The clinical experience is a key component of education for students enrolled in doctor of audiology (AuD) programs. Throughout a variety of clinical rotations, students learn how to diagnose, treat, counsel, support, and empower patients with hearing loss. To become effective clinicians, students must be able to participate in and experience these rotations to the fullest. 

How do we support our students who are d/Deaf or hard of hearing (HOH) themselves in this setting? We educate our patients and encourage self-advocacy skills that they can use in their everyday lives. How can audiologists incorporate this same practice for our student clinicians who are d/Deaf or HOH? 

Students and preceptors alike might wonder how to address these issues most effectively so that a positive clinical experience is shared by all. Finding answers requires a collaborative effort. Building a partnership and tackling these questions together is important for good communication between student and preceptor and will yield the best outcomes for the student.

Although self-advocacy and transparency about needs are the student’s responsibility, new students are not typically aware of all their options or the kinds of clinical situations they might encounter during their education. This is where the preceptor can step in, applying their role as a mentor to provide support, as well as audiology knowledge and skills to help students brainstorm effective solutions. 

It may seem obvious that a partnership between preceptor and student is necessary for the student’s development of strategies and clinical independence; however knowing where to begin can be difficult (Allen and Culbertson, 2002). This article, authored by two audiologists who are Deaf and have cochlear implants and a final-year AuD extern with hearing loss who uses a hearing aid, will outline some potential challenges for our students who are d/Deaf or HOH and offer suggestions for ways to tackle these issues successfully.

Potential Difficulties for Students Who Are d/Deaf or Hard of Hearing

Similar to their performance in the classroom setting, students who are d/Deaf or HOH are fully capable of completing clinical tasks; however, they may need accommodations to do so. Every student is different, but some common difficulties may include: listening checks, word- and sentence-recognition scoring, the role of test assistant for conditioned play audiometry (CPA) and visual reinforcement audiometry (VRA), general relationships with clinicians and support staff, and environments where listening and speech reading are difficult. This list, while not comprehensive, provides the common scenarios where the majority of students who are d/Deaf or HOH may find themselves in need of accommodations. 

As a clinical preceptor, being aware of these potential difficulties and assisting your student in learning about appropriate ways to meet their access needs is critical for their success. Students who are d/Deaf or HOH may have experience in advocating for themselves and finding their own accommodations, but taking this on within clinical environments can be daunting. 

The decision to disclose a hearing loss lies with the student. When clinical preceptors offer support for determining the best accommodations, students who are d/Deaf or HOH often find this very impactful in their journey toward becoming an audiologist.

Recommendations for Managing Potential Difficulties

Clinical preceptors should encourage students to try a few accommodation options to determine what works best for them. As a graduate student clinician, the student may be allowed access to a student lab where they can practice clinical skills. Taking advantage of this time is important! 

Students also have access to a university office for students with disabilities. Encourage them to provide their audiological records to this office, if they have not done so already, so that the appropriate setup for their success can be documented and available for all instructors and preceptors. 

As the students progress in their program, experimenting with different accommodations might be necessary to ensure the best possible outcome. The next section reviews some recommendations to try for specific difficulties in the clinical environment.

Listening Checks

If the student uses a personal assistive listening device (ALD), many options exist for converting the device into a custom listening scope. For example, a student who uses a Phonak Roger Pen or Select may be able to use the device’s audio jack to connect with a lapel microphone, then connect listening cups to the microphone via size 13 hearing aid tubing (Atcherson and Spangler, 2014). The patient’s hearing aid receiver can then be coupled to this listening scope so that the student can perform a listening check on the hearing aid. 

A similar step may also be possible for performing listening checks on cochlear implant processors. The audio jack from the ALD can be plugged into the listening sets for Advanced Bionics and MED-EL, allowing the student to perform a listening check. 

