International Journal of Audiology 2014; 53: 115–120
Original Article
Measuring the effectiveness of an audiological counseling program Kris English* & Sue Archbold† *School of Speech Pathology and Audiology, The University of Akron, Ohio, USA, and †The Ear Foundation, Nottingham, UK
Abstract Objective: Audiologists routinely observe patients struggle with psycho-emotional difficulties associated with hearing loss, yet are often underprepared to manage this vital aspect of patient care. For this reason, a workshop was developed for audiologists interested in expanding their counselling skills. Since one-time workshops typically do not result in changes in practice, this program adopted a distributed-over-time learning model, consisting of 20 hours of participation across six weeks. The extended nature of the program provided multiple opportunities to learn several counselling strategies, and apply and evaluate the effectiveness of these strategies in clinical settings. Design: Learning objectives were assessed throughout the six-week program. However, at the conclusion of each program, it was unknown whether new knowledge carried over into sustained new skills. Therefore, we surveyed attendees six months after their program, to determine if the program had affected changes in their practice. Study sample: Twenty clinicians (response rate ⫽ 91%) participated in the survey. Results: All respondents made some, and often many, changes in patient communication. They applied several counseling concepts to their work settings and reported positive changes in patient-clinician dynamics. Conclusion: Results suggest that a six-week program is effective in helping clinicians change their counseling skills within their practice.
Key Words: Counseling; assessment; patient-centered communication
Audiologists have long observed the range of psychological and emotional difficulties associated with living with hearing loss. Parents often find it difficult to understand and remember the details of their child’s diagnosis (Watermeyer et al, 2012) and may feel too overwhelmed to take action (Luterman, 2008; Young & Tattersall, 2007). As they grow, children with hearing loss often lack support in developing emotional self-awareness and important social skills (Cappelli et al, 1995; Oliva, 2004), and during their teen years, they are inclined to forsake amplification to fit in with peers (Elkayam & English, 2003; Kent & Smith, 2006). Additionally, adults who acquire hearing loss often wait for years before addressing their communication problems (Action on Hearing Loss, 2011; Kochkin, 2012) and even after they make an initial appointment with their General Practitioner, 45% are not referred for hearing test (Action on Hearing Loss, 2011). Even after an assessment, they may reject hearing help. For instance, a recent study of over 700 adults in the USA (age 70⫹) reported that nearly two thirds of its subjects had a treatable hearing loss, but only 40% reported hearing-aid use (Lin et al. 2011). Those who do pursue hearing help often get discouraged, resulting in one out of six hearing aids ending up in a drawer (Kochkin, 2007). Whether because of stigma, lack of support, or other reasons, many of our patients can be described as ‘stuck’ in the helping-seeking process (Clark & English, 2014). A limited background in the area of counselling may lead audiologists to assume that, as recognized experts in their field, our
recommendations should be followed; if patients opt out, their decision is an expression of their autonomy, over which we have no influence. However, while the value of informed patient choice is increasingly recognized in all areas of medical related fields (Calman, 2004), these choices are not made in a vacuum. Contemporary interpretations of patient autonomy stress the ‘relational interdependence’ between health- care providers and their patients (Entwistle et al, 2010; Tresolini, 2000), which relies on effective patient communication and the ability to establish therapeutic patient relationships. An indication of the growing emphasis placed on relationship-building can be found in a change made to a popular textbook used in medical schools in the United States. Cole’s (2000) update of The Medical Interview: The Three Function Approach now begins with the new function to ‘build the relationship,’ preceding the original two functions to ‘assess the patient’s problem’ and ‘manage the patient’s problem.’ Relationship-building can seem an unaffordable luxury in these times of financial challenges worldwide, with increasing demands made on health-care services, and increasing demands for costeffectiveness and efficiency. As evidence-based professionals, audiologists would want to know if counseling actually makes a difference, and if so, what kind of difference? Although counseling is often not a significant part of audiology training, abundant research has been published on the topic in the field of medicine. Recently, Zolnierek and DiMatteo (2009) sought
Correspondence: Kris English, The University of Akron, School of Speech Pathology and Audiology, 181 Polsky, Akron, OH 44325-3001, USA. E-mail: [email protected] (Received 27 April 2013; accepted 15 August 2013) ISSN 1499-2027 print/ISSN 1708-8186 online © 2014 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.3109/14992027.2013.837224
116
K. English & S. Archbold
to answer the question, ‘What is the relationship between physicians’ communication skills and their patients’ decision to follow their recommendations?’ (that is, patient adherence rates). The result of their meta-analysis indicated a strongly positive and significant relationship (p ⬍.001) between these two variables. Specifically, when physicians used patient-centered communication, their patients were far more likely to follow their physicians’ recommendations. Patient-centered communication includes the ability to: • • • •
Elicit and validate patients’ concerns Inquire about and legitimize patients’ ideas and expectations Assess the impact of symptoms on functioning Respond to indications of emotional distress by using empathic language
The authors concluded that effective counseling is a teachable/ learnable skill, and that health-care providers improve adherence rates by earning their patients’ trust with careful listening and patient-centered communication. In other words, counseling skills matter. To support audiologists as counsellors, one-time workshops are occasionally offered, typically for half-day or full-day sessions. However, because the explicit or implicit goal of such workshops is to affect a change in practice, it seems reasonable to ask, ‘Do one-time workshops result in measurable change? Do attendees not only learn some basic counselling skills and remember them later, but also apply them in their clinical setting, thereby demonstrating a new level of counselling competence?’ According to available research on workshop effectiveness, it appears that when professionals attend traditional one-time workshops, they typically acquire some new information, but the new knowledge does not translate into changes in practice (Davis, 1998). A recent meta-analysis concluded that ‘educational meetings alone are not likely to be effective in changing complex behaviours’ (Forsetlund et al, 2009, p. 2). However, less traditional workshop designs do seem to be effective in changing practitioner behaviours, for instance when they include practice opportunities (Davis et al, 1999) and additional post-workshop coaching (Carrick, 2010). Since the goal of a counselling workshop is to change a clinician’s practices (for the purpose of improving patient outcomes), it seems logical to design a program capable of supporting that change. Such a program should include multiple venues for active learning, opportunities to reflect upon current practices, study the evidence supporting different practices, interact and learn with peers and instructors, and receive coaching and feedback (Penuel et al, 2007). To this end, a workshop was designed with the express purpose of supporting professional change. The workshop is offered by the Ear Foundation in Nottingham, UK, and is entitled ‘Introduction to Audiologic Counselling.’ The Ear Foundation program has adopted a distributed-over-time learning model consisting of three parts: 1. An introductory in-house five-hour workshop, to provide information on audiologic counselling using lecture, videos, and large/small group discussion. 2. Six weeks of independent study, consisting of guided reading (textbook and articles), writing (case studies and other assignments), video conferencing, and email discussions with the course instructor. 3. A concluding five-hour in-house workshop, focusing on the application of key concepts (e.g. professional boundaries, relationship-centred care, coping strategies, effective/ineffective
responses to patient comments) using guided discussion techniques (Brookfield & Preskill, 2005). This model results in approximately 20 hours of engagement over six weeks. The extended nature of the program affords an opportunity not only to learn and understand a set of basic counselling strategies, but also to discuss, apply, and evaluate the effectiveness of these strategies. Learning objectives were ambitious but considered achievable when given sufficient time. Interested readers can access an Appendix listing these learning objectives at http:// informahealthcare.com/doi/abs/10.3109/14992027.2013.837224. Ongoing assessment of learning outcomes was conducted throughout the six-week program, and immediate post-program evaluations indicated attendees found the workshop well-organized and relevant, and gave an average score of 99% for course content. However, at the conclusion of each workshop, we did not yet know if new knowledge and short-term experiences translated into new skills and sustainable changes in practice. To find out, in our closing remarks, we informed attendees that we would request their input with a follow-up questionnaire designed to collect information about changes to their practice as a result of workshop participation.
