Conversation breakdowns in the audiology clinic: the importance of mutual gaze.

BACKGROUND: Conversational breakdowns are a persistent concern for older adults with hearing impairment (HI). Previous studies in experimental settings have investigated potential causes of breakdowns in conversations with a person with HI, and effective strategies for repairing these breakdowns. However, little research has explored the causes of hearing-related communication breakdowns, and their repairs, in extended, naturally occurring conversations in a healthcare setting. AIMS: To analyse systematically instances of clients' initiations of repair within video-recorded initial audiology appointments, and to examine the interactional environment in which they occurred. METHODS & PROCEDURES: Participants included 26 audiologists and their older adult clients (aged 55+ years). Companions were present in 17 of the 63 appointments. Conversation analysis (CA) was used to examine the video-recorded audiology appointments with older adults with HI. The corpus was systematically analysed for all instances of 'other-initiated repair' by clients (initiation of repair targeting the prior speakers' turn). A collection of 51 instances of other-initiated repair were identified. These instances were analysed in detail for: (1) the interactional environment in which they occurred; (2) the strategy by which the client initiated repair; and (3) the strategies used by the audiologist to repair the communication breakdown. OUTCOMES & RESULTS: In 76% (n = 39) of the 51 cases of other-initiated repair from the client, there was a lack of mutual gaze between participants (i.e., either the audiologist or the client were looking away or facing in another direction during the prior turn). More specifically, many of these instances occurred when the audiologist was speaking to the client while multitasking. Audiologists used multiple-repair strategies in their responsive turn in an attempt to repair the communication breakdown efficiently. CONCLUSIONS & IMPLICATIONS: These findings, from extended, naturally occurring conversations with older adults with HI in clinic settings, highlight the importance of face-to-face communication even in quiet one-to-one settings. Clinicians should remain aware of their movements and gaze when speaking to clients during appointments. The findings also provide further support for the importance of communication programs in hearing rehabilitation.

What Is the International Classification of Functioning, Disability and Health and Why Is It Relevant to Audiology?

The World Health Organization's International Classification of Functioning, Disability and Health (ICF) is widely used in disability and health sectors as a framework to describe the far-reaching effects of a range of health conditions on individuals. This biopsychosocial framework can be used to describe the experience of an individual in the components of body functions, body structures, and activities and participation, and it considers the influence of contextual factors (environmental and personal) on these components. Application of the ICF in audiology allows the use of a common language between health care professionals in both clinical and research settings. Furthermore, the ICF is promoted as a means of facilitating patient-centered care. In this article, the relevance and application of the ICF to audiology is described, along with clinical examples of its application in the assessment and management of children and adults with hearing loss. Importantly, the skills necessary for clinicians to apply the ICF effectively are discussed.

The International Classification of Functioning, Disability and Health as a Framework for Providing Patient- and Family-Centered Audiological Care for Older Adults and Their Significant Others.

Hearing impairment is highly prevalent in the older population, and it impacts communication and quality of life for both the people with the hearing difficulties and their significant others. In this article, typical audiological assessment and management of an older adult is contrasted with a best practice approach wherein the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework is applied. The aim of the comparison is to demonstrate how the ICF expands our focus: rather than merely focusing on impairment, we also consider the activities, participation, and contextual factors for both the person with the hearing impairment and his or her family. A case example of an older patient and her spouse is provided, and their shared experience of the patient's hearing impairment is mapped onto the ICF framework. Family-centered hearing care is recommended for individualizing care and improving outcomes for older patients and their families.

Application of the transtheoretical model of behaviour change for identifying older clients' readiness for hearing rehabilitation during history-taking in audiology appointments.

