Health literacy (HL) is defined as an individual's ability to understand basic health care information, access services to make good health care decisions, and clear communication between the patient and the health care provider (Centers for Disease Control and Prevention, CDC, 2016). Affecting 50 percent of adults in the United States, low HL is most often associated with immigrants, minorities, older adults, and those with lower socioeconomic status (Mantwill et al., 2015). Other populations at risk for low HL include the Deaf and hard of hearing (HOH), specifically due to communication challenges, lack of health care knowledge, and risk for marginalization (Kuenburg et al., 2016). Defined as mild-to-moderate hearing loss (World Health Organization, 2019), 37 million US adults report some degree of hearing impairment (Blackwell et al., 2014). Moreover, hearing impairment is associated with lower reading levels (Hrastinski & Wilbur, 2016) and use of American Sign Language (ASL) or lip reading (World Health Organization, 2019), which can contribute to poor health care communication and inability to access health information and/or health care (Brown, 2017).

Recent research examining Deaf knowledge and awareness in the health care setting has included US medical students (Hoang et al., 2011), nurses in Greece (n = 173; Velonaki et al., 2015), Iranian undergraduate (n = 71) and nurse midwifery (n = 22) students (Adib Hajbaghery & Rezaei Shahsavarloo, 2014), and a small sample of nurse practitioners in the United States (n = 10; Pendergrass et al., 2017). The limited research to date examining Deaf culture knowledge among bedside nurses in the United States is concerning, given they are often the first point of contact for first point of contact for patients. Moreover, nurses play an important role regarding health care delivery and provision of health information. Using Purnell's (2002) concepts of cultural consciousness as guiding framework, this study examined nursing students' knowledge and awareness regarding the Deaf culture.

METHOD

University institutional review board approval and informed consent were obtained before any data collection. Using a descriptive, quantitative, cross-sectional design, a convenience sample of 131 nursing students was recruited from the undergraduate and graduate nursing programs at one public university in California. Study information, an electronic link with the informed consent and study questionnaire, was sent via email by the nursing department.

Participant characteristics assessed age, gender, race-ethnic group, level of education, and languages other than English spoken at home. Deaf culture knowledge and awareness were assessed with the 34-item Knowledge of Deaf Cultural Competency Questionnaire (Hoang et al., 2011). The 6 multiple-choice and 28 true-false or "I do not know" questions were specifically developed to assess knowledge of Deaf cultural competency among health care providers. Questions were extensively pilot tested to increase odds of clarity (Hoang et al., 2011).

RESULTS

Thirty percent (131/450) of students completed study questionnaires. The majority were female (n = 113, 83.7 percent), single (n = 82, 60.7 percent), and 28.8 (SD = 7.7) years of age. The sample included three main race-ethnic groups: Asian American (n = 55, 42 percent), Caucasian (n = 32, 24.4 percent), and Hispanic (n = 18, 13.7 percent). Fifty-three percent (n = 69) were in the baccalaureate (BSN) program, 32 percent (n = 42) were in the RN to BSN program, and 15 percent (n = 20) were in one of two master's level programs (family nurse practitioner, nurse educator). Some of the languages other than English spoken at home included Spanish (n = 24, 18.3 percent), Vietnamese (n = 15, 11.4 percent), Tagalog (n = 13, 9.9 percent), Hindi (n = 6, 4.5 percent), and ASL (n = 3, 2.3 percent).

Deaf Culture Knowledge and Awareness

Sixty-seven percent (n = 88) of participants were aware of the Deaf culture; 13.7 percent (n = 18) had taken an ASL class, with 87.8 percent (n = 115) indicating a desire to learn ASL. Few (2.3 percent, n = 3) were aware cochlear implants destroyed residual hearing and 24.5 percent incorrectly thought the implant would allow immediate hearing/understanding of oral conversations. Results regarding use of interpreters suggested 45 percent (n = 59) knew correct positioning of interpreters, 25.2 percent (n = 33) knew clinics had to provide interpreters, 54 percent knew the clinic/hospital was responsible for scheduling the interpreter, and 6 percent knew interpreters were not ethically bound to wait for providers running behind schedule. In addition, 53 percent knew staff should be made aware when a Deaf person is hospitalized. Results regarding newborn hearing indicated 10 percent (n = 12) knew it was the parents' decision whether or not to have their newborn's hearing tested. Of the 124 students who completed the 28 true/false/I do not know Deaf culture questions, 17 percent (n = 22) correctly answered >=50 percent of the questions (see Table 1 in Supplemental Digital Content, available at http://links.lww.com/NEP/A194, for complete results).

DISCUSSION AND LIMITATIONS

This study examined Deaf knowledge and awareness in a racially diverse sample of US nursing students and working nurses. Our findings were similar to Hoang et al.'s (2011) sample of medical students with regard to correct interpreter positioning (45 percent vs. 41.1 percent) and parental newborn hearing test decisions (10 percent vs. 7.4 percent). Although similar, the overall low knowledge level indicates room for growth of cultural consciousness (Purnell, 2002) that will serve to increase Deaf HL. Study findings should be interpreted with caution given the convenience sampling design from one institution, use of a nonvalidated tool, and the mixed sample of students, which included nursing students and working nurses.

CONCLUSIONS/DIRECTIONS FOR FUTURE RESEARCH

Our findings provide some support for integrating care of the Deaf and HOH into nursing coursework to promote cultural competency, patient HL, and health outcomes, for example, use of best communication practices when interacting with Deaf/HOH patients and effective use of interpreters. A future study is warranted to validate the instrument for use with its intended audience of health care professionals. In addition, future research should include larger samples, nurses already in the workforce, and nurses from a diverse range of clinical areas and education levels.

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