Inclusion is a Beginning. Now, How to Promote Belonging?

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Kris English, PhD

Professor Emeritus, Audiology

University of Akron

As person-centered clinicians, we hope that all patients feel welcomed and valued while in our care. Steps toward converting hope to reality include sorting out the difference between the recently ubiquitous term inclusion and compare it to belonging. These terms are not synonyms:

  • Inclusion is an objective social policy (prompted by anti-discrimination law), and only requires performative tolerance by a dominant group. Inclusion requires no more than minimal “instrumental care,”1 e.g., conducting clinical responsibilities merely as a set of tasks.
  • Belonging involves a subjective interpersonal experience where others feel accepted, seen, and valued, and perceive social cues confirming that they fit in, are welcome, and are empowered to have a say in decisions.2-4 

We know that a person can be physically included in a situation or setting, yet not feel like they belong. In our field, for example, healthcare students of minority status report that, even while accepted/included in training programs, they often feel isolated, overlooked, and unwelcomed.5,6 In their professional lives, the feeling of “not belonging” can continue.7

Patients also often report adequate access/inclusion to healthcare and at the same time experience a sense of “not belonging,” based on interpersonal differences such as race, religion, ethnicity, caste, ancestry, language, sexual orientation, gender, and more.4,8 Suffice it to say that “inclusion” meets the letter of the law but not the spirit of person-centered care.

Why Belonging Matters: A Human Need that Impacts QOL

Belonging is not a new concept, having been recognized by Maslow9 in 1943 as one of five basic needs in his theory of human development. Humans need to be seen as persons who belong in any space just as much as any other person.10  When individuals feel they belong, they are more likely to seek support and engage actively in their own care.11 Individuals who experience belonging have been found to be healthier, less stressed, and more satisfied with their lives.12

Compare to “belonging uncertainty,” wherein individuals harbor doubts as to whether they will be accepted or rejected by others.13-15  Uncertainty supports the impression that one’s belonging is up for negotiation and always at risk, and surfaces when social cues indicate that one’s identity (e.g., race, religion, sexual orientation) might adversely affect personal goals and even safety. Psychologists have called this experience a type of “social pain.”16

Communicating Belongingness Requires Intentionality

We can move forward by first acknowledging the limitations of inclusion, and then find ways to communicate to patients that they unquestionably fully belong.17,18 Communicating belongingness “entails an unwavering commitment to not simply tolerating and respecting difference (which is no small thing in a world of violent othering), but to ensure that all people are welcome and feel that they belong in the society with agency and not as provisional guests”(p. 160).4

Prioritizing belonging may require intentional cognitive and behavioral changes, described as a “Remaking of the Self,”4 a process that sounds daunting but one we’ve worked through since childhood.  An example is our shared journey in becoming audiologists: the “self” we were in early college years has evolved with every course taken in graduate school and early work experiences, developing specialty areas, to the present (but not final) growth stage.  In other words, we continually revise our existing identities, including how we manage our unconscious biases that might signal a “nonbelonging” attitude.

In our ongoing project to “remake ourselves,” the Belonging  Barometer12 is a helpful tool as we consider our impact on patient experiences, including whether they are:

  • Feeling emotionally connected
  • Being welcomed and included
  • Perceiving that they are able to influence decision-making
  • Feeling able to be their whole and authentic selves
  • Being valued as persons and for their contributions
  • Being in relationships that are as satisfying as they want them to be
  • Feeling like insiders who understand how the environment works
  • Feeling comfortable expressing their opinions
  • Being treated equally
  • Feeling that they truly belong

The Barometer measures “belonging” in five contexts (family, friend, workplace, local, national) – none directly applicable to experiences in a healthcare setting but a potential research project.

The process of “remaking the self” is achievable. Sukhera et al19 found that brief exercises designed to increase self-awareness, reflect on biases, and build competences led to sustained explicit behavioral changes 12 months later. Guidance can be found in Cohen’s text Belonging: The Science of Connection and Bridging Divides.20

Conclusion

A generation ago, clinicians expected patients to comply with a “doctor knows best” posture. Fifteen years ago, the Ida Institute advanced audiology’s adoption of person-centered care. Five years ago, audiology began the necessary DEI/diversity-equity-inclusion work. Knowing the limitations of inclusion, it’s time to move onward to a new professional goal: “belongingness for all.”

For inspiration, consider Fred Rogers (1928-2003), a beloved host of a children’s show on public television in the US. In 1969, he exemplified the value of belonging by inviting a friend to join him in cooling off in a splash pool, at a time when persons of color were still denied access to public pools. Later in life, Mr. Rogers observed, “The older I get, the more convinced I am that the space between people who are trying their best to understand each other is hallowed ground.”

References

  1. Ming Y et al. (2019). Analyzing patients’ complaints: Awakening of the ethic of belonging. Advances in Nursing Science, 42(4), 278-288.
  2. Baumeister RF, Leary MR. (2017). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. In R. Zukauskiene (Ed.), Interpersonal Development (pp. 57-89). New York: Rutledge.
  3. Roberts LW. (2020). Belonging, respectful inclusion, and diversity in medical education. Academic Medicine, 95(5), 661-664.
  4. Powell JA, Menendian, S. (2024). Belonging Without Othering: How We Save Ourselves and the World. Stanford University Press.
  5. Sivananthajothy, P. (2024). Equity, diversity, and… exclusion? A national mixed methods study of “belonging” in Canadian undergraduate medical education. Advances in Health Sciences Education, 29(2), 611-639.
  6. Dietz S et al. (2023). Assessing a culture of belonging in a higher education context: Development and initial validation of the Culture of Belonging Barometer. Journal of Student Affairs Research and Practice, 61(2), 202–218.
  7. Serrano-Diaz CR et al. (2025). Occupational therapy practitioners’ and students’ experiences of diversity, equity, and inclusion: An international scoping review. American Journal of Occupational Therapy, 79(2), 7902180070.
  8. Cooper LA et al (2006). Delving below the surface: Understanding how race and ethnicity influence relationships in health care. Journal of General Internal Medicine, 21(Suppl 1), 21-27.
  9. Maslow AH. (1943). A theory of human motivation. Psychological Review 50(4), 370–96.
  10. Keenan S. (2021). Space and belonging. In The Routledge Handbook of Law and Society (pp. 225-228). New York: Routledge Press.
  11. Carter BM et al. (2023). Overcoming marginalization by creating a sense of belonging. Creative Nursing, 29(4), 320-327.
  12. Over Zero and The American Immigration Council. (2024). The Belonging Barometer: The State of Belonging in America. Revised ed.
  13. Brady ST et al. (2025). The unsettled questions of belonging uncertainty. In PJ Caroll, K. Rios, & KC Oleson (Eds.), The Routledge Handbook of the Uncertain Self (2nd), pp. 303-320. New York: Routledge Press.
  14. Stillman TF, Baumeister, RG. (2009). Uncertainty, belongingness, and four needs for meaning. Psychological Inquiry, 20(4), 249-251.
  15. Jaremka LM et al. (2023). The impact of threats to belonging on health, peripheral physiology, and social behavior. Advances in Experimental Social Psychology, 67, 277-338
  16. Eisenberger N. (2014). Social pain and the brain: Controversies, questions, and where to go from here. Annual Review of Psychology, 66, 601–29.
  17. Macartney MC. (2012). Teaching through an ethics of belonging, care and obligation as a critical approach to transforming education. International Journal of Inclusive Education,16(2) 171-183.
  18. Livingstone L et al.(2025). Do I belong here? The lived experience of navigating health services as a Black person living with stroke in England. BMC Health Services Research, 25(1), 1158.
  19. Sukhera J. (2020). Implicit bias in health professions: From recognition to transformation. Academic Medicine, 95(5), 717-723.
  20. Cohen GL. (2022). Belonging: The Science of Connection and Bridging Divides. NY. Horton & Co.

Vulnerability in Audiological Care: Insights from Brené Brown and Kristin Neff

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reprinted with permission from ENT & Audiology, Sept-Oct 2025, 34(4).

