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The communication needs of deaf people

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Optometry in Practice 2014 Volume 15 Issue 1 19 – 28
The communication needs of deaf people
Marek Karas1,2 BSc(Hons) MCOptom and Jo Laud1 BSc(Hons) MRCSLT MHCPC
1
SeeAbility, Epsom, UK
2
Welsh Optometric Postgraduate Centre, Department of Optometry and Vision Sciences, Cardiff University, Cardiff, UK
EV-18093 C-35018
1 CET point for UK optometrists
Introduction
As a practitioner working in the UK today we can expect to
have a working life of maybe 45 years. This means that in
full-time practice we are likely to engage in some 100 000
patient consultations throughout this period. Each one of
these interactions will involve an individual communication
process with our patient, which will be repeated many times
each day. As with many professions (Casey and Wallis 2010;
General Medical Council 2009), being able to communicate
effectively is cited as one of our core competencies (General
Optical Council 2011).
Instinct would suggest that good communication is at the
heart of a successful consultation for both patient and
practitioner. Research in general medical practice suggests
that communication has a role to play in patient satisfaction,
compliance with treatment regimens and improved health
status (Beck et al. 2002; Safran et al. 1998). In more specialist
areas such as cancer care (Stewart et al. 2007) and mental
health (McCabe et al. 2002) good communication has been
identified as a positive contributor to patient satisfaction and
better health outcomes.
Communication skills are now an integral part of medical
education (Hargie et al. 2010; Von Fragstein et al. 2008),
being taught as a set of core competencies (Silverman et al.
2005) which make up theoretical frameworks for approaching
the medical interview or consultation process (Kurtz et al.
2003; Makoul and Schofield 1999). The consensus is that all
communication skills curricula should include the teaching of
skills to allow communication with patients with a sensory
disability or learning disability and cover the skills needed to
work alongside communication workers who may be assisting
them (Von Fragstein et al. 2008).
In these two articles we will look at how people who are deaf,
deafblind or have profound and multiple learning disabilities
might choose to communicate. We will consider how we
can prepare for a consultation with someone with additional
communication needs and how we should interact with
different methods of communication that may be used during
the eye examination. In this first article we will consider the
communication needs of deaf people.
Date of acceptance: 18 November 2013. Address for correspondence: M Karas, SeeAbility, 41 East Street, Epsom, Surrey KT17 1BL, UK.
marekpkaras@gmail.com.
© 2014 The College of Optometrists
The deaf population
It is estimated that about 10 million people in the UK are
affected by hearing loss – about one in six of the population.
Of this total, 6.4 million are of retirement age and 3.7 million
are of working age. The same estimates suggest this total
will increase to 14.5 million by the year 2031. Currently
800 000 people are thought to have profound levels of
deafness. There are around 45 000 children in the UK who
are deaf. There are thought to be about 365 000 people with
some level of combined hearing and sight loss in the UK,
with most of these, 62%, being 70 years or older (Roberston
and Emerson 2010). This group is often identified as deafblind
or as having dual sensory loss.
Hearing is considered restricted if a person cannot
identify sounds below a threshold of about 25dB across all
frequencies. The greater this threshold, or hearing level, the
greater the hearing loss. As an example, a normal conversation
between two people will have a loudness of about 65dB while
a petrol lawn mower, considered a loud noise, will be about
100dB. Standing near the speaker stack at the Glastonbury
Festival you would experience noise levels of 115dB, enough
potentially to damage your hearing. The severity of the hearing
loss is defined by the range of ‘loudness’ that can be heard:
mild, moderate, severe and profound. This is one way that
deafness can be classified. Table 1 gives some examples of
what different levels of hearing loss mean in everyday life.
Hearing loss can also be classified by its type (conductive or
sensorineural), its time of onset related to language learning
(pre- or postlingual), its cause (genetic or environmental),
whether it is syndromal or non-syndromal or whether it is
progressive or not (Middleton 2009; Smith 1999).
Deafness is the most common form of birth defect, with
1 in 500 babies having bilateral permanent sensorineural
hearing loss of ≥40dB (Morton and Nance 2006). More
than half of early-onset deafness is genetic in cause and
the remainder is acquired (Nadol and Merchant 2001) as a
result of external environmental factors, the most common
being prenatal and postnatal infections. The most frequent
of these infections in the developed world is congenital
infection with cytomegalovirus (Smith 1999).
19
 M Karas and J Laud

