Alignment of Audiologists' Values With Best-Practice Standards: Insights From a National Survey

Abstract

Objectives:

Previous research documented the values of audiology through a qualitative content analysis of documents representing traditional, best-practice hearing health care. The primary objective of this study was to validate the existing list of audiology values. Through a nationwide survey, this study aimed to elicit the values of practicing audiologists, with a specific focus on the prescription and dispensing of amplification devices, to ensure a comprehensive understanding of their priorities. Additionally, this study sought to identify any values missing from the original list and determine the rank order importance of these values, comparing this to the prioritization of values found in best-practice audiology documents. This comparison aimed to assess the alignment of recommended guidelines and real-world practices in hearing health care.

Design:

An online survey was distributed to audiologists to elicit the prioritization of values from hearing health care providers. Participants were tasked with sorting and ranking 18 items, each representing a specific value in hearing health care, based on importance. Respondents were encouraged to suggest and rank the importance of additional values not included in the list. Audiologists were recruited from professional association mailing lists and direct contact. Respondent demographics were representative of U.S. audiologists. Qualitative content analysis was used to interpret values suggested by audiologists. Kendall's rank distance test was used to compare values prioritization between audiologists and best-practice audiology documents.

Results:

After filtering out incomplete or disqualifying responses, data from 289 audiologists across 46 states were analyzed. Additional values suggested by respondents aligned with existing values from best-practice documents; thus, no new values were added as a result of this study. A ranked list of values based on mean order of importance was elicited from U.S.-based audiologists. There was substantial agreement between survey results and the rank order of values found in best-practice audiology documents. A demographic subgroup analysis revealed a broad agreement among audiologists in the rank order of values.

Conclusions:

This study validated a comprehensive list of values in audiology and identified the rank order of values among a nationally representative sample of audiologists. The findings provide a foundation for future investigations into how these values influence decision-making processes for individuals with hearing difficulty. Addressing values conflicts as potential barriers to hearing health care usage can lead to solutions aligned with values of specific populations, ultimately improving the adoption and effectiveness of hearing health care interventions.

Supplemental Material:

https://doi.org/10.23641/asha.27478149

There is a critical need to increase help-seeking behavior among the millions of American adults with hearing loss who could benefit from hearing health care resources (Donahue et al., 2010; World Health Organization, 2021). The introduction of novel service delivery models such as telehealth and over-the-counter (OTC) hearing aids (Muñoz et al., 2021; U.S. Food and Drug Administration, 2017) presents an opportunity to further develop evidence-based solutions that directly address patient needs. This study extends previous research utilizing value-sensitive design (VSD) to guide innovation in hearing health care toward solutions that embrace stakeholder values. Gaining information about the values of individuals can help us understand the factors guiding their decision making and has significant predictive power in anticipating behaviors, attitudes, and preferences (Schwartz, 2007). It has been demonstrated that consumer behavior is driven by the perception that products and services reflect their values (Brunsø et al., 2002; Tanrikulu, 2021). VSD is a qualitative research approach that has been used across fields to design systems that account for human values (Friedman et al., 2002). VSD provides methodology for designing systems and technologies that embody specific values (Friedman et al., 2013). Understanding the values of patients and how those values are reflected in hearing health care products and services may be the key to reducing the burden of untreated hearing loss.

Audiologists are central stakeholders in the field of hearing health care, serving as the primary service provider for patients seeking care for hearing loss in the United States. Gaining a better understanding of audiologists' values can provide insight into the underlying factors that shape their approach to patient care. The primary focus of this study is to better understand the values surrounding the prescription and dispensing of amplification devices. Hearing aids were made the primary focus in an effort to elucidate the reasons behind the low uptake of treatment among adults with hearing loss, despite hearing aids being the principal intervention. Our previous values-based work (Menon et al., 2023) encompassed a wider range of diagnostics and treatments across various audiology subspecialties, providing a comprehensive overview of audiological values. The current study focused on hearing aids to specifically address the persistent issue of untreated hearing loss in the United States. By narrowing our focus, we aimed to uncover the underlying value-based provider factors that may contribute to the reluctance of individuals to seek treatment, thereby advancing our understanding of this public health concern and informing strategies to improve hearing aid adoption rates.

In our previous work, we compiled a comprehensive list of audiology values by coding values embedded in documents representative of best practice of audiology (Menon et al., 2023). The documents chosen for analysis were a valid representation of the standard of clinical care by selecting documents that embody specific dimensions of values relevant to VSD (Shilton et al., 2013). Three categories of documents were analyzed—clinical practice guidelines, codes of ethics, and questionnaires. Clinical practice guidelines were analyzed because they are a record of what audiologists do, following best-practice recommendations where available. Codes of ethics were included because these documents dictate moral behavior for audiologists as determined by governing organizations related to the profession. Clinical questionnaires were included because they are the primary tool used by audiologists to assess outcomes and determine treatment success. Values were derived through iterative coding, a process of assigning symbolic meaning to text data (Locke et al., 2020). We aimed to estimate the relative importance of values overall and within each document category, using rank order comparisons of the frequency of each coded value (Hsieh & Shannon, 2005). The frequency of coding references served as a proxy for importance, with values exhibiting more coding references ranked higher on the list and those with fewer references ranked lower. Through leveraging a VSD approach and careful selection of documents, the codebook reported in Menon et al. (2023) represents a list of values that hold significance in the context of current best practices in the field.

