We Think We Are Patient-Centered But the Evidence Says All of Us Have a Few Things to Learn...

Author: Caitlin Grenness, Ph.D.

My patients sit in the center of the clinical room: Am I patient-centered?
Over the last decade, the term patient-centered care has boomed in popularity and is considered synonymous with high quality health care; yet, often the term is used vaguely and inappropriately. So what is patient-centered care? And does patient-centered care occur in adult audiologic rehabilitation (AR)? To answer these pertinent questions, this article will present an overview and summary of recent research conducted in the context of adult AR. Following the review, this article will offer some practicable strategies for implementing patient-centered care into your practice.
What is patient-centered care?
Patient-centered care means different things to different people and this has led to the term’s overuse and under-impact. From an empirical perspective, patient-centered care has been defined throughout multiple health professions (for a review, see Grenness et al, (2014b)). In medicine, patient-centered care means to understand the patient more broadly or holistically than their health condition, to share power and knowledge, and to engage them in problem solving and health decisions (Mead & Bower, 2002). Similar definitions exist in allied health professions; however, these definitions are born from seeking patients’ perspectives and experiences, rather than borrowing the term from medicine. This way, each definition of patient-centered care considers specific contexts and patient needs. Until 2014, no such definition existed for audiologic rehabilitation.

This gap in knowledge was identified by a group of Australian researchers, and in 2014, Grenness et al (2014a) reported results of a qualitative study which explored the perspectives of older adults who owned hearing aids regarding the definition and presence of patient-centered hearing care. Ten older adults who owned hearing aids were interviewed. Analysis of these interviews revealed a descriptive definition of patient-centered care in audiologic rehabilitation and offered a guide to operationalization (Grenness, Hickson, et al., 2014a).

When participants described what patient-centered hearing care meant to them, a common theme across all participants was the need to individualize hearing care. Moreover, participants were able to describe what it was that they wanted individualized. A central dimension of hearing care that required individualization was the therapeutic relationship. That is, the audiologist needs to take the time to get to know the patient, make them feel comfortable and develop trust (Grenness, Hickson, et al., 2014a). Participants often reported experiencing an absence of trust in the clinician, for example: “Most audiologists are too interested in selling you hearing aids. They don’t really have that much care.” (Participant #10; male, age 77)

An absence of trust could be toxic to the success of the consultation. While the importance of trust is not unique to audiology (Preminger, Oxenbøll, Barnett, Jensen, & Laplante-Lévesque, 2015), it is particularly pertinent in the presence of commercial exchanges and the sales of hearing aids.

What constituted a therapeutic relationship was different for any given participant and thus, audiologists’ skills in deciding what is needed are paramount. It is worth noting that when the audiologist’s skills and attributes were described, participants sought more than friendliness and kindness – participants valued genuine care, flexibility and interest in their person and context. Many of these attributes and behaviors can be observed through verbal and nonverbal communication (Grenness, Hickson, et al., 2014a).

While the audiologist was held primarily responsible for developing a therapeutic relationship, participants recognized their own role in participating in their own hearing care, but sought an environment where they would feel empowered. Beyond describing the important role of the audiologist, participants also described the value of involving significant others. Specifically, participants reported a preference for involvement in decision making and problem solving with hearing aids, which included involvement in the decision on which rehabilitation option was appropriate or which style of hearing aids (if applicable) as well as involvement in how gain and other hearing aid programming changes were made (Grenness, Hickson, Laplante Lévesque, & Davidson, 2014a). Clearly, this level of involvement can only occur when the patient has been appropriately educated and informed.

The benefit of this definition of patient-centered care is that it provides context to what it is to be patient-centered in adult audiologic rehabilitation. However, this description does not provide audiologists with implementable strategies. Thus, the authors re-framed the same findings into an operationalized model of patient-centered AR (see Figure 1). In this model, the therapeutic relationship is still positioned centrally; however, this relationship is carefully balanced by the presence of informed and involved patients, and secured by individualized care. In sum, this model offers clinicians four areas to use clinically. First, audiologists should always value relationship development; second, seek and invest in bilateral exchange of information. Specifically, take the time (particularly in the history phase) to learn about the patient; ask questions that are psychosocial in nature and relate to their lifestyle and be comfortable with letting the patient take the lead. When it comes to offering your expert advice, do so in a way that is accessible from a health literacy perspective, and provide all the genuine treatment and remediation options (not just a hearing aid).

Such a concept is consistent with patient-centered care being described as the ‘meeting of two experts’. In the instance of decision-making, seek patient input, opinions and offer opportunities to ask questions, and ensure that the significant other is a participant. Wherever possible, facilitate the patient and significant other’s ability to conduct their own problem solving, and respect their decisions. Lastly, use all the valuable information you have gathered from your patient in every thing you do for them; that is, individualize their care.

