Qualitative critical appraisal

D ow

nloaded from

http://journals.lw w .com

/ajnonline by

B hD

M f5eP

H K av1zE

oum 1tQ

fN 4a+kJLhE

ZgbsIH o4X

M i0hC

yw C X 1A

W nY

Q p/IlQ

rH D 3P

O oLC

qW plE

eV G B nR

10gjS q3R

6foO 0L6C

A q+K

P H FTsuk=

on 10/22/2020

Downloadedfromhttp://journals.lww.com/ajnonlinebyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3POoLCqWplEeVGBnR10gjSq3R6foO0L6CAq+KPHFTsuk=on10/22/2020

28 AJN ▼ June 2018 ▼ Vol. 118, No. 6 ajnonline.com

HOUR

ORIGINAL RESEARCH Continuing EducationCE

Although people can experience hearing diffi-culties at any age, advanced age is a strong predictor.1 According to the National Insti- tute on Deafness and Other Communication Dis- orders (NIDCD), almost 25% of adults ages 65 to 74 years, and 50% of those ages 75 years and older, experience disabling hearing loss.1 Between 2012 and 2050, the number of older adults is expected to nearly double2; so it stands to reason that the num- ber of those with hearing impairment will also rise. Hearing-impaired older adults are more likely to be hospitalized than those without such impairment,3 and their mortality rates are also higher.4 Clearly, communication difficulties resulting from hearing impairment will adversely affect information ex- change. Such difficulties can also affect overall qual- ity of life in various ways. These include decreased social functioning5; decreased physical functioning6; emotional reactions such as depression, loneliness, frustration, and anxiety5; and exacerbation of cogni- tive decline.7 Among frail elderly patients with mul- tiple comorbidities, hearing loss has been cited as a contributing factor “in common geriatric syndromes such as confusion, falls, social withdrawal, and fail- ure to thrive.”8

Addressing the needs of hearing-impaired patients in the hospital setting can be challenging, given that critical health-related information must be exchanged, often within time constraints. A recent national sur- vey of hospice and palliative care providers found that 88% could recall a situation in which patients’ hearing

Findings from a qualitative study.

deficits hampered communication.9 Indeed, patients with hearing loss may withdraw from conversation5 or misinterpret its content, causing them to be misla- beled as confused.10

Little research has been conducted regarding the experiences of older hearing-impaired adults in the hospital setting. Yet it’s well known that effective communication is crucial to ensuring positive pa- tient experiences and outcomes. Nursing staff must appreciate the particular challenges involved in com- municating with this population, and take steps to ensure that patients understand important informa- tion, both during hospitalization and during subse- quent care transitions.11

Study rationale and purpose. Having a better un- derstanding of the perceptions of hospitalized hearing- impaired older adults and addressing communication barriers in the hospital setting would improve both the patient’s hospital experience and the quality of care. This study was conducted to assess the hospital experience of older adults with hearing impairment, and to use the findings in formulating suggestions for improving nursing care.

BACKGROUND Literature review. We conducted a search of English- language, peer-reviewed publications in the databases Journals@OVID, MEDLINE, and CINAHL for the years 2010 through 2013, using the search terms hos- pital experience and seniors. This revealed two arti- cles that focused on the hospital experience of older

1

Understanding the Hospital Experience of Older Adults with Hearing Impairment

[email protected] AJN ▼ June 2018 ▼ Vol. 118, No. 6 29

ABSTRACT Background: Older hospitalized adults with hearing impairment are vulnerable to adverse outcomes. These patients are at risk for being labeled confused, experiencing a loss of control, experiencing height- ened fear and anxiety, and misunderstanding the plan of care.

Objective: This qualitative study sought to assess the hospital experience of older adults with hearing impairment in order to formulate suggestions for improving nursing care.

Methods: Open-ended interviews were conducted with eight participants, ages 70 to 95 years, who were identified as having a hearing impairment and were admitted as inpatients to a midwestern medical center.

