COMUNICAÇÃO ENTRE O ENFERMEIRO E PESSOA SURDA

RESUMO

Objetivo: compreender os aspectos que interferem na comunicação entre enfermeiro e pessoas surdas durante a assistência à saúde. Método: Trata-se de um estudo qualitativo realizado com dez enfermeiras em uma Estratégia Saúde da Família de um município do estado da Paraíba, de setembro a novembro de 2019. Foi utilizado um roteiro de entrevista semiestruturado com os enfermeiros, utilizando a técnica de entrevista. Para a análise dos resultados foi utilizada a técnica de Laurence Bardin. Resultados: Os resultados mostraram muitas dificuldades na comunicação entre pessoas surdas e enfermeiro, bem como tentar utilizar de mímicas e gestos ou a presença de alguém da família como estratégias de comunicação na assistência à saúde. Conclusão: Constatou-se que a maioria dos profissionais de enfermagem entrevistados apresentaram dificuldades para interagir com pessoas surdas durante as consultas, reforçando a aplicabilidade dos critérios legais, entre eles a implementação/implantação da Libras na formação acadêmica destes profissionais da saúde.

DESCRITORES: Surdez; Comunicação; Enfermeiro.

 

ABSTRACT

Objective: to understand the aspects that interfere in the communication between nurses and deaf people during health care. Method: This is a qualitative study carried out with ten nurses in a Family Health Strategy in a municipality in the state of Paraíba, from September to November 2019. A semi-structured interview script was used with the nurses, using the interview technique . For the analysis of the results, the Laurence Bardin technique was used. Results: The results showed many difficulties in communication between deaf people and nurses, as well as trying to use mime and gestures or the presence of someone in the family as communication strategies in health care. Conclusion: It was found that most nursing professionals interviewed had difficulties interacting with deaf people during consultations, reinforcing the applicability of legal criteria, including the implementation/implantation of Libras in the academic training of these health professionals.

DESCRIPTORS: Deafness; Communication; Nurse.

 

RESUMEN

Objetivo: comprender los aspectos que interfieren en la comunicación entre enfermeros y personas sordas durante la atención a la salud. Método: Este es un estudio cualitativo realizado con diez enfermeros en una Estrategia de Salud de la Familia en un municipio del estado de Paraíba, de septiembre a noviembre de 2019. Se utilizó un guión de entrevista semiestructurada con los enfermeros, utilizando la técnica de la entrevista. Para el análisis de los resultados se utilizó la técnica de Laurence Bardin. Resultados: Los resultados mostraron muchas dificultades en la comunicación entre las personas sordas y las enfermeras, además de tratar de utilizar la mímica y los gestos o la presencia de alguien de la familia como estrategias de comunicación en el cuidado de la salud. Conclusión: Se constató que la mayoría de los profesionales de enfermería entrevistados tuvieron dificultades para interactuar con personas sordas durante las consultas, lo que refuerza la aplicabilidad de los criterios legales, incluida la implementación/implantación de Libras en la formación académica de estos profesionales de la salud.

DESCRIPTORES: Sordera; Comunicación; Enfermero.

 

INTRODUCTION
          Just over one billion people live with some type of disability, according to the World Health Organization (WHO), 2011. It is estimated that there are 466 million people with hearing impairment (HI), representing about 6.1% of the world's population, of which 34 million are children and 432 million are adults. The estimate is that this scenario may worsen by 2050, with the hypothesis that the progression exceeds 900 million people manifesting some condition of hearing loss. Also according to this data, one in four people will live with a hearing loss by mid-2050. ⁽¹⁾

Hearing impairment, or deafness, can be defined as the total or partial loss of hearing and are classified as mild, moderate, severe and profound. ⁽²⁾ The nomenclatures “hearing impairment” and “deafness” are sometimes used in specific ways, with differences between them and, at other times, as similar. It is noteworthy that, in this study, both possibilities will be used.

When talking about HI, it is understood that there will be limitations in the educational and linguistic activities of affected people, but it is important to emphasize that all areas of life will be affected, such as their interaction and social integration. ⁽³⁾

The Care Network for Persons with Disabilities, established by Ordinance No. 793, of April 24, 2012, sought to emphasize the need to have an improvement in the quality of services offered by the Unified Health System (SUS), improving physical structures and professional qualification, from primary care to a highly complex unit. ⁽⁴⁾

With regard to Hearing Impairment, there is the strengthening of the Brazilian Sign Language (LIBRAS - Língua Brasileira de Sinais), which is part of a decree establishing its inclusion in higher education courses, in its different areas of knowledge, reason that favors the Brazilian Sign Language, used by the deaf community as the first and main form of communication, because it has unique characteristics and its own culture.