In summary, in order to provide patient-centered care, an audiologist must individualize. Individualization is a common theme throughout all definitions of patient-centered care; it cannot be separated from the notion of patient-centered care, but it is not causal. By being patient-centered you must individualize; however, by individualizing care you are not necessarily being patient-centered. This leads us to the second question posed in this article.
Does patient-centered care occur in adult audiologic rehabilitation?
If you’re thinking at this point that everything you’ve read so far makes sense to you, that patient-centered care seems logical, then you’re correct; but don’t be mistaken into thinking that it’s easy to implement or frequently provided. Over decades of research in medicine (Roter et al., 1997), nursing (McCormack & McCance, 2006) and other health professions (Cooper, Smith, & Hancock, 2008; Law, Baptiste, & Mills, 1995), evidence consistently reveals that patients rarely receive patient-centered care, despite the overwhelmingly positive impacts for patients and practitioners (Stewart et al., 2000).

With a definition of patient-centered audiologic rehabilitation in hand, it is possible to ask if it exists in clinical practice. One method of answering this question is to film real clinical encounters and explore whether the dimensions of patient-centered AR can be observed therein. Another method is to ask audiologists’ and patients’ and significant others’ opinions on whether patient-centered care occurs in clinical practice. Over the last 24 months, both of these methods have been used in the context of adult AR (Ekberg, Grenness, & Hickson, 2014; Ekberg, Meyer, Scarinci, Grenness, & Hickson, 2014, 2015; Grenness, Hickson, Laplante-Lévesque, Meyer, & Davidson, 2015; Grenness, Hickson, Laplante- Lévesque, Meyer, & Davidson, 2015; Laplante-Lévesque, Hickson, & Grenness, 2014). First, let’s explore what was found when clinical encounters were filmed.

Figure 1. Operationalized Model of Patient-centered Audiologic Rehabilitation (Grenness et al (2014a)

Figure 2. A summary of research findings from filmed consultations between audiologists, adult patient and companions

Thanks to the incredible generosity of audiologists and adults with hearing loss, Grenness et al (2015a; b) was able to film 63 initial audiologic rehabilitation consultations across Australia on an iPod touch mounted on a mini tripod in the corner of clinical rooms. Consultations occurred in private and public practices with 26 different audiologists and a significant other was present in 17 of the consultations. Initial consultations were chosen as this were relationships are initially formed and decisions are often made. While these authors have reported on a number of specific findings – namely exploring verbal communication throughout history taking (Grenness et al., 2015a) and management planning (Grenness et al., 2015b); audiologists’ responses to patients’ concerns about hearing aids (Ekberg, Grenness, et al., 2014); and, family member involvement (Ekberg, Meyer, et al., 2014; Ekberg et al., 2015), these results can be juxtaposed against the operationalized model of patient-centered care to answer the “does patient-centered care occur?” question. This summary is presented with four headings that match the dimensions in Figure 1 and can also be observed in Figure 2.

1. Were communicative behaviours indicative of a therapeutic relationship observed?
All audiologists in this data set presented as friendly, kind, and reassuring people; however, some of the more complex communicative interactions required to develop a strong therapeutic relationship were rarely observed throughout this study. Firstly, audiologists engaged in little emotional talk. For example, on average, empathy was offered zero times throughout a consultation despite patients’ common expression of concern in initial consultations. In instances where patients expressed concerns (usually regarding hearing aids), audiologists tended to either ignore the concern or shift the conversation back to hearing aids via reassurance. This is illustrated in the following example:

Patient: “I just don’t think I’m ready for hearing aids”
Audiologist: “That’s ok, hearing aids are small these days, let me show you”

The consequence of this phenomenon, as reported by Ekberg et al (2014), was that patients re-raised concerns, often using up more clinical time and, ultimately, patients paid less attention to the audiologists’ recommendations. In addition to the aforementioned findings, audiologists asked few questions of psychosocial nature (e.g., “how does it make you feel when that happens?”). Consequently, little information about patients’ readiness and personal perspectives were gained and importantly, few opportunities for the audiologist to reveal and develop their trustworthiness occurred.

2. Was there a bilateral exchange of information between two (or three) experts?
The content of information exchanged from the throughout the consultation tended towards biomedical (i.e., medical history) or hearing aids. That is, 83% of all the information given by the audiologist throughout management planning was biomedical in nature, whereas just 16% related to how a hearing aid might help a patient in their lifestyle or how communication can be optimized in general conversation. This predominance of hearing aid discussion was consistent with the actual presentation of options to the patient. All patients who received an AR recommendation from the audiologist were recommended hearing aids, whereas just 8% of patients were offered alternatives such as group training or ALDs. Interestingly, 56% of patients who were recommended hearing aids left having committed to obtaining devices. Even patients who expressed a disagreement with the notion of hearing aids were given the same level of hearing aid information, often in place of information about effective communication or alternative options.

