COMD 4382 Quiz 2

Evidence-based Practice

clinical decision should be based on 3 things:

• clinical expertise

• patient values

• best research evidence

NOT this is what we’ve always done

• use well-documents research of outcomes

Level 1 Evidence

Systematic Meta-Analysis

most sound/optimal/gold standard type of research

• consists of more than one randomized controlled trial

  • control group: group that receives standard or placebo treatment

  • treatment group: group that receives (aural rehab) treatment that researchers are looking at

  • randomized: researchers do not assign participants to either group themselves

• results from several RCT only studies are synthesized (put together); provides optimum basis for treatment choice

when systematic meta-analysis is unavailable, other levels of evidence may be used, based on credibility

5 Problems with Aural Rehab and EBP

1. heterogeneity of subjects

   1. difficult to get similar subjects to reduce confounding variables

2. skill of clinician

   1. Administration of tests and treatments 

   2. Ability to document outcome 

   3. variation in these skills can vary the concluding effectiveness

3. what makes good outcome measures?

   1. subjective aspects of outcomes make it clinically hard to document and convey in EBP

4. failed treatments aren’t published often

   1. Dont often enough explore outliers and why failed treatment happened 

5. ethical concerns

   1. control group not receiving helpful treatment, longer someone goes without aural rehab

   2. the more difficult it is to recover

subject heterogeneity, clinician skill (administration and documentation), subjectivity in “good” outcome measures, unpublished failed treatments, ethical concerns (for control group)

Types of Evidence

1. cohort study

   • NO CONTROL GROUP, difficult to look at outcomes overall 

   • A group of participants receive treatment and are studied over time 

   • Not necessarily homogenous, get all same treatments, same group overtime 

1. case study

   • Less scientifically sound 

   • Systematic, intensive investigation of a particular subject, or series of individuals 

   • Looks into one individual, overtime, how they do with treatment 

   • Case study in series: Subject 1 subject 2, etc. not compared BUT tracked individually!! 

2. expert committee report

   1. Lowest level of evidence 

   2. communicate a committee's findings, discussions, and formal recommendations to a larger governing body or board

   3. Considered research but not a research paper, a report that could be used for EBP 

cohort study, case study / case study in series, expert committee report

EBP Steps

1. ask straightforward question

   1. during case history, ask their goals, provides direction for aural rehab treatment

2. find best evidence to answer question

   1. RESEARCH VIA DATABASES

3. assess evidence, decide if it applies to patient

4. integrate evidence with clinical judgement and patient values

   1. CLINICAL JUDGEMENT, PATIENT VALUES

   2. EBP TRIANGLE

5. evaluate performance of the plan

   1. POST-TEST

ask straightforward question, find best evidence to answer question, assess evidence (relevant, applicable?), integrate with clinical judgement and patient values, evaluate performance of plan (post-test)

Communication Repair Strategies

Successful communication for individuals with hearing loss is influenced by many variables:

• Effectiveness of their listening device (hearing aid, cochlear implant)

• Speechreading skills

• Amount of residual hearing (whatever hearing you have left after you consider hearing loss)

• Success is also affected by how well people use communication strategies and by their conversational style.

listening device, speechreading, residual hearing, communication strats / convo style

4 Conversational Style

Those with significant hearing loss can exhibit at least four conversational styles:

1. Passive

   • Allows conversation to happen without their input 

   • Misleading body language – just nodding, not giving solid indication they understood/receptive to what you said 

   • Just kind of sat there, not a lot to work with  

2. Aggressive

   1. Dominate conversations in order to avoid having to work to understand their communication partner

   2. May ignore a speaker in order to force him or her to repeat.

   3. Trample on the needs of others, often perceived as hostile or overbearing. 

   4. The person takes over the conversation or talks loudly/over others just to keep control. They do this out of fear that if someone else talks, they won't be able to hear them