Kirsten Ellis, BA, MSc, RHAD, AssocFBSA

Hearing Aid Audiologist

The Hearing Care Partnership (South West), UK

Vulnerability, as defined by Brené Brown, is “uncertainty, risk, and emotional exposure” [1]. In audiology, patients often find themselves in vulnerable positions – whether it be acknowledging their hearing difficulties, accepting the need for hearing aids or dealing with the emotional impact of auditory changes. This sense of vulnerability can lead to feelings of shame, fear or frustration, making it difficult for patients to engage fully in their care.

From a professional standpoint, audiologists also experience vulnerability. They must navigate complex patient emotions, provide difficult diagnoses and manage expectations, all while maintaining their own emotional wellbeing. Recognising and addressing these vulnerabilities can foster stronger, more empathetic connections between patients and practitioners.

The Role of Shame and Courage in Audiological Care

Brené Brown’s research highlights the role of shame in preventing individuals from seeking help or accepting necessary changes. She explains that “shame corrodes the very part of us that believes we are capable of change” [2]. Many individuals with hearing loss delay seeking audiological care due to stigma, societal perceptions or personal fears about ageing and dependence. This shame can lead to denial, social withdrawal and a reduced quality of life.

Audiologists play a crucial role in dismantling these barriers by fostering an environment of courage and trust. Encouraging open discussions about hearing loss, normalising the use of assistive devices and validating patients’ emotions can empower them to embrace change rather than resist it. By incorporating vulnerability into practice, audiologists can shift the narrative from one of deficiency to one of adaptation and resilience.

Self-Compassion as a Tool for Patients and Practitioners

Dr Kristin Neff’s concept of self-compassion provides a powerful framework for addressing vulnerability in audiological care. Neff defines self-compassion as the ability to be kind to oneself in moments of suffering, rather than engaging in self-judgment [3]. Her three core elements of self-compassion – self-kindness, common humanity and mindfulness – are particularly relevant in audiology:

  • Self-kindness over self-criticism. Patients often blame themselves for their hearing loss, feeling as though they have failed in some way. This can be especially true for individuals with noise-induced hearing loss or those who have avoided seeking treatment. Encouraging patients to practice self-kindness, rather than self-criticism, can help them approach their hearing health with a sense of care rather than guilt.

Audiologists, too, benefit from self-kindness. The field of audiology, like many healthcare professions, can be emotionally taxing. Self-compassion allows practitioners to acknowledge their limitations without feeling inadequate. When audiologists extend compassion to themselves, they are better equipped to provide compassionate care to others.

  • Common humanity over isolation
    Hearing loss can feel isolating, both socially and emotionally. Patients may feel that they are alone in their struggles, leading to withdrawal from social interactions. Neff’s principle of common humanity emphasises that suffering is a universal human experience.

When audiologists share relatable stories or connect patients with support groups, they help individuals see that they are not alone in their journey. For audiologists, recognising common humanity means acknowledging that perfection is unattainable. Mistakes happen and challenges arise in clinical practice. By fostering a culture where vulnerability is accepted, audiologists can support each other and their patients more effectively.

  • Mindfulness over over-identification
    Mindfulness involves being present with one’s experiences without excessive identification with them. Patients who over-identify with their hearing loss may see it as a defining characteristic, which can lead to frustration or despair. Mindfulness encourages patients to acknowledge their experiences without becoming overwhelmed by them.

In practice, audiologists can integrate mindfulness techniques by encouraging patients to engage with their hearing challenges in a non-judgmental way. Mindfulness-based listening exercises, for example, can help patients adjust to hearing aids or tinnitus management strategies with greater ease.

Creating a Culture of Vulnerability in Audiology

Embracing vulnerability in audiological care requires a cultural shift within the field. This can be achieved through:

  1. Empathetic communication – Practitioners should actively listen to patients’ concerns, validate their emotions and create a safe space for dialogue.
  2. Educational initiatives – Providing patients with information about the psychological impact of hearing loss can help normalise their feelings and reduce stigma.
  3. Support systems – Encouraging peer support groups or audiology counselling services can help patients feel less alone in their experiences.
  4. Self-compassion training for audiologists – Offering professional development focused on self-compassion and emotional resilience can benefit practitioners’ wellbeing and enhance patient care.

Conclusion

Vulnerability is an inherent aspect of audiological care, affecting both patients and practitioners alike. By applying the insights of Brené Brown on vulnerability and shame, and Kristin Neff on self-compassion, audiologists can create an environment where patients feel supported and empowered in their hearing health journey. Ultimately, embracing vulnerability in audiological practice fosters deeper connections, promotes healing and enhances the overall quality of care.

References

1. Brown B. Daring Greatly: How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent, and Lead. Gotham Books; 2012.

2. Brown B. The Gifts of Imperfection: Let Go of Who You Think You’re Supposed to Be and Embrace Who You Are. Hazelden Publishing; 2010.

3. Neff K. Self-Compassion: Stop Beating Yourself Up and Leave Insecurity Behind. HarperCollins; 2011.

Changing Minds

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Kris English, PhD

Professor Emeritus, Audiology

University of Akron

On May 25, 2020, George Floyd’s murder was captured on video and transmitted around the world, instantly sparking horror, outrage and grief while reigniting the Black Lives Matter movement in the US. During the same time period and since, a wealth of literature and research has been published describing the relationship of provider bias to inequitable healthcare, stimulating difficult and necessary self-examination, discussion and reflection.1-16  

Five years later, it is deeply tempting to believe that bias and prejudice are no longer   issues, and that we can move on…

‘More than brick and mortar:’ DC begins removing ‘Black Lives Matter’ plaza

 

 

 

 

… but one thing we have learned: understanding and managing our many biases is a lifelong endeavor, especially re: our goal of providing person-centered care and counseling. To that end, a refresher course:

From “Think Cultural Health Education”

The table below presents steps we can take to confront our implicit biases and reduce stereotypic thinking. Consistent and conscious use of these strategies can help us create a habit of nonbiased thinking.

STRATEGY DESCRIPTION
Stereotype replacement Become aware of the stereotypes you hold and create non-stereotypical alternatives to them
Counter-stereotypic imaging Remember or imagine someone from a stereotyped group who does not fit the stereotype
Individuating See each person as an individual, not a group member; pay attention to things about them besides the stereotypes of their group
Perspective-taking Imagine the perspective of someone from a group different than your own (“Put yourself in the other person’s shoes.”)
Contact Seek opportunities to engage in discussions in safe environments, spend time with people outside your usual social groups, or volunteer in a community different than your own.
Emotional regulation Reflect on your “gut feelings” and negative reactions to people from different social groups. Be aware that positive emotions during a clinical encounter make stereotyping less likely.
Mindfulness Keep your attention on the present moment so you can recognize a stereotypic thought before you act on it

Leaning Into Necessary Work

As neuroscientists like to say, “If you have a brain, you have biases.”

It is painfully ironic how our growing brains blithely accepted biases as truths, and how challenging it can be to “unlearn” them. And yet, of course, every small “unlearning” is important: “It does not matter how slowly you go, so long as you do not stop.” —Confucius.

Rest in peace, Mr. Floyd.

