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Department: PATIENT SAFETY

Tune into safety for hearing-impaired patients

Smith, Linda S. PhD, MS, RN, CLNC

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doi: 10.1097/01.NURSE.0000461842.08906.27
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In Brief

MRS. S, AN 89-year-old-widow, lives independently in a senior apartment complex. Although her moderate hearing loss has worsened over the past few years, she's maintained good health and a remarkable level of self-care for her age. Mrs. S takes six different medications daily, including an antihypertensive drug and low-dose aspirin.

Mrs. S comes to a busy clinic with signs and symptoms of a urinary tract infection. While teaching her about her newly prescribed medications, her nurse realizes she hasn't heard any of the instructions. What should the nurse do?

To help answer the question, this article outlines how a patient's hearing impairment impacts patient safety, technology enhancements that help mitigate hearing loss, and nursing care strategies that nurses can use when caring for hearing-impaired patients like Mrs. S.

Looking into hearing loss

Hearing loss, the most common sensory deficit in humans,1 diminishes quality of life and impairs the ability to communicate in everyday life. The World Health Organization (WHO) defines hearing loss as a sensory impairment in which a person can no longer hear at a normal level. WHO defines deafness as near-total or total hearing loss in both ears.2

The prevalence of hearing loss in the United States is huge. Using a large, well-characterized representative sample within a data analysis research study, Lin and associates reported an estimated 30 million Americans age 12 and over experience bilateral hearing loss, or about 12.7% of the U.S. population.3 This number increases to 48.1 million, or over 20% of all Americans, when unilateral hearing loss is also included.

Risk factors for hearing loss include gender and age: More men than women are affected, and older people are more likely to be affected than younger ones. Researchers predict greater numbers of Americans with hearing loss as the population ages.3

Impact on patient safety

With more than one-fifth of all Americans experiencing hearing loss, nurses are increasingly likely to care for patients with this sensory deficit. Nonadherence to the treatment plan, including prescribed medications, is greater among patients experiencing hearing loss.4 Because it results in higher healthcare costs and greater morbidity and mortality, nonadherence has a significant negative impact on patient safety.4

In fact, Cardenas-Valladolid et al. found that hearing-impaired older adults taking multiple medications had double the risk of nonadherence when compared with others without hearing loss. This nonadherence occurs, they surmised, because hearing-impaired older adults have a poor understanding of the patient teaching provided by nurses and other healthcare professionals. They also found that healthcare professionals significantly overestimated their patients' adherence to prescribed therapies. A lack of good communication between healthcare professionals and patients was the real problem, they concluded.4

Legal concerns

Safe nursing care depends on good communication between nurses and patients. Equal access to safe, effective care is mandated by federal antidiscrimination laws. Legally, nurses have an obligation to do whatever it takes to effectively communicate with patients who are hearing impaired. For example, nurses are expected to ask the patient or the family to explain the patient's communication needs and describe the communication services required.5

Without good communication, patients and caregivers can encounter these barriers to safe patient care:

  • The nursing process isn't appropriately implemented.
  • Patients misunderstand important information.
  • Informed consent for treatment isn't provided.
  • Medication regimens aren't followed.5

Nurses should be aware of their patients' needs, willingly listen to their needs, and remain flexible and open to providing necessary support services.6 Nurses must also be aware of all support services and resources available in their facility to facilitate communication.

Don't let family and friends act as language interpreters. They don't have adequate medical interpretation skills and are too personally and emotionally connected to their loved one to remain objective. Their involvement can lead to role confusion, breach patient confidentiality, cause a conflict of interest, and prevent effective, accurate, and impartial communication between the patient and the healthcare team. Always rely on a trained language interpreter, if available, or an assistive device or strategy approved for use in your facility. (See Technology-enhanced solutions.)

Care strategies

First and most important, ask hearing-impaired patients for their preferred methods of communication.5 In a clinic or outpatient setting, the message can be conveyed with posters, appointment screen messages, and flyers.6

In an inpatient facility, admission procedures include hearing assessments.7 When deficits are identified, they should be highlighted in the patient's medical record. Then add a screen message that all staff will see.6 Ask how the patient prefers to communicate; for example, by lip reading, language interpreters, written information and notes, voice recognition software, or a combination.5,6 Remember that during times of stress, fatigue, and illness, patients have a reduced ability to concentrate and focus, and a reduced ability to write and read information, thereby worsening their ability to hear and understand.8

Encourage your hearing-impaired patients to wear hearing aids (if available) and learn sign and/or lip-reading strategies.6 Be aware, however, that lip reading is inaccurate and shouldn't be relied upon as a communication vehicle.5 Nurses can take continuing-education classes that focus on the care of hearing-impaired patients.

After determining the strategies and enhancements the patient will need to communicate clearly and safely with you and other healthcare providers, plan to accommodate these needs. Make accommodations to the best of your ability, in accordance with facility policy and federal regulations.5

Even when using a language interpreter, face your patient, position yourself on the same level, and make direct eye contact. Keep bright lights on you, not your patient. Speak directly to the patient, not into a computer screen, and avoid interrupting the patient. As much as possible, keep extraneous noise and distractions to a minimum.6-8

Speak clearly and distinctly, but not too slowly or in an exaggerated way. Never shout. Preface main conversation topics with your patient's name. Eliminate medical jargon whenever possible; use short words and short sentences. Talk about one topic at a time, and before changing topics, ask your patient to repeat to you what he or she understands. When misunderstandings occur, explain things in a different way rather than saying the same phrase over and over.8

Courteously and empathetically listen to your patient and watch the nonverbal responses for signs of misunderstanding. If the patient misunderstands something, correct him or her in a respectful way.