The methods used in Menon et al. (2023) identify potential values. Potential values are inert, prescriptive guidelines (Shilton et al., 2013)—values that exist in theory but are not necessarily enacted in the world. In contrast, performed values are those that a person or system materializes in the world. Performed values can be elicited from people by asking directly about the importance of their values through interviews, surveys, or focus groups. The potential values identified in audiology documents may not align with the performed values of modern audiologists. The practical application of values by audiologists may deviate due to several factors. The limited availability of up-to-date guidelines may lead to a difference between the theoretical values presented in audiology documents and the evolving practices enacted by audiologists in their real-world scenarios.

An example of the limitations of outdated clinical practice guidelines is in the American Speech-Language-Hearing Association (ASHA) guidelines on the provision of hearing aids in adults (ASHA, 1998), most recently updated by Valente (2006). Valente (2006) highlighted the need for regular updates in best-practice guidelines within audiology, but that document remains the most recent revision. The document omits many contemporary aspects of audiological care such as diversity, equity, and inclusion; telehealth; remote management; OTC devices; and many other topics. More recent documents representing audiology best practices have been published and were included in our analysis, with the most recent being standards of clinical practice (Audiology Practice Standards Organization, 2021), but these documents were intended to codify standards rather than supersede aging clinical practice guidelines. Codes of ethics were the only documents coded in Menon et al. (2023) that are regularly updated.

The current study sought to validate the list of potential values obtained from documents representing best-practice audiology by eliciting the performed values of practicing audiologists. The methods used to identify a list of values in Menon et al. (2023) may have missed values that are important to practicing audiologists. Engaging with audiologists in a large-scale survey is an opportunity to identify missing values. In Menon et al. (2023), we ranked the relative importance of values based on their frequency of appearance in audiology documents. The rank order derived from audiology documents primarily reflects the emphasis placed on certain values within an academic and policy-oriented context. However, when we elicit the performed values of audiologists, a different rank order may emerge. This distinction is important, as the rank order of performed values may directly influence the decisions made by patients regarding their health care, for example, the uptake and use of hearing aids. Patients, when deciding on their health care choices, may be more likely to prioritize choices that align with their personal perceptions and experiences (Kelly-Powell, 1997). Therefore, understanding the rank order of values as perceived and enacted by audiologists in practice is critical for delivering care that aligns well with patient values. This perspective may differ from that of audiology policymakers, who likely prioritize potential values based on overarching public health considerations and regulatory frameworks. Balancing the priorities of health care providers and policymakers ensures a comprehensive understanding that has the potential to enhance patient satisfaction and contribute to the development of effective audiology policies.

In this study, our primary goal was to validate the existing list of audiology values. To achieve this, we set subgoals. First, we aimed to elicit the stated values of audiologists, gaining insight into what they consider important in the prescription and dispensing of amplification devices. This was achieved by administering a values-ranking survey to a representative sample of audiologists in the United States. Next, we aimed to identify any values that may be missing from our original codebook of values, ensuring a comprehensive understanding of the diverse values held by hearing health care providers. By validating and expanding the original codebook, this study improves its applicability and relevance to current audiological practice, ultimately supporting more effective patient-centered hearing health care. Lastly, we sought to determine the rank order of these performed values and compare this to the ranking of potential values outlined in best-practice audiology documents. This comparison allows us to assess the alignment between idealized recommendations and real-world practices. Audiologists ranked values from most to least important, establishing an overall group order, which was compared to the overall order of values found in best-practice audiology documents (Menon et al., 2023).

Method

Survey Development

Values survey materials were constructed following published guidelines for survey development (Burns et al., 2008; Passmore et al., 2002). All survey items were written based on previous work identifying values in the system of best-practice American audiology such that values were drawn directly from the codebook of values in hearing health care (Menon et al., 2023). Using this codebook ensures that a comprehensive values inventory is embedded in the empirical data collection method (Fleischmann, 2013). An initial survey was assembled by writing one statement for each codebook value that was intended to capture the definitions and examples from the codebook in a way that is meaningful to audiologists. Once an initial draft of the values ranking survey was developed, the battery was reviewed individually by colleagues, including five audiologists, one colleague who is an expert in VSD, and several Doctor of Audiology (Au.D.) students in the Department of Hearing and Speech Sciences at University of Maryland. The survey was then modified based on colleague feedback.