References

  1. Shen, M., et al. (2018). The effects of race and racial concordance on patient-physician communication: A systematic review of the literature. Journal of Racial and Ethnic Health Disparities, 5(1), 117-140. doi:10.1007/s40615-017-0350-4
  2. Maina, I.W., et al. (2018) A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Social Science in Medicine, 199, 219-22. doi: 10.1016/j.socscimed.2017.05.009.
  3. Chu, J., et al. (2019). The effect of patient-centered communication and racial concordant care on care satisfaction among U.S. immigrants. Medical Care Research and Review. Online ahead of print. doi: 10.1177/1077558719890988
  4. Lipsitz, G. (2019). Sounds of silence: How race neutrality preserves white supremacy. In Crenshaw, K. et al. (Eds.), Seeing race again: Countering colorblindness across the disciplines(pp. 23-51). Oakland, CA: University of California Press.
  5. FitzGerald, C., et al (2019). Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: A systematic review. BMC Psychology, 7(1),29.
  6. Orgin R., et al. (2020). The inter-relationship of diversity principles for the enhanced participation of older people in their care: A qualitative study. International Journal of Equity in Health, 19:16.
  7. Balik C., et al. (2020). A systematic review of the discrimination against sexual and gender minority in health care settings.International Journal of Health Services, 50(1), 44-61.
  8. Joudeh, L. et al. (2021). “Little red flags”: Barriers to accessing health care as a sexual or gender minority individual in the rural southern United States—A qualitative intersectional approach. Journal of the Association of Nurses in AIDS Care, 32(4), 467–480.
  9. Knoebel R. et al. (2021). Treatment disparities among the Black population and their influence on the equitable management of chronic pain. Health Equity, 5(1), 596-605.
  10. Forscher PS, et al. (2019). A meta-analysis of procedures to change implicit measures. Journal of Personality and Social Psychology, 117(3), 522–559.
  11. Paul-Emile, K. (2017). Blackness as disability. LJ, 106, 293.
  12. Williams, D. R., Lawrence, J. A., & Davis, B. A. (2019). Racism and health: Evidence and needed research. Annual review of public health, 40(1), 105-125.
  13. Bazargan, M., Cobb, S., & Assari, S. (2021). Discrimination and medical mistrust in a racially and ethnically diverse sample of California adults.The Annals of Family Medicine, 19(1), 4-15.
  14. Hagiwara, N., Kron, F. W., Scerbo, M. W., & Watson, G. S. (2020). A call for grounding implicit bias training in clinical and translational frameworks.The Lancet, 395(10234), 1457-1460.
  15. Meints, S. M., Cortes, A., Morais, C. A., & Edwards, R. R. (2019). Racial and ethnic differences in the experience and treatment of noncancer pain. Pain Management, 9(3), 317-334.
  16. Meidert, U., Dönnges, G., Bucher, T., Wieber, F., & Gerber-Grote, A. (2023). Unconscious bias among health professionals: a scoping review. International Journal of Environmental Research and Public Health, 20(16), 6569

“My Patient is Not OK…”

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Kris English, PhD

Professor Emeritus of Audiology

The University of Akron, Ohio US

In a previous posting, active listening was described as “listening + engagement.”  The “listening” part is our forte: we heed not only the spoken words but also tone of voice, body language, eye contact, energy levels… all of which can tell us when patients are struggling with stress, self-doubt, discouragement, guilt, depression, or other challenges to their overall well-being — much like many adults.

The mental and emotional impact of hearing loss has been well documented, e.g., high levels of chronic stress and anxiety;1-4  an association between moderate to severe hearing loss/tinnitus and an increased risk of depression, including suicide ideation;5-7  social isolation contributing to depression, irritability, and feelings of inferiority;8-9 parenting stress10-12 and more. We usually perceive these concerns … although, with no clear indication of self-harm, maybe it’s just a bad day? Perhaps we mention something in our clinical notes (“seems somewhat depressed”) …but do we engage?

Many Times, The Answer is NO

In the U.S., counseling coursework and competencies have been a component of audiology training for more than 25 years, and the associated person-centered care (PCC) principles have been fully developed – and yet, evidence continues to alert us to an urgent reality: patients often expect us to not just listen but to engage/help them when they present with hearing loss-related mental health challenges.13,14  We are fully aware of our professional “helping” limitations, as well as the need to refer when those limits are reached, but the next step — advancing a referral — can be daunting.15-17

Readers can probably predict the perceived barriers: a lack of confidence or comfort level with screening or even broaching the topic of referral; no clear pathway to referral; no knowledge of qualified persons to whom we could refer.18,19  Many reasons, but ultimately only one solution: to find a way to address this concern that will work in our unique contexts and environments.20, 21

An Undeniable Challenge: Finding a Psychologist/Counselor Who Understands Hearing Loss. Here is One We Already Know:

Michael Harvey, PhD22 is a clinical psychologist with more than 40 years of experience supporting persons with hearing loss and mental health issues. To bolster our confidence and comfort levels, he recommends the following:

  1. Validate the patient’s feelings. For example, “Many people also say that they feel anxious about their hearing loss. This makes sense.”
  2. Normalize (de-stigmatize) the referral. Be careful when using loaded words such as therapist, mental health, etc. Instead, we can say “There are audiological ways of helping with hearing loss and there are also psychological techniques. The first is something I do; the second is another professional I know.”
  3. Humanize the mental health professional. The more patients know about who they are being asked to see, the less anxiety and fear of the unknown they will experience. For example, “I’ve known Dr. Smith for over 20 years. She’s nice, been practicing psychology for over 30 years. She has a dry sense of humor. I think you’ll like her.”
  4. Emphasize the value of a team approach. You can refer to the mind-body connection or terms such as “holistic or multi-disciplinary approach” which are recognized and accepted in today’s culture. The team can be framed as a partnership between audiology and psychology.

These steps are reassuringly familiar: they are within our boundaries, respectful of the patient’s autonomy, and communicate understanding, care, and acceptance.  We know how to do this! (More of Dr. Harvey’s approach, experiences, and writings can be found here.)

There is a caveat, however: we cannot refer to a “Dr. Smith” until we have established a working relationship with said person. Obviously, the infrastructure must first be in place. How to go about it?

Upskilling to an Essential Standard of Care

Referring a patient to a mental health professional is the kind of skill we acquire after graduation, when we turn to experienced colleagues, mentors, and professional leaders about addressing real-life and context-based audiology issues. The growth process could involve:

  • Asking local and state organizations to develop task forces to design and test viable referral protocols customized to the region;
  • Developing support systems of colleagues who want to learn from and share with each other, and are committed to the PCC principle of overall patient well-being;
  • Identifying local mental health professionals with a deep understanding of the impact of hearing loss and hearing care, and/or the willingness to learn and develop this specialized expertise;
  • Sharing successes and “lessons learned” with the larger audiology community.

Given the serious nature of this aspect of audiology, it seems safe to say that time is of the essence. Clinics and practitioners who have already worked out a process – we need to hear from you!

References

  1. Canlon, B., et al. (2013). Associations between stress and hearing problems in humans. Hearing Research, 295, 9-15.
  2. Gomaa, M. A. et al. (2014). Depression, Anxiety and Stress Scale in patients with tinnitus and hearing loss.European Archives of Oto-rhino-laryngology, 271, 2177-2184.
  3. McClannahan, K. K. S., et al. (2025). Social anxiety, negative affect, and hearing difficulties in adults.Trends in Hearing, 29, 23312165251317925.
  4. Bigelow, R. T., Reed, N. S., Brewster, K. K., Huang, A., Rebok, G., Rutherford, B. R., & Lin, F. R. (2020). Association of hearing loss with psychological distress and utilization of mental health services among adults in the United States. JAMA network open, 3(7), e2010986-e2010986.
  5. Park, J., Lee, O., & McKee, M. (2021). Association between hearing loss and suicidal ideation among middle-aged and older adults.Aging & Mental Health,26(6), 1287–1294. https://doi.org/10.1080/13607863.2021.1919991
  6. Tan, Y., Fang, L., Zhu, Y., & Hashimoto, K. (2024). Relationship between hearing loss and depression: A cross-sectional analysis from the National Health and Nutrition Examination Survey 2015–2018.Journal of Psychiatric Research,178, 1-7.
  7. Lawrence, B.J., Jayakody, D., Bennett, R.J., et al. (2020). Hearing loss and depression in older adults: A systematic review and meta-analysis, The Gerontologist, Volume 60, Issue 3, April 2020, Pages e137–e154, https://doi.org/10.1093/geront/gnz009
  8. McClannahan, K. K. S., McConkey, S., Levitan, J. M., Rodebaugh, T. L., & Peelle, J. E. (2025). Social Anxiety, Negative Affect, and Hearing Difficulties in Adults. Trends in hearing, 29, 23312165251317925.
  9. Monzani D, Galeazzi GM, Genovese E, Marrara A, Martini A. (2008). Psychological profile and social behaviour of working adults with mild or moderate hearing loss. Acta Otorhinolaryngol Ital. 2008 Apr;28(2), 61-66. PMID: 18669069; PMCID: PMC2644978
  10. Continisio, G. I., D’Errico, D., Toscano, S., et al. (2023). Parenting stress in mothers of children with permanent hearing impairment.Children,10(3), 517.
  11. Dall, M., Weber, C., Holzinger, D., et al. (2024). Preschool children with hearing loss: Social communication and parenting stress. Journal of Personalized Medicine, 14(1), 47. https://doi.org/10.3390/jpm14010047.
  12. Marie A, Clabaut L, Corbeil M, et al. (2023) Parenting stress and needs for social support in mothers and fathers of deaf or hard of hearing children. Frontiers in Psychology, Aug 30;14:1229420. doi: 10.3389/fpsyg.2023.1229420. PMID: 37720653; PMCID: PMC10499620
  13. Bennett, R. J., Gerace, D., Meyer, et al. (2024). Supporting older adults’ mental health: A Delphi survey identifying audiology best practices. International Journal of Audiology, 1-10.
  14. Bennett, R. J., Donaldson, S., Kelsall-Foreman, I. et al.. (2021). Addressing emotional and psychological problems associated with hearing loss: Perspective of consumer and community representatives. American Journal of Audiology, 30(4), 1130-1138.
  15. Bennett, R. J., Meyer, C., Ryan, B., Barr, C., Laird, E., & Eikelboom, R. (2020). Knowledge, beliefs, and practices of Australian audiologists in addressing the mental health needs of adults with hearing loss. American Journal of Audiology, 29(2), 129–142. https://doi.org/10.1044/2019_AJA-19-00087
  16. Bennett, R. J., Meyer, C. J., Ryan, B. J., & Eikelboom, R. H. (2020). How do audiologists respond to emotional and psychological concerns raised in the audiology setting? Three case vignettes. Ear and Hearing, 41(6), 1675-1683.
  17. Laird, E. C., Bryant, C. A., Barr, C. M., & Bennett, R. J. (2022). Psychologically informed practice in audiological rehabilitation: audiologist perceived barriers, facilitators, and preparedness. Ear and Hearing, 43(6), 1853-1865.
  18. Woodward, E., & Saunders, G. H. (2023). Do UK audiologists feel able to address the hearing, social and emotional needs of their adult patients with hearing loss? International Journal of Audiology, 63(11), 867–874.
  19. Nickbakht, M., Meyer, C. J., Saulsman, L., Pachana, et al. (2022). Barriers and facilitators to asking adults with hearing loss about their emotional and psychological well-being: a COM-B analysis. International Journal of Audiology, 62(6), 562–570. https://doi.org/10.1080/14992027.2022.205609
  20. Timmer, B. H., Bennett, R. J., Montano, J., et al. (2024). Social-emotional well-being and adult hearing loss: clinical recommendations. International Journal of Audiology, 63(6), 381-392.
  21. Warren, S. E., & Barron, A. L. (2024). Audiologists’ attitudes and practice toward referring for psychosocial intervention with cochlear implant patients. Frontiers in Rehabilitation Sciences, 4, 1306485.
  22. Harvey, M. (2024). 20Q: Audiologist-psychologist collaboration. Accessed March 29, 2025: https://www.audiologyonline.com/articles/20q-audiologist-psychologist-collaboration-29133

