Case Study – Nursing and Auditory Difficulties
Case Study 1 – Source: Carol. R. Nurses with Disabilities. http://www.minoritynurse.com/features/nurse_emp/01-27-02h.html
Kristi Reuille, RN, BSN, a graduate student at Indiana University School of Nursing who has a 35% hearing loss, recalls getting her first amplified stethoscope while in nursing school. "I was concerned about whether I would be able to hear using a regular stethoscope because my hearing loss is in the low tones," she remembers. "Getting an amplified stethoscope helped build my confidence that I wasn’t going to harm a patient by not hearing something. If I ever had a question about what I heard, I would ask a colleague to make sure I wasn’t missing anything."
The pager system used as the hospital where she worked was helpful, Reuille adds, because it decreased the background noise level on the unit, making it easier to hear her patients. "It was done mostly for patient comfort," she says, "but it worked well for me because the background noise, especially when you’re trying to talk one-on-one, is very distracting."
Nurses with disabilities can offer special skills, such as lip-reading and Sign Language. Reuille says that because she is able to read lips, she can understand patients who talk very softly or can’t speak because they have a tracheotomy tube in their windpipe – unlike some of her co-workers. Another nurse with a hearing disability who reads lips says her patients often comment that they know they are getting the best care from her because she is always looking at them and paying attention to what they are saying.
Reuille says "I can envisage someone in my situation thinking it is not possible to be a nurse, but it is possible. There may be some practical issues that need to be worked out, but you can do it."
Case Study 2 – Source: Nurse Uses Mentors to Reach Her Goals. http://www.healthsciencefaculty.org/profile_gallery/molly_jenkins.html
From the time she was born, Molly Jenkins, R.N. of Columbus, Indiana had people she could look to for guidance. Hearing impaired since birth due to a hereditary genetic hearing loss, Jenkins had her mother, also hearing impaired, a both audiologist and mentor. Her mother guided her through the process of acquiring her first hearing aid when she was five, and her choice to use bilateral aids later as her hearing grew worse in college.
Having a hearing impaired mother in the health care field made it an easy choice for Jenkins to pursue a career in the field herself. Jenkins attended DePauw University’s School of Nursing and went on to become a registered nurse. In the DePauw program, Jenkins’ main accommodations were simply the use of her hearing aids and ensuring that she got herself a front-row seat in class to enable her to better lip-read the instructor. Jenkins’s classmates and instructors worked with her to clarify any information that she missed. The director of the nursing program allowed her to spend several hours with a hearing impaired nurse during one of her clinical experiences. This nurse, who worked in cardiac car, acted as a mentor to Jenkins by giving her "a boost of confidence in knowing that [her] goals were attainable" and by showing her some adaptive equipment that she used on the job. One such device was an amplified digital stethoscope. This battery-operated stethoscope can be set to an individual’s specific hearing needs. Jenkins also took advantage of using written procedure instruction handouts in conjunction with verbal instructions when working with patients. This was key when performing sterile procedures which may require the use of masks. "I can actually hear better, when I have something written to follow along with," she explained. She also experimented with the use of an FM system, which is an amplification system in which a speaker wears a microphone that transmits his or her voice directly to a receiver worn by a person with a hearing impairment.
After graduating in 1993, Jenkins took a position at Columbus Regional Hospital on a Medical/Surgical floor. She chose her position carefully, seeking a placement where her hearing wouldn’t affect her job performance. "I would not allow myself to work in an area that I did not consider safe. Because of my hearing impairment, my reaction time would not be as quick, so I just wouldn’t be comfortable in an emergency room or operating room setting."
Columbus Regional Hospital provided her with an amplified stethoscope and a hearing aid compatable phone. She stated on the night shift on Med/Surg, where the utilized lip-reading and visual cues to communicate and assess her patients. "I could use the hall light or a bathroom light at night if I needed to so I wouldn’t have to turn on the light right over the patient," she explains. She found that her reliance on visual communication as well as what the patient told her allowed her to assess their status more quickly and accurately than some of her hearing colleagues. The nurses on her floor approached their work as a team, and although they each had specific patients, they were always available to consult with each other. This was helpful for Jenkins at times when she did not immediately notice a sound. Jenkins, in turn, was often called in to assist other nurses with difficult or disruptive patients because of her skills with visual communication and her ability to put patients at ease.
