Part One: Guidelines for all Health and Social Care Settings
The guidelines describe a standard which we can aspire to. They are written in the knowledge that services may not have financial resources to implement all measures outlined; however, there is an obligation on individuals to ensure that they know what is required of them by law. They also serve as a resource for health and social care professionals who may be planning services in the future.
Many of the key initiatives you can take to make services more accessible are cost neutral. Consideration, compassion and open communication are free. Time spent identifying a person's needs is an investment in safe, effective care which can prevent unnecessary risks to the individual and the staff member.
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1. Guideline One
Developing accessible health and social care services
1.1 Ask, Listen, Learn, Plan, Do
Mainstream systems and practices should be designed to ensure that they are accessible for all services users. When developing accessible services, the following approach may be of assistance to you: Ask, Listen, Learn, Plan, Do.
Ask
Consult with individuals, advocates, disability organisations and staff working closely with individuals to identify patient and service user needs in your area.
- Ask simple questions to find out if service users have any specific requirements that must be accommodated; for example, "Is there anything we can do to assist you?"
- Become aware of what could constitute obstacles or difficulties for people with disabilities using your services
- With the consent of the person with a disability, family members, carers or support workers may also be able to guide on any specific needs
Listen
Recognise that people with disabilities and staff, family members, personal assistants, advocates and disability organisations working closely with individuals are often experts in patient and service user needs.
- Listen attentively to their feedback
- Listen to any suggestions made for addressing their requirements
Learn
Ensure that you have sufficient information to help you to improve service provision.
- Complete any necessary research so that you can learn about the requirements of individuals
- Read the relevant policies, procedures, guidelines and legislation
Plan
While it will not always be possible to meet patient or service user requirements, health and social care services can strive to understand service user needs and, where reasonable, practical and appropriate, they can make positive changes to how services are provided. Where appropriate:
- Set out a programme of action to address identified issues
- Develop a plan in consultation with relevant people to support you to make the services you provide more accessible
- Set out clear protocols and guidance for staff
- Build in coordination across different levels of care
- Set out roles and responsibilities
- Establish and embed policies
Do
- Adopt policies and protocols that:
- set out the standard steps to follow to achieve accessible services; and
- integrate accessibility into your general protocols for service provision
- Implement the adopted policies and protocols
- Provide clear leadership
- Provide training and mentoring
- Establish systems to monitor and review delivery in practice
- Offer a feedback and complaints mechanism
- Ensure feedback informs review of policies and practices
- After a period of time it will be necessary to begin the cycle again
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1.2 Examples of policies, procedures or guidelines for staff
When an agreed standard policy, procedure or guideline (PPG) is in place and implemented, staff are aware of what they can do locally to make services more accessible. Please note that the HSE PPGs are available on the intranet site.
Examples of policies, procedures or guidelines (PPGs) which are advisable for services, or where there are pre-existing national health and social care service PPGs which staff should adopt and apply locally, are detailed below:
- Identifying a person's accessibility requirements
- Reviewing pre-admission planning, in-patient care and discharge planning to ensure that they are accessible (See Integrated Care Guidance: A practical guide to discharge and transfer from hospital)
- Co-ordination of care across General Practice (GP) and hospital services and liaison with the team dealing with the person's primary disability, where appropriate, and maintaining confidentiality as is required dependent on the case
- Patient consent (See National Consent Policy)and decision-making
- Evacuation in an emergency from health or social care settings
- Ensuring that buildings are well-maintained, that all accessibility features are operating correctly
- Ensuring that there are no obstructions which could hinder accessibility or cause a hazard
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2. Guideline Two
Developing disability competence
2.1 Building capacity and understanding for all staff
All health and social care staff should display a positive attitude towards service users. Appropriate training is key to ensuring that staff:
- are aware of the patient and service users needs in the area of accessibility and specific accessibility concerns for people with disabilities, and
- develop the competence and confidence to address these effectively
People with disabilities can face a range of accessibility problems or barriers. For example:
- buildings
- transport
- equipment
- failure to communicate in appropriate ways
- lack of accessible information
- attitudes
- ignorance
- discrimination
Disability training can help staff recognise these barriers and learn practical ways in which they can be addressed.
Local managers should facilitate capacity building for staff. This can be done by arranging awareness training which includes general material on accessible services and communication, as well as tailored training relating to the specific role and setting.
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2.2 Online training resource
The National Disability Authority's Disability Equality Training e-learning is available online atelearning.nda.ie, and also onHSELand.ie, the HSE's online resource for Learning and Development (www.hseland.ie) under "Personal Development". This course is free of charge; it takes about an hour and a half to complete and provides a general introduction to customer service for people with disabilities.
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2.3 Tailored disability training
In some instances, it can be helpful to have training which is tailored to inform participants about a particular disability. For example, Deaf awareness training can explore communicating with Deaf people in more depth.
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2.4 Professional education, training and professional standards
Professional education and training and continuous professional development of health and social care personnel should routinely include training on accessibility as an intrinsic part of their curriculum.
Medical, nursing and therapy schools, professional training bodies, such as the colleges of professional specialties, and regulatory bodies, such as the Irish Medical Council, have a role to play in this regard. Standards set by professional bodies should make provision for accessibility issues.
Staff providing general health and social care need to receive appropriate training to allow them to competently support patients and service users presenting for treatment of medical conditions other than their disability.
Clinical, nursing and allied health professionals should receive training in managing the interplay of different medical conditions and, in particular, where a person's disability may impact on their care plan; for example, how to care for:
- A patient with a spinal injury when they are in hospital with an unrelated condition, as they may need additional supports regarding posture, bowel care and avoidance of pressure sores; or
- A patient with a cognitive impairment who presents with a fractured hip, when they may forget that they need to immobilise it; or
- A patient who is in labour when they are Deaf
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3. Guideline Three
Accessible services - general advice
3.1 Do not assume - ask
People with disabilities are generally experts on their specific accessibility requirements. Not everyone with a disability needs assistance and an accessibility need may not be apparent, so it is important to:
- Ask each person if they would like assistance and about any special requirements they may have
- Ask for instructions, if an offer of help is accepted
- Listen attentively to what their requirements are and how they can be addressed
- Allow the person to help and direct you, if you do not know what to do. The person will indicate the kind of help that is needed
- Not be offended if your help is not accepted, as many people do not need any help; and
- Document any relevant accessibility or communication resources or requirements
Do not assume that a person with a disability would be unable to answer questions about their health or their symptoms. Ask the person themselves in the first instance.
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3.2 Making an appointment
Identify any accessibility requirements
When booking, for example, appointments or procedures, contact the person and provide them with an opportunity to inform you of any accessibility requirements.
Primary contact for appointments is usually by letter. However, where services are aware of a disability, primary and / or follow-up contact should be appropriate to the person's needs, and may be made by letter, telephone, email or text message.
Establish from service users their preferred method of communication, taking into consideration their level of disability; for example, it may be necessary for a person with a visual impairment to receive communication via email or telephone instead of letter.
It is important to note that the method of communication may be different for each person depending on their disability. Also, two people with the same disability may have different communication needs.
Two way appointment systems
Many appointment systems are one-way only or require a person to telephone if they want to change their appointment. These are inaccessible to people who are Deaf or have impaired speech. It is essential to have a two-way system so that all service users may respond; for example, to cancel or change an appointment. This may mean reviewing the existing response methods in an area. Have a system in place to ensure that such messages are responded to promptly.
Using text messages
Where available, use a mobile number or a telephone landline that accepts text messages. (Please note text message services are not available in all areas at present).
- Publicise the number in your service user information; for example, on your website and in your hospital, GP surgery or health centre
- If text is the method used, always give a quick acknowledgment to a text message, even if you do not know the answer to the question that is asked, so that the person knows you have received their message
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3.3 Show flexibility when scheduling appointments
Please note that the following section does not mean that preferential treatment will be given to people with disabilities, but rather that services should exercise consideration for the circumstances of a case where appropriate.
Setting an appointment time
Where possible, services should be flexible about appointment times and visiting hours where they impact on the provision of accessible services. For example:
- Early morning appointments may be unrealistic for people who need more time to get ready or who need a carer or Personal Assistant to help them
- Finding accessible transport may also be more difficult early in the morning
- A later appointment may facilitate family members, personal assistants, or support persons to accompany a person with a disability to attend an appointment or to be there to assist with feeding, drinking, or using the toilet as necessary
Minimising the waiting times for an appointment
It may be appropriate, when possible, to minimise waiting times for a person with a disability when they are attending for appointments where their disability may cause them to experience unnecessary anxiety, distress or pain. For example, a person with a cognitive disability may become agitated or distressed in a new environment or find remaining in one place for a long time difficult.
It can be helpful to take this into consideration when scheduling appointments; for example, the first appointment after lunch may have the shortest waiting time. It can be helpful to schedule appointments with an interpreter so that waiting times and cost of interpretive services are minimised.
Allow additional time for appointments where necessary
Some service users may need more time to communicate effectively with you. Schedule longer appointments where necessary; for example; in cases where the person has a cognitive impairment or impaired speech, or the person communicates through lip-reading or via an interpreter.
Allow enough time for a person with a disability to get from one place to another at her / his own pace.
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3.4 Missed appointments
When a person with a disability misses an appointment, it can be helpful to check whether this was due to inaccessible information or to an inaccessible building or service. Act on the feedback provided.
