Credit goes to Nancy Kingsley, author of Hearing Loss Association of Pennsylvania
Hospitals are required by law to provide access to people with disabilities, and this includes the provision of effective communication to those with hearing loss, whether they are patients or persons who have the authority to make healthcare decisions for the patient. (If the hospital has educational programs for the public, appropriate auxiliary aids and services to ensure effective communication must also be provided for them.)
Important medical information must be clearly understood by the patient (or persons who have the authority to make healthcare decisions for the patient), and the patient must be able to express important information to the provider. Examples include discussions about diagnosis/treatment options, financial obligations for services, and instructions for home care. The hospital does not necessarily have to provide a specific device or service that the patient requests if another aid or service that is more cost-effective will still enable clear, effective communication. It cannot, however, assume that a specific accommodation will work without the patient’s input into the decision. One-to-one communication often requires different accommodations than a group setting where many people will be talking.
The Department of Justice has posted an information bulletin about communication access for deaf and hard hearing people for hospitals at http://www.usdoj.gov/crt/ada/hospcombr.htm. However, the DOJ bulletin focuses primarily on deaf individuals who use sign language interpreters. This publication is therefore intended to complement the DOJ bulletin by providing more information about the communication access needs of the majority of people with hearing loss, who do not use interpreters.
This document is in three parts. The first part gives basic information about hearing loss, assistive equipment for hard of hearing people, and signage. The second part provides information that hospital staff members should know in order to communicate effectively with hard of hearing patients. Current and new employees need to be familiarized with the ways to recognize and accommodate hearing loss as part of their training, and this training should be periodically reinforced to ensure that it is both remembered and utilized. The third part lists sources of additional information.
PART 1: ABOUT HEARING LOSS
Terminology usage varies. People may refer to themselves as “hard of hearing,” “hearing impaired,” late-deafened,” “deaf,” or may say they have a “hearing loss.”
Most people with hearing loss do not use sign language or sign language interpreters. Most rely on residual hearing, hearing aids, cochlear implants, and/or assistive listening devices; some use CART (realtime captioning) or oral interpreters. Note that hearing aids and cochlear implants do not restore normal hearing. This publication focuses on the communication access needs of the nonsigning hearing loss population.
Many are unwilling to identify themselves due to the stigma of hearing loss, or they may deny having such a loss. They are often unaware of the assistive devices and techniques that could improve communication. Their communication needs are often ignored, which may interfere with their understanding of their condition and its treatment.
The Range of Hearing Loss
Hearing loss ranges from mild to profound and can vary across the frequency range (many people have a greater loss in the high frequencies). With a mild loss, hearing is compromised in a noisy setting; with a moderate loss, people require a hearing aid or assistive listening device that amplifies sound. Those with a severe to profound hearing loss may need to utilize speechreading, written communication, and captioning. Note that speechreading—often called lipreading— is mostly useful as a supplement to residual hearing, and not everyone has this skill. In addition, some speakers are harder to speechread than others.
In a Better Hearing Institute survey published in 2005, 31 million people are currently estimated to suffer from hearing loss. Of those 31 million, 29 million people are hard of hearing and 2 million are deaf. And of those 2 million, 1.5 million are late-deafened (deafened after the acquisition of spoken language), according to Working Effectively with Persons Who Are Hard of Hearing, Late-Deafened, or Deaf, published by Cornell University. Percentagewise, according to the Centers for Disease Control, approximately one out of 10 persons has a hearing loss, and the number increases to one of out every three persons at the age of 65. Sixty percent of people with hearing loss are between 21 and 65. In the past, hearing loss was typically associated with aging, but it is now occurring at much younger ages due to exposure to noise.
Statutory and Regulatory Requirements
Hospitals are held to federal standards that require accommodation of people with hearing loss. Along with federal mandates, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has also established standards for hospitals.
The Americans with Disabilities Act (ADA) requires hospitals to provide equal communication access for people with hearing loss. Title III of the ADA covers privately owned healthcare facilities and Title II covers state-owned facilities. Section 504 of the Rehabilitation Act of 1973 covers facilities that receive federal funding and requires accommodations for people with disabilities.
The majority of hard of hearing people can be accommodated by using simple techniques such as making sure that they can see the face of the person speaking to them and that they are wearing their hearing aids. That is why staff training is so important. Others, with a more severe hearing loss, may require an assistive listening device, notetaking, or CART (realtime captioning). A small number utilize an oral or sign language interpreter. Hospitals also need to provide telephone amplifiers, hearing aid compatible phones, and voice carryover text telephones or captioned telephones (CapTel). When patient education videos are used, effective communication (such as captions or written materials conveying the information) must be provided. Patient TVs should have the capability of displaying closed captions and a remote with the ability to turn on the captions.