Active Listening: A Classic Counseling Skill, Revitalized and Measurable

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Kris Engish, PhD

Professor Emeritus, Audiology

University of Akron

Scenario: an audiologist greets a new patient. She introduces herself, gestures towards chairs and, once seated, asks, “Now then … what brings you to our clinic today?” The patient shares recent observations from loved ones about his hearing, expressing some skepticism while acknowledging a small degree of personal concern. The audiologist maintains eye contact, does not interrupt, nods occasionally, takes a few notes, and then stands up. “This is very helpful. Let’s move forward with some testing now.”

Analysis: Did the audiologist listen? Yes, to a limited degree. She did demonstrate “cognitive listening,” a passive process of attending to and processing input.1 But passivity creates a problem: during this encounter, did the patient feel heard? Does it matter? And how does it compare to active listening?

Active Listening = Listening + Engagement

Taking the last question first: active listening is not about listening per se, but about interactivity. (It has been suggested that the term “conversational listening” might be more meaningful.1) While attending to a patient’s narrative, active listeners also verbally respond – with paraphrases, questions, affirmations, requests for clarifications, call-backs to previous topics – to assure patients that they are being heard.2,3

For our listener to feel heard, our reactions and thoughts must be perceptible, via expressions of interest, empathy, respect, and care.4 Our hypothetical audiologist did not convey any of these responses; in fact, as far the patient could tell, she might have been only pretending to listen, pretending to care.

“Feeling Heard” Matters

We know from our own experiences what it is like to not feel heard… a bundle of negative reactions from being ignored or dismissed, resulting in resentment and distrust. In healthcare, these consequences are serious: research indicates that patients who do not feel heard are less likely to adhere to healthcare recommendations.5-8

A New Emphasis on Active Listening

Active listening is not a new concept.9  Interestingly, and surely a sign of the times, it is being reintroduced with the intentional goal of reducing clinician bias.10

11. Smiley (2024)

When persons are internally motivated to work through and past their biases, it helps to focus less on “self” and more on another’s dignity and human desire to be heard.12-19 The commitment to actively listen-empathize-care supports those goals.20

Measuring Active Listening Effectiveness

A new tool called the Feeling Heard Scale (FHS) provides the opportunity to collect feedback regarding our Active Listening efforts.21 The FHS has been evaluated for reliability and validity, and, importantly for busy work settings, is brief. Eight items are measured on a five-point Likert-type scale (1 = Strongly disagree to 5 = Strongly agree), to wit: “In this conversation” or “in this meeting”…

  1. I felt heard by the other person.
  2. I could say what I really wanted to say.
  3. the other person was more concerned with him/herself than with what I said.
  4. the other person listened to what I said.
  5. the other person tried to put him/herself in my shoes.
  6. the other person was insensitive to my thoughts and feelings. 
  7. the other person treated me with respect.
  8. we understood each other.

There is also a single-item alternative to the full scale: “In this conversation, I felt heard by the other person.”

The manual on how to use the FHS22 can be found here (permission granted by the author).

Conclusion: Engaging in active/conversational listening rather than mere “data processing” humanizes the patient, the clinician, and the process. There are many reasons why our responsiveness can lag (fatigue, distractions, personal challenges). There are also many reasons to continue striving for equitable treatment regardless of interpersonal differences. The FHS has not yet been evaluated for clinical use — but what an opportunity for audiology to take the lead, given our commitment to listening as well as hearing!

References

  1. Collins HK. (2022). When listening is spoken. Current Opinion in Psychology, 47, 101402.
  2. Nemic PB et al. (2017). Can you hear me now? Teaching listening skills.Psychiatric Rehabilitation Journal, 40(4), 415-417.
  3. Thistle JJ, McNaughton D. (2015). Teaching active listening skills to pre-service speech-language pathologists: A first step in supporting sollaboration with parents of young children who require AAC. 
  4. Adams K et al. (2012). Why should I talk about emotion? Communication patterns associated with physician discussion of patient expressions of negative emotion in hospital admission encounters. Pt Educ Counsel, 89, 44–50.
  5. Davies C et al. (2024). Factors that support children and young people to express their views and to have them heard in healthcare: An inductive qualitative content analysis. J Child Health Care, 0(0) 1–14.
  6. Edelen MO et al. (2022). A novel scale to assess palliative care patients’ experience of feeling heard and understood. J Pain Symptom Mgmt, 63(5), 689-698.
  7. Shafran-Tikva S, Kluger AN. (2018). Physicians’ listening and adherence to medical recommendations among persons with diabetes. Int J of Listening 32, 140–149.
  8. Stewart M et al. (2024). Patient-centered medicine: Transforming the clinical method (4th ed.) Abington, UK: Radcliffe Medical Press.
  9. Rogers CR, Farson RE. (1957). Active listening. Industrial Relations Center, University of Chicago.
  10. Shelton JN et al. (2023). Responsiveness in interracial interactions. Current Opinion in Psychology, 53,101653
  11. Smiley CJ. (2024). Overcoming the implicit bias shortcut. J Calif Dental Assn, 52(1).
  12. Bamberg K, Verkuyten M. (2022). Internal and external motivation to respond without prejudice: a person-centered approach. J Social Psych, 162(4), 435-454. DOI:10.1080/00224545.2021.1917498
  13. Charlesworth TES, Banaji MR. (2019). Patterns of implicit and explicit attitudes: I. Long-term change and stability from 2007 to 2016. Psychological Sci, 30(2), 174-192.
  14. Charlesworth TES, Banaji MR. (2021). Patterns of implicit and explicit attitudes: II. Long-term change and stability, regardless of group membership. Am Psych, 76(6), 851–869.
  15. Charlesworth TES, Banaji MR. (2022). Patterns of implicit and explicit attitudes: IV. Change and stability from 2007 to 2020. Psychological Sci, 33(9), 1347-1371.
  16. Itzchakov G et al. (2020). Can high quality listening predict lower speakers’ prejudiced attitudes? J Experimental Social Psych, 91, 104022
  17. Itzchakov G et al. (2024). Perceiving others as responsive lessens prejudice: The mediating roles of intellectual humility and attitude ambivalence. J Experimental Social Psych, 110, 104554
  18. LaCosse J, Plant EA. (2020). Internal motivation to respond without prejudice fosters respectful responses in interracial interactions. J Personal Social Psych, 119, 1037–1056.
  19. Rosenblum M et al. (2022). Detecting prejudice from egalitarianism: Why Black Americans don’t trust white egalitarians’ claims. Psych Sci, 33, 889–905.
  20. Santoro E, Markus HR. (2023, December). Listening to bridge societal divides. Current Opinion Psyc, 54, 101696
  21. Roos CA et al. (2023). Feeling heard: Operationalizing a key concept for social relations. PloS One, 18, 11 e0292865.
  22. Roos FHS User Manual (definitive)