OBJECTIVES: The transtheoretical model (TTM) of behaviour change focuses on clients' readiness for adopting new health behaviours. This study explores how clients' readiness for change can be identified through their interactions with audiologists during history-taking in initial appointments; and whether clients' readiness has consequences for the rehabilitation decisions they make within the initial appointment. DESIGN: Conversation analysis (CA) was used to examine video-recorded initial audiology appointments with older adults with hearing impairment. STUDY SAMPLE: The data corpus involved 62 recorded appointments with 26 audiologists and their older adult clients (aged 55+ years). Companions were present in 17 appointments. RESULTS: Clients' readiness for change could be observed through their interaction with the audiologist. Analysis demonstrated that the way clients described their hearing in the history-taking phase had systematic consequences for how they responded to rehabilitation recommendations (in particular, hearing aids) in the management phase of the appointment. In particular, clients identified as being in a pre-contemplation stage-of-change were more likely to display resistance to a recommendation of hearing aids (80% declined). CONCLUSIONS: The transtheoretical model of behaviour change can be useful for helping audiologists individualize management planning to be congruent with individual clients' needs, attitudes, desires, and psychological readiness for action in order to optimize clients' hearing outcomes.

The nature of communication throughout diagnosis and management planning in initial audiologic rehabilitation consultations.

BACKGROUND: Effective practitioner-patient communication throughout diagnosis and management planning positively influences patient outcomes. A patient-centered approach whereby patient involvement in decision making is facilitated, a therapeutic relationship is developed, and information is bilaterally exchanged in an appropriate manner, leads to improved patient satisfaction, adherence to treatment, and self-management. Despite this knowledge, little is known about the nature of audiologist-patient communication throughout diagnosis and management planning. PURPOSE: This research aimed to explore verbal communication between audiologists and patients/companions throughout diagnosis and management planning in initial audiology consultations. Specifically, this study aimed to describe the nature and dynamics of communication by examining the number, proportion, and type of verbal utterances by all speakers (audiologist, patient, and companion when present). In addition, this study aimed to investigate the influence of audiologist, patient, and consultation factors, such as verbal dominance, content balance, and communication control, on the dynamics of communication. STUDY SAMPLE: A total of 62 initial audiological rehabilitation consultations (involving 26 different audiologists) were filmed and analyzed using the Roter Interaction Analysis System. All patients were older than 55 yr, and a companion was present in 17 consultations. DATA COLLECTION AND ANALYSIS: This study focused solely on the communication relating to diagnosis and management planning (referred to as the "counseling phase"). Diagnosis, recommendations, rehabilitation options, and patient decisions were recorded along with the communication profiles and communication dynamics measured using the Roter Interaction Analysis System. Associations between communication dynamics (content balance, communication control, and verbal dominance) and eight variables were evaluated with Linear Mixed Model methods. RESULTS: The mean length of time for diagnosis and management planning was 29.0 min (range, 2.2-78.5 min). Communication profiles revealed that patient-centered communication was infrequently observed. First, opportunities to build a relationship were missed, such that patients' psychosocial concerns were rarely addressed and patients/companions showed little involvement in management planning. Second, the amount of talk was asymmetrical and the majority of audiologists' education and counseling utterances related to hearing aids; yet, only 56% of patients decided to obtain hearing aids at the conclusion of the consultation. Hearing aids were recommended in 83% of consultations where a hearing loss was diagnosed and alternative options were rarely provided. Thus, shared decision making rarely occurred, and audiologists often diagnosed a hearing loss and recommended hearing aids without patient involvement. In addition, when a greater proportion of time was dedicated to diagnosis and management planning, patients had greater input and control by asking more questions and requesting further information. CONCLUSIONS: Patient-centered communication was rarely observed in the 62 consultations. Thus, although not measured in this study, patient outcomes are likely to be affected. Future research should examine the influence of audiologist communication on outcomes and encourage a shift toward patient-centered audiological rehabilitation.

Communication patterns in audiologic rehabilitation history-taking: audiologists, patients, and their companions.

