Counseling: Framing the Clinical Encounter & The Audiologists Perspective

What are barriers to treatment faced by clients?

• Client related barriers

• Clinician related barriers

• Societal infrastructure related barriers

• Technology limitations

Examples of client-related barriers include…

• Denial

• Stigma

• Uniqueness of HL

• Financial limitations

• Degree of HL

What is the most common form of counseling in audiology?

Informational / content counseling

Informational / content counseling

Is unidirectional, technical, and content-driven

What is the problem with informational / content counseling

• The audiologist talks more, limiting the pt’s communication and making the pt a passive participant rather than active

• Mostly closed-questions are asked related to the pt’s hearing, not questions that delve into their readiness to move forward with treatment

• It is NOT patient-centered care

How should we respond better?

• Our responses should reflect the pt’s message

• Our responses should be a kind of mirror

Three types of listening include…

1. Listening for pleasure

2. Listening for information

3. Listening to support others

Listening for pleasure

• Ex. Listening to music- doen’’t demand thinking from the listener

Listening for information

Is slightly more demanding, need to pay attention to details and organize info to make sense of it in from to form an action

• Requires the listener to remember what is said in order to use that information later

Listening to support others

Is more complex than other types of listening because it involves the need to build a relationship

• Additional training is needed

• Awareness of our listening pattern affects others we are listening to

• Most important for a clinician

Steps for listening to support others

• Mindfulness

• Select and organize info

• Interpret communication

• Effective responding

• Remembering

Mindfulness

Active decision to be present and attentive in the moment

• Understand the other’s perspective

• Effective listening begins with the choice to be mindful

Select and organize information

Place focus on the whole person

• Face

• Body language

• Tone

Interpret communication

Learn what the speaker is thinking and feeling

Effective responding

Communicate attention through eye contact, nodding, attentive posture, patience etc.

Remembering

Retain what you heard, develop action plan, monitor patient progress, show patient they matter to us

Patient Journey steps

• Pre-hearing loss

• Pre diagnosis

• Diagnosis

• Post-diagnosis

Models of patient care

• Traditional Biomedical Model   

• Biopsychosocial Model

• Client/Person-Centered Model

• Relationship Centered Care

Traditional Biomedical Model

• Assumes a detaches perspective

• Finds the impaired part

• Fixes it

• If there is a problem not yet solved, it will be in the future

Biopsychosocial Model

• Patient viewed as a whole person

• Patient’s story or narrative is central

• Practitioner fosters an empathetic trusting relationship by understanding and by being understanding

• Communication, decisions, and responsibilities are shared

• Patients are engaged in treatment plans and process

• Systems theory rather than dualism and reductionism

Person/Relationship-Centered therapy

Warmth, empathy, trust, respect, genuineness, and unconditional positive regard define this relationship

Relationship-Centered Care

• Patients relationship with their provider is often the most therapeutic aspect of the health care encounter

• Is an outgrowth of Rogers' persons-centered approach and the biopsychosocial model.

• Patient centered care is enhanced by relationship care because the quality of the relationship determines treatment success

What are essential components of patient-relationship-centered care (PRCC)?

• Cognitive: an accurate perspective of the individual's experience

• Affective: appropriate emotional reactivity

• Behavioral: accurate attunement to and reaction to the patient’s story

What does MINDFUL stand for?

M- moment to moment attention

I- in the here and now

D- detach from unhelpful thoughts

F- forgive and be grateful

U- unconditional acceptance

L- learn with childlike midnset

What are misconceptions about PRCC?

• Patients are already satisfied

• Takes too much time

• Too emotional

• Not cost effective

Clinical communication skills fall under what two categories?

• Content skills

  • History taking and information gathering

  • Physical exam

  • Diagnosis

  • Planning and discussing

• Process skills

  • How you communicate

  • How you structure interaction

  • How you relate to pts

  • Nonverbal skills

• The goal is to integrate all skills at the same time

The consultation guide basic tasks include…

1. Initiating the session

2. Gathering information

3. Audiological examination

4. Explanation and planning

5. Close the appointment

Initiating the session

• Preparation

  • Create an environment conducive to patient-centered care

  • Eliminate distractions during a meeting

• Establishing initial rapport

  • Greet patient and obtain name "well thanks for coming in today what brings you in today?"

  • Introduce self and clarify role

• Identify reason for consultation

  • Use open-ended questions to identify issues "from what I am hearing it sounds like you have been have trouble communicating with your family"

  • Listen without interrupting

  • Check and confirm case history

  • Set agenda for the appointment; consider both patient and physician needs

Gathering information

Explanation of the patients problem with the purpose of discovering:

• Biomedical perspective:

  • sequence of events

  • Symptoms

• The patient perspective:

  • Ideas and beliefs concerning the cause

  • Concerns and worries

  • Expectations and goals

  • Effects on life and family

  • Feelings- encourage patient to express themselves

• Background information:

  • Past medical history

  • History of hearing loss

  • Personal and social history (communication partners, etc.)

• Providing structure:

  • Summarizes response after an inquiry to confirm understanding before moving on

  • Progresses to next section of appointment using transitional statements

  • Attends to timing to keep appointment on task

• Building Relationships:

  • Using appropriate non-verbal behavior (eye contact, facial expressions, posture, movement, taking very concise notes, etc.)

  • Developing rapport

    • Accept validity of patient’s views

    • Provides support

  • Involving the patient

    • Shares thoughts with patient to encourage involvement

    • Explains rationale and process of appointment

Audiological examination

• Equipment calibration

  • Annual calibration

  • Daily biologic tests

• Auditory examinations and tasks

  • Otoscopy, audiometry, balance testing, immittance, ear molds, etc.)

  • Hearing aid fitting and verification, CI programming, other device fitting and orientation

Explanation and planning

• Providing the correct amount and type of testing

• Aiding accurate recall and understanding

• Achieving shared: incorporating the patient’s perspective

• Planning: shared decision making

What is the SPIKES protocol?

It is used to deliver bad news

S- Getting the setting right

P-Assessing what the patient perceives

I- Obtaining an invitation to share the news

K-Giving the knowledge and information

E-Addressing the patient’s emotions

S- Strategy and summary

Close the appointment

• Ensure appropriate closure

  • Summarize all results from the appointment and clarify the plan of care

  • Final check that patient agrees with and is comfortable with plan

• Forward planning

  • Makes a contract with patient regarding the next steps for both patient and physician

  • Safety nets: explaining possible unexpected outcomes, what to do if plan isn’t working, and when/how to seek help