Elmo the Muppet, Carl Rogers, and Congruence

Posted on by

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

On January 29, 2024, a Muppet character from the US television show “Sesame Street” posted a friendly query on social media: “Elmo is just checking in! How is everybody doing?”

https://sesameworkshop.org/our-work/shows/sesame-street/sesame-street-characters/elmo-2/

Initial responses were cheery and light-hearted, but soon more than 20,000 readers responded “from the heart,” describing loneliness, financial and health struggles, depression, and more. It was quickly observed that Elmo (via his handler) seemed to be channeling psychologist Carl Rogers by responding with empathy and warm acceptance (aka unconditional positive regard).1,2

President Joe Biden echoed Elmo’s empathy and warm acceptance: “I know how hard it is some days to sweep the clouds away and get to sunnier days. Our friend Elmo is right. We have to be there for each other, offer our help to a neighbor in need, and above all else, ask for help when we need it. Even though it’s hard, you’re never alone.” Links to several mental health services were also posted.

What About Congruence?

In addition to empathy and warm acceptance, students of Rogerian counseling theory will notice that a third “pillar,” congruence, was not mentioned in news reports – partly because it is “inward work,” not readily observable:3

  • Persons who are congruent honestly understand their internal feelings and thoughts, which supports their ability to outwardly communicate empathy and warm acceptance to others.
  • On the other hand, persons who are incongruent do not honestly understand their internal feelings and thoughts, which may include unaddressed biases of any kind.4

Incongruence hinders our ability to communicate empathy and warm acceptance to persons associated with those biases, and efforts to do so come across as inauthentic.

When patients perceive inauthenticity, trust is difficult to establish – and as clinicians, we too are also aware when there is a disconnect, that at some level we “just don’t feel it for some reason.” The current call for increased awareness and management of implicit bias is consistent with the counseling principle of clinician congruence.5-7

Rogers’ Congruence Journey

It would not be unusual for helping professionals to miss the impact of unconscious / implicit bias on congruence – even Carl Rogers seemed to have overlooked it until rather late in his career. Crisp8 recently reported on two video recordings of Rogers’ therapy sessions with two different Black male patients, conducted 5 years apart. The first session from 1979 was described by peers as having a “therapist-centric perspective” (p. 223) with missed opportunities to respond with empathy to the client’s racism experiences and avoiding an exploration about their racial and cultural differences.

Subsequent experiences in cross-cultural workshops increased Rogers’ awareness of race-related issues and, as part of his commitment to ongoing examination of his unconscious assumptions, modified his definition of congruence to include an awareness of cultural diversity.9

His “reset journey” is perceptible in a second session recorded in 1984: “Rogers was confronted with a client whose difficulties with racism included Rogers himself being a white therapist… He communicated appreciation and respect for the client’s courage in speaking to him honestly, and for his rebellion against the racism in white America” (p. 230 ).

Conclusion

Congruence is obviously easy for Elmo, since he clearly doesn’t have a biased bone (or any bones!) in his body.  For the rest of us, it’s an ongoing project… just as with Carl Rogers.

“Personal development in terms of congruence is considered to be a lifetime process needing devoted commitment and active effort.”10

Salk Institute, La Jolla, California

References

  1. Rogers, C. A. (1961). On becoming a person. A therapist’s view of psychotherapy. Boston: Houghton and Mifflin Company
  2. Rogers, A. (1980). A way of being. Boston: Houghton and Mifflin Company.
  3. Sutanti, N. (2020) 1(2), 47-50 Understanding congruence in person-centred counselling practice: A trainee counsellor’s perspective. Journal of Professionals in Guidance and Counseling, 1(2), 47-50.
  4. Danvers A et al. (2018). Emotional congruence and judgments of honesty and bias. Collabra: Psychology, 4(1), 1-7.
  5. Apodaca, C. et al. (2022). Maybe they had a bad day: How LGBTQ and BIPOC patients react to bias in healthcare and struggle to speak out. Journal of the American Medical Informatics Association, 29(12), 2075–2082.
  6. Boysen, G. (2009). A review of experimental studies of explicit and implicit bias among counselors. Journal of Multicultural Counseling and Development, 37, 240-249.
  7. Hagiwara, N. et al. (2019). Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: Challenges, solutions, and future directions for provider communication training. Patient Education and Counseling, 102, 1738-1743.
  8. Crisp, R. (2020). Carl Rogers’ reset with an African American client: a discussion. Person-Centered & Experiential Psychotherapies, 21(3), 220-234.
  9. Schmid, P. (2015). Person and society: towards a person-centered sociotherapy. Person-centered & Experiential Psychotherapies, 14(3), 217-235.
  10. Kaimaxi, D. & Lakioti, A. (2021). The development of congruence: A thematic analysis of person-centered counselors’ perspectives. Person-centered & Experiential Psychotherapies, 20(3), 232–249.

“Be Sure To Establish Rapport with Your Patient” (gulp)

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Kris English, PhD

Professor Emeritus of Audiology

University of Akron

Student clinicians have a lot on their minds when they begin new clinical assignments. It’s possible that the exhortation to “establish patient rapport” registers as less important than accurate testing, proper use of technology, and precise documentation — and in the back of their minds, they may also be wondering, “What does ‘establishing rapport’ actually mean??”

Fifty years ago, an assistant professor in nursing1 asked the same question. “[Rapport] has become a cliché, an interpersonal bromide. We all know that it’s a good thing to have – but we’re not really sure what it is” (p. 70). Just recently, a scoping review2 determined that there was as yet no agreed-upon definition for rapport relative to healthcare. Elsewhere, however, “rapport” has been framed as a synonym for “therapeutic relationships”3 and described as “a positive, dyadic concept that comprises positive affect (liking), mutual attention, and coordination”(p. 1129).4

These descriptors are helpful, but the stressor point for students may be less about “what rapport is” and more about “how does one achieve it?”

Back to First Principles

This typical definition from Merriam-Webster for “rapport” (noun)…

a friendly, harmonious relationship, especially characterized by agreement or empathy that makes communication possible or easy

…reveals the clinical challenge: describing an existing relationship does not help us understand the process of establishing or building rapport.

“Rapport as process” starts off in an uncomplicated way. It includes familiar and natural behaviors: warm welcomes, conversations about patients’ lives and interests, giving warning before touching patients, and overall taking time to connect as human beings, as confirmed by patients themselves:

‘I used to teach people to drive cars … I would make sure, before I pulled up or picked anyone up, that I knew what their first name was, what their surname was, their date of birth and a little bit about them, before I’d even met them … No matter what you do, if you’re trying to create a bond or a – yeah, a bond will do – they’re the things you need to start with. Following on from that, you need to know the person’s needs … and their wants’(p. 7)5

[My clinician] was friendly and open, explained what was being done and seemed to understand me as an individual … answered my questions at an appropriate level when prompted…I always get a friendly welcome”(p. 198)6

What We May Not Notice: Unintended Hinderances

Less apparent to us are circumstances that hinder rapport-building, e.g.,

  • When patients sense awkwardness and avoidance (not receiving a warm welcome or eye contact; use of unexplained medical jargon)
  • When patients feel judged and uncared for (perceiving conscious or unconscious prejudice and disregard)2

These negative patient impressions resonate in the literature addressing discordant healthcare dyads. As discussed here, the term “discordant” does not mean that discord or friction or tension exists, but simply describes a dyad where differences exist with respect to:

https://www.tmc.edu/news/2019/10/best-intentions-wont-solve-implicit-bias-in-health-care/

  • Gender7-10
  • Age5,11-13
  • LGBTQ+ community14-19
  • Race20-24
  • Culture25,26
  • Socioeconomic status27-31

… plus intersections of these and other characteristics. Realistically, we should expect some degree of “dyadic discordance” on any given workday; more importantly, we should be aware that interpersonal differences could prompt behaviors influenced by unexamined implicit biases, resulting in those patient perceptions of awkwardness, avoidance, feeling judged and uncared for.

