caregiver recall and understanding of paediatric diagnostic information and assessment feedback
TRANSCRIPT
Providing appropriate feedback to patients is an essential compo-
nent of the audiological assessment and an important part of the
audiologist ’ s role as a clinician. It is a multi-faceted process that
necessitates effective communication between the audiologist and
the patient, as well as recall and understanding of information by the
patient. The degree of accurate recall and understanding of informa-
tion has implications for follow-up of treatment options and recom-
mendations by the patient, patient satisfaction, trust, and ultimately
patient commitment and adherence to treatment recommendations
(Watson & McKinstry, 2009; Haskard-Zolnierek & DiMatteo, 2009).
In cases where the child is the patient, the caregiver (parent/guardian)
becomes the dominant recipient of clinical information. It is impera-
tive that this caregiver is able to understand and recall information to
ensure that the child receives appropriate care (Moon et al, 1998).
Poor patient recall and understanding of treatment recommenda-
tions is a common occurrence (Silberman et al, 2008). Research
has indicated that only 50% of information provided by healthcare
providers is retained by patients (Shapiro et al, 1992), and between
40% and 80% of information provided by medical professionals
may be forgotten immediately (Kessels, 2003). Patient factors such
as age, anxiety, language barriers, levels of literacy, and education
may infl uence recall and understanding (Nair & Chienkowski, 2010).
A stressful situation may also affect recall, such as when a parent
is told that their child has a hearing loss (Clark & Brueggeman,
2009). Apart from these factors, the method in which information is
presented and the communicative style used by the audiologist both
play an infl uential role in patient recall and understanding (Kessels,
2003; Schmidt von W ü hlisch & Pascoe, 2010).
In the fi eld of audiology, a distinction has been made between
‘ informational counselling ’ or providing information to patients about
hearing disorders and treatment options, versus ‘ personal adjustment
counselling ’ or assisting patients with psychological and emotional
reactions to hearing loss (English, 2008a; Margolis, 2004). The study
described in this paper focuses on informational counselling with
patients. This type of counselling may involve describing the nature
of the audiological disorder, explaining and interpreting the audio-
gram, providing recommendations for management and/or amplifi -
cation, answering patient questions, and discussing educational and
communication options (English, 2008a; Margolis, 2004).
Although ‘ developing effective informational counselling skills
has yet to be addressed in the audiologic literature ’ (English, 2008a,
p.199), some suggestions have been made regarding how information
Original Article
Caregiver recall and understanding of paediatric diagnostic information and assessment feedback
Jennifer Watermeyer , Amisha Kanji & Auriette Cohen
Department of Speech Pathology and Audiology, School of Human and Community Development, University of the Witwatersrand, Johannesburg, South Africa
Abstract Objective: Providing appropriate feedback to caregivers is an important part of the paediatric audiological assessment. This preliminary study explored caregiver recall and under-
standing of audiological diagnostic information subsequent to an initial paediatric diagnostic assessment. Design : A qualitative study was conducted at an audiology clinic at a hospital
in South Africa. Data collection included observation and video-recording of assessment and feedback sessions as well as post-session semi-structured interviews with the audiolo-
gists and caregivers. Recorded sessions were analysed using sociolinguistic methods and a transcription-less approach. Interviews were analysed via content analysis. Study sample: Participants included four audiologists and fi ve caregivers whose children had been referred for an initial audiological assessment. Results: Feedback sessions included explanations
of the hearing mechanism, tests, audiogram, diagnosis and recommendations. Most caregivers were able to recall the fi nal diagnosis and recommendations, but demonstrated poor
recall and understanding of explanations of the audiogram and hearing mechanism. Conclusions: Results highlight the importance of tailoring information towards specifi c caregiver
needs during feedback sessions and acknowledging the goals and agenda of the caregiver. There is a need for a greater focus on information counselling in curricula and training
programmes, and several suggestions are made in this regard.
Key Words: Recall; understanding; audiology; information counselling; feedback; diagnosis
Correspondence: Jennifer Watermeyer, Department of Speech Pathology and Audiology, University of the Witwatersrand, Private Bag 3, WITS, 2050, South Africa. E-mail: jennifer.
