This paper highlights the importance of family communication and metacommunication in audiology and, more specifically, in hearing aid dispensing. We argue that, as audiologists are trained in communication skills, so too should they be trained in how to include family members in the communication. Metacommunication, or communication about communication, should be the significant method of training for audiologists and the families.
Family communication is important. The ability to communicate both verbally and nonverbally in a variety of relationships makes us human. Families are one source of interaction that requires the human touch. Family communication is also important in health care. For instance, Ross and Levitt (2002) showed that including family members in audiology care was more important in times of health-related difficulties. Still, the recent Handbook of Health Communication (2003) excludes any research directly related to family communication in health care. Although that edition includes the concept of social support, family communication as a distinct concept is overlooked. Also, recent health communication literature overlooks many professional health-related occupations, opting for research specifically dealing with the physician-patient relationship (Ellingson & Buzzanell, 1999; Grant, Cissna & Rosenfeld, 2000; von Friederichs-Fitzwater & Gilgun, 2001; Rimal, 2001).
This article bridges that gap in health communication research by arguing that the family should play a key role in the health care process, especially in relation to the audiologist-patient relationship, and is particularly needed during hearing aid fittings. Communication specialists need to teach audiologists metacommunication skills so the audiologists, in turn, can educate families and patients about health-related communication. Teaching metacommunication to those intending to pursue audiology as a career could also address Cegala and Broz’s (2003) concern that health communication researchers rarely report what “specific communication skills were taught” (p. 96).
We offer specific suggestions for increasing effectiveness of communication in the audiology-patient relationship. Additionally, they suggest that family communication is the crucial element of success in the hearing health-care process. Effective family communication training is needed to help the hearing impaired person to communicate more effectively in using his or her hearing aids and in following the dispenser’s recommendations.¹ Finucane (2004) suggests, health care professionals in general are not being educated in appropriate communication skills, particularly when treating persons who are hearing impaired. We additionally suggest that for greater success family members also need proper communication training. This article addresses the importance of involving the family in the quest to increase communication for all members involved in hearing aid acquisition and use.
Audiology is the health care profession concerned with diagnosis and remediation of hearing loss and vestibular disorders. Audiologists, especially those who dispense hearing aids, work to improve the communicative patterns of their patients. Audiologists diagnose and provide rehabilitation for hearing loss, a disorder with serious consequences for everyday communication. From hearing evaluations to dispensing hearing aids, audiologists strive to improve communication for those with hearing loss but rarely receive sufficient training to address related communication skills.
Hearing Loss and Communication Issues
Hearing loss is more than a sensory impairment. In some cases it is medically treatable; in most cases it is not. It can be congenital (prelingual) or acquired at any point during one’s lifetime (postlingual). It can be hereditary, traumatic, iatrogenic (due to treatment and/or accident), or simply age-related (presbycusis). Hearing impairment is a physical loss that, in essence, disrupts human communication.
Audiologists may define hearing and communication concepts differently than communication theorists. Audiologic definitions do, however, distinguish between physical processes and social communication processes. For clarification, the following working definitions of audiology terminology, from the Comprehensive Dictionary of Audiology (Stach, 1997), are offered for the reader’s reference:
Audiologists focus much of their time on the physical aspects of hearing, while communication theorists define communication as both the biological/physiological process and the sociological process, whereby meaning is created by the individual within relationships (Leeds-Hurwitz, 1995; Trenholm, 1999).
We argue that both the biological and sociological aspects of communication must be addressed in order for audiologists to become aware of the communication constructs and processes needed in their clinical practice. Hence, it is necessary for audiologists to initially address their own communication knowledge and skills so that they might communicate effectively with their hearing impaired patients and the families of those patients. In addition, audiologists need information and training to address the communication process of patients and their families. That way all those involved in the hearing aid process could communicate more effectively
From a human communication perspective, metacommunication is the term that best explains the communication cycle audiologists find themselves using. Defined as communication about communication, metacommunication is the very concept that audiologists use everyday in their professions. However, rarely are they educated about it and rarely do they realize they are using it. This cycle of talking about communication begins when a patient enters the audiologist’s office because of a hearing loss, a communication issue itself. Next the audiologist talks to the patient about his or her own communication problems and tries to identify the problem. In many cases, metacommunication helps people become aware of the areas in which their communication practices are ineffective (Tubbs & Moss, 1981). Metacommunication can often “reduce[s] the likelihood of misunderstanding or inaccurate communication” (Kiesler, 1988, p. 31).
