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The role of audiology technicians in the VA system

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Title:
The role of audiology technicians in the VA system
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English
Creator:
Berardino, John Terry
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University of South Florida
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Tampa, Fla.
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Subjects / Keywords:
Hearing clinics -- Administration   ( lcsh )
Audiologists   ( lcsh )
VA
Dissertations, Academic -- Audiology -- Doctoral -- USF   ( lcsh )
Genre:
government publication (state, provincial, terriorial, dependent)   ( marcgt )
bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )

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Summary:
ABSTRACT: Eligibility reform in the VA and the resulting increased caseloads have brought about unacceptable wait times for new audiology appointments. Mandates to decrease wait times without increased resources have brought new demands on audiology clinics. One proposed solution is the addition of audiology technicians to VA audiology clinic practice. The first purpose of this study was to survey the attitudes of VA audiologists and service chiefs regarding the use of technicians. The second purpose was to ask the survey respondents to assign as generally appropriate or inappropriate, job duties which might be accomplished by an audiology technician. Following a pre-survey to pilot the questionnaire, the final survey was e-mailed to all members of a national e-mail group. Ninety-three acceptable responses were analyzed. The survey responses indicate that a large majority of the respondents hold positive attitudes concerning the use of technicians, believe technicians can accomplish some duties now done by audiologists and believe technicians can help reduce current appointment backlogs. The respondents assigned a number of clerical, assistive, minor hearing aid repair and other duties as appropriate for technicians and many testing, evaluation, programming, and perceived professional duties as inappropriate for technicians. There were several items which were not clearly assigned as either appropriate or inappropriate technician duties. Open-ended responses indicated that strong feelings, both positive and negative, exist within the audiology and service chief community. The survey results will be used to develop an audiology technician job description and to identify specific training needs for establishing audiology technician positions throughout the VA healthcare system.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
Statement of Responsibility:
by John Terry Berardino.
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Title from PDF of title page.
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Professional research project (Au.D.)--University of South Florida, 2000.
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Document formatted into pages; contains 19 p.

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aleph - 001413318
oclc - 47653700
notis - AJJ0734
usfldc doi - E14-SFE0000008
usfldc handle - e14.8
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ABSTRACT: Eligibility reform in the VA and the resulting increased caseloads have brought about unacceptable wait times for new audiology appointments. Mandates to decrease wait times without increased resources have brought new demands on audiology clinics. One proposed solution is the addition of audiology technicians to VA audiology clinic practice. The first purpose of this study was to survey the attitudes of VA audiologists and service chiefs regarding the use of technicians. The second purpose was to ask the survey respondents to assign as generally appropriate or inappropriate, job duties which might be accomplished by an audiology technician. Following a pre-survey to pilot the questionnaire, the final survey was e-mailed to all members of a national e-mail group. Ninety-three acceptable responses were analyzed. The survey responses indicate that a large majority of the respondents hold positive attitudes concerning the use of technicians, believe technicians can accomplish some duties now done by audiologists and believe technicians can help reduce current appointment backlogs. The respondents assigned a number of clerical, assistive, minor hearing aid repair and other duties as appropriate for technicians and many testing, evaluation, programming, and perceived professional duties as inappropriate for technicians. There were several items which were not clearly assigned as either appropriate or inappropriate technician duties. Open-ended responses indicated that strong feelings, both positive and negative, exist within the audiology and service chief community. The survey results will be used to develop an audiology technician job description and to identify specific training needs for establishing audiology technician positions throughout the VA healthcare system.
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ACKNOWLEDGEMENTS I wish to acknowle dge and thank Har vey B. Abrams, Ph.D ., Theresa Hnat h-Chisolm, Ph.D. and Arthur G uilford, Ph.D., the members of my commi ttee. Without their contributions, this study could not have been conducted. Each of them has made unique andvaluable contributions to this report. I would particularly like to thank my VA colleague andfriend, Dr. Harvey Abrams, who has encouraged me and directed me through this entireprocess.

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DEDICATION I would like to dedic ate this to my wife Su san, who has patie ntly tolerated my absence and preoccupation throughout the pursuit of my degree; to my daughters, Allison andSarah, who have h elped me and humor ed me; and to all thr ee of them for en couraging me each step along the way.