their communication needs. People experience hearing

Table 1. Levels of hearing loss loss at different stages of life in very different ways so their
Level of Range of Functional Example
communication needs can be very different.
hearing loss hearing loss impact sound
In common with all disability it is not correct to refer to
Mild 20–39dB Difficulty Whispering:
following normal 20dB ‘the deaf’ as this defines the person by his or her disability.
conversation in a Commonly used terms are ‘deaf people’ or ‘people with
noisy room or if
a person is softly
deafness’. In contrast to people with sight loss, where it
spoken is correct to use the term ‘visually impaired’, the term
‘hearing-impaired’ is not seen as politically correct, possibly
Moderate 40–69dB Will have Normal
difficulty conversation: because hearing loss is not seen by some in the deaf
understanding 65dB community as an impairment. Although the medical and
direct clear research community still tends to use the term ‘impaired’,
conversation in a
quiet room especially in the context of the International Classification
of Functioning, Disability and Health (ICF) (WHO 2013a, b)
Severe 70–94dB Will not be able Loudest
to hear someone doorbell it has been dropped by most charities and support groups
talking to available: (Middleton et al. 2010a).
them or hear a 90dB
doorbell
So how should we understand and use the various terms
Profound 95dB or more Will not be Shotgun linked to hearing loss: hard of hearing, deaf, Deaf, deafened
able to hear blast: 130dB
loud noises and and hearing-impaired? There are no clear definitions of what
are unlikely to these terms mean and they change with time and from
benefit from person to person. Broadly speaking, in the UK, the general
hearing aids
term ‘deaf’ is used to refer to all levels and types of
Adapted from Middleton (2009) and Action on Hearing Loss (2011). deafness. People who refer to themselves as deaf will tend
to have a profound level of deafness. People who refer to
themselves as ‘Deaf’ with a capital D are making the clear point
Of prelingual deafness caused by genetic causes, about 30% that they are culturally deaf. Those who consider themselves
is syndromal. In syndromal deafness the hearing loss is part culturally Deaf will prefer to use sign language and they
of a wider collection of symptoms that may cause other feel most at home in the deaf community rather than the
disabilities. For example, someone with Usher syndrome is hearing world.
born with sensorineural hearing loss and then develops retinitis
pigmentosa, resulting in visual impairment. The remaining 70% Conversely, people who refer to themselves as ‘hard of
of genetically acquired deafness is non-syndromal; that is, the hearing’ or ‘deafened’ may be making the point that they are
hearing loss is not related to other medical issues (Smith 1999). not part of the deaf world. Someone who is hard of hearing is
most likely to be of the older group with age-related hearing
Most deafness after this early-years period is caused by loss. They will tend to have some hearing, use hearing aids
external environmental factors such as ototoxic drugs, and use the spoken word for communication. Someone who
exposure to loud work environments and head injury. When is deafened is most likely to have acquired hearing loss in
considering the total number of people affected by all types early or middle adulthood and it is likely to be profound. Most
of deafness the largest group by far are those of retirement people with NF2 will develop their hearing loss in their 20s or
age affected by age-related damage to the cochlea, termed 30s and they would describe themselves as deafened. They
presbycusis (presbyacusis) (Action on Hearing Loss 2011). will learn to lip read and this may be assisted by a cochlear
or brainstem implant. Few deafened people will learn to sign
Neurofibromatosis type 2 (NF2) is a disorder characterised by proficiently (Table 2).
the growth of multiple benign tumours (schwannomas and
meningiomas) at different locations in the body, resulting in a People who have developed deafblindess at an early age,
wide range of symptoms. Almost all sufferers develop bilateral prelingual or postlingual, may have learned to sign and will
consider themselves D/deaf. Patients whose combined loss
tumours of the vestibular nerve which lead to hearing loss,
occurred before speech was learned (prelingual) are usually
tinnitus and usually total deafness. Removal of these vestibular
termed ‘congenitally deafblind’. Those who develop the
schwannomas can damage facial nerves, resulting in facial
dual loss after speech has been learned (postlingual) are
weakness which can affect eating and facial expression. Other
termed ‘acquired deafblind’. The vast majority of people
common symptoms include balance problems and early-onset
with dual sensory loss will be in their 60s and are considered
cataract (Evans 2009). Patients benefit from management by
‘elderly deafblind’. Many may not even be aware they have
multidisciplinary specialist services (Evans and Gareth 2005)
significant hearing loss (Middleton 2009).
and the often unexpected onset in early adulthood of these
various symptoms has a devastating effect on the patient.
Deaf culture, first talked about in the 1970s, refers to the
belief that deaf people can choose to live mostly in a separate
Identity deaf society mediated by their own language and set of social
Understanding how people with hearing loss see themselves norms (Ladd 2003). In deaf culture, deafness is not seen as a
in relation to the hearing world is key to being able to meet problem but something to be celebrated. Deaf couples may