3. Passive-Aggressive

   1. feels frustrated or embarrassed by their hearing difficulties

   2. instead of asking clearly for what they need, they express their anger or annoyance INDIRECTLY (sarcasm, sullenness, stubborness)

   3. On the surface, the person seems agreeable or cooperative, but they express their anger indirectly.

4. Assertive

   1. Equal turn taking, body language is sincere and appropriate for topic of conversation, not allowing convo to pass you by, alert, present, and contributing to convo – THIS IS WHAT WE WANT ULTIMATELY  

passive, aggressive, passive-agressive, assertive

10 Possible Effects of Hearing Loss

• More interruptions in conversation

• Disrupted turn-taking

  • inappropriate silences may occur if the person with hearing loss does not pick up on the cues that it is there turn to speak OR if they are unable to formulate a response because they did not hear the message

• Modified speaking and listening styles

  • communication partners may speak slowly with precise articulation or exaggerate hand gestures and facial expressions to facilitate understanding. Persons with hearing loss may focus on the speaker's mouth and make infrequent eye contact.

  • Can become exhausting for main communication partner, causes them to withdraw, TAKE ON PASSIVE COMMUNICATION STYLE -> CAUSES BREAKDOWN -> IMBALANCE IN TURN TAKING AND EXCHANGE OF IDEAS  

• Less rich imagery

  • communication partners may only use common words instead of more detailed descriptions

  • Not providing a lot of imagery –> passive convo style

• Failed communication, due to bluffing and pretending to understand

  • They cant tell when people stop talking (if hearing loss is severe enough) or still talking! So then they start overtalking, not realizing because its not their turn 

  • Bluffing: acting like they are present, if they feel its appropriate time to laugh they laugh  

• Inappropriate topic changing

  • person with hearing loss may not recognize previous marks and inappropriately shift topics as a consequence

  • intentionally Steer the topic in the direction they want to go in 

• Frequent requests for clarification 

  • need for clarification due to frequent misunderstandings and diversions from topic

  • They cant hear so they need it to be repeated 

• Disrupted grounding 

  • grounding is a conversational occurrence in which communication partners establish a shared "common ground" of information before moving on with the conversation. People with hearing loss may miss out on some important information early on which will impact their understanding throughout the rest of the conversation

  • All convo partners decided what the convo is going to be about, implicitly agreed to rules of conversation  

  • Rate of conversation is too fast, but if im taking too long to gather my thoughts and take turn, someone disrupts me 

• Breaking social rules 

  • individuals with hearing loss may talk to loud or appear as if they aren't paying attention in conversations

  • Whisper conversations  

• Superficial content 

  • because speech recognition is difficult for people with hearing loss, conversation partners may avoid some complex topics deciding it's "not worth the effort".

  • Less rich imagery, simplified version of whats going on in conversation 

1. convo interruptions

2. turn-taking disruptions

3. modified speaking and listening styles

4. less rich imagery

5. failed communication due to [bluffing, pretending to understand]

6. inappropriate topic changing

7. frequent request for clarification

8. disrupted grounding

9. breaking social rules

10. superficial content

All of these are addressed in aural rehab through aural communication strategies training.

6 Benefits of Training

Benefits are difficult to measure, though many studies have reported a reduction in perceived hearing-related disability. 

Research suggesting benefits generally shows: 

1. Good patient participation or compliance 

2. Change in communication strategies usage

3. Change in perceived hearing-related disability

4. Reduced rate of hearing aid returns 

5. Reported benefit by frequent communication partners 

patient participation/compliance, communication strategy usage increases, perceived hearing related disability improves, reduced rate of returns, communication partners report benefits

Communication Training

Most training programs begin and end with an assessment of 2 things:

1. conversational fluency

2. hearing-related disability

Initial assessment: determine which measures are utilized

• one way: record conversation with patient, observe how convo unfolds/assess afterward to determine CONVERSATIONAL FLUENCY

Final assessment: show if conversational fluency has improved, difficulties diminished