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1 The Role of Audiology Technicians in the VA System By JOHN TERRY BERARDINO A Professional Research Project submitted to the Faculty of the Department of Communication Sciences and Disorders University of South Florida in partial fulfillment of the requirements for the degree of Doctor of Audiology Harvey B. Abrams Chair Theresa HnathChisolm Arthur Guilford December 1, 2000 Tampa, Florida Key Words: Audiology, Audiology Technicians, Support Personnel Copyright 2000, John T. Berardino

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John T. Berardino 2 The Role of Audiology Technicians in the VA System John T. Berardino (ABSTRACT) Eligibility reform in the VA and the resulting increased caseloads have brought about unacceptable wait times for new audiology appointments. Mandates to decrease wait timeswithout increased resources have brought new demands on audiology clinics. One proposedsolution is the addition of audiology technicians to VA audiology clinic practice. The first purpose of this study was to survey the attitudes of VA audiologists and service chiefs regarding the use of technicians. The second purpose was to ask the surveyrespondents to assign as generally appropriate or inappropriate, job duties which might beaccomplished by an audiology technician. Following a pre-survey to pilot the questionnaire,the final survey was e-mailed to all members of a national e-mail group. Ninety-three acceptable responses were analyzed. The survey responses indicate that a large majority of the respondents hold positive attitudes concerning the use of technicians, believe technicians can accomplish so me duties now done b y audiologists and be lieve technicia ns can help reduce curre nt appointment bac klogs. The respond ents assigned a nu mber of clerica l, assistive, minor hearing aid repair and other duties as appropriate for technicians and many testing, evaluation, programming, and perceived professional duties as inappropriate for technicians. There were several items which were not clearly assigned as either a ppropriate or inappropriate te chnician duties. O pen-ended resp onses indicated th at strong feeling s, both positive and negative, exist within the audiology and service chief community. The survey results will be used to develop an audiology technician job description and to identifyspecific training needs for establishing audiology technician positions throughout the VA healthcare syst em.

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John T. Berardino 3 Introduction Recent eligibility reforms within the Department of Veterans Affairs (VA) healthcare system have brought major change to caseloads in the system. Eligibility criteria for manyVA health care services have been eased, resulting in many more veteran patients be ing eligible for many m ore VA services including hearin g aids. The resulta nt increase in caseloads has also increased wait time for new audiology appointments. While backlogs fornew audiology app ointments were, f or decades, abo ut two weeks on ave rage, they repo rtedly now range from 90 to over 365 days nationwide. Indeed, in VISN 8 (which covers Florida,Georgia, and Puerto Rico and in which the investigator is employed) wait times are as long as227 calendar da ys. The VA Undersecretary of Health has mandated a reduction in these backlogs for ne w audiology appointme nts at the VA medic al centers and ou tpatient clinics. T his situation is complicated, however, by mandates to handle the increased caseloads and increased de mands on the system without any major increa se in resources ( Kizer, 1995). Wh ile caseloads in VISN 8 have incre ased by as much as 50%, there have not been any substa ntial increase in staff or space. We are in the process of pursuing many short-term actions to reduce backlogs resulting from these increased caseloads. These include: 1) outsourcing; 2) additional permanent or temporary staff; 3) time compressed schedules; 4) use of facilities earlier andlater each day, as well as on weekends to maximize use of facilities and equipment. We have requested purchase of new equipment and additional space to facilitate productivity. All of these actions, as they are possible, will help reduce the short-term problem. A long termsolution, however, may be the use of audiology technicians. There is a tradition in VISN 8 for the use of audiology technicians in Audiology and Speech Pathology Services. There are several current technician positions filled in the central Florida area. There are 1.5 technicians at Bay Pines VA, one at Tampa VA, one at Orlando VA outpatient clinic and one at the recently opened Brevard County VA outpatient clinic.There is also recruitment ongoing for a technician at the New Port Richey VA outpatient clinic as well. The establishment of audiology tech nicians should prov ide an effectiv e and low cost permanent solutio n to audiology back logs. Health tech nicians in audiolog y are currently paid from $20,395 to $33,065 and audiologists are paid from $50,139 to $65,179 in the VAsystem. The audiology technician will not replace audiologists as the primary care-provider in hearing health. The technician can assist, prepare patients, and accomplish clerical or administrative dut ies which curre ntly keep the audio logist away from pa tient care. Some clinical activitie s can also be acc omplished by the tec hnician. These in clude hearing a id repairs or adjustment, ear impression, electrode placement, patient preparation for ENG and ABR, and identifying problems which will require the attention of the audiologist. Ideally,the audiologist and health technician will function as partners in hearing health care, providing complimentary services. The audiologist will supervise the health technician, and co-sign notes and has ultimate patie nt responsibility. T his investigator’s position is that this is an area with significant potential for the entire profession of audiology – not just VA audiology. Consideration was originally given to the development of a curriculum for the didactic portion o f the technician training, possibly a t a local community c ollege, as the bas is