The survey consisted of four main sections. Section 1 consisted of a screening question to ensure that respondents are audiologists and meet inclusion criteria (i.e., “Are you an audiologist?”) and displayed informed consent information approved by the university institutional review board. Section 2 consisted of the values survey, in which respondents were asked to sort and rank a list of 18 items that represent values in hearing health care. The items included in the survey are shown in Table 1. In this portion of the survey, respondents were invited to contribute other values that did not appear in the initial battery: “If there are any values not listed here that you would categorize as [most important/very important/important/less important] to you, please type them below.” Section 3 consisted of an eight-item demographics survey asking questions about personal demographics and professional environment. Finally, Section 4 consisted of a final open-ended question inviting respondents to share anything else they would like researchers to know about their responses: “Is there anything else you would like the research team to know about your responses to this survey?” The entire survey took approximately 10 minutes to complete. All responses were anonymous, and respondents were able to skip any demographics question that they did not wish to answer. All participants provided electronic consent for study participation, and all procedures were approved by the University of Maryland Institutional Review Board Package Number 2055445.

Table 1.

Values ranking survey items.

Instructions: Below you will see 18 items that have been identified as values in audiology. Please sort each item into the box that best matches how important YOU think it is within the field of audiology. The boxes range from 1 (Most Important) to 4 (Less Important). You may only add up to 6 items in each box. Please sort ALL items into boxes.
Access to care: My patients are able to receive services without excessive travel.
Accuracy: My patients' test results are correct and devices are fit to prescriptive targets.
Comfort: The physical fit of devices does not cause pain.
Cost: My patients find the price of my products and services acceptable.
Design: The style and aesthetics of devices are important.
Ease of use: My patients receive the training to use their devices independently.
Efficiency: The time invested by me and my patient is used effectively.
Equity: I treat all patients with dignity and respect despite personal differences.
Evidence-based: My professional activities are supported by scientific research.
Health: I refer patients for disorders requiring medical intervention.
Objective benefit: Results from aided testing or audibility indices indicate patient benefit.
Privacy: I protect my patients' health information and other private data.
Professional duties: I adhere to standards of conduct and codes of ethics in my field.
Safety: I do not cause harm to my patients through device settings or physical interactions.
Satisfaction: My patients find that devices and services meet their expectations.
Self-efficacy: My patients can overcome the challenges imposed by their hearing ability.
Subjective benefit: Results from questionnaires or self-report indicate patient benefit.

Procedures: Values Survey Data Collection

Participants were first asked to sort items listed in Table 1 into four categories that reflect different levels of importance: 1 = most important, 2 = very important, 3 = important, and 4 = less important. Respondents sorted each item into the box that best matches how important they think it is within the field of audiology. To ensure feasibility of the rank order central to this study, respondents were limited, placing up to six items in each box. This was to prevent all items from being placed in the “most important” box. Next, participants were asked to rank values within each box based on the level of personal importance. The directions for this secondary ranking activity read: “Please arrange the following group of values in order from MOST important to you at the top to LEAST important to you at the bottom. It can be difficult to rank the importance of unrelated values, but try your best to put items that you feel are most important toward the top of the list and items that are less important, although maybe still important, toward the bottom of the list.”

After ranking values in each category, respondents were shown the prompt: “If there are any values not listed here that you would categorize as [most important/very important/important/less important] to you, please type them below.” Directed content analysis (Hsieh & Shannon, 2005) was used to analyze the new values suggested by respondents using framework from the codebook of values in hearing health care established in Menon et al. (2023). Members of the research team familiar with the codebook read individual statements provided by respondents to identify values represented by the codebook and search for values that did not already appear in the existing list. This process is referred to as coding (Locke et al., 2020; Morse & Field, 1995). Responses were first coded by each study author separately, and then study members met to resolve discrepancies. All discrepancies were resolved through unanimous agreement.

Recruitment

Audiologists were primarily recruited from professional association mailing lists. The link to the study was e-mailed directly to audiologists who were members of the ASHA Special Interest Group 6: Hearing and Balance Sciences: Research and Clinical Applications, Group 7: Auditory Rehabilitation, Group 8: Public Health Audiology, and Group 9: Pediatric Hearing and Hearing Disorders. Audiologists were also recruited online through postings of virtual flyers containing a link to the study on the social media sites Facebook (http://www.facebook.com), LinkedIn (http://www.linkedin.com), Twitter (http://www.twitter.com), and Instagram (http://www.instagram.com), where the post could been seen and shared by individuals that the primary investigator is connected with. Some respondents were recruited through personal contact, in which study personnel directly e-mailed the study link to audiologists.

A waiver of documentation of consent from the institutional review board of the University of Maryland, College Park, was obtained because these were anonymous web-based surveys that fulfilled the requirements for such a waiver. We obtained participant consent electronically, rather than with a written statement of consent including the participant's signature.

Statistical Analyses

Kendall's rank distance test (Kendall, 1938) was used to quantify the magnitude of difference in the importance of values between audiology best practices and audiologists. Kendall's rank distance test counts pairwise differences between ranked lists. If one value is ranked above another value in a document, that pair of values would add to the ranked distance if they appeared in the opposite order in a comparison document. A normalized rank distance of 0 indicates that the two lists are identical, and 1 indicates that the lists are in reverse order.