Methods Data were collected from two cohorts who attended programs conducted at the Ear Foundation in the Spring of 2011 (Cohort 1) and 2012 (Cohort 2).
Participants Cohort 1 consisted of nine audiologists and one speech-language pathologist (two male, eight female). Cohort 2 consisted of 15 audiologists (two male, 13 female). All delegates practiced in the UK, either within the National Health Services or in private practice. Participants were recruited via email invitation, sent to the entire roster in one mailing.
Instrument A questionnaire was developed to collect post-program input from the delegates. The questionnaire consisted of these four queries: 1. We are wondering if you changed your practices after completing the counseling course. Could you let us know by reporting a number on a 1–5 scale (1 ⫽ not at all; 2 ⫽ made a few changes; 3 ⫽ made several changes; 4 ⫽ made many changes; 5 ⫽ changed almost everything)? 2. If you made any changes of any kind, please describe. 3. If not, could you explain? Was there anything that we could have done to help? 4. Do you foresee making changes as time goes on? What would help?
Procedures We emailed our questionnaire to all delegates, following up with a reminder note one week later. Respondents replied only to the authors, keeping their input private but not anonymous. However, upon receipt, input was disassociated from sender, first by assigning a number to each sender on a separate list, and then printing out input minus any identifying information. The list of senders was used only for tracking purposes.
Counseling Program
117
Analysis included obtaining the median response and frequency distribution to the responses to Question #1. The narrative data of the remaining three open-ended questions were analysed using a rudimentary version of grounded theory technique (i.e. employing one round of data collection) (Morse, 2009). Knudsen and colleagues (2012) report that grounded theory is commonly found in audiology, and provide a succinct definition of the process: ‘Coding, constant data categorization, and comparison, interpretation, and theorization are used to develop new theory from data without presupposed hypotheses’ (p. 85). The semi-structured questionnaire format provided participants the opportunity to describe their experiences in their own words; we then coded the semantic content of the textbased responses to identify discrete data points and then reviewed for emerging categories and themes relative to our question, ‘Can an audiological counseling program change practice?’
These sub themes are summarized in Table 2 and detailed in Table 3. Eighteen respondents reported providing patients more opportunities to communicate. Four audiologists described ensuring that patients ‘are talking more throughout the appointment than myself.’ Another audiologist made it a priority to ‘ask families what their concerns and priorities are.’ Eight audiologists reported more comfort with silence and waiting, and observing when patients seemed to have something to say but needed time to sort out their thoughts. Additional input included:
Results
Engaging in family-centered discussions led six audiologists to develop stronger partnerships with parents, helping them realize and accept a more active role in their child’s development. This process was described as ‘almost like getting a contract’ about ‘what I was going to do and what I need them to do in return and get their buy in. … Hearing aids need to be worn every day; can you do this?’ Patients and parents may appreciate direct conversation about the challenges that lie ahead, rather than perceiving these challenges as taboo topics. Respondents indicated several positive patient outcomes from increased and more open discussion, for example:
We received responses from all 10 members of the first cohort, and 10 members from the second cohort (66%). Among the five nonrespondents in the second cohort, three persons were not in a clinical setting at the time, and two did not reply to the survey but did extend regrets about not responding due to time constraints. Excluding the three participants not involved in clinical services, our response rate (N ⫽ 20) from 22 active clinicians was 91%. Following is a summary of participant responses.
All respondents (N ⫽ 20) indicated some degree of change (see Table 1). All respondents from the 2011 workshop (N ⫽ 10) indicated ‘yes’ by reporting scores from 2–5 (median ⫽ 3, made several changes). Similarly, all respondents from the 2012 workshop (N ⫽ 10) indicated ‘yes’ by reporting scores from 3–4 (median ⫽ 3, made several changes).
2. If changes were made, please describe. All responses to this question reflected one overarching or major theme: a change in audiologist-patient dynamics. This theme emerged from 55 comments, categorized into five sub themes. These sub themes were:
• • • •
Providing patients/parents more opportunities to ask questions, and express concerns and priorities Changes in self Sharing control with patients regarding the direction and outcomes of the appointment Changes in student training Changes in patient education
Table 1. Median and range of responses (1–5 scale: 1 ⫽ not at all, 5 ⫽ changed almost everything) to Question #1: Rate amount of change in practices after completing counseling course (reported by year attended).
2011 2012
•
•
1. Have you changed your practices after completing the course?
•
•
Median
Range
3 3
2–5 2–4
•
‘Asking the parent what they would like to know after disclosing the diagnosis. Holding back and not filling the parents’ silences.’ ‘I am less ready to jump in and answer without ensuring I understand the question fully.’
‘I have had two major points of progress with families where we have had little progress over a year or more, which is very uplifting.’ ‘I’ve noticed a definite positive change in the way my patients respond since making these changes. A few of them have told me they were really dreading the appointment and their hearing test and have been pleasantly surprised …they were relieved at having someone to talk to about their difficulties and they even quite enjoyed it!’
Eighteen respondents also described several changes in self, reporting that they now ‘listen differently,’ ‘listen to the unspoken,’ and attend more to patients’ emotional states and their grief. Many found themselves more comfortable with boundaries and waiting. • • •
‘When a patient now says to me that they are getting old, I no longer patronize them. I try to acknowledge their feelings of getting old.’ ‘I actively reflect on the sessions more.’ ‘Giving ‘bad news’ is never going to be an easy task but I now feel I have a catalogue of ways to bring about understanding and the journey of acceptance.’
Eleven respondents described their efforts to share control with patients. One respondent wrote: ‘Rather than trying to pull the patient through the pathway toward a hearing-aid fitting, I’m allowing the patient to dictate the pace of the pathway a little more. This allows time to explore any issues that might crop up along the way.’ Another audiologist reported, ‘I have also started to allow the patient to come to conclusions through talking’, rather than dictating next steps. Patients were described as being ‘clearly relieved’ to have someone to talk to, and the lessening of tension seemed to help them consider, rather than reject, recommendations for amplification. Additional input included:
118
K. English & S. Archbold Table 2. One main theme and five sub-themes describing changes in clinical practice per survey responses. Main theme: Changes in audiologist-patient dynamics Sub-themes
• • • •
Increased opportunity for patient to communicate
Changes in self
‘Letting the patients taking [sic] more of a lead during the appointments.’ ‘I am putting more emphasis on addressing any issues important to them [patients] as well as doing the routine tuning checks and hearing tests.’ ‘I have also started to allow the patient to come to conclusions through talking.’ ‘Trying not to be a hearing-aid cop!’
