AJA
Clinical Focus
Hearing Care for Elders: A Personal Reflection on Participatory Action Learning With Primary Care Providers Lorienne M. Jenstada and Martha Donnellya
Purpose: This report is a reflective critical narrative of the authors’ experience with an interdisciplinary collaboration of primary care providers (PCPs) and hearing health care providers (HHCPs) that followed the principles of participatory action research/learning. The goal for this report is to describe the 1st author’s observed barriers to PCPs’ willingness to learn about hearing health care and the subsequent facilitators to learning. Method: A team of PCPs and HHCPs created the “Communication: Hearing Loss in Elders” educational module. The module included (a) prereading developed from a combination of literature reviews and contextual factors and (b) a case study.
Results: The authors present the list of topics included in the module, and they reflect on why and how these topics were deemed important by the team. In particular, 2 topics were identified for motivating PCPs’ behavior regarding hearing health care: (a) the overlap in symptoms and possible causation among depression, dementia, and hearing loss and (b) how hearing can affect efficiency of care regarding other health issues. Conclusions: This personal reflective narrative gives the authors’ opinions about what can make for a successful collaboration and presents some hypotheses regarding information that may motivate behavior change with regard to hearing care.
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Hackett (2002), in an article written for audiologists, stated that “in order for primary care physicians to perform effectively in the role of ‘hearing healthcare gatekeepers,’ substantial changes will have to take place” (para. 4). There is certainly some research evidence to support the audiologists’ view of physicians. The majority of physicians are unlikely to spontaneously raise the topic of hearing health with their patients, and when patients raise concerns themselves, the concerns are often dismissed by the physicians (Wallhagen & Pettengill, 2008). Of individuals who raised concerns with their primary care practitioner, only 6.4% reported receiving help or a referral (Schneider et al., 2010). On the other hand, the majority of physicians surveyed were aware of the prevalence of age-related hearing loss and its consequences (Gilliver & Hickson, 2011). Two thirds of physicians surveyed disagreed that hearing loss was a low-priority health concern (Danhauer, Celani, & Johnson, 2008). Similarly, Johnson et al. (2008) found that primary care physicians felt that hearing and balance were important in older adults but did not have enough time or reimbursement to conduct a screening. This evidence shows that there are discrepancies about the importance and understanding of age-related
an audiologists and primary care providers (PCPs, such as physicians or nurses) be good partners in hearing health care for older adults? I (Lorienne M. Jenstad) have heard from many colleagues that audiologists need to be independent of physicians and that the way forward in adult hearing screening and hearing care for older adults is for audiologists to take charge. When I talk about my work with physicians, I am usually met with skepticism and doubt that hearing care for elders could be within the scope of practice for physicians. My experience shows that it is possible. Some published opinion pieces, written by or for audiologists, express the view that audiology should work independently from physicians, pointing to the “public devaluing of audiology” by the American Medical Association (Shames & Simpson, 2012, p. 30), negative recommendations regarding amplification by physicians (Jones, 1993), and discouraging advice given in response to patients’ questions about hearing care (Whichard, 1998). Popp and
a
University of British Columbia, Vancouver, Canada
Correspondence to Lorienne M. Jenstad: [email protected] Editor and Associate Editor: Larry Humes Received October 3, 2014 Revision received November 17, 2014 Accepted November 21, 2014 DOI: 10.1044/2014_AJA-14-0051
Disclosure: The authors have declared that no competing interests existed at the time of publication.
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hearing loss to physicians. The reality is that if people are starting to notice difficulties with their hearing, they are likely to go see a physician first, rather than an audiologist, as first point of entry into the system (e.g., A. Davis, Smith, Booth, & Martin, 2012; Holliday, Jenstad, Grosjean, & Purves, 2014). I am also noticing more suggestions that we need to start using physicians or other PCPs (e.g., nurses, nurse practitioners) for conducting hearing screenings (e.g., A. Davis et al., 2012; McCullagh & Frank, 2013; G. Saunders, personal communication, August 2014). My goal in writing this article is to narrate my own experience of working with PCPs toward the common goal of hearing care for older adults. I had some false starts and missteps along the way. My own preconceptions got in the way of listening and finding ways for productive partnership. In the end, our collaborations were successful. Through the process, I began to challenge my own thinking about what was possible in working with other health care providers. I had to face my own hubris about “knowing” what was best. At first, I worked on finding ways to communicate “my truth” to the audience. Then, over time, I began to realize that it was not just a communication issue but an issue of being too certain. I had to examine the evidence that I believed to be true and to realize that there were actually different ways of interpreting the same results and a need to modify recommendations based on the context. I am telling this experience in the form of a scholarly personal narrative, rather than a traditional research report, because I cannot separate myself from the process that happened and because my own perspective and thinking changed through the work described here. The scholarly personal narrative uses first person voice to allow the researcher’s story to be told, as a way of exploring hypotheses and illustrating themes (e.g., Nash & Bradley, 2012).
Why Participatory Action Learning? Evidence shows that translation from research to practice across many fields is poorly done (e.g., Glasgow & Emmons, 2007; Glasgow, Lichtenstein, & Marcus, 2003), with consistent gaps identified between research evidence and practice standards (Grol & Grimshaw, 2003). Traditional information dissemination includes review articles, clinical guidelines, continuing education courses, and conferences. However, Grol and Grimshaw (2003), among others (e.g., Bero et al., 1998; D. A. Davis, Thomson, Oxman, & Haynes, 1995; Oxman, Thomson, Davis, & Haynes, 1995), suggest that creativity may be needed in finding new ways to disseminate health care research knowledge, particularly using individualized knowledge transfer that accounts for contextual factors. Participatory action research/learning is promoted as an approach that can potentially meet these challenges (e.g., Hills, Mullett, & Carroll, 2007; Kidd & Kral, 2005; Stuttaford & Coe, 2007) because both researchers and participants are involved in creating the questions and focus. Together, they create a context in which knowledge is generated or reviewed, and thus the knowledge is seen as highly applicable to the problem under consideration.
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A participatory approach becomes very important when developing protocols that might be used with vulnerable or high-risk populations where there are many competing demands for the clinician’s time, such as older adults with multiple complex health needs. There are two authors of this article. What follows is the first author’s reflective narrative regarding the process of developing educational materials on hearing health together with PCPs. The narrative is written in first person to show that the information is written from the personal perspective of the author (Lorienne M. Jenstad). The structure is similar to a framework used by Stuttaford and Coe (2007), who wrote a reflection article on the learning that happens for participants involved in participatory action research / learning. It also draws heavily from Nash’s (2004) book on the scholarly personal narrative. The second author (Martha Donnelly) is a geriatric psychiatrist who was intimately involved in the process described in this article. She wrote some of the text describing the collaboration and the educational module. In addition, she read, commented on, and ultimately accepted the narrative. It was important to me to have her input to ensure that it was a faithful telling of the events that happened. The second author was also the director of the Care for Elders collaboration, out of which the team and educational efforts described here began. Care for Elders was an interdisciplinary health care collaboration centered in the Department of Family Practice at the University of British Columbia within the Special Interest Focused Practice of Community Geriatrics. Funding was from a special populations grant to the university’s Medical School from the British Columbia Ministry of Health. The overall vision of the Care for Elders collaboration was that every British Columbia senior would have access to informed interprofessional teams focused on maximizing the functioning of seniors. The Care for Elders collaboration’s main activity was providing education for health care providers. The primary vehicle for achieving the collaboration’s vision was education of health care professionals through small-group, case-based learning modules on complex health care challenges affecting older adults in particular. Each learning module begins with an evidencebased prereading required for participants before they attend small groups (approximately 10 health care professionals) to work through a case study. Case discussion can be facilitated by a nonexpert facilitator, and cases take about 2 hr to complete, including an evaluation of learning. Nonexpert facilitation is facilitation by health care professionals who are not necessarily content experts in the module topic but rather who are trained to facilitate group discussions. A simple educational pamphlet and video were used to teach facilitation. The use of nonexpert facilitators means the modules can be used anywhere in the province or country where a small group wishes to learn about a particular topic. The individual topics for learning were chosen by a Care for Elders Steering Group representing all of the disciplines within the collaboration. The learning topics include
continence, delirium, falls, persistent pain, and several others. The full list of module topics currently available is provided in the Appendix. Each module is intended to be a stand-alone learning experience that can be completed separately from the other modules. For each topic, a writing team was assembled to develop both the prereading and the case. Communication for seniors was determined by the Steering Group to be an important topic for health care professionals, especially with respect to hearing. My purpose in writing this personal reflection is to describe some of the “how” and the “what” that made the collaboration work for us, and in particular to identify and articulate the barriers to knowledge exchange that we encountered, along with our attempts at getting past the barriers. I recognize that my experience is unique to the situation and people involved; however, I also believe that some aspects of my experience may be helpful to others if they choose to work with PCPs. Some of the opinions I express or conclusions I draw from my experience may be able to form the basis of testable hypotheses for more formalized research.