20

prefer to have deaf children and the birth of a deaf child to a
Deaf couple can be seen as a cause of celebration (Middleton
et al. 1998).
Table 2. Terms used by deaf people to describe
themselves
hearing-impaired Often used by medical professionals but
not considered politically correct by most
deaf people, charities and support groups
deaf A general term to describe all levels of
deafness. Also used by people who have
profound deafness and still use speech.
They may also use a cochlear implant and
lip reading
Deaf People who describe themselves as Deaf
with an upper-case D are culturally deaf
using sign language as their preferred
mode of communication. They are likely to
have profound levels of deafness acquired
earlier in life. Written material may be of
little use to them
hard of hearing Used by people with mild to severe
deafness that is progressive and started
in older age. They will use speech and
written material and benefit from hearing
aids. They are unlikely to use British
Sign Language
deafened Usually used by someone who acquired
a profound level of deafness in adult life.
Unlikely to use a cochlear implant, hearing
aid or British Sign Language. Will rely on
speech reading and written notes
Adapted from Middleton (2009) and Middleton et al. (2010a).
Methods of communication used by
d/Deaf people
Speech
The majority of people with a hearing loss will be older
and have mild to moderate loss. Those in this group are likely
to use a hearing aid, see themselves as part of the hearing
world and rely on speech as their main communication
method. Those who are deafened and may have a more
profound level of hearing loss will still most likely have used
speech at a younger age and so in most cases will still rely
on this as their main communication method. They may use
cochlear implants and lip reading to help them understand
the spoken word. When consulted, both these groups prefer
to have a medical consultation in speech as long as there is a
good understanding of their communication needs (Middleton
et al. 2010b).
British Sign Language (BSL)
BSL is an example of a national sign language (NSL) which
is a system of communication that does not involve the use
of speech but instead communicates meaning through the
use of gesture, spatial relationships and facial expression.
NSLs are not copies of the national spoken languages but are
unique separate languages that have evolved over time with
their own grammar, vocabulary and even regional variations
(Stokoe 2005). Each country has its own NSL and users from
different countries may not be able to understand each
The communication needs of deaf people
other at all. As is the case with spoken language, some NSLs
have evolved from common roots and there are groups
or families of NSLs which share common elements. For
example, BSL, Australian Sign Language and New Zealand Sign
Language have a common root and users will be able to
communicate at a basic level (Brentari 2010). American
Sign Language (ASL) is from a different group, related to
French Sign Language, and BSL users would find it hard to
understand ASL users.
There are thought to be about 60 000 deaf adults who
identify themselves as primary BSL users and there are
estimated to be some 122 000 people who can converse in
BSL (Deafness Cognition and Language Research Center 2013).
Most deaf people who use BSL have learned it at an early
age, have a more profound level of hearing loss and are
more likely to consider themselves culturally Deaf. There are
probably as many non-deaf users who have learned the
language for work or family reasons.
BSL is taught to deaf children from both hearing and deaf
families. The deaf community considers it important that
deaf children are taught about deaf culture even if they are
educated in mainstream school and learning BSL is key to
this (British Deaf Association 2013a). Active teaching and use
of BSL have only occurred in the last few decades, with oral
teaching methods predominating even in deaf schools since
the 1800s (British Deaf Association 2013b). This means that
you may encounter a profoundly deaf older person who has
been educated in a special school but has never had the chance
to become proficient in BSL. Depending on the needs of the
child, most specialist teachers working with deaf children
will be able to use either BSL or Sign Supported English (SSE),
which is a modified version of sign language based on the
spoken word.
People who use English and can use BSL are considered
bilingual and BSL has been recognised as a language by
government, even though it has not been given legislative
protection, as is the case for a regional language like Welsh.
A good place to see BSL in use is the BBC, which repeats many
of its programmes with ‘in-vision’ signing using BSL.
Written communication
Written communication may be crucial for people who are
hard of hearing or deafened both during the consultation,
in the form of note taking, and afterwards, in the form of
written information leaflets to reinforce key messages.
Someone may prefer to communicate with you by
writing down his or her concerns and may come to the
consultation with a set of questions in writing. Using written
notes during the consultation requires the practitioner
to consider carefully the core information needed as the
method is time consuming. A clipboard helps for ease of
writing notes without having to change position constantly.
Conversely it is critical to realise that written English for
many BSL users is a second language, so if we give someone
information in a written format they may struggle to
understand it. This is because BSL will use a unique word
21
 M Karas and J Laud
order different to that of spoken English. It is important
that this is not mistaken for an intellectual failing and that
we adapt how we communicate to compensate. Rather
than relying on a leaflet at the end of an examination we
may take more time to talk through its contents before ending
the session.
Written material can be adapted to be ‘easy to read’ by
tailoring it to the way a BSL user understands language.
Accessible websites will use short films of someone signing
in BSL next to text. This is again because the text is in
written English and the video is in BSL, two separate
languages (Figure 1).
Figure 1. Screen shot from British Deaf Association
website (reproduced with permission).
Sign Supported English
SSE is very different to BSL in that it is based on spoken
English. Signs borrowed from BSL are used in conjunction with
the spoken word to help get the meaning across. The grammar
and hence the sentence structure follow spoken English.
Someone using SSE will clearly mouth each word to help
speech reading as well as use signs; conversely, someone
using BSL would not mouth any words but would use only
signs and facial expression to get across meaning.
As SSE is much easier to learn than BSL it is used more
often outside the Deaf world. Hearing families with a deaf
child will learn it for use around the home and it is used by
most peripatetic teachers supporting children in mainstream
schools. Those with later-onset, less profound hearing loss
who do learn to sign will tend to learn SSE.
Signed English is an exact copy of the English in sign. It is
laborious and so is not used for communication but as a
teaching aid in learning English in school. By signing every
22
part of the sentence (including all the grammatical markers),
it enables deaf children to understand and learn spoken
English grammar and syntax, to ensure they are not
educationally disadvantaged.
Lip reading
Lip reading involves watching someone’s face as he or she
speaks to determine certain speech sounds. Information is
gathered from all of the facial expression and body gestures
and this is known collectively as ‘speech reading’ (Kaplan
1996). Contrary to popular belief, this method is of limited
use as a standalone method. Less than 30% of English
sounds can be clearly lip read and external factors like busy
environments or emotional state of the speech reader quickly
reduce its effectiveness (Harmer 1999). This method is often
used as a supplement to a hearing aid or SSE, which is why
words are clearly mouthed during the use of SSE. To be able
to use this method the user must be able to see the speaker’s
face. There is evidence to suggest that even small reductions
in simulated visual acuity and contrast sensitivity reduce
the effectiveness of this method (Dickinson and Taylor 2011).
This is especially relevant for the older group of patients
who are very likely also to have some form of vision loss.
Text phone and speech to text
Text phone or Minicom is a way of communicating using an
adapted or specialist telephone which allows messages to be
typed and received. The system needs nothing more than a
phone line. For many users text messaging on mobile phones
or live internet chat has replaced text phones but they are
still sold and many older users still rely on them.
Speech to text is a phone line system that uses an
operator as an intermediary to read out the message typed
by the deaf user. This allows for a two-way text to voice
conversation between a hearing user without a text phone
and a text phone user (Figure 2). In 2009 BT’s Text Divert
and Action on Hearing Losses Type Talk were combined
into one service, called Text Relay (Text Relay 2013).
Figure 2. Using textphone and speech to text.
Deaf people and healthcare
Surveys of deaf people suggest that they experience
barriers when accessing and using health services. A recent
survey of both hard of hearing and deaf users of GP services
showed that, after their GP consultation, 28% were unclear
about diagnosis, 26% were unclear about health advice and
19% were unclear about medication. The results for BSL users
are more marked. Sixty-eight per cent asked for an interpreter