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John T. Berardino 4 of the audiology technician education. Instead, this proposal has moved forward within the VA system through Dr. Harvey Abrams, Chief of the Audiology and Speech PathologyService at the Bay Pines VA Medical Center, to the National Program Director of theAudiology and Speech Pathology Program in VA Headquarters, Dr. Lucille Beck. She hasendorsed the concept of increasing the availability of education for audiology technicianswithin the VA system as well as the increased utilization of technicians throughout the VAsystem. She has move d the proposal for ward on to include the Department of Defense (DOD). There are ongoing discussions between VA Headquarters staff and Depa rtment of Defense staff to create a sharing agreement between the VA and the DOD. This agreement would utilize the D OD staff, curri culum and training facilities, alre ady widely used to t rain military technicians, for VA technicians as well. The facilities, staff, curriculum and conceptare well established in the military structure. Some modifications for the unique needs of theVA may be required, these discussions are now taking place between VA Headquarter s and DOD representa tives. Assuming that the audiology technician concept is supported and is likely to go forward, it is important to assess the climate in which the new audiology technician staffwould operate. It has been stated that are already established technician positions at a number of VA hospitals and clinics around the nation. For many VA audiologists the audiologytechnician will be a new concept and may be considered a potential threat. This fear has bee n expressed in the Audiology and Speech Pathology e-mail group, VHAWASASPS. In light of current backlogs and increased caseloads, however, the addition of audiology techniciansmay be welcomed. It was the purpose of this survey to determine the current attitudes of VA audiology staff and Audiology and Speech Pathology Service Chiefs toward the use of audiology technicians. Methods Respondents Potential respondents were all members of a national VA audiology and speech pathology mail grou p (VHAWASASPS). Th e makeup of the gr oup is changing and not well known. The mail-group was inspected visually by scrolling through the membership online and counting the a udiologists and ser vice chiefs by ha nd to estimate poten tial respondents. This inspection indi cated that there were approxima tely 500 total membe rs of the e-mail group, with about 280 being audiologists or service chiefs. It was estimated that the total number of possible respondents was approximately 280. Survey The survey (Appendix A) consisted of eight questions which established occupation, experience and attitude regarding audiology technicians, as well as 40 items which described activities which could be assigned as either audiologist or technician duties. Twenty of theitems were more traditional technician/clerical duties and 20 were more traditional audiologist duties. Some could be assigned to either or both categories. The respondents were asked to assign the items as; 1. “Appropriate”; 2. “Somewhat Appropriate” ; 3. “Neutral” ; 4.“Somewhat Inappr opriate” ; 5. “Ve ry Inappropriat e”; or 6. “No Opin ion” as related t o audiology technic ian duties. Prior to sending the surve y to the field, a pr e-survey (Appe ndix B) was completed by 10 audiologists to confirm that the duties assigned by the author asaccepted traditional audiology or audiology technician duties were similarly assigned by other practicin g clinicians. Also, there was an “op en-commentary” section for comme nts