Results

Participants

We received responses from 759 audiologists. In the analysis, we included data from the 289 U.S.-based audiologists across 46 states who completed the entire survey, shown in Figure 1. The survey was available for two consecutive months from July 20, 2023, to September 20, 2023, via the Qualtrics web tool. Confidentiality was maintained as no identifying information such as name, e-mail address, or social security number was collected. All data downloaded from the Qualtrics web page were stored in a password-protected electronic format. The demographics of respondents are shown in Tables 2 and 3. Geographic location of respondents is shown in Figure 2.

Figure 1.

Breakdown of survey completion across 759 respondents.

Table 2.

Demographic characteristics of audiologist respondents.

Question	n of 289	Approximate %
Gender: Please select the gender that you most identify with
Male	41	14
Female	241	83
Nonbinary/third gender	1	< 1
Do not wish to answer	6	2
Race: Please select the race that you most identify with
African American	3	1
Asian	6	2
Caucasian	261	90
Multiracial	1	< 1
Native American	2	1
Do not wish to answer	16	6
Please select the ethnicity that you most identify with
Hispanic	6	2
Not Hispanic	270	93
Do not wish to answer	13	4
Age (years): Please select your age
18–24	1	< 1
25–34	75	26
35–44	83	29
45–54	49	17
55–64	45	16
65+	30	10
Do not wish to answer	6	2
Education: Please select the highest degree you have earned
M.A., M.S.	22	8
Au.D.	232	80
Ph.D.	31	11
Sc.D.	2	1
M.B.A.	1	< 1
Do not wish to answer	1	< 1
Income (dollars): Please select your approximate household income in dollars
< 25,000	1	< 1
25,000–50,000	4	1
51,000–75,000	17	6
76,000–100,000	54	19
101,000–125,000	67	23
151,000–175,000	59	20
200,000+	58	20
Do not wish to answer	29	10

Note. M.A. = Master of Arts; M.S. = Master of Science; Au.D. = Doctor of Audiology; Ph.D. = Doctor of Philosophy; Sc.D. = Doctor of Science; M.B.A. = Master of Business Administration.

Table 3.

Professional characteristics of audiologist respondents.

Question	n of 289	Approximate %
Geographic environment: Which of the following best describes the geographic environment where you are employed?
Rural	40	14
Suburban	137	47
Urban	109	38
Do not wish to answer	3	1
Primary focus: Which of the following best describes your primary professional focus?
Administer balance/vestibular testing	7	2
Conduct research	9	3
Dispense hearing aids	97	34
Teach	16	6
Work with adult diagnostics	65	22
Work with cochlear implant patients	11	4
Work with pediatric population	49	17
Support audiologists	3	1
More than one of these choices	15	5
All of the above	3	1
Other (please explain)	13	5
Do not wish to answer	1	< 1
Professional environment: Which of the following best describes the professional environment where you are employed?
ENT office/outpatient facility	60	21
Hospital setting	50	17
Private practice	82	28
School setting	12	4
University setting	37	13
VA/Military	5	2
Nonprofit	5	2
Research setting	2	1
Manufacturer/industry	10	3
Retired	4	1
Government	2	1
Public health	2	1
Other (please explain)	17	6
Do not wish to answer	1	< 1

Note. ENT = ear, nose, and throat; VA = Veterans Health Administration.

Figure 2.

Responses to the question: “Please enter the U.S. state where you live.” We received complete responses from audiologists in 46 states and the District of Columbia. Seven out of 289 total respondents did not wish to answer.

Representativeness of Survey Data

An assumption of the methods used to analyze survey data was that the rank order of values has a central tendency across audiologists. We used a subgroup analysis to determine differences in values across demographic categories of survey respondents. The survey reached a group of audiologists across the United States, with demographic characteristics representative of the field of audiology and with a dominant majority of respondents being non-Hispanic, White females. As a result, there was not enough variation in the race, ethnicity, or gender of study respondents to evaluate rank order differences in these categories. Respondents varied in the categories of age, geographic location, and primary professional specialization. We used pairwise Kendall's tau comparisons (Kendall, 1938) among subgroups to determine if the rank order of values differed within these categories. Kendall's rank correlation coefficient represents the degree of similarity between each pair of ranked lists. For all subgroups within the categories age, geographic location, and professional focus, the pairwise Kendall's tau values indicate that most pairs of lists exhibit relatively high levels of agreement, ranging from approximately 0.71–0.84. The aggregate Kendall's tau value confirms that, on average, the ranked lists are highly similar, with an overall Kendall's tau ranging from approximately 0.81–0.83. The results are shown in Figure 3. Across these demographic factors, the rank order of values was markedly uniform. Accuracy was the top ranked value in all subgroups with one exception in which it was ranked second. The bottom two values, access to care and design, were consistent across all subgroups. The results of the subgroup analysis support the assumption that the rank order of values has a central tendency within audiology and, to the limited extent that diversity exists within audiology, varies little across audiologists.

