RESEARCH ARTICLES

Communication between the nursing team and people with hearing deficiency

Thayana Rose de Araújo Dantas^I ; Thayris Mariano Gomes^II ;Tatiana Ferreira da Costa^III; Thalita Rodrigues de Azevedo^IV ; Silmery da Silva Brito^V ; Kátia Nêyla de Freitas Macedo Costa^VI

ABSTRACT: This study objective to analyze the communication between the nursing team and people with hearing deficiency in a school hospital, in the city of João Pessoa-PB. Descriptive research, with quantitative approach, conducted with 23 nurses and 21 nursing technicians in the period of August 2011 to January 2012. The data were collected through semi-structured interview and analyzed based on the reference of content analysis. It was evident that the nursing team has  difficulties in establishing a communication with people with hearing deficiency, for not knowing the Brazilian Sign Language (LIBRAS), thus they utilize strategies such as: labial reading, mimic, writing and the intermediation of the escort. As suggestions to improve the communication, it were cited the inclusion of disciplines in formation and training in LIBRAS. It is concluded that is fundamentally the insertion of this thematic in professional education, in order to provide a quality and holistic assistance to this population.

Keywords: Communication; assistance; nursing team; hearing deficiency 

INTRODUCTION

The disability is seen as an impediment to physical, intellectual or sensory nature, which in interaction with various barriers, may hinder full and effective participation of an individual in society¹.

According to an estimate from the Brazilian Institute of Geography and Statistics (BIGS), 24.6 million people - 14.5% of the total population - have some form of disability, such as difficulty seeing, hearing, move about and, also, physical or mental deficiency. Of these total, 17% are hearing deficient. In Brazil, 12.7 million people (6.7% of the population) have some severe deficiency. Severe hearing deficiency has a prevalence of 1.1%. Among the states, Paraíba is which records the highest number of cases of this deficiency, whereas 18.8% of the population claimed to be the bearer of some permanent disability².

Currently, we have discussed a lot about social practices to include this population, that commonly, is a victim of prejudice or excluded from society. Some are auto-exclude because they feel inferior; other isolate themselves from people considered normal and try to live with other similar deficient³. Comparing with other deficiencies, hearing is the one that is facing more difficulties in social inclusion, since hearing is a fundamental sense to obtain the language and employ it.

In this scenario, the National Health Policy for People with Deficiencies established strategies to attend, in a qualified way, people with deficiencies, giving priority to the development and education of health professionals to work from primary care in the Family Health Strategy, to the tertiary care level⁴. Among these professionals, the Nursing staff is distinguished, which runs along the patient most of the time. However, although the issue of social inclusion of people with deficiencies is being highlighted, it is realized that lack of preparation and awareness of health professionals and encouragement by governments, in order to enable them to successfully meet this population. Thus, the assistance of the nursing staff to these patients tends to develop in a fragmented way, and not, humanized, which contradicts the principles established by the Unified Health System (UHS).

In this context, we emphasize the importance of communication between the nursing staff and people with hearing deficiencies, in order to promote social inclusion of those people and enhance care practice, through the creation of strategies for verbal and nonverbal communication and acquiring knowledge of the Brazilian Sign Language (LIBRAS), since it is through communication that professionals can understand the real needs of the patient, understand it as being holistic and provide an appropriate and effective assistance⁵.

Thus, we realized the need to address the communication process between these subjects, seeking to clarify how this interaction is occurring. Thus, this study aimed to analyze the communication between the nursing staff and people with hearing deficiencies.

LITERATURE REVIEW

The World Health Organization (WHO) defines disability as loss or abnormality of a psychological structure or function, physiological or anatomical. Among the various deficiencies, there is a hearing, by the impact that promotes the social life of the people. According to WHO, hearing loss is classified according to the threshold of hearing. Therefore, it can be: mild (26 - 40 dBNA), moderate (41 - 60 dBNA), severe (61 - 80 dBNA) or profound (+ 80 dBNA)⁶.

Hearing is one of the noblest sense, since their main function is linked to the acquisition and development of oral language, essential in interpersonal relations and the environment. This deficiency is considered highly disabling, because of its effects on human communication and the impact that causes the cognitive and psychosocial development and oral and written language. The impact of an auditory sensory deprivation interferes with the ability to interpret speech sounds and implies economic and educational disadvantages⁷.