Results: Through data analysis, three common themes emerged: health care communication difficul- ties, passivity and vulnerability, and frustration with family.

Conclusions: Nurses will benefit from having a deeper understanding of the hospital experience of this vulnerable population. Efforts to address their needs can be accomplished through the following nursing actions: assess, accommodate, educate, empower, and advocate.

Keywords: hearing impairment, hospital experience, older adults

adults but did not specifically address hearing- impaired patients. One of these, a systematic review of qualitative studies published between 1999 and 2008, focused on the hospital experience of older adults and their family members.12 The researchers found that communication difficulties may contrib- ute to feelings of anxiety and powerlessness. The sec- ond article reported on a qualitative study conducted among frail elderly patients.13 The researchers found that many such patients perceive the hospital setting as “an institution of power with which it is not pos- sible to argue or disagree.” Communication difficul- ties were cited as a barrier to information exchange.

We conducted additional searches using “senior or older adults or elderly” combined with hearing loss, hearing aids, hospital experience, continuity of care, or communication, and this revealed several more studies. We also consulted the reference sections of identified studies to locate additional sources, and we repeated the literature searches for the years 2013 through 2016 during the writing of this article. In one study that did not specifically consider hearing impairment, Rustad and colleagues interviewed hos- pitalized elderly patients about their experiences with the transition from the hospital to community health care services.11 The researchers found that while some participants were content with “handing over the responsibility” for the transition, most wanted to be more actively involved and wanted more informa- tion. Citing other research, Rustad and colleagues noted that power inequities between patients and professionals leave patients “in a vulnerable position and [they] may therefore be reluctant to communi- cate their preferences.” The identified articles that did involve hospitalized older adults with hearing impairment focused solely on hospice and palliative

care patients. Smith and colleagues, using an illustra- tive “case presentation” of a hospitalized patient on palliative care, noted that patients may delay disclo- sure of hearing loss and that such loss can interfere with communication during care meetings.14 Olson and McKeich provided three illustrative “case sce- narios” involving hearing-impaired older adults (one hospitalized and two in home settings) to highlight the communication barriers these patients encoun- ter.15 Both articles recommend proactively screening patients for hearing loss, training providers in effec- tive communication strategies for hearing-impaired patients, and using such strategies.14, 15

A few sources addressed hearing aids. According to the NIDCD, fewer than 30% of people ages 70 years and older who would benefit from using hearing aids actually do so.1 And in an analysis of data from the 1999–2006 National Health and Nutrition Exami- nation Survey, Chien and Lin found that only one in seven hearing-impaired adults ages 50 years and older used hearing aids.16 The authors cited the absence of hearing aid reimbursement from insurers as one pos- sible factor. The relatively high cost of these devices might also cause some patients to leave them at home during a hospitalization. Lastly, a study by Midha and Malik found that hearing aids were often ineffective.17

METHODS Setting and sample. The setting was a 600-bed hospi- tal in the Midwest. Institutional review board approval was secured before data collection began. A purpo- sive sampling technique was used. Nurse managers on adult inpatient floors were educated on the study through leadership meetings and follow-up e-mails. The nurse managers were asked to share this infor- mation with bedside nurses, who then identified

By Amy Funk, PhD, RN-BC, Christina Garcia, PhD, RN, and Tiara Mullen, BSN, RN

30 AJN ▼ June 2018 ▼ Vol. 118, No. 6 ajnonline.com

potential patient participants. Once a nurse identi- fied a potential participant, inclusion criteria were applied and verified. Inclusion criteria included be- ing an inpatient, being 65 years of age or older, and having self-reported hearing loss. The exclusion crite- rion was having cognitive impairment severe enough to impede communication and prevent participation in an interview. Bedside nurses screened out such patients.

Eight patients who met the criteria consented to participate in the study. Efforts to recruit more patients were hampered by time constraints and a lack of refer- rals; nevertheless, this sample size was adequate to per- mit common themes to emerge. The participants were five men and three women, ranging in age from 70 to 95 years. All were white. Their lengths of hospital stay ranged from two to nine days. See Table 1 for more demographic information.

