WWD Communicating Using Interpreters and Communication Aids[1]

8/8/2019 WWD Communicating Using Interpreters and Communication Aids[1]

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educational programs

Womenwith

Disabilities



Communication



Health Professions Curricula

³help´

American Sign Language

Communicating Using Interpreters and

Communication Aids



Women Who Are Blind

Total blindness is the complete

lack of form and light perception.

The term ³blind,´ however, is

frequently used to describe severe

visual impairment with residual

vision.



Low Vision and Blindness

Formal definitions exist, but informally,those who, even with corrective lenses,cannot read the biggest letter on an eyechart are considered legally blind.



Braille

Large print

Technology with voice output

Accessible Internet

The patient will generally bring her own equipment to the

physician visit if she relies on a specific technology.

P eople who are blind or have low vision use various

assistive technologies to enable them to access printed texts.

R eading Aids and Devices for Womenwho are Partially Sighted or Blind



Braille

Braille is not a language. It is a code by which alllanguages may be written or read.

Braille can be read with the fingers by people who areblind, deaf-blind, or visually impaired.

The Braille cell is an arrangement of six raised dots.Different patterns represent letters, numbers, etc.

The average reading speed is about 125 words per minute, but skilled Braille users can read at speeds of several hundred words per minute.



R eading and Writing Braille

BrailleNote mPower A personal computer that functions like a

sighted person¶s laptop²the Braille

keyboard allows the user to input material and access it later via Braille or

voice synthesizer.

Reizen RL350 Braille Labeler

E mbosses Braille on vinyl or magnetic

tape for labeling files, notes, etc.



Making Large Print Clear

Print SizeGenerally 18±24 point; depends on individual.

Color and Contrast

Contrast between background and text is a vital factor in legibility.

Typeface Avoid italic or handwriting fonts and instead use a common sans-serif

typeface like Arial; when writing use a thick black felt pen.

Paper Use good-quality paper that doesn¶t show print through on the other

side and is not glossy.



How Can I Assist My Patient in My

Office? Make Things Bigger

Write using large letters

and magnify.

Be BoldUse a thick black felt pen to

contrast against white paper.

Brighten upImprove general lighting levels

or provide direct lighting.



R eading Large Print

People who read largeprint may read with:

± prescription lenses

± special magnifiers ± closed circuit television

(CCTV) technology

A CCTV consists of acamera, under which the

user places the text; thecamera enlarges andprojects the text imageonto a television-likescreen



Audio Output Devices

Patient records informationfor later playback

± Digital recorders

± Standard cassetterecorders



Devices & Assistive Technology Aids:Patient R eferrals

Guide for Funding Assistive Deviceshttp://www.atnet.org/education/fundingat.htm

HumanWare

http://www.humanware.com

The Braille Notehttp://www.freedomscientific.com

The Braille Labeler

http://www.sightconnection.com

MaxiAid Products for Independent Livinghttp://www.maxiaids.com



The Internet

Speech programs readinformation on the screen or output to Braille printer; blind

person uses keyboardcommands to navigate.

The Internet transformedinformation access for people

who are blind or low vision. Federal regulations require

federal websites (NIH) to beaccessible (www.section508.gov).



Adapting Written Communication

Encourage patient to record or take notesduring interview

Communicate medical information andother written instructions via email

± patient will be able to access at home

Specific medical information is availableon accessible websites

Talking Rx® prescription reader

± doctor or pharmacist records prescriptioninstructions; patient can play back at anytime



Women withCognitive Disabilities

The concept of cognitive disability

is extremely broad.

In general terms, an individual

has greater difficulty with mental

tasks than the ³average´ person.



Types of Cognitive Disabilities

There are too many cognitive disabilities to

list, but some of the major categories are:

traumatic brain injury

developmental disability

aphasiamental impairment

learning disability



Cognitive Disabilities

Cognitive disabilitycan affect one or moremental processes:

± thought ± perception

± reasoning

± intuition

± memory

± information processing

Individuals withcognitive disability canexhibit one or more

states: ± confusion

± acute memory disorder

± delirium

± dementia

± organic brain syndrome

± psychosis



Determining Competency for Medical Decision-Making in the Patient with Cognitive

Disabilities

³So long as the patient appears to adequately understand and appreciate the personal significance of the following:

(a) that she has a general medical or mental disorder,(b) the nature and course of the disorder, and

(c) the risks and benefits of the proposed intervention and of thealternatives, including the alternative of no intervention; and so

long as the patient makes a non-coerced choice that does not appear to be unduly influenced by a mental disorder, then the

patient may be considered to possess capacity even if her choiceappears to the physician to be unreasonable.´

Moore, Randall F., MD, JD, Assistant Professor of Psychiatry, Department of Psychiatry, Texas A & M University Health Science Center College of Medicine. A Guide to the Assessment and Care of the Patient Whose Medical Decision-MakingCapacity is in Question. Medscape General Medicine, November 10, 1999. Online:http://www.medscape.com/viewarticle/408024_1.



