Creative Nursing, Volume 17, Issue 4, 2011

Sensitive Care for the Deaf:

A Cultural Challenge

Joyceann Fileccia, PhD, RN, CNS, LCPC, LCCC

Of the more than 36 million American adults who have some degree of hearing loss
(Centers for Disease Control and Prevention [CDC], 2008), 500,000 are acculturated
into the culturally Deaf community who share behavioral norms, values, customs,
­educational institutions, and organizations. This article discusses the Deaf community,
their culturally based health care needs, and health care providers’ (HCPs) lack of
understanding and recognition of Deafness as a distinct culture, which individually or
cumulatively result in barriers to culturally sensitive care that can lead to ­disparities in
care. It suggests transcultural methods HCPs can use to narrow the cultural ­divide.

A s I walked into the emergency department to interpret for a Deaf patient, I

saw him sitting on a gurney in the hallway. The doctor was yelling at him in
an attempt to increase his comprehension. With exaggerated speech and gestur-
ing, the physician thrust the consent form into the patient’s hands yelling, “Here,
read this and sign it.”
While simultaneously using American Sign Language (ASL) and voice, I
­introduced myself to the patient and physician as the ASL interpreter. The ­doctor
turned to me and asked, “What? Is he stupid or something that he can’t read,
­understand, and sign the form without an interpreter present?”
Situations like this show the cultural chasm that divides health care
­providers (HCPs) and the culturally Deaf. Although the need for specialized ser-
Joyceann ­Fileccia, vices for ­cultural and linguistic minorities is becoming more recognized, health
PhD, RN, CNS, LCPC,
care ­disparities that impede equal access to care exist because of lack of under-
LCCC, is an assistant
professor in the Accel-
standing. HCPs must consider the Deaf as representative of a linguistic minority.
erated BSN Program HCPs must realize that Deaf people do not define their inability to hear as
at the UMDNJ School a pathological problem that necessitates medical or nursing ­intervention. Rather
of Nursing in Newark, than an audiological deficit, Deafness is a distinct identity. Deaf people consider
NJ; an adjunct faculty themselves proud members of a diverse Deaf community stemming from their
for ­American Sign
rich and culturally Deaf heritage (Kluth, 2006).
Language (ASL) at
Brookdale Commu-
nity College in Lincroft, WHO ARE THE DEAF?
NJ; and a freelance
medical/religious ASL Of the more than 36 million Americans who have some degree of hearing loss
interpreter. (­Centers for Disease Control and Prevention [CDC], 2008), approximately 500,000

174 © 2011 Springer Publishing Company

 http://dx.doi.org/10.1891/1078-4535.17.4.174
are ­considered members of the Deaf community and are culturally Deaf (Williams
& Abeles, 2004). Within the Deaf community, the Deaf collectively share commu-
nication, commitment, and experience. Like members of other cultural groups,
Deaf people have their own behavioral norms, values, language, customs, arts,
history, folklore, educational institutions, and organizations. The culturally Deaf are
deafened prelinguistically, prior to the age of 3, and represent a distinct linguistic
minority (Sutton, 2011).
Within the Deaf community, the Deaf (capital D) are distinguished from
the deaf (lower case d) by type of hearing loss, language use, and ­acculturation
(Berke, 2010). The Deaf are individuals who have profound hearing loss, use ASL
as a primary language, and are acculturated into the Deaf ­community. The deaf are
partially deaf, hard of hearing or hearing impaired, do not use ASL as a primary
language, and are not acculturated into the Deaf community. They are referred to
as deaf, deafened, hard of hearing, and hearing i­ mpaired.
Culturally Deaf people find offensive the names that HCPs have ­historically
used to refer to them, including deaf mute, deaf and dumb, “dummy” Hoy (after Deaf people
the famous 19th Century Deaf baseball player William Ellsworth Hoy) (Start find offensive
ASL, 2011), and hearing-impaired. Few HCPs are aware that the only culturally
the names that
­acceptable label for Deaf people is Deaf.
HCPs have
In Deaf culture, the term Deaf of Deaf refers to the approximately 7% of ­culturally
Deaf parents who produce Deaf offspring (Deaf ­Understanding, 2011; ­Mitchell & historically used
Karchmer, 2002). HCPs are often amazed to learn that Deaf parents generally ­desire to refer to them,
Deaf offspring so that their children can be ­acculturated into Deaf culture and the including deaf
Deaf community and learn ASL as a primary language. mute, deaf and
Hearing children born to Deaf parents are referred to as Children of Deaf Adults dumb, “dummy”
or CODAs (CODA, 2011). Generally, CODAs use ASL as a primary ­language in their
Hoy, and
family of origin and learn English as a second language during their years of formal
hearing-impaired.
education. Often, CODAs spend their lives bridging the gap between the Deaf cul-
ture and the hearing culture as they become ASL interpreters for their Deaf parents. Few HCPs are
When providing health care to the Deaf, HCPs must understand that using ASL- aware that the
speaking family members or friends as interpreters is culturally insensitive. The only culturally
desire for privacy, embarrassment, or issues of confidentiality may hinder the Deaf acceptable label
patient from sharing information and from asking health-related questions. Family for Deaf people
and friends may fail to accurately convey necessary health care ­information, and in
is Deaf.
some cases, they may change the message to “protect” the Deaf patient or others.