Figure 3.

Subgroup analysis of value rankings across demographic categories of age, geographic location, and professional focus compared to overall group rankings. Numeric values and shading indicate the average ranking position of each value within the subgroups. The lighter shading is associated with a higher ranking position relative to the darker shading.

Addition of New Values

An objective of this study was to identify values in audiology that were missing from the original codebook of values in hearing health care (Menon et al., 2023). We received a total of 43 responses to the prompt: “If there are any values not listed here that you would categorize as [most important/very important/important/less important] to you, please type them below.” The complete list of suggested new values is shown in Supplemental Material S1. While many respondents suggested additional values for consideration, we found that all suggested values were encompassed by one or more existing values reported in Menon et al. (2023). For example, one respondent suggested “Making appropriate medical referrals” as an additional value. The definition of the value of health in the codebook of values in hearing health care is “diagnosis and/or referral for medical conditions.” Therefore, this suggested response would fall under the value of health. As another example, one respondent suggested “Regain communication function with friends, family, and co-workers” as a new value. This suggestion falls into the category of subjective benefit, since the codebook lists “Improvement in audibility, intelligibility, localization, clarity, sound quality; reduction in activity limitation; decrease of participation restriction; perception of self; reduction of listening effort” as examples of how this value may appear. A complete list of statements and how they were interpreted relative to values outlined in Menon et al. (2023) is available in the Supplemental Material S1.

Two responses suggested the addition of a value related to family-centered care (FCC), “Respect for patients/families to make decisions based on their values,” and “Family-centered care: My patients, along with their significant others, can participate in sessions related to their hearing health care.” The concept of patient-centered care (PCC) can be considered a metavalue because the components that make up PCC are themselves values (e.g., autonomy, self-efficacy, evidence based). FCC and PCC share these components, but they differ in defining the family as a whole as the target of intervention rather than the individual (Ekberg et al., 2023; Epley et al., 2010). No new value was added to the list of values in the present study because the language used by respondents did not explicitly differentiate patient versus family centeredness. Future work eliciting values from different stakeholders in hearing health care should explore the degree to which it is relevant to consider the family and other communication partners separately or in addition to the patient.

Audiologists' Values Rankings

Overall group rankings were determined by calculating the mean ranking position of each value among 289 respondents, shown in Figure 4. This relative ranking of values among audiologists was compared to the ranking of values found in audiology best practices (Menon et al., 2023). Kendall's distance (K_d) = 0.346, indicating that approximately 35% of code pairs were in the reverse order in the audiologist survey compared to audiology documents. A Kendall's distance of 0.35 indicates that while there are some differences in the ordering of the rankings between the two data sets, there is still a substantial amount of agreement. This relatively low level of discordance suggests that respondents' values generally align well with established best practices; however, professional experiences might lead to different priorities in performed audiological care.

Figure 4.

Comparison of values rankings between audiologists and documents that represent the best-practice provision of audiology (Menon et al., 2023).

We received a total of 45 responses to the final open-ended question: “Is there anything else you would like the research team to know about your responses to this survey?” Responses primarily discussed general survey feedback and clarification as to current employment. The complete list of respondent feedback is shown in Supplemental Material S2.

Comparison to Values in Best-Practice Documents

Another objective of this study was to compare the relative prioritization of values in best-practice hearing health care to audiologists' prioritization of the same values. We compared the rank order of potential values found in best-practice audiology documents (Menon et al., 2023) to the overall rank order of performed audiologist values determined in this study. Kendall's rank distance test showed that approximately two thirds of all values were in the same rank order when comparing survey responses to the number of words coded to each value best-practice documents, indicating substantial agreement between the order of the two lists. The similarity in rank order likely reflects the fact that the documents used to generate the rank order in Menon et al. (2023) were developed by audiologists to encode audiology practice. To the extent that they differ, the ranked order of each list represents the priorities that underlie its source. The documents included in Menon et al. (2023) represent the potential values of audiology, whereas the survey results represent the values audiologists perform or intend to perform in their clinical practice.

Discussion

Top 3 Audiologist Values: Accuracy, Safety, and Equity

We conducted an online survey to systematically assess the prioritization of values in hearing health care among U.S.-based audiologists. The results of this study validate the existing list of audiology values and provide insight into the current priorities of hearing health care providers. Through a values-ranking survey, stated values were elicited from of a representative sample of audiologists, highlighting the importance they place on various aspects of their practice, particularly in the prescription and dispensing of amplification devices. The survey responses revealed that the values identified in documents outlining best practices remain relevant and applicable, with a substantial alignment between the values prioritized by audiologists and those outlined in best-practice audiology documents. The absence of additional values from the large-scale survey of audiologists suggests that the list established in Menon et al. (2023) is comprehensive and accurately reflects the values practiced by audiologists. The rank order analysis demonstrated agreement between the recommendations in best-practice documents and the real-world values performed by audiologists, thus reinforcing the utility of the codebook of values in hearing health care in guiding effective and patient-centered hearing health care interventions.

