Communication difficulties and strategies used by the nurses and their team in caring for the hearing impaired

Objectives: To identify communication difficulties faced by the nursing staff and to learn the strategies developed for non-oral communication. Methods: This is a descriptive, exploratory, level I study with a quantitative approach. The sample group comprised 37 registered nurses and 63 licensed practical nurses of a private hospital who, after undergoing the ethical-legal procedures, answered a questionnaire to identify difficulties faced and strategies used in the care for hearing-impaired patients. results: Difficulty in explaining matters of interest to the patient was reported by 66% of professionals; and 32% reported difficulties in understanding patients in their way of communicate. The strategy adopted by 100% of respondents was mimicry, followed by lip reading, used by 94% of respondents; help from a person accompanying the patient was used by 65%, and written communication by 42% of respondents. Only 1% used communication via the Brazilian Sign Language (LIBRAS). conclusions: The difficulties found and the strategies adopted by the nursing staff in communicating with hearing-impaired patients justify the need to train these professionals to deliver a more humanized care, developing a more inclusive society for those with special needs.

Descritores: Pessoas com insuficiência auditiva; Comunicação não verbal/enfermagem; Comunicação não verbal/educação; Equipe de enfermagem; Equipe de enfermagem/educação; Humanização da assistência; Resolução de problemas; Linguagem de sinais; Surdez intrODUctiOn Oral-auditory language or the spatial-visual channel enables the communication among individuals and enhances one's capacity to organize ideas and thoughts.Hearing loss compromises the main means of communication in our society and prevents access to oral-auditory communication (1) .
Communication may be defined as a process through which we share, send and receive messages, ideas, feelings and all sorts of emotions.It happens through the written and spoken word, and also through nonverbal mechanisms which may or may not influence the behavior of people who will react to it based on their beliefs, values, background and culture (2) .
Hearing is the sense through which we perceive the sounds.In the case of the hearing impaired, the failure or lack of this sense interferes in one's relation with society (3) .Amongst all communication disorders, deafness is the most prevalent in Brazil, reaching rates of 60% among related disorders (4) .
Communication barriers faced by those with special needs are not perceived by other people, frequently because these barriers are of environmental nature (5) .As far as nurses are concerned, communication with patients is considered a process fundamental not only to identify signs, symptoms and problems that affect the patient, but also to consider the development of a therapeutic communication between healthcare professionals and patients (6) .
Therapeutic communication is the professional skill in using knowledge about communication to help people with temporary tension to overcome their problems, live better together with others, visualize the experience lived, adapt to what can not be changed, face the selfrealization blocks and help them find new behavioral patterns (7) .
There are non-verbal communication techniques -for example, lip reading, Brazilian Sign Language (LIBRAS), mimicry, drawing, figures, writing, a companion present most of the time the patient is at the hospital, and body language; all these activities help in the therapeutic communication between the healthcare team and the patient (3) .Some studies carried out with nursing professionals show that there are failures in non-verbal communication in the interaction with hearing loss patients, which characterizes the need for attention and training in order to not impair care delivered (3,4,7) .
The culture and language of hearing impaired patients are different, and must be understood and respected according to ethical principles.To communicate with these clients is a challenge, especially for healthcare professionals (8) .
Through the communication established with the patients, the professionals are able to understand them as a holistic being and perceive their ideas of the world, that is, the way they think, feel and act, thus understanding their needs and being able to provide proper care, minimizing their discomfort (9) .

OBJectiVeS
To identify the communication difficulties of the nursing team with the hearing impaired patients throughout nursing care and to understand the strategies developed by the nursing team for non-verbal communication.