(Received 6 June 2012 ; accepted 10 August 2012 )
ISSN 1499-2027 print/ISSN 1708-8186 online © 2012 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society
DOI: 10.3109/14992027.2012.721014
International Journal of Audiology 2012; 51: 864–869
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should be provided to patients. These include (1) providing adequate
information for decision-making in a clear and concise manner, (2)
providing explicit concrete instructions, (3) presenting important
information fi rst, (4) repeating information, (5) avoiding the use of
misleading and confusing terminology, and (6) using an anatomi-
cal model or diagram of the ear to supplement verbal descriptions
(Margolis, 2004; Musiek et al, 2007).
Language barriers, cultural diversity, and the presence of a third
party are other factors that need to be considered when providing
feedback to patients and caregivers. Language barriers can dimin-
ish access to primary and preventative care, weaken patient com-
prehension, limit patient adherence, and reduce patient satisfaction
(Wilson et al, 2005). South Africa ’ s unique linguistic and cultural
diversity provides an interesting contextual backdrop for examining
communication processes. The country has 11 offi cial languages,
with many healthcare interactions taking place across linguistic and
cultural barriers (Penn, 2007), and many patients accessing tradi-
tional healing systems in conjunction with biomedical options (de
Andrade & Ross, 2005).
Minimal research has been conducted in the fi eld of paediatric
audiology in relation to caregiver recall and understanding. Addi-
tionally, the literature does not appear to provide any evidence base
for suggested guidelines regarding the provision of feedback and
informational counselling with audiology patients. Hence, this paper
describes a study that examined caregiver recall and understanding
following informational counselling during a feedback session after
a paediatric audiological assessment. The study aimed to document
information counselling practices, examine the information content,
and determine the degree of accuracy of caregiver recall and under-
standing.
Methods
The study adopted a qualitative research design. Research was con-
ducted at an audiology clinic at a tertiary hospital in South Africa.
Ethical clearance for the study was obtained from the University
IRB and permission was obtained from the hospital ’ s chief execu-
tive offi cer. All participants were provided with verbal and written
information about the study and written consent was obtained from
all participants.
Data collection included observations of fi ve paediatric audiologi-
cal assessment and feedback sessions, followed by semi-structured
interviews with the caregivers and audiologists involved. Four audi-
ologists participated in the study. All of the audiologists were female
and two were dually qualifi ed as speech-language therapists and
audiologists.
Five caregivers participated in the study. In South African public
healthcare contexts, there is typically a language and culture mis-
match between caregivers and audiologists, with feedback typically
conducted in English. Caregiver participants thus had to be able to
speak and understand English in order to participate in the study, and
language profi ciency was determined via caregiver report. Caregiv-
ers ’ education levels were not used as a criterion for inclusion in the
study, as it was felt that a variety of education levels would be a more
reliable representation of a typical sample of caregivers in this setting
(see Table 1 for caregivers ’ demographic information). The caregiv-
ers ’ children had been referred for an audiological assessment, and in
most cases this was the fi rst time they had received such an assess-
ment. In each case, audiological testing included an otoscopic exami-
nation, tympanometry, visual reinforcement audiometry (VRA) (if
the child was old enough), automated auditory brainstem response
(AABR) and/or otoacoustic emission (OAE) measures.
Inclusion criteria allowed for observing assessments in which hear-
ing loss was diagnosed as well as those in which hearing was found
to be within normal limits. The data set does not however include
any assessments in which a hearing loss was diagnosed, although it
does include cases where referrals and/or treatment recommenda-
tions were made, primarily due to no such assessments occurring
during the data collection period.
The audiological assessment and feedback sessions were observed
by the third author, and videos were recorded for later analysis. The
presence of the video camera was acknowledged as potentially intru-
sive, but the use of video was deemed necessary in order to capture
non-verbal behaviours in the interactions. The discourse features of
the recorded feedback sessions were analysed using a hybrid sociolin-
guistic approach based on Armstrong et al ’ s (2007) transcription-less
analysis and Heath et al ’ s (2010) suggestions for analysis of recorded
interactions. Analysis focused on the verbal content and methods of
information-giving that were utilized by the audiologists as well as
non-verbal responses of the caregivers (such as eye gaze, nodding,
facial expression, and body language) during the feedback session.