A lesser sub theme included changes in student teaching. Five respondents described using the counseling content to create a new course, or adding a new emphasis in existing courses and presentations. While we cannot know whether changes in student training will directly impact future audiologist-patient dynamics, respondents reported that students expressed the opinion that a counseling course should be a core requirement rather than optional. Feedback indicated the students were already well aware of the impact of a supportive audiologist-patient relationship. Finally, three participants described changes in patient education. They reported considering patient readiness for new information; recognizing and avoiding the problem with information overload; and not relying on content/education when situations become difficult. Respondents recognized that instead of connecting with patients, they created distance by providing more information than the patient desired, or avoiding emotional situations with technical discussions.
3. If changes were not made, could you explain? Was there anything that we could have done to help? Since all respondents reported some degree of change, most respondents did not answer this question. However, one respondent expressed a general concern for time constraints within the healthcare system, and several suggestions were made for future workshops. One respondent recommended disseminating the course content to a wider audience (e.g. Higher Training Scheme), and, to
Sharing control
Changes in student training
Changes in patient education
help sustain professional development, one respondent suggested pairing up classmates to conduct peer reviews. Six respondents requested more online communication among attendees, and two respondents recommended more discussion and post-workshop partnerships with attendees who work with similar populations, especially children, teens, and patients with unilateral or mildmoderate hearing loss.
4. Do you foresee making changes as time goes on? What would help? Eleven respondents did not provide an answer to this question. Those who did reported plans to (1) continue referring to the course material and (2) encourage colleagues to be ‘less prescriptive’ and use more rehabilitation tools and questionnaires to help keep the focus on patient concerns. One respondent reported future plans to enroll in a counseling degree program for further professional development, and another has given a presentation on the material to colleagues. One audiologist planned on soliciting a peer review from a colleague using a counseling skills rubric.
Discussion Interest continues to grow in developing counseling skills for audiologists, most apparent in the inclusion of formal graduate-level coursework in several countries. Additionally, more workshops and presentations on counseling are now routinely included in professional conferences and elsewhere. However, there has been little analysis of the possible changes that might be effected in practice. Throughout two six-week programs for audiologists on counseling skills, we conducted ongoing assessment of learning outcomes (remembering, understanding), and attendees shared anecdotes about their initial attempts to apply new counseling skills. Since a program’s value is limited if it does not result in meaningful change in clinical settings, we surveyed delegates six months after each program, and the results indicated that all respondents implemented
Table 3. Characteristics of sub-themes describing changes in audiologist-patient dynamics. Sub-theme
No. of respondents
Increased opportunity for patient to communicate Changes in self
18
Sharing control
11
18
Changes in training
5
Changes in patient education
3
Sample comments Encouraging patient to do more talking than me. Using mostly open-ended questions now. Waiting; not rushing to fill silences. Striving to find out why certain comments keep getting mentioned. Genuinely listening, truly curious. No longer patronizing when patients say they are getting old. I reflect on sessions more. Am refraining from using ‘tech speak’ as a shield. Am giving ‘bad news’ more effectively/ more carefully. Not trying to fix but instead help patient find own solutions. Asking patients what they would like to know; asking parents what their priorities are. Patients are bringing notes to appointments now. Giving ‘room’ for patients to come to their own conclusions. Created a new course. Using content for presentations. Feedback from students: ‘third ear listening’ is having an impact. Avoiding information overload. Aware of ‘content trap.’ No longer automatically reviewing audiogram; what does patient want to know?
Counseling Program some degree of change in how they counseled their patients, the majority making many changes. These changes may be subtle enough to go unremarked upon by the casual observer, so it is all the more important to highlight them here. Voluntarily and independently, the majority of respondents made conscious decisions to interact differently with patients. They elected to apply the characteristics of patient-centered communication described earlier, by choosing to elicit and validate patients’ concerns and expectations, exploring the impact of symptoms on patients’ lives, and responding to emotional distress with empathic language. Participants reported changes in their relationships with patients, including a change in the power dynamic that exists in any healthcare encounter. As we know, when meeting an audiologist for the first time, patients are in a vulnerable situation: they don’t know what to expect, they don’t have answers yet to their questions, they may not even know what their questions are (Goodyear-Smith & Buetow, 2001). Patients present with a problem they don’t yet understand, may be worried or dismayed about test results, upset about our recommendations, and distrustful of our motivations. In a very real sense, they come to the appointment with little power, while the audiologist, wearing a prestigious white lab coat and surrounded by diplomas and expensive technology, can be perceived as having a great deal of power. Although ‘power’ was not a talking point in the counseling programs, participants still addressed this inequity, each in his or her own way. Instead of expecting to be the one person in charge, they found ways to help patients come to their own decisions. They actively monitored ‘talk time’ to make sure they talked less and listened more, and made sure they understood what they heard. They re-evaluated their approach to patient education and considered ways to adjust to memory limitations and patient questions, rather than operating from a script. They changed how they communicated to let patients know their opinions, concerns, and emotions were valued. No two participants reported exactly the same changes, but they all reported a concerted effort to ‘balance the power’ in patient relationships. As mentioned, the concept of power was not directly mentioned in the workshop, but it is the foundation of audiological counseling overall: to perceive and work with emotional or psychological states in order to help patients move forward, and by definition that means actively seeking a balance and sharing the power between clinician and patient. It should not be assumed that making these changes was easy. Sixteen respondents (80%) used the term ‘becoming more comfortable’ with the changes they were making, suggesting that their decision to step out of their ‘comfort zone’ to try something new caused some degree of discomfort. It is a truism of human nature that ‘change is hard,’ but when change brings positive results, changes can become the ‘new normal’ (O’Brien et al, 2001). Positive patient feedback was seen as reinforcement for the changes made. This study did not attempt to assess whether patients had noticed changes in appointments themselves, and this would be an interesting exercise. As Heath and Heath (2010) reminds us, ‘Change isn’t an event; it’s a process’ (p. 253), and by definition, ‘process’ requires investing some time in a productive way. ‘Change as process’ was an implicit goal of the six-week program, but one respondent was clearly aware of that goal by observing that without ongoing coaching and feedback, she ‘may have defaulted back to previous practices.’ In a challenging health care environment with increasing accountability for time and finance, only one respondent spontaneously noted
119
that time might be an issue and a challenge in an NHS funded service. It would be interesting to investigate whether it was an issue for others.
Limitations of study An obvious limitation to our survey results is the relatively small number of participants. It is encouraging to learn that both workshop cohorts provided similar responses, but we plan to continue the sixmonth surveys to glean more insights from participants on further programs regarding changes in their patient counseling practices. Comparisons to a control group would help us further understand the effects of a long-term program. Since the Ear Foundation routinely receives requests for one-day programs, we plan to deliver the first in-house session as a traditional stand-alone program, not only to meet those requests but also to serve as a control. We will recruit attendees with identical questionnaires and backgrounds to compare any changes in practice as a consequence to both the one-day and six-week programs. It is noted that these results rely on self-report alone. Future research should include exploring how to relate self-reports to patient reports, and ideally to develop objective tools designed to measure changes in behavior. While a familiar process in health care in general (e.g. O’Brien et al, 2001; Penuel et al, 2007), such steps have not yet been applied to audiology.
Future program refinements and research Respondents added suggestions to improve upcoming programs, and these will be carefully considered. There was a clear need for more peer group discussion, particularly with those with similar interests, and for this to be done in a time-effective way. Access to online learning and communication is planned, as is peer-to-peer support to facilitate ongoing professional development. We will also consider how to upgrade our learning objectives (Appendix) to include higher-level learning per Bloom’s (1956) taxonomy of intellectual behaviours. Currently 11 of our 12 goals expect attendees to remember and understand the workshop material, but attendees have demonstrated the ability to apply knowledge to skills, and analyse new skills as well. In developing our pre-course evaluations to include more specific information we will be able to measure the changes in behaviours more effectively.
