Dr. L. Penny Rosenblum: Welcome to Supporting Individuals with Visual Impairments in the Healthcare Setting. My name is Dr. L. Penny Rosenblum, and I'm the director of research at the American Foundation for the Blind. I'm a white, middle-aged woman with graying hair. I'm also wearing glasses. And you may note, as you watch me throughout this video presentation, that my eyes are a bit unusual, and that is because I have low vision. So I do not see in the way a typically sighted person does.

Dr. Carlie Rhoads: I'm Dr. Carlie R. Rhoads, and I am a research specialist for the American Foundation for the Blind. I am a female in my thirties, with dark hair and biracial, and I'm wearing a multi-colored shirt today. My previous experience is in working with individuals with deafblindness, and I have close to 10 years of experience working with this population.

Dr. Arielle Silverman: I'm Dr. Arielle Silverman. I'm a research consultant with the American Foundation for the Blind. I am a white woman in my mid-thirties with brown hair, and today I'm wearing a multi-colored dress. I'm also a person who is functionally blind, meaning that I can only see light and some shadows.

Dr. Rhoads: Our objectives for today are as follows. We are going to clarify terminology tools and techniques used by individuals with visual impairments. We will help you to understand how a visual impairment impacts an individual. And we will identify strategies you can use in your interactions with individuals who are visually impaired. We are also going to be modeling accessibility throughout this presentation by making sure we are describing images and reading what is on the slides to model best practices for working with individuals with visual impairments.

First, we are going to go over terminology, tools, and techniques used by individuals with visual impairments. There are four terms that we will be going over and they are blind, low vision, legally blind and deafblind. On this slide, we have a picture of a young infant female with CHARGE syndrome. She is deafblind and sitting in a stroller looking up and just pass the camera.

Our first term is blind. Total blindness is less common than low vision. Not all people who are blind read braille or use a guide dog. People who are blind do not have better hearing, but they may use their hearing more efficiently. One of our terms is low vision. Vision is on a continuum from total blindness to typical vision. Every individual uses their remaining vision differently. Visual acuity is the clarity with which someone sees an image. So let's take a look at this elevator bank. The first picture is what someone with 2020 typical vision will see. It's a very clear picture. You can see all of the details. The next picture is what someone with a visual acuity of 2070 will see, and you can see the picture is a little bit blurry and a little harder to see. The next picture is what someone with a visual acuity of 2200 will see.

And the final picture is someone with a visual acuity of 2400. And as you can see from that picture, very few details are discernible in the picture.

Dr. Rosenblum: So Dr. Rhoads, I'm curious. If somebody comes into the healthcare setting with that visual acuity of 2400, what will they be able to see?

Dr. Rhoads: So if we look at this picture of what some of them have 2400 could see, the entire picture is incredibly blurry. You can't make out any of the print, any of the signs. So if someone were to walk into a medical setting with 2400 acuity, they likely will not be able to read a name badge. They will not be able to read small print on a computer screen to check in. They will not be able to read their paperwork when they're being discharged. And they may need assistance in navigating because they will not be able to read maps.

Then with visual fields, which is your peripheral vision, so what you see from the sides, above and below, we have some examples of this. Here is the admissions' area being viewed by someone with typical vision. They're able to see the entire picture. If someone's visual field is reduced to 20 degrees, this picture is what they are seeing. As you can see, they are only seeing that blue arrow in the admissions' area and nothing else. The third picture is if the visual field is reduced to five degrees, this is all they can see. Remember that blue arrow we saw with the 20 degrees? With five degrees, it's like they're looking through a straw and that's all they can see. So the smaller the number, the less the person is seeing around them.

Dr. Rosenblum: What kind of problems might somebody with a visual field of 20 degrees have when they come into the healthcare setting, Dr. Rhoads?

Dr. Rhoads: So when you walk into a healthcare setting, immediately some of the first things you see are signs all over the place. There might be signs directing you to different areas of the facility or how to get to your doctor's office or where the admissions' desk is. But if you have a restricted field of just 20 degrees, it's a lot more difficult for you to take in all this information and find where you need to go. So while you might be able to see a little bit, you have to look very purposefully and meaningfully in different areas to figure out what information you need to see. And because you have such a restricted field of vision, you might be missing out on important details that just are outside your field of vision.