Although there are improvements in care for people with HI, they face social vulnerabilities related to low socioeconomic and educational levels, as they deal with obstacles to accessing dignified living conditions and access to health. ⁽⁵⁾ When it comes to health care, professionals report the difficulty in assisting patients with hearing impairment due to the complexity of the sensory impairment and because they do not receive training and permanent education to achieve mastery and fluency in communication. ⁽⁶⁾
It is identified that in the care offered by the nursing professional, it is necessary to emphasize that one of the most accurate instruments in the provision of care is communication. For there to be success in the reception and in the resolution of the service and positive results, effective communication is essential. It is through communication that professionals understand the user as a holistic being and understand their social insertion and their worldview, being able, from this moment on, to raise their concerns and needs, developing adequate assistance, so that the discomforts of this process can be minimized. ⁽⁷⁾

In this context, nurses have a legal and ethical responsibility to provide health care for deaf users who use sign language, in the same way they provide other users with effective communication, autonomy and secrecy. (8)

In view of this reality and considering that the pillar of health care, from the anamnesis to the moment of guidance, is good communication between the professional and the user, it is to be expected that, when this becomes flawed, the possibilities of diagnostic errors and, consequently, of problems in their resolution are great. The lack of qualification of health professionals can create damage during care, resulting in embarrassment, misdiagnosis, difficulty in correctly preparing the medical record and inadequate treatment for possible pathology. ⁽⁸⁾

Thus, the premise chosen to understand the aspects that interfere in the communication between nurses and deaf patients is to expand health care for deaf patients and plan efficient communication alternatives, that is, possibilities that optimize understanding and interlocution, without generating new limiting factors and establishing the naturalness of the process.

However, based on this premise, the research had as its guiding question: What are the factors that interfere in the communication between a nurse and a patient with hearing impairment during health care? In this perspective, the objective was to understand the aspects that interfere in the communication between nurses and patients with hearing loss during health care.

 

METHOD

This was a descriptive and qualitative exploratory study, carried out in 10 Basic Family Health Units (UBSF), in the city of Campina Grande-PB, from September to November 2019.

Study participants were ten ESF nurses chosen at random, up to the point of saturation of speeches, obeying the following inclusion criteria: exercising the role of ESF nurse for more than a year and having performed care for people with deafness. Nurses who were on leave or enjoying scheduled benefits were excluded.

The data collection procedure was developed using a standardized semi-structured interview script. During the interviews, guiding questions were used to facilitate the participants' ease in constructing their speeches, as well as keeping them focused on what was asked of them, addressing the following topics: Communication between nurses and deaf people and communication strategies in health care for deaf patients.

Participating nurses, at the time of data collection, were informed about the purpose of the research and invited to participate in it by appointment, at a convenient time, in a reserved space of the work institution they were linked to, in order to guarantee secrecy and anonymity. The interviews lasted approximately 45 minutes. At the time of the interviews, after signing the Free and Informed Consent Form (TCLE) and permission from the interviewees, their statements were recorded on a cell phone.

For the analysis and presentation of the results, the Laurence Bardin technique was used ⁽⁹⁾ which is divided into 3 stages: The first stage is the Pre-analysis, in which floating readings of the literally transcribed interviews were carried out, allowing the researcher to have a deeper contact with the speeches of the included participants, allowing impressions to flow. The second stage was the exploration of the collected material, in which the record and context units, as well as the analysis categories were defined by the researcher, after the floating reading process. And finally, the treatment of the results, in which it was possible to list a series of criteria that allow a correct categorization of the data, among which the grouping by themes stands out.

The speeches, from the interviews with the research participants, were analyzed from the perspective of the Content Analysis technique, considering that this allows the researcher to understand the representations that the individual presents in relation to his/her reality. ⁽¹⁰⁾

The presentations of the results were discussed in categories and to preserve the identity of the participants in the presentation of the results, the identification was represented by N, for nurse and its number corresponding to the order of the interviews.

The research was conducted within the standards of Resolution 466/12, of the National Commission for Ethics in Research (CONEP), and the project was approved by the Research Ethics Committee of CESED under protocol CAAE and opinion nº 69472117.9.0000.5175.

 

RESULTS

Data processing allowed two thematic categories to emerge: Communication between nurse and deaf patient; Communication strategies in health care for deaf patients.