Conclusion Early outcome measures indicate that an innovative workshop can support clinician change in the area of counseling skill development. By providing time, relevant assignments, discussion, and feedback, attendees advance beyond remembering and understanding counseling skills to applying and analysing those skills in their clinical settings. They reported learning how to listen more and speak less, thereby providing patients more opportunities to ask questions and express concerns. They learned to observe when patients are not processing instructions, and adjust their educational efforts. Participants successfully learned how to change their counseling approaches, and reported achieving improved patient relationships as a result. This workshop model will be continually refined and evaluated in order to provide the most effective learning experiences possible. The reader might be left to wonder, why would practitioners take themselves out of ‘auto pilot’ and change their approach to patient communication, even though it feels unfamiliar and therefore, for the short term, uncomfortable? Granted, program attendees were
120
K. English & S. Archbold
self-selected participants open to the prospect of learning counseling skills over time. Additionally, from the first session they were provided compelling evidence indicating that counseling/patientcentered communication has been shown to make a positive difference: that counseling supports the development of patient trust, and trust increases patient adherence (English & Kasewurm, 2012; Fiscella et al, 2004; Hall et al, 2002; Stewart et al, 2003; Thom et al, 2004). In the end, though, changes were voluntary. It has been encouraging to work with audiologists who are willing to risk some discomfort and attempt change in order to enhance their patient relationships and earn their patients’ trust.
Acknowledgements We extend our appreciation to Advanced Bionics, which supported the first author’s travel. The Ear Foundation gratefully acknowledges educational grants provided by the hearing care industry. Declaration of interest: The first author received a stipend as the instructor of the workshops described. The second author reports no conflict of interest. The authors alone are responsible for the content and writing of the paper.
References Action on Hearing Loss. 2011. Hearing Matters: Taking Action on Hearing Loss in the 21st Century. Available online: http://www.actiononhearingloss.org.uk/˜/media/Documents/Policy%20research%20and%20influencing/Research/Hearing%20matters/Hearing%20matters_pdf.ashx Bloom B.S. 1956. Taxonomy of Educational Objectives: The Classification of Educational Goals. New York: David McKay. Brookfield S. & Preskill S. 2005. Discussion as a Way of Teaching. San Francisco: Jossey-Bass. Calman K.C. 2004. Evolutionary ethics: Can values change? J Med Eth, 30, 366–370. Cappelli M., Daniels T., Durleux-Smith A., McGrath P.J. & Neuss D. 1995. Social development of children with hearing impairments who are integrated into general education classrooms. Volta Rev, 97, 197–208. Carrick L. 2010, November 15. Demystifying the EI (emotional intelligence) quick fix. T ⫹ D Magazine. Available online: http://www.astd.org/ Publications/Magazines/TD/TD-Archive/2010/11/Demystifyingthe-EI-Quick-Fix Clark J. & English K. 2014. Counseling-infused Audiologic Care. Boston: Allyn & Bacon. Cole S. 2000. The Medical Interview: The Three Function Approach. St. Louis: Mosby. Davis D. 1998. Does CME work? An analysis of the effect of educational activities on physician performance or health care outcomes. Int J Psych Med, 28, 21–39. Davis D., O’Brien M., Freemantle N., Wolf F., Maxmanian P. et al. 1999. Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health-care outcomes? JAMA, 282, 867–74. Elkayam J. & English K. 2003. Counseling adolescents with hearing loss with the use of self-assessment/significant other questionnaires. J Am Acad Audiol, 14, 485–499. English K. & Kasewurm G. 2012. Audiology and patient trust. Audiol Today, 24, 33–38.
Entwistle V., Carter S., Cribb A. & McCaffery K. 2010. Supporting patient autonomy: The importance of clinician-patient relationships. J Gen Int Med, 25, 741–745. Fiscella K., Meldrum S., Franks P., Shields C., Duberstein et al. 2004. Patient trust: Is it related to patient-centered behavior of primary care physicians? Med Care, 42, 1049–1055. Forsetlund L., Biørndal A., Rashidian A., Jamtvedt G., O’Brien et al. 2009, April 15. Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database Systematic Review: http://apps.who.int/rhl/reviews/CD003030.pdf Goodyear-Smith F. & Buetow S. 2001. Power issues in the doctor-patient relationships. Health Care Anal, 9, 449–462. Hall M.A., Dugan E. Camacho F., Kidd K., Mishra A. et al. 2002. Measuring patients’ trust in the primary care providers. Med Care Res Rev, 59, 293–318. Heath C. & Heath D. 2010. Switch: How to Change Things When Change is Hard. New York: Broadway Books. Kent B. & Smith S. 2006. They only see it when the sun shines in my ears: Exploring perceptions of adolescent hearing-aid users. J Deaf Stud Deaf Edu, 11, 461–476. Kochkin S. 2007. MarkeTrak VII: Obstacles to adult non-user adoption of hearing aids. Hear J, 60, 24–50. Kochkin S. 2012. Twenty-five years of MarkeTrak: The highlights. Available online: http://www.audiologyonline.com/articles/20q-25-yearsmarketrak-highlights-6616 Knudsen L.V., Laplante-Lévesque A., Jones L., Preminger J., Nielsen C. et al. 2012. Conducting qualitative research in audiology: A tutorial. Int J Audiol, 51, 83–92. Lin F.R., Thorpe R., Gordon-Salant S. & Ferrucci L. 2011. Hearing loss prevalence and risk factors among older adults in the United States. J Geron, 66, 582–590. Luterman D. 2008. Counseling Persons with Communication Disorders (5th ed.). Austin, USA: Pro-Ed. Morse J. 2009. Developing Grounded Theory: The Second Generation. Walnut Creek, California: Left Coast Press. O’Brien M.A, Freemantle N., Oxman AD, Wolf F., Davis D. et al. J. 2001. Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD003030. DOI: 10.1002/14651858. CD003030. Oliva G. 2004. Alone in the Mainstream: A Deaf Woman Remembers Public School. Washington, DC, USA: Gallaudet University Press. Penuel W., Fishman B., Yamaguchi R. & Gallagher L. 2007. What makes professional development effective? Strategies that foster curriculum implementation. Am Educ Res J, 44, 921–958. Stewart M., Brown J. & Freeman T. (eds.), 2003. Patient-centered Medicine: Transforming the Clinical Method (pp. 3–15). Abingdon, UK: Radcliffe Medical Press. Thom D., Hall M.A. & Pawlson L.G. 2004. Measuring patients’ trust in physicians when assessing quality of care. Health Aff, 23, 24–132. Tresolini C.P. 2000. Health Professions Education and Relationship-centered Care. San Francisco: Pew-Fetzer Professions Commission. Watermeyer J., Kanji A. & Cohen A. 2012. Caregiver recall and understanding of paediatric diagnostic information and assessment feedback. Int J Audiol, 51, 864–869. Young A. & Tattersall H. 2007. Universal newborn hearing screening and early identification of deafness: Parents’ responses to knowing early and their expectations of child communication development. J Deaf Stud Deaf Educ, 12, 209–220. Zolnierek K.B.H. & DiMatteo M.R. 2009. Physician communication and patient adherence to treatment: A meta-analysis. Med Care, 47, 826–834.