but did not get one, 74% had to remind the GP about their
communication needs and 41% who had had a consultation
with a BSL interpreter present were left confused about
their medical condition (Ringham 2012). Previous surveys of
people’s experiences of both primary and hospital care have
highlighted very similar problems, with poor deaf awareness
among staff and lack of communication support always
being cited (Middleton et al. 2010b; Reeves and Kokoruwe
2005; RNID 2004). There are no similar insights into deaf
people’s experiences of optometry services but it is a
reasonable assumption that similar problems will exist.
There is also a suggestion that deaf people have poorer
health than the general population (Alexander et al. 2012)
and a recent review shows evidence of higher levels of
mental health problems in deaf people when compared
to the hearing population (Fellinger et al. 2012). Poor
communication is always cited as a main contributor to
deaf people’s interactions with healthcare (Anonymous
2012) and the recommendations are always the same: an
improvement in deaf awareness and communication at an
organisational and individual level (Middleton et al. 2010a;
Ringham 2012; RNID 2004).
This work from the primary and secondary care sector shows
that communication is the key barrier to accessing health
services. All health service providers, including optometrists
and dispensing opticians, have an obligation under the
Equalities Act 2010 to provide equal access to their services
by making reasonable adjustments. Meeting someone’s
communication needs is as much a reasonable adjustment as
providing wheelchair access. What are some of the ways to
make the services we provide more accessible to deaf people?
Improving deaf awareness
Preparation
Improving deaf awareness and making reasonable
adjustments involve looking at all parts of the services we
offer to ensure they are going to be as easy to access and
use as possible.
Before we examine someone who is deaf that person needs
to be aware our service exists and then feel able to book
an appointment easily. A recent survey of deaf users of GP
services showed that 72% used the phone to book their
appointments but only 44% said this was their preferred
method. Visiting the practice to make an appointment
was even less popular, with only 9% preferring this method.
Thirty-one per cent suggested that email was their preferred
method of booking (Ringham 2012).
As the telephone is still a mainstay of communication, staff
need to be aware that there are adapted ways of using it,
such as amplifiers, Minicom or Text Relay. Someone using an
amplifier or loop at their end in conjunction with their own
hearing aids will be able to listen and talk but the conversation
may be slow and need repetition. Some users may still use
Minicom or a similar telephone text system and staff should
be able to offer these as options and know how to use them
with confidence. Table 3 suggests some ideas for improving
appointment systems.
The communication needs of deaf people
Table 3. Improving appointment systems
• Offer appointments by email
• Offer online booking
• Offer appointments by text
• Make staff aware of how Text Relay can be used
• Make sure staff ask about communication needs
when booking the appointment
• Arrange for staff training on all communication
methods
Hopefully patients or carers will make you aware that
someone is deaf when they make the appointment. Staff
should be encouraged to ask about specific communication
needs when the appointment is booked so that arrangements
can be made in advance.
The environment
The environment of both the waiting area and the consulting
room needs to be considered. The waiting room should be
arranged so that patients will be able to see you coming to
ask them into the consulting room. Display units with
numbering systems are recommended for busy waiting areas
(Ringham 2012), but the display showing the next number in
line needs to be large and bold, and patients need to be aware
of how the system works. Hearing loops if fitted will only be
of use if they are switched on and reception staff know how
to use them. There is no substitute for staff being aware of the
deaf person’s communication needs before arrival and having
an understanding of how these can be met.
The consultation needs to happen in a room with minimal
background noise which might interfere with hearing aids.
Lighting needs to be uniform with no glare sources which may
inhibit clear lip reading.
Interpersonal communication
Ideally we will be aware that someone has hearing difficulties
before we begin the examination but the absence of a hearing
aid does not mean someone is not deaf. Most people who
are culturally Deaf would not wear a hearing aid, preferring
to stay within the Deaf world. If we discover someone is deaf
then we need to take the time to establish the best way to
communicate and be empathic about this.
As deaf people’s experiences of health services are generally
poor, they may be embarrassed, withdrawn or even hostile
to what they perceive as an uncaring medical establishment
(Middleton et al. 2010a). Attending an appointment in an
unfamiliar environment whilst not being able to ask questions
or have a conversation with those around you can be an
overwhelming experience and we need to keep this in mind.
In addition deaf people have a greater incidence of mental
health issues throughout life (Fellinger et al. 2012) and a
