using this scenario what barriers are there and explain in relation to podiatry professionalism
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Communication Barriers in Podiatry — Scenario 1 Analysis
This scenario presents a highly complex communication environment. The following breaks down each barrier category and explains its significance within podiatric professionalism, drawing on the Health and Care Professions Council (HCPC) Standards of Conduct, Performance and Ethics, the College of Podiatry standards, and published evidence.
1. Sensory Barrier — Deafness / Hearing Loss
The patient is deaf, which immediately removes verbal communication as a primary channel. This is the most immediately visible barrier in the scenario.
Weerapol & Leelakanok's 2024 systematic review and meta-analysis (AJHP, PMID: 38430534) — the highest-quality evidence available — found that:
- Gestures were the most common substitute (pooled prevalence ~55%), but few healthcare professionals could use sign language
- Access to qualified interpreters was consistently limited
- Hearing aids were the most prevalent communication aid (~57%), but their use depends on whether the patient wears one and whether it is functioning
Abou-Abdallah & Lamyman (Clinical Medicine, 2021, PMID: 35192482) reported that over 70% of people aged over 70 have hearing loss, yet deaf patients experience persistent health inequalities and poorer outcomes — specifically due to communication failures. They identified three overlapping barrier domains: cultural, educational, and organisational.
In relation to podiatry professionalism:
- The HCPC Standards require registrants to communicate effectively and to make reasonable adjustments (Equality Act 2010, s.20) for disabled patients
- A professional podiatrist must, before the assessment, consider requesting a British Sign Language (BSL) interpreter, using written notes, visual aids, or augmentative communication tools — not simply relying on the carer to relay information
- Failure to do so is not just a communication failure but a professional and legal shortfall
2. Cognitive/Intellectual Barrier — Learning Disability
The carer also indicates the patient has a learning disability. This compounds the deafness: even if sign language were available, comprehension of clinical concepts may still be limited.
Learning disabilities affect an estimated 2% of the UK population and create additional healthcare access barriers including:
- Difficulty understanding abstract concepts (e.g., injury severity, consent)
- Altered pain perception and expression — the patient's response of pulling away and becoming distressed may be the primary non-verbal communication available
- Reliance on carers for history-giving, which introduces the risk of carer-mediated distortion (see below)
In relation to podiatry professionalism:
- The Mental Capacity Act 2005 (MCA) requires a capacity assessment before assuming the patient cannot consent. Capacity is decision-specific and time-specific — the podiatrist must not assume incapacity simply because of a learning disability diagnosis
- Under the MCA's best interests principle (s.4), if the patient lacks capacity for a specific decision, the podiatrist must act in their best interest, involving the carer as an appropriate consultee — but not deferring entirely to the carer
- The HCPC requires podiatrists to respect dignity and individuality, meaning the patient should remain central to the interaction, not sidelined because of disability
- Using Easy Read materials, simple vocabulary, repeating key points, and using gesture/demonstration are evidence-supported strategies
3. Emotional/Psychological Barrier — Patient Distress and Withdrawal
The patient initially cooperates but then pulls their foot away and becomes distressed. This is both a communication barrier and a clinical signal.
