K., Winters, P. C., Fiscella, K., Zazove, P., Sen, A., &
https://doi.org/10.1080/10810730.2015.1066468
McKee, M., Winter, P., Sen, A., Zazove, P., & Fiscella, K. (2015). Emergency department
utilization among deaf American sign language users. Disability and Health Journal,
Meeks, L. M., Engelman, A., Booth, A., & Argenyi, M. (2018). Deaf and hard-of-hearing
1014–1018. https://doi.org/10.5811/westjem.2018.8.38550
Miller, C. A., Biskupiak, A., & Kushalnagar, P. (2019). Deaf LGBTQ Patients' disclosure of
Palese, A., Salvador, L., and Cozzi, D. (2011). One-dimensional scales for pain evaluation
doi:http://dx.doi.org.ezproxy4.library.arizona.edu/10.1891/1061-3749.19.2.91
Pertz, L., Plegue, M., Diehl, K., Zazove, P. & McKee, M. (2018). Addressing mental health
needs for deaf patients through an integrated health care model. The Journal of Deaf
36
10.1093/deafed/eny002
Yuksel, C. & Unver, V. (2016). Use of simulated patient method to teach communication with
deaf patients in the emergency department. Clinical Simulation in Nursing, 12(7), 281-
289. https://doi-org.ezproxy4.library.arizona.edu/10.1016/j.ecns.2016.03.007