- Published on 02 March 2017
In the last decade, family-centred care (FCC) has become a successful model in healthcare, and is becoming increasingly popular in the hearing aid sector.
Today we know that the family plays a central role in the health of affected people. This is why hearing instrument wearers and those closest to them are more and more included as partners on equal terms in the planning, implementation and assessment of treatment. Studies have substantiated the numerous advantages of this care approach. To ensure successful implementation in daily practice, it is important to be aware that the affected person and his or her family do not always have the same perception of the hearing loss and its importance. When hearing aid specialists take this into account and apply a few recommendations in their discussions, all those involved can benefit from family-centred care.
Family-centred care is based on the recognition that a disease does not only affect those who have the condition, but also those around them. As a result, it seeks to involve the family closely in the care process. An expert panel brought together by Phonak under the leadership of Dr. Louise Hickson, Professor of Audiology and Head of the School of Health and Rehabilitation Sciences at the University of Queensland, Australia, has developed specific recommendations in this area for the hearing sector. The panel made use of current scientific insights from family-centred care and practical experience in hearing rehabilitation, as well as knowledge from other areas of healthcare.(1)
One family, multiple perceptions
In audiology, it is well known that hearing loss has negative psychosocial consequences not only for affected people but also for those around them.(2) These include necessary changes in lifestyle, constraints in joint activities and communication difficulties, but also an emotional burden related to the hearing loss of others. These negative psychosocial consequences also affect the perception of hearing loss by the family and what they expect from hearing solutions. Here, the perspective of the family is often quite different from that of the affected people themselves. Through conventional patient care, hearing aid specialists are familiar with difficult discussions during their dialog with affected people, for example when there are reservations about hearing devices or unrealistic expectations of what can be achieved. If a family member joins the discussion, there is even greater complexity. What happens if the affected person and the family member contradict each other? What if there are reproaches from either side, or even an open argument? Or if the family monopolizes the discussion and the affected person simply takes a back seat? In this context, it may appear tempting not to integrate the family in the discussion at all, to avoid complicating things unnecessarily. However, it would be unfortunate not to involve the family from the outset because family-centred care offers multiple opportunities and advantages.
An important recommendation when implementing family-centred care in an audiology practice is to indicate at the start of the appointment that the opinions of the hearing aid wearer and of the family are needed. If the affected person and the family perceive the situation in the same way, and are both open to help from the hearing aid specialist, the consultation can go ahead and remain on target. If this is not the case, you might quickly get the unpleasant feeling that you have opened Pandora’s Box when engaging in a three-way discussion in which both sides are asked about their views of the hearing loss and the use of hearing aids.(3)
Family matters (4)
An example in practice: a son believes that his father urgently needs a hearing solution but the father explains during the initial joint appointment with the audiologist that he hears perfectly well for his age and only came along to the appointment because his son had been insisting for ages… The son takes a deep breath and launches into the corresponding response… In this moment, it may seem advisable just to concentrate on the father and to try and provide him with a hearing test with clear results, with a view to offering a hearing solution.(5) This may well save time and avoid conflict but the father will probably not change his mind at the end of the appointment because he wouldn’t want to admit to the hearing loss in front of his son when he had been denying it for so long. Even though it may seem more efficient to avoid the tension in the room by directly switching to problem-solving mode, it is important to remember that in difficult conversations in family-centred care, it is always about feelings(6) and that it is counter-productive to ignore this. Only when the concerns, reservations, expectations and wishes of all those involved in the discussion have been addressed will the hearing aid wearer and the family feel adequately informed and satisfied with the result. Therefore, in this type of dialog, the goal should always be to help the father find a way to see the situation differently and if possible from his son’s perspective. So it is essential that the audiologist not only talks to the father and then the son, but that he or she gets them to talk to each other. One strategy might be to ask the father and the son what they like to do together as a family. This may help to rapidly bring the conversation to the things that no longer take place or that are limited because the father can no longer hear so well. By digging deeper, it might be possible to help the father to accept that his son is suffering from the situation because he always enjoyed the time spent together, and that he didn’t insist on his father coming to an appointment with an audiologist because he is irritated, but rather because he would like to have more family time again.
Choosing the right strategy
In the example above, four different strategies are available to the audiologist to confidently overcome difficult conversations and to achieve a positive outcome (4):
1) It is better not to ignore the emotions in the room, even when it may seem tempting to stay in your comfort zone and not pay attention to the tension between the affected person and their family, and to focus on core competencies, i.e. the hearing test and guidance concerning the results. Also, this is a valuable occasion to win the client and their family’s trust by being proactive in dealing with tension and how people are feeling.
2) Use open-ended questions to bring both sides to a common sharing process, for instance by asking the family what they like to do together. The initial answers may not involve challenging hearing situations directly, but these will come up of their own accord as the discussion gets going.