If using a technology-enhanced communication device, make sure you're thoroughly familiar with how it works and continuously evaluate its quality, usability, and effectiveness.

Put important information in patient handouts. Here's where voice recognition software (speech to text) can be very helpful. Clearly dictate words into the microphone, show the on-screen written transcript during your conversation and dictation, and give related printouts to your patient. With all written information you share, consider carefully the patient's literacy level and language skills.

If you work in a clinic or outpatient facility, encourage hearing-impaired patients to book and confirm appointments electronically through text messages, secured online website scheduling, or e-mail. Also, instead of calling hearing-impaired patients from the waiting room, use a visual call system display using their first name and last initial or walk over to them and escort them to the exam room. Don't violate patient privacy by speaking loudly within the hearing range of others.

Speak up for safety

While performing patient teaching with Mrs. S, her nurse asks her what communication strategies will best help her understand her new medications. She says she's a high school graduate who's literate in English and that although she's very hard of hearing, she'll be able to “catch” most things as long as the nurse takes her to a quiet private place, speaks slowly, faces her at eye level, and supplements the teaching with printed information.

During the teaching process, the nurse periodically asks Mrs. S to repeat important points and provides feedback as needed. At the conclusion of this teaching/learning session, Mrs. S thanks her nurse for all the help and support. She says that because the nurse took extra time with her, she feels quite confident that she'll be able to take her new medications exactly as prescribed.

Technology-enhanced solutions

New tools for those who are hearing impaired seem to be emerging at a dramatic pace. In-person on-site interpreters may not be available during emergencies and crises, and alternative technology-based solutions may be needed. A few of the technology-based services nurses may need to implement for their hearing-impaired patients are described here. When using them, patient needs and wishes must be respected, nondiscrimination laws followed, and privacy, confidentiality, and Health Insurance Portability and Accountability Act compliance must be assured.

  • Video Relay Services (VRS) are used when the patient and nurse are in different locations and the patient understands and uses signing. VRS users employ computer monitors and webcams. Real-time communication occurs when the sign language user signs to the video interpreter who, in turn, provides voice interpretation to the nurse.9
  • Captioned Telephone (CapTel) assists hearing-impaired patients with a word-for-word caption of their telephone conversation. This is similar to a captioned movie or TV program in that the listener can hear the person's voice as well as “see” his or her words as typed by a transcriptionist. Via web or specialized telephone, conversations between two persons in different locations are transcribed by a third person in real time; this transcription appears on a display monitor or screen. Hearing-impaired patients can then read the text of everything said by the nurse during their telephone discussions.9
  • Communication Access Real-time Translation (CART) is a real-time (immediate) assistive written translation of what's said that's converted into a digital display using specialized computers, software, and stenography machines. This method is primarily used for hearing-impaired patients who don't use sign language. All spoken information is transcribed into English by a trained stenographer and displayed on a video screen.5,9 CART isn't a telephone service; instead, it's an opportunity for real-time captions that can be displayed on a small screen for one person (such as during a one-on-one teaching/learning session), an overhead projector for small groups, or broadcast on larger screens or the Internet. It works very well for classrooms and meetings when hearing-impaired patients are attending presentations or group sessions, such as during diabetes education classes.9
  • Video Remote Interpreting (VRI) is used when the nurse and patient are in the same location and the hearing-impaired patient understands and uses sign language. This interpreting service is used only if and when a live on-site qualified sign language interpreter isn't available. The video interpreter, present via Internet-based video conferencing technology, can listen to and see the conversation between nurse and patient and interprets the conversation using voice and sign. VRI is useful in remote rural areas as well as in emergency situations that require accurate, qualified sign interpretation.9,10
  • Voice recognition software and computer-generated displays and printouts can also be employed. Voice recognition software has been used to streamline medical documentation. Nurses are also using this technology to communicate with hearing-impaired patients. Using voice recognition software on a laptop or other device, speech is almost instantly displayed on a computer monitor. If the patient is also visually impaired, the font size can be enlarged and a printout of the display given to the patient—all in real time and all while the patient sees as well as “hears” the nurse speaking.

REFERENCES

1. Deuster D, Matulat P, Schmidt CM, Knief A. Communication skills for interviewing hearing-impaired patients. Med Educ. 2010;44(11):1130–1131.
2. World Health Organization. Prevention of blindness and deafness. 2013. http://www.who.int/pbd/en.
3. Lin FR, Niparko JK, Ferrucci L. Hearing loss prevalence in the United States. ArchIntern Med. 2011;171(20):1851–1852.
4. Cárdenas-Valladolid J, Martín-Madrazo C, Salinero-Fort MA, et al. Prevalence of adherence to treatment in homebound elderly people in primary health care: a descriptive, cross-sectional, multicentre study. Drugs Aging. 2010;27(8):641–651.
5. National Association of the Deaf. Questions and answers for health care providers. 2013. http://nad.org/issues/health-care/providers/questions-and-answers.
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7. UW Medicine. University of Washington Medical Center. Culture clues: communicating with your head-of-hearing patient. 2012. http://depts.washington.edu/pfes/PDFs/HardOfHearingCultureClue.pdf.
8. UCSF Medical Center. Communicating with people with hearing loss. 2015. http://www.ucsfhealth.org/education/communicating_with_people_with_hearing_loss.
9. U.S. Department of Labor Office of Disability Employment Policy. Relay services factsheet. 2013. http://www.dol.gov/odep/categories/workforce/rs_factsheet.htm.
10. National Association of the Deaf. Position statement: VRI services in hospitals. 2008. http://www.nad.org/print/issues/technology/vri/position-statement-hospitals.
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