Hearing Aid Fitting Orientation and the APSO Standard

Abstract

The Audiology Practice Standards Organization (APSO) which was formed in 2017 set out to compile basic services that audiologists within the field should adhere to in their practice. The second standard of the APSO is the Hearing Aid Fitting Standard for Adult and Geriatric Patients. Among the services outlined for an adult hearing aid fitting, orientation is discussed. A hearing aid fitting orientation needs to be device- and patient-centered while also covering various aspects of hearing aid orientation that supports patient's success during the process. This article discusses APSO Standard 12 regarding hearing aid orientation and details how this standard can be implemented in the clinic.

STANDARD DISCUSSED

• 12. Hearing aid orientation is device- and patient-centered and includes use, care, and maintenance of the hearing aid(s) and accessories.

As hearing healthcare professionals, audiologists provide identification, assessment, diagnosis, and treatment of hearing and balance dysfunctions. ^{1 2} The goal of these specific actions is to mitigate the negative impacts audiologic disorders have on an individual's communication and quality of life. In their scope of practice document, the American Academy of Audiology lists audiologists' various roles. These roles include clinician, therapist, teacher, consultant, researcher, and administrator. ² While these can be distinct roles that define the tasks of an audiologist in their position, these roles can also overlap. In an appointment with a patient, the audiologist may carry out activities and skills that fulfill the roles of clinician, therapist, consultant, and even administrator. Audiologists execute these roles minute by minute and often simultaneously to ensure their patients receive quality care.

While the scope of practices discusses the breadth of practice within a profession, it does not provide practice standards. Practice standards are the foundation for clinical practice and outline the minimum that a clinician should be adhering to in their practice. In 2017, the Audiology Practice Standards Organization (APSO) was formed with the intent of “developing and educating colleagues about practice standards.” The organization's mission focuses on developing, maintaining, and promoting practice standards for the profession of audiology that that are evidence based and support best practices. ³ Having national practice standards that are universally accepted by the profession creates a common ground for practitioners. The second standard of the APSO is S2.1: Hearing Aid Fitting for Adult and Geriatric Patients.

Having the APSO standard for adult and geriatric patients' hearing aid fittings is an opportunity for audiologists to present in a formal way the various components of a hearing aid fitting. It is a chance for the profession to remind various stakeholders that there is a process audiologists progress through when dispensing a hearing aid. Previous articles discuss aspects of determining appropriate devices and fitting, which are all central to ensure proper treatment of hearing loss. This article aims to shift the focus of the hearing aid from what the clinician does to the device to ensure it is appropriate and properly functions for the patient and moves to how the audiologist supports the patient in their interactions with the device to foster success.

The APSO standard S2.1 outlines 15 basic services audiologists are expected to include in the provision of fitting a hearing aid for an adult patient. Number 12 states, “Orientation is device- and patient-centered and includes use, care, and maintenance of the hearing aid(s) and accessories.” ⁴ This is critical to a patient's success in using their hearing aid(s) and accessories. It has been reported that only 10 to 30% of hearing aid users in the United States above the age of 60 years effectively use their hearing devices on a day-to-day basis. ⁵ Hearing aids are medical devices used as a treatment option for patient to reduce their communication breakdowns which makes proper usage imperative.

An individual with hearing loss and their conversation partners will not experience improved communication and could even encounter an increase in communication breakdowns with improper hearing aid use. This would not only be counterproductive but could increase the manifestations that hearing aids are aimed at ameliorating. ^{6 7} The objective of audiologists is to reduce the negative impacts of hearing disorders. This requires ensuring orientation to hearing aids and other assistive listening devices is useful to patients. The aim of this article is to expand on the APSO hearing aid fitting standard regarding hearing aid orientation to promote patient confidence and self-efficacy.

