Hearing Impairment and Introduction of Mandatory Face Masks

It is estimated that one-third of all adults over the age of 65 require treatment due to some form of hearing loss, of which a sizeable proportion make up acute care admissions. ¹ There are many reports that both audible and visual stimulation help understanding and appreciation of vocal stimuli. ² During the COVID-19 pandemic, the use of mandatory face masks at all times in the health care setting when speaking to a patient, counseling, or history taking has come into play. In the acute care setting, this has meant that use of disposable masks has become prevalent. This shift, although necessary, leaves the population of patients who are hearing impaired in a precariously difficult situation.

There is a sizeable proportion of hearing-impaired patients, from mild, moderate, or severe hearing loss, who rely heavily on lip reading as well as other facial expressions.^3,4 With the introduction of facial masks, this subset of patients may well find it far more difficult to recognize facial cues or lip read.^5,6 This becomes more critical when responding to health care questions, communicating concerns, or understanding their diagnosis or management, particularly during history taking in a speedy acute medical fashion. Furthermore, many of these patients do not wear “hearing-impaired” badges or other identifiable hearing disability signs (patients with hearing loss may not recognize as a disability). ⁷

The World Health Organization recognizes that masks, while with good intention, can provide some negative aspects to delivery of healthcare, particularly to those hard of hearing. ⁸ Masks can muffle high-frequency portions of sound that are essential to speech. ⁹ Furthermore, in areas notable for loud background noise, such as emergency departments or acute care wards, communication will be increasingly challenging.

Lack of recognition or consideration of hearing impairment is one of the leading healthcare barriers for hearing-impaired patients. ¹⁰ Healthcare providers who do not provide provisions in order to address the needs of hearing impaired patients, even during a pandemic, breach ethical and professional duties and may face malpractice suits. ¹¹ Furthermore, deaf patients who may otherwise have relied upon family members or friends to translate consultations for them are increasingly being told to visit health care services on their own without visitors. Admission onto wards with nursing staff wearing masks also creates distinctive barriers. This enhances the need for recognition of this increasingly important potentially “invisible” disability.

Poor communication likely results in poor health outcomes including discontinuity of care, unnecessary investigations, and patient dissatisfaction. ¹² In order to address this, it is important that clinicians are mindful of hearing-impaired patients. Recognizing who is hearing impaired can be from patient body language, asking directly or reading patient general practitioner notes before interacting with the patient. Although wearing masks may cover half the visible face, facing patients is still important when communicating; this allows facial expression through eyes and other facial muscles to be interpreted. Short, loud sentences while checking understanding is also important. ⁶

The use of clear masks provides patients with hearing difficulties the option to lip-read. However, their use is sparse and many hospital departments, until recently, did not stock them. Unfortunately, there has been multiple changes to recommendations on the use of clear masks in hospitals causing unwarranted confusion on their distribution. Most recently, the government has awarded a multimillion pound contract to “ClearMask,” a company that will provide an initial 250 000 clear masks to the NHS during a trial period. ¹³ Benefits include ease of understanding between patients and doctors and disability inclusion. We are encouraged by this and further argue that the benefits far outweigh the costs in managing care for hearing-impaired patients not just in hospital acute settings but also in communities. Forty-seven percent of people with some form of hearing loss reported that coronavirus impacted their access to health care in comparison to 16% of people with no form of hearing loss. ¹³

Virtual consultations are becoming more prevalent, and the ability to lip-read on such devices has been noted to be difficult. Innovation is currently underway by leading technology firms to alleviate the burden on hearing-impaired patients who are now faced with virtual doctors with lagging screen and lip movements. ¹⁴ Use of clipboards or Google assistant to convert speech in real time into written language has been shown to be beneficial. ¹⁵

There are constant rising barriers in communication presented not just for hearing-impaired patients but also for hearing-impaired health care professionals. In the acute care setting, during emergency situations such as a cardiac arrest, health care professionals who are hearing impaired who rely on social cues for communication, particularly lip reading, may feel more isolated or ineffective. Widespread use of masks in hospitals can make the work of such colleagues more difficult, including difficulty communicating management plans with nursing staff, communicating with patients, and social aspects of work. ¹⁴

The introduction of masks in the acute care setting has increased communication burdens on the hearing-impaired patients. Recognition of this is fundamental. The best way to communicate with hearing-impaired patients may vary from patient to patient; however, some of the suggestions highlighted in this article may well work. We encourage a departmental to departmental recognition of the issue and local discussions on potential solutions through quality improvement projects or audits. Furthermore, colleagues with hearing impairments may be silently struggling during this pandemic. Their abilities to listen intently to patients and work around their hearing impairment can make them far more compassionate doctors. It is up to the rest of us to assist where we can utilize technology/equipment such as transparent masks, in order to make sure we still have their much needed insight and contribution to the overall health care workforce.

The difficulty for hearing-impaired people during this pandemic extends far outside that of the acute care setting, including daily life interactions. As health care professionals, we should be mindful of this fact and make sure effective provisions are in place to aid such patients, if they wish.