By Kathi Mestayer
Older adults are more likely to have hearing loss and to spend time in healthcare settings. Taken together, these factors can present serious challenges.
What happens to people in healthcare settings really matters. A mistake, even a small one, can have big consequences.
That’s hard to argue with. Whether you’re in a hospital, rehabilitation center, or nursing facility, if you’re the patient, you have a strong interest in getting the best outcome. And so do healthcare professionals.
But communication breakdowns can affect results. Can you hear the voice on the intercom speaker? Can you understand directions over the thrum of hospital devices? Can you always hear a “do not” in a long sentence of medical instructions?
Then there’s the baseline stress of being the patient. Exhaustion, illness, and medications can make speech harder to understand, even in an ideal, quiet setting with one person facing you and talking clearly.
Kathi before surgery holding her own personal amplifier. She says, “When I asked the staff, at the pre-surgery check-in, if they had any assistive listening devices, and I told them I was hard of hearing, the nurse said, “Ma’am, I have no idea what you’re talking about.”
An Aging Population
As we age, we are more likely to have trouble hearing. Two-thirds of people ages 70 and older have bilateral hearing loss, and almost three-quarters have hearing loss in at least one ear, according to a 2016 American Journal of Public Health report.
Age also brings a greater likelihood of spending time in the hospital. People older than 65 comprise over 40 percent of the total days of care in a hospital, according to the Centers for Disease Control and Prevention.
So hospitals are full of older patients who are often hard of hearing, and data suggests that this affects healthcare outcomes. A study of patients in the Medicare system, published in the Journal of the American Geriatrics Society in 2018, compared readmission rates of patients who self-reported hearing loss with those who did not.
The patients with hearing loss “had, on average, 32 percent greater odds of hospital readmission” within 30 days of discharge. Results were adjusted for age, so the higher rate was specifically associated with hearing loss.
Not Hearing, and Not Saying So
We know that having a hearing loss requires practicing a lot of self-advocacy. But this can be hard to do in a hospital setting. When you’re ill, tired, and anxious, do you really want to risk creating tension with the doctor by asking them to repeat what they just said, or to take off their surgical mask? Do you even have the energy?
A small study suggests the answer is no. Researchers interviewed eight patients who self-reported hearing loss, ages 70 to 95. “A surprising finding was that they did not expect the health system to change, but rather seemed a passive participant during the hospital stay,” says study coauthor Amy Funk, Ph.D., of Illinois Wesleyan University’s School of Nursing. “In many cases, patients did not mention to staff that they had a hearing deficit.”
As a result of the report in the American Journal of Nursing, Funk’s team devised key communication strategies for use by healthcare professionals. These include advising staff to proactively ask the patient whether they have a hearing issue, and to reassure them that asking questions is not only expected, but welcome.
Noisy Hospitals
Every hospital patient needs peace and quiet to rest, heal, and communicate. Any noise can make speech harder to comprehend—heating and air conditioning systems, other voices, medical alerts, or that device under the mattress that keeps inflating and deflating 24 hours a day, making sleep impossible. A 2018 editorial in the journal BMJ says noisy hospitals have been linked to the development of high blood pressure and increased pain sensitivity, not to mention stress and poor mental health.
In fact, you don’t have to be awake to be disturbed by noise. A 2012 Annals of Internal Medicine study of sleep disruption in the hospital exposed 12 sleeping patients to a number of sounds, such as alarms, phones, ice machines, outside traffic, and helicopters, at a range of volumes. Measurements of brain activity and heart rates indicated disruption at various stages of sleep. Noise matters, even if it doesn’t wake you up.
To better understand noise and its effects, scientists are collecting sound-level data from hospital and other healthcare facilities. Erica Ryherd, Ph.D., an associate professor of architectural engineering at the University of Nebraska–Lincoln, researches hospital acoustics, noise, and occupant response and is a member of the Acoustical Society of America’s noise and architectural acoustics technical committees. In 2016, her team measured sound levels and frequencies in a sample of hospital wards: 24-hour measurements were taken in 15 rooms and at five nurses’ stations across five wards in a Midwest hospital.
The sound data was then compared with patient ratings of “quietness” in the same wards, also from 2016, with a sample size of almost 2,000. The patient ratings came from a Medicare program called HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), which requires hospitals to survey and report data from patients on a variety of topics after discharge.
A comparison of their sound data to the HCAHPS patient data showed, not surprisingly, that both agreed on the two loudest wards. For speech intelligibility in the five wards, three were ranked “marginal” and two were “poor”; none reached the “good” level. And the baseline background noise levels—measured in unoccupied rooms—were louder than levels recommended by the World Health Organization and other health and safety institutions.