DEVICE- AND PATIENT-CENTERED ORIENTATION

APSO states that a hearing aid orientation needs to be device- and patient-centered. Focusing on both the devices and the patient when completing an orientation ensures patients receive the specific information the individual needs to be successful with the specific devices they are acquiring. Having an individualized orientation is important for both new and existing hearing aid users to support them and ensure they are comfortable with their technology. ^{8 9 10}

Conducting an orientation that is device-centered is important for all hearing aid users to ensure the patient is familiar with their instruments. For new hearing aid patients, a device-focused conversation provides them with the foundational knowledge needed to feel confident with their hearing aids. The goal for this group is to educate them regarding the devices and increase their understanding of their equipment. Having the vocabulary and understanding of the different parts of the device is a way to empower patients and increases their belief in their ability to manage the device. By giving them the words to use in the orientation, patients will be able to be specific in asking for what they need in the future.

While device orientation is often completed as a one-time event, the benefits of continued exposure has been shown. ^{8 11} Kemker and Holmes ⁸ used the Glasgow Hearing Aid Benefit Profile (GHABP) and showed that pre- and post-fitting hearing aid orientation sessions benefit patients, especially for those who self-identify as having greater disability. The hearing aid orientation conducted included aural rehabilitation aspects such as nonverbal and situational cues along with information about the specific instruments. Participants were also given written materials that aligned with the sessions. Being able to review information at a later date allows a patient the ability to revisit information in their own space and on their own timeline.

The concept of empowering patients with material they can was also used by Ferguson et al ¹¹ in their study looking at reusable learning objects (RLOs). They describe RLOs as “short, highly visible chunks of interactive multimedia learning that illustrate concepts to support a specific learning goal.” This study found that first-time hearing aid users benefitted from the use of RLOs along with the orientation at the hearing aid fitting. Using additional resources beyond the hearing aid fitting to support orientation is a successful way to support patients. In healthcare, time is always a consideration which makes using supplemental materials, such as written or video, as a way for audiologists to support patients after their fitting appointments.

Although it may seem unnecessary to complete an orientation with an experienced hearing aid user, it is critical this is completed. Desjardins and Doherty ¹⁰ found that even among experienced hearing aid users, understanding of how to use the devices ranged widely. By assessing existing hearing aid users with an objective test focused on manipulation of the hearing aid, it was found that a patient's ability to properly manipulate their hearing aid is an important factor to their satisfaction with the devices. They also determined that even experienced users fell short in basic tasks such as hearing aid cleaning. This information shows clinicians that although patients may appear to balk at having an orientation, it has benefit even if they have experience with hearing aids. In the end, the goal of orientation efforts is self-efficacy and knowing the specific parts of the device is critical to this undertaking.

Hearing aid orientation needs to go beyond simply showing the patient the parts of their devices and explaining what they are. The experience also needs to be patient-centered. There is evidence to support the notion that a patient's success with hearing aids starts even before the devices are dispensed. The Expected Consequences of Hearing aid Ownership (ECHO) questionnaire found that expectations prior to hearing aid fitting impacted hearing aid satisfaction ratings. This 15-item self-report questionnaire found that moderately higher ratings of hearing aid satisfaction were found in individuals with positive expectations prior to fitting. ¹² While other questionnaires, such as the Satisfaction with Amplification in Daily Living (SADL), look at patient satisfaction with their hearing aids, the ECHO is an instrument designed to measure a patient's expectations.

Addressing expectations and providing information prior to the hearing aid fitting supports positive outcomes. ¹³ Using a tool like the ECHO is one way in which clinicians can gauge the patient's expectations and address them appropriately. For instance, if a patient perceives hearing aids will not be “worth the trouble” even before they get them, a discussion can address this position prior to the fitting appointment. The audiologist may also take a different approach during the hearing aid fitting appointment based on the information they gained from the questionnaire and home in on areas they know are concerns for the patient. Knowing different aspects that can influence the orientation process for a specific patient during the hearing aid fitting allows for the clinician to provide patient-centered support.

The ECHO measures the expectations patients bring with them to the clinic and their thoughts on how successful they will be with hearing aids and their accessories. These perceptions impact a hearing aid fitting orientation along with the impressions they receive from the clinic. An audiologist's narrative during the appointment has an impact on patient's expectations. The words the audiologist uses to discuss the technology during the orientation impacts not only how the patient perceives their ability to be successful but also has been shown to impact aided assessments, such as speech in noise testing. ¹⁴ Knowing that how professionals talk about hearing aids and describe them to patients can have a positive or negative impact not only on their view of the devices but also their performance makes it imperative that orientation be completed mindfully.