Method Participants In this project (and consistent with principles of participatory action research/learning), there was no distinction between researchers and participants, so the authors are among the participants described. Participants were a subset of members of the Care for Elders collaboration, plus additional individuals who were recruited for their content expertise. The final team included individuals who all had clinical and/or research experience with health care for older adults. We ensured that we had both “content experts” and “context experts.” The individuals ranged in age and in experience with learning modules and came from a broad cross-section of disciplines. The team was made up of a speech-language pathologist, an audiologist, and a graduate student in audiology (together referred to as “communication specialists”), and a registered nurse, a retired medical social worker, a geriatrician whose area of interest is education, and a family physician /geriatric psychiatrist who led the Care for Elders program (together referred to as “health care professionals”). The final team member was a senior, representing her peers, who also had extensive experience with learning modules on other topics.
Module Development The prereading for the module was developed using reviews of the literature in specific areas of hearing health care, combined with evidence from clinical experience provided by the health care professionals. This two-armed approach was used because it is explicitly recommended as part of evidence-based practice in medicine, as well as by many of those concerned with clinical implementation of research evidence (e.g., Grol & Grimshaw, 2003). The prereading was written by the members of the module
development team. It was a 34-page document that included overviews of research evidence, basic information about hearing loss, and practical tips, such as good communication strategies and hearing aid troubleshooting. The learning module was developed with the intention of outlining current best practices in hearing care for older adults by health care providers within a format that would facilitate participants being able to implement the recommendations in clinical practice. There are existing educational programs for health care providers on hearing health (e.g., Bentur, Valinsky, Lemberger, Ben Moshe, & Heymann, 2012) that have been shown to be effective in changing some clinical practices and attitudes. We drew upon existing evidence and education materials, but we created our own literature review and teaching materials based on the strategies identified by the Canadian Interprofessional Health Collaborative (2009) for increasing uptake of best practice guidelines and optimizing knowledge exchange. In particular, effective knowledge exchange involves “mutual learning [that] occurs through the process of planning, producing, disseminating, applying, evaluating and revising existing or new research and leading practices resulting in evidence-informed decision making for improved health service delivery” (Canadian Interprofessional Health Collaborative, 2009, p. 34). Consistent with the recommendation that there be many opportunities for face-to-face interaction in this process, we met at least monthly for several months, with regular e-mail exchanges between meetings.
Results Challenges and Solutions This section is not meant to be a complete account of the challenges encountered but to highlight some of the more salient experiences we had as a group. Initial conversations about the scope of the document (i.e., the prereading and the case study) were very revealing; the agenda of the communication specialists was different from that of the other health care professionals, so the first step was for everyone to be clear about their expectations and what they thought was important in regard to hearing health. This meant that the communication specialists had to put aside their own beliefs about what other health professionals “should” know about hearing and hearing loss and actively listen to the questions and suggestions of the people who would be implementing the information from the module into their regular practice. The contextual factors articulated as possible barriers were (a) limited time with a patient and the need for prioritizing in that time, (b) the importance of establishing rapport and not doing any procedures considered too invasive at an initial visit, and (c) the involvement of different professionals in the care of an individual and the difficulty in ensuring continuity of care. These contextual factors were considered throughout the preparation of the module. After discussion, it was agreed that the topics listed in Table 1 would be addressed. These topics formed the basis
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Table 1. Complete contents for the module prereading. 1. Overall good communication practice with older adults, regardless of known hearing status 2. Communication disorders (especially hearing) as significant health problems a. Prevalence b. Consequences of hearing loss for the following: i. Other health care (e.g., ease of communication during an appointment with physician) ii. Safety in the home iii. Psychosocial sequelae such as depression and isolation iv. Possible confusion with dementia 3. Identifying a possible hearing loss a. What is hearing loss? (not an “all or nothing” phenomenon and therefore not always readily identifiable) i. Different types and degrees ii. Can vary by frequency b. Screening tools for hearing loss: how to implement, how to interpret 4. When and how to make appropriate referrals for follow-up a. How to find an audiologist b. When and how to make a referral or recommendation to see an audiologist 5. Basic information about the technology for management of hearing loss that could have an impact for the health care provider’s daily work a. How hearing aids work b. How Pocketalkers work and the benefits for use in routine clinical practice c. What to expect i. Realistic benefits and limitations d. Troubleshooting, insertion, and so forth 6. A guided case study
for the learning objectives and provided an outline for the evidence-based prereading for the education module. I use the framework of the topics and subtopics to narrate our discussions and highlight how and why certain decisions were made. 1. Overall good communication practice with older adults, regardless of known hearing status The “buy-in” to the topic was stronger if we included practical information that could be used with all patients. 2. Communication disorders (especially hearing) as significant health problems a. Prevalence The health care providers found it helpful to have a sense of how often they were likely to encounter untreated hearing loss among their patients. b. Consequences of hearing loss The topic titled “consequences of hearing loss” was an extremely important topic to help motivate the need for even learning about hearing loss when so many other needs were pressing for the health care provider’s time and attention. i. Other health care (e.g., ease of communication during an appointment with physician)
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As a group, we talked about how the removal of barriers to communication could improve the efficiency and effectiveness of other health care by reducing the time spent on conversation repairs or dealing with the consequences of misunderstood instructions. ii. Safety in the home Health care providers working with older adults are very concerned about helping elders to age in place rather than be institutionalized. Safety in the home is one of the major determinants of whether one can stay at home, and untreated hearing loss can interfere with safety in the home because hearing loss may cause the individual to not hear alarms or people knocking or entering the house. iii. Psychosocial sequelae such as depression and isolation iv. Possible confusion with dementia Health care providers working with elders deal with concerns about depression and dementia quite often. It is documented that hearing loss can exacerbate both depression and dementia (Genther et al., 2014; Lin, 2011; Lin et al., 2011), and, in addition, the symptoms of hearing loss overlap with both conditions. Diagnosis and treatment of hearing loss can help reduce the psychosocial consequences as well as aid in the diagnosis of depression and dementia. 3. Identifying a possible hearing loss a. What is hearing loss? i. Different types and degrees ii. Can vary by frequency To aid the physician in recognizing possible signs of hearing loss, we found that it was important to provide some information about hearing loss. In particular, it was important to clarify that there are different types and degrees of loss and that it can vary by frequency. This point was important to emphasize that hearing loss is not always easily recognizable; it is not an “all or nothing” phenomenon, and it may manifest differently across individuals. b. Screening tools for hearing loss: how to implement, how to interpret I go into this topic in a little more detail because it illustrates an interesting dynamic that occurred during the module development. We read an
evidence-based review of the literature on hearing screening tools (Yueh, Shapiro, MacLean, & Shekelle, 2003) that revealed three screening methods that resulted in high sensitivity and specificity: Hearing Handicap Inventory for the Elderly (Ventry & Weinstein, 1983), pure-tone screening using a hand-held screener, and the Whispered Voice Test (WVT; Swan & Browning, 1985). The other content experts and I had a clear preference for the pure-tone screening method and initially tried to convince the health care professionals that it would be feasible for nonaudiologists to adopt pure tones as a screening method. However, the health care professionals had a clear preference for the WVT; they said that they were already using that method. In addition, the health care professionals shared that it would be prohibitive to purchase a hand-held screener and, in particular, that it would not be practical to carry to home visits with patients. A closer look at the research literature revealed that the WVT is actually a good screening method, if an exact procedure is followed (Yueh et al., 2003). I had to set aside my own previous biases and acknowledge that the WVT could be useful, and the health care professionals had to set aside what they thought the WVT was and learn the correct procedure. Ultimately, all three screening methods were included in the learning module as feasible options, with pros and cons of each one listed, so that individual practitioners have the necessary information to make a decision regarding which protocol will best fit with their clinical practice. The role of clinical experience in evidence-based practice becomes very important, then, for the clinician to choose the screening method that works best with his or her situation. 4. When and how to make appropriate referrals for follow-up a. How to find an audiologist b. When and how to make a referral or recommendation to see an audiologist This information will vary by region, but it is important information to include to ensure that a lack of ready information does not become a barrier to the next step. 5. Basic information about the technology for management of hearing loss that could have an impact for health care providers’ daily work a. How hearing aids work b. How the Pocketalker® works and the benefits for use in routine clinical practice c. What to expect i. Realistic benefits and limitations
d. Troubleshooting, insertion, and so forth As we know from Jones (1993), Kochkin (n.d.), and Whichard (1998), physicians are unlikely to make referrals if they do not think that hearing aids will work. We found it helpful to include some basic information about what hearing aids can and cannot do, and the outcomes that can be expected, in order to help motivate the referrals to happen. Particularly for PCPs working directly with clients with hearing loss, we gave some basic information about how to troubleshoot a hearing aid, check the battery, and insert the hearing aid, all of which can increase efficiency in an appointment. Finally, in acknowledgment of the PCPs’ enthusiasm for Pocketalkers in their own practice, we included a short section on these devices, how they can be obtained, and how they can be used clinically if the communication is less than ideal. 6. Finally, all of these topics were illustrated with a guided case study.