3) Give the family the chance to reformulate how they feel about the situation. Family members most often concentrate on the things that frustrate them during the appointment, such as how loud the TV is or frequent misunderstandings. And this can lead to mutual accusations. It should be made clear that the idea is not to lay blame but rather to show that family life is suffering because of the reduced hearing and that the family is looking for a solution. This perspective may help the affected person to better understand the family’s point of view and motivate him or her to consider a hearing solution.
4) Take a step back, even if you get the impression that your clients expect you to fill in the gaps during the dialog. When one or both of the people you are talking to make eye contact with you, indicating that they want you to intervene, it may be worthwhile to pause briefly before joining the discussion again. Often, there is still more that needs to be expressed, even if the client and accompanying person need some time to reflect and get their thoughts in order. If you avoid intervening immediately, there will often be further dialog that can lead to mutual understanding and a common perspective on the situation.
The family is the patient
Of course, not all families are close and have a real interest in supporting the affected person. In difficult family contexts, audiologists are advised to remain within specific boundaries because they are naturally not family councellors. (7) However, since it is rare that there is absolutely no family in the broad sense that is interested in supporting the affected person along the path of hearing rehabilitation, and since the benefits of family-centred care have been clearly demonstrated (12), the main goal should generally be to involve those who are close to the affected person in the care process.
Based on experience from family-centred care, to have the best chances of conducting a positive assessment and providing a beneficial hearing system, it is best to heed the following advice that is central in paediatric audiology: the family is the patient.(9)(11) After an appointment or a fitting session, this means asking whether the family feels well understood, whether the family is satisfied, and whether the family is getting along well with the new situation. This approach admittedly requires a certain shift in mentality and handling difficult conversations calls for new abilities. According to Browning et al.(12), audiologists must recognize their own shortcomings and vulnerability to be able to deal confidently with an unwanted course of conversation. They must also prepare for uncertainty and increased complexity in their dialog with clients and their families. This increased awareness of the emotional aspects of hearing rehabilitation, along with the technical ones, may seem a challenge at first. But experience has shown that it is possible to systematically feel at ease even during difficult conversations, and to channel this effectively.(13)(15) We are convinced that it is worthwhile to become engaged in these aspects and to acquire these abilities, because when the hearing aid user and the family are equally satisfied, the whole care process runs better. And in the end, the affected person is more likely to decide on a hearing solution.
2. Scarinci N, Worrall L, Hickson L. The effect of hearing impairment in older people on the spouse development and psychometric testing of the significant other scale for hearing disability (SOSHEAR). Int J Audiol. 2009;48:671-683.
3. Martin E, Mazzola N, Brandano J, Luff D, Zukarowski D, Meyer E. Clinicians recognition and management of emotions during difficult healthcare conversations. Patient Education and Counselling. 2015;98;12248-1254
4. Kris English et al Working with Difficult Conversations. Hearing review, 23(8):14.
5. Grenness C, Hickson L, Laplante-Levesque A, Meyer C, & Davidson B. Communication patterns in audiological history-taking: Audiologists, patients and their companions. Ear Hear. 2015;36(2):191-204.
6. Stone D, Patton B, Heen S. Difficult Conversations: How to Discuss What Matters Most. NY: Viking Press;1999.
7. Clark J, English K. Counseling-infused Audiologic Care. Boston: Allyn & Bacon;2014.7 Mahoney CFO, Stephens SDG, Cadge BA. Who prompts patients consult about hearing loss? Brit J Audiol. 996;30(3):153-158.
8. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press;2001.
9. Harrison M. Facilitating communication in infants and toddlers with hearing loss. In: Seewald R, Tharpe AM, eds. Comprehensive Handbook of Pediatric Audiology. San Diego: Plural Publishing;2016: 829-847.
10. Allmond B. The Family is the Patient: Using Family Interviews in Children’s Medical Care. Baltimore: Williams and Wilkins;1999
11. Meyer E et al. Difficult conversations: Improving communication skills and relational abilities in health care. Pediatric Critical Care Med. 2009;10(3):352-359.
12. Browning DM, Meyer EC, Troug RD, Solomon MZ. Difficult conversations in health care: Cultivating relational learning to address the hidden curriculum. Medical Education. 2007;82:95-113.
13. Back AL, Arnold RM, Baile WF, Tulsky JA, Fryer-Edwards K. Approaching difficult communication tasks in oncology. Cancer Journal for Clinicians. 2005;55:164-177.
14. Epner D, Baile W. Difficult conversations: Teaching medical oncology trainees communication skills one hour at a time. Academic Medicine. 2014;89(4).
15. Meyers L. Counseling today: All in the family. September 2014. Available: http://ct.counseling.org/2014/09/all-in-the-family