good understanding of current health information cannot
23
 M Karas and J Laud
be assumed (Barnett 2002; Harmer 1999). This means that
we need to consider all stages of our consultation process
carefully and proactively try to improve communication.
Meeting people’s communication needs takes time, which is
why preparation is essential.
Communication with hard of hearing
speech users
If patients are non-sign language users they are likely to
be using a mix of methods to try and communicate. They
may be listening to speech via a hearing aid and relying on
some speech reading as well as using guesswork to fill in the
gaps. The use of notes is common and written information,
such as pathology leaflets, to reinforce key messages is
useful. Table 4 gives some tips for improving communication
with speech users.
Table 4. Communication with someone who is hard
of hearing
• Get the person’s attention before speaking
• Face the person while speaking
• Maintain eye contact. Stand or sit at the same level
as the patient, 1–2m away
• Be careful not to turn away to take notes whilst
speaking, as this is cited as the main reason
for patients’ confusion with a consultation
(Ringham 2012)
• Do not shout as this will only distort the pattern
of speech, making it more difficult to understand
• Do not cover your mouth when speaking
• Do not exaggerate mouth movements
• Ensure the person knows what you are about
to discuss
• Review the person’s understanding often
• If the patient does not understand, then rephrase
rather than keep repeating the same wording
• Indicate when you intend to change to a new
topic because the range of vocabulary is likely to
be different
• Use ‘signposting’ in the conversation, such as,
‘We are going to talk about your ocular history
first, then I will start to examine your eyes’
• Any cue is useful – use mime, gesture and
body language
• Use visual aids such as models or diagrams
• Before carrying out tests on the patient explain clearly,
before you begin, what you are going to do and how
you wish the patient to cooperate
• Use pen and paper if necessary
• Use open-ended questions
• Have patience – check that you have been understood
• Consider carefully how to give your advice at the end.
Consider using summary leaflets
• Ensure others are aware of the person’s communication
needs if you are sending the patient to another
department or colleague
Adapted from Barnett (2002) and Middleton et al. (2010a).
24
Adapting the way we are talking to someone may involve
speaking more slowly, reviewing understanding as we
progress and note writing. All this takes longer than standard
conversation so the whole appointment will take longer.
This means that we need to offer either more time or two
shorter appointments. Ask the patient before the appointment
if he or she would like an extended appointment or two
separate slots.
Communication with a BSL user
For most of us, communication with someone who is a
BSL user will involve working with an interpreter. When
booking a BSL/English interpreter you need to ensure that he
or she is registered with the National Registers of
Communication Professionals working with Deaf and
Deafblind People (NRCPD). You might be offered an NRCPD
Registered Sign Language Interpreter (RSLI), who carries a
yellow photo ID card, or an NRCPD Trainee Sign Language
Interpreter (TSLI), who carries a purple photo ID card. For legal
and mental health appointments an RSLI should be used.
Working with an interpreter will be an unusual experience
for most of us and again preparation is needed. Even though
interpreters can work in any environment it is useful to contact
them beforehand to ensure they understand the nature of the
appointment and can prepare for any specialist vocabulary.
Interpreting at a business meeting will be very different to
interpreting in a one-to-one medical consultation. Often a
deaf person may have a preferred local interpreter who has
developed the specialist vocabulary needed. If an agency
interpreter is to be used then speaking to him or her ahead of
the appointment is crucial.
BSL interpreters work for a maximum of 30 minutes at a time.
It may be possible to carry out the eye examination in this time
but be prepared for things to move at a slower pace, especially
if there is a complicated history or lots of explanation needed
from the optometrist. It is possible to book two interpreters
to extend your time to an hour but you need to ask patients
their preference and be aware that the process can be tiring
for all concerned. Table 5 reviews some of the preparations
and etiquette rules that need to be followed when using a
BSL interpreter.
Conversation structure in BSL
As health professionals we will have developed an expectation
of how conversation during a consultation will progress.
An initial general discussion usually leads to a more indepth
conversation about why the person is attending and the key
medical issues. For sign language users the conversation is
often structured differently, with the main point being
addressed first and then general issues being discussed later
on (Meador and Zazove 2005). Addressing the main point
first is not considered rude; it is expected. Sign language users
will also use repetition a lot, use facial expression to add
meaning, wave a hand to attract attention and will expect
to maintain eye contact at all times while communicating
(Middleton 2009).

