Advances in technology and research have allowed the profession of audiology to grow and further expand its scope of practice. Despite the professional growth, the number of licensed audiologists has declined by 3.3 percent over the last eight years (Hosford-Dunn, 2017). This negative growth rate is due to there being fewer graduating audiologists than there are audiologists who are exiting the workforce, whether due to retirement, change of career, or otherwise (Windmill and Freeman, 2013).

The challenge then becomes how to effectively provide service to those seeking it. As of 2008, 34.25 million people in the United States reported having a hearing impairment (Kochkin, 2009) and that number is expected to grow to 41 million in 2025 (Kochkin, 2005). Those numbers do not take into account patients with dizziness, tinnitus, or auditory processing disorders who do not otherwise have hearing loss. Thus, demand for audiological care is increasing while the number of personnel capable of providing audiological services is declining. One proposed solution to this dilemma is to significantly increase use of audiology assistants. 

Assistants have helped audiologists meet the ever-growing demand for audiological services for decades. They have been called many names. The Academy of Doctors of Audiology (ADA) and the American Speech–Language–Hearing Association (ASHA) call them “audiology assistants,” and, up until 2016, the Academy called them “audiology assistants” or “audiologist’s assistants.”

In 2016, the Academy started using the title “audiology technician” when referring to a membership category for assistants. Whether you call them “audiology assistant,” “audiologist’s assistant,” “technician,” or “support personnel” makes no difference in day-to-day operations; however, it does make a difference when trying to classify this job and set guidelines at the state level. 

FIGURE 1. Percentage of respondents who agree a given task is appropriate to be within the scope of practice of an audiology assistant; only tasks where greater than 70 percent agreed are shown.
FIGURE 1. Percentage of respondents who agree a given task is appropriate to be within the scope of practice of an audiology assistant; only tasks where greater than 70 percent agreed are shown. The vertical black hash marks represent the percentage of respondents who agreed from the data collected by Hamill and Freeman (2001). Hash marks are only shown where there was a statistically significant (p value >.01) difference between current results and those prior findings. 

Currently, there is considerable variability across the states regarding the entry requirements needed to become an audiology assistant and even more variability within the profession as to what should be included in an assistant’s scope of practice. In an ideal world, the profession of audiology would agree to one of these terms in an effort to define the roles for this position. That said, the term “audiology assistant” (AA) will be used throughout this article, as this was the term used to collect the survey data that sought to help the profession define the roles appropriate for the assistant.

In 2004, Cushing surveyed members of the Academy on the topic of AAs. At the time of the survey, 92 percent had previously heard of an AA and 22 percent were currently working with an AA. The majority of those surveyed felt “at least mildly threatened” when asked if an AA would be a threat to audiology’s scope of practice. Additionally, there was an overwhelming fear among respondents that otolaryngologists would view an audiologist and an AA as having interchangeable abilities (Cushing, 2004). These candid responses reveal that, although audiologists are open to the idea of using assistants, professional insecurity and the fear of job displacement may be preventing such implementation from taking place.

FIGURE 2. Percentage of respondents who agree a given task is appropriate to be within the scope of practice of an audiology assistant; only tasks where 30 percent to 70 percent agreed are shown.
FIGURE 2. Percentage of respondents who agree a given task is appropriate to be within the scope of practice of an audiology assistant; only tasks where 30 percent to 70 percent agreed are shown. The vertical hash marks represent the percentage of respondents who agreed from the data collected by Hamill and Freeman (2001) where there was a statistically significant (p value >.01) difference (black = more agreed currently and red = more agreed in 2001). 

If the field of audiology is to overcome the fear that assistants will encroach on its scope of practice, both the regulation of assistants and the scope of practice of assistants should be discussed within the profession. The Academy defines an AA as “…a person who, after appropriate training and demonstration of competency, performs delegated duties and responsibilities that are directed and supervised by an audiologist” (American Academy of Audiology, 2010). The AAA guidelines state that an AA can perform tasks such as minor repairs on hearing aids, patient set-up, assisting the audiologist while testing a patient, and performing office duties. The Academy firmly states that an AA should never be in a position to perform diagnostic assessment of any nature (American Academy of Audiology, 2010). 