Jenkins now works as a home services nurse out of the same hospital. She spends about 80% of her day caring for patients in their homes and feels that this is a good match for her abilities. "I get to work with patients one-on-one without any distractions, such as call lights going off or doctors and nurses running around," she says. Her communication skills and her ability to pick up on subtle visual and olfactory cues make her the resident expert on assessing whether a new client’s home is a safe setting with which to provide home health care. Jenkins patients, many of whom are elderly and also hearing impaired, find her easy to communicate with and a safe and comfortable person to have in their homes.
Jenkins tells her patients that she is hearing impaired and has found only positive reactions. "I think the patients are mostly curious and like to be educated about my hearing impairment. They want to learn more about it." Along with her knowledge and friendly demeanor, Jenkins credits her disability with her ability to put patients at ease. "Doctors and nurses are often thought of as being on a higher level. I think this is because patients often feel a loss of control when they are sick. They see me as a little less than perfect, and they may see me as being more real to them."
Jenkins clearly believes that her hearing impairment brings added value to the quality of the care she provides. As mentors with hearing impairments in her own life assisted her, she continues to advocate for others with disabilities to pursue a career in health care. "Go for it," she says, "you need to experiment and be given a chance. You don’t know the true value of a disability until you are in the working world."
Case Study 3 – Source: Quality and Performance Improvement Dissemination and Department for Education and Employment. October 1999. Modern Apprenticeships and People with Disabilities. http://quality.wwt.co.uk/quality/qual_map/gpsrp1.pdf
Sector: Direct Care
Region: North West
Employer: Private Residential and Nursing Home for the Elderly
Disability: Profoundly deaf in both ears
Adjustment: Ensuring close and face to face communications at all times; the use of a special pager which is linked to alarm/resident calling systems; willingness of staff to respond and adjust working practices.
Education Prior to MA
Brian attended a mainstream school where he successfully completed nine GCSEs, two of which were at grade C (English Literature and German). He first developed hearing problems at the age of 11 which progressed throughout his teenage years. Brian’s father and sister also both have hearing impairments. Brian was initially shocked and embarrassed at having to wear his first hearing aid – especially when he needed to use a bilateral aid.
Brian can hear quite effectively with his hearing aids but he sometimes mis-hears words (particularly on the telephone) and can sometimes get the wrong ‘gist’ of a conversation (a fact that he admits can be quite amusing). He has developed excellent lip reading skills, but at school he needed the support of a note taker. Flexibility was also shown in his aural German exam which he successfully completed by lip reading.
Brian received a careers interview in his final year at school and discussed his interests, primarily in care work, but also in catering. He was given helpful advice about training and employment in catering but was told it was unlikely he would succeed in the care sector because his hearing impairment would present problems in the work place e.g. hearing and responding to patient calls. Brian was very disappointed but accepted the advice.
Experience of Employment
Brian started working as a YT trainee in a restaurant but found his duties as a kitchen porter tedious, and the conditions poor. He left after three months. Brian’s next job was in a factory, manufacturing optical lenses. He planned to leave when he found a better opportunity in catering. Brian had expected the work (polishing glass) to be monotonous, but found the attitude of other workers difficult to cope with as they continually teased him about his hearing aids, treating him as if he were stupid. Brian left after only one month.
Brian was pleased when he saw a vacancy in the newspaper for a kitchen assistant at an old peoples nursing home. He telephoned the home for further information but was told the position had been filled. Brian decided to enquire about a care assistant vacancy which the home had also advertised. The matron (and owner of the home) saw no reason why Brian should not be considered for the vacancy and so invited him to attend an interview for the job.The senior matron (and other care/nursing staff) was immediately taken by Brian’s personality and enthusiasm. The decision was taken to appoint him on an initial six months trial. The senior matron disagreed with, and was somewhat angered by, the careers advice Brian had received at school. Based on his aural and communication abilities in the interview, she did not feel his hearing impairment would affect his ability to carry out the duties of a care assistant.