Other Outcomes: Further Opportunities for Knowledge Exchange Evidence that the team functioned well comes from our willingness to continue collaborating on research and educational projects. At least two research projects have been conducted as a result of the collaborative process, both addressing hearing health care for older adults, with further projects in the planning stages. The research questions themselves emerged from the literature reviews conducted for the module prereading. One area of research involves collaboration between audiology, geriatric medicine, and geriatric psychiatry to investigate the consequences of untreated hearing loss (specifically depressive symptoms) in older adults who have not sought care for their hearing loss (MacDonald, Jenstad, & Donnelly, 2014). A second area of research involves collaboration between audiology, speechlanguage pathology, and social work to investigate facilitators and barriers to hearing aid uptake in older adults (Winsor, Jenstad, Sims-Gould, & Purves, 2014). Another activity that has been a direct result of the team described here is an annual interprofessional educational event. Every year the audiology students invite residents from the Geriatric Medicine program to attend a 1.5-hr discussion, as part of the “Hearing and Aging” course in the audiology curriculum. The structure can vary, depending on the needs of the participants each year, but generally, the residents informally tell the audiology students about geriatric medicine and their role within the health care system. They answer questions from the audiology students about specific issues with caring for elders. Then the audiology students provide information, generally following the topics outlined in Table 1 along with hands-on training with troubleshooting and inserting hearing aids. Because this is a class that the audiology students
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are evaluated on, the students have to track down the information themselves rather than extract it from the prereading for the module, but I do provide them with the outline of topics used in the prereading. Having run this session for several years now, I can see that the topics continue to be powerful motivators for sparking discussion regarding hearing health care.
Pilot Evaluation of Module For the sake of a complete picture, I present some of the evaluation results from initial runs of the module. According to the Care for Elders model, each module is pilottested three times before being considered complete; ongoing evaluations are used to revise the modules as needed. The first pilot test of this module was a complete runthrough of the case with the authors of the module, who were all very familiar with the content of the prereading. No ratings were obtained from this pilot group; instead, comments and suggestions from the group were incorporated into revisions. The suggestions were generally along the lines of improved wording of questions, prompts for the facilitator, or material that needed to be added or removed in order to improve flow. These revisions were made prior to the next two pilot groups. Pilot Group 2 consisted of four practicing health care professionals and medical residents, and Pilot Group 3 consisted of five practicing health care professionals. Both pilot groups were facilitated by trained nonexpert facilitators, as recommended by Care for Elders. The ratings provided by these two groups of participants are given in Table 2. The table shows the item to be rated in the left-hand column. The next four columns are the possible rating categories (ranging from strongly disagree to strongly agree). The numbers in each column show the number of participants who chose each rating.
Most ratings fell within the somewhat agree to strongly agree categories, indicating positive ratings for all items rated. Only two ratings of somewhat disagree were obtained. One somewhat disagree rating pertained to the “organization, room, and timing,” and the comment in response to the question about how the session could have been improved was “slightly bigger room.” The other somewhat disagree rating was in response to the statement “The prereading package covered information that was new to me.” Without knowing the background of that individual, it is difficult to interpret the reason for that response. However, given that the remainder of the pilot group participants agreed that the information was new, it seems that we were on track with the level of information provided.
Conclusions and Hypotheses for Future Work Through this experience, I have consistently observed two pieces of information to be important when it comes to motivating change with regard to PCPs’ behavior regarding hearing health care for older adults. Both pieces of information relate to establishing the importance of hearing health within the context of all that needs to be done (multiple priorities) for older adults presenting in the physician’s office. The first piece of information was detailing the overlap in symptoms between hearing loss, depression, and dementia. Depression and dementia are prevalent (dementia: 5%–7% of adults 60 years of age and over, World Health Organization, 2012; depressive disorders: 3%–4.5%, Aziz & Steffens, 2013) and, frankly, worrying in this population. If some or all of the worrying symptoms are found to be hearing loss, that can actually be a relief. The second piece of information was the importance of hearing for the general efficiency of client care within the physician’s office. It may be obvious to audiologists that good hearing will contribute to smooth oral conversation about other health
Table 2. Evaluations from Pilot Group 2 (N = 4) and Pilot Group 3 (N = 5). Item rated
Strongly disagree
Somewhat disagree
The organization, room, and timing of the session were adequate. The prereading package covered information that was new to me. The prereading package was well organized and easy to read. Today’s session did improve my knowledge of interdisciplinary roles, responsibilities, and team dynamics. The facilitator was effective in keeping discussion moving forward. The facilitator provided new, critical information as needed. The case complexity or difficulty was appropriate for my level. The discussion in my group was helpful for my learning.
Neutral
Somewhat agree
Strongly agree
1
1
7
1
1
7
1
8
2
7
1
8
2
7
1 1
8 1
Note. Numbers shown are the number of participants (collapsed across the two groups) who chose each rating.
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issues, but it does not always seem obvious to others. We can make the case that if hearing loss is identified and treated, the conversation in the physician’s office will need fewer conversation repairs (thus saving time), and there is likely a reduced chance for misunderstandings that have possibly serious consequences. As I have outlined above, I learned many other things along the way, but I would like to emphasize these two. The biggest barrier to willingness to learn about hearing care is that it does not seem important in the context of other health needs. Once we start with the evidence regarding the importance of hearing health, I think we have created the willingness to learn and now have a base from which to begin further education.
Epilogue What I have written here are my personal opinions, based on my observations within a participatory action process. I see two immediate next steps for this general area. The first is to begin formally testing whether the two pieces of information regarding importance of hearing loss really can be used to change motivation of PCPs and thus their behavior with regard to hearing health for adults. The second next step is to add the voice and perspective that is missing in this write-up, the voice of the consumer, an essential piece for a true participatory action process (forthcoming in Holliday et al., 2014).
Acknowledgments The following individuals all made significant contributions to the learning module “Care for Elders: Communication: Hearing Loss in Elders”: Sara Alberni, Jacquie Bailey, Marcia Carr, Daniela Chifor, Andrea Cosentino, Janet Kushner Kow, Adrian Lister, Margaret McPhee, and Barbara Purves.