Both verbal and written informed consent were obtained before an interview began. The primary in- vestigator (one of us, AF) conducted the open-ended interviews, which were held either in the patient’s room or in a private lounge area, whichever the pa- tient preferred. Each interview was audio recorded, and was subsequently transcribed by a member of the research team (AF, CG). In order to ensure confi- dentiality, pseudonyms were used in the transcribed interviews, and each transcript was assigned a num- ber. The number key was kept in a different location from the transcripts and field notes. During the inter- views, periodic checks were conducted to confirm the participant’s willingness to continue. Participants were also monitored for fatigue; if fatigue was noted, they were offered a break. A personal sound ampli- fier was made available to participants during inter- views but was not utilized. No reasons were given for declining its use. (Personal sound amplifiers work similarly to hearing aids, but are less expensive and don’t require consultation with an audiologist; a vari- ety of such devices is available.)

Data collection. Interviews were conducted be- tween July 1 and December 31, 2014. Six interviews were conducted in a private hospital room and two were conducted in a private lounge area. The inter- views followed the four phases outlined by Jovchelo- vitch and Bauer: initiation, narration, questioning, and concluding talk.18 Each interview began with an open-ended invitation to the participant to share her or his experience as a hospitalized patient with hear- ing impairment. As each person’s story unfolded, ad- ditional questions that arose naturally were asked. A brief concluding talk phase was completed after the recorder was turned off. Field notes were also taken.

Data were collected until saturation was reached. Saturation was defined as the point at which no new themes emerged from the interviews. The last two in- terviews provided no new information, but served to corroborate previous findings.

Data analysis. The interview transcripts were checked for accuracy by a member of the research team (AF, CG). Data from the interviews and field notes were coded for themes by all of the research- ers, using a process described by Jovchelovitch and Bauer.18 First, a serial paraphrasing procedure was used: paragraphs were paraphrased into summary sentences, and these sentences were further distilled into summary keywords or phrases. Then, as themes emerged from individual interviews, they were com- piled into common themes or categories represent- ing patients’ hospital experience.

FINDINGS Data from the interviews and field notes revealed three relevant themes: health care communication difficulties, passivity and vulnerability, and frustra- tion with family.

Health care communication difficulties. All of the participants discussed communication barriers within the hospital setting. Some participants indicated that they avoided sharing with staff that they were having difficulty hearing. Barriers to such disclosure included frustration and embarrassment in relation to misun- derstanding conversation and not wanting to inconve- nience staff. For example, during a conversation with a nurse, one participant thought he heard a sexual comment, though he knew this didn’t fit the context.

[The nurse] didn’t say anything like that. That could have caused me a good deal of embarrassment. (Nate)

Another participant commented,

It gets a little irritating to have to say, “What’d ya say?”(Virgil)

It was also noted that participants evaluated both ver- bal (tone of voice) and nonverbal (facial expression)

Patient Pseudonym Sex Age (years) Length of Stay (days)

Curt male 88 3

Alice female 95 7

Nate male 70 7

Ava female 84 3

Virgil male 78 9

Matt male 80 4

Irene female 76 2

Ken male 73 7

Table 1. Participant Demographics

[email protected] AJN ▼ June 2018 ▼ Vol. 118, No. 6 31

cues of health care staff when deciding whether to dis- close hearing loss.

Some participants mentioned trying to judge which conversations were important enough to war- rant asking for clarification. Barriers to understand- ing conversations included speech with unfamiliar accents, staff speaking too loudly, difficulty hearing telephone conversations, and difficulty hearing con- versations through the call system speakers. One par- ticipant said,

I can’t hear over [the call system speaker] when I call the nurse. I can’t hear what she says back to me. (Irene)

Some participants noted that they had left their hear- ing aids at home with family members, out of con- cerns about loss and replacement costs.