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3.5 Plan visits for routine check-ups or surgery in advance
Where there is a pre-planned visit, such as a routine check-up or pre-planned surgery, it is possible to identify and plan in advance to meet any accessibility requirements.
Contact the person before admission and provide them with an opportunity to inform you of any accessibility requirements they will have on the day.
A pre-visit may be helpful in some situations to familiarise the staff and patient. For example, pre-visits to a hospital or clinic can help build trust for a person with an intellectual disability, so that they are more comfortable and in control when they are admitted to hospital or when they attend for treatment.
Let other staff know when and where the person is arriving and what the plan is.
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3.6 Queuing to be seen
Visual Display Units in waiting rooms and public areas can inform people of appointments, directions, information or queuing information. A visual system could be a ticket machine, a visual display or a white board.
If possible, have both an audible and visual system for letting people know their turn. This is to ensure that people with impaired vision and people who are hard of hearing or Deaf are aware that they are being called for their turn.
If you use a ticket system for the queue, ensure that the ticket machine is at a height where a wheelchair user or a person of short stature can reach it (and that there is an alternative for people who are blind).
Inform people how they will be called and the location of the visual display units, so that they can sit where they can see or hear when they are called.
In the absence of a visual display unit in the waiting room, make sure that people with impaired vision or those who are Deaf or hard of hearing are informed when it is their turn to be seen.
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3.7 Filling forms
Ask if the person needs assistance filling in a form.
Services should also consider having easy-grip pens available for those with manual dexterity problems.
If the receptionist's counter is too high, for example, for a wheelchair user, you may need to step around it to complete your business with the patient / service user.
A clipboard can be helpful for people unable to reach the counter when filling out forms or signing documents.
If possible, it may be helpful to provide the option for the form to be accessed and completed online in advance of an appointment.
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3.8 Information and notices
Provide information about how you can accommodate someone's disability; for example:
- Contact details for the person who will deal with queries about accessibility if you cannot answer their query
- The symbol for a hearing loop, if available
- A notice about your policy on Guide Dogs and Assistance Dogs; and
- A notice on the provision of an Irish Sign Language Interpreter on request
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3.9 Mobility aids
Many people with physical disabilities rely on mobility aids, such as manual and electric wheelchairs or mobility scooters, and walking aids, such as crutches, walking frames and walking sticks.Do not:
- move mobility aids without permission from the owner (unless they are causing an obstruction which urgently needs to be moved)
- push a person's wheelchair or take the arm of someone walking with difficulty, without first asking if you can be of assistance
- lean against a person's wheelchair when talking to them. For a wheelchair user, their chair is part of their personal space
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3.10 Focus on the person
During a consultation, focus on the person, not their disability. There can be a risk that clinicians could attribute symptoms to a person's underlying disability, and thus miss some signs of an unrelated health condition.
- Take the person's presenting health condition / clinical needs into consideration.
- Give consideration to their underlying disability and the potential impact (if any) of the same on the presenting health condition and / or their care plan
- Be flexible in order to address individual needs
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3.11 Concurrent therapeutic or care needs
An individual's primary disability or other pre-existing condition may involve specific treatment or care protocols. It is important to know about these when diagnosing and treating another condition.
- Talk to the person, their carer, GP, consultant or key worker in their disability support service as appropriate, as they are important sources of information
- Identify any specific care or therapeutic requirements related to existing health conditions or to their disability, such as requirements in relation to personal care, feeding, lifting, posture, prevention of pressure sores or bowel care
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3.12 Maintain confidentiality
Confidentiality is a basic principle in the provision of health and social care.
A person's privacy could be compromised if there is intimate or sensitive information being conveyed or discussed with third parties without their consent.
Health and social care providers should be mindful of this when communicating with third parties, such as family members, personal assistants, staff, advocates etc. Staff should use their discretion to ensure that they do not compromise the individual's right to confidentiality.
Relying on children and family members to interpret or translate is not recommended on ethical and legal grounds. The document 'On Speaking Terms' (see http://www.hse.ie/eng/services/publications/) gives more information on this. However, there may be some situations where this is unavoidable; for example, an emergency situation where a family member is asked to translate for a Deaf service user. However, this should be the exception. Children should not be asked to interpret or translate for their parents.
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3.13 Health Promotion
All patients and service users should be considered in the development of any health promotion strategy:
- Provide health promotion information and guidance in a range of accessible formats
- Ensure people with disabilities are included in any population screening programmes and health checks as deemed clinically appropriate; for example, a mammogram
Health screening premises and equipment should be designed so that all patients and service users can use them. If this is not the case, efforts should be made to offer an alternative. For example, a Magnetic Resonance Imaging (MRI) scan requires a patient to remain still for a period of time; some patients may need sedation prior to undergoing this scan.
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3.14 Integrated Discharge Planning
"To ensure service users are discharged or transferred safely and on time requires full assessment of their individual healthcare needs, planning and co-operation of many health and social care professionals."
Make a plan for continuity of care and support after discharge in accordance with the Integrated Care Guidance: A practical guide to discharge and transfer from hospital.The following nine steps are taken from the document"Discharge and transfer from hospital-The nine steps quick reference guide".
"Discharge and transfer from hospital-The nine steps quick reference guide".
- Step one: Begin planning for discharge before or on admission
Pre-admission assessments conducted for planned admissions to hospital, such as elective procedures, or alternatively at first presentation to the hospital for unplanned admissions.
- Most accurate pre-admission medication list should be identified prior to administration of medication in the hospital
- Prior history of colonisation with a multi-drug resistant organism, example, Methicillin-resistant Staphylococcus Aureus (MRSA) or healthcare associated infection should be recorded in healthcare record, and healthcare staff informed as per local hospital policy
- Timely referrals are made to multidisciplinary team and receipt of referrals recorded on integrated discharge planning tracking form within 24 hours of receiving referral NOTE: this includes referrals from hospital to primary care services
- Each service user should have an estimated length of stay (ELOS) / estimated date of discharge (EDD) identified within 24 hours of admission and documented in the healthcare record, related to the estimated length of stay required (Special Delivery Unit, 2013)
- Step two: Identify whether the service user has simple or complex needs
The service user's needs are assessed either prior to admission or on first presentation and indicate whether the service user has simple or complex needs.
- The ELOS / Predicted Date of Discharge (PDD) is determined by whether the service needs are simple or complex
- The service user is placed on an appropriate clinical care programme care pathway, relevant to the service user's diagnosis, to support seamless care and management
- Step three: Develop a treatment plan within 24 hours of admission
All service users have a treatment plan documented in their healthcare record within 24 hours of admission, which is discussed and agreed with the service user / family and carers.
- The treatment plan includes a review of pre-admission against admission medication list, with a view to reconciliation
- Changes to the treatment plan are communicated to the service user and relevant primary care services as appropriate, and documented in the healthcare record
- Step four: Work together to provide comprehensive service user assessment and treatment
The multidisciplinary team comprises of the appropriate healthcare professionals to proactively plan service user care, set goals and adjust timeframes for discharge where necessary.
- Regular multidisciplinary team meetings or case conferences for complex care cases are held where appropriate
- Roles and responsibilities for proactive management of discharge are clarified
- Step five: Set a predicted date of discharge / transfer within 24 - 48 hours of admission
The ELOS / PDD is identified by the admitting consultant in conjunction with the multi-disciplinary team, during pre-assessment, on post admission ward round or within 24 hours of admission to hospital (for simple discharges) and 48 hours (for complex discharges), and documented in the healthcare record.
- The ELOS / PDD is agreed by specialty and proactively managed against a treatment plan by a named accountable person (SDU, 2013)
- The ELOS / PDD is displayed in a prominent position
- Changes to the treatment plan and ELOS / PDD are documented in the healthcare record (SDU, 2013)
- Step six: Involve service users and carers so they make informed decisions and choices
The treatment plan is shared with the service users, and they are encouraged to ask questions about the plan.
- Develop information pack for service user / carer, example, medications list, care of any indwelling devices such as intravascular lines or urinary catheters, wound care and instructions for the service user to share with their GP, community pharmacist and other relevant healthcare provider
- Counsel and educate the service user, considering the needs of service users with poor vision, hearing difficulties, cognitive deficits, cultural and language barriers.
- Step seven: Review the treatment plan on a daily basis with the service user
Practitioners talk to the service user daily about progress.
- The treatment plan is monitored, evaluated and updated (where necessary) and changes to the treatment plan and ELOS / PDD are documented in the healthcare record (SDU, 2013)
- Any problems or actions required are identified and are escalated or resolved as necessary
- Step eight: Use a discharge checklist 24 - 48 hours before discharge
The family / carers, Primary Care Team / GP, Public Health Nurse (PHN) and other primary and community service providers are contacted at least 48 hours before discharge to confirm that the service user is being discharged and to ensure that services are activated or re-activated.
- Discharge arrangements are confirmed 24 hours before discharge (SDU, 2013)
- Clinical teams conduct discharging ward rounds at weekends (SDU, 2013)
- Process in place for delegated discharging to occur between clinical teams or to other disciplines, within agreed parameters (SDU, 2013)
- Step nine: Make decisions to discharge / transfer service users each day
Each service user discharge is effected no later than 11am on the day of discharge (SDU, 2013).