In a 2001 survey, Hamill and Freeman found that the majority of respondents believed an assistant should be permitted to perform calibration checks, pure-tone and ABR screenings, tympanometry, assist with pediatric testing, provide instruction on hearing aid cleanings and use, send hearing aids out for repair, and complete administrative duties around the office. In the past 15 years, increasing numbers of audiologists have had experience with assistants. The survey presented in this manuscript and administered in 2015 was completed to obtain an updated viewpoint of what audiologists deem appropriate tasks for an assistant to complete.

Survey Respondents

A survey consisting of 22 questions for those who currently work with or have worked with an assistant and 17 questions for those who have never worked with an assistant was sent to 2,216 audiologists by e-mail. Additionally, a weblink was posted on social media. This survey was similar to the one completed by Hamill and Freeman (2001) and chi-squared analysis was completed where direct comparisons could be made. 

A total of 357 responses were obtained. A third of the respondents (34 percent) currently work with an AA and another third (35 percent) have previous experience working with an AA. When compared to Hamill and Freeman’s data (2001), there has been a 24 percent increase in the percentage of audiologists who either work with or have worked with an AA, which is statistically significant. If we extrapolate this finding to the total estimated 12,500 audiologists working clinically, that would mean that there are an estimated 4,250 assistants in the United States.  

Scope of Practice Opinions

Potential tasks an AA could provide were listed; the respondents were asked to decide whether they believed the tasks should be within the scope of practice of an assistant, and whether they would allow an assistant to complete it based on best patient care standards alone, ignoring state rules and regulations. 

FIGURE 3. Percentage of respondents who agree a given task is appropriate to be within the scope of practice of an audiology assistant; only tasks where < 30 percent agreed are shown.
FIGURE 3. Percentage of respondents who agree a given task is appropriate to be within the scope of practice of an audiology assistant; only tasks where < 30 percent agreed are shown. The vertical hash marks represent the percentage of respondents who agreed from the data collected by Hamill and Freeman (2001) where there was a statistically significant (p value >.01) difference (black = more agreed currently and red = more agreed in 2001).

Opinions on whether tasks were appropriate for delegation to the assistant are shown in FIGURES 1, 2, and 3. Direct comparisons to Hamill and Freeman’s (2001) data were made, when appropriate. Any statistically different values are represented by a vertical hash mark on the bar graph, which represents the earlier survey response results when a significant difference was found. The absence of a hash mark means that either the results were similar or the same question was not asked. 

FIGURE 4. Minimum education deemed necessary for audiology assistants by percentage of respondents.
FIGURE 4. Minimum education deemed necessary for audiology assistants by percentage of respondents. 

Assistant Training and Education

Additionally, questions related to training and education were asked on the survey. For those working with assistants, 44 percent had assistants who had on-the-job training only, and another 40 percent of them had on-the-job training along with formal education. The remaining 16 percent had either formal education only, previous experience from another practice, or other training such as being an audiology student. 

When asked “what level of education do you feel is needed at minimum for an assistant,” about three-quarters of the respondents preferred a certificate of training along with formal education while the remaining quarter felt that one form of formal education alone was necessary (FIGURE 4).

Compensation and Use of Time

Respondents who have worked with an AA within the last five years were asked to report on their assistants’ wages. The compensation breakdown (FIGURE 5) reveals that the majority of assistants are paid somewhere between $10 and $20 per hour, which is relatively consistent with what audiologists who do not have an assistant reported they would be willing to pay. When compared to data collected in 2001, this shows an increase in compensation; however, this is most likely due to inflation (Hamill, 2016). 