Table 5. Preparing for a consultation using a British
Sign Language interpreter
• Ask the patient if he or she has a preferred
local interpreter
• Speak to the interpreter in advance so he or she is
aware of the nature of the work
• Book a maximum 30 minutes appointment for
each interpreter. Consider a further appointment if
30 minutes is not enough
Communicating with someone who is
a sign language user with an
interpreter present
• Ensure the interpreter is seated so that the
deaf person can see the interpreter clearly. In a
consultation environment this will usually mean
next to you, facing the patient
• Gain the patient’s attention before speaking
• Face the person while speaking and direct your
speech to the patient, not the interpreter
• Allow the deaf person time to look at written
material or visual aids. The deaf person cannot
simultaneously look at these and the interpreter
• Only one message can be interpreted at a time.
It is important that only one person speaks or signs
at a time
• Be prepared that the interpreter may need to
interrupt you or the patient to ask for repetition
or clarification to be able to interpret what is
being said
• The interpreter is not part of the discussion and will
not offer an opinion
• The interpreter will interpret everything that is
said by you
• State topic changes clearly
• Ask the patient about the quality of the
communication periodically
• Check the client has understood each topic clearly
by asking him or her to summarise the key points
Using other communication support workers
In addition to BSL interpreters there is a wide range of
communication workers who offer support to deaf people.
For example, someone who is a speech user may still
want a communication support worker to assist during
the consultation. The different types of support workers
have specific roles, so it is crucial to identify the needs of
the person before booking a service. Table 6 describes the
types of communication support roles that are regulated
by the NRCPD.
The communication needs of deaf people
Table 6. Communication support roles that are
regulated by the National Registers of Communication
Professionals working with Deaf and Deafblind People
Sign language Sign language interpreters transfer
interpreting meaning from one spoken or signed
language into another signed or spoken
language
Sign language Sign language translators will translate
translators written text from one language into
another. Most often this will be from
written English into a signed language
for the purposes of broadcasting or
web access
Note takers Note takers produce an accurate
summary record of speech, which a
deaf person may use for reference
Interpreters for Interpreters for deafblind people use
deafblind people manual communication to enable
deafblind people to understand,
participate and interact. The interpreter
will also relay visual and other
non-verbal information, for example
reactions to what has been said,
movement of other people and what they
are doing
Lip speakers Lip speakers repeat spoken messages
for people who can lip read. They can
be used to ensure clear communication
in critical situations, or in situations
where there is more than one voice to
follow. Lip speakers use facial expression,
natural gesture and finger spelling to
support communication
Speech to text Speech to text reporters take words that
reporters are said and use a phonetic keyboard
to relay them instantly on to a monitor
or screen. They provide a complete
transcription of spoken words and
include notes of environmental sounds,
like laughter and applause
Adapted from NRCPD (2013).
For each type of worker there is an etiquette and set of
requirements which can be found in a range of factsheets
from NRCPD (Table 7). If you wish to book one of these
workers you should read the relevant factsheet before
the appointment.
Table 7. National Registers of Communication
Professionals working with Deaf and Deafblind
People factsheets
• Working with a lipspeaker
• Working with a notetaker
• Working with a sign language interpreter
• Working with a sign language translator
• Working with a speech to text reporter
• Working with an interpreter for deafblind people
Adapted from NRCPD (2013). Available online at
http://www.nrcpd.org.uk/page.php?content=53.
25
 M Karas and J Laud