The third author conducted this transcription-less analysis and the
fi rst and second authors then conducted an independent analysis of
the recordings. A comparison of the observations revealed that they
were suffi ciently similar and the transcription-less approach was thus
deemed a reliable method for this study.
Interviews with participants were conducted by the third author
subsequent to audiological testing and feedback. The interviews
were audio recorded and later transcribed. Interviews with caregivers
focused on their perceptions of the feedback session and the content
discussed by the audiologist. In particular, caregivers were asked to
recall specifi c details such as the results of the audiological tests and
Abbreviations
AABR Automated auditory brainstem response
IRB Institutional Review Board
OAE Otoacoustic emissions
VRA Visual reinforcement audiometry
Table 1. Case details and caregiver demographic information.
Caregiver Age Gender
Home language
Level of education
Approximate age of child Child ’ s presenting complaint
1 32 F Zulu Grade 8 7 years Behavioural and academic diffi culties
2 39 M Sepedi Grade 12 5 years Delayed talking
3 30 F Zulu Grade 10 Infant Newborn hearing screening follow-up
4 25 F Zulu Grade 12 Infant Previous infection
5 28 F Sotho Grade 8 Infant Newborn hearing screening follow-up (high-risk infant)
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866 J. Watermeyer et al.
the recommendations made, as well as to explain their understand-
ing of the audiogram and the hearing mechanism as described by the
audiologist. Interviews with the audiologists focused on their percep-
tion of the feedback sessions, goals and protocols for the sessions,
methods used to enhance understanding, and challenges experienced
during the sessions. The interviews were analysed using principles
of content analysis (as described by Knudsen et al, 2012): response
categories were identifi ed according to the interview schedule and
responses were then compared and contrasted across participants.
The data from the recordings and interviews were then triangu-
lated: in particular, the verbal information given by the audiologists
during the feedback session was compared to the information recalled
by the caregivers as evident during the interviews. This paper will
focus on this comparison.
Results
Structure of the feedback sessions Although there is no formal protocol at the hospital for providing
feedback or informational counselling, the observed feedback ses-
sions all followed a similar format in terms of content. Table 2 pro-
vides a detailed description of the content of each feedback session.
The recorded sessions ranged in length from 1 minute 39 seconds to
8 minutes 16 seconds (with an average of 4 minutes 50 seconds).
In all cases, the audiologists provided some explanation of the
mechanisms of hearing and this was accompanied by a variety of
techniques such as pointing to a cross-sectional diagram of the ear
that hung on the wall of the consulting room, drawing a picture of the
inner ear, sometimes explaining terms such as ‘ hair cells ’ and ‘ nerve
impulses ’ , and using analogies such as referring to the ear canal as
a ‘ core ’ . All of the feedback sessions also included an explanation
of the various tests used during the assessment and there was some
attempt by the audiologists to link each test to the relevant part(s) of
the ear. Two of the cases included an explanation of the audiogram
and concepts such as ‘ pitch ’ , ‘ loudness ’ , and ‘ hearing within nor-
mal limits ’ . Recommendations were usually given and then repeated
within each session.
The audiologists attempted to repeat information and simplify
concepts. As Audiologist 2 reported, ‘ I try [to] make it very simple
so I kind of judge the patient so if they can ’ t handle the full informa-
tion I make it as simple as possible ’ . The information provided in the
feedback sessions, however, often appeared to be very detailed and
complex. For example, in Case 5, the audiologist described the OAE
assessment by drawing the cochlea and likening it to a snail shell.
She then drew hairs in the cochlea and explained that the OAE test
was assessing how the hairs were working. The caregiver appeared
confused by the drawing, but the audiologist proceeded to explain
the results of a different test: AABR test results were presented in
relation to norms together with a discussion of the results graph on
the computer screen.