Copyright of International Journal of Audiology is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Original Article
Measuring the effectiveness of an audiological counseling program Kris English* & Sue Archbold† *School of Speech Pathology and Audiology, The University of Akron, Ohio, USA, and †The Ear Foundation, Nottingham, UK
Abstract Objective: Audiologists routinely observe patients struggle with psycho-emotional difficulties associated with hearing loss, yet are often underprepared to manage this vital aspect of patient care. For this reason, a workshop was developed for audiologists interested in expanding their counselling skills. Since one-time workshops typically do not result in changes in practice, this program adopted a distributed-over-time learning model, consisting of 20 hours of participation across six weeks. The extended nature of the program provided multiple opportunities to learn several counselling strategies, and apply and evaluate the effectiveness of these strategies in clinical settings. Design: Learning objectives were assessed throughout the six-week program. However, at the conclusion of each program, it was unknown whether new knowledge carried over into sustained new skills. Therefore, we surveyed attendees six months after their program, to determine if the program had affected changes in their practice. Study sample: Twenty clinicians (response rate ⫽ 91%) participated in the survey. Results: All respondents made some, and often many, changes in patient communication. They applied several counseling concepts to their work settings and reported positive changes in patient-clinician dynamics. Conclusion: Results suggest that a six-week program is effective in helping clinicians change their counseling skills within their practice.
Key Words: Counseling; assessment; patient-centered communication
Audiologists have long observed the range of psychological and emotional difficulties associated with living with hearing loss. Parents often find it difficult to understand and remember the details of their child’s diagnosis (Watermeyer et al, 2012) and may feel too overwhelmed to take action (Luterman, 2008; Young & Tattersall, 2007). As they grow, children with hearing loss often lack support in developing emotional self-awareness and important social skills (Cappelli et al, 1995; Oliva, 2004), and during their teen years, they are inclined to forsake amplification to fit in with peers (Elkayam & English, 2003; Kent & Smith, 2006). Additionally, adults who acquire hearing loss often wait for years before addressing their communication problems (Action on Hearing Loss, 2011; Kochkin, 2012) and even after they make an initial appointment with their General Practitioner, 45% are not referred for hearing test (Action on Hearing Loss, 2011). Even after an assessment, they may reject hearing help. For instance, a recent study of over 700 adults in the USA (age 70⫹) reported that nearly two thirds of its subjects had a treatable hearing loss, but only 40% reported hearing-aid use (Lin et al. 2011). Those who do pursue hearing help often get discouraged, resulting in one out of six hearing aids ending up in a drawer (Kochkin, 2007). Whether because of stigma, lack of support, or other reasons, many of our patients can be described as ‘stuck’ in the helping-seeking process (Clark & English, 2014). A limited background in the area of counselling may lead audiologists to assume that, as recognized experts in their field, our
recommendations should be followed; if patients opt out, their decision is an expression of their autonomy, over which we have no influence. However, while the value of informed patient choice is increasingly recognized in all areas of medical related fields (Calman, 2004), these choices are not made in a vacuum. Contemporary interpretations of patient autonomy stress the ‘relational interdependence’ between health- care providers and their patients (Entwistle et al, 2010; Tresolini, 2000), which relies on effective patient communication and the ability to establish therapeutic patient relationships. An indication of the growing emphasis placed on relationship-building can be found in a change made to a popular textbook used in medical schools in the United States. Cole’s (2000) update of The Medical Interview: The Three Function Approach now begins with the new function to ‘build the relationship,’ preceding the original two functions to ‘assess the patient’s problem’ and ‘manage the patient’s problem.’ Relationship-building can seem an unaffordable luxury in these times of financial challenges worldwide, with increasing demands made on health-care services, and increasing demands for costeffectiveness and efficiency. As evidence-based professionals, audiologists would want to know if counseling actually makes a difference, and if so, what kind of difference? Although counseling is often not a significant part of audiology training, abundant research has been published on the topic in the field of medicine. Recently, Zolnierek and DiMatteo (2009) sought
Correspondence: Kris English, The University of Akron, School of Speech Pathology and Audiology, 181 Polsky, Akron, OH 44325-3001, USA. E-mail: [email protected] (Received 27 April 2013; accepted 15 August 2013) ISSN 1499-2027 print/ISSN 1708-8186 online © 2014 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.3109/14992027.2013.837224
116
K. English & S. Archbold
to answer the question, ‘What is the relationship between physicians’ communication skills and their patients’ decision to follow their recommendations?’ (that is, patient adherence rates). The result of their meta-analysis indicated a strongly positive and significant relationship (p ⬍.001) between these two variables. Specifically, when physicians used patient-centered communication, their patients were far more likely to follow their physicians’ recommendations. Patient-centered communication includes the ability to: • • • •
Elicit and validate patients’ concerns Inquire about and legitimize patients’ ideas and expectations Assess the impact of symptoms on functioning Respond to indications of emotional distress by using empathic language
The authors concluded that effective counseling is a teachable/ learnable skill, and that health-care providers improve adherence rates by earning their patients’ trust with careful listening and patient-centered communication. In other words, counseling skills matter. To support audiologists as counsellors, one-time workshops are occasionally offered, typically for half-day or full-day sessions. However, because the explicit or implicit goal of such workshops is to affect a change in practice, it seems reasonable to ask, ‘Do one-time workshops result in measurable change? Do attendees not only learn some basic counselling skills and remember them later, but also apply them in their clinical setting, thereby demonstrating a new level of counselling competence?’ According to available research on workshop effectiveness, it appears that when professionals attend traditional one-time workshops, they typically acquire some new information, but the new knowledge does not translate into changes in practice (Davis, 1998). A recent meta-analysis concluded that ‘educational meetings alone are not likely to be effective in changing complex behaviours’ (Forsetlund et al, 2009, p. 2). However, less traditional workshop designs do seem to be effective in changing practitioner behaviours, for instance when they include practice opportunities (Davis et al, 1999) and additional post-workshop coaching (Carrick, 2010). Since the goal of a counselling workshop is to change a clinician’s practices (for the purpose of improving patient outcomes), it seems logical to design a program capable of supporting that change. Such a program should include multiple venues for active learning, opportunities to reflect upon current practices, study the evidence supporting different practices, interact and learn with peers and instructors, and receive coaching and feedback (Penuel et al, 2007). To this end, a workshop was designed with the express purpose of supporting professional change. The workshop is offered by the Ear Foundation in Nottingham, UK, and is entitled ‘Introduction to Audiologic Counselling.’ The Ear Foundation program has adopted a distributed-over-time learning model consisting of three parts: 1. An introductory in-house five-hour workshop, to provide information on audiologic counselling using lecture, videos, and large/small group discussion. 2. Six weeks of independent study, consisting of guided reading (textbook and articles), writing (case studies and other assignments), video conferencing, and email discussions with the course instructor. 3. A concluding five-hour in-house workshop, focusing on the application of key concepts (e.g. professional boundaries, relationship-centred care, coping strategies, effective/ineffective
responses to patient comments) using guided discussion techniques (Brookfield & Preskill, 2005). This model results in approximately 20 hours of engagement over six weeks. The extended nature of the program affords an opportunity not only to learn and understand a set of basic counselling strategies, but also to discuss, apply, and evaluate the effectiveness of these strategies. Learning objectives were ambitious but considered achievable when given sufficient time. Interested readers can access an Appendix listing these learning objectives at http:// informahealthcare.com/doi/abs/10.3109/14992027.2013.837224. Ongoing assessment of learning outcomes was conducted throughout the six-week program, and immediate post-program evaluations indicated attendees found the workshop well-organized and relevant, and gave an average score of 99% for course content. However, at the conclusion of each workshop, we did not yet know if new knowledge and short-term experiences translated into new skills and sustainable changes in practice. To find out, in our closing remarks, we informed attendees that we would request their input with a follow-up questionnaire designed to collect information about changes to their practice as a result of workshop participation.