Always need a pretest and posttest  

Pretest - Initial baseline/assessment 

• Indicates what communication strats to teach and use 

• Provides insight into why person’s convo lacks fluency  

Posttest 

• If hearing has improved  

• If hearing related disability has improved 

Conversational Fluency

1. High Conversational Fluency

• Minimal communication breakdowns

  • Communication breakdown: Lack of exchange of ideas and information, subsequent impacted understanding  

• Ideas exchanged easily between speakers

  • Ease in which convo happens

• No dominance amongst one speaker

  • equal number of turn taking

  • with each turn, needs to be a fair number of utterances

• Minimal silence

  • minimal pauses between each turn

  • silence from one makes other want to talk even more to get them to jump in, now dominating the convo

  • if you end the convo due to silence, that ends exchange of ideas (communication)

2. Low Conversational Fluency

• Numerous communication breakdowns

• Minimal exchange of ideas between speakers

• One speaker dominates

• Awkward silence

Considerations for Evaluation

May require many measures to appropriately evaluate BECAUSE conversational fluency and communication difficulties can be dependent on many variables — setting convo is happening in, topic of convo, convo partner, etc.

• Conversational fluency and success in managing communication difficulties vary as a function of the conversational setting, situation, communication partner, topic of discussion.

• Communication difficulties do not always arise. E.g., a person may experience many communication difficulties in the workplace but not while talking to a speech and hearing professional in a quiet setting

5 Procedures for Measuring Conversational Fluency

1. Interview

• PRO Yields pt-specific information; CON Difficult to quantify information

• Give patient all definitions, describe concepts of conversation, then interview them if they experienced any of those effects of hearing loss, from their own perspective  

• Low ecological validity; may not be getting the info we want to get it — Patient may lie! 

 

2. Questionnaire

• PRO Quick and easy to administer; CON May miss pt-specific information

• Add scales or ask measures of frequency to quantify information (On a scale of 1-5, how difficult would you say on average )

• Find a way to put a number on it in order to have solid pretest and posttest with good validity/reliability, not subjective data  

• Predeveloped, don’t have to come up with questions BUT not personalized to person’s experience  

• Makes it difficult to develop a goal that will really help them  

• Thats why combo of interview and questionnaire is important to gain view of what client is going through  

3. Daily log

• PRO Provides quantitative information about an extended time period; CON? Can be a reactive procedure 

• Did you experience a breakdwon? Yes or no 

• How do you know? oppurtunity ot give detail 

• What did you do about it/what did your partner do? Give detail 

• Reactive – document reaction

Did you ever indicate that you did not understand a spoken message today (Yes or No)?

• What did you do when you did not understand a message? (Check all that apply)

• I asked the talker to repeat the message.

• I said “huh” or “pardon”.

• I asked the talker to use different words.

• I asked the talker to indicate what he or she was talking about.

• I decided the message was not important enough to keep trying.

• I asked the talker to spell or write the message.

• Other, describe_______

4. Group discussion

• PRO Stimulates pts to introspection and reflection; CON Some pts may be reluctant to participate 

5. Unstructured communication interactions

• PRO Good ecological validity b/c it best mimics real-world interactions; CON Results may vary as a function of the communication partner and they may be labor intensive to analyze 

1. carry out spontaneous exchange between communication partners

2. clinician uses elicitations techniques to create breakdown

3. assess client’s use of repair strategies (via formal or informal assessment)

ULTIMATE GOAL IS SPONTANEOUS COMMUNICATIONS INTERACTIONS 

Measuring Conversational Fluency

The following 6 factors can define conversational fluency:

• Time spent in repairing communication breakdowns.

• Exchange of information and ideas.

• Sharing of speaking time.

• Time spent in silence.