We argue that metacommunication is a necessary first step for audiologists to improve their patients’ communication. Audiologists need to be made aware of its value. Communication is a process and as Cegala & Broz (2004) explicate, teaching communication skills “must involve paying attention to all conversational partners’ contributions and perceptions” (p. 114). Talking about communication, no matter how ineffective it is, (as in the case of a hearing impaired person) must include the family. Communication issues must be addressed including the communication patterns of the audiologist, the patient, and the family. Sarason, Sarason, and Gurung (1997) express similar sentiments in regards to communication and the family. Peters (1999) argues that communication is often difficult and troubled—it is not as easy as sending and receiving a message. Making time to talk about communication processes and how they effect patient and family life is crucial to success in the hearing aid acquisition and use process.
People who experience loss of hearing have difficulty communicating verbally, and this communication problem affects not only the person who is hearing impaired but also significant others, family, friends, and even strangers encountered in everyday situations. The ability to communicate orally and auditorily is taken for granted by most individuals—until even a simple transaction becomes impossible because one party in the communication chain has a hearing loss. Amplification in the form of hearing aids, especially those using high-end digital technology, is usually considered the solution to hearing loss. However, hearing aids alone cannot restore normal hearing or normal communication function.
An aspect of hearing loss that is rarely discussed is the fact that, in terms of health care and health-related issues, the occurrence of hearing loss is generally not considered a crisis situation. Certainly, if an individual awakens with a sudden hearing loss, this is considered a crisis: a situation that audiologists and physicians agree must be handled expeditiously. However, in the usual occurrence of hearing loss, particularly age-related gradual hearing impairment (presbycusis), neither patients nor physicians consider this a crisis. Therefore, obtaining hearing aids or other amplification to help hearing and facilitate communication are not initially considered critical issues by the audiologist. However perceptions of the patient and family members may be very different. They may view hearing aid acquisition as a crisis, and audiologists need to be able to discern if the family is in that kind of crisis.
Gradual hearing loss undoubtedly becomes a crisis, however, when the hearing loss progresses enough that the individual can no longer hear normal conversation. Until this significant degree of hearing loss is reached, the patient’s family might actually accommodate their loved one by speaking a little louder, tolerating the loud volume setting on the television, even reinterpreting missed words in conversation. But when the hearing loss becomes more severe, family members notice the severity of the impairment and how difficult even simple communication situations have become, for their loved one and for themselves. This is stressful and can even be unsafe, and simple human communication is adversely affected. According to Jones, Beach, and Jackson (2004) “the potential effect of positive and negative family processes on health behaviors is clear” (p. 655). Therefore, we contend that family communication in crisis situations must be evaluated and discussed by the audiologist.
Drew Leder (1990), physician and author of The Absent Body, highlights the notion of the pathologized (or ill) body. He argues that because of Western medicine’s reliance on mind-body dualism, the body is often ignored until it becomes ill or disabled. He says that we don’t recognize all of the systems that keep our bodies working. However, the minute we feel pain we then recognize that body part and become fixated on all of the things it does. For instance, when we eat our dinner tonight, Leder would argue that unless that dinner makes our stomachs hurt, we will not even stop to think about all of the digestion that had to occur. He says that without any feeling of physical pain in our stomachs we will be unaware of all the work our bodies do in order to digest the food. Leder attributes this phenomenon to what he calls “the body’s own tendency toward self concealment” (p. 69). In this sense when patients who are experiencing loss of hearing choose to go to the audiologist, it is usually in response to some pathological signs, which call awareness to the body, specifically to the ears. Once people are called to pay attention to their bodies, they then begin the process of being aware of their bodies and getting ready for their role as patient and consumer. The first step in this process is to call for an appointment.