- Discharge medication reconciliation and development of the discharge medication communication takes place in a planned and timely fashion, preferably on the day before the service user leaves the hospital
- Primary Care services and homelessness services should be notified when a service user who is homeless or living in temporary or insecure accommodation is due for discharge
Helpful tips
- While it is important to respect the person's privacy, it is also important that family members, carers, support persons or those assisting them understand key information for their safety; for example, what medication should be taken and when, and under what conditions the person needs to return to the hospital
- Liaise with the person and others as appropriate (their family, carers, relevant service providers, including disability services or the medical team) around discharge arrangements, aftercare and follow-up. Confirm discharge arrangements as appropriate
- Prepare an information pack and provide information and education to the service user and the family / carer in the appropriate language, verbally and in written form. This should be provided in a format that is accessible to them, where possible. See page 37 -38 in the "Integrated Care Guidance" for what information to include in an information pack.
- If follow-up is required, ensure that a communication method appropriate to the service users accessibility needs is identified prior to discharge
- Signpost a person towards disability organisations for support, information about benefits and services that they can avail of in the community and, where possible, tell them who to contact in specialist disability services
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4. Guideline Four
Communication
4.1 General principles of good communication
Albert Mehrabian's Communications Model
- 7% verbal (words only)
- 38% vocal (including tone of voice inflection and other sounds
- 55% non verbal (body language)
Communication is made up of 7% verbal communication (what we say), 38% vocal communication (how we say it), and 55% non-verbal communication (body language). When a person has a disability, it can impact significantly on how they communicate. This could include, for example, someone with impaired speech or hearing, someone with limited or no language, or someone whose communication is impaired because of dementia or brain injury.
Failure to make appropriate provision for a person's communication difficulty may result in avoidable serious risks and errors for both the patient and health care provider.
This section provides guidance on communication under the following headings:
- Communication skills
- Communicating with a person who has a disability
- Communication aids and appliances
Remember communication should be non-judgmental, unbiased and respectful. Treat an adult with a disability as you would any other adult.
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Communicating Skills
4.2 Establish how the person prefers to communicate
Establish the person's preferred method of communication. This can be done when contact is first made with the service.
A person with a significant disability may have a family member, carer or support person who can provide guidance on the appropriate methods of communication in situations where the person cannot do so themselves. This might include information on a specific communication aid and device which makes communication with the person possible.
In cases where English is not the person's primary language, it may be necessary to arrange for a professionally trained interpreter. It may be helpful if the interpreter has an understanding of how the chosen method of communication works or if necessary to take time to understand.
4.3 Notify relevant staff of the preferred method of communication
Information on a person's preferred method of communication should be passed on to relevant staff so that people do not have to repeat their requirements at each stage of the service user journey. This information should be included in the patient's chart or (with the person's consent) in a sign at their hospital bed.
4.4 Communicating with the person
Active Listening
- Communication is a two-way process. Where possible, always communicate directly with the individual, rather than their carer, support person or interpreter. Be aware of individual differences and diverse needs
- It is important to not only listen, but to hear the message
- Give communication the time needed so that staff and the patient / service user can communicate and understand what is being communicated by the other. A person who is unable to speak or to hear, who has difficulty processing or retaining information, or who cannot read may require more time. As with all interactions with patients and service users, more time may also need to be factored in to communicate bad news in a sensitive way
Verbal communication
- Speak clearly, concisely and slowly
- Use plain language that is easy to understand. If you must use a medical term, explain what it means first
- Give accurate information
Effective questioning
- Ask one question at a time (avoid bombardment)
- Give the person time to respond without unnecessary interruption
- Give the person time to ask questions
- Do not be afraid to ask the same question twice. Repeat what you have said when a person is having difficulty understanding, and verify that they have understood
- Phrasing questions in a way that a person can give a simple "yes" or "no" answer can be helpful in some situation
Non-verbal communication - positive body language
- Face the person you are communicating with
- Maintain eye contact (although this may not be possible or comfortable for some patients / service users)
- Non-verbal communication, such as gestures, facial expressions and appropriate touch, can be important when communicating with people who are experiencing communications difficulties
- Gestures and facial expressions can be used to express an emotion. For example, a thumbs-up can be an acceptable way of reassuring a person that things are all right
Use visual aids
- Drawings, diagrams or photographs are a useful tool in communicating information. They can be particularly useful in communicating with someone who is Deaf or hard of hearing, or someone with an intellectual disability or a brain injury
Give information to take away
- People with disabilities can find it useful to have the information you have communicated to them orally given to them in a format they can review later; for example, a person with a cognitive impairment may need written information to help them remember any instructions they received. This is particularly important for information about follow-up care, exercise or medication
- Write down what you have said in plain English clearly, concisely and accurately
- Avoid using jargon and technical medical language
- Always explain any abbreviations
- Remember typed information is easier to read than handwriting
- Where possible, provide information in an accessible format suitable to the individual's needs. This could be in large print (change the font size), by e-mail, by text message or where practicable in audio format
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Communicating with a person has a disability
4.5 Communicating with a person who is unable to stand or who uses a wheelchair
Position yourself at eye level by sitting beside the person. If this is not possible, stand a step back so that the person does not have to strain their neck to see you, or crouch down if appropriate.
4.6 Communicating with a person with speech difficulties
Talk to the person as you would talk anyone else, and listen attentively.
Ask the person to help you to communicate with her or him.
If the person uses a communication device, such as a manual or electronic communication board, ask the person how best to use it. These devices can provide visual information that makes language accessible for people with speech impairments.
Allow time to get used to a person's speech pattern.
Allow time to reply as it may take the person a while to answer. Wait for the person to finish, rather than correcting or speaking for the person.
Ask short questions that require brief answers, or a nod "yes" or "no".
Never pretend to understand if you are having difficulty doing so. If you do not understand what the person is saying to you, let them know this. Ask the person to repeat the message, tell you in a different way, or write it down if possible.
Repeat what you have understood and allow the person to respond. The response will guide your understanding.
Make eye contact with the patient or service user even when someone else is interpreting for them.
4.7 Communicating with a person who has a visual impairment
Be punctual. Lack of punctuality can cause a person with sight loss unnecessary stress.
Remember also that the person may not be able to see whether you have arrived.
- Always let a person with sight loss know when you are approaching. A sudden voice at close range when they did not hear anyone approach can be very startling
- Speak first from a little distance away and again as you draw closer. Say their name so that they know you are speaking to them
- Greet a person by saying your name and what your role is. Do not assume they know who you are, even if they know you
Talk directly to the person, by name, rather than through a third party.
Do try to speak clearly, facing the person with sight loss while you do so.
Do not assume what help they need. Before giving assistance, always ask the person first if they would like help and, if they do, ask what assistance is needed.
A person with a visual impairment may request 'sighted guide' assistance so that the person can find her / his way around the emergency department or to the toilet. If a person with sight loss says that they would like to be guided:
- Offer them your elbow
- Keep your arm by your side, and the person with sight loss can walk a little behind you, holding your arm just above the elbow
- When assisting, it is helpful to give commentary on what is around the person; for example, "the chair is to your right"
- If you have been guiding a blind person and have to leave them, bring them to some reference point that they can feel, like a wall, table or chair. To be left in an open space can be disorientating for a person with no vision
- Ensure that they know what is around them. Describe what is in the room, including equipment, and describe the room from left to right. Give clear instructions about the location of toilets, drinks machines, any steps or other features, such as changes in floor surfaces
Do not assume that a person using a white cane or guide dog is totally blind. Many people with some remaining vision use these.
Do not assume that, because a person can see one thing, they can see everything. If necessary, ask the person if they can see a particular landmark or object.
Never distract a guide dog when in harness.
Do not point if you are giving directions. Give clear verbal directions; for example, "the door is to your left".
If you have been talking to a person with sight loss, tell them when you are leaving, so that they are not left talking to themselves.
Explain procedures to someone who cannot see what you are doing.
- Clearly explain all the procedures and what will be done step-by-step
- If a person is asked to lie on an examination couch, give clear verbal instructions about what will happen, where the couch is and what the person should do
- Tell the person what parts of their body you will examine and where you will touch
- If you are giving an injection or a needle prick, explain where you will put the needle and what will happen (for example, drawing blood, inserting a drip or giving sedation)
- If a person is having an MRI scan or x-ray, explain all procedures clearly and let the person know when you move behind a screen or into another room
- When serving food, staff should:
- Tell people that the meal has arrived and has been placed in front of them
- Identify the food on the plate using the clock system, if a person has a visual impairment; for example, "the meat is at six o'clock, beans at three o'clock and potato at nine o'clock"
Helpful hints
- If food is served on a tray that has a good edge, anything spilled will stay on the tray
- A good colour contrast between a drink and its container is useful to avoid accidents -brightly coloured cups may be seen more easily. For example, a glass of water may not be easily seen; tea in a white mug is easier to see than in a brown mug
The National Council for the Blind of Ireland has developed specific information resources for healthcare professionals, which can be accessed at http://www.ncbi.ie/information-for/healthprofessionals.