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John T. Berardino 5 regarding the respondents’ opinions or attitudes regarding audiology technicians. Procedures Following minor modifications based on pre-survey results, the final survey was emailed to all members of the national mail-group (VHAWASASPS). The respondents wereasked to reply within five workdays. All survey responses sent electronically by the end ofthe fifth workday were accepted for analysis. There were four sur veys returned as undeliverable. There were 97 surveys returned by the respondents. Of these 97, four we re either partially completed, or were corrupted en route. These four were e xcluded. A total of 93 surveys were considered good responses and were analyzed. Results and Discussion The initial set of questions were designed to define the survey respondents. Of the respondents, 70 (75%) were from audiologists, 21 (23%) were from service chiefs, and 2(2%) were identified as “other” and were noted as assistant service chiefs. The assistant service chiefs were included in the audiologist group, totaling 72 audiologists (77%) and 21service chiefs (23%). There was a second part to question one of the survey, which asked for the respondent’s degree. The majority of respondents (57%) did not answer the question. Of the 43% who answered the question there were 15 doctorate level responses (16%) and 25masters level responses (27%). These results were likely affected by the placement of the item as part of the first question as th e item was appare ntly missed by most re spondents. Questions two, three, and four asked respondents about their current or previous experience working with audiology technicians. In examining responses to all three questions, it was found that 51 (55%) of the respondents did not currently nor had everworked with an audiology technician. Forty-two (45%) either currently work with an audiology technic ian or had at some t ime in the past. One of the goals of the current study was to evaluate whether there would be differences be tween responden ts who worked with a udiology technicia ns and those who did not. Table 1 summarizes the differences in attitudes between those audiologists who had experience wor king with technicia ns and those who did not. In general, clinicians with experience wor king with technicia ns had more positive attitudes and expe ctations than those who had no experience. The greatest difference between the groups was the perceived threa t to the profession of audiology. A small percentage (25%) of respondents with experience with techniciansperceived technicians as a threat compared to 47% of clinicians with no technician experience. In addition to assessing the attitudes of audiologists and service chiefs, the purpose of the survey was to u se the responden ts’ opinions to const ruct a theoretic al list of accepta ble technician job dut ies. There were 40 items presente d to the survey par ticipants. The clinicians’ responses to the list of possible technician job duties can be divided into three groups. The first group consisted of items for which the majority of responses were judged as being very appropriate or somewhat appropriat e as technician duties. The second group included the somewhat inappropriate and very inappropriate responses. The third group included duties where the responses were inconclusive in terms of

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John T. Berardino 6 respondent judge ments. Table 1 A Comparison of Atti tudes Between Clini cians With Experi ence With Techn icians and Those Without Experience Question Respondents with pa st experience with technicians Respondents with no experienced withTechnicians #5. Is your opinion of working with an audiologytechnician overall negativeor positive Positive (94%) Positive (76%) #6. Do you feel that an audiology technic ian could help reduce duties now performed by au diologists which could be performed as easily by technician educated staff? Yes (94%) Yes (79%) #7. Do you feel that working with theassistance of audiology technicians could pose a threat to audiolog y as a profession? Yes (25%) Yes (47%) #8. Do you feel tha t in your practice situation, theaddition of an audiology technician would help reduce your current level of new appointment backlogs? Yes (69%) Yes (63%) Those duty items that were judged to be very appropriate or somewhat appropriate for the audiology t echnicians as jud ged by at least 51% of the responden ts are listed in Tab le 2. Those duty items that were judged to be somewhat inappropriate or very inappropriate by at least 51% of the respondents, are listed in table 3. Finally, those items for which there was no majority of respondents judging the duties as either appropriate or inappropriate are listed in table 4.

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John T. Berardino 7 Table 2 Duties Judged to be Very Appropriate or Somewhat Appropriat e by a Majority of Respondents Item # Description % of RespondentsRating Item Appropriate % of RespondentsRating ItemsInappropriate 1 Shipping and Mailing 90% 3% 2 Data Entry / QUASAR 83% 6% 3 Checking in hearing aids from manufacturer 85% 5% 9 Prepare patient for ABR 54% 10 Prepare patient for ENG 51% 22% 15 Order and stock supplies 87% 5% 16 Patient follow-up or reminder calls 84% 6% 17 Minor hearing aid repair, such as battery doors 84% 6% 18 Screening interviews 54% 23% 20 Equipment calibration scheduling 78% 6% 21 Equipment minor maintenance 57% 19% 22 Hearing aid cle aning, wax, etc 84% 8% 24 Earmold tubing replacement 80% 11% 25 Hearing aid outc ome and data collection 52% 28% 30 Daily Biological Calibration 54% 25%

