Clinical Communication with Patients who are Deaf or Hard of Hearing

abstract human face 3d illustrationIt is 1 o’clock Saturday morning and the police have just arrived with a middle aged man to book into jail for an assault that took place in the city an hour ago. He has abrasions on his face, neck and hands; he is observant and seems compliant with the officers’ instructions. Custody staff complete booking and he is brought to medical for intake health screening. The officer tells the nurse that the man is deaf. The nurse writes on a notepad “Can you read and write?” The detainee nods his head affirmatively. The nurse puts the intake screening form in front of the detainee and points to each question on the form. The detainee nods his head in a “no” gesture to each of the screening questions. The nurse takes vital signs, examines the abrasions, applies a bactericidal ointment and then observes the detainee while he is changing into the jail uniform. His deafness and abrasions are noted; no other problems are identified by the nurse and the detainee is given a handbook that explains how to access health care when he is released to housing.

Did this nursing encounter meet the standard of care for persons in correctional settings who are deaf or hard of hearing?

The components of receiving screening defined by the American Corrections Association (ACA) and the National Commission on Correctional Health Care (NCCHC) are that a screening form is used to inquire about the status of each detainee’s health and that reception personnel observe the detainee’s condition for signs of illness or injury before making decisions about disposition. NCCHC also states in the discussion of the standard that “Receiving screening is conducted using a form and language fully understood by the inmate, who may not speak English or may have a physical (e.g., speech, hearing, sight) or mental disability” (2014, page 72). The nurse modified how the receiving screening data was collected when the detainee indicated that he could read and write. Literally interpreted the accreditation standards were met. But were best practices used to screen for potential emergency situations, treating illness or continuing prescribed medication?

The Americans with Disabilities Act passed in 1990 establishes specific requirements that apply to persons who are deaf or hard of hearing in correctional settings. These include:

  • Giving primary consideration to providing the aid or service requested by the person with the hearing disability.
  • Communication aids and services may not be denied except when a particular aid or service would result in an undue burden or a fundamental change in the nature of the law enforcement services being provided.
  • Only the head of the agency or his or her designee can make the determination that a particular aid or service would cause an undue burden or a fundamental change in the nature of the law enforcement services being provided.
  • Not charging for communication aids or services provided.
  • Providing effective, accurate, and impartial interpreters when needed.

In this case the nurse did not inquire about the type of communication aid or service the detainee preferred but instead only asked if the detainee could read and write. Relying on writing or pointing to items is effective communication for brief and relatively simple face-to-face conversations. Having the detainee fill out the health history portion of the intake screening form may be appropriate if he is literate enough in medical terminology. While many who are deaf and hard of hearing indicate the ability to read lips nurses need to be cognizant that only about 30% of what is said can be accurately interpreted (Shuler et. al., 2013). If the detainee indicates he has any medical or mental health problems, is seeing a provider in the community or is taking medication the nurse will have to use a more interactive and accurate communication method. These include:

Sign language interpreters: There are several kinds of sign language, including American Sign Language (ASL) and Signed English. When arranging for an interpreter be sure to ask what form of sign language the detainee uses.

Oral and cued speech interpreters: Some individuals have been trained in lip reading and with assistance from an interpreter can understand spoken words fairly well.

Transcription services: Many people who are deaf or hard of hearing are not trained in either sign language or speech reading. There are several types of devices that allow a person who is deaf or hard of hearing to communicate by typing. These include Computer Assisted Real-time Transcription (CART) and text telephone (TTY or TTD).

Video services: use high speed internet and wireless connections to link a camera or videophone that transmits sign language to an interpreter who conveys the message verbally to the hearing person.

Each state defines the education and training required to be considered a qualified interpreter and may also require certification. Since the ADA requires that interpreters in correctional settings be effective, accurate, and impartial special care should be taken in arranging for interpreters. Using staff who “know sign language” or family members to interpret may not meet these criteria. Further the nurse needs to document in the detainee health record what effort was made to inquire about communication preferences, arrangements made to provide assistance and if an interpreter is used document their name, certification or qualification and contact information.

The detainee in this example was scheduled to be seen by a nurse the following day to review the intake screening information and complete the history portion of the initial health assessment. Correctional staff at booking inquired about the detainee’s communication preferences and had noted in the classification system that he used American Sign Language (ASL). The nurse was aware of this and made arrangements for the presence of a qualified interpreter at the nursing encounter the next day. The ADA does not require that the services of an interpreter be immediately available  at intake for example but that arrangements are made in a reasonable amount of time when they are necessary.

Best practices summary

• Before speaking, get the person’s attention with a wave of the hand or a gentle tap on the shoulder.

• Face the person and do not turn away while speaking.

• Try to converse in a well-lit area.

• Do not cover your mouth or chew gum.

• Minimize background noise and other distractions whenever possible.

• When you are communicating orally, speak slowly and distinctly. Use gestures and facial expressions to reinforce what you are saying.

• Use visual aids when possible, such as pointing to printed information or photos.