Depending upon the student’s hearing devices, other listening-check options might be more appropriate. Examples include placing the earpieces of a traditional listening scope over the student’s device microphones, making a hole in a rubber thimble or similar object for coupling directional ALDs (e.g., ReSound Mini Mic, Oticon ConnectClip) to the patient’s hearing aid receiver or ordering personalized coupling devices for connecting a student’s cochlear implant processor microphones to a listening tube. 

For more information, refer to the American Academy of Audiology/Student Academy of Audiology Students with Hearing Loss Task Force (SWHL) Unconditional Listening Check Guides in the Resources section at the end of this article. In addition, using objective measures such as electroacoustic analysis to check for distortion and other hearing aid problems is also helpful for many students who are d/Deaf or HOH.

Word- and Sentence-Recognition Scoring

Encourage the student to share if they have difficulty with hearing during word- and sentence-recognition testing. Students might be hesitant to disclose these challenges, due to a concern that their preceptor will question their competence as a student clinician. Let your student know from the beginning that they have your support in finding a reasonable accommodation that will result in accurate scoring for these tests. 

Finding the method that works best might require some trial and error. Position the patient in front of the booth window at a slight angle for the student’s optimal speech-reading access, dim the lights on the examiner’s side to reduce glare from the window, and encourage the student to ask for repetition when needed. If the student is comfortable doing so, encourage them to share their hearing loss with the patient so that any miscommunication can be resolved quickly. 

Depending on the individual student’s needs, other possible accommodations include: asking the patient to wear the student’s personal ALD during testing; asking the patient, patient’s parent, or an audiology assistant to write the patient’s responses; and working with accommodations provided by the student’s university such as American Sign Language (ASL) interpreters or communication access real-time translation (CART) writers. 

In our experience, automated speech-to-text applications do not work well for the purpose of word- and sentence-recognition scoring, as these apps do not always reproduce the patient’s responses accurately. You and the student (or the student and another person) could practice word-recognition scoring through a mock word-recognition exercise, or you could score alongside your student and compare words missed and scores at the end of the appointment. 

Keep in mind that your student might struggle more with patients who have facial hair or unfamiliar accents. Reviewing the research on critical differences in word-recognition scores (Carney and Schlauch, 2007; Thornton and Raffin, 1978) may also be helpful for preparing to work with a student who is d/Deaf or HOH.

Test Assisting

Serving as a test assistant for CPA and VRA may be challenging for students who are d/Deaf or HOH who rely heavily on speech reading for understanding spoken language. If test assisting is difficult for a student, the first step in addressing the challenge is to determine exactly what is difficult. The issue may be resolved by finding a solution that involves higher quality auditory access, improved visual access, or both. 

Think about the norms at your clinic for CPA and VRA testing. Do the tester and test assistant usually communicate with each other during testing? If so, does that happen through the sound-field speakers, a set of headphones, an FM system, or by some other means? Allow the student to use their personal ALD to hear you on the other side of the booth if these options do not provide them with sufficient auditory access. 

What is the booth setup? If possible, position the student so that they have convenient visual access to the tester at all times. This might require positioning a patient with their back toward the tester so that the right and left speakers/reinforcers would be reversed. 

What are your expectations for the role of the test assistant? Clarify these with your student up front and ask if any of the expectations seem challenging. If the student finds frequent commentary from the tester difficult to process while assisting, find ways to reduce the number of words used when communicating with the student test assistant. 

Examples include using words with low-frequency vowels, such as on and tone, to indicate that the tester is presenting, using the name of an animal reinforcer (e.g., sheep or bunny) if your student has trouble understanding left and right, and saying big and little instead of the exact numbers for intensity levels of presentations. 

Resources

American Academy of Audiology and Student Academy of Audiology 
Students with Hearing Loss (SWHL) Resources 
  • Unconventional Listening-Check Guides 
  • Tips for Interviewing 
  • Legal Rights Resource 
  • Resource Packet
  • Resource for Access
  • Mock Word-Recognition Testing Resource (requires another person) Contact emily.camacho@wustl.edu for this resource. 