In this sense, the communication with hearing deficient is a major obstacle for professionals in the health field, because it harms the relationship with these patients and the care that should be dispensed to them. Recognizing the deficiency in communication, in care situation facing the health, leads the professionals to reflect about these issues and improve the services⁸.

So, communication is posited as a basic and essential instrument for care of the nursing staff, particularly when referring to this population, which has a communication segment more complex, as often arise barriers that end up hurting the provided assistance.

METHODOLOGY

This is a study of descriptive nature, exploratory, qualitative approach, performed in a teaching-hospital in the city of João Pessoa - PB, in the sectors of: surgical clinic, medical, of infectious diseases, obstetric, pediatric and unit intensive care. The choice of these clinics is justified by the large turnover of patients. In some situations, people with hearing deficiencies may be permitted. For this reason, it is particularly important to be a good communication at the time that the professional will meet them.

23 nurses and 21 nursing technicians participated in the study. The selection met the following criteria: to be part of the nursing team, being bound to the cited hospital and agree to participate in the study and signed an informed consent form (ICF). The data were collected from August 2011 to January 2012. Therefore, it was used the technique of semi-structured interviews, with the aid of a tape recorder Mp4 type. The first part contained characterization data such as gender, age, specialty, length of education and working experience in the hospital; the second, eleven subjective questions that met the study objective.

It is noteworthy that this study met the requirements of Resolution No. 196/96 of the National Health Council, which regulates research involving human beings¹⁰, and was approved by the Ethics Committee on Research under protocol number 292/2011. To preserve the anonymity of the participants in the research, they were identified by the letter N (for nurses) and T (technical), followed by the serial number, for example, (E1. .. E23) and (T1. .. T21), respectively.

RESULTS AND DISCUSSION

Subject's statements are presented to a better understanding and visibility of communication between the nursing staff and people with hearing deficiency, according to the identified categories.

Category 1: Perception of nursing staff about communication with people with hearing deficiency

This category was developed from the responses of the interviewees about how the nursing team realizes the communication with people who have hearing deficiency, revealed in the speeches below:

What we perceive is a great difficulty for the professional in communicating with the hearing deficient, if they are literate it helps a lot, but if not it is complicated. (E1)

I realize communication as too needy, because exist a lack of professional preparation for contact with these patients. The staff really have trouble. (E17)

I can not say how I would act, because I never had contact, but if I had, I would have to do a refresher. (E21)

Communication is essential for socializing and understanding between people, is an essential instrument prerequisite for skilled assistance of the nursing staff. However, in their statements, these professionals express difficulties of establishing communication with these patients due to lack of preparation and training, not knowing their language and the absence of an interpreter at the institution.

Among the statements, it was identified as a relevant observation to educational level of the patient. Professionals should, in principle, to know this information so they can choose the best form of communication to be used, as people with severe hearing loss may be limited, as the education level, the use of isolated and own gestures, understood solely in the family environment³.

Like other population groups, people with hearing deficiency also need a means to gain access to health institutions. But what we see is a lack of acceptance and interest of the institution and professionals to facilitate the inclusion of this population. In their statements, the professionals demonstrate that, despite being aware of existing needs and their professional difficulties, they have no interest in seeking changes, such as training, for example, to enhance and improve their practice.

The following statements express a transfer of responsibility to the hospitals and their own education, which did not allow this experience and this learning:

Here it is very difficult because we do not have a specific education to communicate with them. And as it is a closed environment, the entry of the interpreter is prohibited, the person who has the ease of communication with him. (T6)

We are not prepared, it should be taught, Libras since school. We are at a very advanced age, but communication is still very worrying. (E11)

These statements denote that institutions and the education of professionals still leave much to be desired. Thus, there is a clear social exclusion to which these patients are exposed. Nor is fulfilled the Law No. 10.436, of April 24, 2002, establishing the implantation of LIBRAS in public health institutions and ensures appropriate attendance and treatment for hearing deficiency carriers, as well as the inclusion of courses in high and upper education of public and private schools of the LIBRAS, as part of the National Curriculum Parameters¹¹.

Category 2: Difficulties and facilities in communication...

In this category, interviewees were asked to answer what are the difficulties and the facilities found in the nursing staff communication with deaf people.

