Deaf culture awareness among physicians and advanced practice providers in the emergency department: A multicenter study

Abstract

Background and Objective

In areas with a large Deaf/hard‐of‐hearing (DHH) population, emergency medicine (EM) providers may benefit from cultural awareness training as this has been shown to foster delivery of more equitable care in other minority populations. Rochester, New York, has been touted to be the home to the largest per‐capita DHH population in the United States. Given the large local DHH community and DHH professionals working in Rochester, University of Rochester (UR) providers likely have higher exposure to DHH people than most other EM providers in the United States. All UR providers receive annual institutional cultural sensitivity e‐training that includes information about the DHH community. In addition to the e‐training, the UR EM residents also receive a workshop during intern year and recurrent DHH culture education throughout their residency. The purpose of this study was to measure impact of preexisting cultural sensitivity training and higher DHH person exposure on DHH cultural awareness in UR providers compared to non‐UR EM providers who may have lower DHH person exposure and culture training.

Methods

In this cross‐sectional study, a survey on DHH cultural awareness was distributed to UR and Emergency Research Network in the Empire State (ERNIES) emergency departments. As surrogates for cultural awareness, the survey evaluated providers’ exposure, knowledge, comfort, and attitudes to Deaf culture. Descriptive statistics were employed to characterize the sample. Bivariate analysis was performed to compare UR provider responses to others using chi‐square and Fisher's exact testing.

Results

Of 83 recruited participants, 75 providers completed the survey, and 53/75 (71%) responders were from UR. While high percentages of UR and non‐UR participants reported seeing DHH patients recently (98% vs. 96%, respectively), one‐third (24/75) of all participants reported having no experience or training on Deaf culture. Compared to only 10% of other providers, one‐third of UR providers were better able to identify cultural nuances within the DHH community (p = 0.01). UR providers were significantly less comfortable communicating with Deaf patients via lipreading, which is typically an unreliable/unsafe mode of communication (11% vs. 69%, p = 0.002). When knowledge was assessed, UR providers better identified Deaf patient rights in a clinical setting (89% vs. 77%, p = 0.002). Also, all trainees had significantly higher scores on questions related to Deaf culture compared to all advance practice providers and attendings (mean scores 6.86 vs. 6.06 and 6, respectively, p = 0.03).

Conclusions

EM providers with high exposure to DHH people and DHH culture training are more comfortable with and able to better identify nuances of Deaf culture. Additionally, EM providers with DHH culture training are less comfortable communicating using lipreading with DHH patients suggesting increased awareness of a common, yet ineffective and inaccurate, communication pitfall with this population. The study suggests that implementing Deaf culture education in areas with a large DHH population may enhance cultural awareness and comfort of future providers in caring for Deaf patients.

INTRODUCTION

For any non‐English language preference patient, accessing medical care can be challenging, particularly for members of the Deaf and hard‐of‐hearing (DHH) community for whom American Sign Language (ASL) is their primary language. In emergent situations, adequate and timely access to medical care is crucial in ensuring appropriate diagnosis and treatment. Disparities in care exist for patients in which direct communication is difficult, as is the case for patients who rely on lipreading, assistive hearing devices, or interpreters for communication. ¹ , ² , ³ , ⁴ Until recently, there has been little attention on research involving DHH health disparities in the field of emergency medicine (EM) and even less involving DHH community members themselves. ⁵ , ⁶ , ⁷ , ⁸ For example, in a recently published article by Conner et al., ⁹ it was discovered that emergency department (ED) encounters with ASL users were less likely to include labs ordered, placement of peripheral intravenous lines, and imaging orders even among high‐acuity patients in comparison to their English‐speaking counterparts. Additionally, despite the complex decision‐making process to seek treatment in the ED, DHH patients often face providers’ insufficient cultural awareness and unwillingness to provide accommodations (e.g., ASL interpreters). ¹⁰ , ¹¹