Finding communication support workers

Most large hospitals will have interpreter services available
and clinical commissioning groups/council areas will either
have an in-house team (Islington Council 2013) or contract
the service out to a specialist provider (NHS Camden 2013).
This means that someone who is eligible for a sight test
under the General Ophthalmic Services system can also
have a communication support worker provided. If the
patient is not eligible for an NHS sight test it is arguable the
practice would need to provide communication support and
bear the cost themselves.
If a BSL interpreter is not available in person then online
services may offer an alternative solution, although access
to a PC with webcam and internet access is needed. This type
of approach is being increasingly used by GP practices and
some hospitals (Sign Translate 2013).
Conclusion
People can be affected by hearing loss at all stages of
life and to differing degrees. There are a wide range of
communication methods and adaptations that they may
choose to use, and in the case of BSL users, the method
defines them culturally. Deaf people’s experiences of health
services are generally poor due to poor deaf awareness
among staff. In this article we have aimed to address this
by looking at the ways that deaf people may choose to
communicate and how we can accommodate these choices
by preparing for a consultation with a deaf patient. In
the second of these articles we will look at the more
complex issues involved in communicating with deafblind
patients and those with profound and multiple learning
disabilities (PMLD).
Summary
Hearing loss affects people from all age groups and
is caused by a wide variety of pathologies or
environmental factors. The age of onset and severity
of deafness will affect the way individuals will
communicate and in some cases how they define
themselves in relation to the hearing world.
• The majority of deaf people you will encounter in
practice will be of retirement age, affected by
age-related hearing loss. They may not be fully
aware of their hearing loss and are likely to have
some degree of sight loss.
• Understanding how people with hearing loss see
themselves in relation to the hearing world is key to
being able to meet their communication needs.
• Someone with early-onset deafness is more likely
to define themselves as culturally Deaf and use a
national sign language (NSL).
• People defining themselves as hard of hearing
or deafened are more likely to have later-onset
deafness and use a variety of communication
methods other than NSL.
It is suggested that deaf people have poorer health
and their experience of all levels of healthcare
provision is not positive. Poor deaf awareness and
communication support are always cited as the
main problems.
• Speech, aided by hearing aids or speech reading, is
an important method of communication for most
deaf people
• An NSL is a standalone language, not a signed
version of the spoken word.
• Each type of communication method and
communication support worker has an etiquette
associated with it which you should be familiar
with before the consultation starts.