Recommendations offered by participants for improving communication included staff exhibiting more patience, using pencil and paper to convey in- formation, repeating things more than once, and shar- ing information about patients’ hearing deficits at shift handoffs so patients don’t have to keep remind- ing staff. As one participant noted,

Once you know someone has trouble hear- ing, just change [your] behavior for the next encounters—don’t ask them to keep remind- ing you and asking to repeat. (Matt)

Passivity and vulnerability. In all of the inter- views, the frailty of the participants was noted. Their dependence on staff for help with even mi- nor activities, such as finding the call light in the dark or moving up in bed, was a source of frustration and helplessness. Having hearing deficits added to this dependence, increasing their sense of vulnerability and contributing to a certain passivity. Asked whether there was anything staff could improve on with re- gard to communication, one participant (Alice) said, “No, you can’t improve my hearing.” Several par- ticipants reported that they had not told staff about specific barriers to hearing, such as difficulty with the call system speakers, multiple people speaking at once, and unfamiliar accents. The interviewer’s im- pression was that participants were used to waiting

for care rather than actively seeking it. The overall fast pace and noise of the hospital setting were also dis- tressing, and exacerbated these feelings of frustration and helplessness.

One factor was a perceived disconnection from the staff who were providing care. Participants did not expect staff members to accommodate their hear- ing impairment and consequently withdrew from participating in their care. Several participants indi- cated that they only disclosed hearing loss to staff members who showed concern about, and interest in helping with, communication difficulties. One partici- pant said,

I usually don’t [tell staff that I have hearing loss] unless they ask me about it. Sometimes I do, and other times I just figure—why bother? They don’t really care. (Nate)

Even when participants did ask staff to repeat or clarify information, they reported that they often gave up if they still didn’t understand or had to ask repeatedly. One participant said,

It’s disturbing, because needless to say I want to know what’s being discussed. . . . I just lose interest after a while if I don’t follow what’s going on. (Matt)

Their vulnerability in this regard was often expressed as irritation or anger. Participants spoke of frustra- tion not only with other people, but also with their own hearing deficits. Another participant stated,

It just kinda irritates me that I am not able to hear. Or that . . . I thought I heard something that I did not hear. Yes, and then I get angry. Sometimes in return, they get angry. It just creates a very unpleasant experience. (Nate)

Frustration with family. Although participants weren’t directly asked about family members, sev- eral disclosed emotional pain related to family inter- actions, both in the hospital setting and at home. Family members often participate in care conversa- tions, and several participants indicated that family members actively assist them with health issues. Thus such disclosures are relevant, and are included with

Several participants indicated that they only disclosed hearing loss

to staff members who showed concern about, and interest in

helping with, communication difficulties.

32 AJN ▼ June 2018 ▼ Vol. 118, No. 6 ajnonline.com

the findings. Hearing-related communication issues with family members caused participants significant tension and distress, which was conveyed not only verbally but also through their facial expressions and tone of voice. One participant said,

I tell you the truth—the one I have the most trouble understanding is my own son. He speaks so soft. And I’ll say, “What did you say?” and he’ll speak soft again and it’ll keep going . . . “Talk up, would you?” I’ve had him repeat stuff often enough, you’d think he’d automatically raise his voice but he doesn’t. (Virgil)

Several participants shared stories in which they missed the point of something that was said or re- sponded incorrectly to questions, and family members laughed at these errors. One participant felt that, be- cause of his hearing deficit, younger family members lacked respect for his life experiences and place in the family. Another said,

My family all being younger, you know, I can’t keep track of them. It becomes almost a joke. They know I am not picking up what’s going on. And I repeat things I think they are saying. . . . They don’t have the patience. They just go right on. “What you hear is what you hear, Dad.” (Matt)

Another participant misunderstood something his sister said while visiting him in the hospital.