PROTECTION FOR THE DEAF

Numerous laws, special interest groups, and governmental agencies serve to
protect the Deaf from discrimination, especially in the area of access to communi-
cation. Although disabled is a culturally distasteful label to Deaf people, they accept
the term because it enables them to receive protection under the legal statutes of
the Americans with Disabilities Act (ADA) of 1990 (U.S. Department of Justice,
2005), which provides them the right to a reasonable accommodation by HCPs and
health care facilities.

THE BASICS OF DEAF COMMUNICATION

The average Deaf person accurately lip-reads less than 30% (Deaf Expressions, 2011).
Sounds formed on the lips phonetically (e.g., words beginning with the ­letters m

Sensitive Care for the Deaf 175

 or b) often look the same, which can lead to misinterpretation. Rather than risk
embarrassment or ridicule from HCPs, Deaf people may feign u ­ nderstanding.
ASL is a complete complex language that employs signs made with the hands
and other movements, including facial expressions and body postures (Gates &
Hoffman, 2010). It can become finger-spelling individual alphabet letters when
Deaf people revert to finger spelling for proper names, when they do not know
the appropriate sign for an object, or when no sign exists. Signs can vary tremen-
dously from neighborhood to neighborhood and state to state. In fact, ASL is not
universal (Gates & Hoffman, 2010). Across the globe, hundreds of sign languages
make up the core of local Deaf cultures.
As an orally As an orally expressed and written language, English is foreign to many Deaf
expressed and people who use ASL. Oralism (voicing), idioms, conjunctions, and the verb to be
written language, are not generally used or understood. Providing the Deaf with documents in writ-
ten English does not necessarily mean that they will understand their meaning.
English is foreign
This is especially problematic when HCPs ask Deaf people to read and sign legal
to many Deaf
consent forms and other written documents.
people who In most instances, ASL translations will not convey the original English mes-
use American sage intended. Unlike English, ASL is a three-dimensional and gestural language
sign language. that uses a grammatical syntax of time, noun, adjective, and verb, referred to as
Providing the TNAV. The Deaf patient’s inability to translate spoken English to its intended
Deaf with meaning relates to the difference between ASL and English sentence syntax.
The order of a typical English sentence is noun, then verb; for example, the HCP
documents in
states, “You may need thyroid medication.” In ASL syntax of time/noun/verb,
written English
the Deaf person may interpret this incorrectly as, “In May, I will need thyroid
does not ­medication.”
necessarily mean
that they will
understand their PROVIDING SAFE AND EQUITABLE CARE
meaning. In conjunction with the Joint Commission for the Accreditation of Health Care
­Organizations, the Office of Minority Health National Culturally and Linguisti-
cally Appropriate Services (CLAS) delineates standards of care for hospitals and
HCPs that mandate the provision of access for effective communication through
­qualified ASL interpreters and D/deaf telecommunication devices such as TTY/
TDD, closed-captioned televisions, and real-time video interpreting services
(U.S. Department of Health and Human Services [USDHHS], 2000). HCPs must
know the protocols within their health care facilities for securing qualified ASL
­interpreters and related telecommunication devices for ease and accessibility in
communication. They should be aware that the ADA mandates that HCPs must
attempt to obtain a qualified ASL interpreter for equal access to communication
(USDJ, 2005). These attempts should be documented on the patient’s legal record.
At the bedside, telecommunication equipment (TTY/TDD) as well as closed-
­­captioned-ready televisions should be provided for Deaf patients to enhance equal
access to communication. Flashing light warning systems must be available to in-
dicate a need for immediate assistance.