The topics covered include:
| Health Professional |
Publication |
| For All Health Professionals |
- Guiding a Person With a Vision Impairment
- Getting in Touch With our Services
|
| Nursing Staff |
- Assisting Adults With Sight Loss in Hospital
- Assisting Children With Sight Loss in Hospital and at the Doctor's Surgery
|
| Care Staff |
- Practical Tips for Care Staff
- Leisure Activities for Day Centres
|
| Public Health Nurses |
- Older People With Sight Loss - Living at Home
- Practical Tips for Care Staff
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4.8 Communicating with a person who is hard of hearing or Deaf
A person's hearing may be affected at any stage of their life, from the time of birth or in their later years. Loss of hearing may be an invisible disability.
People who have grown up with hearing loss may have Irish Sign Language (ISL) as their primary means of communication, and these are termed the Deaf community. As English is considered their second language, some have difficulty with written English. It is important to use plain English, and to provide information in simple, concrete terms. Visual aids are also helpful.
People who experience hearing loss as they grow older may rely on hearing aids, on lip-reading or on written information. They generally will not have learned Irish Sign Language.
Learning a few basic signs of Irish Sign Language can help Deaf people feel at home and welcome. The Irish Deaf Society has produced a DVD called "Everyday signed vocabulary in medical settings for service user care", and a booklet of "Basic Medical Signs for Irish medical institutions on common medical sign language for service user care". You can find basic signs and information about Irish Sign Language classes onwww.IrishDeafSociety.ie
In the Palliative Care setting, the type of information that needs to be conveyed can be difficult. Many patients wish to know about their diagnosis or prognosis; however, others may prefer to negotiate a gradual disclosure of information. Much of palliative care practice is about symptom management, requiring accurate history taking. This can be more difficult when a service user is Deaf. In this regard, it is important to ensure that an ISL Interpreter is available to interpret.
It is thought that, when a person is dying, the person may still be able to hear despite being very weak and mainly sleeping, and many healthcare professionals continue to speak with the person to provide them with reassurance and support. When a person is Deaf, it is important to be mindful that other forms of communication, such as touch, may convey emotional support. However, it can be helpful to check with the person or their family in advance as to whether or not they would be comfortable with touch.
General points
- Ask if someone can hear you clearly; do not assume that they can
- Ask the person with a hearing difficulty how they want to communicate. This could be spoken English, written English, Irish Sign Language or communication appropriate to someone who is deafblind
- You may need to tap the person's arm gently to get their attention. If touch is not appropriate, you may need to use another approach; for example, in the case of a burn victim you might wave your hand in their line of sight or switch a light on and off
- Where possible:
- provide induction loop systems for hearing aid users or a portable listening device for hard of hearing service users, and test them regularly
- provide written versions of any audio notices and communications
- support the information given in conversation with written handouts
- and provide diagrams or pictures which may be useful in supporting text.
- Make sure that only one person speaks at a time
- Use gestures, body language and facial expressions to emphasise the sense of what you are trying to communicate; for example, nod rather than saying "hmmm" to show you are listening. Take care that these do not appear over-exaggerated or patronising
4.9 Communicating with a person who lip reads
Get and keep the person's attention
- Gain the person's attention; for example, tap the person's arm gently to get their attention, wave your hand in their line of sight or switch a light on and off
- Talk directly to the person
Position yourself well
- Position yourself three to six feet from the person and at the same level as them
- Make sure your face is in good light while you speak. Do not stand with a light or a window behind you as shadows may make it difficult to read your lips
- Check with the person that they can see you clearly
- Minimise any background noise
Assist the person to see your face and lips
- Make sure they have a clear view of your face and lips
- Do not cover your mouth or have anything in or covering your mouth; for example, chewing gum, pen, paper, hands
- Keep your head still where possible
- Stop talking when looking down or away
Speak clearly
- Let the person know the topic of conversation and signal any change in topic by pausing
- Speak at a moderate pace and maintain a normal rhythm of speech
- Do not shout because this can distort your lip patterns
- Do not over-emphasise mouth movements as this will distort your lip patterns
- Sentences or phrases are easier to understand than single words
- If a word or phrase is not understood, use different words with the same meaning
Assist the person to understand
- Know that lip reading is tiring
- Allow time for the person to take in what you have said
- Use natural body language and facial expression but avoid exaggerated gestures
- Check with the Deaf or hard of hearing person regularly to ensure they understand. Some health care providers make the common mistake of presuming Deaf or hard of hearing people can lip read. This is not always the case. Even if the person can lip read, accuracy in lip reading is estimated at 30%, resulting in disproportionately high rates of miscommunication and misunderstanding. This may have very serious implications for medication management or in the follow up care of a condition
- Some of what you say may be missed - supplement what you say with written information, notes and diagrams. When you write something down, use plain English
4.10 Communicating in writing with a Deaf or hard of hearing person
- Ask the person how they would prefer to communicate
- Pen and paper, text messaging, e-mail, speed text and written handouts of information provided are useful ways to communicate with someone who is Deaf or hard of hearing
- If using e-mail or text messages to arrange an appointment, ensure any e-mail system or text message service can receive replies (rather than a no-reply number or e-mail account) so that people can respond and can discuss access requirements for an upcoming appointment. If not, make alternative arrangements to enable a reply
- Always follow clear print guidelines. (See thewww.ncbi.ie for further information)
- If the person wants to communicate by note-writing:
- Be patient, it may take longer
- Always use plain English
- Ensure your handwriting is clear and legible
- Allow the person to keep ownership of the notes
- Ask the person's permission if you want to use the notes as part of their treatment plan; and
- Treat all handwritten communications as you would a private conversation
4.11 Communicating with a person who uses Irish Sign Language
Some Deaf or hard of hearing patients and service users use Irish Sign Language (ISL) as their first language and preferred method of communication. Not everyone who signs will use ISL; for example, someone from England who is on holiday will use British Sign Language (BSL), an American will use American Sign Language (ASL), and they are all very different.
Patients and service users are entitled to request and be provided with a qualified sign language interpreter. While the onus is on the service user to request an interpreter, it is the responsibility of staff to make the arrangements. Staff should routinely let service users know that:
- they have the right to an interpreter to assist in communication
- there is no cost to the service user; and
- staff will arrange for the interpreter
It is considered good practice for services to arrange an interpreter without being prompted in cases where repeat visits are necessary or where it is known in advance that the service user needs one.
Not providing a qualified sign language interpreter when delivering care to a patient or service user places the health or social care provider in a precarious situation:
- information may be misinterpreted or misunderstood which may lead to a potential adverse outcome for the patient or service user; or
- the lack of provision of a qualified sign language interpreter may result in invalid consent for invasive medical or surgical procedures
An interpreter may also be necessary if the primary carer or advocate of a patient / service user is Deaf; for example, Deaf parents with a child who can hear.
The HSE guidance document on using language interpreters, 'On Speaking Terms', is available on www.hse.ie
If it is not possible to get an Irish Sign Language interpreter in an emergency or on short notice, it can be helpful to have a standard pre-prepared list of written questions, pictures and symbols that you can use to communicate with a person who is Deaf. The questions or pictures should reflect the usual questions you ask when someone is admitted to hospital, such as "where does it hurt?", "do you have previous health conditions that we should know about?", or "are you on any medication?" Make sure that the questions are written clearly and in plain English.
To book and ISL interpreter, see www.slis.ie or e-mail bookings@slis.ie. You may need to book an interpreter up to two weeks in advance.
4.12 Irish Sign language interpreters
Sign language interpreters are there to translate between Irish Sign Language and English. They interpret for both the Deaf person and health and social care staff.
Professional Irish Sign language interpreters:
- Work to a Code of Ethics and Professional Conduct where confidentiality is a core value
- Translate not only the words but also the cultural meanings; and
- Are trained to be impartial. Do not expect them to give a personal opinion of a patient
The interpreter is not a caseworker or an advocate. They may intervene, for example, to ask someone to sign or speak more slowly, to clarify understanding or to ask that information be repeated.
With the consent of the Deaf person and where possible, provide the interpreter with background notes and information in advance. This will enable the interpreter to carry out higher quality interpretation.
Allow extra time when working through an interpreter especially in medical settings where terms may not be easily understood.
Make sure that the interpreter sits next to you and that the Deaf person can see both of you clearly.
Direct what you say and make eye contact directly with the Deaf person, not with the interpreter.
Give the interpreter sufficient time to translate what is communicated. Remember that an interpreter has to interpret everything that both a Deaf person and a hearing person say during the course of an interpreting session.
4.13 Deaf interpreters
Deaf interpreters are Deaf or hard of hearing people who have been professionally recognised as accredited interpreters. Contact via bookings@slis.ie.
- They have fluency in Irish Sign Language and work in tandem with Irish Sign Language interpreters or Deaf advocates
- They are skilled in techniques of interpretation and translating meaning between languages and cultures
- They have in-depth knowledge of the Deaf community and can interpret for Deaf foreign nationals, for vulnerable Deaf individuals, in mental health settings and for Deaf individuals with an intellectual disability
- They work to the same guidelines, ethics and standards as Irish Sign Language interpreters
4.14 Irish Remote Interpreting Service (IRIS)
The Irish Remote Interpreting Service (IRIS) uses a web-based programme to connect to a central internet server where an interpreter acts on behalf of the practitioner and the Deaf person.
