Throughout the years, health-care service delivery models progressed from a provider-centered method of care toward a greater focus on the patient. In addition, increased prominence has been placed on the use of empirical evidence in the decision-making process to promote clinical accountability. But how can audiologists best provide patient-centered care when each patient is so unique?
Decision-Making: A Shared Approach
A paternalistic approach, in which the clinician makes decisions for the patient, has historically dominated the health-care scene. However, rehabilitative audiology decision-making has been described as “a vital stage in the rehabilitative process in that key decisions are made jointly between the professionals and the hearing impaired” (Stephens, 1996). In its most basic sense, patient-centered care refers to patient–clinician interactions and it emphasizes the importance of relationship building, as well as sharing of input and control in information exchange and decision-making (Boisvert et al, 2017).
A relationship that has patient-centered care, communication, and shared decision-making at its center leads to better adherence by the patient, greater overall satisfaction, and a stronger sense of trust between the patient and clinician (Figure 1). Communication between the clinician and patient can enhance adherence through several mechanisms. For example, communication contributes to patients’ understanding of their hearing loss, as well as their treatment options. A clinician’s skill at communicating during the appointment is a central factor in achieving patient adherence as it improves the transmission and retrieval of important information; facilitates patient involvement in decision-making; and allows an open discussion of benefits, risks, and barriers to adherence. In addition, it builds rapport and trust and offers patients verbal and nonverbal support and encouragement (Zolnierek and DiMatteo, 2009).
A patient’s journey from the initial hearing evaluation, to hearing aid selection and follow-up care, involves numerous occasions during which decisions must be made. Patients must determine the extent to which they are affected by their hearing loss and if amplification or other treatment options are right for them. They must also consider the amount of time, expense, and follow-up care to which they are willing to commit, as well as make decisions involving counseling, communication strategies, individualized auditory training, amplification, and aural rehabilitation. With all the options and various paths to take in a hearing health-care plan, patients are bound to feel overwhelmed. Therefore, it is important for the clinician to provide patient-centered care with an emphasis on empirical evidence to make joint, informed decisions, tailored specifically to each patient.
Including Empirical Evidence
It is the audiologist’s role to facilitate informed decision-making throughout clinical care. Though decision-making is a joint endeavor between the patient and clinician, patients typically rely on the clinician to narrow down the options that will work best for them. Therefore, it is imperative to establish a rapport with the patient from the beginning to create a trusting relationship with an open dialogue.
The American Academy of Audiology (Academy) includes the implementation of evidence-based practice as part of its “core values.” The Academy defines evidence-based practice as “to practice according to best clinical practices for making decisions about the diagnosis, treatment, and management of persons with hearing and balance disorders, based on the integration of individual clinical expertise and best available research evidence” (Academy, n.d).
Combining patient-centered care with empirical evidence may help to build rapport with the patient, which may lead to greater overall patient satisfaction. However, despite efforts to implement empirical evidence into audiology practice, gaps continue to exist between the best evidence-based research and what is being done in clinical practice (Moodie et al, 2011). For example, one survey found that only 52 percent of the 420 participating clinicians routinely used real-ear measurements for hearing aid verification (Mueller and Picou, 2010), though the use of real-ear measurements during the hearing aid fitting is considered a widely evidenced process for verifying amplification settings and improving patient satisfaction (Aazh and Moore, 2007).
A study conducted by Boisvert and colleagues (2017) aimed to investigate the sources of information audiologists commonly use when discussing rehabilitation choices with patients. Results of the study indicated that patient factors and test results are considered the most important by audiologists for their clinical decision-making as compared to information from peer-
reviewed literature and textbooks. This study suggested that many audiologists value patient preferences when making rehabilitative clinical decisions. Though empirical evidence was reported to be used less often than expert opinion in complex decision cases, the use of empirical research has increased over the years.
However, evidence-based practice is the integration of clinical expertise, patient preferences, and empirical evidence into the decision-making process (Figure 2). In patient-centered care, the clinician can bring professional experience and skills, while the patient brings his or her own personal preferences, concerns, values, and expectations (Sackett et al, 1996). By including empirical evidence in patient-centered care, the clinician can facilitate care with greater confidence and support the decision-making process.