Ensuring device- and patient-centered orientation creates a space where patients build confidence and self-efficacy around the experience of hearing aids. For audiologists, keeping the device specifics and patient perspective in the framework of a hearing aid fitting orientation ensures the practice standard is met.

USE, CARE, AND MAINTENANCE

In addition to stating that a hearing aid fitting orientation should be device- and patient-centered, it should also state that the orientation needs to include discussion of “use, care, and maintenance of the hearing aid(s) and accessories.” ⁴ This is where the device- and patient-centered aspects of the orientation come together to support the patient's success. It is important for clinicians to recognize that while the use, care, and maintenance aspect of hearing aids are straightforward to them, it needs to be explicitly discussed and demonstrated to patients.

Patients need to know the different parts of their hearing aids and the accessories to be able to effectively ask for what they need and advocate for themselves. On top of knowing the parts of the device, they need to know how to use them effectively. Patients need to be directed on the basics of hearing aids such as how to power them, batteries or charger, and how to insert them along with individualized instruction on usage. Audiologists are an integral part in showing and supporting proper use of hearing aids, as these are aspects that can be changed based on the programming.

Hearing aids come with instructions on the use of the devices, but these are generic and often cover various models from the manufacturer. While the booklet can support the discussion about the use of the device, it is impractical for a clinician to assume it has all of the information the patient will need to use the hearing aid effectively. These devices support various configurations that the audiologist programs based on what is appropriate for their patient. How the programming is set needs to happen in collaboration with the patient and how to access the different aspects of programming needs to be clearly explained by the audiologist. They need to know the difference between a short press and a long press, the function of the top versus the bottom of the rocker switch, and if the change will impact both hearing aids to list just a few different scenarios that a patient may encounter and be able to effectively manipulate.

Along with their hearing aids, many patients utilize accessories including smart phones to access apps and stream audio. While connectivity may have been considered a perk years ago, it is now becoming an integral part of hearing aid use for many patients. ^{15 16} Audiologists need to be able to complete orientation on how hearing aids and smart phones interact. Showing patients the features of the manufacturer's app should also be a part of the orientation process. If the orientation process is viewed as an activity beyond the initial fitting appointment, these extension activities can be included. Individualized treatment will dictate if the patient should be oriented to the app at the initial fitting, during the acclimatization period, or if the patient will not utilize the app.

Along with specific use of the hearing care, maintenance is another area patients need to work for a successful orientation to their devices. Care includes how a patient needs to handle the devices to ensure they remain in working order. Maintenance includes activities that need to be completed on a semi-regular basis for routine upkeep. No matter the model, bundled or unbundled, that the clinic follows, audiologists want their patients to be able to manage their devices. Being a support to patients during the orientation will make them they are more independent over time.

Care and maintenance vary from daily activities to those that need to be completed on an as-needed basis. Ensuring patients are aware and capable of completing care and maintenance is critical during hearing aid orientation. As previously discussed, improper use of hearing aids can result in outcomes that are the opposite of the intention and the same can be said for care and maintenance. If a patient does not properly care for their hearing aid, it is possible that they could encounter effects that make hearing and communication more difficult. An example of this is the common result of cerumen build up in a hearing aid. If this is not properly cared for, it is possible the patient will have a more difficult time hearing with their hearing aid even if it is in properly and they are fully aware of how to use the device.

CONCLUSION

The APSO is an organization with the mission of developing, maintaining, and promoting national standards for the profession of audiology. ³ The second standard of the organization is the Hearing Aid Fitting for Adult and Geriatric Patients. Within this document, orientation to hearing aids and accessories is determined to be necessary in a hearing aid fitting. An orientation that is device- and patient-centered is considered a basic service for audiologists to provide their patients. This needs to include specifics on individualized use, care, and maintenance to ensure patients have the knowledge and skills necessary to be successful hearing aid users.

Funding Statement

FUNDING S.K.M. is supported by a grant from the National Institutes of Health (K23DC016855).