Transition to MA
Training and development is given a high priority within the nursing home and all staff are encouraged to complete NVQs and other professional qualifications in care. Brian first completed an initial six month training programme which covered all aspects of direct care before commencing his Level 2 in Direct Care. This is a practice the employer adopts with all staff (especially young people) who can initially find NVQs quite complex and daunting.
Following the completion of his Level 2, Brian was encouraged to continue his training and complete his Level 3 in Continuing Care as a Modern Apprentice. Brian saw this as a great opportunity to further his qualifications and increase his responsibilities within the residential/nursing home.
MA and Adjustments
Training – on the job
Brian loves his job at the nursing home which involves helping residents wash and dress in the morning, helping feed and toilet them and generally looking after their physical well-being in the home. He thoroughly enjoys working with (and feels very much part of) the team of staff at the home who have been extremely supportive and willing to make adjustments in response to Brian’s hearing needs.
Staff have learned to speak clearly and face Brian when they are talking to him or training him, and not to call out or give instructions from a distance. When practicing emergency drills (e.g. resuscitating a resident) the team give consideration to Brian’s positioning in order that he can clearly hear (or lip read) important directions.
There have been occasions when Brian has not hear one or more of the three internal calling/alarm systems (e.g. resident buzzers, the front door bell, and fire alarm). With financial support from the TEC (£350), a special pager has been purchased and linked to the internal calling systems. This vibrates and shows a light to indicate which calling system has been triggered.
A key element of Brian’s work (and training) is taking the blood pressure of residents. This has proved particularly difficult for Brian as his hearing aids can get in the way of the stethoscope, but removing them significantly reduces his ability to hear a pulse. Advances in medical technology have helped to overcome this problem as a simple new wrist device is now available (as used in all hospitals) to take blood pressure.
Training – off the job
Brian attends day release at one of the TEC’s training agents to complete his NVQ theory and Key Skills. His tutors are aware of the need to face the class when talking and encourage Brian to sit near the front to facilitate his hearing and lip reading.
The option of having a note taker has been discussed with Brian but, as he has had few difficulties in his classes, he has not needed this support.
Brian is extremely happy with the training and development he is gaining at the nursing home and feels his greatest achievements (to date) have been; passing his NVQ Level 2, organising a fund-raising barbecue for the residents Comfort Fund; and being interviewed for (and featured in) the TEC’s Modern Apprenticeship Prospectus. Brian has also passed his British Sign Language Stage 1 exams, something of which he is justifiably proud.
His employer (and all staff at the home) have a high regard for Brian and are pleased with the progress he has made – the residents also adore him. He has grown in confidence (and stature), and is always keen and motivated to take on new responsibilities in the home. He has a good sense of humour and is extremely good natured, showing a great deal of sensitivity and tenderness towards residents – according to his employer, Brian is "a natural in the job".
Brian is still in the early stages of his MA and expects to complete his Level 3 in Continuing Care in December 1999. He feels greatly encouraged by staff at the home to continue his training and study to be a registered nurse. He has recently learned that he will be accepted onto a course on the completion of his MA. Brian has also been proactive in seeking voluntary work during his days off (the home operate a week on/off shift system) and hopes to start working in a hospital or in the community.
Brian is also planning to buy his own pager in order that he can respond to telephone calls from potential employers. Now that she has invested in equipment, Brian’s employer is also keen to recruit more staff with hearing difficulties.
Points of Interest
The key points to emerge from this case study are:
- New technology has the potential to overcome difficulties a disability might present in the work place. Experts in the field can provide assistance.
- Some disabilities require only simple adjustments in the work place or in training – additional support might not always be needed.
- Young people with disabilities are experts in knowing their strengths and weaknesses and will be able to help find solutions to any difficulties.
Case Study 4- Source: http://jarmin.com/demos/resource/interviews/05.html
This is an extract from a longer interview.
On the course
So you said about (name of access centre), you had an assessment. How did that kick in? You say once you got accepted on to the course.
That was very good I got support through equipment and I was given an allowance for a note taker but it was very difficult to find a note taker that was actually suitable who understood the subject. A lot of it was all typed up lectures which meant extra reading. When we eventually found a note taker, I only actually had a note taker during the whole course for about six months because I found it so difficult to find someone who could do those hours who had medical knowledge and who could be there for the gaps between academic and clinical.