Civil Rights Requirements for Medicare Certification
The U.S. Department of Health & Human Services, Office for Civil Rights issued a Civil Rights Information Request for Medicare Certification. Hospitals must provide the following documents of procedures to communicate effectively with hard of hearing individuals:
- Process to identify individuals who need assistive services
- Procedures to provide auxiliary aids and services
- List of available auxiliary aids and services
- Methods to inform persons that assistive services are available at no cost to the person being served
- Notices of program accessibility and methods used to disseminate information to patients about the existence and location of services and facilities that are accessible
The following policy example is provided:
“(Name of facility) will take appropriate steps to ensure that persons with disabilities, including persons who are deaf, hard of hearing…have an equal opportunity to participate in our services, activities, programs and other benefits. The procedures outlined below are intended to ensure effective communication with patients involving their medical conditions, treatment, services and benefits. The procedures also apply to, among other types of communication, communication of information contained in important documents, including waivers of rights, consent to treatment forms, financial and insurance benefits forms, etc. All necessary auxiliary aids and services shall be provided without cost to the person being served.
All staff will be provided written notice of this policy and procedure, and staff that may have direct contact with individuals with disabilities will be trained in effective communication techniques.”
Types of hearing aids by size include:
- Completely-in-the-canal (CIC) – the smallest model for mild to moderate hearing loss
- In-the-canal (ITC) – not as small as CIC, but slightly better power
- In-the-ear (ITE) – larger than ITC, enough power to benefit a wide range of hearing losses and enough room for some special circuitry
- Behind-the-ear (BTE) – offers special programming, special coupling ability to other devices, special circuitry and power
Recently there are also surgically implanted hearing aids (bone-anchored hearing aids, or BAHA) used by a small number of people who cannot wear traditional hearing aids.
In terms of technology, there are conventional analog hearing aids, analog programmable hearing aids, and digital processing hearing aids.
A cochlear implant is a small, computerized electronic device that can provide sound to a person who has a severe to profound hearing loss. The implant is surgically placed under the skin behind the ear and used in conjunction with an externally worn processor. An implant does not restore normal hearing. Instead, under the appropriate conditions, it provides useful auditory understanding of the environment and speech.
It is important to note that most cochlear implants have MRI restrictions – either they can only be used with limited-power MRIs, or the implanted magnet needs to be surgically removed prior to an MRI, or they cannot have MRIs at all as long as the implant is in place. There are electrocautery restrictions as well. The cochlear implant manufacturer or surgeon should be contacted if there is a question about either of these procedures.
Assistive Listening Devices and Systems (ALDs)
Assistive listening devices and systems augment an individual’s hearing. ALDs can be installed in large areas (where they may be referred to as “assistive listening systems”) or be portable for an individual’s personal use. Hospitals should have procedures in place to provide hard of hearing patients with ALDs.
One-to-One Communicators – Sound is amplified through a microphone and delivered via a wired cord directly into a hearing aid or headset. Users can adjust the volume for personal comfort. One benefit of using the one-to-one communicator is that private conversations can remain private. Some are very inexpensive and may be sent home with the patient. This type of device is the most practical for typical hospital settings.
Frequency Modulation (FM) Systems – similar to miniature radio stations operating on special frequencies assigned by the Federal Communications Commission. There are both personal and large area FM systems. A personal FM system is similar to a one-to-one communicator, except that it is wireless. Personal FMs are usually used in conjunction with hearing aids, and consist of a small transmitter and microphone used by the speaker and a receiver used by the listener. The receiver transmits the sound to the individual’s hearing aid either through direct audio input or through an induction loop cord worn around the neck (such neckloops must also be provided). Some patients may have their own FM attachments for their hearing aids and will ask hospital personnel to speak into the accompanying microphone. The transmitter of a large-area FM system sends the sound through the microphone of the room’s sound system, and the individual’s FM receiver works as described under personal FM systems, or it can be used with headphones if hearing aids are not worn.
Infrared Systems – These use infrared light waves to transmit sound, and are used in large areas such as auditoriums. They are especially useful when privacy is desired, as the sound is not transmitted outside the room. The user needs an infrared receiver. Be sure to provide receivers with jacks for plugging in neckloops (for hearing aid and cochlear implant users with telecoils).