Discordance is Not Destiny

Working through rapport challenges: A lot to unpack

Implicit biases are part of the human experience, but are not irrevocable. Trainees might benefit from readings,32 discussions, role-playing, feedback about efforts, successes, struggles, and insights.

Of course, difficulties with patient rapport may also be related to shyness, insecurity, self-consciousness, under-preparedness, fear of failure… concerns that supervisors may refer to professional counselors.

Conclusion

A clinician’s ability to establish rapport cannot be taken for granted, and may actually require considerable attention. It may elude definition in research articles but in real-life clinic, we know that authentic patient rapport lays the groundwork for person-centered care.

References

  1. Travelbee J. (1963). What do we mean by rapport? American Journal of Nursing,63(2), 70–72.
  2. English W. et al. (2020). The meaning of rapport for patients, families, and healthcare professionals: A scoping review. Patient Education and Counseling, 105, 2-14.
  3. Norfolk T et al. (2007). The role of empathy in establishing rapport in the consultation: A new model. Medical Education, 41, 690-697.
  4. Henry S. et al. (2017). Associations between thin slice ratings of affect and rapport and perceived patient-centeredness in primary care: Comparison of audio and video recordings. Patient Education and Counseling, 100, 1128-1135.
  5. Orgin R. et al. (2020). The inter-relationship of diversity principles for the enhanced participation of older people in their care: A qualitative study. International Journal of Equity in Health, 19:16.
  6. Potter M. et al. (2003). The physiotherapy experience in private practice: The patients’ perspective. Australian Journal of Physiotherapy, 49, 195-202.
  7. Choudhury A. et al. (2020, October). Impact of gender on doctor-patient communication and emotion: Exploratory analysis. 2020 IEEE International Symposium on Systems Engineering (ISSE)(pp. 1-10)
  8. Gross R. et al. (2008). The association of gender concordance and primary care physicians’ perceptions of their patients, Women & Health, 48(2),123-144.
  9. Schieber AC et al. (2014). Do gender differences affect the doctor–patient interaction during consultations in general practice? Results from the INTERMEDE study. Family Practice, 31(6), 706-713.
  10. Wallis J. et al. (2022). Association of surgeon-patient sex concordance with postoperative outcomes. JAMA Surgery, 157(2), 146-156.
  11. Elliot M. et a. (2022). The hospital care experiences of older patients compared to younger patients. Journal of the American Geriatrics Society, 70, 3570-3577.
  12. Gilbert D., Hayes E. (2009). Communication and outcomes of visits between older patients and nurse practitioners. Nursing Research, 58(4), 283-293.
  13. Stewart M. et al. (2000). The influence of older patient-physician communication on health and health-related outcomes. Clinics in Geriatric Medicine, 16(1), 25-36.
  14. Balik C. et al. (2020). A systematic review of the discrimination against sexual and gender minority in health care settings. International Journal of Health Services, 50(1), 44-61.
  15. Bonvicini K. (2017). LGBT healthcare disparities: What progress have we made? Patient Education and Counseling, 100, 2357-2361.
  16. Joudeh L. et al. (2021). “Little red flags”: Barriers to accessing health care as a sexual or gender minority individual in the rural southern United States—A qualitative intersectional approach. Journal of  the Association of Nurses in AIDS Care, 32(4), 467–480.
  17. Malta M. (2023). LGBTQ+ health: Tackling potential health-care professionals’ bias. Nature Review Disease Primers. 
  18. McDowell M et al. (2020). Strategies to mitigate llinician implicit bias against sexual and gender minority patients. Psychosomatics, 61(6), 655-661.
  19. Sabin J. et al. (2015). Health care providers’ implicit and explicit attitudes toward lesbian women and gay men. American Journal of Public Health, 105(9), 1831-1841.
  20. Cuevas A., et al. (2016). African American experiences in healthcare: “I always feel like I’m getting skipped over.” Health Psychology, 35(9), 987-995.
  21. Hajiwara N. et al. (2017). Physician racial bias and word use during racially discordant medical interactions. Health Communication, 32(4), 401-408.
  22. Knoebel R. et al. (2021). Treatment disparities among the Black population and their influence on the equitable management of chronic pain. Health Equity, 5(1), 596-605.
  23. Mhaimeed N. et al. (2023). Shared decision making with black patients: A scoping review. Patient Education and Counseling, 110, 107646
  24. Shen M. et al. (2018). The effects of race and racial concordance on patient-physician communication: A systematic review of the literature. Journal of Racial and Ethnic Health Disparities, 5(1), 117-140. 
  25. Berlin A. et al. (2010). Watchfully checking rapport with the primary child health care nurses – A theoretical model from the perspective of parents of foreign origin. BMC Nursing, 9(14).
  26. Pérez-Stable J, El-Toukhy S. (2018). Communicating with diverse patients: How patient and clinician factors affect disparities. Patient Education and Counseling, 101, 2186-2194.
  27. Davies J. et al. (2023). The association between socioeconomic position and the symptoms and concerns of hospital inpatients seen by specialist palliative care: Analysis of routinely collected patient data. Palliative Medicine, 37(4), 575-585.
  28. Mercer M, Watts G. (2007). The inverse care law: Clinical primary care encounters in deprived and affluent areas of Scotland. Annals of Family Medicine, 5(6), 503-510.
  29. Rowley J. et al. (2021). The impact of poverty and deprivation at the end of life: A critical review. Palliative Care and Social Practice, 15, 1-19.
  30. Xesfingi S, Vozikis A. (2016). Patient satisfaction with the healthcare system: Assessing the impact of socioeconomic and healthcare provision factors. BMC Health Services Research, 16:94. 
  31. Yuan Y. (2021). Public satisfaction with health care system in 30 countries: The effects of individual characteristics and social contexts. Health Policy, 125, 1359-1366.
  32. Vela M. et al. (2002). Eliminating explicit and implicit biases in health care: Evidence and research needs. Annual Review of Public Health, 43, 477-501.

Can a “Patient Dignity Question” Mitigate Heathcare Inequities? Part 1/2

Posted on by

Kris English, PhD

Professor Emeritus of Audiology

University of Akron

This article is posted as we near the three-year anniversary of George Floyd’s murder (May 25, 2020). In the US, this crime reignited the Black Lives Matter movement, as well as renewed support for the LGBTQ+ community, indigenous persons, and others experiencing injustice.

However, as often happens, momentous events lose their impact over time. Protest signs fade and attention is directed elsewhere … all the more reason to routinely recommit to cultural humility and equitable audiologic care.

Cultural humility includes treating others with dignity. Following is a discussion of relational dignity, and how it might be communicated in audiology appointments.

Dignity

The concept of dignity is both commonplace and difficult to define, apart from a generalized belief that “We know when we see it, and we know when we don’t see it.”1-3 There is at least general agreement that dignity is a human right,4-6 and is “attached to all human beings irrespective of any of their achievements” (p. 71).7

Jacobson8 describes this specific aspect of dignity as “dignity-in-self.” Another aspect, highly relevant to person-centered care, is known as “dignity-in-relation…[referring] to the ways in which respect and worth are conveyed through expression and recognition… a matter of action and interaction …” (p. 17)

Relational dignity is reciprocal and mutual: “I dignify you by recognizing your self-respect; by dignifying you, I also dignify myself…”(p. 16).8  When dignity is not acknowledged in either direction, trust breaks down.9

We are fully aware that not all humans are treated as though they have equal worth. However, we may not be aware of the many subtle breaches in relational dignity. Jacobson lists a continuum of 24 types of social violations of dignity, many of which are egregious (e.g., exploitation, assault) and would never be permitted in a clinic setting. But the “lesser” end of the continuum should give us pause: they include dismissal, disregard, and grouping.