• When using an interpreter, look at and speak directly to the deaf person, not to the interpreter.

  • Talk at your normal rate, or slightly slower if you normally speak very fast.
  • Only one person should speak at a time.
  • Use short sentences and simple words (U.S. Department of Justice, Civil Rights Division, Disability Rights January 2006).

It is estimated that up to nine percent of the population has some degree of hearing loss, and this percentage will increase as the population ages. So as correctional nurses, we expect to come into contact with people who are deaf or hard of hearing. In your opinion was the standard of care met in the intake screening and assessment of this detainee’s health status? What are the challenges in providing nursing care for detainees who are deaf or hard of hearing? Please share your opinions and experience by responding in the comments section of this post.

For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.


American Corrections Association. (2010). 2010 Standards Supplement. Alexandria, VA.: American Corrections Association.

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

Shuler, G.K; Mistler, L.A.; Torrey, K.; Depukat, R. (2013). Bridging communication gaps with the deaf. Nursing 2013 43 (11): 24-30.

U.S. Department of Justice, Civil Rights Division, Disability Rights. (January 2006). Communicating with People Who Are Deaf or Hard of Hearing: ADA Guide for Law Enforcement Officers. Accessed June 16, 2014 at

U.S. Department of Justice, Civil Rights Division, Disability Rights. (October 2003). ADA Business BRIEF: Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings. Accessed June 16, 2014 at

Photo credit: © koya979 –

Health Literacy Tools and Resources

photo“Nurses at a large maximum security prison are teaching patients about sexually transmitted diseases. While the inmates await their chronic care appointment in the clinic holding area, they are given written material printed from the Centers for Disease Control website. During the nurse portion of the chronic care visit, each inmate is asked if they received the material and if they have any questions. If they have no questions, the nurse documents successful patient teaching on the topic in the medical record.”

This example (page 11) from the Essentials of Correctional Nursing invites us to think about the situation and to “Describe flaws in this process and suggest improvements in the teaching method.”  Last week’s post pointed out that at least 36% of the population have limited health literacy. The following are “best practices” to improve health communication. How many would apply to the case example above?

Identify the audience and focus the message: Our ability to understand and act upon communication is effected by the factors listed below:

  • age
  •  gender
  •  race
  •  ethnicity
  •  religion
  •  sexual orientation
  •  economic experience
  •  language
  •  communication ability
  •  occupation
  •  life experiences
  •  attitudes
  •  behavior
  •  social experiences


  •  cultural experiences
  •  beliefs

Communication of health information will be more relevant if it is sensitive to the characteristics of the intended audience. For example, would youth at a detention facility prefer to receive information about basic oral hygiene via a cartoon with rap music or in a film of a dentist in an office setting brushing a large set of false teeth? These options and many more are available for free on Youtube, just type in the search term, oral hygiene. The more the information and it’s delivery can be tailored to the preferences of the audience the more successful the communication will be.

Best Practices for Oral Communication: The problem with verbal information is that patients only retain about half of what they are told and they are uncomfortable asking to have information repeated.  To increase patients’ retention the following are considered “best practices”:

  • speak slowly and keep the message simple
  • limit the amount of advice to no more than 4 points
  • cover the most important point first
  • advice should focus on patient behavior that is the most important to a good outcome
  • organize information logically with the simplest coming before more complicated information
  • give concrete, specific and vivid instructions; avoid abstract or general statements
  • use active rather than passive voice
  • use plain language and a thesaurus to avoid medical terminology or jargon

Best Practices for Print Communication: Patients prefer to have pictures or graphics accompany written information. Pictures also improve comprehension.  Printed material should not replace personal interaction and is most effective when it reinforces verbal information. Patients prefer information presented with simple visuals especially when ill or adjusting to a new diagnosis. The following are “best practices” for print communications:

  • the most important point should appear first
  • use 12 point font, limit sentences or lines to 40-50 characters.
  • use headings and bullets to break up text
  • avoid using all capital letters (this is akin to shouting), italics or fancy script
  • use a lot of white space in the margins, between points and to separate paragraphs or ideas
  • avoid decoration; all print material should be specifically relevant to the point being made
  • pictures are encouraged when the picture
    is linked to the text
    is concrete, not complex
    supports key points
    is without unnecessary detail

Evaluate the Patient’s Understanding of the Message: Don’t assume that the patient understands if they don’t ask any questions.  In fact asking patients to restate what they have been told is among the top patient safety practices recommended by the Agency for Healthcare Research and Quality in their 2001 report.  This technique, referred to as “teach-back”, improves retention and allows the nurse to correct misunderstandings.  The following are tips on how to evaluate patient comprehension:

  • Ask open ended questions. In the example above it would be better if the nurses asked “What questions do you have about sexually transmitted diseases?” rather than “Do you have any questions about STDs”
  • Questions that start with “what” or “how” are more likely to be open ended.
  • Ask the patient to tell you in their own words what they understand. One way to do this is to say “I want to make sure I didn’t leave anything out so would you please tell me in your own words what we have discussed” or “What will you tell your (family member) about your condition?”
  • Present the patient with a problem or scenario to see if the patient can apply the information. The nurse might ask the patient receiving STD education “What should you do if you experience pain and burning upon …”
  • If the patient is unclear about one of the points, re-phrase the information rather than repeat it.

