Dr. Silverman: Thank you, Dr. Rhoads. So people often wonder how is the best way to interact with someone who is blind or has low vision, because they want to be sure not to offend. They want to be respectful. And that's wonderful. So I'm going to talk a little bit about some basic do's and don'ts that convey respect and help meet the needs of someone who is blind or has low vision.
A couple of things to keep in mind. One is to announce yourself. Say who you are and your title or what your role is, because the person might not be able to see your uniform or your name badge. So even if you've met the individual before, saying something like, hi, my name is Ted and I work in admissions or I'm a nurse and that sort of thing, helps set the stage for a respectful interaction.
Another important thing is to ask the individual if they need assistance and what kind of assistance is best for them. Some people might not need any particular assistance. Some individuals might want verbal directions to get from one part of the hospital to another. Some individuals may prefer to have a human guide, or just to have a little bit more information about how to get from one place to another. Different individuals may have different ways of accessing paperwork. So it's really important not to assume. Instead, ask the person how you can assist them.
Another important thing to keep in mind is to let the individual know what you are doing before you do it, especially if you are providing some healthcare services like drawing blood or taking vital signs and things like that. It's really respectful for the individual to know ahead of time what is happening.
Also, it's okay to use words like look and see around someone who is visually impaired. You don't need to worry about censoring your language. And in fact, it is really respectful to use the same kinds of language with us as you would with someone who is fully sighted.
And a couple of basic don'ts to keep in mind. Don't talk to the person who is with the individual. If they come with someone who maybe is driving them or with a family member, it's important to direct your questions and your communication directly to the person that you're interacting with.
And finally, don't grab or push the individual. Don't touch the individual without asking for permission or letting them know why you need to touch them and what you're going to be doing. It's just a matter of respect and treating the person how you would want to be treated.
So now I'm going to present a scenario and give you a chance to think about what you would do in this particular situation. So imagine that two women approach where you were working at the information desk. And you notice that the older woman is holding a white cane in one hand, and holding the younger woman's arm, just above the elbow, with the other hand. What do you do?
Dr. Rhoads: Option A says, you make eye contact with a younger woman and ask, how can I help her? This option is incorrect because when you have someone approached the information desk, you need to treat everyone equally and with respect. So you want to make sure that you're addressing both women and making sure you're meeting the needs of both of them.
Let's take a look at option C now.
Dr. Rosenblum: And this option says, you come out from behind the desk and go up to the older woman and say loudly, I'm right here to help you. This is not the right choice. Often, that's really perceived as being condescending. First off you wouldn't leave from behind the desk for anybody else, so why do you want to do this for somebody just because they happen to have a white cane? You want to treat people equally. Second off, you don't need to raise your voice because somebody has a cane. Now, if the person asked you to speak louder because they also happen to have a hearing impairment, then you can do that.
Dr. Silverman: So finally, choice B says, you look in the direction of both women and ask, how may I help the two of you? And that really is the best choice. As Dr. Rhoads said, it's important to treat both women with respect. And you don't necessarily know which one of the two women is the one who needs to check in. It's possible that the woman using the white cane has the appointment and needs to check in, but it's also possible that the sighted woman is the one who needs to check in. So by looking at both of them and acknowledging both of them, you're allowing for any sort of conversation to occur.
So a few things to keep in mind about human guide if someone requests human guide. One of the most important things is that the person who is providing the guidance should be the person in front. And you can offer for the individual who is blind or low vision to hold onto your arm just above the elbow, rather than taking their arm or trying to steer them from behind. And so that allows the person to follow you and the person will be able to feel the direction that you're walking in and be able to follow behind you.
Walk naturally, allowing the individual being guided to remain slightly behind you.
Ask the individual if you should tell them about going through a door. So when you're going through a narrow doorway, the person will probably want to get directly behind you instead of being slightly off to the side. And some people like to be told if there's a step up or down, whereas other people might be using a cane at the same time as they're being guided, or they'll just notice, they'll feel your body going up and down and they'll be able to pick up on that.
It's also important to communicate and check in with the person about the pace that they want to walk at, because some people maybe are using a guide because they're in a hurry and they need to make it to an appointment and so they want to walk quickly. Whereas other people, especially if they're not feeling well, might not be able to walk quickly and might prefer to walk slower. So just check in with the individual.
And most important of all, be yourself.
So the next thing that I'm going to talk about is providing orientation to the physical environment. And that means if someone is in their hospital room or you're taking them into an exam room or an x-ray room, something like that, one way that you can help them is to provide them with some information about what's around them in the room.