- This is on-screen video interpretation over an internet connection
- The web based programme does not replace face to face interpretation and should only be used for generic appointments; for example, booking an appointment, checking times or details with the Deaf person
- If an appointment becomes more serious or requires more in-depth discussions, a face to face meeting should be booked
- A service provider or service user will need access to broadband, a microphone, speakers and a camera / video facility on their PC or laptop
- Contact www.slis.ie
4.15 Deaf Peer Advocates
Deaf Peer Advocates can assist in breaking down, understanding and making sense of information received.
- They are not social workers, carers or sign language interpreters
- Their role is to ensure the patient or service user's rights are upheld. They are impartial and work for the best for the client.
4.16 Communicating with a person who is deafblind
A person who is deafblind has combined sight and hearing loss.
- A white cane with a red band signifies that someone is deafblind
- A person who is deafblind needs a specialised interpreter. This person works in tandem with the deafblind peer advocate to ensure the person is understood and understands what is being said
- A peer advocate is a person whose touch and communication style is known to the person who is deafblind and who can relay information to the healthcare worker
- How to communicate with a person who is deafblind is an individual matter. The practitioner adjusts their strategy to the person's need for support
- The deafblind alphabet is a system to fingerspell words on to the hand of a person who is deafblind
4.17 Communicating with a person with an intellectual disability
People with an intellectual disability may have difficulty understanding language that is complex, contains abstract concepts or technical jargon. It is therefore important when talking with someone with an intellectual disability to:
Speak directly to the person concerned.
- If it is necessary to obtain the information from a carer or family member, maintain the focus on the person with the disability through eye contact and body language
Speak clearly and more slowly using simple plain English and short sentences.
- Address the person and use a tone of voice consistent with their age - so speak to an adult as another adult
- Pause frequently to enable the person to process what you are saying
- Choose a quiet place with few distractions if possible
- Give only one piece of information at a time, in short sentences
- Check you have both understood
- Don't pretend to have understood when you haven't
- Use words and phrases familiar to all
- Make it clear if you are changing the subject
- Don't ignore the person or walk away if you don't understand. Tell them you don't understand so you are going to find help
Some people with an intellectual disability may have trouble expressing their thoughts or feelings so it is important to provide enough time for the person to reply, comment and formulate their questions or answers.
- Ask one question at a time and provide adequate time for the person to formulate and give their reply
- Use visual cues - such as objects, pictures or diagrams - and facial expression and body language to convey information, and to try and understand what someone is trying to say
- If the person uses a communication device, then ensure they have access to it, read the directions (usually on or in the device or book) and use it with them
Some people with an intellectual disability can find it hard to recognise and communicate their symptoms, pain or discomfort. As a result, health and social care staff may rely on family members or support workers to bring health problems to the attention of healthcare staff and to provide a good medical history.
- It is important to remember, however, that support workers may also be unaware of symptoms and, with a turnover in support staff, may not always know the person well
Recognise that difficult behaviour may be because the person is in pain, anxious, confused. There may be times when you do not understand what the person is saying. In this situation, it may be helpful:
- To ask the person to repeat what they have just said
- If you could ask an accompanying support worker / family member to help you understand or to show you how the person says "yes" and "no", and then ask yes / no questions to identify what it is they are saying; or
- If you still can not understand, show respect for the person and acknowledge the importance of their message by apologising for failing to understand them
Physical examination may also take longer due to a combination of difficulties with communication, with accurate history-taking or with physical examination due to anxiety or challenging behaviours, and this means that lengthier assessments should be planned for.
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4.18 Other communication challenges
Patients and service users may have a number of difficulties which impact on their communication skills; for example:
- Problems and difficulties with social interaction, such as a lack of understanding and awareness of other people's emotions and feelings
- Impaired language and communication skills, such as delayed language development and an inability to start conversations or take part in them properly
- Unusual patterns of thought and physical behaviour. This includes making repetitive physical movements, such as hand tapping or twisting. A service user can become upset if the set routines of behaviour are broken or disturbed
- The current stage of a person's wellness may impact communication. Challenges experienced may reference the individual's desire and capacity to engage in a recovery focussed process. When a person is well the same challenges may not exist
- Years of institutional care within mental health or intellectual disability services, whereby people may have been dependent on others by necessity or by choice, may have an impact on how a person engages with staff. They may need additional support in a staged and appropriate way for a period to initiate greater participation and enable them to assume responsibility for directing and / or managing their own care to the greatest extent possible
Patients and service users may also have a disability which results in adverse reactions to noise, crowds, waiting, food, and smells among others. This may cause difficulty when accessing health or social care services. Recognise that people will have different levels of comprehension, dependent on the individual and circumstances. In view of this, the following are general guidelines may be helpful.
- Consider using visual aids to help; for example, pictures, pointing, pictorial timetables
- Explain what is going to happen before starting
- De-clutter communication - be aware of background noise and not having over stimulation
- Use clear simple language with short sentences
- Use few words instead of many and use as little abstract language as possible
- Make your language concrete and avoid using idioms, irony, metaphors and words with double meanings; for example, "It's raining cats and dogs out there". This could cause the person to look outside for cats and dogs. Some patients and service users may interpret language literally which can cause confusion
- Give direct requests -such as "Please stand up" rather than "Can you stand up?" -as this may result in the person staying seated or answering "yes", as the person may not understand what you are asking them to do
- Give one command at a time and check that the person has understood what you have said - some people may speak clearly but can lack full understanding
- Do not over depend on using non-verbal communication - be as concrete as possible
- Allow for extra processing time - some people need ten seconds or more to process what they are being asked or told
- If necessary, you may need to restate the message in another way and emphasise the most important aspects of the message
- Do not insist on eye contact. Lack of eye contact does not necessarily mean that the person is not listening to what you are saying
- Remember that when a person is quite stressed, he or she may not listen or process your words until he or she is calm
- Do not be personally offended if the person does not appear to engage with you.
- A person with significant communication challenges may benefit from a home visit or a pre-visit to the health and social care setting prior to a scheduled appointment where possible
The following table provides a list of questions that staff can ask to help them identify a services users communication needs.
Ask yourself:
- 1. How much language can the person understand?
- 2. How well does he or she understand the nonverbal aspects of communication?
- 3. Does the person need more time to process information; for example, will you need to slow your rate of speech, shorten sentences, or allow time for the person to absorb information?
- 4. Does it help to word your message in a particular fashion or deliver it in a specific style? Will the person "tune-out" people who use a particular communication style (for example, assertive and loud, soft-spoken etc.)?
- 5. What is the best way of getting and keeping his or her attention other than eye contact? (For some individuals, eye contact is difficult).
- 6. Will background noise, other stimuli (such as people, food, movement, etc.) impact on the person's ability to process a message?
- 7. Is the person able to process a message when upset? How do you know the person is upset and what can you do in this case?
- 8. Will gestures, visual aids or text to aid in the comprehension of messages?
- 9. Does the person have personal space boundaries that should not be violated? This may mean no touching or not standing too close.
- 10. Does the person find it hard to understand subtle references or hidden meanings?
- 11. Has the person been in institutional care within a mental health or intellectual disability setting for an extended period of time? If so, they may be more dependent on others by necessity and sometimes choice.
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Communication aids and appliances
4.19 Communication boards
Manual or computerised communication boards provide visual information that makes language accessible for people with speech impairments. They display written words, photographs and symbols. A symbol showing a cup communicates "I want a drink", or letters can be spelt out using a finger, hand or foot. They are portable. They can be fitted to a lap tray for use by a wheelchair user.
4.20 Communication passports
Communication passports are sometimes used by people with an intellectual disability or people who have difficulty in speaking to record their views, preferences and communication requirements.
- They can often help staff to understand the person with a disability and promote successful communications. Communication passports are a way of making sense of formal assessment information and recording the important things about a person, in an accessible and person-centred way, in order to support a person's transitions between services
- They aim to describe the person's most effective means of communication, and how others can best communicate with and support the person
- They can draw together information from past and present and from different contexts to help staff and others understand the person in order to have successful interactions
For further information and templates for communication passports, refer to: http://www.communicationpassports.org.uk/Home/
4.21 Lámh signs
Provision of Lámh signs can be used to support communications with people who have an intellectual or communications disability. Lámh is a manual sign system used by children and adults with intellectual disability and communication needs in Ireland. Lámh signs are based on Irish Sign Language (ISL) and speech is always used with Lámh signs. For further information, refer to www.lamh.org
4.22 Induction loops
Hearing induction loop systems for hearing aid users are devices that can be provided in a fixed location or worn around a person's neck as a portable device.
4.23 Communication aids as part of communication strategy
It can be helpful to use communication aids as part of an overall strategy for communicating with people with specific disabilities. For example, Lámh signs can be used alongside communication passports and other visual supports, such as pictures and symbols, to assist communications with people with an intellectual disability. Assistive technology, audio and large print documents can be used to complement information provided verbally for people with impaired vision.
4.24 Provide information about communication aids available
Let people know how to access communication aids and adaptive technology.
- Provide information about the communication aids you provide on your section of the web site and in your patient or service user information booklets or leaflets, where possible
- Provide signs indicating where a hearing aid user can use an induction loop
- Place a notice at reception about how and who to contact in the health and social care service so that the staff member may book an Irish Sign Language interpreter in advance
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5. Guideline Five
Accessible information
5.1 Why provide information in an accessible format?
Public bodies are obliged by the legislation to ensure, as far as practicable, that information provided to people with a hearing impairment, a visual impairment or who have an intellectual disability is provided in a form that is accessible to the person concerned.