MetHODS
This is a descriptive, exploratory, level I study, with a quantitative approach, carried out at Hospital Israelita Albert Einstein (HIAE), a private and large general hospital located in the southern region of the City of São Paulo (10) .
The sample was made up of registered nurses (RN) and licensed practical nurses (LPN) in the Internal Medicine and Surgery units of the HIAE, throughout the three work shifts.The sample inclusion criteria were to have the professionals working with healthcare during the second semester of 2008, and acceptance to participate in this study after having signed the informed consent form.
Data was collected respecting ethical and legal principles, according to the standards present on Resolution 196/1996, after the research project was approved by the Scientific Committee of Faculdade de Enfermagem do Hospital Israelita Albert Einstein (Nursing School) and by the Research Ethics Committee of Hospital Israelita Albert Einstein.
For data collection, a questionnaire (Appendix) was prepared and consisted of two parts.The first was associated with the characteristics of the professionals, such as gender, age, professional classification, year of graduation, and work shift.The second part, made up of multiple choice questions, approached the difficulties that the nursing team faces in the care for hearingimpaired patients, as well as the strategies used for nonverbal communication.

reSUltS
One hundred nursing professionals, 37 nurses (37%) and 63 LPN (63%) were interviewed.Most nurses were females (61%), as shown in figure 1.The age of these professionals varied between 23 and 52 years, and the age range of 48% of the interviewees was between 30 and 36 years, while 56% of professionals had between 11 and 20 years of experience in the field, as shown in figures 2 and 3.This study was conducted with professionals working in three shifts, 28% in the morning, 57% in the afternoon and 15 % in the night shift.Among the interviewees, 97% had cared for patients with hearing impairment and 3% -three LPN -stated that they had not had any contact with hearing-impaired individuals at the hospital.Therefore, out of the 97 interviewees who cared for patients with hearing impairment, 37 were RN and 60 were LPN and answered the issues regarding communication difficulties and strategies used for communication between the nursing team and hearing impaired patients.
Figure 4 depicts communication difficulties with hearing impaired patients, highlighted by the nursing team.Difficulties in explaining topics of the patient's interest were reported by 57% of RN (21) and 72% of LPN (43), which represents answers from 66% of all the interviewees (64).For 31 interviewees (32%), the difficulty was in understanding the patient based on his/her means of communication, and this answer was chosen by 43% of RN (16) and by 25% of LPN (15).Two licensed practical nurses did not report difficulties in communicating with patients, since they were partially hearing-impaired themselves and used hearing aids (Figure 4).
The nursing team reported more than one communication strategy used in the care for these patients.Thus, when asked about the strategies used, considering both RN and LPN, all the interviewees (100%) reported using mimicry to communicate with hearing impaired patients.Lip reading was reported by 94% of professionals as the means of communication mostly used by the patients.The help of a companion (65%) and writing (42%) were also used as communication strategies.Only 1% used the Brazilian Sign Language (LIBRAS) to communicate and 2% used other means of communication (Figure 5).Among the strategies used by the healthcare professionals that assisted hearing impaired individuals, mimicry was mentioned by 100% of professionals, 37 RN and 60 LPN; lip reading was reported by 34 RN (92%) and by 57 LPN (95%); one LPN (2%) reported using LIBRAS; writing was used by seven RN (19%) and by 34 LPN (56%); communication through the escort was reported by 16 RN (43%) and 47 LPN (78%) and two licensed practical nurses (2%) used other means of communication (Table 1).
When asked about when the nursing team should be trained to provide care to people with special needs, 100% of the RN (37) said it should happen during