Induction Loop Systems – An induction loop wire is permanently installed (perhaps under a carpet) and connects to a microphone used by a speaker. (In the case of individual systems, a wire loop is laid on the floor around the speaker and the person who is hard of hearing.) The speaker’s voice creates a current in the wire that makes an electromagnetic field in the room. When the hard of hearing person switches the hearing aid to the “T” (telecoil/telephone) setting, the hearing aid telecoil picks up the electromagnetic signal, and users can adjust volume through the hearing aid. A loop receiver is required for those who don’t have telecoils (T-switches) in their hearing aids or cochlear implant processors.
Television Devices – Closed captioning on televisions is very helpful even if the patient can hear some of the dialogue. Personal television listening systems are available that allow the patient to increase the volume without disturbing others.
Telephone Devices – Amplifiers can be located in the receiver or used as a separate attachment to the phone; there are also special amplified phones. Voice carryover (VCO) TTY telephones are used with the telephone relay service, which enables the person to read a typed transmission of what the other party is saying. CapTel captioned telephones are used with a special phone number (1-877-243-2823) and need an adaptor for some phone systems. Phone alerters flash lights when the phone rings.
Information on Assistive Devices – More information on the types of assistive devices available and where they can be obtained is available through the Pennsylvania Initiative on Assistive Technology (PIAT). The website provides information on its lending library of the various types of equipment. It is vital that the hospital have their own equipment on hand, since most patients will not be able to wait for equipment to be ordered for their use. This is especially important in emergency care facilities.
Signage and Written Notification
Even when patients self-identify as having a hearing loss, they may not know what accommodations they need from hospital staff or what is available. Signs should be posted where people usually go for information, including admission, registration, and emergency care areas, stating that the hospital provides reasonable accommodations free of charge to deaf and hard of hearing people. Written information listing available auxiliary aids and services for communication access should also be provided to patients when they arrive.
Posted signs should specifically mention the availability of assistive listening devices and CART (realtime captioning) as well as interpreters, and display the appropriate symbols. The symbol for assistive listening devices is:
Some patients who don’t self-identify are reluctant to try a one-to-one communicator and need encouragement to do so. When patients self-identify that they have a hearing loss, hospital staff should ask about their preferred mode of communication and relay this information to appropriate staff in all units throughout the hospital stay. Ensuring communication with hospital staff can be accomplished through the use of a sticker with the International Symbol of Access for Hearing Loss:
The stickers can be obtained from the Hearing Loss Association of America. The symbol should be placed on the patient’s medical chart and wristband and any other documents that will ensure that staff have an awareness of the special needs of the patient. With the patient’s consent, a larger version of the symbol may be placed on the patient’s door and over the patient’s bed.
PART 2: IDENTIFYING AND COMMUNICATING WITH HARD OF HEARING PATIENTS
Hospital staff members need to be trained in identifying hearing loss and communicating with hard of hearing patients. The hospital also needs to ensure that appropriate staff members know how to access and utilize assistive technology when needed.
Identifying Hearing Loss*
The following signs indicate that a person may have a hearing loss. These signs should prompt a healthcare provider to ask the individual if he/she has difficulty hearing. (This wording is more effective in identifying hearing loss than asking people whether they’re hard of hearing or have a hearing loss, or whether they need communication accommodations.)
• Asks to have things repeated often
• Misunderstands conversations
• Does not always respond when spoken to or responds inappropriately
• Indicates that he/she hears but does not understand
• Complains that people are mumbling
• Has trouble understanding when it is noisy or when in large group settings
• Has trouble understanding women’s or children’s voices but can understand deeper voices
• Has trouble understanding when the speaker’s face is not visible
• Must be close to the person speaking in order to understand
• Has trouble understanding when spoken to from another room
• Does not react to loud noise
• Ignores sounds coming from behind
• Turns the TV or radio volume up loud
• Has trouble understanding on the telephone
• Strains to hear
• Turns head toward the person speaking
• Speaks too loudly or too softly; has nasal speech or less distinct articulation
* This information was adapted from Self Help for Hard of Hearing People, Inc., People with Hearing Loss and Health Care Facilities: A Guide for Hospitals to Comply with the Americans with Disabilities Act. (Self Help for Hard of Hearing People is now known as the Hearing Loss Association of America.)
Communicating with Hard of Hearing Patients
• Ask the patient how you can best communicate with him/her. However, keep in mind that many people with hearing loss do not know what would facilitate communication.
• Don’t attempt to communicate when there is a great deal of noise in the background.
• Get the patient’s attention first by touching or by waving your hand so that the person is looking at you before you begin talking.
• Face the person and ensure there is light on your face.