It is important to provide information in an accessible format which is clear and easy to understand. It enables and empowers people to:
- Find the services they need
- Make informed choices and decisions
- Understand medical procedures, treatments and after-care; and
- Avoid medication errors
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5.2 Information about accessibility of premises and services
Information about accessibility of your premises and your services should be readily available and in a range of formats on request (where practicable).
Provide information in accessible formats -for example, in your patient information booklet or on your section of the website -about your health and social care facility. The following information is helpful:
- Details of the location of your premises, public transport access, car park, set-down and pick-up arrangements, and of where the entrance is
- The location of specific services and facilities, including reception and waiting areas, and accessible toilets and zones which have an audio loop system (for hearing aid users)
- Details of opening hours
- Details of how to make contact or appointments, and of any accessibility arrangements, such as, the facility to make appointments via text message; and
- Information about who to contact for specific assistance and how to contact them
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5.3 Providing information in different formats
Ask the person with a disability how she / he would like information to be provided. Some people may need information to be transmitted in an accessible format; for example, via e-mail or a text message in the case of a blind person who cannot read letters sent via post.
In cases where the patient or service user will have regular contact with the service, a record is kept of the preferred method for information provision.
When preparing printed information, such as a leaflet, or posting information to your website, consider also how this can be provided in ways that are accessible to people with disabilities. This could include large print, information on your website that is accessible, Easy to Read, audio, video or Braille or on coloured paper.
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5.4 Some tips on written information
Get your key messages across with written information that is clear, concise and simple.
Ask yourself: Who is your audience? What is your key message to them?
The following guidance will help also:
- Write simply and clearly in plain English
- Keep anything you write accurate
- Avoid using jargon and technical medical language
- Always explain any abbreviations
- Using a minimum of 12-point font in documents (or as advised in the HSE National templates for Policies, Procedures and Guidelines)
- Provide a larger-print version for those who need this
- Align text to the left (this is important as the spacing of justified text can cause difficulties for people with dyslexia who are trying to assimilate the information)
- Provide clear headings
- Highlight important words in bold. Avoid using all capitals, italics or underlining, as this makes it harder for people with sight difficulties to make out the shape of the word
- Keep sentences short. Keep one point to each sentence
- Use short paragraphs. Use bulleted lists
- Have good contrast between the text and background colours. Do not use pale colour print
- Use non-reflective paper (for example, a matt finish); and
- Test the document before you go to print to see if people who use your service can understand it easily
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5.5 Large print
People with impaired vision may be more comfortable with documents in large print, from 14 point font and upwards.
- Large print versions of key publications and information can be produced simply by changing the font size in your word processing software
- You can produce large print versions of leaflets, forms, prescriptions, hospital menus or other documents as required
- Ask the person if they require information in large print and if there is a particular font size
they require Ensure that links on the internet site can be accessed by visually impaired people who have a reader on their computer.
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5.6 Use pictures and symbols
Pictures and symbols can help people who have intellectual disabilities and people who have difficulty in reading, or in dealing with situations that are difficult to discuss.
Access to pictures to explain symptoms may be helpful in some settings; for example, a mobile phone.
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5.7 Easy to Read
'Easy to Read' means providing information through very simple text, with accompanying pictures. This makes it easier for some people with intellectual disabilities and people with literacy difficulties to follow.
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5.8 Website
Information on your website should be accessible to people with sight problems who use technology to read to them what is on the screen.
Some simple guidance:
- Make your website easy to navigate (easy to find the information you are looking for)
- Structure your documents using headings styles from your word processing package
- Provide a text description of any images - how you would describe them to someone over the phone
- Make sure people can get all the important information from your videos and audio, even if they cannot see or cannot hear them
- Provide enough colour contrast between written information and its background; and
- It can be helpful to subtitle video clips
- The National Disability Authority has detailed advice on how to make a website fully accessible. http://www.universaldesign.ie/useandapply/ict. Your webmaster and web developer should be familiar with these standards and this advice.
- Ensure everything on your website meets the recognised accessibility standard which is Level AA conformance with the Web Content Accessibility Guidelines 2.0
- All your content, including word and pdf documents, maps, audio, video and html content, should meet these standards
• It is possible to have the accessibility of your website independently checked
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5.9 Video and audio
Keep CDs or DVDs and online videos or audios short so that people can find it easier to absorb and remember the information.
Provide a voice-over (audio description) so someone with impaired vision can follow a video.
Provide subtitles, to help people who are hard of hearing.
A video in Irish Sign Language is a good way to provide information to the Deaf community.
Consider incorporating Lámh signs.
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5.10 Braille
Braille is a writing system of raised dots that are read by touch. With newer technologies available, the demand for Braille documents is relatively low. Have an arrangement in place to convert documents into Braille where practicable if this is requested.
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5.11 Further information
5.11 Further information
| Further Information |
Reference |
| Accessible information for Deaf or Hard of Hearing people |
Organisations that provide symbols include:
|
Accessible information for
blind people |
Contact the National Council for the Blind of Ireland's media centre for further guidance on how to provide alternatives, including Braille and good quality audio, for people with impaired vision: www.ncbi.ie |
| Accessible information for Deaf or Hard of Hearing people |
The Irish Deaf Society has facilities for producing signed videos and DVDs: www.irishdeafsociety.ie |
| Accessible information where English is not a first language and translation is required |
www.lenus.ie/hse/bitstream/10147/207010/1/Lostintranslation.pdf |
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6. Guideline Six Accessible buildings and facilities
6.1 General information
Public bodies are obliged by the legislation to "…ensure that its public buildings are, as far as practicable, accessible to persons with disabilities"
People with disabilities can face particular challenges getting into, moving around and using the facilities of some buildings.
The challenges may be somewhat different for people who walk with difficulty, those who use walking aids, wheelchair users, people with a visual impairment (people who have difficulty seeing or people who are blind), people with hearing difficulties or people with intellectual disabilities. There are a range of different features that are required if a building is to be fully accessible.
Building managers should ensure that the premises are designed to be accessible and that accessibility is maintained.
Those responsible for commissioning equipment should ensure that the wide range of needs and circumstances is catered for, including people with disabilities.
Ask people about their physical access requirements so that an individual's requirement can be met where practicable.
Provide information about the physical accessibility of your premises and your service, including accessible aids and equipment, in any patient information material or on your website.
Detailed technical guidance on different aspects of physical accessibility can be found in the National Disability Authority's Building for Everyone http://www.universaldesign.ie/ buildingforeveryone
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6.2 Providing information about the accessibility of premises and facilities
Information about the accessibility of your premises and your services should be readily available and in a range of formats on request (where practicable).
Provide information in accessible formats; for example, in your patient information booklet, or on your section of the website about your health care facility. The following information is helpful:
- Details of the location of your premises, public transport access, car park, set-down and pick-up arrangements, and of where the entrance is.
- The location of specific services and facilities, including reception and waiting areas and accessible toilets and zones which have an audio loop system (for hearing aid users).
- Details of opening hours.
- Details of how to make contact or appointments, and of any accessibility arrangements, such as the facility to make appointments via text message.
- Information about who to contact for specific assistance and how to contact them.
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6.3 Points to consider - A checklist for accessible buildings and facilities
The following table is a checklist. It provides a list which services can use to support the provision of accessible buildings and facilities. It should be noted that this is not an exhaustive list and can be added to for each area as required.
The list describes a standard to aspire to. It is written in the knowledge that services may not have financial resources to implement all measures outlined; however, there is an obligation on individuals to ensure that they know what is required of them by law.
Points to consider
A checklist for accessible buildings and facilities
General points
- Can people with disabilities get into your building easily?
- Can people with disabilities move around the building easily, and find their way to where they need to go?
- Can you evacuate people with disabilities safely in an emergency?
- Is there a warning system in place for Deaf people who cannot hear any alarms?
- Are there accessible WCs where people need them?
- Is your furniture and equipment suitable for people with disabilities?
- Have you systems in place to ensure accessibility of your premises and facilities is maintained?
Entrance and approach
- Is there a set-down and pick-up point that is clearly sign-posted close to the entrance to the building?
- Are there accessible parking bays close to the entrance?
- Is there one or more parking meter or payment machine which can be operated when seated?
- Is there an unobstructed route from parking or public transport to the entrance?
- Is there a non-slip pathway with dished kerbs and with tactile surfaces at crossing points?
- Is there a level step-free entrance to the building? Otherwise, there should be both steps and a gentle ramp at the entrance with continuous handrails. A contrast in texture of the paving will let someone with a visual impairment know they are at the entrance.
- Are ramps no steeper than 1:20, and preferably no longer than 10 meters?
- Are steps non-slip and marked along the edges? Is there clear, well-lit signage with good colour contrast?
- Are the entrance doors easy to open or do they open automatically?
- If there is a double set of doors to minimise draughts at an entrance, is there enough space between the outer and inner doors for someone with limited mobility or a wheelchair user to negotiate?
- Are door handles visible and easy to use and at a height which a wheelchair user can access?
- If the door does not have a self-locking device, are there pull-handles to close the door?
- Are there door entry control systems, such as intercoms, where necessary that have features that work for people who have vision or hearing impairments?
- Is there a designated area outside for a guide dog to relieve himself? Foyer, reception and waiting areas
- Is there clear signage showing where to find different services and facilities?