Be specific and avoid general terms that rely on vision. For example, a lot of sighted people might give directions by pointing and saying over there, but that's not useful to someone who is blind or who's unable to see you pointing. So being specific and providing specific information, using terms like right and left, front and behind, to give the person reference points.
Allow the individual to take control and have control over what kind of information you're giving them. I mentioned earlier not grabbing or pushing the individual without consent, and following along with that, do not move the individual's things without asking. It'll be harder for them to find those things again when they need them. So for example, if the person has a purse or a bag that they need to set down while they're getting weighed or x-rayed, and you need to move those things out of the way, it's important to ask and let them know where those things are being moved to.
Also along similar lines, do not grab a person's white cane or their guide dog harness or anything like that. Explain what you're going to do before you do it and ask what kind and what level of information they want. For example, I am one of those people who gets dizzy when I think about needles or blood. So if I'm having my blood drawn and I'm also a blind person, when I'm having my blood drawn I don't want to know all the details about what's happening with my blood, but I do want to know right before I get poked. So some people might want a play-by-play of exactly what you're doing and other people might be content to have just a little bit of information or even to be totally distracted and not involved in the task. But it's important to let the person have control and make those choices.
So what would you do in this situation? You're leading Ms. Garcia into the x-ray room. She is blind. What do you say to her?
Dr. Rosenblum: I would bring Ms. Garcia to this room and I want to make sure that she really knows what's here. So I would start out by telling her that there are cabinets on the back wall, that there is a lot of equipment hanging down from the ceiling, that there's a station with a monitor, that there's a bed for her to lay down on, there's a doorway. Because I would really want to make sure she knew everything that was in this room. Is that what you would do, Dr. Rhoads?
Dr. Rhoads: If I was leading Ms. Garcia into the x-ray room, I would lead her in and just tell her the pertinent information that she really needs. So as soon as we walked in, I would tell her there is a bed on the right for her to sit on, and there is some equipment above, so try to watch her head and not hit herself on that. And if she needs to put her jacket down, there are chairs on the left.
Dr. Silverman: So Dr. Rhoads, that is a perfect amount of information, because if you describe all the cabinets and everything, she probably won't remember all of that and then she might miss some of the really important information, like where to put her jacket. So I think saying, there's a bed on the right, and then also maybe letting her know if she needs to put her head in a particular spot on the bed, providing that information would be useful. And if there's anything that she might bump into or trip over, it might be good to give a little overview of that kind of stuff, but you don't need to share every single detail of what's in the room.
So here's another scenario. You go to Mr. Hong's hospital room to check his vitals and dispense his pills. And on Mr. Hong's chart, it says that he is visually impaired. So the question is, you'll want to do all the following, except which one should you not do?
Dr. Rosenblum: For choice A, announce yourself and let Mr. Hong know each step you are doing as you check his vitals, is really important. Because if he doesn't know who you are, and he doesn't know what you're doing, you're going to cause him a lot of anxiety, and when you go to grab his wrist, he may whack you in the face. So it's really important that you communicate who you are and what you're going to do.
Dr. Rhoads: Option B, which is, tell him you are putting the pill cup containing his pain pill on his tray by his right hand, is also something that you will want to do. You need to be really clear when working with an individual with a visual impairment, where you are putting things and you want to be precise and exact. So letting him know that his super important pain pill is placed exactly on his tray and it's by his right hand is really critical.
Dr. Silverman: Choice C is, take his white cane positioned along the side of the bed and move it without telling him. And you definitely don't want to do that because he might need his cane and if you move it, he won't know where it is.
Now, let's turn it back to Dr. Rosenblum, and she will talk to us a little bit about options for accessing print.
Dr. Rosenblum: Thank you. Offer the individual alternatives to regular print. So if there's a form they need to fill out, they may want it electronically. You can text it to them. You can email it to them. You can make sure that your website's accessible and they can get that form. Now, this assumes that they have technology and they have the technology skills. So don't assume that everybody wants an electronic copy. But you will find that many people do.
You can prepare materials in large print. However, keep in mind that if the print is too large, it's going to be difficult for the person with low vision to see. Not all people want large print. And for some people, even with a fair amount of usable vision, no matter how big you make it, they're not going to be able to read it for a sustained amount of time to get information, such as discharge directions.
A lot of people do read Braille who are blind, but a lot of people don't. Also, you may prepare materials in Braille and it may be a year or two years until somebody comes and needs that material in Braille. So one thing to keep in mind is that when you're doing pre-appointment paperwork and information with somebody, if you ask them ahead of time if they need an alternative format and they do say they need Braille or large print or electronic, you have time to get them the information in the format they want.
