BEST PRACTICES IN PROVIDING HEALTH CARE TO DEAF POPULATIONS

By

CHRISTINE MARIE WALSH

____________________

A Thesis Submitted to The Honors College

In Partial Fulfillment of the Bachelors degree with Honors in

Nursing

THE UNIVERSITY OF ARIZONA

DECEMBER 2020

Approved by:

____________________________

Dr. Melissa Goldsmith

College of Nursing
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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.
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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.

Background of Issue Importance

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

themselves as having lost their hearing, nor do they wish to be hearing.

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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

areas (Ferguson & Shan, 2016).

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
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this healthcare gap, many programs unintentionally discourage deaf student from pursuing

specialties like emergency medicine.

Misconceptions also lead to communication errors and hampered provider relationships.

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

ages and the population with hearing loss increases.

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).

Though disparities in communication exist between healthcare providers and deaf

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

within a predominantly hearing world.

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
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(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).

Nurses need to develop a standard of asking “what is your communication preference?”

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

hopefully the field of nursing will accommodate for such possibilities.

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
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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

and hard of hearing populations will be provided.

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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

fewer emergency department visits for non-emergencies.

Establishing Patient Trust

The purpose of the Pertz et. al. (2018) study was to design an integrated mental health

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

that incorporates telemental health services.

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

regression examined the relationships between sexual orientation, patient centered

communication, sharing health information with healthcare providers in the presence of an

interpreter, and disclosing sexual orientation to healthcare providers.

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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

choosing to engage in the study.

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

enforcement officers throughout major cities in California attended a cultural competency

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

significant impact on capabilities (p = .74) (Engelman & Deardorff, 2016). Participants

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

training could be affected by heightened motivation at baseline; it is difficult to say how

effective and well-received a long-term training would be.

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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

open-ended question topics pertaining to the women’s most recent births.

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.
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Assessing Current Provider Training

The research by Yuksel & Unver (2016) sought to provide a decision tree for student

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,

especially in training nursing students.

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
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legal access required for deaf students. The various mechanisms for communicating with deaf or

heard of hearing students were provided as findings in this study.

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

before verbally explaining everything. Additionally, with lectures beforehand, instructional

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

deaf or hard-of-hearing patients communicated in the exact same form.

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.

Ensuring Effective Communication

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

understanding (McKee et. al, 2015)].

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

scale (VAS), interpretation depends on presentation. Specifically, horizontal vs vertical

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

was also limited by a small sample size of nurses and patients.

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

communication via an interpreter. More research is needed on the nurse’s understanding—not

just among pharmacists—of the legal obligations to provide an interpreter.

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.
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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

displayed in Table I, along with levels of evidence for each article.

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

have been researched and identified as steppingstones for improvement.

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”).
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Table 1:

Best Practice Recommendations: Providing Health Care to Deaf Populations

Recommendat Rationale References Level of

ion Evidence
A small team of Hubbard, L., D’Andrea, E. & Carman, L. (2018). Level VI
healthcare Promoting best practice for perinatal care
providers of deaf women. Nursing for Women’s
throughout prenatal Health, 22(2), 126-136.
care and birth has https://doi.org/10.1016/
shown to reduce j.nwh.2018.02.002
anxiety in deaf
Establish women
patient trust
The deaf Pertz, L., Plegue, M., Diehl, K., Zazove, P. & Level VI
community has a McKee, M. (2018). Addressing mental
history of medical health needs for deaf patients through an
mistrust, especially integrated health care model. The Journal
with regards to of Deaf Studies and Deaf Education,
mental health 23(3), 240-248.
https://doiorg.ezproxy4.library.arizona.ed
u/ 10.1093/deafed/eny002

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

A consistent Hubbard, L., D’Andrea, E. & Carman, L. (2018). Level VI

interpreter Promoting best practice for perinatal care
throughout of deaf women. Nursing for Women’s
prenatal, labor, and Health, 22(2), 126-136.
postpartum care https://doi.org/10.1016/
improved women’s j.nwh.2018.02.002
 19