DiScUSSiOn
Within the hospital setting -which creates lack of confidence due to its characteristics -patients must feel safe and trust the professionals in order to deliver care, and this trustworthiness bond depends on interpersonal communication (2,7) .
In the present study, to explain an issue of interest to the hearing-impaired patient was a communication difficulty reported by most registered nurses and licensed practical nurses.However, the minority of RN and LPN found difficult communicating with the patient based on his/her means of communication.
The difficulties reported involve people with difficulties to perceive and emit non-verbal messages, or processing them.The results of the present study are confirmed by literature data, in which RN and LPN cannot use oral/auditory language and, which may cause problems in interacting with hearing-impaired patients (11) .Some studies show that healthcare professionals need to better communicate with the hearing impaired to avoid their frustration with health care, such as a feeling of hopelessness and impatience from the nursing professionals (12) .Notwithstanding, despite the studies, reports and case reports, healthcare services have neglected this both in public and private sectors (13) .
It is important to understand the patient within his/her individual needs, assessing organic and psychological aspects in order to properly systematize nursing care (14) .
Regarding the strategies used by health care professionals to communicate with hearing-impaired patients, the results obtained show that the entire nursing team -RNs and LPN alike -used mimicry during their work.Lip reading was used by almost all professionals, the help from an escort by the majority and the writing by the minority.Rarely communication was done using the Brazilian Sign Language (LIBRAS).
The other means of communication mentioned by some LPN corresponded to the patients who use hearing aids and did not have communication difficulties.
Mimicry is a compensatory communication strategy, because movement, gestures and facial expression are perceived by vision.Notwithstanding, studies have shown that the symbolic function of mimicry is not always understood, since it started in primitive ages and has substantially changed along the centuries, leading individuals to interpret differently the gestures based on their own ways of thinking (15) .
Lip reading is viable in interacting with the hardof-hearing listener, but it is not responsible for understanding itself, since the hearing challenged have to keep focused on the person he/she is communicating with, for any change in face position may cause loss of information.Nonetheless, lip reading, a very much used strategy, is overestimated and can cause specific problems in the patient-nurse relationship (16) .
To count on the escort's help to communicate with the patient would be a possible resource for a better interpersonal relationship between the patient and the nursing team, since the companion understands each gesture, each symbol, each facial expression used by the patient for communicating.However, in order to have the escort continuously present, it is necessary to have the team ready for it, since a hospital stay with the patient may cause conflicts and the hospital must have an environment that provides comfort for both -patient and escort (11,17) .
In the case of the institution where this study was carried out, the rooms are private and all patients are allowed to have an escort present during the entire stay.
It is often necessary to resort to writing, and it is a means of interpersonal communication, especially dealing with hearing impaired.However, such resource may be difficult to use, for people with hearing impairment since childhood have writing as a second language, and thus it can be difficult to master, causing embarrassment and frustration to the patient (11,14,18) .
Sign language is used worldwide, having its differences and particularities in each continent (11) .In Brazil, it is known as LIBRAS (Brazilian Sign Language).It is a modality that uses the visual space and hand coordination, and in some cases even noises, in which the signs and codes transmitted are received by the eyes and transmitted by the hands (11,19) .What sets it apart from mimicry is that each LIBRAS gesture means much more than one word.Depending on the context, with one gesture one can form an entire sentence.Usually, LIBRAS learning starts in childhood, making this form of communication easier; when hearing loss is acquired later, the hearing impaired person may be limited to the use of gestures alone (15,17,20) .
The nursing team must develop care practices, skills, instruments, techniques and competence to better communicate with patients (6) .
There are many barriers in carrying for the hearing challenged, and even if the meeting is temporary, it becomes a challenge for health care professionals to communicate with these individuals (21) .During the nursing course and also during the professional career, hearing impairment is discussed as a disease, without trying to find specific ways to interact with these patients (12,21,22) .
It is necessary that health care professionals acquire knowledge about communication techniques by introducing specific courses in their syllabus curricula focusing on the care of people with special needs and/ or specialization programs and continuing education programs at the hospital.

cOnclUSiOnS
Our findings show that the nursing team faces difficulties with regard to providing information to hearing impaired patients and in understanding the patient based on his/ her way of communicating.Healthcare professionals try to overcome these barriers through different strategies; but most of the interviewees use mimicry as a means of communication.
Training the health team in order to develop knowledge to assist the hearing-impaired patient's needs is very important to promote a humanized care highlighted on the context of a more inclusive society.

Figure 1 .
Figure 1.Characterization of the interviewees per gender and professional category

Figure 2 .Figure 3 .
Figure 2. Characterization of the interviewees per age group

Figure 4 .
Figure 4. Communication difficulties faced by RN and LPN in care of hearing impaired patients

Figure 5 .
Figure 5. Percentage of professionals who mentioned communication strategies

table 1 .
Communication strategies used by the nursing team in care of hearing-impaired patients