References Aziz, R., & Steffens, D. C. (2013). What are the causes of late-life depression? The Psychiatric Clinics of North America, 36, 497–516. doi:10.1016/j.psc.2013.08.001 Bentur, N., Valinsky, L., Lemberger, J., Ben Moshe, Y., & Heymann, A. D. (2012). Primary care intervention programme to improve early detection of hearing loss in the elderly. The Journal of Laryngology & Otology, 126, 574–579. Bero, L. A., Grilli, R., Grimshaw, J. M., Harvey, E., Oxman, A. D., Thomson, M. A., & Cochrane Effective Practice and Organization of Care Review Group. (1998). Closing the gap between research and practice: An overview of systematic reviews of interventions to promote the implementation of research findings. British Medical Journal, 317, 465–468. Canadian Interprofessional Health Collaborative. (2009). Stronger together: Collaborations for system-wide change. A knowledge exchange strategy for discussion. Retrieved from http://www.cihc.ca/files/publications/CIHC_KEStrategy_ Jan09.pdf Danhauer, J. L., Celani, K. E., & Johnson, C. E. (2008). Use of a hearing and balance screening survey with local primary
care physicians. American Journal of Audiology, 17, 3–13. doi:10.1044/1059-0889(2008/002) Davis, A., Smith, P. A., Booth, M., & Martin, M. (2012). Diagnosing patients with age-related hearing loss and tinnitus: Supporting GP clinical engagement through innovation and pathway redesign in audiology services. International Journal of Otolaryngology, 2012, 290291. doi:10.1155/2012/ 290291 Davis, D. A., Thomson, M. A., Oxman, A. D., & Haynes, R. B. (1995). Changing physician performance: A systematic review of the effect of continuing medical education strategies. JAMA: The Journal of the American Medical Association, 274, 700–705. Genther, D. J., Betz, J., Pratt, S., Kritchevsky, S. B., Martin, K. R., Harris, T. B., . . . Lin, F. R. (2014). Association of hearing impairment and mortality in older adults. Journal of Gerontology: Series A: Biological Sciences and Medical Sciences, 70, 85–90. Gilliver, M., & Hickson, L. (2011). Medical practitioners’ attitudes to hearing rehabilitation for older adults. International Journal of Audiology, 50, 850–856. doi:10.3109/14992027.2011. 601468 Glasgow, R. E., & Emmons, K. M. (2007). How can we increase translation of research into practice? Types of evidence needed. Annual Review of Public Health, 28, 413–433. doi:10.1146/ annurev.publhealth.28.021406.144145 Glasgow, R. E., Lichtenstein, E., & Marcus, A. C. (2003). Why don’t we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. American Journal of Public Health, 93, 1261–1267. Grol, R., & Grimshaw, J. (2003). From best evidence to best practice: Effective implementation of change in patients’ care. The Lancet, 362, 1225–1230. doi:10.1016/S0140-6736(03) 14546-1 Hills, M., Mullett, J., & Carroll, S. (2007). Community-based participatory action research: Transforming multidisciplinary practice in primary health care. Revista Panamericana de Salud Publica, 21, 125–135. Holliday, H., Jenstad, L. M., Grosjean, G., & Purves, B. (2014). “You can lead a horse to water . . .”: Focus group perspectives on initiating and supporting hearing health change in older adults. Manuscript submitted for publication. Johnson, C. E., Danhauer, J. L., Koch, L. L., Celani, K. E., Lopez, I. P., & Williams, V. A. (2008). Hearing and balance screening and referrals for Medicare patients: A national survey of primary care physicians. Journal of the American Academy of Audiology, 19, 171–190. doi:10.3766/jaaa.19.2.7 Jones, M. R. (1993). The primary-care physician: Obstacle or opportunity in hearing health care? The Hearing Journal, 46, 23–28. Kidd, S. A., & Kral, M. J. (2005). Practicing participatory action research. Journal of Counseling Psychology, 52, 187–195. doi:10.1037/0022-0167.52.2.187 Kochkin, S. (n.d.). Myths about hearing loss. Retrieved from http://www.betterhearing.org/hearing_loss/myths_about_ hearing_loss/index.cfm Lin, F. R. (2011). Hearing loss and cognition among older adults in the United States. Journal of Gerontology: Series A: Biological Sciences and Medical Sciences, 66, 1131–1136. doi:10.1093/ gerona/glr115 Lin, F. R., Ferrucci, L., Metter, E. J., An, Y., Zonderman, A. B., & Resnick, S. M. (2011). Hearing loss and cognition in the Baltimore Longitudinal Study of Aging. Neuropsychology, 25, 763–770. doi:10.1037/a0024238
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MacDonald, M., Jenstad, L. M., & Donnelly, M. (2014). Consequences of untreated hearing loss. Manuscript in preparation. McCullagh, M. C., & Frank, K. (2013). Addressing adult hearing loss in primary care. Journal of Advanced Nursing, 69, 896–904. doi:10.1111/j.1365-2648.2012.06078.x Nash, R. (2004). Liberating scholarly writing: The power of personal narrative. New York, NY: Teachers College Press. Nash, R. J., & Bradley, D. L. (2012). The writer is at the center of the scholarship: Partnering me-search and research. About Campus, 17, 2–11. doi:10.1002/abc.21067 Oxman, A. D., Thomson, M. A., Davis, D. A., & Haynes, R. B. (1995). No magic bullets: A systematic review of 102 trials of interventions to improve professional practice. Canadian Medical Association Journal, 153, 1423–1431. Popp, P., & Hackett, G. (2002). Survey of primary care physicians: Hearing loss identification and counseling. Retrieved from http://www.audiologyonline.com/articles/survey-primary-carephysicians-hearing-1179 Schneider, J. M., Gopinath, B., McMahon, C. M., Britt, H. C., Harrison, C. M., Usherwood, T., . . . Mitchell, P. (2010). Role of general practitioners in managing age-related hearing loss. Medical Journal of Australia, 192, 20–23. Shames, Y., & Simpson, J. (2012). Audiology’s struggle for independence. The Hearing Journal, 65(5), 26–30. doi:10.1097/01. HJ.0000414384.90116.b0
Stuttaford, M., & Coe, C. (2007). The “learning” component of participatory learning and action in health research: Reflections from a local sure start evaluation. Qualitative Health Research, 17, 1351–1360. doi:10.1177/1049732307306965 Swan, I. R., & Browning, G. G. (1985). The whispered voice as a screening test for hearing impairment. Journal of the Royal College of General Practitioners, 35, 197. Ventry, I. M., & Weinstein, B. E. (1983). Identification of elderly people with hearing problems. American Journal of SpeechLanguage Pathology, 25, 37–42. Wallhagen, M. I., & Pettengill, E. (2008). Hearing impairment: Significant but underassessed in primary care settings. Journal of Gerontological Nursing, 34, 36–42. Whichard, S. (1998). Gaining referrals through a physician marketing program. Hearing Review, 5, 12–16, 43. Winsor, D., Jenstad, L. M., Sims-Gould, J., & Purves, B. (2014). Barriers and facilitators to hearing aid uptake in older adults: A qualitative study. Manuscript in preparation. World Health Organization. (2012). Dementia: A public health priority. Retrieved from http://whqlibdoc.who.int/publications/ 2012/9789241564458_eng.pdf Yueh, B., Shapiro, N., MacLean, C. H., & Shekelle, P. G. (2003). Screening and management of adult hearing loss in primary care: Scientific review. JAMA: The Journal of the American Medical Association, 289, 1976–1985. doi:10.1001/jama.289.15.1976
Appendix Full List of Topics Available in the Care for Elders Module Series Successful Aging Interprofessional Team Work Falls Medications and the Older Adult Chronic Neurological Disorders Depression and Grief Dementia I (Early) Dementia II (Late) Delirium Persistent Pain Palliative Care Informal Support Systems Continence Nutrition, Oral Health, and Dysphagia Patient Safety Communication: Hearing Loss in Elders British Columbia (BC) Incapability Assessment I and II Interprofessional Collaborative Practice—Residential Care Context Interprofessional Collaborative Practice—Acute Care Context Note. Further information about the modules, access to prereading, facilitator instructions, and contact information for obtaining the full modules can be found at http://www.elearning.chd.ubc.ca /.