The three values ranked most highly by audiologists were accuracy, safety, and equity. Accuracy, defined in this survey as “my patients' test results are correct and devices are fit to prescriptive targets,” was ranked as the most important value among our sample of respondents. This is consistent with previous work showing that clinical test results are among the most important factors for audiologists when making decisions (Boisvert et al., 2017). There is evidence that accuracy is valued across the field of hearing health care as a whole; accuracy is highly prioritized in both best-practice audiology documents and regulatory documents that describe the implementation of OTC hearing aids (Menon et al., 2023, 2024). The widespread promotion of routine real-ear measurement (REM) in clinical practice (Amlani et al., 2017; ASHA, 2006) underscores the importance of accuracy in audiological care, yet fewer than 30% of audiologists consistently perform REM (Mueller & Picou, 2010; Valente et al., 2018). REM is only one of the many objective tests that audiologists perform, with other critical testing including audiometric threshold testing, speech audiometry, and tympanometry, all of which require precise results to ensure accurate diagnoses and effective treatments (ASHA, 2006; OpenAI, 2023). The high value placed on accuracy by survey respondents reflects its crucial role in enhancing patient outcomes, suggesting a need to address barriers to the consistent implementation of these practices.

Safety (ranked 2/18) is another core value among our sample of audiologists, reflecting the Hippocratic principle to “first do no harm.” While the larger field of otolaryngology is generally regarded as a “safe specialty” due to low morbidity/mortality rates (Danino et al., 2017), it is possible to harm audiology patients with inappropriate interventions. Within clinical audiology, harmful device settings or physical interactions can lead to further hearing loss, physical discomfort, or other complications (Macrae, 1991). The high prioritization of safety among our sample of audiologists indicates a commitment to protect patients from potential harm or discomfort as the result of audiological intervention. In a practical sense, ensuring safety helps avoid potential legal ramifications. If a patient is harmed due to negligence or oversight, the provider may face lawsuits, financial repercussions, or loss of licensure (Domico, 1993).

The high prioritization of equity (ranked 3/18) from audiologists reflects the goal of ensuring that individuals receive effective hearing health care regardless of their background or circumstances. Audiologists prioritize that every individual be treated with respect and dignity, regardless of their background or personal differences. By emphasizing equity, audiologists appear to affirm this fundamental right and can work to reduce health care disparities that might arise from socioeconomic factors, racial biases, or other systemic issues (Abrahams et al., 2023; OpenAI, 2023). When patients perceive that they are being treated with equity, it can foster a sense of trust, which is crucial for a beneficial relationship (Ford-Gilboe et al., 2018). A trusting patient–provider relationship can lead to better communication, which is essential for accurate diagnosis and effective treatment (Drossman et al., 2021; Fox & Chesla, 2008). One respondent explained, “As an audiologist and owner of a small private practice—my success is 100% based on the quality of care for patients, which results in trust, respect, patient personal confidence and care,” and continued, “my patients trust me to do what is best for them, not what is written in the books and journals, not what everyone else is doing, and not what the researchers tell us we have to do.” Every patient comes with a unique background and set of experiences, and treating patients equitably allows audiologists to gain a holistic understanding of their patients, leading to more personalized and effective care. When patients feel heard and respected, they may be more likely to trust their health care provider and experience success when adhering to the prescribed treatments (Martin et al., 2005; OpenAI, 2023).

However, equity also appears to be a politically loaded, divisive term among audiologists. In this study, the audiology statement that accompanied the value “equity” was as follows: “I treat all patients with dignity and respect despite personal differences.” This was the only definition given to the value equity, and the word equity did not appear in any other part of the survey. Despite this, some responded with critical feedback regarding the use of the word equity in this survey: “‘Equity’ is a woke term that is originally derived from Marxism. Please do away with all woke terminology as it is divisive in our profession. Stay focused on the audiology profession and not on the damaging effects of political agendas.” The same respondent continued, “Eliminate woke terminology and related questions. Those political agendas are divisive and not unifying. It is a major disservice to the audiology profession to inject political agendas into the wonderful work we do for our patients and our profession.” However, other respondents had different attitudes toward the word equity: “The word is ‘equity’ is a deceiving term. I agreed with your description of equity, which is often different than the description of equity in greater society.” Another respondent took issue with only specific aspects of equity: “I treat every patient with dignity and kindness, and it is important to me, however, I am not a supporter of the continuing [education] requirements for gender equity.” Despite this conflicting feedback, equity was ranked as the third most important value among respondents, indicating that this value is highly prioritized by audiologists.