The flaws in the example at the beginning of this post are:

  • the material provided does not appear to have been selected with a specific audience in mind
  • printed material was used in lieu of oral communication
  • there was no evaluation of the patient’s understanding of the information given

Here are some tools and resources to address health literacy:

1. Clear Language and Design evaluate readability, examples, online Thesaurus

2. Plain language thesaurus

3. More on Plain Language

4. Creating easy to understand materials

5. Clear & Simple: Developing Effective Print Materials

6. Health Literacy Tools

7. Gateway to Health Communication and Social Marketing

8. Health Communication, Health Literacy, and e-Health

What resources have you found particularly helpful in addressing the care of patients with low health literacy? Please tell about your experience, success and resources addressing health literacy in the correctional population by responding in the comments section of this post.

To read more about correctional nursing practice order your copy of the Essentials of Correctional Nursing directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: Catherine Knox 2/28/2013

Cultural Competency

CULTURE. Wordcloud illustration.Inclusion of a patient’s cultural preferences into the plan of care when at the same time the correctional setting demands that we be “firm, fair and consistent” in all our interactions with offenders is a distinguishing feature of correctional nursing. Weiskopf describes this feature as nurses negotiating the boundaries between custody and caring (2005).  Incorporating the patient’s cultural preferences into nursing care has been part of the ANA’s Corrections Nursing: Scope and Standards of Practice since the first edition in 1995 (2007, pg. 74).

Failure to address ethnicity, culture and language has been found to exacerbate health disparities and lower health care quality according to a recent Cochrane Review (Horvath 2011). Cultural and racial minorities are disproportionately represented in the corrections population. The health needs of these groups are discussed at length in the Essentials of Correctional Nursing.  In correctional settings inmates do not get to choose their health care provider and likewise nurses cannot pick their patients, therefore it is inevitable that challenges, misunderstandings and conflict resulting from diverse cultures will occur.

Cultural competence is the ability to effectively provide nursing care to patients from different cultures. Take moment to think about your experiences addressing patients’ cultural preferences when providing nursing care in the correctional setting. What successes would you like to share? Please write us in the comments section of this post?  The paragraphs below describe how to build cultural competency.

Self-Awareness: First we must become aware of how our own views may differ from others.  Mark Fleming, PhD., with the Missouri Department of Corrections, described this as “being willing to take a step on a journey of transformation…” in a recent interview with Lorry Schoenly at  A starting place for this journey is to assess our cultural competence. One great resource was specifically developed for primary health care providers and can be accessed at

Communication: As we experience more diversity, the potential for conflict and misunderstanding increases and the ability to communicate effectively becomes even more important (Pearson, 2007). Effective patient-centered communication is characterized by:

  • an absence of assumptions
  • use of open-ended questions
  • active listening
  • expression of empathy
  • non judgmental words and behavior

What are the tools within the organization that support diversity? How do policies, procedures and clinical protocols support cultural differences and preferences for care?  Are qualified interpreters available for communication with patients?  Have staff been taught how to conduct an effective patient encounter when using an interpreter?  Are patient information materials culturally relevant? Communication tools that support culturally sensitive healthcare delivery can be accessed at

Knowledge: Cultural competence is a dynamic rather than static process so one class in cultural diversity isn’t enough.  Understanding how illness is experienced by different cultural groups enables nurses to better tailor care for individual patients.  We may be able to leverage help from the ethnic and cultural resources at our facility and within the community to deliver health care that is more relevant and effective with particular patients. These resources may also be able to provide meaningful emotional and social support for the patient.    A free online course in culturally competent care specifically developed for nurses is available at and offers 9 CE credits.

Summary:  My favorite tool is a list of 37 concrete things that demonstrate cultural competency in providing primary health care services. The list can be posted in the clinical area as a handy reference. It also can be used to compare against actual practice and then to build an improvement plan. This resource may be obtained at   Read more about the cultural diversity and related health care needs of our patient population in the Essentials of Correctional Nursing.  Order your copy of the book directly from the publisher and use promotional code AF1209 for $15 off and free shipping at


American Nurses Association. (2007). Corrections Nursing: Scope & Standards of Practice. Silver Spring, MD: American Nurses Association.

Horvath, L. (2011) Cultural competence education for health professionals. Cochrane Database of Systematic Reviews, (10)

Pearson, A. (2007). Systematic review on embracing cultural diversity for developing and sustaining a healthy work environment in healthcare. International Journal of Evidence Based Healthcare. (5), 54-91.

Registered Nurses’ Association of Ontario (2007). Embracing Cultural Diversity in Health Care: Developing Cultural Competence. Toronto, Canada

Weiskopf, C. S. (2005). Nurses experience of caring for inmate-patients. Journal of Advanced Nursing, 49, 336-343.

Photo Credit: © Login –