Legal blindness definition. Here we have the definition of what it means to be legally blind. A legally blind individual has a visual acuity of 2200 or less in the better eye with best possible correction, or visual field of 20 degrees or less. And we have the reference here for you. Legal blindness reality. Many people who are legally blind have usable vision. This means that many people who are legally blind, are able to see to a certain degree. Some services such as transportation are only provided to those who meet the legal blindness definition. An older woman is pictured with a Walker on a lift, getting into a paratransit van. A worker stands close by to assist.

Our fourth and final term is deafblind. Deafblind means someone who has a combined vision and hearing loss. Most deafblind individuals have some usable vision and/or hearing. Not all deaf blind individuals use sign language and or/a hearing aid. Vision and hearing abilities can fluctuate for the individual. An example of someone who is deafblind might be an adult who comes in for an appointment and may need to look up close at written documents and may need you to look directly at them when speaking. Another example of an individual with deafblindness may be someone who enters in a wheelchair and is wearing hearing aids and may need a sign language interpreter. Deafblindness is a wide spectrum with many, many individuals that present in different ways.

Deafblind communication. There are many ways that individuals with deafblindness communicate. Each system is highly individualized and unique to the person. One example is American Sign Language or ASL, which is traditional signing used in the United States, predominantly amongst individuals who have hearing impairments or identify as being deaf. Another example is protactile. This is a communication system that involves signing on the body. We have a picture of two individuals who are engaging in protactile signing. They have their hands on top of each other and are signing directly into their hands. Tactile and touch cues include actual touches on the body or objects that are touched to indicate a communication system. This could include tapping twice on the body to indicate you're about to pick someone up, or it could include a squeeze on the arm to let them know you will be right back. Objects and symbols can include actual physical objects that represent communication. So for example, if someone wants to communicate that they would like a drink of water, they might hand you an actual cup to indicate they would like a drink.

In this photograph. We see different symbols that are used as object cues. They are placed on a black background for better visibility, and the symbols can be used to create sentences. For example, there is a symbol representing I, there is a symbol representing want, and there is a symbol representing help. So if those were to be put together, we would have the whole sentence I want help. Other symbols in this picture include same, finished, eat, stop, more, not, go, drink, indifferent. Many individuals will have symbols that they use that they specifically know and are familiar with as well as symbols that they might just be learning how to use. This is how individuals build their vocabulary and their ability to communicate.

Our final example is communication devices. These can be a wide range of things from very low tech, all the way to very expensive and very high tech. They could be communication boards that have lots of symbols and are electronic. It could be something such as an iPad that has an app that verbally speaks for the person, or it could be a dedicated device made by a company such as Dynavox that allows the person to pre-program buttons that they push to communicate.

Dr. Rosenblum: Thank you, Dr. Rhoads, for helping us understand some of the terminology that helps describe how somebody with a visual impairment functions in the environment. I'd like to turn our attention now to tools and techniques individuals may use. So for reading, a person may use braille, and I have a photo here where you see a braille page and how the person is using their fingers to read.

And it is not just a bunch of dots. These have meaning the same way that print has meaning to a print reader. We also have a device that is a refreshable braille display. So you'll notice the pins coming up and the person's fingers are on them. Any print that's on the screen or graphics that's been described, the person who is a braille reader can feel those pins to read. Next way, maybe by using a magnifier or a monocular. In this first picture we see an older woman sitting in a chair who is reading a page with a magnifier. Notice she also has some additional lighting. You'll find that some people with visual impairments who have low vision really benefit from extra lighting. The next lady that we see is using a monocular, and a monocular typically is used for distance vision. You can think of mono, one. Bi, two.

So like binoculars, a monocular allows you to see at a distance. This particular monocular also has the ability to do a short focused monocular. So she's able, as you can see as she's looking at this map, to read near. Another magnification device is called a video magnifier and you may also hear people refer to it as a CCTV, like a closed circuit television. I want to show you a quick video clip of a man using a video magnifier to view a pill bottle. I want you to pay attention to how he adjusts the size of the font, and you'll see him able to select different fonts and background colors. So let's watch that video.

Our final way that somebody may read is text-to-speech, where they're listening to a document and being able to understand the images if those images have descriptions. And there are several different screen reading programs. There's one that is called JAWS. Another one is called VoiceOver and it's on all Apple devices. Let's watch a short video clip of a man using an iPhone with VoiceOver turned on.

iPhone VoiceOver: Welcome to H-I-M-G. Heading level one. Forms. Patient. Portal. Visited link. Portal visited. Format selected. Username, your username. Text field. Insertion point dead end. T-T-A-A-I-I-D-S-S. Space. I-I-S-S. Space. T-T-E-S-T-T.