This withdrawal could indicate:
- Pain from the ankle/foot injury (assessment itself is nociceptive)
- Anxiety or fear in an unfamiliar encounter (a stranger at home, touching a painful limb)
- Past negative healthcare experiences — common in people with learning disabilities
- Inability to communicate pain verbally, making distress the only available signal
In relation to podiatry professionalism:
- Professionalism demands that a podiatrist stops the assessment when a patient withdraws consent — even non-verbal withdrawal constitutes withdrawal of consent (MCA 2005; MCA Code of Practice)
- Continuing to touch a distressed patient who is pulling away could constitute lack of respect for autonomy and potentially unprofessional conduct under HCPC Standard 1 (promote and protect the interests of service users)
- The podiatrist should pause, explain, and de-escalate — using calm tone, body language, and involving the carer as a reassuring presence — before attempting further assessment
- Documentation of the distress and the decision to pause is a professional duty (HCPC Standard 10: keep accurate records)
4. Relational/Interpersonal Barrier — Carer-Mediated Communication
The carer is the primary information source about both the patient's conditions and recent history. This creates a structural dependency that introduces several sub-barriers:
| Sub-barrier | Risk |
|---|---|
| Over-reliance | Podiatrist may communicate entirely through the carer, excluding the patient |
| Proxy bias | Carer may filter, interpret, or misrepresent the patient's symptoms/preferences |
| Confidentiality risk | Discussing clinical details in front of a carer the patient has not explicitly chosen as a decision-maker may breach HCPC Standard 5 (confidentiality) |
| Power imbalance | The carer may (consciously or not) override the patient's expressed preferences |
In relation to podiatry professionalism:
- The podiatrist must always address the patient directly first, regardless of communication difficulty — to uphold dignity and demonstrate respect
- The carer should be used as a communication facilitator, not a substitute for the therapeutic relationship
- If the podiatrist is uncertain whether the carer's account reflects the patient's wishes, they should seek independent verification (e.g., GP records, care plan)
- The relationship between carer and patient must be observed for any indicators of safeguarding concern — unexplained injury, anxiety in the carer's presence, or inconsistent history
5. Environmental Barrier — Home Setting
A home assessment introduces environmental challenges not present in a clinic:
- Poor lighting affecting lip-reading ability (critical for deaf patients)
- Lack of clinical equipment (examination chairs, good lighting) may restrict the quality of assessment
- No immediate access to interpreter services, clinical support, or emergency resources
- The patient is on familiar territory — they may feel more empowered to refuse, which is their right; equally, the home may be a source of comfort aiding cooperation
In relation to podiatry professionalism:
- The podiatrist has a professional duty to ensure the environment is safe for both patient and practitioner (HCPC Standard 13: promote and maintain safety)
- If environmental barriers mean a safe and adequate assessment cannot be conducted, the podiatrist must escalate or defer to a more appropriate setting — this is a professional, not a personal, decision
- Documenting environmental limitations is part of appropriate duty of care
6. Language and Health Literacy Barrier
Even setting aside deafness, the patient's learning disability suggests health literacy may be low. Health literacy refers to the ability to understand and act on health information. The UK-estimated rate of limited health literacy is approximately 43% of the working-age population, and this figure is considerably higher in those with learning disabilities.
In relation to podiatry professionalism:
- Using clinical terminology, lengthy explanations, or written consent forms without adaptation fails the patient professionally and legally
- Plain language, visual aids, and the "teach-back" method (asking the patient to demonstrate or repeat what they have understood) are professional communication strategies consistent with person-centred care
Summary Table
| Barrier | Type | Professional Standard Engaged |
|---|---|---|
| Deafness | Sensory | HCPC Standard 2 (communication); Equality Act 2010 |
| Learning disability | Cognitive | MCA 2005; HCPC dignity standards |
| Distress/withdrawal | Psychological | Consent; MCA Code of Practice; HCPC Standard 1 |
| Carer intermediary | Relational | HCPC Standard 5 (confidentiality); safeguarding |
| Home environment | Environmental | HCPC Standard 13 (safety); duty of care |
| Low health literacy | Informational | Person-centred care; HCPC communication standard |
Key References
- Weerapol N, Leelakanok N. Communication between healthcare professionals and patients with hearing loss: A systematic review and meta-analysis. Am J Health Syst Pharm. 2024. PMID: 38430534
- Abou-Abdallah M, Lamyman A. Exploring communication difficulties with deaf patients. Clin Med (Lond). 2021. PMID: 35192482
- Mental Capacity Act 2005. London: HMSO.
- Equality Act 2010. London: HMSO.
- HCPC (2016). Standards of Conduct, Performance and Ethics.
- College of Podiatry. Professional standards for podiatry.
In summary, the scenario presents at least six interlocking communication barriers — sensory, cognitive, psychological, relational, environmental, and literacy-based. Podiatric professionalism requires not just awareness of these barriers, but active, evidence-informed strategies to mitigate each one, with the patient's dignity, autonomy, and safety as the organising principle throughout. Crucially, when barriers cannot be overcome safely in the moment, the professional duty is to pause, document, and escalate — not to proceed regardless.