You always can offer to read the information to the person if you don't have it in the format that works for them. When you do read to somebody, ask them if they want you to read the heading, the table of contents, or just start at the top and read all the way down. Not everybody wants to hear every detail. They want to get the gestalt of what that information is about.
Now, I want you to also think about color, contrast, lighting and glare.
You may have noticed in the video today that my eyes are jerking a little bit. I have what's called nystagmus and I'm a low vision person. So I prefer, as we're seeing in our PowerPoint slides today, a blue background with white font. That provides me with higher contrast. It's important though, that you ask the individual what they want. Some people may prefer yellow on black, for example.
You also want to think about lighting. You may be doing an intake for a patient in a room where that patient is facing the window and the light coming in from that window is really bothering their eyes. So simply by moving your chair, you're able to make a quick adjustment in lighting to make the situation more comfortable for the person.
When we think about contrast, you guys are like, oh, I put that white pill in the white medicine cup and put it down on their tray and they can't find the pill in that white medicine cup. Well, could you have used the blue one? Is there a different color medicine cup you could use? So how can you improve contrast? And sometimes just having a piece of paper that's a different color to provide contrast is all that's needed. So I'll put down a black piece of paper and then I'll put down the pill cup.
I want to show you a sign that's in a hospital. It's a directory. It's already hard to see with the gray background and the black font. For somebody with 2200 acuity, look how difficult if at all, it would be for the individual to read print. So this is why contrast is so important. High contrast between the font and the background.
A much better example is this sign that says CVICU Direct Line Nurse Station. You have a navy blue background with an off white font here, kind of a beige font. And that is providing a much higher contrast for the individual to see the sign. But I do want to point out that that call button that the individual needs to push is a grayish color against this white background. To make it more visible you could simply take yellow or orange tape and go around the outline of that call button to make it stand out more.
Glare can be a real challenge for some people with visual impairments, especially if they have a condition, for example, such as cataracts, where light and glare really plays a challenging role for them. So highly polished surfaces, things that reflect, may be difficult for them to see.
Also, thinking about lighting. Here's an example of an area in the hospital where there's a bank of windows, and that makes it really hard for the person to see. Sometimes you can do something just as simple as where you're sitting and the person is sitting. So for example, if you're doing an intake and the person is sitting facing the window and that person with low vision is squinting a lot or looking uncomfortable, you simply could move your chair so they can face in a different direction towards you and they're not looking into the light.
So you want to think about how you can minimize the challenges of low contrast, lighting, glare. And the best person to ask is the individual with low vision on how you can better support them so they can maximize the use of their vision.
Dr. Rhoads: Now we have another scenario for you. What would you do? You're starting your shift and you go into room 4170, where you've been told there is a patient who doesn't see well. You see the patient has a visual acuity of 2200, according to their chart. Typically, you write information up on the board across from the patient's bed. What do you do? Dr. Silverman, what would you want someone to do for you as a person who is blind?
Dr. Silverman: Well, I would want them to ask me how I would prefer to get the information. One of the best ways they could get me the information would be to send it to me in a text or an email and then I could listen to it on my iPhone with voiceover screen reader. They could also record it for me if I had a pocket recorder or using the recorder app on my phone. Or if I had my Braille slate and stylus with me, they could read it to me and I could Braille it out for myself.
Dr. Rhoads: And Dr. Rosenblum, what would you want someone to do for you as a person with low vision?
Dr. Rosenblum: I've been in the situation more than once, and the thing that I really appreciate is when they ask me what I need, and I'm able to say, could you just write it down on a piece of paper that I can keep here on the bedside so I can pick it up and look at it?
Alternatively, if I'm not feeling well and my vision is really fluctuating, or I've had a procedure where I can no longer wear my glasses, such as an eye procedure, which I've had before, then I really prefer that they make an audio recording for me. Again, like Dr. Silverman, I tend to ask people to record onto my phone.
I might also ask if they had a different color paper other than white, and if they could use a black Sharpie marker when they write for me, because that would provide me with higher contrast.
Dr. Rhoads: So we've talked about how we might approach this with a person who is blind and a person with low vision, but we also need to talk about how we would approach this with a person who is deaf blind. And the most critical part of working with an individual with deaf blindness is to make sure you know exactly how they communicate. Like we talked about earlier, communication systems for individuals with deaf blindness are highly individualized and very unique to the person. So you need to make sure you understand how they communicate and how you can tell them the information that they need. So for example, if you have a person with deaf blindness who communicates using American sign language, you want to make sure you have an interpreter there to convey the information that they need.