Clinical Implications for Shared Decision-Making
By providing empirical evidence, the clinician provides the patient with the necessary information to make an informed decision. However, service does not stop there. The clinician then provides clinical expertise while the
patient expresses his or her preferences, and together they make a shared decision for individualized care.
Shared decision-making is supported by evidence from numerous randomized trials showing knowledge gain by patients, more confidence in decisions, and more active patient involvement (Stacey et al, 2011). When offered a role in the decision-making process, patients may have feelings of uncertainty about what option might be best. If all responsibility for decision-making is transferred to the patient, he or she may feel overwhelmed or abandoned in the process. To avoid these pitfalls, Elwyn and colleagues (2012) developed a three-step model, for shared decision-making in clinical practice. This model includes steps for choice talk, option talk, and decision talk (see Figure 3).
Choice talk is a planning step in which clinicians have an opportunity to summarize findings, offer a choice with justification, check the patient’s reaction, and defer closure for the choices when necessary. During the option talk step, the clinician can check the patient’s knowledge, list options in more detail (including pros and cons of each option), and provide the patient with decision support.
Finally, during the decision talk step, the clinician focuses on the patient’s preferences, moves toward a decision, and reminds the patient that decisions may be reviewed in a positive way to arrive at closure.
Another useful tool to promote shared decision-making is the Decision Aid. The Decision Aid is a visual tool used with patients that helps to organize a set of hearing treatment options. Audiologists can utilize this tool in a shared decision-making context in order to facilitate a conversation with the patient and help them to decide on a treatment plan. This aid can be modified to reflect the treatment options that are available to the patient.
The first page of the Decision Aid shows all the possible options for each patient to consider (Table 1a), while the following pages contain additional information about each of those options (Table 1b), (Hickson et al, 2016). The audiologist and patient discuss these options together in order to reach a shared decision.
Additional tools that enable health-care professionals to support and guide patients through various stages are the “Line, Box, and Circle” (Figure 4). According to the Ida Institute, the “Line, Box, and Circle” describes easy-to-use but highly effective tools that enable health-care professionals to guide patients through various stages necessary to achieve needed behavior changes (Ida Institute, n.d.).
The Line helps to clarify where patients see themselves in the process of change. When using the Line, patients are asked to identify a goal and a process. Patients are asked to rank their response to each question on a visual scale of 0 to 10 or from lowest to highest importance. In addition to ranking a response, it is important for the professional to create a dialogue with the patient regarding his or her answers. For example, an audiologist could ask the patient to elaborate on his answers by stating, “Why did you respond to this question with a score of 4 and not higher?” This allows the patient time for reflection, which is important for the change and decision-making process.
The Box is used in combination with the Line to make patients aware of their own positive or negative ideas surrounding hearing loss and to provide a better picture of what motivates the patient to make a change. The Box is designed to open a dialogue between the professional and the patient. After the patient has completed filling out the Box, the professional may encourage the patient to elaborate on the information provided.
The Circle is a tool that helps the health-care professional to get a sense of how ready the patient is to make a change. It outlines seven different stages that a person goes through when they are in the process of making a change. By using this framework, the professional can adjust his or her recommendations and counseling techniques for each patient.
PAGE 1: MY HEARING OPTIONS
|What Is It?||Hearing Aids||Communication Education||Assistive Listening Devices||No Treatment|
|What Is Involved for You?||
|What Is Involved for Your Family?||
|Options I Want to Know More About|
|Options I Will Think About|
|What Is Involved?||
|What Is Expected from You and Your Family?||
|What Are the Positives?||
|What Are the Negatives?||
Clinical methods that encourage patient-centered care, communication, and shared decision-making constitute a holistic approach that leads to adherence, greater overall satisfaction, and a stronger sense of trust between the patient and clinician. Research has suggested that the most successful patient–clinician interactions result from a collaborative effort from both parties. Therefore, it is the audiologist’s role to combine evidence-based practice with shared decision-making when guiding patients through their hearing health-care journey.