Methods Data were collected from two cohorts who attended programs conducted at the Ear Foundation in the Spring of 2011 (Cohort 1) and 2012 (Cohort 2).
Participants Cohort 1 consisted of nine audiologists and one speech-language pathologist (two male, eight female). Cohort 2 consisted of 15 audiologists (two male, 13 female). All delegates practiced in the UK, either within the National Health Services or in private practice. Participants were recruited via email invitation, sent to the entire roster in one mailing.
Instrument A questionnaire was developed to collect post-program input from the delegates. The questionnaire consisted of these four queries: 1. We are wondering if you changed your practices after completing the counseling course. Could you let us know by reporting a number on a 1–5 scale (1 ⫽ not at all; 2 ⫽ made a few changes; 3 ⫽ made several changes; 4 ⫽ made many changes; 5 ⫽ changed almost everything)? 2. If you made any changes of any kind, please describe. 3. If not, could you explain? Was there anything that we could have done to help? 4. Do you foresee making changes as time goes on? What would help?
Procedures We emailed our questionnaire to all delegates, following up with a reminder note one week later. Respondents replied only to the authors, keeping their input private but not anonymous. However, upon receipt, input was disassociated from sender, first by assigning a number to each sender on a separate list, and then printing out input minus any identifying information. The list of senders was used only for tracking purposes.
Counseling Program
117
Analysis included obtaining the median response and frequency distribution to the responses to Question #1. The narrative data of the remaining three open-ended questions were analysed using a rudimentary version of grounded theory technique (i.e. employing one round of data collection) (Morse, 2009). Knudsen and colleagues (2012) report that grounded theory is commonly found in audiology, and provide a succinct definition of the process: ‘Coding, constant data categorization, and comparison, interpretation, and theorization are used to develop new theory from data without presupposed hypotheses’ (p. 85). The semi-structured questionnaire format provided participants the opportunity to describe their experiences in their own words; we then coded the semantic content of the textbased responses to identify discrete data points and then reviewed for emerging categories and themes relative to our question, ‘Can an audiological counseling program change practice?’
These sub themes are summarized in Table 2 and detailed in Table 3. Eighteen respondents reported providing patients more opportunities to communicate. Four audiologists described ensuring that patients ‘are talking more throughout the appointment than myself.’ Another audiologist made it a priority to ‘ask families what their concerns and priorities are.’ Eight audiologists reported more comfort with silence and waiting, and observing when patients seemed to have something to say but needed time to sort out their thoughts. Additional input included:
Results
Engaging in family-centered discussions led six audiologists to develop stronger partnerships with parents, helping them realize and accept a more active role in their child’s development. This process was described as ‘almost like getting a contract’ about ‘what I was going to do and what I need them to do in return and get their buy in. … Hearing aids need to be worn every day; can you do this?’ Patients and parents may appreciate direct conversation about the challenges that lie ahead, rather than perceiving these challenges as taboo topics. Respondents indicated several positive patient outcomes from increased and more open discussion, for example:
We received responses from all 10 members of the first cohort, and 10 members from the second cohort (66%). Among the five nonrespondents in the second cohort, three persons were not in a clinical setting at the time, and two did not reply to the survey but did extend regrets about not responding due to time constraints. Excluding the three participants not involved in clinical services, our response rate (N ⫽ 20) from 22 active clinicians was 91%. Following is a summary of participant responses.
All respondents (N ⫽ 20) indicated some degree of change (see Table 1). All respondents from the 2011 workshop (N ⫽ 10) indicated ‘yes’ by reporting scores from 2–5 (median ⫽ 3, made several changes). Similarly, all respondents from the 2012 workshop (N ⫽ 10) indicated ‘yes’ by reporting scores from 3–4 (median ⫽ 3, made several changes).
2. If changes were made, please describe. All responses to this question reflected one overarching or major theme: a change in audiologist-patient dynamics. This theme emerged from 55 comments, categorized into five sub themes. These sub themes were:
• • • •
Providing patients/parents more opportunities to ask questions, and express concerns and priorities Changes in self Sharing control with patients regarding the direction and outcomes of the appointment Changes in student training Changes in patient education
Table 1. Median and range of responses (1–5 scale: 1 ⫽ not at all, 5 ⫽ changed almost everything) to Question #1: Rate amount of change in practices after completing counseling course (reported by year attended).
2011 2012
•
•
1. Have you changed your practices after completing the course?
•
•
Median
Range
3 3
2–5 2–4
•
‘Asking the parent what they would like to know after disclosing the diagnosis. Holding back and not filling the parents’ silences.’ ‘I am less ready to jump in and answer without ensuring I understand the question fully.’
‘I have had two major points of progress with families where we have had little progress over a year or more, which is very uplifting.’ ‘I’ve noticed a definite positive change in the way my patients respond since making these changes. A few of them have told me they were really dreading the appointment and their hearing test and have been pleasantly surprised …they were relieved at having someone to talk to about their difficulties and they even quite enjoyed it!’
Eighteen respondents also described several changes in self, reporting that they now ‘listen differently,’ ‘listen to the unspoken,’ and attend more to patients’ emotional states and their grief. Many found themselves more comfortable with boundaries and waiting. • • •
‘When a patient now says to me that they are getting old, I no longer patronize them. I try to acknowledge their feelings of getting old.’ ‘I actively reflect on the sessions more.’ ‘Giving ‘bad news’ is never going to be an easy task but I now feel I have a catalogue of ways to bring about understanding and the journey of acceptance.’
Eleven respondents described their efforts to share control with patients. One respondent wrote: ‘Rather than trying to pull the patient through the pathway toward a hearing-aid fitting, I’m allowing the patient to dictate the pace of the pathway a little more. This allows time to explore any issues that might crop up along the way.’ Another audiologist reported, ‘I have also started to allow the patient to come to conclusions through talking’, rather than dictating next steps. Patients were described as being ‘clearly relieved’ to have someone to talk to, and the lessening of tension seemed to help them consider, rather than reject, recommendations for amplification. Additional input included:
118
K. English & S. Archbold Table 2. One main theme and five sub-themes describing changes in clinical practice per survey responses. Main theme: Changes in audiologist-patient dynamics Sub-themes
• • • •
Increased opportunity for patient to communicate
Changes in self
‘Letting the patients taking [sic] more of a lead during the appointments.’ ‘I am putting more emphasis on addressing any issues important to them [patients] as well as doing the routine tuning checks and hearing tests.’ ‘I have also started to allow the patient to come to conclusions through talking.’ ‘Trying not to be a hearing-aid cop!’
A lesser sub theme included changes in student teaching. Five respondents described using the counseling content to create a new course, or adding a new emphasis in existing courses and presentations. While we cannot know whether changes in student training will directly impact future audiologist-patient dynamics, respondents reported that students expressed the opinion that a counseling course should be a core requirement rather than optional. Feedback indicated the students were already well aware of the impact of a supportive audiologist-patient relationship. Finally, three participants described changes in patient education. They reported considering patient readiness for new information; recognizing and avoiding the problem with information overload; and not relying on content/education when situations become difficult. Respondents recognized that instead of connecting with patients, they created distance by providing more information than the patient desired, or avoiding emotional situations with technical discussions.
