Munoz, K., Ong, C., Borrie, S., Nelson, L., & Twohig, M. (2017). Audiologists’ communication behavior during hearing device management appointments. International Journal of Audiology, Early Online, 1-9.
This editorial discusses the clinical implications of an independent research study and does not represent the opinions of the original authors.
The skill of the audiologist in communicating with a patient can significantly impact rehabilitative outcomes. Nowhere is this more evident than when an audiologist in engaged in managing a hearing device fitting. Studies have suggested a lack of patient-centeredness behavior by audiologists in audiologist-patient interactions, including domination of speaking time, a tendency to overemphasize the technical aspects of device care, interruptions of the patient, an inability to deal with emotion-laden aspects of rehabilitation, expressing empathy, and not actively listening, (e.g., Ekberg, 2014; Grenness, et al, 2014; Grenness, et al, 2015; Knudsen, et, al., 2010; Laplante-Levesque, et al, 2014; Munoz, et al, 2014, and Munoz, et, al, 2015). The counseling tendencies noted above can create a lack of adherence to and understanding of the recommendations and information provided by the audiologist (Robinson, et al, 2008).
Audiologists in training are likely as not to internalize or imitate how their mentors or supervisors interact with patients. Unless their instructors have themselves achieved satisfactory interpersonal communication skills, audiologists may enter the workforce lacking practical counseling and communication skills that may diminish their effectiveness in the clinical setting.
The authors designed this exploratory, longitudinal study to measure audiologist communication behaviors at three time intervals, first, prior to participating in a one-day pre-training workshop, second, at a two-month interval, and third, at a six-month interval. The pre-training workshop focused on the psychosocial aspects of counseling including the use of open-ended questions, validation of emotions, reframing and clarifying patient problems and complaints, methods for increasing motivation, and double-checking patient assumptions. In addition, five one-hour support sessions were offered to the audiologists for a three-month period following the initial workshop, during which topics were discussed such as addressing client barriers, addressing emotions, being present and non-judgmental, and developing reflection/summarizing skills, among others. Attendance ranged from 30% to 90% of participants; one audiologist attended none of the support sessions, but most attended 3-4 sessions.
Ten audiologists actively providing clinical services were evaluated on two rating scales—1) the Behavior Competencies Rating Scale (a 10-item self-rating measure developed by the authors) designed to evaluate the audiologist’s own perception of his/her communication skills, and 2) a modified version of the Counseling Competencies Scale (Swank, et al, 2012), intended to measure counseling skills and behaviors, graded by both the instructor and independently by a psychology graduate student. 53 patients consented to participate and each audiologist-patient interaction was recorded. A set of coding guidelines was developed to recognize and categorize by type the counselling behaviors (interactions) exhibited by the audiologist, as well as the frequency of each of the counseling behaviors. The coding categories for counseling skills included encouragers, questions, listening and reflecting feelings, confrontations, goal setting, focus of counseling, and expressions of appropriate empathy, care, respect and unconditional positive regard.
The article gave examples of expressions and statements during counseling that would fall into specific coding categories. For example, an open-ended question such as “What do you think is the most challenging part of wearing (or taking care) of your hearing aids?” would be categorized as assessing and addressing barriers and motivation. An audiologist might comment to a patient who mentions they are in the process of moving, “So you have a lot going on,” which would be interpreted as an instance of listening and reflection. Or the audiologist might suggest, “For homework, I’d like you to work on using a couple of the strategies we discussed,” a statement that would fall into the category of planning for behavior change.
The average length of each recorded counseling session was 46 minutes, from which a selected ten-minute sample was extracted, coded and subjected to analysis. The rate of change of audiologist behaviors, expressed as the percentage frequency of occurrence per session, was measured at the three time intervals mentioned above, baseline, one-month post-training, and at a six-month follow-up.
The authors found that audiologists devoted the greatest amount of clinical interactions throughout the six-month period to general fitting discussions followed by educational and technical instruction. The frequencies of occurrence (interactions) devoted to these two variables increased slightly post workshop, but thereafter decreased. The fewest number of the clinicians’ interactions per session over the six-month period was spent in listening and reflection, clarifying treatment goals, assessing and addressing motivation and barriers, and discussing behavior changes. Although small changes were noted in the frequencies of occurrence of these behaviors over the study period, the authors concluded that the observed changes were so minimal as not to be practically meaningful. Of interest, they also found the time per session devoted to irrelevant conversation and small talk increased linearly from a relatively low point to a higher level throughout the time of the study.
A striking outcome was the significant reduction in personal speaking time of audiologists following a pre-training workshop. When the speaking time of both patients and audiologists were compared (audiologists dominated during pre-training) both were approximately equal after the workshop. Although speaking time was not explicitly stressed in the workshop, these findings suggest a reduction in audiologist verbal dominance after training, suggesting that the training positively impacted this counseling behavior.
Finally, the audiologists, in rating their personal communication behaviors, perceived a marked improvement in their own communication skills on the self-rating scale. This improvement was not entirely supported by the data, as the observer-rated data showed little clinically important changes in psychologically relevant interactions over the study period.
The authors suggest that one of the reasons for lack of meaningful change in clinician communication behavior might have been the complexity of counseling skills taught within a relatively short time frame. The provision of a short workshop on communication skills is insufficient and that the importance of teaching patient-centered communication skills to audiologists-in-training as early as possible cannot be overstated.
Although there was evidence of improvement in audiologists’ counseling skills following the pre-training workshop and with supplementary instruction, it was limited. Hesitation to address patients’ psychosocial concerns, express empathy when appropriate, and address client’s emotions, indicate a possible gap in training and education. The authors recommend that clinical supervisors should be aware of the critical role patient-centered counselling plays in providing positive clinical outcomes. Further, these supervisors should recognize within themselves the need for improving personal counseling skills by furthering their own continuing education.
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