In 2011, authors from the University of California San Francisco created and published a survey, validated by members of the DHH community, that assessed knowledge of DHH culture as a surrogate for cultural competency. ¹² Their research found that medical students and faculty members who completed a deaf health education pathway scored significantly higher on the survey compared to their peers who did not. This has also been previously studied in populations of individuals who have the potential to interact often with those who identify as DHH or communicate using ASL, including medical students, physicians, audiologist students, otolaryngology trainees, law enforcement, and genetic counselors. ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ In 2021, Rotoli et al. ⁸ studied prehospital providers’ (e.g., EM technicians [EMTs] and paramedics) communication practices with the DHH community and found that EMTs perceived communicating with DHH patients as challenging. Due to language discordance and lack of visual communication tools, EMTs noted patient frustration, felt that information was lost, and felt that care was limited (uncomfortable explaining a treatment plan, obtaining relevant past medical history, and obtaining history of present illness); however, after an educational training, nearly all providers reported improvement in deaf cultural knowledge, communication strategies, and pitfalls to avoid. These findings underscore the need for improving deaf cultural awareness and understanding in EM.

Rochester has been reported to have the highest per‐capita DHH community in the United States allowing for University of Rochester (UR) providers to potentially have increased exposure to DHH patients than in other cities. ¹⁸ , ¹⁹ Additionally, UR has more than 70 DHH professionals (e.g., faculty, nurses, staff, students) and more than 40 staff ASL interpreters. At UR, EM residents are exposed to recurring education on care for patients in the DHH community. For example, all interns participate in a 1‐hour experiential workshop led by UR DHH professionals and ASL‐fluent hearing EM providers. During this annual workshop, residents learn Deaf culture norms, communication preferences, pitfalls to avoid, and strategies to maximize information exchange while caring for the DHH patient in the ED. As part of a diversity, equity, and inclusion curriculum integrated into didactic conference, all residents also participate in simulations on working relationships with interpreters (once every 3 years), witness panels of DHH community members describing their health care experiences (annually), and receive lectures on improving accessibility for people with disabilities in the ED (once every 18 months). As part of an annual institutional in‐service, all UR providers (including attendings and advance practice providers [APPs]) have a 2‐hour asynchronous annual cultural sensitivity e‐training that includes information regarding DHH culture and communication preferences.

The purpose of this study was to measure impact of preexisting cultural sensitivity training and higher DHH person exposure on deaf cultural awareness in UR providers compared to non‐UR EM providers who may have lower DHH community exposure and deaf culture training.

METHODS

This cross‐sectional study was conducted among UR EM providers and in the Emergency Research Network in the Empire State (ERNIES). The ERNIES is a network of hospital systems across New York state. Representation in the network is dynamic but currently includes representation from a total of five hospital systems in Upstate New York (including hospitals serving the Western and Central New York) and New York City. For the present study, there were four participating hospital systems located in Upstate New York (including UR). All participating sites are large tertiary academic medical hospital with a Level I trauma center seeing greater than 70,000 patients per year and have an EM residency. Study recruitment was performed by emailing currently employed EM providers (attending physicians, resident physicians, fellows, and APPs) from UR and the participating ERNIES sites. EM providers with other clinical roles were excluded from the study. To maximize participation at all sites, an optional raffle was offered to all participants.

Data collection was conducted using a survey to evaluate deaf cultural awareness using the surrogates of comfort, attitudes, and knowledge regarding the DHH community. The comfort questions were developed from our ongoing work in this area. Specifically, a preliminary review of a UR EM quality improvement project identified key areas of EM provider discomfort including performing clinical duties for DHH patients without interpreters, performing clinical duties for DHH patients with video remote interpreters (VRIs), and identifying deaf cultural nuances during the Plan–Do–Study–Act cycle. ²⁰ Through an iterative process and using the research team's expertise, questions were refined and subsequently pretested for errors and comprehension. We did not formally assess construct validity, but the survey was reviewed by content experts and members of the DHH community for face validity. The comfort section used multiple‐choice questions (MCQs) using the 5‐point Likert scale to assess the level of comfort in identifying various elements of deaf culture and comfort level in communicating with DHH patients or parents of DHH patients. The knowledge section used a previously validated 34‐question survey tool (five MCQs and 29 true/false [T/F] questions) to assess comprehension and awareness regarding the DHH community (e.g., terminology, communication preferences, primary languages). ¹⁷ Our study used a modified version to meet the needs of the study population (see Appendix S1).