Dismissal describes the experience of discounting a person’s knowledge, concerns, and feelings. “In health care settings, serious medical conditions go untreated because doctors and nurses dismiss their patients’ ability to recognize and report accurately when something is wrong” (p. 27)8, consistent with Dr. Susan Moore’s experience, reported after she passed away.

https://www.nytimes.com/2020/12/23/us/susan-moore-black-doctor-indiana.html

Disregard is behavior that communicates “I don’t believe you” when a patient reports concerns and needs. For example, a recent poll indicated that 60% of Black respondents reported higher rates of being disbelieved, and of being denied tests, treatments or pain medication they thought they needed.10 “Not being believed” has been a widely reported experience, much of it relating to the myth that Black individuals have a higher pain tolerance than Whites.11-14

Another breach, grouping, is one we already know how to define: “when people are seen and treated not as individuals, but only as indistinguishable and interchangeable parts of a unit” – a type of othering, the separation of “them” from “us.”

Needless to say, these kinds of dignity violations are not limited to Black patient experiences.15-17  As Jacobson18 points out: “Any human interaction can be a dignity encounter—an interaction in which dignity comes to the fore and is either violated or promoted” (p. 1538). Relevant to our commitment to cultural humility, equitable health care, and counseling applications, Jacobson poses this thought-provoking question: How can relational dignity be enacted in the design and delivery of healthcare?

Part 2 of this article will consider the Patient Dignity Question: “What do I need to know about you as a person to take the best care of you that I can?”

https://medium.com/@megansaxelby/dignity-a-framework-to-transform-school-culture-b50a7ace9ec7

 

References

  1. Dutra PEP, et al. (2022). Improving the perception of respect for and the dignity of inpatients: A systematic review. BMJ Open, 12:e059129.
  2. McClellan FM. (2020). Healthcare and human dignity: Law matters. New Jersey: Rutgers University Press.
  3. Schulman A. (2009). Bioethics and the question of human dignity. In B.T. Lanigan (Ed.), Human Dignity and Bioethics (pp. 3-13). Nova Science Publishers, Inc
  4. Baillie L, Matiti M. (2013). Dignity, equality and diversity: An exploration of how discriminatory behaviour of healthcare workers affects patient dignity. Diversity and Equality in Health and Care, 10, 5–12.
  5. Jones DA. (2015). Human dignity in health care: A virtue ethics approach. The New Bioethics, 21(1), 87–97.
  6. Miller, SC. (2017). Reconsidering dignity relationally. Ethics and Social Welfare, 11(2), 108-121.
  7. Nordenfelt L. (2004). The varieties of dignity. Health Care Analysis, 12(2), 69-81.
  8. Jacobson N. (2012). Dignity and health. Nashville: Vanderbilt University Press.
  9. Bazargan M, et al. (2021). Discrimination and medical mistrust in a racially and ethnically diverse sample of California adults. Annals of Family Medicine, 19(1), 4-15.
  10. Kaiser Family Foundation/Undefeated Survey on Race and Health. (2020). Race, health, and COVID-19: The views and experiences of Black Americans.
  11. Akinlade, O. (2020). Taking Black pain seriously. New England Journal of Medicine, e68(1-2).
  12. Hoffman KM, et al. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS, 113(6), 4296–4301. 
  13. Schoenthaler A, Williams, N. (2022). Looking beneath the surface: Racial bias in the treatment and management of pain. JAMA Network Open, 5(6):e2216281.
  14. O’Connor MI. (2021). Equity360: Gender, Race, and Ethnicity: Why Don’t We Believe our patients? Clinical Orthopædics and Related Research, 479, 897-900
  15. Kamen CS, et al.(2019). “Treat us with dignity”: A qualitative study of the experiences and recommendations of lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients with cancer. Support Care Cancer, 27, 2525–2532.
  16. Guadagnolo BA, et al. (2009). Medical mistrust and less satisfaction with health care among Native Americans presenting for cancer treatment. Journal for the Health Care of the Poor and Underserved, 20 (1), 210–226. doi.org/10.1353/hpu.0.0108
  17. Staats K, et al. (2020. )Dignity and loss of dignity: Experiences of older women living with incurable cancer at home, Health Care for Women International, 41(9), 1036-1058.
  18. Jacobson, N. (2009). Dignity violation in health care. Qualitative Health Research, 19(11), 1536-1547.

Can a “Patient Dignity Question” Mitigate Healthcare Inequities? Part 2/2

Posted on by

Kris English, PhD

Professor Emeritus of Audiology

University of Akron

Part 1 began with the observation that addressing healthcare inequities requires vigilance, specifically with attention to the topic of relational dignity. Chochinov1 points out, “Although the literature on dignity is sparse, it shows that ‘how patients perceive themselves to be seen’ is a powerful mediator of their dignity” (p. 184). To “be seen” or to “feel seen” are familiar phrases that describe recognition from another person, referred to in Part 1 as relational dignity.2

Chochinov3 laid the groundwork for an intervention designed for vulnerable patients to help them feel seen, known as the Patient Dignity Question: “What do I need to know about you as a person to take the best care of you that I can?”

Some Background

The Patient Dignity Question (PDQ) was designed to help healthcare providers understand their patients in settings where one’s dignity can feel especially diminished: palliative care, nursing homes, and end-of-life care.3-8  The question, “What do I need to know about you as a person to take the best care of you that I can?” was informed by empirical research to help health care providers (HCPs) understand each patient as a person, not as a mere embodiment of their diagnosis.

The PDQ is described as a “dignity conserving intervention,” and while each PDQ interview will be unique, pre- and post-intervention measures have indicated positive outcomes, including the appreciation for “being seen.” 9,10 It is a validated process, well received by patients and clinicians, and has been recommended as a routine component of care.11 Perhaps because of its simplicity and implied humility, this question has been shown to be quite effective. One example:11

A total of 126 participants (66 patients and 60 family members) responded to the PDQ…93% felt that the information was important for HCPs to know, and 99% would recommend the PDQ for others. A total of 137 HCPs completed 293 evaluations of individual PDQs; 90% indicated that they learned something new from it, 64% that they were emotionally affected by it, 59% that it influenced their sense of empathy, and 44% that it influenced their care.

As noted, the PDQ was designed specifically for palliative and end-of-life care settings. Recently, an additional consideration of patients in the LGBTQ community receiving care in these settings indicated comparably positive PDQ results,12 but also raises a question: why wait until the end stage of healthcare?  Social dignity violations (e.g., dismissal, disregard, grouping) routinely occur across a wide range of healthcare encounters throughout a lifetime.13-18 There seems no reason to wait: researchers very familiar with the PDQ have pointed out that the PDQ “can be used by any provider type and in numerous care settings to understand patient values” as a standard of care.19 Since all patients seek relational dignity throughout their lives, extending the PDQ intervention to all patients in all settings seems feasible, or at the minimum to those with historical concerns regarding inequitable care.

Proposal: Pose the PDQ…

… optimally to all patients! And especially within discordant dyad audiology encounters as an intervention to override implicit bias.

The Patient Dignity Question communicates our goal to be person-centered, and certainly qualifies as another addition to the counseling tool box. It is similar to the “What Matters to You?” query but says more than “tell me about yourself.” By also adding “to take the best care of you that I can” may (hopefully) also be heard as “what matters to you also matters to me” – that is, an authentically humble, respectful outreach, committed to relational dignity.

Concerned about saying the question accurately?  We could:

  • Preview the conversation with a handout for the patient beforehand, with the explanation: “I look forward to our appointment, and as we get to know each other, I would like to ask you this question….”
  • Develop an intake “PDQ form” for contemporaneous notetaking: “To make sure my services are personalized to your needs, I have this form that starts out….” and after reading the Patient Dignity Question, jot down the patient’s responses and incorporate “what I need to know” into the treatment plan.

We can work out several approaches that feel comfortable and appropriate to the moment and setting – but ultimately, find a way to “go there.”

https://www.weforum.org/agenda/2018/10/why-we-need-dignity-more-than-ever-70-years-after-the-universal-declaration-of-human-rights/

Conclusion

Public attention to social inequities in healthcare will ebb and flow, but on a daily basis, individual practitioners can maintain vigilant attention and keep the issue at top of mind.