Factors That Affect Communication with

Women WhoH

ave Cognitive Disabilities

May not be able to report symptoms accurately

May not understand what is happening during the

physical examination May not comprehend or be able to implement follow-up

plan

Physician may not know what is being understood and

what is not Proxy may not be allowing the patient to participate to

the best of her ability



Communicating with a Woman withCognitive Disability

Make the informationas concrete aspossible.

Use gestures,diagrams, or pictures.

Speak slowly andclearly; give theperson time to

think through theInformation.

Use short instructionsand simple, directsentences.



Communicating with a Woman withCognitive Disability

The person may or may not be able toread.

Use gestures,diagrams, or pictures.

If the person has difficulty understanding,repeat using different wording.



R esources for Women with CognitiveDisabilities

The Coleman Institute for Cognitive Disabilities

http://www.colemaninstitute.org

American Association of People with Disabilities

http://www.aapd.com

Ability Hub

http://www.abilityhub.com/cognitive/index.htm

The National Center on Disability and Access to Education

http://ncdae.org

U.S. Dept. of Labor

C ommunicating With and About People with Disabilities

http://www.dol.gov/odep/pubs/fact/comucate.htm



women wit h speech and

language disorders

Communication



Women with Speechand LanguageDisordersSpeech and language disorder is a

broad term t hat refers to problems in

communication and related areas such as oral motor function.



M any times the family or familiar

listeners can understand acertain percentage of their speech, but nonfamiliar listenershave more difficulty.

Communicating with a woman who is nonverbal or whose speech is difficult to understand



Many Common Diagnoses ThatAffect Speech

Cerebral palsy

Stroke

Brain injury

Multiple sclerosis

ALS

Parkinson's

Throat cancer

Autism

Developmental disabilities



Distinguishing Between Speech and

Language Disorders Language is the

understanding of words.

Speech is the waylanguage is voiced or articulated.

An individual can have aspeech disorder, a

language disorder or bothconditions.

N ational Aphasia Association



Implications of Specific Speech and

Language Disorders

Speech disorders are often the result of oral-motor problems and can cause

impaired articulation. Language disorders, like aphasia, are

limitations in the comprehension andexpression of language.



A Specific Note about Aphasia

Aphasia can result in switching wordsthat are:

- close in sound like pain and point- close in meaning like earache andheadache

- opposites like better/worse



Common Communication Barriers

Some women with speech and languagedisorders have cognitive disabilities;others do not

More time is necessary to listen towhat the individual is saying

± verbal communication can be difficult

± may use electronic speech or talking board

People want to rush or completesentences for the person ² not taketime to listen to what is being said



What do I Need to Know When

Communicating with a Patient?

Speech may be difficult to understand or unintelligible.

Speech disorders can cause anxiety,frustration, feelings of inadequacy for thespeaker.



Tips for Improving Communication

Pay attention to the womanand watch her as she talks.

Be honest and let her know

when you have difficultyunderstanding her.

Repeat the part of themessage that youunderstood, so that thespeaker does not have torepeat her entire message.



More Tips If you are unable to understand

the message after repeatedattempts, ask yes/no questionsor have the woman write her message to you.

If you ask a question,sometimes writing down anumber of options can be auseful way for the individual to

choose the answer they arelooking for.



Asking Yes/No Questions

Advantage

Easy for communicationpartner to understandthe yes/no answer.

Disadvantage

Frustrating for the individualwho wants to add moreinformation than just a yes/no.

The communication partner may ask yes/no questions thatare difficult to answer, for example, ³You didn¶t like thatbook, did you?´ ³No´ maymean that the woman did notlike the book, or that shedisagrees with the statementand actually liked the book.