Mean and frequency tables were used to report descriptive statistics including participant demographics, and clinical role and training, along with reporting the univariate analyses of the comfort, attitude, and knowledge sections. The MCQs in the knowledge section were scored based on the number of correct answers selected by participants. Total scores for the knowledge section MCQs, T/F questions, and an overall score (sum of the two total scores) were calculated. Bivariate analyses were performed for all three sections by stratifying by clinical affiliation (UR vs. non‐UR) and the column percentages were reported. In addition, for the bivariate analysis of the comfort section, the 5‐point Likert scale questions were recoded into dichotomous (1, 2, and 3 coded as negative and 4 and 5 coded as positive) variables. Chi‐square and Fisher's exact tests were used as the test of significance for the bivariate analyses. Results were stratified by provider type when appropriate. A p‐value <0.05 was used to determine statistical significance for all comparisons.

RESULTS

The majority of participants were female (49/83; 59%) and White (72/83; 88%), had been working for an average of 6 ± 6.95 years (mean ± SD; range 1–31 years), and had a mean age of 37 ± 9.49 years (mean ± SD; range 25–64 years). Participants included attending physicians (36/83, 3%), APPs (18/83, 21%), residents (28/83, 34%), and fellows (1/83, 1%). Of 83 recruited participants, 75 providers completed the full survey and 53/83 (64%) of responders were associated with UR. UR has approximately 100 faculty and 25 APPs, 42 residents, and 10 fellows representing a UR response rate of 30% (53/177). Total EM provider data from other sites were not available. No participants identified as being a member of the DHH community.

Nearly all UR participants (52/53, 98%) and non‐UR participants (29/30, 96%) had taken care of DHH patients. Over half of the participants reported (51/75, 68%) reported having some sort of training on deaf culture; however, UR participants more frequently reported participating in formal deaf culture training than non‐UR sites (36.2% vs. 7.1%, p < 0.05).

UR providers also reported having in‐person and certified deaf interpreters (CDIs [deaf native ASL user with interpreter training]) more often (96% vs. 28%, p < 0.0001; and 26% vs. 4%, p = 0.03, respectively) while other providers reported having a VRI more frequently (92% vs. 38%, p < 0.0001). Compared to only 10% of other providers, one third of UR‐associated providers were better able to identify cultural nuances within the DHH community (p = 0.01). UR‐associated providers were significantly less comfortable communicating with deaf patients via lipreading, which is typically an unreliable/unsafe mode of communication (11% vs. 69%, p = 0.002). As seen in Table 1, compared to those at UR, providers outside of UR were more comfortable with nearly all aspects of clinical care with the use of VRI (92% vs. 38%, p < 0.001). There were no statistical differences in comfort with clinical care either without an interpreter or with an in‐person interpreter. Lastly, when asked about perceived negative experiences when caring for a DHH person, UR providers reported them more often, on average, than other providers (12.85 ± 12.9 [mean ± SD; range 0–50] vs. 3.79 ± 3.27 [mean ± SD; range 1–15], p < 0.0001).

TABLE 1.

Descriptive, comfort, and knowledge question statistics of study population (n = 83).

Descriptive statistics
	N/Mean	%/SD
Clinical role
Attending	36	43.4
PA/NP	18	21.7
Resident	28	33.7
Fellow	1	1.2
Currently affiliated with UR
Yes	53	63.9
No	30	36.1
Taken ASL class
Yes	16	21.3
No	59	78.7
Missing	8
Taken Deaf culture class
Yes	0	0
No	75	100
Missing	8
No experience/training on Deaf culture
Yes	24	32
No	51	68
Missing	8
Member of Deaf community
Yes	0	0
No	75	100
Missing	8