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John T. Berardino 8 Table 3 Duties Judged to be Somewhat Inappropr iate and Very Inappropriat e by a Majority of Respondents Item # Description % of respondents rating items as inappropriate % of respondents rating items as appropriate 7 Adjusting programm able hearing aids 66% 16% 8 Adjusting nonprogrammable hearing aids 59% 22% 11 HAO, programmab le 56% 24% 12 HAO, non program mable 57% 24% 13 Real ear measures 76% 9% 19 Patient case history 62% 17% 23 Cerumen management 62% 16% 26 Pure tone air 78% 9% 27 Pure tone bone 85% 3% 28 Immitance 85% 3% 29 SRT 88% 1% 31 Stenger Tests 86% 1% 33 MCL VCL 84% 2% 34 Loudness mapping 85% 2% 35 Screening ABR 76% 8% 37 Patient counseling (independent) 65% 13%

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John T. Berardino 9 Table 4 Duties Not Judged as Appropriate Nor Inappropriate by a Majority of Res pondents Item # Description Appropriate Inappropriate 4 Otoscopy 42% 45% 5 Hearing scree ning (fixed level ) 41% 40% 14 Pre and Post Fit assessment (HHIE, COSI, etc) 47% 38% 32 Program notes with co-signature 49% 39% 36 Assist audiologist wi th administration of balance battery 43% 21% 38 Assist audiologist with HAO programmable 42% 29% 39 Assist audiologist with cerumen management 49% 28% 40 Assist audiologist with HAO non-programmabl e 48% 27% 6 Earmold impression 49% 38% There were opportunities within this survey for open-ended responses. Eighty-seven of the 93 respondents (96%) took the opportunity to respond in this way. The responses varied from a few words to narratives that exceeded a full page. Examples of the ope n-ended responses are prsented in Tables 5, 6, and 7. In general, the comments written by the respondents were reflective of the strong feelings which exist in the profession concerning the subject of audiology technicians. The positive comments concerning improved efficiency, for example, were counterbalanced byconcerns regarding potential threats to the audiology profession. The open comments mostly addressed h earing aids, incl uding hearing aid checks, minor and other hearing aid repairs, hearing aid problem triage, phone triage and shipping and mailing of hearing aids. The next most common area mentioned was general clerical and data entry including workload and hearing aid data entry, file maintenance and otherassociated duties. The remaining comments addressed duties such as housekeeping, stocking of supplies, equipm ent maintenance cerumen manag ement, test prepa ration, hearing a id programming, patient satisfaction surveys and otoscopy.

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John T. Berardino 10 Table 5. Examples of Positive Comments for the Op en Ended Response C Technicians would enhance audiologist job satisfaction C Technicians would compliment the profession of audiology C Technicians could make audiologists more efficient C There are other professions which have two or three tiered professions C Well trained assistants would be very helpful in the VA system C Where can I get one? C Wish we had more technicians C One respondent indicated that she responded to the survey not having experience with a technician but tha t they were about to hire a technic ian. Her intention is to complete the survey again after a year to see whether her opinions have changed. Table 6 Examples of “Caut ionary” Comments f or the Open Ended Response C Duties must be uniform within the VA C Duties must be clearly defined C Technicians must be appropriately, strictly supervised C Technicians should do hearing aid work only, no testing or interpretation C Technicians should be credentialed or certified, with strict guidelines C There may be ethical or JCAHO concerns C Technicians must be properly educated C There should be a training program for technicians C Technicians shou ld not do testing, clin ical work, test int erpretation, co chlear implants, cerumen management, real ear, hearing aid evaluation or any audiologist professional duties.