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Clinical Focus
Hearing Care for Elders: A Personal Reflection on Participatory Action Learning With Primary Care Providers Lorienne M. Jenstada and Martha Donnellya
Purpose: This report is a reflective critical narrative of the authors’ experience with an interdisciplinary collaboration of primary care providers (PCPs) and hearing health care providers (HHCPs) that followed the principles of participatory action research/learning. The goal for this report is to describe the 1st author’s observed barriers to PCPs’ willingness to learn about hearing health care and the subsequent facilitators to learning. Method: A team of PCPs and HHCPs created the “Communication: Hearing Loss in Elders” educational module. The module included (a) prereading developed from a combination of literature reviews and contextual factors and (b) a case study.
Results: The authors present the list of topics included in the module, and they reflect on why and how these topics were deemed important by the team. In particular, 2 topics were identified for motivating PCPs’ behavior regarding hearing health care: (a) the overlap in symptoms and possible causation among depression, dementia, and hearing loss and (b) how hearing can affect efficiency of care regarding other health issues. Conclusions: This personal reflective narrative gives the authors’ opinions about what can make for a successful collaboration and presents some hypotheses regarding information that may motivate behavior change with regard to hearing care.
C
Hackett (2002), in an article written for audiologists, stated that “in order for primary care physicians to perform effectively in the role of ‘hearing healthcare gatekeepers,’ substantial changes will have to take place” (para. 4). There is certainly some research evidence to support the audiologists’ view of physicians. The majority of physicians are unlikely to spontaneously raise the topic of hearing health with their patients, and when patients raise concerns themselves, the concerns are often dismissed by the physicians (Wallhagen & Pettengill, 2008). Of individuals who raised concerns with their primary care practitioner, only 6.4% reported receiving help or a referral (Schneider et al., 2010). On the other hand, the majority of physicians surveyed were aware of the prevalence of age-related hearing loss and its consequences (Gilliver & Hickson, 2011). Two thirds of physicians surveyed disagreed that hearing loss was a low-priority health concern (Danhauer, Celani, & Johnson, 2008). Similarly, Johnson et al. (2008) found that primary care physicians felt that hearing and balance were important in older adults but did not have enough time or reimbursement to conduct a screening. This evidence shows that there are discrepancies about the importance and understanding of age-related
an audiologists and primary care providers (PCPs, such as physicians or nurses) be good partners in hearing health care for older adults? I (Lorienne M. Jenstad) have heard from many colleagues that audiologists need to be independent of physicians and that the way forward in adult hearing screening and hearing care for older adults is for audiologists to take charge. When I talk about my work with physicians, I am usually met with skepticism and doubt that hearing care for elders could be within the scope of practice for physicians. My experience shows that it is possible. Some published opinion pieces, written by or for audiologists, express the view that audiology should work independently from physicians, pointing to the “public devaluing of audiology” by the American Medical Association (Shames & Simpson, 2012, p. 30), negative recommendations regarding amplification by physicians (Jones, 1993), and discouraging advice given in response to patients’ questions about hearing care (Whichard, 1998). Popp and
a
University of British Columbia, Vancouver, Canada
Correspondence to Lorienne M. Jenstad: [email protected] Editor and Associate Editor: Larry Humes Received October 3, 2014 Revision received November 17, 2014 Accepted November 21, 2014 DOI: 10.1044/2014_AJA-14-0051
Disclosure: The authors have declared that no competing interests existed at the time of publication.
American Journal of Audiology • Vol. 24 • 23–30 • March 2015 • Copyright © 2015 American Speech-Language-Hearing Association
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hearing loss to physicians. The reality is that if people are starting to notice difficulties with their hearing, they are likely to go see a physician first, rather than an audiologist, as first point of entry into the system (e.g., A. Davis, Smith, Booth, & Martin, 2012; Holliday, Jenstad, Grosjean, & Purves, 2014). I am also noticing more suggestions that we need to start using physicians or other PCPs (e.g., nurses, nurse practitioners) for conducting hearing screenings (e.g., A. Davis et al., 2012; McCullagh & Frank, 2013; G. Saunders, personal communication, August 2014). My goal in writing this article is to narrate my own experience of working with PCPs toward the common goal of hearing care for older adults. I had some false starts and missteps along the way. My own preconceptions got in the way of listening and finding ways for productive partnership. In the end, our collaborations were successful. Through the process, I began to challenge my own thinking about what was possible in working with other health care providers. I had to face my own hubris about “knowing” what was best. At first, I worked on finding ways to communicate “my truth” to the audience. Then, over time, I began to realize that it was not just a communication issue but an issue of being too certain. I had to examine the evidence that I believed to be true and to realize that there were actually different ways of interpreting the same results and a need to modify recommendations based on the context. I am telling this experience in the form of a scholarly personal narrative, rather than a traditional research report, because I cannot separate myself from the process that happened and because my own perspective and thinking changed through the work described here. The scholarly personal narrative uses first person voice to allow the researcher’s story to be told, as a way of exploring hypotheses and illustrating themes (e.g., Nash & Bradley, 2012).
Why Participatory Action Learning? Evidence shows that translation from research to practice across many fields is poorly done (e.g., Glasgow & Emmons, 2007; Glasgow, Lichtenstein, & Marcus, 2003), with consistent gaps identified between research evidence and practice standards (Grol & Grimshaw, 2003). Traditional information dissemination includes review articles, clinical guidelines, continuing education courses, and conferences. However, Grol and Grimshaw (2003), among others (e.g., Bero et al., 1998; D. A. Davis, Thomson, Oxman, & Haynes, 1995; Oxman, Thomson, Davis, & Haynes, 1995), suggest that creativity may be needed in finding new ways to disseminate health care research knowledge, particularly using individualized knowledge transfer that accounts for contextual factors. Participatory action research/learning is promoted as an approach that can potentially meet these challenges (e.g., Hills, Mullett, & Carroll, 2007; Kidd & Kral, 2005; Stuttaford & Coe, 2007) because both researchers and participants are involved in creating the questions and focus. Together, they create a context in which knowledge is generated or reviewed, and thus the knowledge is seen as highly applicable to the problem under consideration.
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A participatory approach becomes very important when developing protocols that might be used with vulnerable or high-risk populations where there are many competing demands for the clinician’s time, such as older adults with multiple complex health needs. There are two authors of this article. What follows is the first author’s reflective narrative regarding the process of developing educational materials on hearing health together with PCPs. The narrative is written in first person to show that the information is written from the personal perspective of the author (Lorienne M. Jenstad). The structure is similar to a framework used by Stuttaford and Coe (2007), who wrote a reflection article on the learning that happens for participants involved in participatory action research / learning. It also draws heavily from Nash’s (2004) book on the scholarly personal narrative. The second author (Martha Donnelly) is a geriatric psychiatrist who was intimately involved in the process described in this article. She wrote some of the text describing the collaboration and the educational module. In addition, she read, commented on, and ultimately accepted the narrative. It was important to me to have her input to ensure that it was a faithful telling of the events that happened. The second author was also the director of the Care for Elders collaboration, out of which the team and educational efforts described here began. Care for Elders was an interdisciplinary health care collaboration centered in the Department of Family Practice at the University of British Columbia within the Special Interest Focused Practice of Community Geriatrics. Funding was from a special populations grant to the university’s Medical School from the British Columbia Ministry of Health. The overall vision of the Care for Elders collaboration was that every British Columbia senior would have access to informed interprofessional teams focused on maximizing the functioning of seniors. The Care for Elders collaboration’s main activity was providing education for health care providers. The primary vehicle for achieving the collaboration’s vision was education of health care professionals through small-group, case-based learning modules on complex health care challenges affecting older adults in particular. Each learning module begins with an evidencebased prereading required for participants before they attend small groups (approximately 10 health care professionals) to work through a case study. Case discussion can be facilitated by a nonexpert facilitator, and cases take about 2 hr to complete, including an evaluation of learning. Nonexpert facilitation is facilitation by health care professionals who are not necessarily content experts in the module topic but rather who are trained to facilitate group discussions. A simple educational pamphlet and video were used to teach facilitation. The use of nonexpert facilitators means the modules can be used anywhere in the province or country where a small group wishes to learn about a particular topic. The individual topics for learning were chosen by a Care for Elders Steering Group representing all of the disciplines within the collaboration. The learning topics include
continence, delirium, falls, persistent pain, and several others. The full list of module topics currently available is provided in the Appendix. Each module is intended to be a stand-alone learning experience that can be completed separately from the other modules. For each topic, a writing team was assembled to develop both the prereading and the case. Communication for seniors was determined by the Steering Group to be an important topic for health care professionals, especially with respect to hearing. My purpose in writing this personal reflection is to describe some of the “how” and the “what” that made the collaboration work for us, and in particular to identify and articulate the barriers to knowledge exchange that we encountered, along with our attempts at getting past the barriers. I recognize that my experience is unique to the situation and people involved; however, I also believe that some aspects of my experience may be helpful to others if they choose to work with PCPs. Some of the opinions I express or conclusions I draw from my experience may be able to form the basis of testable hypotheses for more formalized research.