Written Choice

Technique that allows a person, with help fromthe communication partner, to clearly expressopinions, provide information, and make choices

simply by pointing to a written word or phrase. The more familiar the

communication partners are,the better the choices will be.



Written Choice

Gu i del i nes for the

Commu nic at i on Partner



Augmentative Communication

Au gmentat i ve c ommu nic at i on

Refer s to ³method s of

c ommu

nic at i on that enhanc e, au gment or

replac e c onvent i onal forms

of expressi on.´

U.S. Society for Augmentative and Alternative Communication.



Augmentative Communication

Big Mack device that speaks one

message upon activation

Dedicated communication device thathas 32 messages on a page andeight different levels

Communication softwareprogram on alaptop computer

H i gh-Tec h Sy stems H ave Speec hO u tpu t and Inc l u de the Follow i ng:



You Don¶t Have to KnowHow to Use a Device



Partner-Assisted Scanning

Used to communicate in asituation when a personcannot point to an alphabet

board, or use an existingcommunication system, for example, when positioned inbed on the side, or during an

MR

I Requires no equipment unless

an AEIUO board is available



Procedure for Partner-AssistedScanning

Communication partner asks if the first letter of the word is in the³a, e, i, o, or u´ row, stating oneletter at a time and waiting for aresponse.

Person indicates ³yes´ with amotor movement when she hearsthe correct letter, for example,looking up or down, or making agesture.

Communication partner thennames the letters in that row oneat a time, for instance, if thecommunicator indicates the firstletter is in the ³i´ row, the partner then repeats i, then says j, k, l, m,n, until a ³yes´ is indicated.

The partner may want to writedown the indicated letters onpaper if the message is long, tohelp remember the letters, andperhaps even

to remind thecommunicator what has beensaid so far.



Eye Gaze System

Can be used when the patient has no use of the arms/hands to indicate what she wants or needs

Relies on the communication partner watchingthe person¶s eye gaze to the word/picture thatshe wants to communicate



CommunicationEtiquette

Be patient.

Treat the communicator withrespect at all times.

Don¶t assume the personwith an expressivecommunication disorder hasa cognitive impairment.

Communicate on ³eye´ levelas much as possible.



And More Communication Etiquette

Utilize the person¶s facial expressions and bodylanguage to augment communication.

Don¶t limit conversation to yes/no questions²ask choice questions also.

If you are having significant difficultyunderstanding the person, ask permission to askquestions of the family member/caregiver/significant other accompanying her whenappropriate.

And most important:

Don¶t pretend to u nder stand someonewhen you don¶t!



CommunicationEtiquette withUse of a Device

Remember that people who have

a speech impairment may use a

variety of ways to communicate.

A patient may choose to use

American Sign Language, to write,

to speak, to use a communication

device, or to use a combination of methods. Find out the woman¶s

preferred method and use it.



Non Effective Communication WithPerson Using Device with Speech Output

Video

Two people interactingusing a word board



R esources for Further Explorationinto Augmentative Communication

American Speech-Language-Hearing Association (ASHA)http://www.asha.org/public/speech/disorders/Augmentative-and-Alternative.htm

International Society for Augmentative and Alternative Communication (ISAAC) http://www.isaac-online.org/en/home.shtml

Augmentative Communication, Inc.http://www.augcominc.com

The Journal of Augmentative & Alternative Communicationhttp://www.tandf.co.uk/journals/titles/07434618.asp

Augmentative Communication Consultants

http://www.acciinc.com

United States Society for Augmentative and Alternative Communication

http://www.ussaac.org



Women Who AreDeaf, Deafened, or Hard of Hearing

A pproximately 10% of the population has some degree of

hearing loss. Communication

needs vary greatly depending on

the degree of loss.



How Do Deaf and Hard-of-HearingPeople Communicate?

There is nosi ngle answer.



A Variety of Ways

American Sign Language

Speech reading

Written notes

Computer-assisted real-time transcription

An individual¶s choice of communication oftendepends on the severity of the hearing loss and

whether spokenlanguage was acquired before or after the loss.



N ot all people whoare deaf or hard of hear i ng u se si gnlang u age toc ommu nic ate.



Speech R eading



Some People Speech R ead (Lip R ead) and CanUnderstand Spoken Words Fairly Well with the Speaker¶s Help

Position yourself so patient cansee your face clearly.

Speak slowly and distinctly.

Repeat or rephrase wordsif not understood.

Use natural body languageand gestures.

Supplement with writtennotes when needed.