Leder’s work can be extended to hearing aid patients and their families. In the case of hearing loss it is often the family who begins to recognize changes in the family member’s hearing patterns. Then the hearing impaired person begins to notice a hearing loss and is suddenly aware of his or her own ears and their decreased capacity for sound. When hearing loss occurs, the ears become the body part that is focused upon by the patient and the entire family. Thus, it becomes important for audiologists to engage the family to pinpoint exactly when the hearing loss began and how it affected the hearing impaired person’s familial relationships. It is also important to educate family members about the importance of being aware of their own hearing and paying attention to hearing changes within themselves. WHY?
Leder also helps audiologists to understand that fitting a person with hearing aids means making sure they are not only comfortable with the devices and how they work but also about the idea of always being aware of their ears. The devices, although designed to help, can act as a reminder of a disability and draw attention to a body part that is often taken for granted. In addition, hearing aids might also be a constant reminder to family members, who are drawn to the hearing aids and reminded of the disability each time they communicate with the loved one. Although hearing aids are generally helpful devices, Leder’s work may help to explain why only 22% of hearing aid candidates (Kochkin, 2002) who own hearing aids actually use hearing aids. It might be that together the family and the hearing aid recipient are constantly reminded of the disability and this awareness is too much to handle. Thus, audiologists need to be specifically trained in counseling techniques and related communication strategies that address the issue raised by Leder of bodily awareness of impairment. The awareness of one’s ears might act as a deterrent to improving the hearing impairment for both the patient and his or her family. Importantly, more information about the use of hearing aids could be uncovered if audiologists were more aware of normal family communication processes and more able to communicate and listen to concerns of family members. Such metacommunication, as the key component for audiologists, can be crucial to overall success. Moreover, it is important to take a look at the background of the profession in order to better understand how audiologists are now trained.
The profession of audiology has evolved over time—for as long as individuals with hearing loss have needed help. Accessories and devices to help with hearing impairment have evolved tremendously over time, from mechanical devices such as ear horns that were once used to the miniaturized digital devices available in the twenty-first century. Although the first testing equipment was available in the 1920’s (ASHA, n.d.), audiology as a healthcare profession didn’t emerge until immediately after World War II, when soldiers returned with damaged ears and hearing loss from unprotected noise trauma (ADA, n.d.). Initial audiology services were actually in the form of auditory rehabilitation—lipreading training, auditory discrimination training, and speech conservation therapy. Hearing aids were also provided, although the model of hearing aid delivery was significantly different at that time (Schow & Nerbonne, 2002) than it is now.
For decades, audiologists did not directly dispense hearing aids to their own patients. Dispensing devices was considered an unethical practice. Audiologists performed diagnostic testing, hearing aid evaluations, and aural rehabilitation treatment. Patients were referred to outside vendors to purchase the hearing aids recommended by the audiologist. This prevented any concerns about conflict of interest and profiting from the sale of devices.
Audiologists belonged to the American Speech and Hearing Association (ASHA) as part of the related professions of Speech Therapy and Audiology. A process of certification evolved, providing a nationally recognized standard for certification, the ASHA CCC-A (Certificate of Clinical Competence in Audiology). The association became known as the American Speech-Language and Hearing Association, the name still used today. Until recently, minimum education requirements for entry-level audiologists (and speech-language pathologists) were a Masters Degree in the specific profession with a required clinical fellowship year (CFY) of supervised, paid clinical practice prior to receipt of the CCC-A. In addition, various states created licensure programs, so that audiologists (and speech-language pathologists) would be licensed to practice their individual professions. Almost all states require certification and/or licensure in audiology at this time (ASHA, n.d.).
In the late 1970s, audiologists became frustrated by the traditional model of dispensing devices, partially due to the extended time the process took and partially because often the audiologist never saw their patients after the fitting of the hearing aid(s). Audiologists were not in control of the process, and it seemed that patients were suffering. Audiologists rallied to become the recommender and dispenser of hearing aids. By the early to mid 1980s it was no longer considered unethical for audiologists to dispense hearing aids.
