Integrating Counseling Skills into Existing Audiology Practices.

The distance learning Audiology Doctorate (Au.D.) program offered by Central Michigan and Vanderbilt University Bill Wilkerson Center includes a core class in counseling (CDO 853, "Psychosocial Aspects of Hearing Impairment"). This course not only reviews possible psychological, social, and emotion implications of hearing loss, but also covers a set of basic counseling strategies designed to engage the patient as an active participant in the rehabilitation process. These strategies can be described as one deceptively simple concept: to create an environment whereby patients can describe their problems in all areas of their lives, and define and prioritize their "listening goals" - in other words, to take "ownership" of their hearing problems by understanding and accepting them (Clark & Martin, 1994; English, Rojeski, & Branham, 2000).

Between March 1999 and December 2000, this counseling course was taught seven times, with 180 enrollees (all practicing audiologists, with an average of 15 years experience). As each term progressed, it was noted that many students expressed deep concern about the feasibility of "adding" counseling strategies into already tight schedules. While students readily acknowledged the importance of these strategies, it appeared many worried that effective counseling, as described by the course content, would require extra time -- a commodity or luxury which was simply not available in many work settings. Students were encouraged to explore ways to integrate counseling strategies into existing practices, rather than to consider counseling as a separate (and notably, a "nonbillable") activity.

Unfortunately, there were no data available to address this legitimate concern. Therefore, three questions and a preliminary protocol were devised, to gather data to specifically address these concerns.

1. While taking the counseling course, were you concerned your practice setting would not allow "extra time" counseling might require?

2. 6-12 months after completing the counseling class did you still hold these concerns? Did you find counseling had to be "withheld" due to time constraints? Did you find ways to integrate counseling into existing practices without using additional time?

3. Please provide a brief description of the learning process regarding integrating counseling strategies/principles into existing practices.

Methods

Procedures

During September-December 2000, 108 questionnaires were sent via e-mail to all students who had completed the course within the previous 6-12 months. Six postings were returned as undeliverable; of the remaining 102, 55 were returned (by return e-mail) with completed responses, providing a relatively high (54%) response rate. Two of these responses came from audiologists who were currently working for hearing instrument companies and consequently were not seeing patients; therefore, their responses, while appreciated, were not included in the data analysis.

Subjects

The remaining 53 respondents (13 males, 40 females) reported an average of 14.6 years of professional audiology experience (range = 6-30 years). Their primary work settings included private practice (N = 13, 25%), university training programs (N = 9, 17%), school settings (N = 9, 17%), clinic/ENT offices (N = 7, 13%), VA settings (N = 6, 11%), military settings (N = 5, 9%), and hospital settings (N = 4, 8%).

Results

The first question asked audiologists whether they were concerned about time constraints while taking the counseling course. Almost half of the respondents (43%, N = 23) were "somewhat" to "greatly" concerned that their work setting would not allow for the possible time needed to counsel adequately (Table 1). Reasons given included; lack of control over their schedules, a limited latitude or autonomy with regard to their professional responsibilities, and extreme understaffing situation.



The second question was a follow-up to the first: if a student had been concerned about time initially, were they still concerned 6-12 months after taking the class? The majority of these 23 audiologists (70%, N = 16) reported that they were no longer concerned about time as a variable in counseling. They collectively reported that they found ways to "fold" counseling strategies into their existing practices, rarely describing counseling as an "added-on" component to their services. In fact, many audiologists reported they actually saved time using their newly acquired counseling skills. For instance, three respondents reported that when they asked patients whether they wanted detailed information about their audiograms, most patients said no, preferring to discuss remediation. Sample comments included:

"I am finding that careful listening/counseling in the beginning is resulting in fewer return visits, so in this way I actually come out ahead, time-wise."

"I am now offering the option to patients: Do you want the big picture or the details? 75% want the big picture, and we have just saved about 10 minutes."

"We have actually cut down on the number of follow-up visits because the COSI (Client Oriented Scale of Improvement, Dillon, James, & Ginis, 1997) helps us have a better idea of what the patient is wanting in the first place."