Method Participants In this project (and consistent with principles of participatory action research/learning), there was no distinction between researchers and participants, so the authors are among the participants described. Participants were a subset of members of the Care for Elders collaboration, plus additional individuals who were recruited for their content expertise. The final team included individuals who all had clinical and/or research experience with health care for older adults. We ensured that we had both “content experts” and “context experts.” The individuals ranged in age and in experience with learning modules and came from a broad cross-section of disciplines. The team was made up of a speech-language pathologist, an audiologist, and a graduate student in audiology (together referred to as “communication specialists”), and a registered nurse, a retired medical social worker, a geriatrician whose area of interest is education, and a family physician /geriatric psychiatrist who led the Care for Elders program (together referred to as “health care professionals”). The final team member was a senior, representing her peers, who also had extensive experience with learning modules on other topics.
Module Development The prereading for the module was developed using reviews of the literature in specific areas of hearing health care, combined with evidence from clinical experience provided by the health care professionals. This two-armed approach was used because it is explicitly recommended as part of evidence-based practice in medicine, as well as by many of those concerned with clinical implementation of research evidence (e.g., Grol & Grimshaw, 2003). The prereading was written by the members of the module
development team. It was a 34-page document that included overviews of research evidence, basic information about hearing loss, and practical tips, such as good communication strategies and hearing aid troubleshooting. The learning module was developed with the intention of outlining current best practices in hearing care for older adults by health care providers within a format that would facilitate participants being able to implement the recommendations in clinical practice. There are existing educational programs for health care providers on hearing health (e.g., Bentur, Valinsky, Lemberger, Ben Moshe, & Heymann, 2012) that have been shown to be effective in changing some clinical practices and attitudes. We drew upon existing evidence and education materials, but we created our own literature review and teaching materials based on the strategies identified by the Canadian Interprofessional Health Collaborative (2009) for increasing uptake of best practice guidelines and optimizing knowledge exchange. In particular, effective knowledge exchange involves “mutual learning [that] occurs through the process of planning, producing, disseminating, applying, evaluating and revising existing or new research and leading practices resulting in evidence-informed decision making for improved health service delivery” (Canadian Interprofessional Health Collaborative, 2009, p. 34). Consistent with the recommendation that there be many opportunities for face-to-face interaction in this process, we met at least monthly for several months, with regular e-mail exchanges between meetings.
Results Challenges and Solutions This section is not meant to be a complete account of the challenges encountered but to highlight some of the more salient experiences we had as a group. Initial conversations about the scope of the document (i.e., the prereading and the case study) were very revealing; the agenda of the communication specialists was different from that of the other health care professionals, so the first step was for everyone to be clear about their expectations and what they thought was important in regard to hearing health. This meant that the communication specialists had to put aside their own beliefs about what other health professionals “should” know about hearing and hearing loss and actively listen to the questions and suggestions of the people who would be implementing the information from the module into their regular practice. The contextual factors articulated as possible barriers were (a) limited time with a patient and the need for prioritizing in that time, (b) the importance of establishing rapport and not doing any procedures considered too invasive at an initial visit, and (c) the involvement of different professionals in the care of an individual and the difficulty in ensuring continuity of care. These contextual factors were considered throughout the preparation of the module. After discussion, it was agreed that the topics listed in Table 1 would be addressed. These topics formed the basis
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Table 1. Complete contents for the module prereading. 1. Overall good communication practice with older adults, regardless of known hearing status 2. Communication disorders (especially hearing) as significant health problems a. Prevalence b. Consequences of hearing loss for the following: i. Other health care (e.g., ease of communication during an appointment with physician) ii. Safety in the home iii. Psychosocial sequelae such as depression and isolation iv. Possible confusion with dementia 3. Identifying a possible hearing loss a. What is hearing loss? (not an “all or nothing” phenomenon and therefore not always readily identifiable) i. Different types and degrees ii. Can vary by frequency b. Screening tools for hearing loss: how to implement, how to interpret 4. When and how to make appropriate referrals for follow-up a. How to find an audiologist b. When and how to make a referral or recommendation to see an audiologist 5. Basic information about the technology for management of hearing loss that could have an impact for the health care provider’s daily work a. How hearing aids work b. How Pocketalkers work and the benefits for use in routine clinical practice c. What to expect i. Realistic benefits and limitations d. Troubleshooting, insertion, and so forth 6. A guided case study
for the learning objectives and provided an outline for the evidence-based prereading for the education module. I use the framework of the topics and subtopics to narrate our discussions and highlight how and why certain decisions were made. 1. Overall good communication practice with older adults, regardless of known hearing status The “buy-in” to the topic was stronger if we included practical information that could be used with all patients. 2. Communication disorders (especially hearing) as significant health problems a. Prevalence The health care providers found it helpful to have a sense of how often they were likely to encounter untreated hearing loss among their patients. b. Consequences of hearing loss The topic titled “consequences of hearing loss” was an extremely important topic to help motivate the need for even learning about hearing loss when so many other needs were pressing for the health care provider’s time and attention. i. Other health care (e.g., ease of communication during an appointment with physician)
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As a group, we talked about how the removal of barriers to communication could improve the efficiency and effectiveness of other health care by reducing the time spent on conversation repairs or dealing with the consequences of misunderstood instructions. ii. Safety in the home Health care providers working with older adults are very concerned about helping elders to age in place rather than be institutionalized. Safety in the home is one of the major determinants of whether one can stay at home, and untreated hearing loss can interfere with safety in the home because hearing loss may cause the individual to not hear alarms or people knocking or entering the house. iii. Psychosocial sequelae such as depression and isolation iv. Possible confusion with dementia Health care providers working with elders deal with concerns about depression and dementia quite often. It is documented that hearing loss can exacerbate both depression and dementia (Genther et al., 2014; Lin, 2011; Lin et al., 2011), and, in addition, the symptoms of hearing loss overlap with both conditions. Diagnosis and treatment of hearing loss can help reduce the psychosocial consequences as well as aid in the diagnosis of depression and dementia. 3. Identifying a possible hearing loss a. What is hearing loss? i. Different types and degrees ii. Can vary by frequency To aid the physician in recognizing possible signs of hearing loss, we found that it was important to provide some information about hearing loss. In particular, it was important to clarify that there are different types and degrees of loss and that it can vary by frequency. This point was important to emphasize that hearing loss is not always easily recognizable; it is not an “all or nothing” phenomenon, and it may manifest differently across individuals. b. Screening tools for hearing loss: how to implement, how to interpret I go into this topic in a little more detail because it illustrates an interesting dynamic that occurred during the module development. We read an
evidence-based review of the literature on hearing screening tools (Yueh, Shapiro, MacLean, & Shekelle, 2003) that revealed three screening methods that resulted in high sensitivity and specificity: Hearing Handicap Inventory for the Elderly (Ventry & Weinstein, 1983), pure-tone screening using a hand-held screener, and the Whispered Voice Test (WVT; Swan & Browning, 1985). The other content experts and I had a clear preference for the pure-tone screening method and initially tried to convince the health care professionals that it would be feasible for nonaudiologists to adopt pure tones as a screening method. However, the health care professionals had a clear preference for the WVT; they said that they were already using that method. In addition, the health care professionals shared that it would be prohibitive to purchase a hand-held screener and, in particular, that it would not be practical to carry to home visits with patients. A closer look at the research literature revealed that the WVT is actually a good screening method, if an exact procedure is followed (Yueh et al., 2003). I had to set aside my own previous biases and acknowledge that the WVT could be useful, and the health care professionals had to set aside what they thought the WVT was and learn the correct procedure. Ultimately, all three screening methods were included in the learning module as feasible options, with pros and cons of each one listed, so that individual practitioners have the necessary information to make a decision regarding which protocol will best fit with their clinical practice. The role of clinical experience in evidence-based practice becomes very important, then, for the clinician to choose the screening method that works best with his or her situation. 4. When and how to make appropriate referrals for follow-up a. How to find an audiologist b. When and how to make a referral or recommendation to see an audiologist This information will vary by region, but it is important information to include to ensure that a lack of ready information does not become a barrier to the next step. 5. Basic information about the technology for management of hearing loss that could have an impact for health care providers’ daily work a. How hearing aids work b. How the Pocketalker® works and the benefits for use in routine clinical practice c. What to expect i. Realistic benefits and limitations
d. Troubleshooting, insertion, and so forth As we know from Jones (1993), Kochkin (n.d.), and Whichard (1998), physicians are unlikely to make referrals if they do not think that hearing aids will work. We found it helpful to include some basic information about what hearing aids can and cannot do, and the outcomes that can be expected, in order to help motivate the referrals to happen. Particularly for PCPs working directly with clients with hearing loss, we gave some basic information about how to troubleshoot a hearing aid, check the battery, and insert the hearing aid, all of which can increase efficiency in an appointment. Finally, in acknowledgment of the PCPs’ enthusiasm for Pocketalkers in their own practice, we included a short section on these devices, how they can be obtained, and how they can be used clinically if the communication is less than ideal. 6. Finally, all of these topics were illustrated with a guided case study.