As evident in Table 2, caregivers did not ask questions spontane-
ously, appeared reluctant to engage in discussion during the sessions,
and contributed minimal verbal responses (e.g. ok, alright, yes, mm)
and non-verbal responses (e.g. nodding) during the sessions. The
audiologists however appeared to interpret these minimal contribu-
tions as indicators of recall and understanding. In some instances,
for example in Cases 3 and 5, caregivers ’ non-verbal cues appeared
to demonstrate confusion or lack of understanding, yet these cues
appeared to go unnoticed and unacknowledged by the audiologists.
In all of the sessions, the audiologists attempted to employ strate-
gies to enhance caregiver recall and understanding — for example, by
repeating information, linking verbal explanations to visual strategies,
reminding caregivers of specifi c tests conducted, using examples to
explain concepts, and simplifying language. In all sessions the audiolo-
gists made regular use of questions such as ‘ ok? ’ , ‘ do you understand? ’
and ‘ do you have any questions? ’ to invite clarifi cation requests.
Direct elicitations of a demonstration of understanding were not used
(for example, asking caregivers to summarize and repeat the informa-
tion given), other than by requiring the caregivers to repeat the fi nal
diagnosis and the recommendations before leaving the consultation.
Caregiver recall and understanding of information Table 2 illustrates what caregivers were able to recall from the feed-
back session. All except one caregiver was able to recall the fi nal
diagnosis and recommendations or referrals. In most cases care-
givers were able to recall portions of the information given dur-
ing feedback, but their recall was often inaccurate, especially for
audiologists ’ explanations of the hearing mechanism and diagram
of the ear, with caregiver descriptions indicating limited understand-
ing of the presented concepts. For example, Caregiver 4 related her
understanding of the ear as ‘ a core, it ’ s got a hair so if the ear ’ s got
infection in that core it ’ s gonna … I don ’ t know if the sound won ’ t
pass through the hairs eh. ’
Caregivers also struggled to understand and recall explanations
of various audiological tests. In cases where the audiogram was
explained, caregivers demonstrated limited recall and understanding
and tended to focus on the concepts of ‘ low ’ and ‘ high ’ (related to
frequency). At times the caregivers indicated awareness of their lack
of understanding in this regard — for example, Caregiver 5 stated ‘ the
fi rst test is, I don ’ t know, I don ’ t know what she was saying ’ — but
only one caregiver was able to cite a specifi c piece of information
that was diffi cult for her to remember.
Despite the apparent lack of recall and understanding by the care-
givers, all of the caregivers indicated confi dence in the audiologists ’
abilities. As Caregiver 2 stated, ‘ No everything, [the] explanation
was alright. It was not diffi cult. ’ Similarly, the audiologists were
confi dent of the success of their feedback sessions in terms of pro-
moting caregiver recall and understanding. As Audiologist 1 related
‘ I haven ’ t yet had a situation where the patient has, you know, said
they don ’ t understand. ’
Discussion
Several authors in the fi eld have outlined misgivings regarding the
manner in which informational counselling is typically provided.
Margolis (2004, p. 1) notes that ‘ Audiology, a communication
profession, has almost completely neglected to be concerned with
the effectiveness of our communication of information to patients. ’
English (2008b) describes the common practice of information
‘ dumping ’ in audiological consultations; and Sexton (2009, p. 41)
refers to the ‘ one-way communication download ’ which occurs
in many audiology consultations. Klein et al (2011) highlight the
mismatch between information provided by audiologists and the way
it may be perceived by patients.
The results of this study reveal similar fi ndings and, importantly,
highlight the lack of any kind of tailoring of information-giving
towards the communicative needs of the individual caregivers.
These results have a number of implications for practice and sug-
gest the need for a review of current teaching approaches. A number
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Caregiver recall and understanding 867 Ta
ble
2.
Sum
mar
y o
f as
sess
men
t re
sult
s an
d i
nfo
rmat
ion p
rovid
ed b
y t
he
audio
logis
ts d
uri
ng f
eedbac
k s
essi
ons,
and c
areg
iver
res
ponse
s, r
ecal
l, a
nd u
nder
stan
din
g o
f th
e fe
edbac
k.
Cas
e 1
Cas
e 2
Cas
e 3
Cas
e 4
Cas
e 5
Res
ult
s of
the
asse
ssm
ent
Hea
ring w
ithin
norm
al l
imit
s
in l
eft
ear.