She got angry. One day she was here, and I didn’t understand. I said something, and she says, “Well, I’ll just go back home.” (Nate)

DISCUSSION For the study participants, their communication diffi- culties were made worse when they had to contend with unfamiliar accents, telephone conversations, call system speakers, and not having brought their hearing aids. The interviews also revealed that the participants neither expected nor demanded accommodations, and that their communication difficulties contributed to strained family relationships. Participants indicated

that impatience or derision from family members was deeply hurtful.

Some of the barriers to communication described by the participants have also been identified in the lit- erature. In a study of frail elderly patients, Ekdahl and colleagues found that patients reported strug- gling to understand unfamiliar accents and perceived that hospital staff were too stressed and busy to ac- commodate their hearing deficits.13 The researchers noted that these patients often felt powerless in the hospital setting. Smith and colleagues pointed out that denial of hearing impairment is not uncommon, both for sociocultural reasons and because slow in- cremental hearing loss may not prompt awareness.14 Even when aware, patients may not disclose hearing deficits to providers. Midha and Malik found that hearing-impaired older adults, whether they used hearing aids or not, often experienced feelings of frus- tration and embarrassment.17 A unique finding of our study was that participants considered both ver- bal and nonverbal cues from staff when deciding whether to disclose hearing loss.

Practice implications. Both at the bedside and in leadership roles, nurses can help improve the hospital experience of hearing-impaired older adults. Based on our study findings, the following primary nursing actions are recommended: assess, accommodate, edu- cate, empower, and advocate.

Assess. Bedside screening for hearing impair- ment must be efficient and practical. Nurses should note any nonverbal signs of a hearing deficit, such as cupping the ear or turning the head to one side when asked questions, or misunderstanding ques- tions. One method is simply to ask the patient whether she or he has a hearing impairment. But given that many people are unaware of or deny hav- ing such impairment, the screening should take the form of a short discussion rather than a yes-or-no question. The nurse should ask, “Can you tell me about any problems you have with hearing or un- derstanding conversations?” If hearing problems are revealed, follow-up questions should be asked. These should focus on potential barriers, such as background noise, unfamiliar accents, and call sys- tem speakers. Once specific barriers are identified, the nurse should ask the patient her or his preferred methods for addressing them, such as using personal sound amplifiers, communicating with pen and pa- per, and using other written materials. This informa- tion can then be used in developing a quick plan for facilitating communication.

Another effective, objective hearing test is the fin- ger rub test.14, 19 The test involves asking the patient to close her or his eyes; the clinician then stands six to 10 inches in front of the patient with arms extended and rubs the thumb and middle finger together, first vigorously and then faintly, switching from side to side. Failure to hear the sound two out of three times

All of the participants discussed

communication barriers within the

hospital setting.

[email protected] AJN ▼ June 2018 ▼ Vol. 118, No. 6 33

is considered a positive test. Referrals may be made for follow-up outside the hospital.

Accommodate. Ample time should be given to es- tablishing trust and rapport, which can help a patient feel more willing to disclose hearing issues. The strat- egies described in Key Communication Strategies for Hearing-Impaired Older Patients8, 14, 15, 17 should be used. For example, understanding and accommodat- ing the need for a quiet setting, minimizing extrane- ous noises, and speaking clearly and slowly can all help to prevent or relieve frustration. It’s important for nurses to document the patient-specific strategies used and to share this information during handoffs; doing so can foster more consistent behavior by staff. Nurses should also ensure that a supply of personal sound amplifiers and batteries are available on the unit.

Educate. Bedside nurses can help educate patients and families on the use of key communication strate- gies. A handout outlining these strategies should be made available. Given that many hospitalized pa- tients leave their hearing aids at home, it’s also im- portant for nurses to explain the importance of using hearing-assistive devices during a hospital stay, and to ensure that patients and families know such de- vices are readily available.

Empower. Empowerment can be crucial for these patients, who may feel powerless and become pas- sive. Patients have the right to be informed about their plan of care, and encouraging their active par- ticipation improves their understanding and involve- ment in decision making. As such it’s also likely to

improve patient outcomes during hospitalization and discharge, and may help prevent rehospitalization.