FIGURE 5. The compensation of audiology assistants as a percentage of the respondents. The blue bar represents respondents who have worked with an assistant within the last five years. The orange bar represents what respondents who have never had an assistant would be willing to compensate an assistant. The yellow bar represents what respondents in 2001 were willing to compensate an assistant.
FIGURE 5. The compensation of audiology assistants as a percentage of the respondents. The blue bar represents respondents who have worked with an assistant within the last five years. The orange bar represents what respondents who have never had an assistant would be willing to compensate an assistant. The yellow bar represents what respondents in 2001 were willing to compensate an assistant. 

Assistant schedules were also explored. Most respondents relayed that their assistant saw patients on a walk-in basis for hearing aid services and assisted the audiologist with testing such as visual reinforcement audiometry (VRA). Few respondents allowed for assistants to maintain their own patient schedule and some did not allow assistants to see patients at all. The amount of time audiologists spent supervising assistants varied greatly and likely is highly dependent on the tasks the assistant was assigned. 

Respondent Comments 

The last portion of the survey allowed for comments; 65 of the 357 respondents provided candid, open-ended opinions and experiences. A thematic analysis was completed by three reviewers and three major themes emerged: AAs are beneficial to the profession (n=31), AAs are harmful to the profession and not needed (n=30), and AAs need standardized training/certification (n=18). Some respondents offered comments on more than one theme. Given that the number of comments supporting and opposing AAs is similar, it is clear that there is a great divide on the acceptance of AAs by audiologists, regardless of whether or not they had experience with an AA.

The fear of AAs encroaching on audiologists’ scope of practice that was noted at the time of Hamill and Freeman’s (2001) survey is still evident today. Several respondents felt that if AAs were trained to complete tasks within an audiologist’s scope of practice that otolaryngologists would hire the AA rather than an audiologist. Along these same lines, a minor theme was that AAs are often mistaken as the audiologist by patients (confusion about who is who) and that they would be diluting our field further (“too many people in the pot already”). 

Another major theme was that AAs were invaluable to the majority of the respondents’ practice. Having an AA assist with walk-in hearing aid patients afforded the audiologist time to complete diagnostic appointments and hearing aid fittings. Some relayed that their assistant helped greatly with scheduling, tracking hearing aids, and infection control. An underlying theme throughout the comments was that the value of the AA depended greatly on the level of training and supervision provided to the AA.

The last major theme was concern regarding quality-of-care, and the wide range of educational and training requirements across the states, and even practice to practice. Most agreed that AAs should not be completing diagnostic care nor should they participate in interpretation or counseling. The comments regarding training were consistent in conveying that training should be supervised and there should be a standardized curriculum of knowledge and skills.

Conclusion

This survey reveals an increase in the utilization of assistants as well as a broadened scope of practice for assistants. However, many still express concern about widespread use of assistants. A decade ago, Jerry Northern (2006) discussed the underlying fear in an article titled “Look Around: The Audiology Assistants Are Here!,” where he called for the profession to be proactive in developing the assistant role and training. The Academy has since created multiple position statements regarding assistants (2006, 2010, and 2016) and a membership category for them. Additionally, ADA also has a membership category for assistants and had an education track at their 2016 conference with about 25–30 assistants attending (Freeman, 2017). Unfortunately though, not much action has been taken with regard to standardizing education and training requirements for AAs. Regulation, or lack thereof, of AAs occurs at the state level similar to licensure for an audiologist. If the audiology community could come to a consensus regarding minimum standards, we could then all lobby our individual states in an effort to see more uniform regulation of this rapidly growing position. If we don’t determine what is in our and our patients’ best interest with regard to assistants, then who will?   

TABLE OF ABBREVIATIONS

ABR

Auditory brainstem response

COSI

Client oriented scale of improvement

HHIE/A

Hearing handicap inventory for the elderly/adult

MCL

Most comfortable level

OAE

Otoacoustic emissions

RIC

Receiver-in-the-canal

UCL

Uncomfortable level

VRA

Visual reinforcement audiometry

VNG

Videonystagmography

VEMP

Vestibular evoked myogenic potential