Nee
d t
o r
eturn
for
furt
her
ass
essm
ent
of
right
ear
as r
esult
s w
ere
inco
ncl
usi
ve.
Hea
rin
g w
ith
in n
orm
al l
imit
s.
Imp
acte
d c
eru
men
in
bo
th
ears
.
Hea
rin
g a
pp
eare
d t
o b
e w
ith
in
no
rmal
lim
its.
Hea
rin
g w
ith
in n
orm
al l
imit
s.
So
me
ceru
men
pre
sen
t in
th
e
rig
ht
ear.
Un
able
to
co
mp
lete
tym
pan
om
etry
as
ear
can
als
too
nar
row
. O
AE
res
ult
s
inco
ncl
usi
ve.
Info
rmat
ion g
iven
by
the
audio
logis
t
Expla
ins
that
she
wil
l dis
cuss
the
test
s an
d r
esult
s.
Bri
ef e
xpla
nat
ion o
f hea
ring
mec
han
ism
usi
ng d
iag
ram
of
the
ear
pas
ted o
n t
he
wal
l.
Expla
nat
ion o
f oto
scopy
,
tym
pan
om
etry
, pure
-tone
audio
met
ry.
Exte
nsi
ve
expla
nat
ion o
f
audio
gra
m,
inte
nsi
ties
and
freq
uen
cies
.
Exte
nsi
ve
expla
nat
ion o
f
AA
BR
.
Nee
d t
o r
eturn
for
furt
her
test
ing.
Ref
erre
d t
o c
hil
d p
sych
olo
gy
clin
ic d
ue
to c
hil
d ’ s
beh
avio
ura
l is
sues
.
Ex
pla
ins
that
sh
e w
ill
dis
cuss
th
e
test
s an
d r
esu
lts.
Bri
ef e
xp
lan
atio
n o
f h
eari
ng
mec
han
ism
usi
ng
dia
gra
m o
f
the
ear
pas
ted o
n t
he
wal
l (w
hil
e
stan
din
g n
ext
to d
iag
ram
).
Ex
pla
nat
ion
of
oto
sco
py a
nd
tym
pan
om
etry
Det
aile
d e
xp
lan
atio
n a
nd
dem
on
stra
tio
n o
f tr
eatm
ent
for
imp
acte
d w
ax.
Ex
pla
nat
ion
of
VR
A.
Det
aile
d e
xp
lan
atio
n o
f
aud
iog
ram
, in
ten
siti
es a
nd
freq
uen
cies
.
Des
crip
tio
n o
f A
AB
R a
nd
wh
at
this
ass
esse
d.
Ref
erra
l to
sp
eech
th
erap
y a
nd
clin
ic f
or
wax
rem
oval
.
Bri
ef e
xp
lan
atio
n o
f d
iag
ram
of
the
ear
pas
ted
on
th
e w
all
and
hea
rin
g m
ech
anis
m.
Bri
ef e
xp
lan
atio
n o
f o
tosc
opy
,
tym
pan
om
etry
an
d A
AB
R
test
an
d r
esu
lts.
Hea
rin
g l
oss
no
t su
spec
ted,
how
ever
if
the
care
giv
er h
as
any
co
nce
rns
she
sho
uld
retu
rn t
o t
he
clin
ic.
Rea
son
fo
r re
ferr
al (
pre
vio
us
infe
ctio
n).
Bri
ef e
xp
lan
atio
n o
f o
tosc
opy
and
ty
mp
ano
met
ry.
Bri
ef e
xp
lan
atio
n o
f h
eari
ng
mec
han
ism
usi
ng
dia
gra
m o
f
the
ear
pas
ted
on
th
e w
all.
Ex
pla
nat
ion
of
AA
BR
wit
h a
dra
win
g.
Rec
om
men
dat
ion
fo
r
reas
sess
men
t in
th
ree
mo
nth
s.
Ch
ild
’ s e
ar c
anal
s ar
e to
o
nar
row
so
tes
tin
g i
s
inco
ncl
usi
ve.