"I have found that people do not need to hear all my 'stuff;' most simply want my recommendations after they have been able to tell their story. Bottom line: I saved time, and the time we spend together is much more beneficial to the patient (and me)."

Respondents described several changes in how they delivered their services, in order to incorporate counseling into their schedules. For example;

"Instead of spending 10 minutes talking about test results and management strategies, I try to ask the patient what they thought about the testing, and let the patient guide the direction of the conversation."

"I have found that putting away the audiogram opens up a whole new way of addressing the patient - it has seemed to break all my routines right at the source."

"Eliminating the audiogram as a prop altered my approach to the patient. Now I was forced to discuss the hearing loss in terms of the person and not the graph. Very eye-opening."

"No more time 'convincing' the patient to do this or that. If you can determine...what information they desire as it relates to their hearing loss, you won't spend time, unnecessarily, giving information they are not wanting."

The seven audiologists who expressed ongoing concern about time for counseling (30%, or 13% of the total respondents) reported external pressure in terms of number of patients seen in a day, or having no control over the addition of unscheduled patients.

To determine how students were able to apply these strategies into their daily practices, they were asked to asked to describe the learning process as easy, difficult, or "somewhere in the middle." Three respondents did not directly answer the question, and are not included here. Of the remaining 50, twenty audiologists (40%) reported this process as relatively easy, often because of previous exposure to counseling in graduate school, or their "personal outlooks on life" being congruent with the material. One student reported she could integrate counseling "so that it becomes transparent. The patient never realizes that they are guiding what I say by what they say (or don't say, as the case may be)."

More than half (54%, N = 27) reported the learning process as "somewhere in the middle," almost always because "it is hard to break old habits:" "If you have been in practice a long time, you tend to think you know all the answers and can anticipate the individual's problems." The challenge of training students while simultaneously evaluating/modifying one's own practices was also identified as a moderate professional challenge.

Three audiologists (6%) described the learning process as difficult; one respondent found it very challenging to "leave 'cruise control' after so many years," while another found the learning process required a "fundamental change in attitude" ("First, you can't fix everything. Second, patients need to chart their own course."). Two of these three audiologists reported finding time constraints to be a significant problem in their practices.

Discussion

This study was an initial investigation into the question posed by the subjects themselves, "Where will we find the time to counsel our patients effectively?" Responses to a 3-item questionnaire, completed by 53 practicing audiologists, indicated the following:

1. Approximately half of the students were concerned about the anticipated time required to incorporate counseling strategies into their practice.

2. Most of the students concerned about time constraints later found that with practice and reflection, they had developed techniques which did not require additional time. In fact, many students reported that, because they "followed the patient's lead," they actually saved time.

3. The learning process used to incorporate counseling strategies into existing audiology practices was described as an easy-to-moderate challenge by 47 of 50 respondents (94%).

The number of respondents to this questionnaire was not large (N = 53), nor were they randomly selected. Therefore, the ability to generalize these findings across the profession of audiology is very limited.

Nonetheless, based on this preliminary study, it appears that effective counseling can be incorporated into most clinical practice settings in an efficient and effective manner, without negatively impacting the time constraints of the practicing audiologist, and with only a perception of an "easy-to-moderate" challenge. Further in-depth studies are recommended to advance our knowledge regarding the impact of integrating new counseling skills into existing audiology practices.

Acknowledgments

The author would like to express appreciation to all respondents for "taking time" in providing extensive, thoughtful, and valuable input.

References

Clark, J. G., & Martin, F. M, (1994). Effective counseling in audiology. Englewood Cliffs, NJ: Allyn & Bacon.

Dillon, H., James, A., & Ginis, J. (1997). Client Oriented Scale of Improvement (COSI) and its relationship to several other measures of benefit and satisfaction provided by hearing aids. Journal of the American Academy of Audiology, 8(1), 27-43.

English, K., Rojeski, T., & Branham, K. (2000). Acquiring counseling skills in mid-career: Outcomes of a distance education course. Journal of the American Academy of Audiology, 11(2).