3. If changes were not made, could you explain? Was there anything that we could have done to help? Since all respondents reported some degree of change, most respondents did not answer this question. However, one respondent expressed a general concern for time constraints within the healthcare system, and several suggestions were made for future workshops. One respondent recommended disseminating the course content to a wider audience (e.g. Higher Training Scheme), and, to
Sharing control
Changes in student training
Changes in patient education
help sustain professional development, one respondent suggested pairing up classmates to conduct peer reviews. Six respondents requested more online communication among attendees, and two respondents recommended more discussion and post-workshop partnerships with attendees who work with similar populations, especially children, teens, and patients with unilateral or mildmoderate hearing loss.
4. Do you foresee making changes as time goes on? What would help? Eleven respondents did not provide an answer to this question. Those who did reported plans to (1) continue referring to the course material and (2) encourage colleagues to be ‘less prescriptive’ and use more rehabilitation tools and questionnaires to help keep the focus on patient concerns. One respondent reported future plans to enroll in a counseling degree program for further professional development, and another has given a presentation on the material to colleagues. One audiologist planned on soliciting a peer review from a colleague using a counseling skills rubric.
Discussion Interest continues to grow in developing counseling skills for audiologists, most apparent in the inclusion of formal graduate-level coursework in several countries. Additionally, more workshops and presentations on counseling are now routinely included in professional conferences and elsewhere. However, there has been little analysis of the possible changes that might be effected in practice. Throughout two six-week programs for audiologists on counseling skills, we conducted ongoing assessment of learning outcomes (remembering, understanding), and attendees shared anecdotes about their initial attempts to apply new counseling skills. Since a program’s value is limited if it does not result in meaningful change in clinical settings, we surveyed delegates six months after each program, and the results indicated that all respondents implemented
Table 3. Characteristics of sub-themes describing changes in audiologist-patient dynamics. Sub-theme
No. of respondents
Increased opportunity for patient to communicate Changes in self
18
Sharing control
11
18
Changes in training
5
Changes in patient education
3
Sample comments Encouraging patient to do more talking than me. Using mostly open-ended questions now. Waiting; not rushing to fill silences. Striving to find out why certain comments keep getting mentioned. Genuinely listening, truly curious. No longer patronizing when patients say they are getting old. I reflect on sessions more. Am refraining from using ‘tech speak’ as a shield. Am giving ‘bad news’ more effectively/ more carefully. Not trying to fix but instead help patient find own solutions. Asking patients what they would like to know; asking parents what their priorities are. Patients are bringing notes to appointments now. Giving ‘room’ for patients to come to their own conclusions. Created a new course. Using content for presentations. Feedback from students: ‘third ear listening’ is having an impact. Avoiding information overload. Aware of ‘content trap.’ No longer automatically reviewing audiogram; what does patient want to know?
Counseling Program some degree of change in how they counseled their patients, the majority making many changes. These changes may be subtle enough to go unremarked upon by the casual observer, so it is all the more important to highlight them here. Voluntarily and independently, the majority of respondents made conscious decisions to interact differently with patients. They elected to apply the characteristics of patient-centered communication described earlier, by choosing to elicit and validate patients’ concerns and expectations, exploring the impact of symptoms on patients’ lives, and responding to emotional distress with empathic language. Participants reported changes in their relationships with patients, including a change in the power dynamic that exists in any healthcare encounter. As we know, when meeting an audiologist for the first time, patients are in a vulnerable situation: they don’t know what to expect, they don’t have answers yet to their questions, they may not even know what their questions are (Goodyear-Smith & Buetow, 2001). Patients present with a problem they don’t yet understand, may be worried or dismayed about test results, upset about our recommendations, and distrustful of our motivations. In a very real sense, they come to the appointment with little power, while the audiologist, wearing a prestigious white lab coat and surrounded by diplomas and expensive technology, can be perceived as having a great deal of power. Although ‘power’ was not a talking point in the counseling programs, participants still addressed this inequity, each in his or her own way. Instead of expecting to be the one person in charge, they found ways to help patients come to their own decisions. They actively monitored ‘talk time’ to make sure they talked less and listened more, and made sure they understood what they heard. They re-evaluated their approach to patient education and considered ways to adjust to memory limitations and patient questions, rather than operating from a script. They changed how they communicated to let patients know their opinions, concerns, and emotions were valued. No two participants reported exactly the same changes, but they all reported a concerted effort to ‘balance the power’ in patient relationships. As mentioned, the concept of power was not directly mentioned in the workshop, but it is the foundation of audiological counseling overall: to perceive and work with emotional or psychological states in order to help patients move forward, and by definition that means actively seeking a balance and sharing the power between clinician and patient. It should not be assumed that making these changes was easy. Sixteen respondents (80%) used the term ‘becoming more comfortable’ with the changes they were making, suggesting that their decision to step out of their ‘comfort zone’ to try something new caused some degree of discomfort. It is a truism of human nature that ‘change is hard,’ but when change brings positive results, changes can become the ‘new normal’ (O’Brien et al, 2001). Positive patient feedback was seen as reinforcement for the changes made. This study did not attempt to assess whether patients had noticed changes in appointments themselves, and this would be an interesting exercise. As Heath and Heath (2010) reminds us, ‘Change isn’t an event; it’s a process’ (p. 253), and by definition, ‘process’ requires investing some time in a productive way. ‘Change as process’ was an implicit goal of the six-week program, but one respondent was clearly aware of that goal by observing that without ongoing coaching and feedback, she ‘may have defaulted back to previous practices.’ In a challenging health care environment with increasing accountability for time and finance, only one respondent spontaneously noted
119
that time might be an issue and a challenge in an NHS funded service. It would be interesting to investigate whether it was an issue for others.
Limitations of study An obvious limitation to our survey results is the relatively small number of participants. It is encouraging to learn that both workshop cohorts provided similar responses, but we plan to continue the sixmonth surveys to glean more insights from participants on further programs regarding changes in their patient counseling practices. Comparisons to a control group would help us further understand the effects of a long-term program. Since the Ear Foundation routinely receives requests for one-day programs, we plan to deliver the first in-house session as a traditional stand-alone program, not only to meet those requests but also to serve as a control. We will recruit attendees with identical questionnaires and backgrounds to compare any changes in practice as a consequence to both the one-day and six-week programs. It is noted that these results rely on self-report alone. Future research should include exploring how to relate self-reports to patient reports, and ideally to develop objective tools designed to measure changes in behavior. While a familiar process in health care in general (e.g. O’Brien et al, 2001; Penuel et al, 2007), such steps have not yet been applied to audiology.
Future program refinements and research Respondents added suggestions to improve upcoming programs, and these will be carefully considered. There was a clear need for more peer group discussion, particularly with those with similar interests, and for this to be done in a time-effective way. Access to online learning and communication is planned, as is peer-to-peer support to facilitate ongoing professional development. We will also consider how to upgrade our learning objectives (Appendix) to include higher-level learning per Bloom’s (1956) taxonomy of intellectual behaviours. Currently 11 of our 12 goals expect attendees to remember and understand the workshop material, but attendees have demonstrated the ability to apply knowledge to skills, and analyse new skills as well. In developing our pre-course evaluations to include more specific information we will be able to measure the changes in behaviours more effectively.