 

CATEGORY 1: Communication between nurse and deaf patient

For the communication process to occur between the nurse and the deaf person, arguments such as mutual understanding between the parties involved were pointed out, emphasizing the need to become understood by each other in a way that makes one understand, as evidenced in the reports.

 

It is communication in which the user or the patient and the professional understand each other, understand each other, make themselves understood. (N-2)

It would be to speak in a way that the patient understands, if you see that the patient did not understand, you say it more than once, not to get upset because he sometimes does not understand, so we start noticing each patient, the one who understands better, those who understand less, we change the language, the approach according to each patient that we assist. (N-3)

 

Also considering that the welcoming process requires interaction and requires effective communication, the lack of training in Libras was also highlighted as aspects of difficulties:

 

Yes, there are many difficulties. Because I don't have a specific course that gives me the ability to perform the service.(N-1)

Because I haven't had any preparation since graduation and until today I haven't tried to train myself. (N-4)

 

The lack of professional training in Libras was mentioned in the participants' reports, and it was evidenced that all those who participated did not have specific preparation for the use of non-verbal communication techniques or specifically Libras, this being one of the reasons for the barrier to establish adequate communication in carrying out health care.

 

I don't consider my communication process adequate, we have a case of a deaf patient, and I don't know how to speak sign language, I don't know how to speak Libras, and so it's very difficult. (N-1)

So, I say for myself, and it's the whole system, at least I have no knowledge, there are few professionals, at least in the strategy I work with, I don't know any professional who is trained to work with deaf people (N-3)

We have a case of a deaf patient, I don't know how to speak sign language, and so it's very difficult, including this deaf patient, we actually never made an approach to her, then suddenly she arrived pregnant, and that's when we really saw the need for us to be able to interact, understand. (N-3)

Communication strategies in health care for deaf patients

Regarding the strategies used to favor communication with deaf patients who need communication and language resources such as Libras, adaptation strategies were found on the part of professionals who do not have the ability and mastery of sign language and make use of occasional language tools.

 

I use mime, I use paper if the patient can read and write (N-1)

It is possible to understand even with great difficulty, and sometimes I ask that a companion come, someone from the family who makes himself understood, who transmits to me the message he wants to say (N-2 )

 

DISCUSSION

The reports showed that the communication process is readjusted, as long as a link of understanding is maintained between the interlocutors of the process, in the case of nurses and deaf patients, using the message to be transmitted and the channel or means used to transmit the messages.

Thus, this condition of understanding between the parties was highlighted in all speeches, and this condition is necessary for communication and health care to be established.

This interaction is essential to allow coexistence in society and for nursing, communication between patient and professional is considered a basic instrument to conduct care, due to the relationship between the health team and the patient. ⁽⁸⁾

In this context of relationship and understanding between the parties involved in the communication process, the resource pointed out by the nurses as absent, but above all necessary, was Libras. The participants argued that they are not sufficiently prepared to care for the deaf person, justifying that they had not received training, much less the necessary training to care for this population. The statements describe Libras as a necessary strategy, but unavailable in the academic training of professionals.

It is noted that there is a gap with regard to the care of deaf people, for this it is necessary that health professionals and governments collaborate with knowledge and research, to qualify the attention of society, so that the content that guarantees knowledge for a better coverage of care can be implemented in the academic curriculum, with the purpose of qualifying professionals who provide care. ⁽¹¹⁾

Analysis performed by Marquete et al. ⁽⁸⁾, contributes to the results found in the research, in which he informs that in the studies carried out at the municipal hospital in the municipality of Barra do Garças (MT), 80.85% of the professionals did not have basic knowledge of Libras, in which they recognize that language is fundamental for establishing communication, and that 95.2% do not obtain specialization to learn sign language.

According to these data, the health situation for the deaf person has generated great concern, as this situation feeds an ineffective health of a universal health system, aggravated by the lack of communication between professionals and users of the SUS.

The preparation of health teams can also be an essential factor that would represent a way to minimize the difficulties arising from the disability and promote better health care. Developing knowledge in Libras makes it possible to obtain critical, reflective and creative capacity established by the health care of the deaf person, jointly, this learning also guarantees the promotion of health in social transformations, nurturing responsibility and commitment. ⁽¹²⁾

Accordingly, the fight for accessibility in Libras resulted in the recognition and approval of Federal Law n°10.436/02, in which he describes that “public institutions and concessionaires of public health care services must guarantee adequate care and treatment for deaf people, in accordance with the legal norms in force” ⁽¹³⁾, jointly with Decree No. 5626, of December 22, 2005, ensures that “institutions must have at least five percent of civil servants, employees and employees trained in the use and interpretation of Libras”. (14)