Can the “Patient Dignity Question” reduce healthcare inequities? Let’s try it and find out – and share experiences and insights with the profession.

“Not everything that is faced can be changed. But nothing can be changed until it is faced.” — James Baldwin

References

  1. Chochinov HM. (2007). Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care. British Medical Journal, 3359(9761), 184-187.
  2. Jacobson N. (2012). Dignity and health. Nashville: Vanderbilt University Press.
  3. Chochinov HM, et al. (2005). Dignity therapy: A novel psychotherapeutic intervention for patients near the end of life. Journal of Clinical Oncology, 23(24), 5520-5525.
  4. Hadler RA et al. (2022). “What do I need to know about you?”: The Patient Dignity Question, age, and proximity to death among patients with cancer. Supportive Care in Cancer, 30, 5175–5186.
  5. Johnston B, et al. (2015a). The person behind the patient: A feasibility study using the Patient Dignity Question for patients with palliative care needs in hospital. International Journal of Palliative Nursing, 21(2), 71-77.
  6. Johnston B, et al. (2015b). The dignified approach to care: A pilot study using the patient dignity question as an intervention to enhance dignity and person-centred care for people with palliative care needs in the acute hospital setting. BMC Palliative Care, 14(9).
  7. Łabuś-Centek M, et al. (2020). The meaning of dignity patient question and changes in the approach to this issue of cancer patients during home hospice care. Palliative Medicine in Practice, 14(2), 89–94.
  8. McDermott P. (2019). Patient Dignity Question: Feasible, dignity-conserving intervention in a rural hospice. Canadian Family Physician, 65(11), 812-819.
  9. Arantzamendi M, et al.(2016). Promoting patient-centred palliative care: A scoping review of the patient dignity question. Current Opinion in Supportive and Palliative Care, 10(4), 324-329.
  10. Meier E, et al.( 2019). Conversations regarding personhood: Use of the Patient Dignity Question in an outpatient psycho-oncology clinic. Journal of Palliative Medicine, 22(12), 1574-1577.
  11. Chochinov HM, et al. (2015). Eliciting personhood within clinical practice: Effects on patients, families, and health care providers. Journal of Pain Symptom and Management, 49(6), 974–980.
  12. Javier NM. (2021). Palliative care needs, concerns, and affirmative strategies for the LGBTQ population.Palliative Care and Social Practice, 15(1), 1-17.
  13. Banerjee D, et al. (2021). Role of dignity in mental healthcare: Impact on ageism and human rights of older persons. American Journal of Geriatric Psychiatry, 29(10),  1000−1008.
  14. Blair I, et al. (2013). Clinicians’ implicit ethnic/racial bias and perceptions of care among Black and Latino patients. Annals of Family Medicine, 11(1), 43-52.
  15. Carlström R, et al. (2021). ‘Treat me with respect’: Transgender persons’ experiences of encounters with healthcare staff. Scandinavian Journal of Caring Sciences, 35, 600-607
  16. Job C, et al. (2022). Health professional’s implicit bias of adult patients with low socioeconomic status (SES) and its effects on clinical decision-making: A scoping review protocol. BMJ Open, 12:e059837
  17. Schnierle J, et al. (2019). Implicit bias: What every pediatrician should know about the effect of bias on health and future directions. Current Problems in Pediatric and Adolescent Health Care, 49, 34-44.
  18. van der Geugten W, Goossensen A. (2020). Dignifying and undignifying aspects of care for people with dementia: A narrative review. Scandinavian Journal of Caring Science, 34, 818–838.
  19. Hadler RA, et al. (2022). “What do I need to know about you?” The Patient Dignity Question, age, and proximity to death among patients with cancer. Supportive Care in Cancer, 30, 5175–5186.

Ida Institute’s Legacy: Person-Centeredness

Posted on by

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

In early February 2023, the Ida Institute in Denmark announced that it is “significantly scaling back activities” as its funding comes to an end. Fortunately, its deep library of tools, online courses and other resources will remain available. These developments are highlighted here to honor Ida’s direct and enduring impact on audiologic counseling.

An Easy-to-Miss “Ida Impact:” A Consistent Focus on Person-Centeredness

Because of the many contributions Ida has made to audiologic practices in the past 15 years, its philosophical commitment to the concept of person-centered care could be taken for granted. When the organization began to define itself in 2007, the term had not been widely used; just 6 years prior, the Institute of Medicine’s (2001) report identified the concept of patient-centered care as a pillar of quality health care. Because of IOM’s stature, “PCC” became a widely accepted concept. Soon, however, concerns were raised about the term’s inherent limitations (e.g, Clarke & Fawcett, 2016; Mezzich et al, 2010; Miles & Mezzich, 2011). By listening carefully to those concerns as expressed by persons and families living with hearing loss and by thought leaders in audiology, Ida became one of the early adopters of another version of “PCC:” the more empowering concept of person-centered care.

The difference in wording may not have been immediately appreciated, but over time it began to sink in: the shift from patient to person reflects a difference in power, focus, and priorities. Compare these distinctions (Eklund et al., 2019):

The goal of Patient-Centered Care is to support a functional life…

  • as defined by clinicians
  • determined by test results (words, sentences in quiet, noise, etc)
  • to address listening challenges at home, work.

Whereas … the focus of Person-Centered Care is to support a meaningful life…

  • as defined by individuals with hearing loss and family
  • determined by understanding the whole person (“what matters to you?”)
  • whose individual goals may change over time.

 

Implications: Checking Our Priorities

These two models of centeredness represent different priorities, which by definition means assigning more weight or importance to one “thing” than to other things. For instance, clinician trainees understandably prioritize the dozens of details involved with assessment and treatment — there is indeed a lot to remember and apply. However, when those tasks have been mastered, we can shift to a broader priority, i.e, “being more focused on the person than on the task” (DiLollo & Favreau, 2010; Granberg & Skagerstrand, 2022; Grosch et al, 2008).

“Being More Focused on the Person Than on the Task”

This short phrase is easy to remember and carries two salient points: (1) being “focused” implicitly includes behaviors typically associated with counseling (active listening, empathy, shared decision-making, etc), and (2) it doesn’t dismiss the importance of our tasks. We can attend to both the person and the tasks in the time allotted, but only if we actively prioritize. When we focus our undivided attention to someone’s personhood for even a very brief time, that person’s experience is about feeling unique, being heard, and sharing responsibility (Feldthusen et al, 2022). Students may not perceive this balance as they master the necessary tasks, but we need to advise them: once these are mastered, move on! Figuring out how to focus more on the person in front of us is our life-long goal.

To the Ida Team…

… Lotte, Ena, Hans, Cher, Natalie, Clint, Anne, Mei and all the change agents at Ida: You brought audiologists together, helped us move forward, and helped persons with hearing loss be heard.

References

Clarke PN, Fawcett J. (2016). Nursing knowledge driving person-centered care. Nursing Science Quarterly, 29(4), 285-287.

DiLollo A, Favreau C. (2010). Person-centered care and speech and language therapy. Seminars in Speech and Language, 31(1), 90-97.

Eklund JH, et al. (2019). “Same same or different?” A review of reviews of person-centered and patient-centered care. Patient Education and Counseling, 102, 3-11. 

Feldthusen C et al. (2022). Centredness in health care: A systematic overview of reviews. Health Expectations, 25, 885–901.

Granberg S, Skagerstrand Å. (2022). Enhancing person-centered audiologic rehabilitation: Exploring the use of an interview tool based on the International Classification of Functioning, Disability, and Health Core Sets for Hearing Loss. Frontiers in Rehabilitation Sciences, 3, Article 945464.

Grosch K, Medvene L. (2008).  Person-centered caregiving instruction for geriatric nursing assistant students. Journal of Gerontological Nursing, 34, 23–31.

Institute of Medicine. (2001). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.

Mezzich J et al. (2010). Toward person-centered medicine: From disease to patient to person. Mount Sinai Journal of Medicine, 77, 304-306.

Miles A, Mezzich J. (2011). Person-centered medicine: Advancing methods, promoting implementation. International Journal of Person Centered Medicine, 1(3), 423-428.