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

Perception of Miller, C. A., Biskupiak, A., & Kushalnagar, P. Level III

patient-centered (2019). Deaf LGBTQ patients' disclosure
communication of sexual orientation and gender identity
increases likelihood to health care providers. Psychology of
of disclosing sexual sexual orientation and gender
orientation to diversity, 62(2), 194–203.
providers https://doi.org/10.1037/sgd0000319

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

Determining a Yuksel, C. & Unver, V. (2016). Use of simulated Level VI

patient’s
communication
preference, keeping
lips visible, and
sitting face-to-face
enhances the
patient’s medical
experience
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
 20

Cultural Miller, C. A., Biskupiak, A., & Kushalnagar, P. Level III

competency (2019). Deaf LGBTQ patients' disclosure
training for of sexual orientation and gender identity
healthcare to health care providers. Psychology of
providers on deaf sexual orientation and gender
culture improves diversity, 62(2), 194–203.
provider skills in https://doi.org/10.1037/sgd0000319
caring for deaf
individuals

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

learning platforms 8550

Hubbard, L., D’Andrea, E. & Carman, L. (2018).

Prenatal clinics are Promoting best practice for perinatal care Level VI
encouraged to have of deaf women. Nursing for Women’s
closed-captioned Health, 22(2), 126-136.
childbirth education https://doi.org/10.1016/
videos for loan to j.nwh.2018.02.002
expecting families

97% of pharmacy Mathews, J. L., Parkhill, A. L., Schlehofer, D. A., Level V

students found role Starr, M. J., & Barnett, S. (2011). Role-
reversal helpful in Reversal Exercise with Deaf Strong
understanding Hospital to Teach Communication
Implement language barriers Competency and Cultural Awareness.
simulation firsthand American Journal of Pharmaceutical
training for Education, 75(3), 1—10.
students and
nurses Nursing students Yuksel, C. & Unver, V. (2016). Use of simulated Level V
better understood patient method to teach communication
patient preferences, with deaf patients in the emergency
body posture, department. Clinical Simulation in
speech speed, and Nursing, 12(7), 281-289. https://doi-
body language after org.ezproxy4.library.arizona.edu/10.1016/
playing both patient j.ecns.2016.03.007
and nurse

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

Summary of Best Practice Recommendations

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

patient-centered care by determining a patient’s communication preference and maintaining eye

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

by partaking in simulation learning (Mathews et. al, 2011). In terms of communication of

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

(Hubbard et. al, 2018; Pertz et. al, 2018).

The recommendations provided in this thesis provide significant improvement in the

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

implementing these recommendations will be discussed in Chapter 4.

CHAPTER 4

Implementation and Evaluation

This chapter will focus on the implementation and evaluation of an evidence-based

hospital and outpatient specialty clinic protocol for providing care for deaf individuals. The

proposed protocol is compiled utilizing recent, relevant evidence-based research. Information

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

annual in-person training simulations.

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

legal obligation to provide accommodations as needed. Finally, general etiquette will be

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

will be the framework for the evaluation section.

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

potentially larger scale (Institute for Healthcare Improvement, 2020).

Implementation

Implementing Hospital Decision Trees and Trainings

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

details involved in implementing the evidence-based program. The objective of 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

detailing what they learned and how prepared they feel.

Summary

The implementation process to apply evidence-based recommendations into the clinical

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

a slightly greater scope.

Strengths and Limitations of Thesis Project

A prominent strength of this best practice recommendation thesis is the inclusion of a

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

as women and LGBTQ individuals. Furthermore, implementation of a decision tree, cultural

competency training, and detailed in-person trainings demonstrate to be a potentially effective

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

overcoming communication barriers among deaf populations. Current literature shows

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.

Current literature supports the implementation of accessible hospital resources and

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

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responding to domestic violence emergencies with the deaf and hard of hearing: A

Mixed-Methods Evaluation. Health Promotion Practice, 17(2), 177–185.

https://doi.org/10.1177/1524839915621538

Ferguson, M., & Shan, L. (2016). Survey evaluation of pharmacy practice involving deaf

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0897190014568379

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