OBJECTIVES: The nature of communication between patient and practitioner influences patient outcomes. Specifically, the history-taking phase of a consultation plays a role in the development of a relationship and in the success of subsequent shared decision making. There is limited research investigating patient-centered communication in audiology, and this study may be the first to investigate verbal communication in an adult audiologic rehabilitation context. This research aimed, first, to describe the nature of verbal communication involving audiologists, patients, and companions in the history-taking phase of initial audiology consultations and, second, to determine factors associated with communication dynamics. DESIGN: Sixty-three initial audiology consultations involving patients over the age of 55, their companions when present, and audiologists were audio-video recorded. Consultations were coded using the Roter Interaction Analysis System and divided into three consultation phases: history, examination, and counseling. This study analyzed only the history-taking phase in terms of opening structure, communication profiles of each speaker, and communication dynamics. Associations between communication dynamics (verbal dominance, content balance, and communication control) and 11 variables were evaluated using Linear Mixed Model methods. RESULTS: The mean length of the history-taking phase was 8.8 min (range 1.7 to 22.6). A companion was present in 27% of consultations. Results were grouped into three areas of communication: opening structure, information exchange, and relationship building. Examination of the history opening structure revealed audiologists' tendency to control the agenda by initiating consultations with a closed-ended question 62% of the time, followed by interruption of patient talk after 21.3 sec, on average. The aforementioned behaviors were associated with increased verbal dominance throughout the history and increased control over the content of questions. For the remainder of the history, audiologists asked 97% of the questions and did so primarily in closed-ended form. This resulted in the audiologist talking as much as the patient and much more than the companions when they were present. Questions asked by the audiologist were balanced in topic: biomedical and psychosocial/lifestyle; however, few emotionally focused utterances were observed from any speaker (less than 5% of utter ances). CONCLUSIONS: Analysis of verbal communication involving audiologists, patients, and companions in the history-taking phase in 63 initial audiology consultations revealed a communicative exchange that was audiologist-controlled and structured, but covered both medical and lifestyle content. Audiologists often attempted to create a relationship with their patients; however, little emotional relationship building occurred, which may have implications later in the consultation when management decisions are being made. These results are not in line with patient-centered communication principles. Further research and changes to clinical practice are warranted to transform patient-centered communication from an ideal to a reality.

Family member involvement in audiology appointments with older people with hearing impairment.

OBJECTIVE: This study aimed to investigate family members' involvement in audiology rehabilitation appointments. DESIGN: Audiology appointments were video-recorded and analysed using quantitative coding and conversation analysis (CA). STUDY SAMPLE: The study sample included 13 audiologists, 17 older adults with hearing impairment, and 17 family members. RESULTS: Initial coding showed that family members participated in 12% of the total talk time during audiology appointments. The CA results demonstrated that family members were not typically invited to join the conversation. However, family members would self-select to speak by: (1) responding to questions from the audiologist which were directed at the client; (2) self-initiating expansions on clients' turns; and (3) self-initiating questions. When family members did participate in the interaction, audiologists typically responded by shifting the conversation back to the client. CONCLUSION: While family members currently have minimal participation in audiology appointments, they display a strong interest in being involved and sharing their experiences of the client's hearing impairment. The findings suggest support for implementing family-centred care principles in audiology practice.

Addressing patients' psychosocial concerns regarding hearing aids within audiology appointments for older adults.

PURPOSE: It has long been documented that patients may experience emotional reactions to a diagnosis of hearing impairment and recommendation of hearing aids. Because of this, patients may raise psychosocial concerns regarding their hearing rehabilitation during audiology appointments, particularly in relation to getting hearing aids. However, thus far there has been little systematic research exploring how patients' concerns about hearing aids are addressed by audiologists within appointments. METHOD: This study used conversation analysis to examine a corpus of 63 video-recorded initial audiology appointments with older adults with hearing impairment. RESULTS: The findings demonstrated that when patients expressed concerns regarding hearing aids, these concerns were typically psychosocial in nature and expressed in a way that carried a negative emotional stance. These types of turns thus invited an empathic response. However, patients' concerns were not typically addressed by audiologists during the appointment. As a consequence, patients persistently re-raised their concerns in subsequent turns, leading to expanded sequences of interaction during the management phase of the appointment. CONCLUSIONS: Older adults' psychosocial concerns regarding hearing aids may not always be sufficiently addressed within audiology appointments. A greater emphasis on emotionally focused communication within audiology could result in improved outcomes from hearing health care services.