In the meantime, audiologists became discontent with the shared professional association, and the American Academy of Audiology (AAA) was founded in the mid-1980s, an association composed solely of audiologists to address the specific and unique needs of audiologists. Now, audiologists can belong to one or the other or both professional associations by choice. Presently, AAA has a mechanism for voluntary Board Certification in Audiology and will offer possible specialty-area certification in the future. In addition, professional associations and licensure boards are recommending and/or requiring ongoing continuing education and continuing competency standards for certified and licensed audiologists, in an effort toward assuring quality care.
In the early 1990s, audiology practitioners and educators assessed the scope of the profession of audiology. Due to technological advances in the knowledge base of human auditory-vestibular structure, diagnostic procedures, rehabilitative processes, and hearing aid technology, it was agreed that a Master’s Degree is no longer sufficient training to practice the profession of audiology. Thus, the doctorate as the entry level for audiologists will be phased in over the next decade. This has opened a new clinical degree status, the Au.D. (Doctor of Audiology) and provided the opportunity for audiology graduate training to review and assess their curricula to accommodate the upcoming change to a doctoring profession.
In New York State alone (where the authors teach), there are approximately 500 audiologists practicing in various employment settings. Of those, more than 200 dispense hearing aids. These numbers will undoubtedly increase in the near future. With the trend toward the Au.D. as the entry level clinical degree for audiologists in the United States, many existing Masters programs are reorganizing to serve the additional curriculum and clinical practicum requirements to attain the entry-level Au.D. degree. The number of new Au.D. programs opening in the United States is staggering. This effort in doctoral level training strives to improve the quality of service and care patients receive. However, it does not necessarily indicate that the communication training and skills by the practitioners will be improved to serve the needs of patients and their family members.
Patients may see an audiologist for several reasons: auditory or vestibular complaints are common. Typically, a patient will see an audiologist either by referral from their physician or by self-referral. The first visit to the audiologist for hearing complaints consists of obtaining a basic health history and a comprehensive hearing history, including the patient’s complaints and perceived needs, diagnostic testing (complete audiologic evaluation), and informational counseling regarding the hearing test results and recommendations. Some patients attend the appointment alone, and some patients are accompanied by, or at least taken by, a family member or friend. The presence of significant others is extremely important and can make a difference in the outcomes achieved in the overall care of an individual.
Hearing aid user satisfaction can be linked directly to pre-fitting preparation and instruction provided to the client and to information regarding effective hearing aid use. This is intuitive for hearing aid dispensers, and it has also been demonstrated that when family members of the individual needing hearing aids are present during such instruction sessions, hearing aid compliance and satisfaction improve significantly compared to those who do not include family in the process (Preminger, 2003). Technological advances in hearing aid amplification are not the primary solution to hearing loss. Again, practicing audiologists know this instinctively as a matter of common sense, but don’t always possess appropriate communication background and counseling skills to assure that hearing aid users gain satisfaction from their amplification systems. They rarely make sure if the family is satisfied as well.
At a professional seminar, Sweetow (2004) discussed a common misconception held by hearing aid candidates, namely, “Hooray, I just bought two new digital hearing aids, now I don’t have to listen anymore!” This statement, or at least its underlying attitude, is commonly heard in dispensing offices. It also stresses the importance of addressing all parties’ communication knowledge, habits, and skills. Hearing aid candidates’ expectations, and the expectations of the family, should be addressed frequently during visits with the audiologist. Not only will this improve the prospect of successful hearing aid use, but it should improve overall communication outcomes in the long run. Sweetow mentions the importance of basic oral communication skills but doesn’t consider how the audiologist, patient, or family can improve their understanding or communication skills.