Communication AccessR eal-Time Transcription (CAR T)

Many people who aredeaf or hard of hearingare not trained in either sign language or

speech reading.

C ART is a service wherean operator types what issaid into a computer that

then displays the words ona screen.

People who have developed a severe hearing loss later in life often use C ART.



A v isu ally i nterac t i velang u age that u ses a c ombi nat i on of hand mot i ons,body gest u res,and faci al expressi ons



The grou p most l ik ely tou se Amer ic an S i gnLang u age (ASL) as

pr i mary lang u age are people deafened at bi rth or early c hi ldhood, beforeacq u i r i ng fl u enc y i n as pok en lang u age.



When sign language is the patient¶s primary formof communication, the services of a qualified signlanguage interpreter are often necessary.

³ sick ́

~ American Sign Language



I Don¶t Need an Interpreter. . .

W r i tten N otes

Many deaf people are notfluent in written English.

Writing detailed informationis time-intensive.

Written notes tend to

condense ideas, leaving outimportant information.



. . . or Do I?

Speec h Read i ng

Most people overestimate theaccuracy of speech reading.

40±60% of English sounds lookalike when spoken.

Speech reading requiressignificant guesswork.



W hat I s the Role

of a S i gn Lang u ageInterpreter?



³assist´


Interpreters bridge the communication gapbetween healthcare providers and patientswho are deaf.



The Interpreter«.

Maintains the integrity of themessage

Conveys the content and spiritof the speaker

Neither adds or deletes anyinformation

A sign language interpreter is a trainedprofessional who facilitates communication sothat hearing and deaf individuals may fullyinteract.



Sign Language Interpreters

Facilitate optimalcommunication

Contribute to optimaloutcomes

Reduce interpretation errors

Improve patient satisfaction



W hat Def i nes a

Q u

al i f i ed S i gnLang u ageInterpreter?



Why Not Have a FamilyMember Interpret?

³ sex u al relat i ons´




Dangers of Ad Hoc Interpreters

Family members, friends, or untrainedstaff are significantly more likely tocommit interpretation errors in generaland, in particular, errors with potentialor actual negative clinicalconsequences.

FloresG, Laws M, Mayo S, et al. Errors in medical interpretation and their potential clinicalconsequences in pediatric encounters. Pediatrics 2003; 111:6-14.



Ad Hoc Interpreters . . .

Are less likely to tell patientsabout medication side effects

Are more likely to misinterpret or

omit questions asked byhealthcare providers

Result in significantly lower patient and clinician satisfactionthan other strategies

FloresG. The impact of medical interpreter services on the quality of health care: a systematic review.M ed C are Res Rev 2005; 62: 255-299.



R isks of Children Interpreting forTheir Deaf Parents

Frequently embarrassed by andtend to ignore questions aboutmenstruation, bowel movements,and other bodily functions

More likely to make interpretationerrors with potential or actual

clinical consequence

Flores 2005.



Patient Safety

Misdiagnosis

Medication errors

Patient discomfort

Patient embarrassment

Iezzoni L, O¶Day B, Killeen M, et al. Communicating about health care: observations from persons whoare deaf or hard of hearing. 2004; Ann Intern M ed 140: 356-362.

Inadeq u ate c ommu nic at i onw i th deaf and hard-of-hear i ng pat i ent s c an lead to:



In Which Situations Are InterpretersNeeded?

³ si gn lang u age´




Any Time the Information to Be ExchangedR equires Effective Communication, Such as...

Taking a medical history

Explaining procedures or diagnoses

Planning treatment Providing discharge instructions

Obtaining informed consent

Instructing medication usage Offering educational

presentations, such as abirthing class



Not Every SituationR equires an Interpreter

It depends on the abilities of the person who isdeaf or hard of hearing and the complexity andnature of the communication.

For example,ex c hang i ng wr i ttennotes or s peec hread i ng may beeffec t i ve for a br i ef follow- u p v isi t.



Types of Interpreters

³ i nterpret´




Sign Language Interpreting

In most cases, this means American Sign Language, or ASL,

although there are other forms of sign language in the UnitedStates, such as Signed ExactEnglish.

Qualified interpreters are fluent inboth forms.



Not all people who are deaf are trained in sign language,but they may use aninterpreter just the same.

Oral interpreters are speciallytrained to articulate speechsilently and clearly, sometimesrephrasing words or phrases togive higher visibility on the lips.Not all interpreters are skilledin this form of interpreting.