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John T. Berardino 11 Table 7 Examples of Nega tive Comments on the O pen Ended Response C Technicians will reduce the quality of care. C The general publ ic is not clear on w hat audiology is C Cost cutting makes technicians risky. Why hire audiologists when technicians are cheaper? C Human resource s could replace a udiologists with tec hnicians, see the m as the same C Who knows what may happen with managed care C We need to protect the procedures within the profession of audiology C We are already viewed by some as technicians C Audiologists are liable for the activities of the technician C We’re shooting ourselves in the foot by hiring technicians C We sacrifice p rofessionalism wh en we hire and tr ain someone to do ou r jobs without a degree C Using a technician keeps the audiologist from knowing what problems occur C We shouldn’t be apathetic and let technicians handle professional duties C Hiring technicians will reduce the number of audiologists and reduce the quality of care C Don’t give away cherished duties. Taking away duties is a threat to audiology C Administrators will want to use techni cians in inappropr iate ways. C Technicians are inappropriate for audiology, are bad for patient care and f or the profession C Audiologists who use technicians are probably giving shoddy care Summary and Conclusions The objectives of this study were to survey the attitudes of VA audiologists and service chiefs regarding the use of audiology tech nicians and to use t he survey respon ses to construct a theoretical list of audiology technician job duties acceptable to practicing VA audiologists and se rvice chiefs. The results of the investigation sugge st that the vast majo rity of the respon dents, both audiologists and service chiefs, have a positive opinion about the use of audiologytechnicians. The re was a differ ence in attitudes regarding audio logy technicians a mong those who have worked with audiology technicians compared to those who have not. Clearly, the response patterns and the open-ended comments confirm that there are strong feelings onboth sides of the issue. Most respondents did not feel that technicians were a threat to the profession, felt that the addition of an audiology technician would help reduce new appointment backlogs and felt that there are duties now performed by audiologists whichcould easily be performed by audiology technicians. The results seem to indicate that the time may be right to proceed with investigation and proposals for future use and training of audiology technic ians. While only a minority of VA audiologists currently practice with audiology technicians, there appears to be a growing interest in utilizing technical support personnel. The open-ended responses to this survey, the high return rate and the personal contacts made to the author abou t the use of techni cians seem to suppo rt this observation The generally

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John T. Berardino 12 positive attitudes towards technicians revealed through this survey as well as the array of duties judged as appropriately performed by technicians are further evidence of the apparent positive future of audiology technicians in the VA. It is recognized that the results re ported here may b e specific to the VA system and its version of audiology practice. Executive orders, congressional mandates, budgetarylimitations, government and non-governmental agency oversight and the sheer number ofpatients served (up to 1700 patients per month at some clinics) create pressures unique to theVA environment. I t is likely that the a ttitudes and judgem ents regarding a ppropriate technician duties may be quite different in other audiology practice environments. To theextent that the re sults of this survey h ave implications f or VA audiology, ho wever, those duties identified a s appropriate can serve as the basis for a prototype job description for the VA audiology technician. In addition to the appropriate duties, those without clear preferences as well as selected inappropriate duties (e.g. ear impressions) should also be considered for the inclusion in the prototype position description. Questionable duties mightbe added with some accommodation for special training and certification. That is, perhapsthose duty items without a clear majority of respondents judging them to be appropriate should be considered optional pending satisfactory completion of a training and/or certification pr ogram. As suggested by the respondents, It is important to have uniformity of training, a standard set of a cceptable dutie s and a standard le vel of supervision from the audiologi st in the practice. It is also important f or the technicia n to have an identit y which is separa te and distinct from the audiologist and recognizable by other professionals, managers and human resource s specialists. As noted previously, the application of these survey results outside of the VA may be limited. It is important to recognize, however, that professional (e.g., the Au.D.) anddemographic tre nds (e.g., an agin g population) will lik ely require audi ologists to increas ingly depend on technical support personnel to meet growing demands for audiologic services. It is suggested that a similar study be conducted to assess the attitudes of audiologists in thenon-VA sector. In addition, it may be of value to assess the attitudes of clinical managers and human resources professionals as those emerged as an identified area of conce rn among some audiologists who completed the survey. Furthermore, an investigation of the history and success of other professions which have a multi-tiered professional structure (e.g.,optometry, pharmacy) seems warranted. It appears that there is considerable interest among VA audiologists for utilizing technical support personnel. Cautious progress is recommended toward the establishment of a prototype position description, a VA-wide training program, and standards of practiceconcerning the audiology technician. If these are accomplished, success of this cooperative professional endeavor seems assured.