Just one step back with that. I’m trying to work out the progress of your assessment. Was it done in the summer before you came in to university?
I think it was done during the induction week in actually.
It was quite early on?
Yes. It was a very extensive report that outlined the kind of support I needed. I should have had language support because really I was picking up new vocabulary.
How did you find the interview for the assessment, you know, the information you got about that? Were you clear on the purpose and goal of it and so on?
Yes. They were good, they were very helpful, understanding. I felt that they offered the kind of help that I did need throughout the whole course. But I didn’t get that help at all.
Now the report goes to yourself and to the Local Education Authority. Did it go to the Course?
Do you know what happened next? Were you invited to talk to the Course Leader? How was the report implemented within (name of university)?
Not at all. The department had received the report and they seemed to ignore everything on it. The kind of educational support that I required, the kind of assistance I needed, the kind of learning support that I needed to get through. They’ve shown no understanding of my disability even though it was very clearly outlined in that. It was just virtually ignored.
Just explain all that’s going on is maybe a good idea.
What’s actually happened with me is that I have done two and a half years clinical. In February this year, which would have been my final year, they suspended me deeming me clinically incompetent. So that went to an inquiry, as a result of which they are still deeming me clinically incompetent. Not because of any malpractice or any ethical issue but purely on the basis that they don’t think I can be a (name of profession) because of my deafness. I’ve had no failure academically, so I can’t graduate, I can’t finish the course as this is six months before.
So you’ve got six months left of the course, effectively. You’ve done two and a half years.
I would have done, yes. I left in February – six months ago. I had six months to complete the qualification when they turned around and said, ‘No, she’s unfit.’
Who’s making that judgement? It’s the clinical placement people?
They’ve come from reports based on clinical, some of them not truthful. But the way I see it, I’m a student. They can write absolutely anything about me, which they have done. Some of them are very, very petty and some of them are very personal and it’s on that basis that the Course Leader decided that I couldn’t continue.
Just tell me what academic support (in lectures) do you need within the university?
I had electrical equipment mainly a computer so that they could send me lecture notes beforehand or the lecturer could communicate more easily with me and then I would have a written copy of what was going on. I never got pre-lecture notes or anything. It wasn’t used as it was intended. I did have a note taker who was very good but she was finding it increasingly difficult to fit in my hours with other students she was working with. A lot of the tutorials were a film viewing or practicals so often she wasn’t needed there. They were small groups and they were easy and we were always in the same groups so I formed relationships with other people so I coped well with them. Other than that, no support was given to me.
What difficulties occur in the lectures?
When we had the lecturers that were based here at the university, they were fine because I got used to his voice and I got used to the lecture format. They generally involved copying off the board or group discussion, so I could cope well with them, if there were any guest lecturers, which could just turn up the day before, because they were arranging a consultant from such a place, we wouldn’t know who they were and they wouldn’t know about me, I would have to tell them ‘Can you make sure you do this, speak clearly and slowly down’, that kind of thing.
In terms of informing people who are lecturers here, have you had to do that or has that been done through the Disability Office?
I’ve had to do it. Although the Disability Office have always been good if I come up against any problems, they’ve always been there as an advocate to put my point of view across.
And how have lecturers responded when you say to them ‘Can you keep still’ or ‘speak more slowly’?
As far as they were concerned nobody else has ever had as much support as me. They thought they were supporting me as much as they could but I’ve since found out that these three deaf students on the (name of course) who have similar hearing problems to me and they have got extensive support: mentors in clinical placement, mentors here… Extensive support, which they said they weren’t aware of, and they’ve only just found this out.
Sorry? Your course tutors just found this out?
Yes, my course have only just found this out.
Are they saying they would have copied that level of support?
You do seminars, group work? You know, you were saying about questions and answers in the lectures. How is that for you, are you okay with that?
We did what was called a multi-disciplinary module, where we were working with prosthetics and they were discussing things. I found that very difficult and I found it very difficult to control where I was sitting, getting people to look at me when they were talking. They would often forget I think and because people were saying some many different things at the same time, I was missing an awful lot.
And did the tutor help in any way, in terms of running the conversation?