Hearing aid manufacturers are attempting to assist dispensing audiologists to utilize digital hearing aid technology appropriately for their consumers. To achieve this, manufacturers’ sales representatives, who are frequently audiologists themselves, routinely schedule training sessions about their specific products but rarely include metacommunication issues, especially related to the family. Such training often occurs in dispensers’ offices on their computers with manufacturer-specific software. In addition, manufacturers frequently schedule regional seminars, including possible continuing education opportunities, again emphasizing training specific to their own digital hearing aid products and software updates. This serves to train the dispensing audiologists technologically and provides updated information regarding auditory processing and how the newer digital technology meets the hearing requirements of persons who are hearing impaired. However, this doesn’t necessarily serve to train audiologists to counsel and prepare the consumer and a significant other, both of whom are experiencing a breakdown in communication. Communication training by communication scholars is a feasible option, especially since dispensing audiologists are already setting aside time to meet with manufacturers. Training in metacommunication and family communication issues could be incorporated into these already existing sessions, especially if the manufacturers’ audiologists are specifically trained in such skills.
Audiologists need to perform appropriate informational counseling and preparation for hearing aid use that includes the family. Indeed, some type of hearing aid training for new hearing aid users is imperative to achieve hearing aid satisfaction. Many audiologists, in different practice settings (private practice, clinics, hospital departments, rehabilitation centers, corporate settings, franchise dispensing businesses) provide different types of informative training for new hearing aid users, and their families are frequently invited to attend the sessions. Many audiologists or treatment centers do this at no cost to the consumer, some charge for the sessions, and some professionals might bundle this into the cost of the new hearing aids. Attendance at such sessions may include incentives to the consumers, such as an extended Trial Period with new hearing aids and/or a more flexible hearing aid return privilege for attending all sessions. Rarely is attendance mandatory for consumers or their families. These sessions might be informational, but metacommunication and family communication issues are rarely addressed. Although families are encouraged to talk about communication issues, this is met with resistance. It is important, therefore, for audiologists to be trained in how to encourage meaningful communication.
Most audiologists also provide written brochures and pamphlets to their consumers, and invariably the initial evaluation and the initial fitting sessions include informational counseling to prospective hearing aid users. Whether or not hearing aid users take advantage of the hearing aid orientation and training, or even read the written materials, or actively understand and retain the large amount of information and training provided, and whether these persons use the information actively, are important issues to practitioners. Consumers, however, seem to obtain benefit from attendance at some form of hearing aid training (audiologic rehabilitation), especially if significant others attend along with them. Group sessions, as opposed to individual sessions, have the advantages of cost-effectiveness, group dynamics, and the possibility of group members helping others. Individual sessions have the primary advantage of scheduling flexibility for a particular individual.
Typically, these training or orientation sessions occur immediately after the hearing aids are fitted, during the required Trial Period. This does not replace the need for pre-fitting counseling, nor does it replace routine follow-up throughout the life of the hearing aids and during the entire relationship between practitioner and consumer. Audiology and Aural Rehabilitation texts for all pre-professional education levels, professional journals, and even consumer literature, invariably include information regarding individual and group sessions to orient hearing aid users to their new hearing aids. Ross (n.d.a), an audiologist, researcher, and hearing aid consumer advocate, provided consumers with a checklist containing information they should expect to receive from their dispensing audiologist, including individual and/or group sessions that can be attended by both the patient and his/her family. In another consumer article, Ross (n.d.b) indicated that, as part of a formal audiologic rehabilitation program, focus groups and family sessions have been found to diminish the perceived handicap experienced by individuals who have hearing loss and are utilizing hearing aids.
Luterman (2001) is a strong proponent of family involvement in the (re)habilitation process and of group sessions to facilitate improved outcomes. Clark and English (2004) detail the use of group "Hearing Help Workshop" sessions and family involvement in those sessions and the entire hearing aid procurement process. Orientation sessions for new hearing aid users are also discussed by Matonak (1999), Clark and English (2003), and elsewhere throughout audiology literature. Wayner and Abrahamson (2001) market a complete program designed for professionals to utilize in their daily practice with individuals, groups, and involved family members. This includes a detailed guide for providing hearing aid information aimed at successful hearing aid use.