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Communication Barriers in Podiatry — Scenario 1 (with Harvard In-Text Citations)
1. Sensory Barrier — Deafness / Hearing Loss
The patient is deaf, which immediately removes verbal communication as a primary channel. Weerapol and Leelakanok (2024) conducted a systematic review and meta-analysis examining communication modes between healthcare professionals and patients with hearing loss, finding that gestures (pooled prevalence ~55%) and hearing aids (~57%) were the most commonly used alternatives, while few healthcare professionals could use sign language and access to qualified interpreters was consistently limited. This is particularly significant in an elderly population: Abou-Abdallah and Lamyman (2021) report that hearing loss affects more than 70% of people over 70 in the UK, yet deaf patients continue to experience persistent health inequalities, poorer disease prevention outcomes, and reduced care engagement — largely driven by cultural, educational, and organisational communication barriers.
In relation to podiatry professionalism, the Health and Care Professions Council (HCPC, 2016) requires registrants to communicate effectively and adapt their approach to meet each patient's needs. Under section 20 of the Equality Act (2010), the podiatrist is legally obliged to make reasonable adjustments for a disabled patient. Professionally, this means planning ahead — requesting a British Sign Language (BSL) interpreter, preparing written or visual materials, or using augmentative communication tools — not relying solely on a carer to relay information.
2. Cognitive/Intellectual Barrier — Learning Disability
The carer informs the podiatrist that the patient also has a learning disability, compounding the sensory barrier. People with learning disabilities may find it difficult to understand abstract clinical concepts, may have altered pain perception or expression, and frequently depend on carers for history-giving (Mencap, 2012). The patient's behaviour of pulling their foot away and becoming distressed may represent the primary available form of non-verbal communication rather than simple non-cooperation.
The Mental Capacity Act 2005 (Great Britain, 2005) requires that capacity is presumed unless there is evidence to the contrary, and that any assessment of capacity is decision-specific and time-specific. A podiatrist must not assume incapacity on the basis of a learning disability diagnosis alone. Where capacity is genuinely in doubt, the podiatrist should conduct a capacity assessment and, if the patient is found to lack capacity for a specific decision, must act in their best interests under section 4 of the Act — involving the carer as a consultee, but not substituting the carer's preferences for the patient's own wishes and feelings (Great Britain, 2005). The HCPC (2016) requires podiatrists to respect the dignity, individuality, and autonomy of every service user, meaning the patient must remain central to the interaction.
3. Emotional/Psychological Barrier — Patient Distress and Withdrawal
The patient's withdrawal and visible distress constitute both a communication barrier and a significant clinical signal. Distress in patients with learning disabilities during healthcare interactions is well documented and may reflect pain, fear, prior negative healthcare experiences, or an inability to verbalise discomfort (Heslop et al., 2013). In this scenario, the distress emerges during foot examination — a physically and psychologically vulnerable moment.
Professionalism demands that a podiatrist pauses the assessment when a patient withdraws. Even non-verbal withdrawal — pulling away, turning away, crying — constitutes a withdrawal of consent, and continuing regardless would contravene the principles of autonomy and non-maleficence central to healthcare ethics (Beauchamp and Childress, 2019). Under Standard 1 of the HCPC (2016), the registrant must promote and protect the interests of service users, which includes responding to distress signals by de-escalating, explaining, and allowing time before attempting to continue. The podiatrist should also document the distress and their response, as this forms part of their duty of care (HCPC, 2016, Standard 10).
4. Relational/Interpersonal Barrier — Carer-Mediated Communication
With the patient unable to communicate verbally, the carer becomes the primary source of history and context. This creates a structural dependency introducing several risks. The podiatrist may inadvertently communicate entirely through the carer, effectively excluding the patient from their own care episode — an act that undermines dignity and person-centred practice (Brooker, 2007). The carer may also, consciously or not, filter or misrepresent the patient's symptoms and preferences (a phenomenon sometimes termed proxy bias), or may hold views about risk and treatment that do not reflect the patient's own best interests.
Discussing confidential clinical information in the carer's presence without the patient's explicit consent also raises concerns under Standard 5 of the HCPC (2016), which requires registrants to respect and protect confidential information. Additionally, the presence of a carer during an assessment of an injury of uncertain cause requires the podiatrist to maintain safeguarding awareness: the Safeguarding Vulnerable Groups Act (Great Britain, 2006) and subsequent statutory guidance (Department of Health and Social Care, 2023) place an obligation on all regulated health professionals to be alert to signs of abuse or neglect in vulnerable adults. An unexplained or inconsistent injury history, or visible anxiety in the patient when the carer is present, should prompt referral to the appropriate safeguarding lead.