Nurses can add short, empowering statements during daily care. For example, the nurse might say, “If you have trouble hearing the doctors or nurses, please ask us to write the information down, speak more slowly, or explain in a different way. We want to make sure you hear us and understand what we’re saying”; and “If we forget to turn off the television, close the door, and face you when we speak, please remind us!” Nurses should also invite and encourage patients to participate in care discussions,11 and to ask staff to make necessary accommodations that fa- cilitate communication.

Advocate. Nurse leaders can advocate system-wide education on hearing impairment in older adults. A lack of awareness of and knowledge about hearing

impairment will impede the identification of such pa- tients and the prioritization of making accommoda- tions. Although we could find no statistics specific to inpatient clinicians, a recent survey of hospice and palliative care providers found that only 21% had received training in the management of hearing loss.9 Jenstad and Donnelly have reported that one barrier to addressing hearing-related communication difficul- ties is that providers have limited time and competing priorities when they assess older adults with multiple health care issues.20

Staff education should promote awareness that failing to address hearing deficits can have potentially serious consequences.20 It should include information on how the various types of hearing loss can affect

Key Communication Strategies for Hearing-Impaired Older Patients8, 14, 15, 17

• Use nonverbal and verbal means of communication to convey a calm and caring presence. • Reassure the patient that clarifying questions are expected and welcome. • Position yourself at eye level with the patient, making sure she or he can see your mouth. • Do not yell; instead, speak clearly and drop your voice to a lower pitch. • Offer a personal sound amplifier. If the patient has brought hearing aids, encourage the patient to use them.

• Reduce extraneous noise by shutting off media devices and closing the room door. • Use pictures and printed information to help convey information. • Use the teach-back method—ask the patient to repeat or rephrase the information presented. • If the patient asks you to repeat a question, rephrase instead of repeating it—different words may be more easily heard.

At the bedside, nurses can advocate for their patients by

ensuring that hearing accommodations are followed.

34 AJN ▼ June 2018 ▼ Vol. 118, No. 6 ajnonline.com

communication,20, 21 and should cover the screening techniques and communication strategies described earlier. Nurses could lead an initiative to evaluate and improve system-wide processes for identifying and ac- commodating the needs of older patients with hearing impairment. At the bedside, nurses can advocate for their patients by ensuring that hearing accommoda- tions are followed and by periodically reassessing the plan of care and its outcomes.

Limitations. Because all of the participants were white, the findings may not be generalizable to pa- tients of other races or ethnicities. Only subjective measures of hearing loss and cognitive function were employed in assessing potential participants; the use of objective assessment methods would have been ideal. The sample size was small and may not fully represent the hospital experience of older adults with hearing deficits. Moreover, we were unable to reach satura- tion based on the number of interviews. Follow-up interviews with participants or the use of focus groups would have increased the strength of our findings.

Further research. The hospital experience of hearing-impaired older adults is unique, and much remains to be discovered. To improve our understand- ing, more patient interviews are needed. Specific ar- eas that warrant further research include hospital procedures for accommodating the needs of this pop- ulation, the knowledge level of staff, and adverse pa- tient outcomes related to hearing deficit.

CONCLUSIONS Hearing impairment in older adults impairs commu- nication and functionality both within the health care system and the family. In the hospital setting, older patients with hearing deficits often withdraw from care discussions or misunderstand what is being said, thus missing crucial information. By addressing com- munication difficulties through screening and care planning, nurses can significantly improve the hospi- tal experience of these patients. Nurses can educate patients and family members in how to use key com- munication strategies, and can advocate that clini- cians make appropriate accommodations during the hospital stay. The patients’ vulnerability and tendency toward passivity can be counteracted through em- powerment, encouraging them to participate in care conversations. When possible, nurses should lead ef- forts to improve relevant policies and procedures within the health care system and advocate for better staff education regarding hearing impairment. Lastly, with patients’ permission, nurses can address the frus- tration that hearing-impaired patients often feel re- garding communication with family members. ▼

Amy Funk is an assistant professor in the School of Nursing at Illinois Wesleyan University, Bloomington. Christina Garcia is an associate professor and Tiara Mullen is a staff nurse at Saint Francis Medical Center College of Nursing, Peoria, IL. Contact author: Amy Funk, [email protected]. The authors and planners have disclosed no potential conflicts of interest, financial or oth- erwise.