Bri
ef e
xp
lan
atio
ns
of
oto
sco
py
and
ty
mp
ano
met
ry u
sin
g
dra
win
g o
f th
e ea
r.
Dra
win
g a
nd
ex
pla
nat
ion
of
the
ear
and
hea
rin
g m
ech
anis
m.
Det
aile
d e
xp
lan
atio
n a
nd
dra
win
g o
f in
con
clu
sive
OA
E
asse
ssm
ent
and
res
ult
s.
Rec
om
men
dat
ion
to
ret
urn
fo
r
reas
sess
men
t in
tw
o m
on
ths.
Dis
cuss
ion
of
bab
y ’ s
po
siti
ve
beh
avio
ura
l re
spo
nse
to
sou
nd
s at
ho
me.
Car
egiv
er b
ehav
iours
and
resp
onse
s duri
ng
feed
bac
k s
essi
on
Consi
sten
t ap
pro
pri
ate
noddin
g
duri
ng a
udio
logis
t ’ s
expla
nat
ions.
Som
e m
inim
al
ver
bal
res
ponse
s. B
ecom
es
more
inte
ract
ive
when
audio
logis
t dis
cuss
es t
he
resu
lts.
Did
not
resp
ond t
o
the
audio
logis
t ’ s i
nvit
atio
n t
o
ask q
ues
tions
about
the
audio
logic
al f
eedbac
k.
Car
egiv
er d
id a
sk a
ques
tion
about
spec
ial
schooli
ng f
or
her
chil
d.
Lim
ited
no
n-v
erb
al c
ues
su
ch a
s
no
dd
ing
to
in
dic
ate
po
ssib
le
un
der
stan
din
g.
So
me
min
imal
ver
bal
res
po
nse
s. D
id n
ot
ask
any
qu
esti
on
s d
uri
ng
th
e
sess
ion
.
Lim
ited
no
n-v
erb
al c
ues
su
ch
as n
od
din
g t
o i
nd
icat
e
po
ssib
le u
nd
erst
and
ing
. S
om
e
min
imal
ver
bal
res
po
nse
s.
Aft
er a
ud
iolo
gis
t h
ad
exp
lain
ed t
he
dia
gra
m o
f th
e
ear,
car
egiv
er c
on
tin
ued
to
star
e at
th
e d
iag
ram
sev
eral
tim
es d
uri
ng
th
e se
ssio
n a
nd
seem
ed d
istr
acte
d f
or
the
rem
ain
der
of
the
sess
ion
.
Fre
quen
t u
se o
f n
od
din
g a
nd
min
imal
ver
bal
res
po
nse
s.
Rep
eats
‘ th
ere ’
s n
o i
nfe
ctio
n ’
afte
r th
e au
dio
log
ist
say
s th
is.
Wh
en a
ud
iolo
gis
t st
ated
th
at
chil
d ’ s
hea
rin
g w
as w
ith
in
no
rmal
lim
its,
car
egiv
er ’ s
dem
ean
ou
r an
d f
acia
l
expre
ssio
n r
elax
ed.
Did
no
t
ask a
ny q
ues
tio
ns
du
rin
g t
he
sess
ion
.
Car
egiv
er a
pp
eare
d c
on
fuse
d b
y
the
dra
win
g o
f th
e ea
r. S
he
con
sist
entl
y r
esp
on
ded
‘ yes
’
to t
he
aud
iolo
gis
t ’ s q
ues
tio
ns
bu
t fa
cial
ex
pre
ssio
ns
ind
icat
ed c
on
fusi
on
. W
hen
asked
if
she
had
any
qu
esti
on
s, c
areg
iver
ap
pea
red
un
cert
ain
an
d r
esp
on
ded
‘ no
’ .
Car
egiv
ers ’
rec
all
and
un
der
stan
din
g o
f th
e
info
rmat
ion p
rese
nte
d
Corr
ectl
y a
ble
to r
ecal
l fi
nal
dia
gnosi
s an
d
reco
mm
endat
ions.
Unab
le t
o d
escr
ibe
the
ear
and
the
audio
gra
m c
orr
ectl
y.