Dr. Rosenblum: Right, so we've talked about ways that somebody with a visual impairment can read. Now, let's talk about how somebody may get around. Now, many people who have low vision or are blind, do not need any assistance tools to get around, but many people do. And so I want to talk to you about the three most common tools. Now I'm sure you've seen a white cane before. Let's watch a gentleman walk with his white cane. This particular gentleman is also a guide dog user. Let's watch the gentleman walk with his guide dog. Often people who use guide dogs will also use a cane in certain situations. Sometimes they'll use the two tools together. The final technique I want to talk to you about and we'll revisit again a little bit later in the presentation, is human guide. So you can see in this picture that the man is being guided by the woman. And notice how he is holding onto her arm.

I'd like to talk for a moment with you about service animals versus emotional support animals. And sometimes this can be really blurred when somebody is coming into a healthcare setting. Under the Americans with Disability Act or ADA, service animals are defined as dogs that individuals have received and these dogs have been trained to perform tasks for the people with disabilities. For example, we saw in the video how the dog was guiding the gentlemen. There are only two questions that you legally can ask somebody who is bringing a dog into the facility. The first is, is this a service animal? And the second is what tasks does this animal perform? If they tell you that the dog is there or the other animal, maybe they're bringing a cat or canary, is there to provide them support because they have anxiety, that is not considered a service animal.

It's considered an emotional support animal. And it's really important that only service animals are allowed into healthcare settings and many other places as well. To help you understand the difference between service animals and emotional support animals and what the law says, we have a reference here from the U.S. Department of Justice for you. So when we think about guide dogs and other service animals on the slide, guide dogs and other trained service dogs are allowed to stay with the individual only in the public parts of the hospital, such as the emergency room, waiting room, or exam room. If the guide dog needs to receive care or the service animal needs to receive care, it's not the hospital staff or the medical staff's responsibility. It's the responsibility of the person who was there receiving care and uses that guide dog or service animal. This can be tricky if somebody let's say has a broken leg and is in your facility for that reason. Then you really need to work with the individual who is the guide dog or service animal user and their support people to come up with a plan.

It's really important that you think about your responsibility when you do see a guide dog. The dog is working. Please, please, please, when you see a dog in harness, do not go up and pet the dog. Similarly, do not distract the dog, do not call its name, do not give attention, and absolutely under no circumstances ever give a dog food. The dog is with the individual to perform its job, and these dogs are very highly trained. So now that I've had an opportunity to talk with you about some of the tools that visually impaired people use and to help you understand the important role that guide dogs play in the lives of people with visual impairments, I'm going to turn it back over to Dr. Rhoads who's going to talk to you about how a visual impairment impacts an individual.

Dr. Rhoads: Thank you, Dr. Rosenblum. So first we're going to talk about difficulty with navigation. Some individuals with visual impairments may not see signs, see where you are pointing, easily be able to read maps if at all, or be able to detect drop-offs such as curbs or steps. If you look at the two images that we have here, the first image is what a typical person would be able to see of a map. The second image shows how that exact same map would look to someone with 2400 acuity. As you can see, the picture is incredibly blurry and you're not able to discern any usable information. Difficulty accessing information. The individual may not see employees' names printed on badges or uniforms. So don't assume they can see your name and be sure to verbally tell it to them.

The individual may not easily, if at all, read information on forms or other paperwork. They may not be able to see information on a computer screen because they do not have sufficient vision. There is poor contrast and/or the text size is too small. They may not be able to hear information you or others verbalize, especially if there is other noise in the environment. So an important tip to remember is to ask the individual to repeat important information back to you. You may observe some of these things, such as the individual's vision fluctuating. So at one point they may be able to see something quite well, and at another moment, they may not be able to see as well, and that can change throughout an appointment, depending on the time of day, how tired someone is, what kind of lighting they have. A lot of things can contribute to this.

The individual's ability to travel with or without assistance during their stay at the facility may vary. And the individual's familiarity with staff and the facility may influence their use of vision, hearing, and other senses. So now that we've talked a little bit about how vision impairment can impact an individual, I'm going to pass over the presentation to Dr. Silverman, who is going to talk about strategies you personally can use when interacting with individuals with visual impairments.