It is noteworthy that only one nurse said that has facility on this communication process:

Facility, we can say that they are good, they help greatly to establish communication, the difficulty is that lack of qualification to communicate, the example is the LIBRAS. (E5)

The ease that refers to the idea that a person with hearing deficiency adapt to the environment, which promotes a setback in the progress of social inclusion, as it is currently conceived the idea that society should adapt to the needs of all people, whether deficient or not, and the principles of universality, fairness and integrity of UHS⁴.

In this sense, we consider relevant the development of strategies for welcoming and full care and adoption of public policies with affirmative action to achieve health equity for people with deficiency. Therefore, it is crucial to consolidate accountability of the services/professionals/managers /political actors in the context of inclusive care¹².

The difficulties, however, were mentioned in the speeches of all professionals, as follows:

We receive the patient and no one even warns that this patient is deficient, when we are talking [...] we notice that he is not corresponding. There is a lot of lack of communication from the staff who is bringing [the patient] to whom is receiving. (T10)

The hearing deficient, they create their own language. When they know LIBRAS is easy, but when they do not know is difficult. So they are isolated in the clinic, is not easy. (T13)

Difficult, because many internal deficient here themselves did not know sign language and were not attending any school, so they communicated through gestures created by their own family. (E3)

As can be perceived in one of the statements, there is a disruption in care for people with hearing deficient, because there is no integration of professionals, and it begins at the entrance of the institution. Thus, the deficiency, often goes unnoticed, and the patient's needs are not resolved, which causes more conflict for these individuals.

To share the same cultural and linguistic values, does not guarantee equality of rights for persons with hearing deficient or to equal care in the hospitals. Therefore, a barrier is imposed on the population and the professionals, because they do not share the same language¹³. As reported in the statements, commonly, the hearing deficient do not know employ LIBRAS. In this case, it is essential to use non-verbal communication, through lip reading, gestures and mimics.To capture the messages, nurses must be skilled, in order to interpret them and empower them creatively, because the greater the ability to decode nonverbal, more conditions must properly issue the nonverbal signals¹⁴.

In a survey of people with severe or profound deafness about the perception of communication with health professionals, the respondents emphasized that find many difficult to have an adequate health care, due to factors such as: lack of adequate intermediation and lack of preparation of the professionals who serve the deaf, from their reception until the moment of final guidelines about the care and treatment¹⁵.

It is possible to realize, yet, that the result of the lack of communication with people with hearing deficiency is isolation and, therefore, an unsuccessful assistance.

Category 3: Strategies used by nursing staff to communicate ...

The nursing staff is responsible for the care and health education in order to meet the bio-psychosocial and spiritual needs of the patient. For persons with deficiency, support should not only be in rehabilitation, but also on prevention and promotion in health. In this context, the subjects were asked which strategies employed by nursing staff to establish communication with people with hearing deficiencies. The responses were as follows:

With deaf mutes I try to make gestures, read lips and seeking someone close that understand, because I have great difficulty understanding. (E14)

Through writing and gestures, I seek the social services to find the family. (E18)

The family help, so they passes the information to us, because I can not communicate with the hearing deficient. (E22)

Depending on the need, we use mimics, gestures, which is necessary for them to understand us and we also understand these people. (T11)

As evidenced, the most widely used forms of nonverbal communication were lip reading, gestures and mimics. However, not always this type of communication is successful because, often, when these strategies are used, the patient cannot do lip reading or the professional cannot understand the mimics and gestures, as shown in the following speech:

I do not have any skill, I have had contact with a hearing deficient mother and I was frustrated, because I tried to use gestures and realized that was not working and she was getting nervous, it was a bad experience. (E9)

The methods are not always clear and are only effective when it comes from short messages. Another disadvantage is that this form of communication takes time and effort of the nurse and patient³. A non-verbal language is needed, but their isolated use is not able to establish an interaction, whereby the nursing staff fully understand the patient and he, the staff.

Another often cited means of communication was the written. This means of interaction would be effective to establish a communication, however, although the Education Ministry propose and encourage the education of the hearing deficient in common schools¹⁶, the reality shows that, usually, these people have no opportunity to frequent these schools and do not learn the Portuguese language³, their second language (considering sign language/mimic the first) that, like any foreign language, it is difficult to be learned¹³.