Recorded Voice: In this short video, we have a white middle-aged woman who is using American sign language to sign, "My right shoulder really hurts."
Dr. Rhoads: If you have a person with deaf blindness who uses objects to communicate, for example, then you want to make sure you have the appropriate objects available so you can communicate the important information.
Recorded Voice: In this photo, we have an example of what it might look like for someone who uses photographs or object cues as a form of communication. Here, we have four photographs of different specific items that represent different requests or comments. In the upper left corner we have a yellow cup, which would signify asking for a drink. In the right top corner, we have a car which would be asking to leave to go home. In the bottom left corner we have a ball, which would be a way to ask to take a break. And in the bottom right corner we have a hat, which may be asking for a piece of clothing because one is cold.
Dr. Rhoads: Now I'm going to pass it back to Dr. Rosenblum who's going to talk about options for completing paperwork.
Dr. Rosenblum: Okay. So if possible, you want to ask the individual how they would like that paperwork ahead of time. Remember, it might be electronic. It might be large print. It might be Braille. It also might be regular print. They might bring a magnifying glass and then hold it closer and then read the print.
You may offer someone to be a scribe for them, somebody who's going to fill in the information for them. So they're going to have to talk to that person, and it's really important that you provide a private room when they're going to be giving information and discussing information that's personal. So you want to plan for that.
You also want to ensure that discharge paperwork is accessible, as the individual may not have someone at home to read the paperwork aloud. And I know often we're thinking that the individual who we're going to be working with is the patient, but keep in mind, the individual with the visual impairment may be the husband or wife or parent or a friend of the patient, and that means that they need to have that discharge information so that they can take care of their loved one or their friend.
Dr. Silverman: So what would you do in this situation? You're responsible for providing Ms. Jager her discharge instructions after her surgical procedure. You hand her the packet with the printed instructions and she tells you she can't see them. What do you do?
Dr. Rosenblum: I would not select option B, which is to ask her if someone at home can read them to her. It's your responsibility to ensure that she has the same access to the discharge instructions as somebody who is sighted who is leaving the hospital. So putting that responsibility on her to have to find somebody at home to read them to her isn't right. And she may live alone, so then what is she supposed to do?
Dr. Rhoads: Option C, which is tell her that the instructions aren't that important and to use common sense, is also incorrect. First of all, everyone deserves equal access to information given to them in medical settings. Second, it is completely unfair to assume that the instructions should be disregarded and to just use common sense. If the instructions are being provided by the surgeon, a doctor, or a medical professional, then by nature they are very important and need to be thoroughly read and understood. So we need to make sure that this individual has complete access to the information that she needs so she can be healthy and well after her surgery.
Dr. Silverman: I would recommend option A, read them aloud to her or offer to email her a copy. So you're giving her a couple of options and she can let you know what works best for her.
Dr. Rosenblum: All right. Well, we have covered a lot of information in our time together today. And we appreciate your interest in learning how to be effective with an individual with a visual impairment. We want to end with just a couple of final thoughts.
Be sure to announce yourself. You've got to let people know who you are and what you're doing.
Ask how can you assist them? Don't just make assumptions.
Let the individual know what you are going to do before you do it and give them the option if they want to be distracted. But how much information do they want if they do want information. We really want you to think about how you could offer alternatives to maximize the individual's independence. So when you can come up with a list of ways that they can get the information or take part in their healthcare, then you're giving the power to them. You're treating them with respect.
At the same time, we want to remind you to be yourself. Just because somebody happens to have a disability doesn't mean that you don't get to be who you are. Laugh, enjoy, interact, be supportive. You will find that people who are blind or have low vision or are deaf blind, are more like you than different.
We want to end by expressing our thanks to the James H. And Alice Teubert Charitable Trust, which funded the work that the American Foundation for the Blind did leading up to the creation of these materials.
We also want to thank the Cabell Huntington Hospital Foundation, who worked very closely with us and the Teubert Charitable Trust.
Chad Allen RN, BSN, Patient Experience Manager at St. Mary's Medical Center, and Holly Mount, MSN, RN, CPPS, Director of Patient Experiences, Mountain Health Network and Cabell Huntington Hospital, have both worked with us throughout this process.
Thank you to Vispero, which is the company that provided us the video clip of the gentleman using the RUBY video magnifier.
And a special thanks to our colleagues here at the American Foundation for the Blind, for all their support.
If you need more information, please email me, Dr. Rosenblum, at firstname.lastname@example.org.
Thank you for your attention and your interest in this topic.
Recorded Voice: Logo. AFB, American Foundation for the Blind. Expanding possibilities for people with vision loss. www.afb.org.