Using Programmed Instruction in Your Clinic: An Interview with Kari Lane, Ph.D., RN

Author: Brian Taylor, Au.D. and Kari Lane, Ph.D., RN

Nearly every audiologist, who fits hearing aids, places their patients on some sort of a wearing schedule. Typically, this wearing schedule consists of either verbal or printed guidance suggesting to the patient that, over the course of the first few weeks after purchase, they should gradually increase the daily use time of their hearing aids. Most audiologists provide this information about use time during the initial fitting and reinforce the message during the first follow-up visit. The challenge, in many cases, of course, is that a significant number of older adult patients who might be struggling with cognitive and physical issues need support and guidance in other dimensions of hearing aid use. For example, as most audiologists know, a substantial number of patients need re-instruction on inserting and removing their hearing aids, or they may need a software adjustment to their hearing aids settings. All of these things take time away from ensuring the patient is following some type of regimented approach to acclimatization – that is, allowing their auditory system ample time to “get used” to sounds they haven’t heard in years.

Providing patients with a wearing schedule that increases usage of hearing aids over a specific period of time is also grounded in science. Studies have shown that it takes the average patient at least a few days to get fully acclimated to many of the sounds they have not heard for several years. Since every individual is a little different with respect to acclimating to new sounds, it is wise for clinicians to approach the adjustment of new sounds in a conservative manner and have patients gradually increase how long and where they wear their hearing aids over a few weeks.

One way to ensure that patients follow a regimented approach to initial use is through the application of programmed instruction. Programmed instruction is a self-guided, step-by-step approach to learning a new skill. Programmed instruction, which breaks learning into small chunks and provides the learner with immediate reinforcement and feedback, is used from everything for learning how to cook a soufflé to flying an airplane. Since learning to hear unfamiliar sounds is a skill, the use of programmed instruction would be a logical way for new hearing aids users to maximize the benefit of hearing aids. From the audiologist’s perspective, using programmed instruction allows the patient to get more actively involved in his treatment, and it takes one more item off patient’s plate. Luckily, a registered nurse, who spends a lot of time with older adults, has developed a program that uses programmed instruction that audiologists can literally take off the shelf and use in their own clinics. The HEAR program is a good example of a service provided by audiologists that could stand alone from the delivery of hearing aids. In fact, the HEAR program could be used with any sort of amplification device. Further, it is a great example of how audiologist can improve patient care by collaborating and sharing ideas with other healthcare professions.

This interview with Kari Lane, Ph.D., RN, sheds light on a system she developed, called HEAR, which uses programmed instruction to increase hearing aid use time. As Dr. Lane mentions, her program may even be turned into a smartphone-based app that identifies patients who need more face time with their audiologist. Read further to see why Dr. Lane developed her HEAR program and how you can use it in your own clinic.

AP: Dr. Lane, thanks for taking time away from your clinic to be with us. First, please tell us about yourself.

KL: My name is Kari Lane. I am an Assistant Professor at The University of Missouri Sinclair School of Nursing. I teach Geriatric Nursing, pathophysiology, and I conduct research on hearing loss. I enjoy working with older adults to help them communicate more effectively so that they can be actively engaged in their community. I am a registered nurse and I hold a Ph.D. in nursing.

AP: How did you become interested in working with adults with hearing loss?

KL: I was primarily motivated by my grandmother. She had a hearing loss for as long as I can remember. Hearing loss runs in the family. My dad, my uncle, my grandmother, and countless others have been impacted. My grandmother had a cochlear implant when I was in my 20’s and it truly changed her life. I also have a hearing loss. I wear a hearing aid on the right and a cochlear implant on the left. I worked with my grandmother to learn how to best communicate with her and then saw similar characteristics when I worked in the clinical setting. I also noticed that many times nurses and physicians did not know how to communicate effectively when a person has a hearing loss. Advocating for those with a hearing loss is important to me.

AP: Earlier this year you received some press with a treatment program you created. It’s known by the acronym HEAR. What is the Hearing Aid Reintroduction (HEAR) program?

KL: The HEAR program is a way to introduce hearing aids to persons (especially those who struggle with adjusting to hearing aids) so they can adjust to using them more easily. As I imagine, audiologists too keenly know, it takes significant time for some individuals to adjust to hearing aids because they hear so much more with hearing aids than they have for a long time. I believe this sensory overload is the main reason why persons have difficulty adjusting. The HEAR program allows a person to adjust gradually to noise (by slowly increasing the time hearing aids are worn) and gradually increasing sound exposure from more simple environments to more complex ones. The HEAR program was developed by persons with hearing loss.