• If the patient normally wears glasses, make sure that he/she is wearing them in order to be able to speechread.
• Ensure that your mouth is visible and clear of hands, pencils, gum, and food so your speech can be more easily seen. Be aware that it is difficult for the patient to speechread if the patient has to look up.
• Do not shout; this distorts speech and makes it harder for the patient to understand.
• Speak clearly and at a natural pace (not too rapid but not too slow), taking care not to over-enunciate. Use short sentences and rephrase (instead of continually repeating) if necessary.
• Check that the patient fully understood what you have communicated. Hard of hearing people will often smile and nod as if they understood you even when they did not. To verify, ask the person repeat back what you said.
• Be aware that it may be difficult for hard of hearing people to understand staff members with accents. Get another staff member with clear spoken English if the patient has trouble understanding an accent.
• Provide a one-to-one communicator if the patient doesn’t use a hearing aid.
• Go over to the patient in a waiting area instead of calling his/her name.
• Go to the patient instead of using an intercom.
• Convey any important information prior to the surgical staff entering a sterile environment wearing surgical masks (which prevents speechreading) and prior to removing hearing aids and cochlear implants.
• Allow the patient to use hearing aids, cochlear implants, one-to-one communicators, and glasses (for speechreading) until the last possible moment before being anesthetized. Ensure that these devices are secure and made available as soon as the patient is able to resume using them.
• Write down important information that may be misunderstood. (Be aware that some people who have been hard of hearing since childhood have limited English literacy, and notes may not be effective for them.)
• Bear in mind that hard of hearing individuals may not hear as well if they are tired or ill and will not be able to hear when hearing aids and cochlear implants are removed, as for sleeping. The means by which staff communicates with the patient will change based on whether the patient is using the device. Therefore it should be established in advance of removing the device how communication will take place after removal.
PART 3: SOURCES OF INFORMATION
Below is a list of agencies that can provide information regarding hard of hearing needs.
Hearing Loss Association of America (formerly known as SHHH)
Address: 7910 Woodmont Avenue, Suite 1200, Bethesda, MD 20814
Phone: 301-657-2248 Voice, 301-657-2249 TTY
Promotes awareness and information about hearing loss, communication, assistive devices, and alternative communication skills through publications, exhibits, and presentations.
League for the Hard of Hearing
Address: New York Location: 50 Broadway, 6th Floor, New York, NY 10004
Phone: 917-305-7700 Voice, 917-305-7999 TTY
Mission is to improve the quality of life for infants, children, and adults with all degrees of hearing loss, by providing hearing rehabilitation and human services for people who are hard of hearing or deaf, and their families, regardless of age, ability to pay, or mode of communication, and by striving to empower consumers to achieve their potential.
Association of Late-Deafened Adults
8038 MacIntosh Lane
Rockford, IL 61107
815-332-1515 Voice/TTY or (toll-free) 866-402-2532 Voice/TTY
Supports the empowerment of people who are deafened. Provides resources and information and promotes advocacy and awareness of the needs of deafened adults.
Alexander Graham Bell Association for the Deaf and Hard of Hearing
Address: 3417 Volta Place, NW, Washington, DC 20007-2778
Phone: 202-337-5220 Voice/TTY
A membership organization and information center on pediatric hearing loss and spoken language approach.
Better Hearing Institute
Address: 515 King Street, Suite 420, Alexandria, VA 22314
Phone: 703-684-3391 Voice/TTY
Non-profit organization whose mission is to educate the public and medical profession on hearing loss, its treatment and prevention. BHI maintains a toll-free “Hearing HelpLine” telephone service that provides information on hearing loss, sources of assistance, and other available hearing help to callers anywhere in the Unites States and Canada.
Hearing Loss Association of Pennsylvania
Address: 4 State Road, #109, Media, PA 19063
Office of the Deaf and Hard of Hearing
Address: 1521 N. Sixth Street, Harrisburg, PA 17102
Phone: 800-233-3008 V/TTY (Pennsylvania only) or 717-783-4912 V/TTY
Pennsylvania Initiative on Assistive Technology (PIAT)
Address: Institute on Disabilities, 1601 N. Broad Street, University Services Bldg., Suite 610, Philadelphia, PA 19122
Phone: 800-204-7428 V or 866-268-0579 TTY (both Pennsylvania only) or 215-204-1356 V/TTY
NOTE: This guide includes information from a publication of the NJ Hospital Association and from the NJ Division of Civil Rights fact sheet, “Ensuring Open and Effective Communication in Hospitals for Persons Who Are Deaf or Hard of Hearing.”
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