Oral Interpreting



Deaf-Blind Interpreting

Interpreter c ommu nic at i ng w i th an i nd i v i d u al who is deaf-bl i nd



Interpreting for persons who are bothdeaf and blind requiresspecialized skills.

Several interpretationmethods can be useddepending on theclient¶s preference.Not all interpreterspossess these skills.



H ow Can I

W or k Effec t i vely w i th an Interpreter?



³ c onnec t´


S k Di tl t



Speak Directly tothe Person Who Is Deaf

Don¶t ask the interpreter:

³Does she have any questions?³

Ask your patient:

³Do you have any questions?´

R li Th t th I t t



R ealize That the InterpreterCannot . . .

Provide any informationabout the patient

Counsel, advise, or interject personal opinions

Enter the conversation

U d t d Th t th I t t



Understand That the Interpreter M ust . . .

Interpret all that is saidin the presence of thepatient who is deaf

Not edit out anythingspoken as an aside or

to others in the room



Qualified interpreters adhere to an industryCode of Ethics.

Confidentiality is a fundamental tenet of the code.

Qualified interpreters respect the privacyof their clients and hold in strict confidenceall information obtained in the course of the provider-patient interaction.



Video Clip 2

Provider-patient interactionwith sign language interpreter a) incorrect etiquetteb) correct etiquette



As R equired by Law

Title III of the ADA obligates healthcare providers to makereasonable accommodations to meet the needs of peoplewith disabilities.

Providers have a duty to provide effective communicationusing auxiliary aids and services that ensure

communication with people who have a hearing loss is aseffective as communication with others. 28 C.F.R.S36.303 (c)

Qualified interpreters are considered auxiliary aids.

T i tle III of the Amer ic ans w i th Disabi l i t i es Ac t of 1990

P.L.101-336



But I Only Have a Small Practice

T i tle III of the AD Aappl i es to all pr i vatehealthc are prov i der s,regardless of siz e of the off ic e or nu mber of employees.



Prov i d i ng Acc essi bleCommu nic at i oni n You r Off ic e

A Step-by-Step A pproach



First, in consultation with your patient,determine the appropriate aid or serviceneeded to facilitate effective communication.

Cou rt s have fou nd an AD A v i olat i on where the prov i der deci des not tou se an i nterpreter and

the method u sed d i d not resu lt i n effec t i vec ommu nic at i on.



Office Management

Designate a staff person to be an ADA coordinator.

Arrange for staff training on

how to respond to patientrequests for accessibleaccommodations.

Develop an office policy

and procedure oncommunication with patients whoare deaf and hard of hearing.

How Do I Find a



How Do I Find aQualified Interpreter?

Contact an interpreter service agency in your community.

Describe type of interaction. ± routine office visit,

counseling, surgery

Inquire about credentials of assigned interpreter.



Associated Costs

The healthcare provider or facilitymust pay for the cost of aninterpreter.

Providers c annot impose asurcharge on the patient either directly or indirectly to offsetinterpreting costs.

Interpreter costs should betreated as an overhead expensefor tax and accounting purposes.



Tax R elief

An IRS tax credit of up to 50% for business expenditures made incompliance with ADA standards isavailable.

Expenditures must exceed $250 but not$10,250.

Eligible expenses include

cost of interpreters.

Omnibus Budget Reconciliation Act of 1990 P.L. 101-508, S 44.



R elated R esources

American Medical Association. Americans with Disabilities Act andhearing interpreters. www.ama-assn.org.

Barnett S. Cross-cultural communication with patients who use American Sign Language. F am M ed. 2002;34(5):76-82.

National Association of the Deaf. ADA questions and answers for healthcare providers. www.nad.org.

Registry of Interpreters for the Deaf. Standard Practice Paper:Interpreting in medical settings. www.rid.org.

U.S. Department of Health and Human Services, Office of Civil

Rights. Questions and Answers: Communicating with hearing-impaired individuals. www.hhs.gov/ocr.

U.S. Department of Justice, Civil Rights Division. ADA Business Brief:Communicating with people who are deaf or hard of hearing inhospital settings. www.ada.gov.



Rec ogniz ed symbol

denot i ng avai labi l i ty of a si gn lang u agei nterpreter



educational programs

Womenwith

Disabilities

WWD Communicating Using Interpreters and Communication Aids[1]

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