According to the decree, Libras must be included as a mandatory curricular subject in teacher training courses, at secondary and higher levels, speech therapy, educational institutions, public and private at all levels of power, so it must be applied to perform accessibility in the care of deaf people, dealing in a holistic and integral way by future health professionals, being established as implementable in undergraduate courses in all areas. ⁽¹⁵⁾

The lack of preparation of health professionals is a condition that disables the performance of qualified assistance due to the occurrence of barriers between mutual communication, this can affect the results in nursing care, this factor also favors the idealization that the health service becomes an obstacle for deaf people. ⁽¹⁶⁾

In this sense, it is observed that communication is essential for the development of health care, and professionals who work in this care need to provide the discipline of studies in Libras, improving the training of professionals and meeting the need in health establishments, serving in a universal and humane way. ⁽⁸⁾

It is highlighted in the speeches that the presence of the family represents for the professional as a means that facilitates the performance of care, in this way, the communication process is established between the nursing team and between the parents/companions and this causes loss of privacy and protagonism of the individual with hearing impairment, or even embarrassment due to the presence of the companion during the consultation.

As communication is facilitated, considering that the companion knows the patient's personal information, especially the family, on the other hand, the presence of this in emergencies can have negative consequences on the information of real signs and symptoms that only the patient feels, these situations can generate feelings of incomprehension by patients. ⁽¹¹⁾

There is a limitation between the clinical meeting of health professionals and the deaf patient, this relationship appears to be inadequate and restrictive, this challenges the idea generated by accessibility in the expected health care, therefore, it is important to verify whether health professionals are qualified to accommodate the deaf in their multiple needs, contributing to autonomy and health promotion. ⁽¹⁵⁾

In addition to the criterion of the presence of a probable interlocutor/companion, whether a relative or not, or even an interpreter in the health professional and patient relationship, which in a way disadvantages the link in a professional secrecy relationship, in addition to the use of secondary and immediate resources, seeking to build probable communication with the use of mime and lip reading.

In a study on the interaction between doctor and deaf patient carried out in the city of Maringá, Paraná, it was observed that lip reading was one of the communication strategies most used by deaf people. However, this method, in addition to demanding a lot of concentration, the presence of obstacles to vision such as mustaches, accent, changes in position and use of a mask, does not guarantee that it is an effective way for interpretation. ⁽¹⁵⁾

The interaction between the patient and the professional is fundamental for the establishment of adequate communication, welcoming and the bond generated by this interaction are factors that corroborate to improve health practices, and this professional must understand the needs and which promotion and prevention actions can contribute to social inclusion. ⁽¹⁶⁾

This fact leads to the discussion that communication establishes the exposure of the individual's thinking and feeling, with this, it is necessary to have better communication between health professionals and users with which a mutual understanding is established that guarantees an improvement in health care, not only through writing, gestures or lip reading, but also by the proper use of sign language, Libras, by professionals. ⁽¹²⁾

Service in sign language contributes to a process of social inclusion, as well as enabling more effective communication between deaf people and health professionals, ensuring communication accessibility when they seek services.
In a study carried out in an Associação dos Surdos de Pinheiro (ASURPI), in the state of Maranhão, with deaf clients, they often left consultations without information about the proposed treatment, corroborating with fear and lack of confidence, needing the help of others to carry out the recommendations to be followed.

About identifying and analyzing strategies and barriers in communication between the nursing team and the deaf, an integrative literature review, carried out in 2019, points out communication strategies with the hearing impaired, they are: offer training and protocols to acquire interpreters and provide disciplines in the professional training of nurses. ⁽¹⁶⁾

 

CONCLUSION

Difficulty was found for most nursing professionals in interacting with the deaf person during the consultation or educational activities in guidance and prevention, as they are not properly qualified for this new language proposal.

While the patient uses language to express his needs and desires, the nursing professional uses communication as an indispensable tool for his assistance.

Namely, having Libras as the second official language in our country, a gap was found during the training of these professionals, which interferes with the quality of care due to the lack of adequate reception.

The difficulties that permeate the nursing consultation with the deaf person were highlighted, not only in terms of speech, but the feeling of incapacity of the professional himself before this patient, even adopting strategies to facilitate this consultation, such as the use of mime, lip reading, presence of a professional interpreter, or the presence of a family member.

Therefore, it is understood with this study that it is essential to reflect on this problem, reinforcing the applicability of legal criteria, including the implementation/implantation of Libras in academic training as a necessity, as well as rethinking public policies of inclusion to this population segment , as a way of ensuring accessibility and adequate reception of health services.

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