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John T. Berardino 13 References Beck, L., (Personal Communication, 2000) Kizer, K. (1996) Prescription for Change Internal Veterans’ Administration Document. U.S. Public Law 104-262, The Veterans’ Health Care Eligibility Reform Act of 1996.

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John T. Berardino 14 Appendix A. Audiology Technician Survey The following survey is designed to determine the opinions held by audiologists and ASP service chiefs regarding the issue of audiology technicians. This current survey is designed to address only the audiology issues at this time, not speech pathology. Please answer the questions as they reflect your personal opinions and experience. Since the issue of audiology technicians is taking on new importance in the current atmosphere of eligibility reform and backlog reductions, your opinion is important and canmake a difference in future VA plans and activities. Please take the time to express youropinions about this issue. A response within 5 workdays would be greatly appreciated. Instructions for responding1. click on the “reply” button 2. scroll down to the survey 3. fill in answers an d mark the duty items 4. once completed, click on the “send” button 5. if unable to respond via e-mail or if you prefer to FAX, print, complete, and FAX to (813) 978-5812 Attn: John Berardino 1. Your profession is: Audiologist____ Service Chief____Other______ your degree___ (please specify) 1. Do you currently work with an audiology technician? Yes____No____ 2. If you do not currently work with a technician, have you ever worked with an audiology technician? Yes____No____ 3. If former military, have you worked with an “ENT technician?” Yes____No____ Not former military _____ 4. Is your opinion of th e possibility of wor king with an audiolo gy technician ove rall Negative____or Positive____? 5. Do you believe that an audiology technician could help reduce duties now performed by audiologists which could be performed as easily by technically ed ucated staff? Y es____No____. If yes, please give examples. Do you feel that working with the assistance of audiology technicians could pose a 6. potential threat to audiology as a profession? Yes____No____. Please explain. 7. Do you feel that in your practice si tuation, the additio n of an audiology te chnician would help reduce your current level of new appointment backlogs? Yes____No____.

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John T. Berardino 15 Appendix A. (Continued) Please review t he following potenti al work activities Indicate how you fe el about the APPROPRIATENESS OF A TECHNICIAN PERFORM ING EACH TASK by marking (for e-mail return) or circling a number next to the activity (for mail orFAX return.) The numbers from one to six indicate:One= very appropriate 8. Two= somew hat appro priate Three=neutral Four=somewhat inappropriateFive= very inappropriate Six= no opinion Activities Rating 1. Shipping and mailing activites………………………………1__2__3 __4__5__6__ 2. Data entry (such as QUASAR or encounter forms)……...….1__2__3__4__5__6__3. Checking hearing aids in from manufacturer………………..1__2__3__4__5__6__4. Otoscopy……………………………………………………..1__2__3__4__5__6__5. Hearing screening (fixed level, pass-fail)……………………1__2__3__4__5__6__6. Earmold impressions…………………………………………1__2__3__4__5__6__7. Adjusting programmable hearing aids……………………….1__2__3__4__5__6__8. Adjusting non-programmable hearing aids…………………..1__2__3__4__5__6__ 9. Preparing patient for ABR (instructions, electrode prep.etc)...1__2__3__4__5__6__10. Preparing patient for ENG (instructions, electrode prep.etc)..1__2__3__4__5__6__11. Hearing aid orientation (HAO),(programmable)…………….1__2__3__4__5__6__ 12. Hearing aid orientation (HAO),(non-programmable)………..1__2__3__4__5__6__ 13. Real ear Measures………...………………………………….1__2__3__4__5__6__14. Pre & post fitting assessments (HHIE/A, COSI, etc)………..1__2__3__4__5__6__ 15. Ordering & stocking supplies, batteries………………..……1__2__3__4__5__6__16. Patient follow-up or reminder calls……………………..…...1__2__3__4__5__6__ 17. Minor hearing aid repairs (batteries, battery door etc.)…..….1__2__3__4__5__6__18. Screening interview (not case history)……………………....1__2__3__4__5__6__19. Patient case history…………………………………………..1__2__3__4__5__6__ 20. Equipment calibration scheduling………………………..….1__2__3__4__5__6__ 21. Equipment minor maintenance…………………………..…..1__2__3__4__5__6__22. Hearing aid cleaning (wax removal, etc.)………………..…..1__2__3__4__5__6__ 23. Cerumen management…………………………………..…...1__2__3__4__5__6__ 24. Earmold tubing replacement, cleaning1…………………..…1__2__3__4__5__6__25. Hearing aid outcome data collection, analysis……………....1__2__3__4__5__6__26. Pure tone audiometry………………………………………...1__2__3__4__5__6__