As observed, the professionals also seek the help of others to interpret what is said. However, besides the patient, usually seek the service without assistance, the communication intermediation inhibits the hearing deficient person, and he ends up depriving talking about their real needs¹³. Accordingly, it is common for the right to privacy and right to individuality of these patients being impaired, affecting the exercise of their autonomy, which raises a question of ethics and morality¹⁷.

Although the strategies referred assist communication between the nursing staff and the person with hearing deficiency, it appears that there are still many gaps in this interaction. Although the contents of communication are important, not always, are addressed in the process of nursing education at various levels and are few in broader subjects¹⁸. As advocate the National Curriculum Guidelines for Undergraduate Nursing, the Nursing education requires a training course that provides ability and skills to the proper use of non-verbal language¹⁹.

Therefore, the knowledge of LIBRAS and continuing education are essential for professionals to be able to continuously learn, both in their education and in their practice. Thus, an effective link between the nursing staff and these patients could be established.

Category 4 - Suggestions to improve communication ...

To improve communication between staff and people with hearing deficiency, the interviewees suggested the inclusion of subjects in school and university education, training and courses that prepare professionals to meet these patients appropriately, including LIBRAS courses.

It should be deployed, since high school, a discipline of LIBRAS, for the hearing deficient. The institution should take the initiative to improve our communication with the deficient. (T2)

Training, courses, we do everything to communicate, but communication is not perfect. If there was a concern since graduation would be better for everyone. (E4)

We should have courses in college that addressed the topic, I think that Libras should be mandatory for all nurses and doctors. (E17)

The awareness of the need for change is coming from the base of people education. Thus, as prescribed by law, is necessary to introduce disciplines that address this issue, since high school to higher education, and continuing education¹¹.

In health, the curriculum are still fragmented and structured in disciplines and cycles and focus on the theoretical and pathological systems through biomedical optics. It addresses issues of small opening to other areas of knowledge and prioritizes the hospital-centered model²⁰. This contradicts the proposal of comprehensive and holistic care that must be prioritized and taught to students. In care provided to people with deficiency, this service must be qualified, because each deficiencies has its peculiarities²¹.

In a federal university in the Northeast, was implanted an elective subject for undergraduate students in nursing, which explores aspects of the relationship of nurses with patients with deficiency. After the subject was taught, the students were asked about their positive and negative points and mentioned that communication and relationships with disabled people improved, which resulted in a safety and some skill. One of the negative aspects mentioned by the students was the need to promote health education for these subjects²¹. Health practices encourage people to pursue their well-being, participation and social representation. Thus, they have been given the empowerment of their actions²².

CONCLUSION

In this study, it was found, through statements, the difficulties expressed by professionals to establish a communication with patients with hearing deficiency due to lack of preparation and training, not knowing their language and the absence of an interpreter at the institution. The most used forms of nonverbal communication were lip reading, gestures and mimics. Although employing strategies to be able to establish communication with the hearing deficients, nursing professionals feel many difficulties in this interaction, especially not knowing the LIBRAS, which should be disseminated among professionals and occur through the implementation in the curriculum of health care in addition to training offered for professionals who are already in practice.

This change is important to raise awareness about issues related to people with deficiency in society and in the health field, because the knowledge and skills of professionals to engage with people who have hearing disability can realize the link between these subjects and enable effective care, according to their specific needs.

The scarcity of literature about the subject and the small number of participants allow generalization of the results, and that requires replication of the study in a representative sample of the universe. Still, it is worth mentioning the importance of knowledge and awareness among professionals of the real problem generated by the lack of effective communication between the professional and the person with hearing deficiency. Therefore, it is expected that this research has contributed to deepen the issues related to this interaction and to subsidize new research whose results lead to reflection about the health care aimed at social inclusion of people regardless of their limitations and free prejudices.

REFERENCES

1. Secretaria Especial dos Direitos Humanos. Coordenadoria Nacional para Integração da Pessoa Portadora de Deficiência CORDE. Convenção sobre os Direitos das Pessoas com Deficiência. 2007; [citado em 05 jan 2014].  Available at: http://www.pessoacomdeficiencia.gov.br/app/publicacoes/convencao-sobre-os-direitos-das-pessoas-com-deficiencia

2. Instituto Brasileiro de Geografia e Estatística (IBGE).  Indicadores sociodemográficos e de saúde no Brasil. 2000; [citado em 05 jan 2014]. Available at: http://www.ibge.gov.br/home/presidencia/noticias/noticia_visualiza.php?id_noticia=438&id_pagina=1

3. Pagliuca LMF, Fiuza NLG, Rebouças CBA. Aspectos da comunicação da enfermeira com o deficiente auditivo. Rev esc enferm USP. 2007; 41: 3411-8.