No, not really because they didn’t really understand hearing impairment. I think that’s the basis of it, they didn’t understand the problems I can face. So they just think ‘She’s alright because you can have a conversation with her.’
Yes. But it’s tracking in a seminar. Tell me what makes it difficult, that situation.
It makes it difficult because somebody could jump in with a comment at any time. It was supposed to be different professionals’ opinion of solutions to particular scenarios. Very little was written down so it was difficult to keep up. All this made me very tired and they didn’t seem to understand that. I don’t think giving proper support to the normal students anyway. It’s a very difficult course to get through if you’ve got a family or things like that. There seem to be more mature students so they’re not taking these things into account. I’ve asked them if they could extend the course till Christmas, whether they could extend the clinical component and they said, ‘We’ll see if we can make arrangements for that.’ But I never had any feedback.
How have the other students been? Your friends on the course?
They’ve been fine. Some of them did seem to have an attitude problem but then they got to know me and realised that they could cope with me in a social sense and everything was fine.
You haven’t had any bad experiences? Right, okay, what about the patients? Are they aware, do you make them aware?
Yes, I had to make them aware because it was a health and safety issue. This goes back to the suspension again. I would always introduce myself to the patient first my name and then I would say ‘I’m very hard of hearing so could you speak nice and clearly. If you have any problems or you’ve got your back to me, let me know in such and such a way.’ Depending on the examination I was doing. They were always fine, I think it’s like a self-disclosure really. They open up to you.
But that’s become part of work for you.
As far as I’m aware, no patient has ever made a complaint about me. At either (place name) or (place name).
Can you explain to me what the assessment schedule for the course is? You go for three month’s lectures do you, and then a placement? How does that work across the course?
Usually, it works like that…roughly, not exactly… it’s twelve weeks academic and twelve weeks clinical. It may not always be, it could be three months and six weeks in clinical. You would do the academic modules, you would do (name of subject) say, or Basic Procedures and then go into clinical. Practice those, be assessed on those, and then come back.
For the academic assessment, is it exams and essays?
Yes, there are exams involved at the end of each module. The clinical assessments are formative assessments based on the area that we work in because there’s such a diverse area. So you could be doing (name of subject) academically and go back into practice but you may not have the opportunity, because you’re actually in a clinical environment, to have that experience. Then they would do a formative assessment. I think there are supposed to be five or six assessments per year, perhaps more in the final year but they seemed to do one every week on me.
So they write a report on your progress?
All the time, yes.
Okay, and do you input into that?
In terms of what? Sitting down with the clinician and going through how you feel you’ve progressed. Is it an iterative process or is it just a case of somebody watching what you’re doing the whole time and going away and writing a report?
No really it’s working with people in a normal working environment. At the end of the week, you would get a set assessor. They may not be with you all the time, they may ask other people for their input on it and then the assessment would go forward. It will actually go forward to a clinical examination, a practical examination which is based in here. There’s one every year. So if you pass that, you progress on.
So you passed the first two years even though you had all those difficulties. You’ve had problems but you’ve got through them. What was the final straw for them? Why have they suddenly decided ‘Well, we’ve got her this far and she’s got through. What are they saying is the key factor?
When the Course Leader actually suspended me at the meeting, he did actually turn round and say ‘We feel that you might mis-identify a patient.’ Of course we’ve got to be able to ensure it’s the right patient because we’re giving a medical treatment. It’s not always possible because you’ve got unconscious patients and things like that. But there are different means other than asking their date of birth. They should have nametags and things like that. But never, throughout the two and a half years, did I ever mis-identify anybody or x-ray the left wrist when it should have been the right. I never did anything like that. There was an incident where I loaded a bit of equipment a bit too fast but it was actually very old. I think that because they didn’t use it as much as they could have done, I wasn’t aware of the speed and was unable to control it as much. No accident occurred because of that, but it could have happened so it’s a lot of ‘could ofs’ and ‘might have’ happened.
And now they’re making it specific to your hearing?