REFERENCES 1. National Institute on Deafness and Other Commmunication

Disorders (NIDCD). Quick statistics about hearing. 2016. https://www.nidcd.nih.gov/health/statistics/quick-statistics- hearing.

2. Ortman JM, et al. An aging nation: the older population in the United States. Washington, DC: U.S. Census Bureau; 2014 May. Current population reports; https://www.census. gov/prod/2014pubs/p25-1140.pdf.

3. Genther DJ, et al. Association between hearing impairment and risk of hospitalization in older adults. J Am Geriatr Soc 2015;63(6):1146-52.

4. Contrera KJ, et al. Association of hearing impairment and mortality in the National Health and Nutrition Examination Survey. JAMA Otolaryngol Head Neck Surg 2015;141(10): 944-6.

5. Ciorba A, et al. The impact of hearing loss on the quality of life of elderly adults. Clin Interv Aging 2012;7:159-63.

6. Yamada M, et al. Self-reported hearing loss in older adults is associated with future decline in instrumental activities of daily living but not in social participation. J Am Geriatr Soc 2012;60(7):1304-9.

7. Lin FR. Hearing loss and cognition among older adults in the United States. J Gerontol A Biol Sci Med Sci 2011;66(10): 1131-6.

8. Pacala JT, Yueh B. Hearing deficits in the older patient: “I didn’t notice anything.” JAMA 2012;307(11):1185-94.

9. Smith AK, et al. Hearing loss in hospice and palliative care: a national survey of providers. J Pain Symptom Manage 2016; 52(2):254-8.

10. Laubach G. Speaking up for older patients with hearing loss. Nursing 2010;40(1):60-2.

11. Rustad EC, et al. Older patients’ experiences during care tran- sition. Patient Prefer Adherence 2016;10:769-79.

12. Bridges J, et al. Older people’s and relatives’ experiences in acute care settings: systematic review and synthesis of quali- tative studies. Int J Nurs Stud 2010;47(1):89-107.

13. Ekdahl AW, et al. “They do what they think is the best for me.” Frail elderly patients’ preferences for participation in their care during hospitalization. Patient Educ Couns 2010;80(2): 233-40.

14. Smith AK, et al. Hearing loss in palliative care. J Palliat Med 2015;18(6):559-62.

15. Olson AD, McKeich MA. Assessment and intervention for patients with hearing loss in hospice. J Hosp Palliat Nurs 2017;19(1):97-103.

16. Chien W, Lin FR. Prevalence of hearing aid use among older adults in the United States. Arch Intern Med 2012;172(3): 292-3.

17. Midha P, Malik S. Does hearing impairment affect quality of life of elderly? Indian Journal of Gerontology 2015;29(1): 46-61.

18. Jovchelovitch S, Bauer MW. Narrative interviewing. In: Bauer MW, Gaskell G, editors. Qualitative researching with text, image and sound: a practical handbook for social research. London: SAGE Publications Ltd; 2000. p. 57-74.

19. Torres-Russotto D, et al. Calibrated finger rub auditory screen- ing test (CALFRAST). Neurology 2009;72(18):1595-600.

20. Jenstad LM, Donnelly M. Hearing care for elders: a personal reflection on participatory action learning with primary care providers. Am J Audiol 2015;24(1):23-30.

21. Hardin SR. Hearing loss in older critical care patients: partici- pation in decision making. Crit Care Nurse 2012;32(6):43-50.

For five additional continuing nursing education activities on the topic of hearing impairment, go to www.nursingcenter.com/ce.