Patient-centred audiological rehabilitation: perspectives of older adults who own hearing aids.

OBJECTIVE: Patient-centred care is a term frequently associated with quality health care. Despite extensive literature from a range of health-care professions that provide description and measurement of patient-centred care, a definition of patient-centredness in audiological rehabilitation is lacking. The current study aimed to define patient-centred care specific to audiological rehabilitation from the perspective of older adults who have owned hearing aids for at least one year. DESIGN: Research interviews were conducted with a purposive sample of older adults concerning their perceptions of patient-centredness in audiological rehabilitation, and qualitative content analysis was undertaken. STUDY SAMPLE: The participant sample included ten adults over the age of 60 years who had owned hearing aids for at least one year. RESULTS: Data analysis revealed three dimensions to patient-centred audiological rehabilitation: the therapeutic relationship, the players (audiologist and patient), and clinical processes. Individualised care was seen as an overarching theme linking each of these dimensions. CONCLUSIONS: This study reported two models: the first model describes what older adults with hearing aids believe constitutes patient-centred audiological rehabilitation. The second provides a guide to operationalised patient-centred care. Further research is required to address questions pertaining to the presence, nature, and impact of patient-centred audiological rehabilitation.

An Australian survey of audiologists' preferences for patient-centredness.

OBJECTIVE: Patient-centredness is becoming a core value of health services worldwide, however it remains largely unexplored in audiology. This study investigated audiologists' preferences for patient-centredness and identified factors that explain audiologists' preferences for patient-centredness. DESIGN: All members of the Audiological Society of Australia received two questionnaires: (1) a descriptive questionnaire (e.g. age, gender, place of residence, years in practice, employment characteristics), and (2) a modified patient-practitioner orientation scale (PPOS; Krupat et al, 2000) which measures preferences for two aspects of patient-centredness, sharing and caring. STUDY SAMPLE: In total 663 (46%) audiologists returned both questionnaires fully completed. RESULTS: Mean PPOS scores indicated that audiologists prefer patient-centredness. Linear regression modelling identified that older audiologists, that had practiced longer, and who worked in community education, industrial audiology, or teaching had a significantly greater preference for patient-centredness than their peers. In contrast, audiologists who practiced in a private environment and who worked in the area of assessment of adults had a significantly lesser preference for patient-centredness than their peers. CONCLUSIONS: Audiologists prefer client-centredness and age, years of experience, and employment characteristics can partly explain preferences for patient-centredness. Future research should explore the relationships between patient-centredness and intervention outcomes in audiology.

Patient-centred care: a review for rehabilitative audiologists.

OBJECTIVE: This discussion paper aims to synthesise the literature on patient-centred care from a range of health professions and to relate this to the field of rehabilitative audiology. Through review of the literature, this paper addresses five questions: What is patient-centred care? How is patient-centred care measured? What are the outcomes of patient-centred care? What are the factors contributing to patient-centred care? What are the implications for audiological rehabilitation? DESIGN: Literature review and synthesis. STUDY SAMPLE: Publications were identified by structured searches in PubMed, Cinahl, Web of Knowledge, and PsychInfo, and by inspecting the reference lists of relevant articles. RESULTS: Few publications from within the audiology profession address this topic and consequently a review and synthesis of literature from other areas of health were used to answer the proposed questions. CONCLUSION: This paper concludes that patient-centred care is in line with the aims and scope of practice for audiological rehabilitation. However, there is emerging evidence that we still need to inform the conceptualisation of patient-centred audiological rehabilitation. A definition of patient-centred audiological rehabilitation is needed to facilitate studies into the nature and outcomes of it in audiological rehabilitation practice.