Nurse practitioner perceptions of barriers and facilitators in providing health care for deaf American Sign Language users: A qualitative socio‐ecological approach

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Deaf American Sign Language (ASL) users make up a unique culture often unknown or overlooked by the general population. The majority of individuals who identify themselves with deaf culture were deaf before acquistition of sound‐based language and learned ASL as their primary language. ASL as the primary and preferred communication is actually the strongest binding factor within this culture. Many hearing people mistakenly believe that ASL is simply hand gestures applied to the English language. However, ASL is a complex, visual‐spatial language with syntax and sentence structure very different from English (Holcomb, 2013).
The purpose of this article is to report findings from qualitative research examining nurse practitioner (NP) perceptions of barriers and facilitators to providing health care for people who are deaf and use ASL as their primary mode of communication.
Health care is more effectively communicated in a person's primary language. This is just as applicable to the deaf ASL user. Unfortunately, quality healthcare communication in ASL is rarely provided. The most common methods healthcare providers use to communicate with deaf ASL users are speech‐reading, note‐writing, familial interpreters, and/or gesturing. These methods often lead to barriers, substandard health care, or at best, ineffective communication (Kuenburg, Fellinger, & Fellinger, 2016; Scheier, 2009). Many hearing people, including health professionals, assume most people who are deaf can effectively read lips. Lip‐ or speech‐reading is rarely an effective mode of communication; people who are hard of hearing or became deaf later in life after having primarily communicated in spoken English are more likely to speech‐read (Sheppard, 2014). Only about a third of the English language is visible on the lips in optimal conditions such as good lighting, speaker is close, looks directly at the reader, and has no facial hair, tics, or other hindrances. The rest is guesswork or interpretation based on context, expressions, gestures, and surroundings. In a complex environment such as health care, accurately filling in gaps becomes much more difficult.
Note‐writing all complex healthcare communication would rarely be effective for anyone, especially a nonmedical person. Even with highly educated and fluent readers, note‐writing for vital and sensitive communication restricts the flow of interactive discussion. Reading and comprehension is phonetically based. Reading proficiency is challenging to achieve for people who have never heard the language (Mayer & Trezek, 2014). Therefore, deaf ASL users often have a much lower reading level than the general population (McKee et al., 2015).
The use of family members or friends of deaf ASL users as interpreters is rarely effective for several reasons. Family and friends may know some ASL but may not be fluent. In fact, the majority of deaf ASL users do not have a single family member with whom they can converse fluently. If nonfluent family members then try to interpret complex medical terminology they struggle to understand, this compounds the potential for misinterpretation. Furthermore, the deaf ASL user should have the same autonomy and privacy as any other adult. Vested family members may interpret what they want the deaf ASL user or provider to know. Deaf ASL users may want or need to discuss sensitive issues with a provider they may not want the family member acting as interpreter to know (Kuenburg et al., 2016; Scheier, 2009).
The Americans with Disabilities Act (ADA, 1990) requires that healthcare providers ensure equal healthcare treatment and effective communication for people who are deaf or hard of hearing. Equal access includes the same considerations of confidentiality and autonomy as that provided for other patients seen in the same setting. Generally, speech‐reading, gesturing, note‐writing, and use of a familial interpreter do not meet ADA requirements.
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