They won’t actually turn round and say it’s because of that. I understand their reasons for not saying it and I think they’re cowards. They’re saying it’s because I’ve had a lot of minor errors but these minor errors have occurred, from my point of view, because the atmosphere that I was working in was absolutely atrocious. I was getting no help, I was getting no support at all. The course at that time was very difficult. We had a lot of academic work to do even though we were working 9 to 5. For me, my working day was actually twelve hours – I had no study time. I was under a lot of stress and pressure and I’ve gone to them and told them this and they’ve kind of used what I’ve said to put the nails in the coffin.
Do you get any additional help with examinations or have you had any extensions for assignments, that kind of thing? Was that recommended in the report?
I’ve had extensions because of personal or mitigating circumstances but they were only usually a week. As far as exams go, no, I’ve had no help in written exams. I don’t think I needed it anyhow. In practical exams, the only support I was given, was being told what areas to revise or look into. We work in a clinical environment; they did these examinations here at the university which is actually in a false environment which made it difficult for all of us anyway. But no, I wasn’t given any additional help.
And you don’t feel that there’s anything linked to your hearing impairment that would have helped? Is that not an area that you’re particularly affected by?
I’m not sure whether they could have helped me further with that. In some respects they could have understood the disability more then they may come up with ideas for it how to help me because they’re more used to setting up the examination and marking the projects.
Was everything going all right on the placement?
I was originally placed at (name of hospital). I did roughly about eighteen months there. I did come up against personal problems with one of the senior members of staff who was actually involved in writing one of these assessments when she hadn’t been involved in assessing me in the first place. But they weren’t objective enough. They were very personal. So the decision was made to move me to (place name). It’s a long way from home. It’s a twenty five mile journey/round trip every day.
It used to take me an hour and a half each way on public transport because I don’t drive. They were aware of that. I was actually the only student in my year up there so I had no peer support. The clinical tutor was very good to a point and I moved up there last February so I did twelve months there.
You said that was the only placement that would accept you?
Why is that?
Because the local hospitals didn’t think that they could give me the support that I needed. But I didn’t get the support at (place name) anyway. I had virtually no support.
They felt ‘Yeah, okay – we’ll have the student. We’ll be able to support her.’ But in reality…? They didn’t know what was involved. There were reports done at both placements, which were done independently. They called them Risk Assessments and they were conducted by (assessor’s name) who was actually the tutor. She’d come in and assess the work place. We’d need to go through the files in a quiet area, we’d need to explain things properly to her and make sure she understood and these were deemed minimal recommendations under the Disability Discrimination Act. (Hospital’s name) totally ignored them.
They said I should have had a ‘Buddy System’ so I knew what was going on. I should have had constant feedback that was monitored, a telephone that I should have been able to use. There was nothing, absolutely nothing.
Did you say the hospital mentioned those three things or was this from the report?
This was from report, what the hospital should implement. The general feeling was that the (member of staff) there didn’t like it, didn’t want to make these adaptations. They made no effort at all to fit me into that placement. There was just an attitude there and I couldn’t break that barrier down on my own because I’m the only deaf student they’ve ever taken on. They had no experience, (name of professional body) turned round and said ‘Nowhere in the country has it ever been tried before’. So it was an experiment. They didn’t even consult the (name of professional body) as to what learning support I would need when they should have done. Basically, they’ve ignored a lot of things. They thought that because I can speak so well and communicate so well one-to-one, they didn’t envisage what problems I would actually have in clinical. Now, they would be a better judge of that when I started the course because I didn’t know what the course involved. It’s hard for me to turn round and say ‘I need this’ and ‘I need that’, I needed somebody to come from outside and just tell them, which they did but they just ignored it.
That was (place name) and then a similar sort of thing occurred at….
They’ve had their reports, as you said, the two independent reports. Who do the reports go to? They’ve gone to anybody who’s ever been involved in my education; clinical tutors, the staff, Course Leaders, Equalities Office…everyone.
And what was the situation at (hospital’s name) then? Have they implemented any of those recommendations? Was another Risk Assessment done with them?
Yes, there was. (Name of assessor) actually took decibel counters into the environment to see what problems there are, it’s a very noisy environment anyway because you’ve got printers and processors and all kinds of noisy equipment. All it simply needed was quiet areas to discuss things like procedures and information involving patients. There were quiet areas available but they didn’t use them, they just let me carry on as though they were training somebody else, a normal (sic) person.