	UR	Non‐UR	p‐value
	N (%)	N (%)
Formal Deaf culture training a
Yes	17 (36.2)	2 (7.1)	<0.05
No	30 (63.8)	26 (92.9)
Total	47	28
Comfort questions (Likert scale 1–5; 1 = not comfortable and 5 = very comfortable)
Differentiate between deaf and Deaf
Comfortable (scores 3–5)	19 (35.8)	3 (10.0)	0.01*
Not comfortable (scores 1–2)	34 (64.2)	27 (90.0)
Use of in‐person ASL
Comfortable (scores 3–5)	45 (95.7)	7 (28.0)	<0.0001*
Not comfortable (scores 1–2)	2 (4.3)	18 (72.0)
Use of CDI (native CDI)
Comfortable (scores 3–5)	12 (25.5)	1 (4.0)	0.03*
Not comfortable (scores 1–2)	35 (74.5)	24 (96.0)
Clinical care with use of VRI
Comfortable (scores 3–5)	18 (38.3)	23 (92.0)	<0.0001*
Not comfortable (scores 1–2)	29 (61.7)	2 (8.0)
Obtaining history with VRI
Comfortable (Scores 3–5)	29 (54.7)	26 (92.8)	<0.0001*
Not Comfortable (Scores 1–2)	24 (45.3)	2 (7.2)
Performing a Physical Exam with VRI
Comfortable (Scores 3–5)	31 (58.5)	29 (96.7)	<0.0001*
Not Comfortable (Scores 1–2)	22 (41.5)	1 (3.3)
Performing a Procedure with VRI
Comfortable (Scores 3–5)	24 (45.3)	24 (80.0)	<0.0001*
Not Comfortable (Scores 1–2)	29 (54.7)	6 (20.0)
Delivering a Diagnosis/Answer with VRI
Comfortable (Scores 3–5)	23 (43.4)	25 (83.3)	<0.0001*
Not Comfortable (Scores 1–2)	30 (56.6)	5 (16.7)
Patient counseling with VRI
Comfortable (scores 3–5)	24 (45.3)	23 (76.7)	<0.0001*
Not comfortable (scores 1–2)	29 (54.7)	7 (23.3)
Obtaining patient consent for invasive procedure with VRI
Comfortable (scores 3–5)	22 (41.5)	25 (83.3)	<0.0001*
Not comfortable (scores 1–2)	31 (58.5)	5 (16.7)

Knowledge questions
All participant scores MCQ score (stratified by provider and site [out of 10]) b
	UR			Non‐UR			Total
	N	Mean	Median	N	Mean	Median	N	Mean	Median
Attending	21	5.9	6	15	6.1	6	36	6	6
PA/NP	9	6.3	6	9	5.8	7	18	6.1	6
Resident/fellow	23	7	7	6	6.5	6.5	29	6.9	7

All participant scores (stratified by provider)
	Mean ± SD	p
MCQ score (out of 10)
Attending	6 ± 1.47	0.03*
PA/NP	6.06 ± 1.11
Resident/fellow	6.86 ± 1.38
T/F score (out of 29)
Attending	20.34 ± 4.81	0.74
PA/NP	21.00 ± 2.40
Resident/fellow	19.79 ± 6.50
Overall score (out of 39)
Attending	26.34 ± 5.04	0.91
PA/NP	27.06 ± 2.63
Resident/fellow	26.64 ± 7.01

All participant scores (stratified by site)
	UR	Non‐UR	p‐value
	Mean ± SD	Mean ± SD
T/F score (out of 29)	20.60 ± 5.08	19.77 ± 5.10	0.96
Overall score (out of 39)	27.04 ± 5.62	25.87 ± 5.04	0.53

Abbreviations: ASL, American Sign Language; CDI, certified Deaf interpreter; MCQ, multiple‐choice question; PA/NP, physician assistant/nurse practitioner; T/F, true/false; UR, University of Rochester; VRI, video remote interpreter.

^a UR sites more frequently reported engaging in formal Deaf culture training than non‐UR sites (36.2% vs. 7.1%, p < 0.05).

^b Mean and median MCQ scores stratified by provider type and site are provided in the table. Due to small sample size to test this association, statistical significance was not assessed.

^*Fisher's exact test was used instead of chi‐square since some cells have small sample sizes (<5).

When knowledge was assessed, UR providers better identified the rights of DHH patients in the clinical setting than other providers (89% vs. 77%, p = 0.002). Additionally, all trainees had significantly higher scores on MCQ related to Deaf culture compared to all APPs and attendings (mean score 6.86 vs. 6.06 and 6, respectively, p = 0.03). There was no statistical significance in overall knowledge scores between UR and other providers.