Useful websites
Organisations
Action on Hearing Loss, formerly known as the RNID:
www.actiononhearingloss.org.uk/
Association of Teachers of Lipreading to Adults. Professional
association for teachers of lipreading to adults who have
become deaf: www.lipreading.org.uk
British Deaf Association. Run by Deaf people, the BDA
campaigns for the status and recognition of the Deaf
community and BSL in the UK: www.bda.org.uk
National Registers of Communication Professionals who
Work with Deaf and Deafblind People. Organisation
that accredits interpreter and communication support
workers in the UK: www.nrcpd.org.uk

26
 The communication needs of deaf people

Royal Association for Deaf People. Promotes equality for General Medical Council (2009) Tomorrow’s Doctors.
Deaf people through the provision of accessible services: London: GMC
www.royaldeaf.org.uk General Optical Council (2011) Optometry Core Competencies
Signature. An organisation that campaigns to improve (Stage 1). London: GOC
the standards of communication with deaf and deafblind Hargie O, Boohan M, McCoy M et al. (2010) Current trends
people in the UK: www.signature.org.uk in communication skills training in UK schools of medicine.
Text Relay. BT-run telephone service for communication Med Teacher 32, 385–91
via an operator between deaf, text-based phone users: Harmer L (1999) Health care delivery and deaf people: practice,
www.textrelay.org problems, and recommendations for change. J Deaf Studies
Online BSL interpreting providers Deaf Educ 4, 73–110

www.adcommunications.org.uk Islington Council (2013) Deaf and Hard of Hearing Services.

Available online at: http://www.islington.gov.uk/about/help/
www.signtranslate.co.uk accessibility/deaf/Pages/default.aspx (accessed 22/09/2013)
www.signvideo.co.uk Kaplan H (1996) Speech reading. In: Moseley MJ, Bally SJ (eds)
Communication Therapy: An Integrated Approach to Aural
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Beck RS, Daughtridge R, Sloane PD (2002) Physician–patient
McCabe R, Heath C, Burns T et al. (2002) Engagement of
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Brentari D (2010) Sign Languages. Cambridge: Cambridge
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Middleton A (2009) Working with Deaf People. Cambridge:
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CET multiple choice questions
This article has been approved for one non-interactive
point under the GOC’s Enchanced CET Scheme. The
reference and relevant competencies are stated at
the head of the article. To gain your point visit the
College’s website www.college-optometrists.org/oip and
complete the multiple choice questions online. The deadline
for completion is 31 January 2015.
Which of the following is true about levels of hearing loss?
(a) A person with hearing loss in the range of 70–94dB is
formally classified as having moderate loss
(b) A patient with severe hearing loss may experience
difficulty hearing a doorbell
(c) A person with severe hearing loss should manage to hear
a conversation if it is in a quiet room
(d) A patient with a range of hearing loss between 20 and
39dB will experience difficulty with clearly spoken
conversation in a quiet environment
28
Which of the following is incorrect about people who
consider themselves culturally Deaf?
(a) They relish their life as part of Deaf culture
(b) They are likely to use sign language
(c) They are likely to choose not to wear a hearing aid
(d) They are likely to consider their deafness an impairment
Which of the following is true about deafness?
(a) 3.7 million people in the UK affected by hearing loss are
of retirement age
(b) In the UK, over a quarter of a million people aged 70 or
older have some level of combined hearing and sight loss
(c) 30% of prelingual deafness caused by genetic causes is
non-syndromal
(d) The term ‘deafened’ is a synonym for Deaf
Which of the following is true about British Sign Language
(BSL)?
(a) Word order with BSL is the same as SSE
(b) BSL contains the same word order of spoken language,
including punctuation
(c) National sign languages may have their own regional
variations
(d) BSL is not the communication method of choice for the
Deaf community in the UK
Which method of communication would you least expect
an older patient who is hard of hearing to find useful?
(a) The use of notes to communicate
(b) Giving written information about clinical conditions
(c) Using a sign language interpreter
(d) Speech
Which of the following is not appropriate when
communicating with someone who is hard of hearing?
(a) Shouting
(b) Using ‘signposting’ to explain what is going to happen
(c) Intermittently pausing and reviewing the conversation
so far
(d) Using written communication if necessary
CPD Exercise
After reading this article can you identify areas in
which your knowledge of the communication needs of
deaf people has been enhanced?
How do you feel you can use this knowledge to offer
better patient advice?
Are there any areas you still feel you need to study and
how might you do this?
Which areas outlined in this article would you benefit
from reading in more depth, and why?
 The communication needs of deaf people

Reflection
1. What impact has your learning had, or might it have, on:
• your patients or other service users (eg those who refer
patients to you, members of staff whom you supervise)?

• yourself (improved knowledge, performance, confidence)?

• your colleagues?

2. How might you assess/measure this impact?

To access CPD Information please click on the following link:

college-optometrists.org/cpd

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