- Is the reception desk close to the entrance and in a location to minimise internal and external noise?
- Is there a two-tier height reception desk that can serve both those who are standing and those who are seated (including wheelchair users) with adequate knee space?
- Is there a chair at the reception desk for the person making inquiries?
- Is there a suitable-height surface for signing any forms?
- Is there a loop system at reception desks to facilitate those with hearing aids?
- Is there a portable loop so that a service user can take a loop from one room to another?
- Is there good lighting on the receptionist's face to facilitate lip-reading? Avoid lighting behind the receptionist where possible.
- Is there adequate space for both manual and powered wheelchairs to enter and turn around?
- Is there adequate seating in any waiting area? Where possible, provide some with armrests that are easier to stand up from.
- Does the layout of the seating enable a wheelchair user to sit beside a companion?
- Are written notices in large print, in a clear typeface, with good colour contrast and on a matt background to reduce glare?
- Are leaflet display stands accessible to people who are standing or who use wheelchairs?
- Can people with limited dexterity take a leaflet from a leaflet display stand easily?
- Is there space for a guide dog close to the seating in waiting areas and a water bowl if required?
General areas and circulation
- Are there non-slip floor surfaces that are dry, well-maintained and easy to use by someone on crutches, with a walking aid or in a wheelchair?
- Are there contrasts in colour and texture for floor coverings to define different areas of the building or to mark a route?
- Are doorways, corridors and circulation spaces wide enough for powered or manual wheelchair users to navigate and turn?
- Are corridors, waiting rooms or wards free of any obstacles that could restrict mobility or cause injury? Check that trolleys, cleaning equipment or wall-mounted objects like fire extinguishers or other materials do not protrude and / or are not placed where they could be an obstruction or a hazard.
- Are there handrails and seating in all waiting areas and along circulation routes to enable a person with a walking difficulty, a person who has balance difficulties or a person experiencing chronic pain to get around the building and take a break if they need it?
- Are there handrails where there are changes in floor levels and where there are steps or ramps?
- Is there a glazed vision panels on doors so that one can see what is beyond the door?
- Are there markings on glass doors so that they can be clearly seen?
- Are the edges of any steps marked so that they are visible?
- Is there an alternative for those who cannot use steps, such as a lift or a ramp?
- Are all controls, such as lift controls, door handles or switches, at a height which people who are seated or standing can use?
- Is the lift a talking lift that specifies which floor you are on?
- Is there a minimum clear opening of 900mm in the lift?
- Are the controls in the lift accessible?
- Is there good lighting, without glare?
- Can a wheelchair user position themselves alongside any seating to enable a companion to take a rest?
- Is there sufficient space for a wheelchair user to access and grab rails in key parts of the building, such as along corridors, alongside ramps and in toilets?
Toilet facilities
- Are toilet facilities accessible? These should be large enough a person using a powered wheelchair to use. For technical details, see Book 5 (Sanitary Services) in "Building for Everyone": www.universaldesign.ie/buildingforeveryone
- Is there an accessible toilet near the examination room so that a person can give a urine specimen, if required?
- Are door handles, wash-hand basins, taps and the toilet fully accessible? Door handles and taps should be usable by people with restricted dexterity.
- Are there appropriately placed grab rails and accessible handles for entry and exit?
- Are accessible toilets maintained and repaired promptly if out of order? Accessible toilets should be maintained free of obstruction and not used as a storage area for cleaning or other materials.
Consulting and treatment rooms
- In designing and building treatment rooms, have the relevant professionals taken account of the acoustic properties of rooms where consultations take place? Choose materials that dampen sound. Avoid noisy ventilation or air conditioning systems that can make it difficult for a person to hear.
- Are treatment rooms of a sufficient size to enable a manual or powered wheelchair user to turn?
- Can the treatment room accommodate a lifting hoist to enable a person to transfer safely and comfortably onto an examination or treatment table or chair?
- Are examination couches centrally located with access from both sides (or can they be moved easily so that they are)? Are they height-adjustable so that a person can be examined in a range of positions -lying, standing or seated?
- Is diagnostic equipment, such as a mammography machine, capable of being accessed by a person in a seated position?
- Are handgrips provided to help people with mobility or vision impairments to have support when standing beside a diagnostic machine or on weighing scales?
- Are there accessible weighing machines so that people who are not able to stand on the weighing scale can be weighed safely and comfortably? For example, there should also be accessible weighing scales that allow individuals to be weighed in a wheelchair.
- Is at least one dressing room accessible to manual and powered wheelchair users and people with limited mobility? Are there hand grips and seating in the dressing room and a call bell if a person requires assistance?
- At least one consultation or treatment room should have a hearing loop system available for a person who is a hearing aid user. Provision should also be made for a portable loop system to be available if a person is required to move between consultation or treatment rooms.
Hospital wards
- Are there accessible and automatic height-adjustable beds available if a service user needs one?
- Are hoists and monkey poles available to enable people be lifted or to lift themselves, in particular to enable transfer between bed and bathroom or into and out of a bedside chair?
- Is there sufficient space around a bed for a manual and powered wheelchair user to turn beside a bed?
- Is there a fully accessible toilet and bathroom adjacent to the ward, with a choice of shower or bath facilities and with suitable hoists available as required?
- Is there a single room available on all wards, which can help infection control or offer more privacy or quiet for those who require it because of their illness or disability, where possible? Some disabilities may result in a person being uncomfortable or find it difficult to communicate in a noisy or bright environment.
- Is there a range of chairs in the day room to suit people with limited mobility and with arm rests to assist them when they go to stand?
- Is the environment free of obstacles or hazards?
- Is there a television provided? If yes, is the option of subtitles available?
Signs and notices
- Is there a clear way-finding system around the building?
- Is there clear signage at an appropriate height above floor level?
- Are the signs made from a material that does not reflect light? Glare can make them difficult to read.
- Is plain English used in signs and notices?
- Do the signs use clear and consistent language and images?
- Is there a colour contrast between lettering and background on information notices and signs?
- Are picture signs and symbols used that can be readily understood by all; for example, people with literacy difficulties, people with intellectual disabilities and people who do not read English?
- Is there a notice where you have a hearing loop?
- Are notices in a minimum of 18pt font? Do they use large symbols with a combination of upper and lower case lettering?
- Do signs meet the recommended guidelines? See the HSE Signage Policy 2005 for more information.
- Internal signs:
- The recommended size for internal location identification and directional signs is at least 60mm height and viewing distance up to 20 metres (m)
- The recommended height of a sign is between 1300-1600 mm above floor level
- The height of the signs should be chosen for comfort in reading; that is, as close to eye level as possible for internal signs and external pedestrian signs. In general, eye level is considered to be approximately 1500mm from ground. This is also the recommended height for tactile and Braille signs. (National Council for the Blind of Ireland - Recommendations for Signage)
- External signs:
- External location identification and motorist directional signs should be 90mm high and legible from approximately 45m
- Where possible, provide Braille or raised lettering so that people with impaired vision can read them by touch
Safe evacuation
- Is there an appropriate plan in place for the safe evacuation of everyone, including people with disabilities, in the case of an emergency?
- Is the fire alarm both audible and visible so they can be perceived by people who are Deaf or hard of hearing?
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7. Guideline Seven
Consent
"Consent is the giving of permission or agreement for an intervention, receipt or use of a service or participation in research following a process of communication in which the service user has received sufficient information to enable him / her to understand the nature, potential risks and benefits of the proposed intervention or service."
National Consent Policy, HSE, May 2013
Please note, the following section "Guideline Seven: Consent" should be read in conjunction with the National Consent Policy, HSE which is available on www.hse.ie. These guidelines are also subject to change pending forthcoming legislation.
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7.1 General Principles of Consent
The need for consent extends to all health and social care interventions conducted by or on behalf of health and social care services on patients and service users in all locations (for example, hospitals, community, residential care settings).
It is a basic rule at common law that consent must be obtained for medical examination, treatment, service or investigation. Consent must also be sought for a person to take part in a health and social care service research project.
Therefore, other than in exceptional circumstances, treating service users without their consent is a violation of their legal and constitutional rights and may result in civil or criminal proceedings being taken by the service user.
No other person such as a family member, friend or carer and no organisation can give or refuse consent to a health or social care service on behalf of an adult service user who lacks capacity to consent unless they have specific legal authority to do so.
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7.2 What is valid and genuine consent?
Consent is the giving of permission or agreement for an intervention, receipt or use of a service or participation in research following a process of communication about the proposed intervention. The process of communication begins at the initial contact and continues through to the end of the service user's involvement in the treatment process, provision of social care or research study. Seeking consent is not merely getting a consent form signed; the consent form is just one means of documenting that a process of communication has occurred.
The healthcare worker should aim to maximize the capacity of the service user as far as possible to provide or refuse consent. Getting consent is a process involving effective communication between the service user and healthcare professional. The provision of appropriate and accessible information to the service user will be critical in facilitating and supporting them to make an informed choice. In some situations, involving an appropriate third party to facilitate the exchange of information and communication between the healthcare professional and service user will be necessary (for example, where the service user is non-verbal or requires sign language interpretation).
