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Research | August 2016 Hearing Review Recommendations for moving toward a family-centered model in hearing healthcare. By Kris English, PhD; Mary Beth Jennings, PhD; Christopher Lind, PhD; Joseph Montano, EdD; Jill Preminger, PhD; Gabrielle Saunders, PhD; Gurjit Singh, PhD; Elizabeth Thompson, AuD A family-centric approach to hearing healthcare must acknowledge the fact that discord and disagreement about the severity and importance of the hearing loss can occur between the patient and his/her family members. When parties are in disagreement, difficult (but important!) conversations can arise. This article presents four strategies and examples for handling these conversations, while pointing to a need to acquire “difficult conversation competencies.” Editor’s note: As reported in The Hearing Review online news (November 6, 2015), Phonak has convened a select group of hearing healthcare experts to provide evidence-based recommendations to hearing care providers on how to better engage family members. The objective of this group is to facilitate family involvement throughout the hearing remediation process. The first installment, “Family Centered Adult Audiologic Care: A Phonak Position Statement”,1 appeared in the April 2016 Hearing Review. This is the second paper from the group’s work. Difficult conversations are a part of everyday life, involving people we work with, live with, and care about.2 Audiology certainly has its share of difficult conversations, perhaps epitomized by the responsibility of informing parents of a child’s hearing loss.3 Other examples of difficult conversations in audiology include: Explaining to a teen patient that her hearing loss is indeed permanent; Acknowledging the impact of stigma with a patient who dreads appearing old, infirm, or unattractive; Calibrating high expectations with realistic outcomes. We may feel generally prepared for these kinds of conversations because they are part of our daily one-on-one patient encounters. However, when a family member is included, the complexity of the conversation inherently increases and may catch us off guard. Consider an example shared by a student who was assessing a patient with tinnitus, but had not expected the husband to express his own concerns: “The husband, while being caring and defensive for his wife, tried time and time again to get information....‘What is causing this? What is the likelihood of it getting better? Why are you passing us off to the physician? Why won’t you give us answers?’ I [the student] had not appropriately devoted time to helping the husband understand my role in the process. He heard my suggestions for technology and other options, but he had not heard me validate his or his wife’s personal journeys.”4 As a reflective-practitioner-in-training,5 the student realized that, of course, family members will have concerns, and they will want to be included in the appointment. This realization doesn’t necessarily help us feel comfortable with the prospect, because there are still so many unknowns: What if patient and family perspectives contradict? Can we help patient and family develop common ground? What if the family member takes the lead or even dominates the conversation? Will we lose control of the appointment? Wouldn’t it be better to avoid the situation altogether? Figure 1. Let the patient and family member know that input will be sought from both of them: patient first, and then family member. These are the kind of questions that could lead audiologists to opt out of “family-centered” audiologic care, even in light of several known benefits. Singh et al1 recently published a position paper regarding the benefits or why’s of family-centered care: to benefit the patient, the family, the clinician, the business, and the relevance and longevity of the profession. The position paper also offered 10 suggestions on how to implement family-centered audiologic care. The three they recommend starting with are: 1) Invite a family member to appointments and reinforce the reasons why they should attend; 2) Arrange the physical environment so that family are comfortably included rather than being relegated to a seat in the back of the room; 3) Let the patient and family member know that input will be sought from both of them: patient first and then family member (Figure 1). This last suggestion will inform us whether the patient and family are on the same page regarding the patient’s hearing problems. If they both see the situation the same way—and both are open to our help—we can move forward. However, when the parties are not in agreement, we likely find ourselves in a difficult conversation. Let us consider a scenario wherein a patient (Mr Roberts) and his son are present for an appointment: Audiologist: It’s nice to meet you, Mr Roberts. And you are? Son: I’m his son, Joseph. Audiologist: Welcome to you both. Mr Roberts, I’d like to focus on you first, and then, Joseph, I’m hoping you will add your thoughts? [Joseph