Bottom 3 Audiologist Values: Cost, Access to Care, and Design

The three lowest ranked values, cost, access to care, and design, are all potential barriers limiting the use of hearing health care. The value of cost (ranked 16/18) encompasses several facets of hearing health care, including aspects related to money, warranty, price of devices, and payer. Before claiming that cost is a low priority to audiologists, we must first acknowledge that the way cost was presented in our survey may have affected its ranking. Our survey presented cost as related only to the price of devices paid by patients. Respondents indicated a broader definition of cost in their suggestions for additional values. One suggested facet of hearing health care that could be encompassed by cost is provider compensation. Respondents wrote that audiologists “need to have higher pay across the board and be more valued” and “ … should bill appropriately and completely for services rendered and receive compensation commensurate with those services.” Payer and bundling were additional cost-related concerns specifically mentioned by respondents. In certain environments, audiologists consider cost paramount. One respondent wrote, “I work in a very rural area with a wide range of patients coming from all over the state. I want to make sure I am fulfilling my role as an audiologist, providing them with quality care, and then helping with cost/travel. My practice offers low budget hearing aids to allow patients to have high quality aids while still being able to receive care from an audiologist.” This statement suggests that both cost and access to care are high priorities in the context of rural audiology.

Nevertheless, cost was ranked toward the bottom in our results and some audiologist statements reinforced this low ranking. One respondent stated, “some people find everything too expensive.” Several respondents explained that because of adequate third-party coverage, cost had no impact on their clinical interactions. “Because I work for the military, the cost of products and services is not a consideration when providing care … ” wrote one respondent. Another at a Veterans Health Administration (VA) clinic wrote “ … with VA, cost is not an issue for the patient and not listed as a high priority for the provider.” Third-party coverage outside of the military and VA is poor but improving in the United States (Jilla et al., 2023; Windmill, 2022), including increased coverage of hearing health care by Medicare (Arnold et al., 2024; Tipirneni et al., 2019). Coverage for hearing aids by Medicare—which explicitly bans such coverage at this time—may be on the horizon (Lin et al., 2022; Medicare Hearing Aid Coverage Act of 2023; Willink et al., 2019), and this would likely cascade into near-universal coverage for hearing aids by private insurers, similar to the introduction of Medicare Part D prescription drug coverage more than a decade ago (Duggan et al., 2008; OpenAI, 2023). Our results suggest that the cost of hearing health care services is a lower priority than most other concerns.

Audiologists reported access to care (ranked 17/18) as a low priority, and this may be due to several contextual factors. Audiologists operate within a broader health care system, and regional disparities in health care infrastructure can limit access to care. An individual audiologist working in most clinical settings can do little to improve the travel and wait times experienced by patients and may feel powerless to address these systemic challenges. However, the increasing availability of telehealth solutions for device fitting and troubleshooting, counseling, aural rehabilitation, and other audiology services empower audiologists to improve access to care (Brice & Almond, 2022; D'Onofrio & Zeng, 2022). Community health workers have been shown to facilitate hearing health care in underserved areas (Coco et al., 2023; Marrone et al., 2022; Nieman et al., 2022). Some respondents valued access to care; one emphasized that “patients can choose where they go for healthcare, and how far they travel,” pointing out the shortage of hearing health care professionals in underresourced rural areas (Powell et al., 2019; Pudrith et al., 2021).

It is important to consider audiologists' prioritization of cost and access to care in the context of the changing landscape of hearing health care. Cost and access to care are considered a major barrier to the use of hearing health care services (Donahue et al., 2010; National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Health Sciences Policy, Committee on Accessible and Affordable Hearing Health Care for Adults et al., 2016; President's Council of Advisors on Science and Technology, 2015), leading to the introduction of OTC hearing aids (U.S. Food and Drug Administration, 2017). OTC hearing aids challenge conventional payment structures in the field of hearing health care and may affect the perception of cost among practitioners (Coco, 2024; Sheffield et al., 2022). The elevation of cost and access to care, along with autonomy, represents a values shift in hearing health care from the audiology model of maximizing individual benefit to a public health model of maximizing the number of people receiving care (Menon et al., 2024).

Design was ranked in the lowest position (ranked 18/18) in both our analysis of best-practice documents and in the audiologist survey. In this survey, the value design was associated with the statement, “The style and aesthetics of devices are important.” This statement was interpreted by at least one respondent in the context of device recommendations, indicated by their statement, “Style and aesthetics are important but should not be the only determinant as to whether the device is the best one for the patient.” Here, the appearance of the device was implied to be in competition with its ability to benefit the patient. However, appearance is related to the stigma of hearing aids, and stigma is a major barrier to hearing aid use (Erler & Garstecki, 2002; Johnson et al., 2005). The results of this study suggest that audiologists are primarily concerned with maximizing individual patient benefit, as indicated by the high ranking of accuracy and values related to satisfaction and benefit, and less concerned about barriers to hearing health care, which include the three lowest ranked values of design, cost, and access to care.