5. Environmental Barrier — Home Setting
Conducting an assessment in a home environment introduces barriers absent from a clinical setting. Poor or variable lighting reduces lip-reading ability — a key compensatory strategy for many deaf individuals (Abou-Abdallah and Lamyman, 2021). The absence of a height-adjustable examination chair and adequate illumination may limit physical assessment of the ankle and foot. There is no immediate access to clinical colleagues, interpreter services, or emergency support should the patient's condition deteriorate.
Under HCPC Standard 13 (HCPC, 2016), registrants must promote and maintain the health and safety of service users and others. Where environmental conditions make a safe, adequate assessment impossible, the professional duty is to escalate or defer to a more appropriate setting — not to proceed with a substandard assessment. Documenting the environmental limitations encountered is part of appropriate record-keeping and protects both the patient and the practitioner.
6. Health Literacy Barrier
Beyond the specific barriers above, the patient's learning disability is likely to be accompanied by limited health literacy — the capacity to understand and act on health information. Approximately 43% of working-age adults in England have limited health literacy (NHS England, 2022), and this figure is significantly higher among people with learning disabilities. Clinical terminology, lengthy verbal explanations, and standard written consent forms are unlikely to be meaningful to this patient.
Podiatric professionalism requires the practitioner to adapt their communication style: plain language, visual demonstrations, and the teach-back method — asking the patient to indicate in some way what they have understood — are consistent with person-centred, inclusive practice (Nursing and Midwifery Council, 2018, which, while written for nurses, reflects shared Allied Health Professional values also articulated in the College of Podiatry's professional standards).
Reference List
Abou-Abdallah, M. and Lamyman, A. (2021) 'Exploring communication difficulties with deaf patients', Clinical Medicine, 21(4), pp. e339–e342. https://doi.org/10.7861/clinmed.2021-0111
Beauchamp, T.L. and Childress, J.F. (2019) Principles of biomedical ethics. 8th edn. Oxford: Oxford University Press.
Brooker, D. (2007) Person-centred dementia care: Making services better. London: Jessica Kingsley Publishers.
College of Podiatry (2021) Professional standards for podiatry. London: College of Podiatry. Available at: https://cop.org.uk/professional-development/professional-standards (Accessed: 27 April 2026).
Department of Health and Social Care (2023) Care and support statutory guidance. London: HMSO. Available at: https://www.gov.uk/government/publications/care-act-statutory-guidance (Accessed: 27 April 2026).
Equality Act 2010 (c. 15). London: HMSO. Available at: https://www.legislation.gov.uk/ukpga/2010/15/contents (Accessed: 27 April 2026).
Great Britain (2005) Mental Capacity Act 2005. London: HMSO. Available at: https://www.legislation.gov.uk/ukpga/2005/9/contents (Accessed: 27 April 2026).
Great Britain (2006) Safeguarding Vulnerable Groups Act 2006. London: HMSO. Available at: https://www.legislation.gov.uk/ukpga/2006/47/contents (Accessed: 27 April 2026).
Health and Care Professions Council (2016) Standards of conduct, performance and ethics. London: HCPC. Available at: https://www.hcpc-uk.org/standards/standards-of-conduct-performance-and-ethics/ (Accessed: 27 April 2026).
Heslop, P., Blair, P., Fleming, P., Hoghton, M., Marriott, A. and Russ, L. (2013) Confidential inquiry into premature deaths of people with learning disabilities (CIPOLD). Bristol: Norah Fry Research Centre.
Mencap (2012) Death by indifference: 74 deaths and counting. London: Mencap. Available at: https://www.mencap.org.uk/sites/default/files/2016-08/Death%20by%20Indifference%20-%2074%20deaths%20and%20counting.pdf (Accessed: 27 April 2026).
NHS England (2022) Health literacy: Applying All Our Health. Available at: https://www.gov.uk/government/publications/health-literacy-applying-all-our-health (Accessed: 27 April 2026).
Nursing and Midwifery Council (2018) The code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. London: NMC. Available at: https://www.nmc.org.uk/standards/code/ (Accessed: 27 April 2026).
Weerapol, N. and Leelakanok, N. (2024) 'Communication between healthcare professionals and patients with hearing loss: A systematic review and meta-analysis', American Journal of Health-System Pharmacy, 81(12), pp. e321–e333. https://doi.org/10.1093/ajhp/zxae045
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