nods; audiologist turns back to Mr Roberts]. Mr Roberts, tell me about yourself… [He introduces himself and talks about his occupation, family, interests, etc] This is all helpful to know. And now, what brings you here today? Mr Roberts: [rolling his eyes] Joe did—he made this appointment and he also drove me here. He’s making a big fuss about nothing. Son: [Leans in, and the audiologist turns his way.] Audiologist: What’s your take on the situation, Joseph? Son: He keeps saying that, but it’s not true. He is really missing almost everything people say these days. Mr Roberts: And yet I’m understanding him perfectly right now. I’m an old man; it’s normal to stop listening to every silly word. Figure 2. As the conversation moves forward, the audiologist can attempt to reframe a difficult conversation item and help the patient and family member(s) build accord and find positive solutions. We realize we have opened the proverbial “can of worms,” a concern shared by other healthcare professionals as well.6 The patient is defensive and feels demeaned; the son is concerned and frustrated. We’ve learned their conversation has been going on for some time, and has not been productive. Our first instinct might be to withdraw from the uncomfortable situation, bypass the familial tension, and focus only on the patient.7 However, this approach would likely yield only short-term gains: we might maintain some efficiency in terms of testing time, but our test results and recommendations may not help the patient change his viewpoint. He has taken a position and, human nature being what it is, will hold on to it: “Once one has made a public pronouncement, matters of pride and consistency push one toward clinging to that position, no matter how discredited.”8 Rather than avoid this difficult conversation, we can take an extra step and try to help the patient reframe the situation, ideally from his son’s point of view. To do so, the conversational flow needs to change, so the audiologist seeks a way to help them talk to each other, not to her (Figure 2). Audiologist: You’ve talked about this before [they nod] and it’s become a sore spot? [They nod again.] Let’s change gears a bit: it would help me to learn a little bit about what is important to you as a family. What kind of things do you do together? Mr Roberts: Not much together these days. I’m retired now and Joe works. But I fill in as babysitter a lot; I’ve got three grandchildren, they keep me going. Son: They love hanging out with you. Yesterday I told them about how you and I used to fish together on weekends, and they said they’d like to try that. Mr Roberts: That would be great... [He makes eye contact with the audiologist but she waits for Joseph to finish his thought.] Son: But Dad, maybe you don’t realize why we stopped doing it. When we’d fish, we’d also talk for hours—well, whisper, of course. To me, that really was the best part. But the last time we fished, I had to raise my voice for you to hear me—practically shouting—and that kept the fish away. We didn’t catch a thing and we just stopped trying. Mr Roberts: [Facial expression changes, realization sets in. The audiologist waits again, resisting the impulse to take control of the conversation.] Son: This is what I’m getting at, Dad. It’s not about fishing. I like talking with you; I want you to hear me, hear the kids. Mr Roberts: [Nods.] Those were good times. Fair enough. I guess I can give it a try. [He and Joe turn to the audiologist.] Where do we start? Initially, the audiologist’s ability to help was blocked by family emotions (defensiveness, frustration). We cannot directly change those emotions, but we can provide opportunities to help both parties talk to each other about what hurts, what matters, and what they want. Try as we might, there is no avoiding this truism: feelings are at the very core of these difficult conversations.2 It may seem efficient to leapfrog over emotions into problem-solving mode, but rushing the process is counterproductive since, ultimately, “unacknowledged feelings do not disappear. They fester.”9 What Helped This Difficult Conversation? The audiologist carefully employed four behaviors to advance this conversation: 1) Acknowledging the emotions in the room. “You’ve talked about this before and it’s become a sore spot?” It is tempting to overlook the tension in an appointment and stay in our “comfort zone” (testing and explaining results). However, when we do so, we risk patient disengagement and the decision not to adhere to our recommendations.10,11 Our opportunities to earn patient trust are few and time-constrained, but we can optimize the opportunities by honestly addressing patient and family emotions. 2) Using open-ended queries. “What kind of things do you do together?” This question is an invitation to both parties to co-develop the family story. The initial responses may not include listening challenges, but soon the son will allude to the reason for...

Tag: Kris English

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