For the consent to be valid, the service user must:
- Have received sufficient information in a comprehensible and accessible manner (in a way that they can understand) about the nature, purpose, benefits and risks of an intervention / service or research project (for example, proposed treatment, diagnostic procedure)
- Not be acting under duress, and
- Have the capacity to make the particular decision
7.3 Importance of individual circumstances
How much information service users want and require will vary depending on their individual circumstances. Discussions with service users should as much as possible be tailored according to:
- Their needs, wishes and priorities
- Their level of knowledge about, and understanding of, their condition, prognosis and the treatment options
- Their ability to understand the information provided / language used
- The nature of their condition
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7.4 Informing the person before getting consent
The amount of information to be provided about an intervention will depend on the urgency, complexity, nature and level of risk associated with the intervention.
It is important to:
- Communicate and provide information at a level and in a format which is appropriate to the needs of each patient or service user. (See Guideline Four: Communication for guidanceandGuideline Five: Accessible information for guidance respectively)
- Invest the time and effort needed to ensure that patients or service users:
- understand the nature of the procedure or treatment
- understand the consequences of refusing treatment
- have enough information to make an informed decision
- have an opportunity to ask questions about their condition and the procedure or treatment
Information about risk should be given in a balanced way. Service users may understand information about risk differently from those providing health and social care. This is particularly true when using descriptive terms such as 'often' or 'uncommon'. Potential biases related to how risks are 'framed' are important: a 1 in a thousand risk of a complication also means that 999 out of a thousand service users will not experience that complication.
In order to best support service users in assessing the risk and benefits of various interventions / course of action consideration should be given to providing the information in an accessible and understandable format using plain language.
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7.5 How and when information should be provided
The manner in which the health and social care options are discussed with a service user is as important as the information itself. The following measures are often helpful:
- Discussing treatment options in a place and at a time when the service user is best able to understand and retain the information. Sensitive issues should be discussed in an appropriate location to ensure that the service user's privacy is protected to the greatest degree possible in the circumstances
- Providing adequate time and support, including, if necessary, repeating information
- Use of simple, clear and concise English and avoidance of medical terminology where possible
- Supplementing written or verbal information with visual depictions,for example, pictures
- Asking the service user if there is anything that would help them remember information, or make it easier to make a decision; such as bringing a relative, partner, friend, carer or advocate to consultations
Service users should be given the time and support they need to maximise their ability to make decisions for themselves. It is particularly important to ensure this is the case for those with limited literacy skills or who may lack capacity due to a condition. However, it should not be automatically assumed that service users with certain type of disabilities (for example, intellectual, cognitive, communication difficulties) lack capacity to understand information or make a decision. A person's capacity can be improved and maximised with appropriate and accessible information and supports so all practicable steps should be taken in this regard.
For those with communication difficulties, speaking to those close to the service user, to an advocate, a personal assistant or to other health and social care staff about the best ways of communicating with the service user, taking account of confidentiality issues, may be helpful. For example, additional measures may be required for people with limited English proficiency, people who are deaf and hard of hearing and blind and visually impaired service users.
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7.6 How should consent be documented?
It is essential for those who provide health and social care, to document clearly a record of both the service users' agreement to the intervention and the discussions that led up to that agreement if:
- The intervention is invasive, complex or involves significant risks
- There may be significant consequences for the service user's employment, or social or personal life
- Providing clinical care is not the primary purpose of the intervention, for example, clinical photographs or video clip to be used for teaching purposes or blood testing following needle stick injury to staff
- The intervention is innovative or experimental, or
- In any other situation that the service provider considers appropriate
This may be done either through the use of a consent form or through documenting in the service user's notes that they have given verbal and / or non verbal consent.
If a consent form is used and the service user is unable to write, a mark on the form to indicate consent is sufficient. It is good practice for the mark to be witnessed by a person other than the clinician seeking consent and for the fact that the service user has chosen to make their mark in this way to be recorded in the healthcare record.
Written consent forms should be clear and easy to understand.
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7.7 Capacity to consent
Has the service user the capacity to make the decision?
Best practice and international human rights standards operate from the presumption that all adult service users have capacity when making decisions unless the contrary is shown and all adult service users shall not be considered as unable to make a decision in respect of the matter concerned unless all practicable steps have been taken, without success, to help the person to do so.
Where the decision-making capacity of the service user may be in doubt, best practice favours a 'functional' or issue-specific approach to defining decision-making capacity. According to this, the service user's capacity is to be judged in relation to a particular decision to be made, at the time it is to be made -in other words, it should be issue specific and time specific - and depends upon the ability of an individual to understand, retain and to use or weigh that information as part of the process of making the decision. The service user must also be able to communicate the decision by any means (for example, using sign language, assistive technology) to the healthcare professional.
Duty to maximise capacity
Best practice and international human rights standards favour "supported decision-making" where possible. This requires that all practicable steps must be taken to maximise the service user's decision making capacity to allow them to make their own decisions where possible.
Most service users will be able to make some decisions, but may find it difficult to make other decisions which may, for example, be more complex and involve choosing between a number of options. Fluctuations in a person's condition such as confusion, panic, shock, fatigue, pain or medication may temporarily affect the person's decision making capacity so as far as possible, seeking consent should be delayed until the person has regained capacity to do so.
It is important to give those who may have difficulty making decisions the time and support they need to maximise their ability to make decisions for themselves.
For further information on assessing capacity see the National Consent Policy and forthcoming legislation.
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7.8 Emergency situations with service users who lack capacity
In an emergency situation where a service user is assessed to lack capacity, the health and social care professional may treat the service user provided the treatment is immediately necessary to save their life or to prevent a serious deterioration of their condition and that there is no valid advance refusal of treatment. The treatment provided should be the least restrictive of the service user's future choices
While it is good practice to inform those close to the service user - and they may be able to provide insight into the service user's will and preferences -nobody else can consent on behalf of the service user in this situation.
For further information see the National Consent Policy.
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7.9 Consent, Children and Young People
Best practice and international human rights standards favour an approach which provides that a child's or young person's wishes are taken into account and, as the child grows towards maturity, given more weight accordingly. Where children are unable to give a valid consent for themselves owing to the legal age of consent, they should nonetheless be as involved as much as possible in decision-making as children may have opinions about their healthcare and have the right to have their views taken into consideration by giving their assent to the proposed treatment or service.
For more detailed information see the National Consent Policy which also addresses the issue of when it may be necessary to obtain the consent of both parents / guardians and / or when the consent of one is sufficient.
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8. Guideline Eight
Role of family members and support persons
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8.1 Role of family members and support persons
Family members and other support persons often play a critical role in enabling access to health and social care for people with disabilities, navigating the health and social care system with them and supporting them while in hospital or in other health and social care facilities.
If a person with a disability does not want to be accompanied by a carer or family member, this should be respected.
The family member, carer or support person will generally understand the person's disability and can provide information and insights into a person's accessibility requirements. This is important where people with disabilities are unable to communicate their requirements easily. Staff should be aware of their important role and facilitate it.
An interpreter may be necessary if the primary carer or advocate of a patient / service user is Deaf; for example, Deaf parents with a child who can hear. While the onus is on the service user to request an interpreter, it is the responsibility of staff to make the arrangements. It is considered good practice for services to arrange an interpreter without being prompted in cases where repeat visits are necessary or where it is known in advance that the service user needs one.
Collaboration between family carers or other support persons and health and social care staff can help to ensure that the basic needs and accessibility or communication requirements of a patient with a disability are met.
Family or other care support persons may be able to provide assistance with activities of daily living (such as assisting the person to eat or drink, dress or undress, move around, or use the toilet) where this is required and is what a person with disability wishes. However, family carers and other support persons should never be used to replace general nursing or medical care staff.
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8.2 Right to privacy
People with disabilities have the same right to privacy and confidentiality as any other person. The National Healthcare Charter, You and Your Health Service states that everyone has the right to have their privacy respected and that, as staff, "We will do our best to ensure that you have adequate personal space and privacy when you use our health services. We maintain strict confidentiality of personal information".
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8.3 Discharge
See "Guideline Three: Accessible services - general advice, Section 3.14, Integrated Discharge Planning", for more information on discharge planning. Also see "Integrated care guidance: A practical guide to discharge and transfer from hospital".
Make a plan for continuity of care and support after discharge. On discharge from hospital, those playing a significant caring and support role to the person with a disability, including the GP, should also be informed about and understand the person's medical and drug regime, any specific issues of care management, and under what conditions the person may need to return to the hospital. Where appropriate, make time to discuss a diagnosis and treatment plan with family members, carer or support person.
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8.4 Carer needs
Family carers may themselves be elderly or frail and may have difficulties in providing physical assistance. Health care staff should be alert for signs of distress in the carer and limits on assistance they would be able to provide to the patient. Staff may be able to advise the person or their family about important sources of support and where further information is available.
Health care staff in policy and management positions can give consideration on supports which might be offered to relatives who need to visit hospitals or health centres frequently.
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8.5 Advocacy
An independent advocate can represent the interests of vulnerable people and play a role in assisting people them to access services, rights and entitlements. An advocate can help them to identify and articulate accessibility requirements and assist them in making choices. Where this support is indicated, health staff should facilitate a person with a disability to access an independent advocate.
Any form of advocacy used must be agreeable to both the service user and the health and social care service.
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13 Extract from Integrated Care Guidance-A practical guide to discharge and transfer from hospital. (back to footer 13)
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