To improve hospital soundscapes, Ryherd says acoustics need to be considered earlier, during building design (or renovation). This can include the size, dimension, and acoustical needs—such as patient speech privacy—of different spaces. Existing hospitals can install sound-absorbing materials such as ceiling tiles and use sound masking to dampen jarring sudden noises. Staff can limit conversations and cell phone use in hallways and paging over loudspeakers, and work to reduce noise from trolleys, televisions, and phones.
There are also many research efforts examining how to reduce the volume and frequency of alarm sounds in hospitals, which affect staff as well. The use of sound patterns and haptic (touch) stimuli are among the possible solutions.
Be Aware
Medicare collects and shares a wealth of data about hospitals and communication, including the HCAHPS survey data used by Ryherd. This includes patient ratings of staff listening skills and their ability to explain things clearly.
The Medicare website has a Hospital Compare tool at medicare.gov/hospitalcompare. You can search for a hospital and view its scores for each question in the HCAHPS survey. For my local hospital, I was able to see the percentage of patients who said their nurses or doctors “always” communicate well, or that their room was “always” quiet at night, and compare this with state and national averages. The information can help you better prepare for a hospital visit and choose a hospital, if you have that option.
Medicare also takes action based on the collected data. For example, its Readmission Reduction Program decreases the Medicare reimbursement rates for hospitals with high readmissions (while taking into account hospitals’ demographics and special patient groups).
The U.S. Department of Justice (DoJ) plays an active role in patients’ rights as well. Its Barrier-Free Health Care Initiative, announced in 2012, has investigated hospitals and other healthcare institutions. Most cases involve the failure to provide American Sign Language interpreters for patients who are deaf, which is a clear violation of the Americans With Disabilities Act. The DoJ’s cases against healthcare institutions to rectify access for the deaf not only grab headlines—and drive solutions— they also stipulate changes that benefit those with hearing loss.
For instance, the settlement agreements used to resolve cases include requiring access to assistive listening devices, captioning, telephone amplifiers, and hearing aid–compatible telephones; and requiring that each patient’s needs for effective communication are detailed at the time of admission. Hospitals understand the consequences of not meeting these requirements, which can include reopening the investigation.
Making Progress
For the many professionals involved in providing healthcare, training in communication is a big, and often unmet, need. A 2016 Journal of Pain and Symptom Management study of over 500 palliative care and hospice doctors and nurses reports: “Although 61 percent felt comfortable with their communication skills for patients with hearing loss, only 21 percent reported having received formal training in its management, 31 percent were unfamiliar with resources for patients with hearing loss, and 38 percent had never heard of a pocket talker amplification device.”
At a pre-surgery appointment a couple of years ago, I asked the nurse if the hospital had any assistive listening devices. She responded, “Ma’am, I have no idea what you’re talking about.” So I bought a basic handheld amplifier and brought it with me to the surgery. Similarly, my father’s cochlear implant battery was tossed in the trash with his hospital lunch tray. And the director of nursing of a local hospital system told me that they don’t encourage patients to bring their hearing aids; if the devices get lost, the hospital has to replace them. But—then how can we hear?
This spurred me to get involved personally. I have been conducting sessions for nurses about how to help patients with hearing loss, at the request of the nurse who manages the training program at a local university. We discuss hearing basics, such as the effects of noise and the benefits of speech-reading (lip-reading), along with low-tech solutions, such as writing things down. When we try an easy-to-use, relatively inexpensive handheld amplifier, the nurses are amazed at the volume and clarity.
So, how to hear better in hospitals? Tell hospital staff that you are hard of hearing; if you have a choice in hospitals, use the Medicare website to pick a quieter one; minimize unnecessary noise in the room from alerts or machines; make sure the speaker has the listener’s attention and shows their face when speaking; use written instructions; and when needed use a portable amplifier. Also, wear your hearing aids and store them in a clearly marked container!
The good news is that an increasingly large and diverse network of individuals and organizations are working to improve the system, spanning the fields of gerontology, otolaryngology, audiology, nursing, acoustics, architecture, and hospital management. They are collecting, interpreting, and sharing data; creating and enforcing standards; designing and building better facilities; training healthcare providers; and advocating for patients. The collective focus is to improve communication and, as a result, healthcare outcomes for the large, and growing, number of older adults with hearing loss.
Kathi Mestayer serves on advisory boards for the Virginia Department for the Deaf and Hard of Hearing and the Greater Richmond, Virginia, chapter of the Hearing Loss Association of America. This article originally appeared in the Fall 2019 issue of Hearing Health magazine. For references, see hhf.org/fall2019-references.