PROVIDING CULTURALLY SENSITIVE CARE

Often, Deaf people will avoid seeking health care because of inability to communi-
cate effectively with providers. This bespeaks an underlying lack of ­understanding

176 Fileccia
of the Deaf as a distinct culture that must be provided with culturally sensitive
HCPs are often
care (Meador & Zazove, 2005).
To provide culturally sensitive care, HCPs need to know about the linguis- amazed to learn
tic and sociocultural aspects of Deaf patients and recognize their uniqueness as that Deaf parents
a ­cultural and linguistic minority. To view and treat the Deaf within the context generally desire
of their culture, HCPs would do well to consider nursing theorist Madeleine Deaf offspring
Leininger’s theory of culture care diversity and universality that is based on the so that their
premise of care, which is largely culturally derived and requires culturally based children can be
knowledge and skills for efficacious nursing practice (Leininger, 2011).
acculturated
Leininger theorizes that people solve problems about the human condi-
tion based on their perceived cultural frameworks. Furthermore, when clients into Deaf culture
­experience health care that is not reasonably congruent with their beliefs and and the Deaf
values, they demonstrate signs of cultural conflict evidenced by increased stress, community
decreased attention to medical care, and decreased compliance regarding health and learn ASL
care services. Considering this, care provided for the Deaf by HCPs ideally occurs as a primary
when Deafness as a culture is recognized and understood (see Figure 1). language.
In addition, HCPs should strive to build relationships of mutual respect and
trust. Actions that HCPs should either perform or avoid to build relationships
and provide culturally sensitive care to the Deaf include the following (Meador &
­Zazove, 2005):
• Avoid making judgments about the Deaf based on their inability to hear.
• Acknowledge that Deaf people are part of a culturally based linguistic
­minority in which Deafness is considered a proud label of identity.
• Recognize that the only appropriate descriptor for a culturally Deaf person
is Deaf.

Figure 1.  The ASL interpreter (far right) uses sign to bridge the communication
­between HCP and patient.

Sensitive Care for the Deaf 177

 • Realize that for most Deaf people, English is a foreign language not easily
Through
understood or used for reading and writing.
education,
• Recognize that shouting, gesturing, and mouthing English will not increase
HCPs will come
the Deaf person’s comprehension or ability to hear.
to know that
• Comply with governmental agencies and laws to provide equal access to
deafness is
communication through qualified ASL interpreters and deaf electronic and
not always a regulatory safety and warning devices within health care facilities.
pathological
condition in CONCLUSION
need of medical
By learning about the Deaf culture and the basics of ASL through continuing edu-
fixing; rather, it
cation courses or college classes, HCPs can put this knowledge into practice and
is a proud label
help bridge the divide. Through education, HCPs will come to know that deaf-
of identity for ness is not always a pathological condition in need of medical fixing; rather, it is a
members of the proud label of identity for members of the Deaf community. As the former presi-
Deaf community. dent of Gallaudet University, the nation’s only liberal arts university for the Deaf,
once proclaimed, “Deaf people can do anything hearing people can do, except
hear” (Jordan, 2006).

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Correspondence regarding this article should be directed to Joyceann Fileccia, PhD, RN, CNS, LCPC, LCCC, at
fileccjo@umdnj.edu

Sensitive Care for the Deaf 179

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