Patient-practitioner interactions: older adults and their audiologists

© 2014 Dr. Caitlin Mae GrennessHearing impairment increases in prevalence with ageing. If left untreated, hearing impairment can be a barrier to successful ageing and can cause a variety of negative consequences. Recent investigations of factors associated with hearing aid uptake and use by older adults revealed a paucity of research examining the value and influence of patient-audiologist interactions. Within the health professions, there is a growing interest in patient-practitioner interactions and in particular the quality of professional exchanges termed “patient-centred”. Philosophical and clinical definitions of the term are reported throughout literature where decades of research illustrate relationships between patient-centred care and improved patient outcomes. Before such relationships can be examined in audiological rehabilitation for older adults, the term needed first be defined and the existence of patient-centred interactions explored. This research utilised a mixed-methods design to triangulate patient-centred care in audiological rehabilitation as defined by older adults with hearing impairment with observed patient/companion-audiologist communication in audiology consultations. A sequential exploratory design was used across two studies. Firstly, a qualitative descriptive study was conducted with a purposively sampled group of older adults who owned hearing aids. This study explored participants’ experiences with audiologists and their definition of patient-centred audiological rehabilitation. The findings of this study are represented visually in two models. The first model describes the people, behaviours and processes required to provide patient-centred audiological rehabilitation: a therapeutic relationship was seen as central to patient-centred audiology interactions; the audiologist and patient were seen as key players; and the way two processes occurred (information exchange and decision-making) was considered instrumental in whether audiological rehabilitation was patient-centred. The second model provided an operationalised description of how patient-centred care can be clinically implemented. In this model, there were four dimensions: 1) therapeutic relationship, 2) informed patients, 3) involved patients and 4) individualised care. Results from Study 1 provided a rationale and focus for the examination of patient-audiologist communication in initial consultations and thus informed the second study. In Study 2, 63 initial consultations between audiologists and older adults (and companions in 17 cases) were filmed and analysed using the Roter Interaction Analysis System (RIAS). This method was used to examine the presence and nature of patient-centred communication. Analyses were conducted in two phases: Study 2a focussed on the history-taking phase of initial consultations and Study 2b focussed on the counselling phase. Taken together, the results revealed a dearth of patient-centred communication in initial consultations. That is, little communication was invested in developing a therapeutic relationship; patients were primarily informed only about hearing aids and audiologists asked closed-ended, biomedical questions thus limiting information received about patients’ needs. Little patient and companion involvement was observed. Audiologists rarely sought input from those accompanying the client and, in the presence of a companion, asked fewer psychosocial and lifestyle questions and offered less psychosocial and lifestyle education than when a companion was not present. Limited individualisation of information and options was observed. At the conclusion of this thesis, the results of Study 2 were juxtaposed with the results of Study 1. The overall findings present an imperative to value and promote the quality of patient-audiologist interactions, beyond technical skills, in the provision of “patient-centred” audiological rehabilitation for older adults and in the education of students of audiology

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.</p

Information Leakage Analysis by Abstract Interpretation

Protecting the confidentiality of information stored in a computer system or transmitted over a public network is a relevant problem in computer security. The approach of information flow analysis involves performing a static analysis of the program with the aim of proving that there will not be leaks of sensitive information. In this paper we propose a new domain that combines variable dependency analysis, based on propositional formulas, and variables’ value analysis, based on polyhedra. The resulting analysis is strictly more accurate than the state of the art abstract interpretation based analyses for information leakage detection. Its modular construction allows to deal with the tradeoff between efficiency and accuracy by tuning the granularity of the abstraction and the complexity of the abstract operators

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

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

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

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

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