In addition to the content of information exchanged, the delivery of information was explored (Grenness et al., 2015). Typically, information about hearing aids was presented in long, complex sentences which included jargon (e.g., directional microphones, high frequency, channels and feedback canceller). Such communication is not inline with the principals of health literacy (Smith & West, 2006) and may limit patients’ understanding. An additional observation relating to the way information was exchanged relates to how audiologists asked questions of patients (and significant others). That is, in the history taking phase, two thirds of opening questions were closed-ended thus limiting patients’ ability to express their reason for attendance and main concern (an efficient way of understanding patients’ needs), and patients were interrupted after just 21 seconds in 76% of consultation openings. Throughout the remainder of the history, closed-ended questions predominated (86%) again limiting patients’ contribution to the audiologists’ understanding of their perspective and experiences.

3. Was an environment of empowerment and involvement fostered?
At a crude level, one way to measure involvement is via counting the number of statements made by those present in the consultation. On average, the audiologist talk outnumbered patient talk 1.6:1 and significant others, when present, contributed approximately 10% of the conversation. To be empowered and involved both patients and significant others’ opinions are needed. In the filmed consultations, opinions were explicitly sought on average five times a consultation (shared between patient and significant other) and statements that offered partnership (e.g., “we can work through this together”) occurred on average once per consultation. Interestingly, in consultations were a significant other was present, audiologists gave significantly less psychosocial and lifestyle-related information and asked fewer questions on these topics (Grenness et al., 2015).

4. Was hearing care individualized?
While significant variation was observed throughout the consultations filmed, audiologists were surprisingly consistent in their own practice; that is, few communicative changes were observed with different patients. Ultimately, individualization is observed if the information gained from patients is effectively used throughout the remainder for the consultation; that is, the audiologists uses the patients’ examples in management planning, the clinician alters complexity of language; and specific questions are addressed (Grenness et al., 2015). Overall, given all of the results described above, it appears there is significant scope for greater individualization of audiologic rehabilitation even at the most simple level of explaining rehabilitation options in the context of the patients own priorities.

In summary, despite the kindness and varied degrees of experience and workplaces participating audiologists came from, many significant areas for improvements in implementing patient-centered care in AR were observed. These studies provide a unique and valuable insight into audiology clinical practice. Just three other recent studies report on actual communication between audiologists and patients/family members in audiology (Nair & Cienkowski, 2010; Watermeyer, Kanji, & Cohen, 2012; Watermeyer, Kanji, & Mlambo, 2015) and all report a similar conclusion: there is more work to be done.

What the aforementioned methodology does not offer readers is insight into audiologists’ preferences for providing patient-centered care. After all, it is very likely that clinicians would like to be patient-centered, but are limited by time constraints, confidence or other factors. Thus, the second methodology used to explore whether patient-centered care occurs in clinical practice is seeking the opinions and preferences of audiologists, patients and significant others.

Audiologists’ preferences for providing patient-centered care were explored via a validated survey (the Patient Practitioner Orientation Scale; (Krupat, Yeager, & Putnam, 2000)) (Laplante-Lévesque et al., 2014). In this study, audiologists were asked 18 questions about their beliefs regarding ideas such as who should be in control of audiology consultations and how important factors such as developing management that would fit into patients’ lives.

Audiologists’ were asked to rate their agreement with statements on a scale of 1 to 6 where a higher score represented greater preference for patient-centeredness. Results of this study revealed that audiologists held a strong preference for providing patient-centered care with the average item score was 4.46 (Laplante-Lévesque et al., 2014). More specifically, audiologists with the following characteristics reported stronger preferences for patient-centered care: older audiologists (over 45 years); audiologists with more than 21 years experience; and, audiologists working in tertiary institutions, industrial contexts, or communication education. In contrast, audiologists working in private practice reported less preference for patient-centered care as did audiologists working in adult audiologic assessment (Laplante-Lévesque et al., 2014). These results offer an important juxtaposition to the results of Grenness et al (2015a&b) in that it reveals audiologists’ desire to provide patient-centered care. Thus, it is clear barriers exist to shifting preferences towards action.

To date, little research has explored patients’ and family members’ beliefs about the occurrence of patient-centered care in audiologic rehabilitation consultations. This is an important area for future research. Despite the lack of empirical information on this topic, clinicians can seek their patients’ opinions by conducting regular surveys focused on the patient experience rather than just hearing outcomes.
How to implement invidividualized care
The results described in the previous section highlight the scope for improvement in the way hearing care is delivered for adults. However, such improvements can only be made when clinicians and hearing care organizations genuinely consider the model of hearing care that is being provided. That is, it is much easier to observe and criticize how others work rather than observing and critically appraising your own work. In this section, four key areas for implementation will be presented. The reader is encouraged to consider if such behaviors and processes currently exist in their practice, and if so, how do they know this is the case and how can they be continually improved; or, if such behaviors and processes don’t currently exist in their practice, how they be implemented.