Other Outcomes: Further Opportunities for Knowledge Exchange Evidence that the team functioned well comes from our willingness to continue collaborating on research and educational projects. At least two research projects have been conducted as a result of the collaborative process, both addressing hearing health care for older adults, with further projects in the planning stages. The research questions themselves emerged from the literature reviews conducted for the module prereading. One area of research involves collaboration between audiology, geriatric medicine, and geriatric psychiatry to investigate the consequences of untreated hearing loss (specifically depressive symptoms) in older adults who have not sought care for their hearing loss (MacDonald, Jenstad, & Donnelly, 2014). A second area of research involves collaboration between audiology, speechlanguage pathology, and social work to investigate facilitators and barriers to hearing aid uptake in older adults (Winsor, Jenstad, Sims-Gould, & Purves, 2014). Another activity that has been a direct result of the team described here is an annual interprofessional educational event. Every year the audiology students invite residents from the Geriatric Medicine program to attend a 1.5-hr discussion, as part of the “Hearing and Aging” course in the audiology curriculum. The structure can vary, depending on the needs of the participants each year, but generally, the residents informally tell the audiology students about geriatric medicine and their role within the health care system. They answer questions from the audiology students about specific issues with caring for elders. Then the audiology students provide information, generally following the topics outlined in Table 1 along with hands-on training with troubleshooting and inserting hearing aids. Because this is a class that the audiology students
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are evaluated on, the students have to track down the information themselves rather than extract it from the prereading for the module, but I do provide them with the outline of topics used in the prereading. Having run this session for several years now, I can see that the topics continue to be powerful motivators for sparking discussion regarding hearing health care.
Pilot Evaluation of Module For the sake of a complete picture, I present some of the evaluation results from initial runs of the module. According to the Care for Elders model, each module is pilottested three times before being considered complete; ongoing evaluations are used to revise the modules as needed. The first pilot test of this module was a complete runthrough of the case with the authors of the module, who were all very familiar with the content of the prereading. No ratings were obtained from this pilot group; instead, comments and suggestions from the group were incorporated into revisions. The suggestions were generally along the lines of improved wording of questions, prompts for the facilitator, or material that needed to be added or removed in order to improve flow. These revisions were made prior to the next two pilot groups. Pilot Group 2 consisted of four practicing health care professionals and medical residents, and Pilot Group 3 consisted of five practicing health care professionals. Both pilot groups were facilitated by trained nonexpert facilitators, as recommended by Care for Elders. The ratings provided by these two groups of participants are given in Table 2. The table shows the item to be rated in the left-hand column. The next four columns are the possible rating categories (ranging from strongly disagree to strongly agree). The numbers in each column show the number of participants who chose each rating.
Most ratings fell within the somewhat agree to strongly agree categories, indicating positive ratings for all items rated. Only two ratings of somewhat disagree were obtained. One somewhat disagree rating pertained to the “organization, room, and timing,” and the comment in response to the question about how the session could have been improved was “slightly bigger room.” The other somewhat disagree rating was in response to the statement “The prereading package covered information that was new to me.” Without knowing the background of that individual, it is difficult to interpret the reason for that response. However, given that the remainder of the pilot group participants agreed that the information was new, it seems that we were on track with the level of information provided.
Conclusions and Hypotheses for Future Work Through this experience, I have consistently observed two pieces of information to be important when it comes to motivating change with regard to PCPs’ behavior regarding hearing health care for older adults. Both pieces of information relate to establishing the importance of hearing health within the context of all that needs to be done (multiple priorities) for older adults presenting in the physician’s office. The first piece of information was detailing the overlap in symptoms between hearing loss, depression, and dementia. Depression and dementia are prevalent (dementia: 5%–7% of adults 60 years of age and over, World Health Organization, 2012; depressive disorders: 3%–4.5%, Aziz & Steffens, 2013) and, frankly, worrying in this population. If some or all of the worrying symptoms are found to be hearing loss, that can actually be a relief. The second piece of information was the importance of hearing for the general efficiency of client care within the physician’s office. It may be obvious to audiologists that good hearing will contribute to smooth oral conversation about other health
Table 2. Evaluations from Pilot Group 2 (N = 4) and Pilot Group 3 (N = 5). Item rated
Strongly disagree
Somewhat disagree
The organization, room, and timing of the session were adequate. The prereading package covered information that was new to me. The prereading package was well organized and easy to read. Today’s session did improve my knowledge of interdisciplinary roles, responsibilities, and team dynamics. The facilitator was effective in keeping discussion moving forward. The facilitator provided new, critical information as needed. The case complexity or difficulty was appropriate for my level. The discussion in my group was helpful for my learning.
Neutral
Somewhat agree
Strongly agree
1
1
7
1
1
7
1
8
2
7
1
8
2
7
1 1
8 1
Note. Numbers shown are the number of participants (collapsed across the two groups) who chose each rating.
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issues, but it does not always seem obvious to others. We can make the case that if hearing loss is identified and treated, the conversation in the physician’s office will need fewer conversation repairs (thus saving time), and there is likely a reduced chance for misunderstandings that have possibly serious consequences. As I have outlined above, I learned many other things along the way, but I would like to emphasize these two. The biggest barrier to willingness to learn about hearing care is that it does not seem important in the context of other health needs. Once we start with the evidence regarding the importance of hearing health, I think we have created the willingness to learn and now have a base from which to begin further education.
Epilogue What I have written here are my personal opinions, based on my observations within a participatory action process. I see two immediate next steps for this general area. The first is to begin formally testing whether the two pieces of information regarding importance of hearing loss really can be used to change motivation of PCPs and thus their behavior with regard to hearing health for adults. The second next step is to add the voice and perspective that is missing in this write-up, the voice of the consumer, an essential piece for a true participatory action process (forthcoming in Holliday et al., 2014).
Acknowledgments The following individuals all made significant contributions to the learning module “Care for Elders: Communication: Hearing Loss in Elders”: Sara Alberni, Jacquie Bailey, Marcia Carr, Daniela Chifor, Andrea Cosentino, Janet Kushner Kow, Adrian Lister, Margaret McPhee, and Barbara Purves.