Conclusion Early outcome measures indicate that an innovative workshop can support clinician change in the area of counseling skill development. By providing time, relevant assignments, discussion, and feedback, attendees advance beyond remembering and understanding counseling skills to applying and analysing those skills in their clinical settings. They reported learning how to listen more and speak less, thereby providing patients more opportunities to ask questions and express concerns. They learned to observe when patients are not processing instructions, and adjust their educational efforts. Participants successfully learned how to change their counseling approaches, and reported achieving improved patient relationships as a result. This workshop model will be continually refined and evaluated in order to provide the most effective learning experiences possible. The reader might be left to wonder, why would practitioners take themselves out of ‘auto pilot’ and change their approach to patient communication, even though it feels unfamiliar and therefore, for the short term, uncomfortable? Granted, program attendees were
120
K. English & S. Archbold
self-selected participants open to the prospect of learning counseling skills over time. Additionally, from the first session they were provided compelling evidence indicating that counseling/patientcentered communication has been shown to make a positive difference: that counseling supports the development of patient trust, and trust increases patient adherence (English & Kasewurm, 2012; Fiscella et al, 2004; Hall et al, 2002; Stewart et al, 2003; Thom et al, 2004). In the end, though, changes were voluntary. It has been encouraging to work with audiologists who are willing to risk some discomfort and attempt change in order to enhance their patient relationships and earn their patients’ trust.
Acknowledgements We extend our appreciation to Advanced Bionics, which supported the first author’s travel. The Ear Foundation gratefully acknowledges educational grants provided by the hearing care industry. Declaration of interest: The first author received a stipend as the instructor of the workshops described. The second author reports no conflict of interest. The authors alone are responsible for the content and writing of the paper.
References Action on Hearing Loss. 2011. Hearing Matters: Taking Action on Hearing Loss in the 21st Century. Available online: http://www.actiononhearingloss.org.uk/˜/media/Documents/Policy%20research%20and%20influencing/Research/Hearing%20matters/Hearing%20matters_pdf.ashx Bloom B.S. 1956. Taxonomy of Educational Objectives: The Classification of Educational Goals. New York: David McKay. Brookfield S. & Preskill S. 2005. Discussion as a Way of Teaching. San Francisco: Jossey-Bass. Calman K.C. 2004. Evolutionary ethics: Can values change? J Med Eth, 30, 366–370. Cappelli M., Daniels T., Durleux-Smith A., McGrath P.J. & Neuss D. 1995. Social development of children with hearing impairments who are integrated into general education classrooms. Volta Rev, 97, 197–208. Carrick L. 2010, November 15. Demystifying the EI (emotional intelligence) quick fix. T ⫹ D Magazine. Available online: http://www.astd.org/ Publications/Magazines/TD/TD-Archive/2010/11/Demystifyingthe-EI-Quick-Fix Clark J. & English K. 2014. Counseling-infused Audiologic Care. Boston: Allyn & Bacon. Cole S. 2000. The Medical Interview: The Three Function Approach. St. Louis: Mosby. Davis D. 1998. Does CME work? An analysis of the effect of educational activities on physician performance or health care outcomes. Int J Psych Med, 28, 21–39. Davis D., O’Brien M., Freemantle N., Wolf F., Maxmanian P. et al. 1999. Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health-care outcomes? JAMA, 282, 867–74. Elkayam J. & English K. 2003. Counseling adolescents with hearing loss with the use of self-assessment/significant other questionnaires. J Am Acad Audiol, 14, 485–499. English K. & Kasewurm G. 2012. Audiology and patient trust. Audiol Today, 24, 33–38.
Entwistle V., Carter S., Cribb A. & McCaffery K. 2010. Supporting patient autonomy: The importance of clinician-patient relationships. J Gen Int Med, 25, 741–745. Fiscella K., Meldrum S., Franks P., Shields C., Duberstein et al. 2004. Patient trust: Is it related to patient-centered behavior of primary care physicians? Med Care, 42, 1049–1055. Forsetlund L., Biørndal A., Rashidian A., Jamtvedt G., O’Brien et al. 2009, April 15. Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database Systematic Review: http://apps.who.int/rhl/reviews/CD003030.pdf Goodyear-Smith F. & Buetow S. 2001. Power issues in the doctor-patient relationships. Health Care Anal, 9, 449–462. Hall M.A., Dugan E. Camacho F., Kidd K., Mishra A. et al. 2002. Measuring patients’ trust in the primary care providers. Med Care Res Rev, 59, 293–318. Heath C. & Heath D. 2010. Switch: How to Change Things When Change is Hard. New York: Broadway Books. Kent B. & Smith S. 2006. They only see it when the sun shines in my ears: Exploring perceptions of adolescent hearing-aid users. J Deaf Stud Deaf Edu, 11, 461–476. Kochkin S. 2007. MarkeTrak VII: Obstacles to adult non-user adoption of hearing aids. Hear J, 60, 24–50. Kochkin S. 2012. Twenty-five years of MarkeTrak: The highlights. Available online: http://www.audiologyonline.com/articles/20q-25-yearsmarketrak-highlights-6616 Knudsen L.V., Laplante-Lévesque A., Jones L., Preminger J., Nielsen C. et al. 2012. Conducting qualitative research in audiology: A tutorial. Int J Audiol, 51, 83–92. Lin F.R., Thorpe R., Gordon-Salant S. & Ferrucci L. 2011. Hearing loss prevalence and risk factors among older adults in the United States. J Geron, 66, 582–590. Luterman D. 2008. Counseling Persons with Communication Disorders (5th ed.). Austin, USA: Pro-Ed. Morse J. 2009. Developing Grounded Theory: The Second Generation. Walnut Creek, California: Left Coast Press. O’Brien M.A, Freemantle N., Oxman AD, Wolf F., Davis D. et al. J. 2001. Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD003030. DOI: 10.1002/14651858. CD003030. Oliva G. 2004. Alone in the Mainstream: A Deaf Woman Remembers Public School. Washington, DC, USA: Gallaudet University Press. Penuel W., Fishman B., Yamaguchi R. & Gallagher L. 2007. What makes professional development effective? Strategies that foster curriculum implementation. Am Educ Res J, 44, 921–958. Stewart M., Brown J. & Freeman T. (eds.), 2003. Patient-centered Medicine: Transforming the Clinical Method (pp. 3–15). Abingdon, UK: Radcliffe Medical Press. Thom D., Hall M.A. & Pawlson L.G. 2004. Measuring patients’ trust in physicians when assessing quality of care. Health Aff, 23, 24–132. Tresolini C.P. 2000. Health Professions Education and Relationship-centered Care. San Francisco: Pew-Fetzer Professions Commission. Watermeyer J., Kanji A. & Cohen A. 2012. Caregiver recall and understanding of paediatric diagnostic information and assessment feedback. Int J Audiol, 51, 864–869. Young A. & Tattersall H. 2007. Universal newborn hearing screening and early identification of deafness: Parents’ responses to knowing early and their expectations of child communication development. J Deaf Stud Deaf Educ, 12, 209–220. Zolnierek K.B.H. & DiMatteo M.R. 2009. Physician communication and patient adherence to treatment: A meta-analysis. Med Care, 47, 826–834.
Copyright of International Journal of Audiology is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