Facebook Groups

American Academy of Audiology and Student Academy of Audiology Students with Hearing Loss 

Association of Audiologists with Hearing Loss 

Association of Medical Professionals with Hearing Loss (The AMPHL Portal) 

Mentorship

Audiology Students and Professionals Who Are d/Deaf or HOH Meeting at the American Academy of Audiology Annual Conference

Association of Medical Professionals with Hearing Loss 

Association of Audiologists with Hearing Loss
 

Relationships with Preceptors and Other Professionals

At times, misunderstandings and communication breakdowns may occur when working with students who are d/Deaf or HOH. From the student perspective, these experiences can be embarrassing and difficult to discuss afterward. Show your student compassion during these times and approach the misunderstanding directly, rather than avoiding it. If the student does not know that a misunderstanding occurred, the problem is likely to occur again. If your student does not follow your instructions, it is possible that the instructions were not heard or understood clearly. 

Support your student by keeping your face fully visible and staying in close proximity during conversations. Any conversation about progress, goals, or personal strengths and areas for improvement should take place in a quiet environment where clear communication is possible for all involved parties. 

A common challenge for students who are d/Deaf or HOH is obtaining sufficient visual cues while meeting preceptors’ expectations for efficiency. If you are providing feedback after an appointment with a student who needs visual cues while the student is in the process of recording test data or another related task, arrange to debrief at another time. 

Your student might be worried that they are not being as efficient as you would like and their looking away from you could be their attempt to balance their need for visual cues with the expectation for recording all information efficiently. This is a matter of particular concern for students who need visual cues to take a case history and, therefore, cannot save time by asking questions while performing otoscopy or tympanometry. 

Keep in mind that your student who is d/Deaf or HOH might not have heard that a person was saying “Hello” to them in the hallway or might not have realized that the person was talking to them. Although this kind of misunderstanding can create frustration from other professionals in the clinic who might perceive the student as aloof, it can be avoided by encouraging your student to share with others that “If you say hello to me and I don’t respond, it’s because I didn’t hear you.” You might also want to ask your student’s permission to share with your colleagues that a student who is d/Deaf or HOH will be learning in the clinic this rotation. 

Encourage your student to find mentor audiologists who are d/Deaf or HOH. For additional support, refer them to the Association of Audiologists with Hearing Loss Facebook page, the meeting at the American Academy of Audiology annual conference for audiologists who are d/Deaf or Hard of Hearing, the SWHL Task Force page, and other listings in the Resources section at the end of this article.

Environment 

Certain clinical environments may be challenging for your student who is d/Deaf or HOH in terms of auditory and/or visual access. These include dark spaces such as electrophysiologic and vestibular test labs, spaces arranged so that the audiologist and student are not facing the patient at all times, and sterile spaces such as operating rooms where everyone is masked and background noise levels are high. 

If your student relies heavily on visual cues, consider what can be modified in the environment to provide better access. During electrophysiologic and vestibular assessments that require lights dimmed or off, the patient can wear the student’s personal ALD or you can wear it yourself so that the student can hear you better. For setups where an auditory brainstem response (ABR) patient is on one side of a booth and the tester is on the other, if a monitor speaker is set up with the audiometer in the booth, the student can place their personal ALD beside the audiometer. 

Arrange desks and chairs in consultation rooms so that the student will not need to face away from the patient while programming, verifying, or running electroacoustic analysis on hearing devices. For sterile and other environments that require masks, transparent masks can be obtained at a low cost. These would allow the student to have visual access while maintaining safety within the environment.

Conclusion

By using these tips for supporting audiology students within the clinical setting who are d/Deaf or HOH, preceptors can foster a supportive learning environment where these students can thrive. Discussions about challenges and accommodations are best approached through a partnership where you and the student work together to ensure that everyone’s needs are being met and all concerns are addressed. If you would like more resources for working with and supporting students who are d/Deaf or HOH, see the list of resources in the sidebar.