Otherwise known as Audiologic Rehabilitation, all proponents of training or hearing aid orientation sessions include information about the following aspects of hearing loss and use of hearing aids:
Typically, sessions meet once weekly for four to six weeks. Sessions may be facilitated (not led) by an audiologist, technician, graduate intern, or even an experienced “successful” hearing aid user. At times, long-time users of hearing aids may choose to attend the sessions at their own request to update themselves, or the audiologist may suggest these persons attend in order to become even “better” hearing aid users or to help a “difficult” patient. When significant others attend these training sessions with the hearing aid user, there are significant benefits obtained by both the individual with (new) hearing aids and the family, resulting in improved communication, understanding, and empathy (Preminger, 2003). Strategies are in place for hearing aid consumers to achieve positive results, but still a majority of hearing aid candidates are not utilizing their hearing aids or are not receiving metacommunication-based training. The authors argue that within these training sessions it is relatively easy to incorporate discussion about metacommunication.
The value of such hearing aid training and orientation aimed at consumers is not in question. The value of including the family in the entire process of obtaining hearing aids and utilizing them effectively is also not in question. What is in question is the education audiologists require in order to sufficiently prepare consumers who are hearing impaired and require hearing aids. Doctoral-level audiology coursework should include information on ways to determine when patients do not understand the large quantity of information being provided prior to and during the hearing aid fitting process. Educating audiologists how to appropriately prepare prospective (and even current) hearing aid users could assure greater numbers of satisfied hearing aid users and successful hearing aid fittings. Effective counseling regarding reasonable expectations will be useful in helping consumers understand the value of costly technology relative to the benefits they can help themselves to achieve. In addition, audiologists should be prepared to recognize persons at-risk for detrimental psychosocial issues requiring a referral for other professional services.
Certainly a comprehensive curriculum for a doctoral-level course that contains training in interpersonal communication, group communication, family communication, metacommunication, and counseling skills specifically for dispensing audiologists (and other health care professions) should be included in educational training programs. In addition, such information can be offered to experienced professionals to achieve continuing competency.
We are dedicated to highlighting the communication that pervades the audiologist-patient relationship and to elevating this relationship to the forefront of health communication research. There is a self-imposed need by researchers (Ross & Levitt, 2002; VanVliet, 2003; and Campbell, 2002) in the field of audiology that communication training and skills be a top priority of audiologists and hearing aid dispensers. Intertwined in that need is the notion that successful hearing aid fitting and use cannot happen without the involvement of the family. Not only do audiologists need to be aware of their own communication patterns in order to help their patients who are experiencing their own communication difficulties, but audiologists need to increase the role of family communication in their profession so that the family can be helpful in the communication situation. Audiologists are the communication doctors whose main goal is to help people hear well, so they can, in turn, communicate better with their families. Families need to be involved in that process of metacommunication.
Training the audiologist to call upon a patient’s family as a resource to metacommunicate with the patient is a crucial step in improving hearing aid usage. In essence, the authors of this paper are calling for communication training at all levels of involvement, by the audiologist, the patient, and family members.
Footnote
¹The researchers are aware of the recent HIPAA privacy laws that require permission of the patient for the family to be involved in patient care and information sharing. However, the researchers believe that audiologists can still adhere to HIPAA policy and still involve the family. Family communication is too important in audiology relations and does not necessarily have to involve a breach of privacy. Done correctly the family can be involved and HIPAA rules can be followed. It is beyond the scope of this paper to delve further into the issue. For more information on HIPAA visit http://www.hhs.gov/ocr/hipaa/
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Ann Marie Cianci, Au.D., Assistant Professor of Speech and Audiology, Iona College, Department of Speech Communication Studies, New Rochelle, NY.
Diane Ferrero-Paluzzi, Ph.D., Assistant Professor of Human Communication, Iona College Department of Speech Communication Studies, New Rochelle, NY.
Dr. Ann Marie Cianci is Board Certified in Audiology by the American Board of Audiology, a certified member of the American Speech-Language and Hearing Association, a licensed audiologist in the states of New York and Connecticut and an Assistant Professor of Speech and Audiology at Iona College.
Dr. Diane Ferrero-Paluzzi is Assistant Professor of Human Communication in the Department of Speech Communication Studies at Iona College in New Rochelle, NY, with research interests focusing on health communication and health care relationships.