AP: Yes, over the years, most audiologists develop their own approach to helping patients ease into hearing new sounds again. Your approach seems a little more systematic. Please share with us why you created this more regimented approach, called HEAR?

KL: In my experience, a great number of persons experience difficulty adjusting to hearing aids; therefore something was needed not only to reach out to these persons, but to encourage them in a more structured approach to hearing well again.

AP: In a recent study you authored, involving 15 participants, you found that use of the HEAR improved hear aid use time, could you share with us some of the details of the study?

KL: Sure. To test the success of the HEAR intervention, I enlisted individuals who have previously tried hearing aids but failed to adjust and those who were trying hearing aids for the first time. We found an 80 percent increase in patients’ hearing aid wear time due to the HEAR intervention. The study participants were also able to tolerate more complex noises and reported more satisfaction with their hearing aids.

Overall, I think the simple answer to your question is the study participants’ methodically followed the program. The core of the program is to gradually increase use time of hearing aids and gradually become exposed to sound over time. The bottom line is that the persistence of the participants in following the program was the main contributor to their success. (The title of the study is "Older Adults and Hearing Aids." It was published earlier this year in the Journal of Phonetics and Audiology.)

AP: Did you learn anything else?

KL: Yes. In my experience, patients may not be aware of how many times they need to visit their audiologist. Many patients only meet with their audiologist twice, but they need to meet with them as many as eight times when first receiving a hearing aid. That may be why many patients give up on their hearing aids. In the future, apps might be used to create a stronger relationship between audiologists and patients, and pinpoint those patients that need more face-to-face help.

AP: Interesting. Please share with us some of the details of HEAR in its current form.

KL: The HEAR intervention currently is supported through a workbook that provides instructions, tips and encouragement. Patients are able to record their progress in a journal as well as questions or concerns for their audiologist. With HEAR intervention, the duration of hearing aid use increases slowly from one hour on day one to 10 hours on day 30. In addition, sound complexity also increases, beginning with sounds that the house makes, such as fans and the dishwasher, to complex listening situations such as a restaurant or theater. I am sure that audiologists already have their own way of counseling their patients on re-introducing sounds over time, HEAR just does it in a more methodical fashion.

AP: Speaking of audiologists, what is their role in the use of HEAR?

KL: The audiologist is the key to the HEAR program. In addition to ensuring the hearing aid settings are optimized, the audiologist provides encouragement and positive reinforcement as a patient follows the HEAR’s programmed instruction. In my professional opinion, in a lot of cases, adding HEAR could save time and get the patient and their significant others more involved in the process.

AP: How can audiologists better collaborate with nurses and other healthcare professionals to improve access to care and quality of care?

KL: It is important that audiologists and nurses collaborate better. Nurses can refer persons with a hearing loss to audiologists and can assist with the teaching and reinforcement when persons are adjusting to the hearing aids. Nurses can also provide anticipatory guidance teaching, regarding the high prevalence of hearing loss, and tips for preventing hearing loss related to noise exposure. Audiologists must strive to develop good relationships with healthcare providers to ensure they receive referrals. It would also behoove audiologists to provide educational literature to nurses on the high prevalence of hearing loss, and begin anticipatory guidance for all persons regarding hearing loss in older age. The public needs to become better prepared for hearing loss and the cost of hearing devices.

AP: What are your future plans with HEAR?

KL: This data will be used to help create a complementary app, which will allow patients and audiologists to communicate more effectively regarding hearing aid use. Patients will be able to input their progress, which will be saved to their digital health records for their audiologist to view. In turn, the audiologist will be able to answer questions and send encouragement.

AP: How can audiologist start using HEAR?

KL: The HEAR program is available from me. The cost is $25 for one workbook. You can send a check to me at S417a Sinclair School of Nursing, University of Missouri, Columbia, MO 65211.    
Kari R. Lane, Ph.D., RN, MOT is an assistant professor at the University of Missouri. Dr. Lane’s professional nursing career has spanned 20 years. Her early practice emphasized cardiac telemetry and critical care, with mid-management experience. Early in her career, she sought teaching positions, as she enjoyed working with students and empowering them to grow and learn. Mid-career, Dr. Lane taught at a diploma program (4 years), and associate degree program (3 years) and a baccalaureate online program (7 years). During this time, she also worked in a critical access emergency room as charge nurse and oriented all new nurses to the ER. Personal work experience and family experiences with hearing loss have inspired her to assist those with hearing loss in achieving improved communication experiences. She can be contacted at