Dem
onst
rate
d l
imit
ed
under
stan
din
g o
f th
e te
sts
com
ple
ted.
Co
rrec
tly
able
to
rec
all
fi n
al
dia
gn
osi
s an
d r
eco
mm
end
a-
tio
ns,
in
clu
din
g r
efer
ral
to
spee
ch t
her
apy
an
d t
he
ou
tpat
ien
t cl
inic
fo
r w
ax
rem
oval
.
Lim
ited
rec
all
of
trea
tmen
t st
eps
for
the
impac
ted w
ax (
e.g.
use
of
dro
ps
to s
oft
en w
ax).
Co
uld
no
t re
call
th
e te
sts
com
ple
ted
.
Co
rrec
tly
able
to
rec
all
fi n
al
dia
gn
osi
s an
d
reco
mm
end
atio
ns.
Un
able
to
rec
all
the
dia
gra
m o
f
the
ear
and
th
e re
sult
s o
f th
e
AA
BR
ass
essm
ent.
Co
rrec
tly
able
to
rec
all
fi n
al
dia
gn
osi
s an
d
reco
mm
end
atio
ns.
Un
able
to
pro
vid
e an
y
info
rmat
ion r
egar
din
g t
he
ou
ter-
an
d m
idd
le-e
ar r
esu
lts.
Lim
ited
un
der
stan
din
g o
f th
e
AA
BR
ass
essm
ent
and
expla
nat
ion
of
the
coch
lea.
Lim
ited
rec
all
and
un
der
stan
din
g o
f re
sult
s an
d
reco
mm
end
atio
ns.
Confu
sion r
egar
din
g d
raw
ing o
f
the
ear.
Inco
rrec
t re
call
of
reas
on
fo
r
foll
ow u
p a
pp
oin
tmen
t.
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868 J. Watermeyer et al.
of authors have highlighted their concerns regarding the manner in
which students are taught to conduct information counselling and
assessment feedback, for example, teaching students to provide
complete details of the assessment rather than the fi nal result or the
‘ big picture ’ (English, 2008b), focusing on the use of anatomical
diagrams and pictures (Musiek et al, 2007) and teaching students
what information needs to be conveyed to patients rather than how it
can be conveyed effectively (Clark & Brueggeman, 2009). There is
clearly a need for a greater curricular focus on the ‘ nuances ’ of infor-
mation counselling and the provision of such counselling in a sensi-
tive, tailored, and effective manner according to specifi c situations
and patient needs (English, 2008b; Clark & Brueggeman, 2009).
Some suggestions in this regard will be discussed using examples
from the study described in this paper.
The results of this study seem to contradict recommendations in
the literature that encourage the use of diagrams and pictures to
supplement verbal explanations — and in some cases they led to mis-
understanding. If examined further, it becomes evident that the use of
visuals alone may not be the cause of limited recall and understand-
ing, but perhaps giving too much complex information at once may
lead to further misunderstanding. Schmidt von W ü hlisch and Pascoe
(2011) confi rm that complex, disorganized, and excessive informa-
tion giving may have a negative impact on caregiver recall. Ross
(2004) notes that audiologists ’ attempts to explain the audiogram
to patients leads to confusion in many cases. In addition, although
the use of pictures in medical interactions may improve recall of
information even in low literacy populations (Houts et al, 2001),
caution needs to be exercised with regard to cultural differences in
the interpretation of pictures (Dowse & Ehlers, 2004).
Audiologists need to decide what information is essential to
include in feedback sessions, as both the type of information as well
as the amount of information presented may impact recall. Watson &
McKinstry (2009) suggest that discussion of the most important
issues at the beginning and end of a consultation may improve recall.
In this study it was evident that most caregivers were able to recall
the fi nal diagnosis and recommendations discussed at the end of the
consultation, but they displayed poor recall and understanding of the
diagram of the ear and the audiogram that were explained towards
the beginning of the feedback sessions. While it may be essential
in some cases to explain the impact of a hearing loss on speech
perception using the audiogram, this study demonstrates that lengthy
explanations about the hearing mechanism and each assessment pro-
cedure may not be necessary or effi cient, for example, in cases where
a hearing loss is not detected. In this study, information related to the
audiogram was not recalled correctly or even at all by some of the
caregivers, and in some cases, this part of the feedback session led
to further misunderstandings and increased caregiver anxiety.