Mean Length of speaking Turn (MLT) = Average words spoken during turn

• count the number of words in term

Mean length turn ratio (MLT ratio) = Ratio of MLTs of two speakers

• add all words, then divide sum by amount of utterances

• speaker a MLT divided by speaker b MLT = MLT Ratio

1:1; 0.80-1.20 good, balanced, high convo fluency

2:3; minor imbalance, mid convo fluency

below 0.50 (speaker B speaking more) severe imbalance, low convo fluency

1:3; severe imbalance

above 2.00 (speaker A speaking more) severe imbalance, low convo fluency

Evaluating unstructured communication interactions 

1. Transcription analysis 

   1. Word-for-word

   2. Count number of turns, MLT ratio, and number of  topics

2. Ratings 

   1. Rating scale to assess fluency 

transcription analysis (word for word, no. of turns, MLT ratio, no. of topics)

ratings (scale to assess fluency)

Stages of Communication Breakdown

usually 3 stages for rectifying a communication breakdown

1. DETECT communication breakdown

2. choose course of action

3. use repair strategy / disregard utterance / bluff

• repair strategy: tactics implemented by a participant in a conversation to rectify a breakdown in communication

• communication breakdown: occurs when one communication partner does not recognize another’s message

effective use of repair strategies is often included as a goal in the aural rehab plan

Facilitative Communication Strategies

1. Influence talker

2. Influence message

3. Influence environment

4. Influence message reception

5. Maladaptive strategies

6. Anticipatory strategies

talker, message, environment, reception, maladaptive, anticipatory

Facilitative Communication Strategies

In communication strategies training, patients are taught to use facilitative strategies.

6 general strategies:

1. Strategies that influence the talker.

   • first, Patients identify practices that impede their speech recognition

   • second, Instruct partner on how to alter this behavior in a graceful, effective manner

2. Strategies that influence the message.

• messages can be tailored to elicit a more desirable conversation outcome “message tailoring” “closed set conversation”

• Acknowledgement gestures (nodding) by those with hearing loss can better convey their understanding to their communication partners

• i.e. communication partner being more specific with questions or statements 

• Asking specific choice questions that get the info for both people that is needed 

• Both convo partners does this!  

• “box” someone in  

• Steering convo in such a narrow direction, not 1500 directions, want info for a specific purpose, then convo can move on 

3. Strategies that influence the environment.

• review of the communication environment to identify those elements that can be modified or exploited to optimize communication

• Reverberating voice in room, creates distortion, creates lack of clarity 

• Tiling, carpeting, large rooms with pillars  

• Sound bounces off of hard surfaces 

• Soft surfaces Carpet absorbs intensity; So room doesnt echo and reverberate as much 

• turning lights off room, distance (close or reduce distance between speakers) Further away from source of sound, less intense it is 

4. Strategies that influence a message’s reception.

• Some persons with hearing loss can feel anxious during a conversation with an unfamiliar person.

• In such instances, it is helpful to breath deeply, consciously relax, focus on the conversation, and attend to the talker’s lip movements. 

• Making sure your hearing aids/cochlear implants working well – distorts message makes it harder to receive it  

• Tinnitus – ringing sound without a source (can be worsened by stress, cant hear, cant focus) 

• strats: Deep breathing, Settling down, Acknowledging that you're anxious, Figuring out what you can do to soothe yourself and do while your body calms down, Learn how to speech read, gives brain something else to focus on to get back your attention to message on hand  

• Psychological therapy, hearing loss could jst be another layer and theres a deeper cause that needs addressing  

• Counseling!! Main role in communication repair strategies 

5. Maladaptive strategies

• Cope with communication difficulties in inappropriate manner

Tactics include:

• Bluffing aka pretending to understand

• Withdrawing from communicative interactions

• Dominating conversations

• Developing feelings of anger and self-pity

• **Maladaptive strategies sometimes yield short-term benefit but incur long- term costs.

6. Anticipatory strategies

• those with hearing loss can anticipate potential vocabulary and conversational content.

• Example: prior to a job interview, a person might become familiar with typical interview questions, as well as the employer’s policies or key staff