References Aziz, R., & Steffens, D. C. (2013). What are the causes of late-life depression? The Psychiatric Clinics of North America, 36, 497–516. doi:10.1016/j.psc.2013.08.001 Bentur, N., Valinsky, L., Lemberger, J., Ben Moshe, Y., & Heymann, A. D. (2012). Primary care intervention programme to improve early detection of hearing loss in the elderly. The Journal of Laryngology & Otology, 126, 574–579. Bero, L. A., Grilli, R., Grimshaw, J. M., Harvey, E., Oxman, A. D., Thomson, M. A., & Cochrane Effective Practice and Organization of Care Review Group. (1998). Closing the gap between research and practice: An overview of systematic reviews of interventions to promote the implementation of research findings. British Medical Journal, 317, 465–468. Canadian Interprofessional Health Collaborative. (2009). Stronger together: Collaborations for system-wide change. A knowledge exchange strategy for discussion. Retrieved from http://www.cihc.ca/files/publications/CIHC_KEStrategy_ Jan09.pdf Danhauer, J. L., Celani, K. E., & Johnson, C. E. (2008). Use of a hearing and balance screening survey with local primary
care physicians. American Journal of Audiology, 17, 3–13. doi:10.1044/1059-0889(2008/002) Davis, A., Smith, P. A., Booth, M., & Martin, M. (2012). Diagnosing patients with age-related hearing loss and tinnitus: Supporting GP clinical engagement through innovation and pathway redesign in audiology services. International Journal of Otolaryngology, 2012, 290291. doi:10.1155/2012/ 290291 Davis, D. A., Thomson, M. A., Oxman, A. D., & Haynes, R. B. (1995). Changing physician performance: A systematic review of the effect of continuing medical education strategies. JAMA: The Journal of the American Medical Association, 274, 700–705. Genther, D. J., Betz, J., Pratt, S., Kritchevsky, S. B., Martin, K. R., Harris, T. B., . . . Lin, F. R. (2014). Association of hearing impairment and mortality in older adults. Journal of Gerontology: Series A: Biological Sciences and Medical Sciences, 70, 85–90. Gilliver, M., & Hickson, L. (2011). Medical practitioners’ attitudes to hearing rehabilitation for older adults. International Journal of Audiology, 50, 850–856. doi:10.3109/14992027.2011. 601468 Glasgow, R. E., & Emmons, K. M. (2007). How can we increase translation of research into practice? Types of evidence needed. Annual Review of Public Health, 28, 413–433. doi:10.1146/ annurev.publhealth.28.021406.144145 Glasgow, R. E., Lichtenstein, E., & Marcus, A. C. (2003). Why don’t we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. American Journal of Public Health, 93, 1261–1267. Grol, R., & Grimshaw, J. (2003). From best evidence to best practice: Effective implementation of change in patients’ care. The Lancet, 362, 1225–1230. doi:10.1016/S0140-6736(03) 14546-1 Hills, M., Mullett, J., & Carroll, S. (2007). Community-based participatory action research: Transforming multidisciplinary practice in primary health care. Revista Panamericana de Salud Publica, 21, 125–135. Holliday, H., Jenstad, L. M., Grosjean, G., & Purves, B. (2014). “You can lead a horse to water . . .”: Focus group perspectives on initiating and supporting hearing health change in older adults. Manuscript submitted for publication. Johnson, C. E., Danhauer, J. L., Koch, L. L., Celani, K. E., Lopez, I. P., & Williams, V. A. (2008). Hearing and balance screening and referrals for Medicare patients: A national survey of primary care physicians. Journal of the American Academy of Audiology, 19, 171–190. doi:10.3766/jaaa.19.2.7 Jones, M. R. (1993). The primary-care physician: Obstacle or opportunity in hearing health care? The Hearing Journal, 46, 23–28. Kidd, S. A., & Kral, M. J. (2005). Practicing participatory action research. Journal of Counseling Psychology, 52, 187–195. doi:10.1037/0022-0167.52.2.187 Kochkin, S. (n.d.). Myths about hearing loss. Retrieved from http://www.betterhearing.org/hearing_loss/myths_about_ hearing_loss/index.cfm Lin, F. R. (2011). Hearing loss and cognition among older adults in the United States. Journal of Gerontology: Series A: Biological Sciences and Medical Sciences, 66, 1131–1136. doi:10.1093/ gerona/glr115 Lin, F. R., Ferrucci, L., Metter, E. J., An, Y., Zonderman, A. B., & Resnick, S. M. (2011). Hearing loss and cognition in the Baltimore Longitudinal Study of Aging. Neuropsychology, 25, 763–770. doi:10.1037/a0024238
Jenstad & Donnelly: Hearing Care for Elders
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MacDonald, M., Jenstad, L. M., & Donnelly, M. (2014). Consequences of untreated hearing loss. Manuscript in preparation. McCullagh, M. C., & Frank, K. (2013). Addressing adult hearing loss in primary care. Journal of Advanced Nursing, 69, 896–904. doi:10.1111/j.1365-2648.2012.06078.x Nash, R. (2004). Liberating scholarly writing: The power of personal narrative. New York, NY: Teachers College Press. Nash, R. J., & Bradley, D. L. (2012). The writer is at the center of the scholarship: Partnering me-search and research. About Campus, 17, 2–11. doi:10.1002/abc.21067 Oxman, A. D., Thomson, M. A., Davis, D. A., & Haynes, R. B. (1995). No magic bullets: A systematic review of 102 trials of interventions to improve professional practice. Canadian Medical Association Journal, 153, 1423–1431. Popp, P., & Hackett, G. (2002). Survey of primary care physicians: Hearing loss identification and counseling. Retrieved from http://www.audiologyonline.com/articles/survey-primary-carephysicians-hearing-1179 Schneider, J. M., Gopinath, B., McMahon, C. M., Britt, H. C., Harrison, C. M., Usherwood, T., . . . Mitchell, P. (2010). Role of general practitioners in managing age-related hearing loss. Medical Journal of Australia, 192, 20–23. Shames, Y., & Simpson, J. (2012). Audiology’s struggle for independence. The Hearing Journal, 65(5), 26–30. doi:10.1097/01. HJ.0000414384.90116.b0
Stuttaford, M., & Coe, C. (2007). The “learning” component of participatory learning and action in health research: Reflections from a local sure start evaluation. Qualitative Health Research, 17, 1351–1360. doi:10.1177/1049732307306965 Swan, I. R., & Browning, G. G. (1985). The whispered voice as a screening test for hearing impairment. Journal of the Royal College of General Practitioners, 35, 197. Ventry, I. M., & Weinstein, B. E. (1983). Identification of elderly people with hearing problems. American Journal of SpeechLanguage Pathology, 25, 37–42. Wallhagen, M. I., & Pettengill, E. (2008). Hearing impairment: Significant but underassessed in primary care settings. Journal of Gerontological Nursing, 34, 36–42. Whichard, S. (1998). Gaining referrals through a physician marketing program. Hearing Review, 5, 12–16, 43. Winsor, D., Jenstad, L. M., Sims-Gould, J., & Purves, B. (2014). Barriers and facilitators to hearing aid uptake in older adults: A qualitative study. Manuscript in preparation. World Health Organization. (2012). Dementia: A public health priority. Retrieved from http://whqlibdoc.who.int/publications/ 2012/9789241564458_eng.pdf Yueh, B., Shapiro, N., MacLean, C. H., & Shekelle, P. G. (2003). Screening and management of adult hearing loss in primary care: Scientific review. JAMA: The Journal of the American Medical Association, 289, 1976–1985. doi:10.1001/jama.289.15.1976
Appendix Full List of Topics Available in the Care for Elders Module Series Successful Aging Interprofessional Team Work Falls Medications and the Older Adult Chronic Neurological Disorders Depression and Grief Dementia I (Early) Dementia II (Late) Delirium Persistent Pain Palliative Care Informal Support Systems Continence Nutrition, Oral Health, and Dysphagia Patient Safety Communication: Hearing Loss in Elders British Columbia (BC) Incapability Assessment I and II Interprofessional Collaborative Practice—Residential Care Context Interprofessional Collaborative Practice—Acute Care Context Note. Further information about the modules, access to prereading, facilitator instructions, and contact information for obtaining the full modules can be found at http://www.elearning.chd.ubc.ca /.
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American Journal of Audiology • Vol. 24 • 23–30 • March 2015
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