Study Limitations and Critical Feedback

This survey focused on amplification devices, primarily the prescription and dispensing of hearing aids. Several respondents noted that they would have liked to “see more areas of audiology represented beyond prescriptive/dispensing.” One respondent stated, “Everything was focused on devices. Nothing was offered re: […] diagnostic testing, balance etc. Perhaps that was intent of the survey, but our profession is not just about devices…. ” Since this survey was written to focus on aspects of audiology that have to do with treatment from devices, it is possible that the values of audiologists with specialties other than hearing aid dispensing were not fully captured. For example, “I do not fit or dispense hearing aids. I have a vestibular specialty, thus most of these responses were geared towards dispensing audiologists” and “Your survey is limiting as it appears to focus on hearing aid fitting(s) and the design seems to make me answer a question I would not necessarily answer the way presented. I worry it is misleading and does not allow me to really address what your research question is supposed to address. The survey comes across as a way to put an answer in a category that does not depict the way I think about audiology at all.” This investigation may not have comprehensively captured certain values differences inherent in audiology due to limitations in the data set stemming from an insufficient number of valid responses. Additionally, the survey design did not specifically address the identification of values differences among specializations within audiology, such as those associated with vestibular, occupational, and educational domains. Consequently, the outcomes may not fully capture the entire spectrum of values conflicts within hearing health care, underscoring the need for more targeted methodologies in future research to systematically explore and capture nuanced variations in professional values across different audiological specializations (ASHA, 2006; OpenAI, 2023).

A limitation of this study was introduced by the tools chosen via the Qualtrics web application. To facilitate the sorting and ranking of values, the question type “pick, group, and rank” was used. However, there were multiple issues with the parameters of the question type and the user interface. First, we were unable to ensure that respondents sorted all values into categories ranging from most to less important. This resulted in 38 responses where audiologists ranked more than one but less than 18 of the listed values. These 38 responses were eliminated for the final analyses since overall group rankings are biased with partial nonresponse data (Brick & Kalton, 1996). The second issue was that some respondents found the user interface for the “pick, group, and rank”–style questions difficult to complete on some mobile devices. Respondents reported that “The first part of the survey is not very mobile friendly” and that “It was hard to drag and drop things on an iPhone.” While the Qualtrics interface was designed specifically for use with mobile devices, some respondents found it cumbersome to complete the sorting and ranking activities on their mobile device. This could have led to fewer complete responses from audiologists who received the survey link.

Another possible limitation regarding this survey study is the validity of the ranking strategy. Respondents reported concerns about their ability to judge the rank order importance of values or found it acceptable to sort items into different boxes but had difficulty ranking values within boxes. One respondent reported that it was “ … hard to rank and prioritize items as so many overlap and are of equal importance.” Another said, “The answers for the first three categories were difficult to classify as degrees of importance as all of categories are important.” We expected audiologists to experience a moderate amount of difficulty while completing the sorting and ranking activities, as we predicted that all values would be important to respondents having started from a list of values in audiology. Some respondents were concerned that the methodology behind this survey was designed to trick or embarrass audiologists: “This survey seems to place my answers in a box and corners me into a thought process I do not agree with necessarily. I feel like the survey is designed to trap my answers and potentially view [an] outcome that is not accurate… . ” Another respondent noted that they are “somewhat concerned about how these data will be presented, by forcing rankings of clearly important issues to be ‘less important.’” We anticipated this concern and attempted to mitigate it both in the survey instructions and in the labeling of categories, where the lowest level of importance was labeled “Less Important” rather than, for example, “Unimportant.” The chosen methodology inherently results in some values ranking lower, and it would be incorrect to interpret a low ranking in our results as unimportant. Despite these limitations, giving audiologists an opportunity to rank values provides insight into how audiologists prioritize and enact different values in practice, in contrast to the word count method used to rank values in Menon et al. (2023). Understanding the relative priority of values provides insight into the processes that underlie the complex decision making in audiological practice.

Conclusions

We validated a comprehensive list of the values of best-practice audiology and identified the rank order of values of hearing health care providers. The fact that no additional values were added to the list after eliciting values from audiologists using a large-scale survey indicates that the list established in Menon et al. (2023) is comprehensive and reflects the performed values of practicing audiologists. The performed values of audiologists and potential values of the best-practice audiology system largely align, with two thirds of values in the same rank order in both lists. Eliciting values of hearing health care providers in this study will facilitate future comparisons between audiologist and patient values. If audiologist values are not aligned with values of non-users of hearing health care, potential solutions can be developed tailored to the values of specific populations. Such solutions may reduce barriers to hearing health care and reduce the individual and societal burden of untreated hearing loss in the United States.

Data Availability Statement

The data sets generated and/or analyzed during this study are available from the corresponding author on reasonable request.

Artificial Intelligence Statement

This article was prepared using tools to assist with language editing based on large language models. These tools were used to generate suggestions for improving the clarity and readability of the article.

Funding Statement

This work was supported in part by Training Grant DC-00046 from the National Institute on Deafness and Other Communication Disorders.