It has been noted that, in general, audiologists tend to explain
the audiogram by rote memory, often unaware that the caregiver
or patient may not understand it (Ross, 2004). In cases where it
is appropriate to explain the audiogram, this needs to be done in
a simple and understandable manner, according to the particu-
lar communicative and language needs of the caregiver or patient
(Kessels, 2003; Margolis, 2004). Some innovative suggestions
have been made in this regard (see for example the IDA Institute ’ s
‘ Defi ning the Audiogram ’ challenge; Peryman, 2007).
English (2008b) suggests asking patients at the start of the feed-
back session about how much information and detail they would
like to hear, which speaks to the need to acknowledge the goals and
agenda of the patient as part of the process of information coun-
selling (Parkin & Skinner, 2003). This is a particularly important
step because the amount of correctly recalled information is often
closely linked to the perceived importance of the information
provided (Kessels, 2003). Research conducted by English (2008b)
reveals that most patients actually prefer receiving information about
the overall diagnosis rather than specifi c details of the assessment.
As demonstrated in the results of this study, most of the caregivers
correctly recalled and understood information related to the fi nal
diagnosis and recommendations, which suggests that this was their
primary focus for the session. The audiologists on the other hand
seemed to have a different focus which involved trying to get the
caregivers to understand the hearing mechanism and the assessment
procedures. These results highlight the need for audiologists to
align the information they provide towards the needs of the patient
or caregiver — using patient-centred practice (Hickson, 2012) — in
order to ‘ better help our patients to help themselves ’ (Clark &
Brueggeman, 2009, p. 49). In the case of a young child, the audi-
ologist needs to be aware of the specifi c informational needs of the
caregiver which may change with time, particularly in cases where
the child has a hearing loss (Klein et al, 2011).
The distinction between recall of information and demonstra-
tion of understanding of information is an important one, especially
in situations where a language barrier may be present and where
patients may not feel confi dent to request clarifi cation or indicate
that they have not understood (Meeuwesen et al, 2007). The minimal
contributions made by the caregivers during the feedback sessions
in this study may be related to culture and power differences and
respect for the audiologist as an authority fi gure (Raubenheimer,
1987). If understanding is not directly confi rmed by the audiolo-
gist and assumptions about understanding are made, an ‘ illusion of
shared understanding ’ may arise (Margolis, 2004) and ineffective
information delivery can negatively impact on recall of the informa-
tion (Clark & Brueggeman, 2009).
Perhaps what these results point to most strongly is the need
for a greater focus on encouraging refl ective practice, fl exibility,
and adaptability within individual information counselling ses-
sions (Geltman Cokely & DePlacido, 2012; Ng, 2012). Some of
the above-mentioned diffi culties in providing information coun-
selling may well stem from the way in which students are taught,
as well as their anxieties about demonstrating their profi ciency
and knowledge during clinical practicals. Paying greater atten-
tion to these issues through effective modelling and teaching in
audiological curricula and clinical training programmes will ensure
that negative practices do not transfer into clinical practice after
students graduate (Clark & Brueggeman, 2009; von Hapsburg &
Lauritsen, 2012).
Conclusion
Although this was a preliminary study that did not include any cases
in which a hearing loss was conclusively diagnosed, the results
do highlight several clinical and curricular points for consider-
ation in relation to current information counselling and feedback
practices. These include the need to shift focus from complex
explanations of the audiogram and the provision of generic infor-
mation during feedback sessions to the fi nal diagnosis and rec-
ommendations in order to align feedback to individual caregiver
or patient needs and tailor information counselling accordingly.
Future research which focuses on information counselling prac-
tices in other cases (such as when a hearing loss is diagnosed,
or with adult cases) may be useful for improving practice and
teaching approaches.
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Caregiver recall and understanding 869
Acknowledgements
The authors thank all audiologists and caregivers who participated
in the study.
Declaration of interest: The authors report no declarations of
interest.
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