DISCUSSION

In reviewing the participant totals from each site, it was notable that both UR and non‐UR sites both had high percentages of participants who have cared for DHH patients in the past (98% vs. 96%). Although not statistically significant, the higher‐than‐expected number of participants who cared for DHH patients at non‐UR sites may be from participation bias where those more interested (or uncomfortable) in DHH care were more likely to participate. In general, UR providers were better able to identify deaf cultural nuances, which is typically a result of cultural awareness through active learning or being part of a community. While differences in exposure to DHH patients between the sites cannot account for differences in deaf culture awareness, it is possible that repeated educational efforts, increased interprofessional interactions with DHH professionals, and abundant resources for working with DHH patients fostered improved awareness of the community's needs and communication preferences. It is important to note the increased comfort with use of lipreading and VRI as communication tools by providers outside of UR when communicating with DHH ASL users. Neither VRI nor lipreading are the criterion standard for communication with DHH ASL users and both are fraught with potential for inaccuracies (e.g., only about 30% of English can be lipread; VRI often has variable interpreter quality, poor connectivity, screen clarity, lag, and poor positioning). Decreased comfort with lipreading and VRI among UR providers is likely attributable to increased awareness of DHH patient preferences and how to maximize communication from cultural training, funding for in‐person interpreters, and DHH community exposure. ²¹ , ²² , ²³

Interestingly, UR providers, on average, reported more negative experiences while working with the DHH community. Given the robust deaf cultural awareness training and ample resources, it is possible that this UR providers are more cognizant of and willing to report patient encounters with errors such as miscommunication, challenges with interpreters, or provider–patient interactions that are contrary to deaf cultural norms. Alternatively, as seen in previous literature, bias against the DHH community may still be present in UR providers despite cultural sensitivity training. ²⁴ Future research could investigate the reasons for this finding.

With regard to objective knowledge assessment, UR providers were more aware of DHH patient rights in clinical settings. This is likely attributable to repeated provider training and potential exposure to the DHH community through patient and interprofessional interactions with DHH professionals and ASL interpreters. Interestingly, all trainees (UR and non‐UR) outperformed attending physicians and APPs on the MCQ section of knowledge testing. Although no statistical significance was calculated (due to small numbers), when stratifying total scores by provider type, resident/fellow mean and medians were higher at UR (and in total). These findings may be partially explained by the differences in education between faculty/APPs and residents, with residents receiving more ongoing and detailed training in comparison to faculty/staff at UR. Although we were unable to quantify deaf culture training at other institutions, this performance may also be from recent increased national institutional and residency training emphasis on inclusion and cultural sensitivity when caring for diverse patients in the ED. Moreover, trainees may be more familiar with MCQ testing given their current training status and exposure to this testing format.

LIMITATIONS

There were limitations to this study. Overall, the total number of recruited participants was small, which limits generalizability and power during comparison and statistical analysis. Lack of statistical significance should be interpreted cautiously and the difference in effect estimates should be used to power future studies further evaluating this topic. Despite extensive pretesting for length and usability of our electronic survey, there was a 10% attrition rate during the study, which we believe is likely due to survey fatigue and response burden commonly seen in web‐based surveys. ²⁵ , ²⁶ Although it was multicenter, the study still included a region of the state where there are more DHH people making it challenging to generalize to areas with few DHH people. Also, while we were able to approximate the DHH population in Rochester and quantify the amount of UR EM resident/institutional training, these elements are unable to be quantified at other participating institutions. Additionally, the overrepresentation of UR providers may overrepresent providers with more training in the DHH population. This may lead to an over‐ or underestimation of outcomes. Lastly, as seen in many survey‐based studies, selection bias is also possible as those who have more interest in the survey topic are more likely to participate.

CONCLUSIONS

Emergency medicine providers with high exposure to deaf/hard‐of‐hearing people and deaf culture training are more comfortable with and able to better identify nuances of deaf culture. Additionally, emergency medicine providers with deaf culture training are less comfortable communicating using lipreading with deaf/hard‐of‐hearing patients suggesting increased awareness of a common, yet ineffective and inaccurate, communication pitfall with this population. The study suggests that implementing deaf culture education in areas with a large deaf/hard‐of‐hearing population may enhance cultural awareness and comfort of future providers in caring for deaf patients. Future research should assess causality and include a larger cohort of emergency medicine providers. Additionally, future research should assess quantity and frequency of required education to achieve desired outcomes (e.g., provider comfort with communication) and improve care (e.g., patient satisfaction) for deaf/hard‐of‐hearing patients.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Appendix S1.

Johnson L, Schmitz S, Dillon K, et al. Deaf culture awareness among physicians and advanced practice providers in the emergency department: A multicenter study. AEM Educ Train. 2024;8:e11050. doi: 10.1002/aet2.11050