There are approximately 28 million people living in the United States with some type of hearing impairment.1 Individuals with profound hearing loss after a good understanding of spoken language is learned are considered deaf with a lower case "d." Individuals identifying themselves as part of the Deaf community, often using American Sign Language (ASL), are considered part of the Deaf culture and therefore use a capital "D" in the word Deaf.2 Communication barriers between deaf patients and health care providers is a problem to the Deaf community who may receive inadequate medical attention, privacy breaches, and unnecessary stress during medical care/treatment.3
Interventions such as looking at the patient when talking, establishing eye contact, and asking the preferred method of communication will improve the outcome of a Deaf individual's health care visit.4 Lacking these verbal/nonverbal skills by health care providers and employees can cause Deaf patients to develop feelings of insecurity, anxiety, and stress during their medical appointment or hospitalization.5 The communication barrier between a nurse and the nonhearing patient may affect quality of care. Many health care personnel become nervous when dealing with Deaf patients, because they do not know how to communicate with the patient.6 General awareness training of the Deaf community should be provided to nursing students and the nursing workforce.
The purpose of this project was to develop a simulation for nursing students to learn to communicate with the Deaf. Nursing students interacted directly with Deaf participants and received an educational intervention on techniques of communicating with Deaf persons.
Simulation Development
In collaboration with the director of the local center for the Deaf, Deaf persons were recruited to serve as standardized patients (SPs). Although an SP is generally defined as a person trained to consistently portray a patient[horizontal ellipsis]for purpose of instruction, practice, or evaluation,7 for the purpose of this scenario, they played themselves as a Deaf person with a scripted illness. The SPs completed a 2-hour orientation before the simulation and were paid the regular wage for SPs. The SPs were instructed to simulate going to a clinic for gastrointestinal problems. The project was approved by the University Institutional Review Board, and Deaf SPs and prelicensure students, who volunteered to participate, signed informed consents. The simulation was designed by a nursing honors student, facilitated onsite by staff of the Simulation Center, and assisted by an interpreter from the office of the center for the Deaf.
The Deaf SPs received the training to be SPs with an interpreter known to them. During this training, they not only received general training on participation in simulation but were also given the clinical scenario and what symptoms they would have. The SPs were told that the nursing students were given the task of eliciting the history of the present complaint without being told that the client was also Deaf. The SPs did not participate in the debriefing with the nursing students; however, the interpreter was present and shared observations made by the SPs. Generally, the SPs expressed satisfaction with the opportunity and were pleased that the students were learning how to communicate better with the Deaf.
After an initial experience in communicating with the Deaf SP without any previous preparation (a condition often encountered in practice), students received an educational lecture on communicating with Deaf patients. The educational lecture consisted of communication skills for interactions with Deaf persons (see Table, Supplemental Digital Content 1, http://links.lww.com/NE/A397). Communication skills were reviewed by 2 ASL interpreters and the center director for validity before implementation. One week later, students and SPs again interacted, and students participated in a debriefing.
Student Responses to the Simulation Demonstration
When the students initially entered the simulation room, they did not know the patient was Deaf. Student behaviors ranged from minor nervousness to a complete lack of ability to decide what to do. Although 1 student made eye contact most of the time, the student also displayed exaggerated lip/mouth movements. In 1 initial response, the SP did not convey she was Deaf. The SP instead stared at the student with a confused facial expression until the student recognized the SP was Deaf and started writing the questions on paper. At that point, the SP began interacting with the student. In some of the interactions, students' body language revealed that they were uncomfortable during the interaction. For example, students turned away from the SP, which can be interpreted by a Deaf patient in a negative way. SPs expressed the need for nurses to stand close to them, interpreted as the nurse being engaged. Another student during the initial interaction walked out of the SP's room without informing the patient that the student was going to get help. Outside the room, the student asked appropriately for an interpreter; however, leaving the room abruptly and not informing the Deaf patient of the situation may create stress for patients. At the second simulation after having received the education on skills for communicating with Deaf persons, students greeted the Deaf SPs by pointing to their name badge, were better prepared to obtain more detailed information from the SPs, and appeared less nervous and more engaged.
Deaf SPs' Health Care Experiences
When asked about their health care experiences, SPs had both positive and negative responses. One SP with health care training stated that her work history allowed her to understand medical jargon and know what questions to ask her health care team. Another SP indicated that she always educated the nurses and physicians about her needs and the best way to communicate with her. The SPs also shared problems they encountered, such as providers assuming all Deaf patients could lip read and read materials (eg, pamphlets). They also reported feelings of anxiety and annoyance, especially when they could not understand their health care provider.
Implications for Nursing Education
This project was designed to demonstrate the feasibility of a simulation using Deaf persons as SPs and to determine the change in nursing students' communication skills following the experience. Students demonstrated common communication errors, which improved with education. This promoted future advocacy for Deaf.8
This teaching strategy with Deaf SPs could be implemented in other nursing programs. If students are exposed to the Deaf community and learn effective communication tools, they may be better prepared to care for both Deaf patients and the hearing community. According to Velonaki and colleagues,9 exposure to Deaf patients can increase a health care provider's cultural competency of the Deaf community, leading to an improved standard of care. Another recent study by Middleton and colleagues10 concluded that improved communication for the Deaf could be realized by increasing deaf awareness training for health professionals.
Finally, the opportunity to serve as SPs has been shown to be meaningful to persons with disabilities. Smeltzer and colleagues11 engaged SPs with disabilities through focus groups and identified key themes on their experiences. Themes included a desire to improve care for others, joy in seeing students learn, and appreciation in having a voice in educating future nurses to be more sensitive to care for persons with these specific needs.11 In the current example, partnering between the college of nursing and the community center for the Deaf was viewed by both parties as beneficial.
Because the simulation and educational intervention focused on basic skills, it was appropriate for nursing students in an introductory health assessment course. It also could be used in an interprofessional simulation for multiple health professions. The simulation enhanced the awareness of the Deaf community among nursing students and has potential for use in other prelicensure nursing programs.
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