4. Ministério da Saúde (Br). Secretaria de Atenção à Saúde. Política Nacional de Saúde da Pessoa Portadora de Deficiência. Brasília (DF): Editora MS; 2009.

5. Pagliuca LMF, Régis CG, França ISX.  Análise da comunicação entre cego e estudante de Enfermagem. Rev Bras Enferm. 2008; 61: 296-301.

6. Organização Mundial de Saúde (OMS). Classificación internacionalde las deficiências, actividades e participación: um manual de las dimensiones de la inhabilitación e su funcionamento. Genebra (Swi): OMS; 1997.

7. Arakawa AM, Sitta EI, Caldana ML, Sales-Peres SHC. Análise de diferentes estudos epidemiológicos em audiologia realizados no Brasil. Rev CEFAC. 2011; 13(1):152-58.

8. Freire BF, Gigante LP, Beria JU, Palazzo LS, Figueiredo ACL, Rayamann BCW. Acesso de pessoas deficientes auditivas a serviços de saúde em cidade do Sul do Brasil. Cad Saúde Pública. 2009; 25:889-97.

9. Bardin L. Análise de conteúdo. Lisboa (Pt): Edições 70; 2009.

10. Ministério da Saúde (Br). Resolução nº 196/96 de outubro de 1996. Dispõe sobre diretrizes e normas regulamentadoras de pesquisa com seres humanos. Brasília (DF): CNS; 1996.

11. Ministério da Educação (Br). Lei nº10.436, de 24 de abril de 2002. Dispõe sobre a Língua Brasileira de Sinais - LIBRAS - e dá outras providências. Diário Oficial da República Federativa do Brasil. 2002; [citado em 15 mar 2012]. Available at: http://www.leidireto.com.br/lei-10436.html

12. Sales AS, Oliveira RF, Araújo EM. Inclusão da pessoa com deficiência em um Centro de Referência em DST/AIDS de um município baiano. Rev Bras Enferm. 2013; 66: 208-14.

13. Chaveiro N, Barbosa MA. Assistência ao surdo na área de saúde como fator de inclusão social. Rev esc enferm USP. 2005; 39: 417-22.

14. Silva MJP. Comunicação tem remédio: a comunicação nas relações interpessoais em saúde. São Paulo: Gente; 2006.

15. Cardoso AHA, Rodrigues KG, Bachion MM. Percepção da pessoa com surdez severa e/ou profunda acerca do processo de comunicação durante seu atendimento de saúde. Rev Latino-Am Enfermagem. 2006; 14: 553-60. 

16. Ministério da Educação (Br). Lei nº 9.394, de 20 de dezembro de 1996. Estabelece as diretrizes e bases da educação nacional. Diário Oficial União.  [citado em 15 mar 2013]. Available at: http://portal.mec.gov.br/seed/arquivos/pdf/tvescola/leis/lein9394.pdf   

17. Soares NV, Dall'agnol CM. Privacidade dos pacientes: uma questão ética para a gerência do cuidado em enfermagem. Acta Paul Enferm. 2006; 24: 683-8.

18. Trecossi MO, Ortigara EPF.  Importância e eficácia das consultas de enfermagem  ao paciente surdo. Rev  enferm URI. 2013; 9(9): 60-9.

19. Ministério da Educação. Resolução CNE/CES 3/2001. Conselho Nacional de Educação. Câmara de Educação Superior. Brasília (DF): CNE; 2001.

20. Ministério da Saúde (Br). Seminário: incentivos às mudanças na graduação das carreiras da saúde. Brasília (DF): SGTES; 2003.

21. Rebouças CBA, Cezario KG, Oliveira PMP, Pagliuca LMF. Pessoa com deficiência física e sensorial: percepção de alunos da graduação em enfermagem. Acta Paul Enferm. 2011; 24: 80-6.

22. Sousa LB, Torres CA, Pinheiro PNC, Pinheiro AKB. Práticas de educação em saúde no Brasil: a atuação da enfermagem. Rev enferm UERJ. 2010; 18: 55-60.