1. From biomedical to biopsychosocial
To understand each individual patient, a clinician must genuinely explore the patient (and significant others) perspectives and needs beyond hearing ability. Such perspectives can only be sought be confidently asking psychosocial questions. While many biomedical questions are necessary to ask (i.e., “have you had ear surgery”), these questions can often be asked via a check-box prior to the consultation and the face-to-face time can be spent in meaningful conversation. Biopsychosocial conversations are more easily started after an open-ended question (or two) and maintained by acknowledging and exploring concerns or emotive issues as they arise. In these instances, audiologists do not need to solve the problem; rather, make a connection and move forward together.

To help visualize the many areas that should be considered when understanding a patient and significant other’s perspective, consider the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) (World Health Organisation, 2001). This simple framework illustrates the need to ask about participation, activities, environmental, and personal factors in addition to conducting the audiogram.

2. Let go of your agenda
Much of the results discussed in the previous section results from the audiologist having a consultation agenda and rarely deviating from this. Given the substantive evidence for the long-term value of shared-decision making (Charles, Gafni, & Whelan, 2000) and understanding the patient and a whole person (Mead & Bower, 2000) in success of management of chronic health conditions (Michie, Miles, & Weinman, 2003), audiologists need to seek comfort with sharing the control of the consultation. Beyond conducting the appropriate tasks needed for reimbursement, consider how you can introduce flexibility into your consultations.

3. Involve and engage significant others
An extension to the notion of patient-centered care is that of family-centered care. They key difference between the two concepts is that family-centered care explicitly outlines that an individual does not function without those around them, and often those close by are instrumental in successful implementation of an intervention (Bamm & Rosenbaum, 2008). This is true in audiological rehabilitation, especially as it is known that the significant other often suffers their own impairment as a consequence of their spouses hearing loss (Scarinci, Worrall, & Hickson, 2008).

Significant others can only participate if they are present (so, invite them), and when present, the audiologist needs to offer the opportunity to for them to participate. The risk of opening a challenging conversation is worth it for the benefits (Ekberg, Meyer, et al., 2014; Ekberg et al., 2015). Additionally, the more practiced you are at working with couples or families, the more successful you’ll become. There are a number of tools available to help involve significant others in important clinical process such as decisions making (e.g., the Goal Partner Sharing tool, GPS; http://idainstitute.com/toolbox/communication_partners/get_started/goal_sharing_gps/).

4. Reflect, revise, reflect
Ultimately, improvements and changes to clinical practice only occur when people have the openness to reflect on their own practice, acknowledge areas for improvement and act on them. Like all of the participants in the aforementioned studies, revealing your clinical interactions to your colleagues, peers or even to yourself is a powerful method for professional development and clinical care optimization. Have you ever considered filming your own clinical encounters or having a colleague sit in? Patients are often comfortable with this if they know it is for quality assurance purposes and you can guarantee their confidentiality.
A body of research that explored the meaning and nature of patient-centered care in audiological rehabilitation reported that patients and audiologists prefer patient-centered care, yet extensive evaluation of filmed consultations revealed that there is scope for improvement in implementing patient-centered care in current practice. Irrespective of the geographical location of your workplace, the funding arrangements you work under, or how much your patients already like you, there is always scope for improvement in the quality of care you provide. This article outlined the clinical areas where a paucity of patient-centered care was observed and offered four areas for audiologists to consider in their own practice. In summary, many simple improvements can be made through considering your interactions and communication with clients. To provide optimal audiologic rehabilitation to your clients, consider the question “do I provide patient-centered care?” If the answer is yes, then ask again as there are always a few new things to learn.    
Dr Caitlin Grenness is an Assistant Professor at the University of Melbourne in Australia. Caitlin is an audiologist who completed her audiology training in 2008 and her Ph.D. in 2014. Caitlin and her fellow research team focus on improving outcomes for adults with hearing impairment and their families with a specific focus on patient- and family-centered care. That is, optimising patient-practitioner communication, implementation of evidence-based practice and models of practice. This research is conducted using both qualitative and quantitative methods and is informed by an implementation science and behaviour change approach. This research has implications for how future audiologists are educated and current audiologic service delivery. Beyond research, Caitlin is heavily involved in educating future audiologists in the Master of Clinical Audiology at the University of Melbourne and she is also a Director of Audiology Australia, the peak professional body for audiologists in Australia.
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