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John T. Berardino 16 Appendix A. (Continued) One= very appropriate Two= somewhat appropriateThree=neutral Four=somewhat inappropriateFive= very inappropriateSix= no opinion Activities Rating 27. Bone conduction audiometry…………………………...1__2__3__4__5__6__ 28. Immittance audiometry…………………………………1__2__3__4__5__6__29. Speech reception threshold……………………….….…1__2__3__4__5__6__30. Daily biological calibration……………………….……1__2__3__4__5__6__ 31. Stenger tests (pure tone, speech)………………….……1__2__3__4__5__6__32. Write progress notes (with cosignature)………….…….1__2__3__4__5__6__ 33. MCL,UCL measures………………………………..…..1__2__3__4__5__6__ 34. Loudness mapping tests…………………………….…..1__2__3__4__5__6__35. Screening ABR (without interpretation)…………….….1__2__3__4__5__6__ 36. Assist audiologist with admin. of balance test battery.…1__2__3__4__5__6__ 37. Patient counseling (independent)…………………….…1__2__3__4__5__6__38. Assist audiologist with HAO (programmable)…………1__2__3__4__5__6__ 39. Assist audiologist with cerumen management……….…1__2__3__4__5__6__ 40. Assist audiologist with HAO (non-programmable)….…1__2__3__4__5__6__ 8. Open commentary Please include here any comments you wish to add relative to the audiology health technician issue. Address: John T. Berardino, M.S., MPH, CCC-A Chief, Audiology & Speech Pathology Service (126) James A. Haley Veterans Hospital 13000 Bruce B. Downs Blvd.Tampa, FL. 33612 Phone: (813) 972-7529 FAX: (813) 978-5812

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John T. Berardino 17 Appendix B. Pre-su rvey Analysis The audiology technician pre-survey was delivered to 12 audiologists to complete. The document was either delivered in person or placed in a workplace mailbox. Five weredelivered to VA audiologists, six were delivered to university audiologists and one to anaudiologist in a group practice. Ten of 12 were returned by the five-day deadline placed bythe investigator. Five copies of the pre-survey were e-mailed to audiologists in a variety ofsettings. Within the five-day deadli ne, none of the emailed pre-surv eys were rece ived. It is postulated that giv en the short respo nse time and that e ach e-mailed sur vey was sent to home e-mail accounts the zero retur n rate resulted f rom infrequently read home e-mai l accounts. Note that the actual survey was send to professional e-mail accounts only, which wereassumed to be used more frequently by most VA audiologis ts. The 10 returned surveys were evaluated and the following was found: for the 20 assigned by the au thor as audiologist duties. Of these 2 0 items, the pre-su rvey respondent s agreed with 16 of these assignments (80%). The agreed-upon items included otoscopy, adjustment of programmable and non-programmable hearing aids, hearing aid orientation for programmable hearing aids, real ear measures, pre and post-fit assessment, case history, cerumen manage ment, pure tone ai r and bone conduc tion immittance, SRT, Stenger tests, most comfortable levels (MCL), uncomfortable levels (UCL), loudness mapping and independent counseling. There were 18 items assigned by the author as appropriate duties for either (audiologist or au diology technicia n). Of these 18 ite ms, the pre-surve y respondents agreed with 10 of these assignments (55%). These ite ms included check ing hearing aids, minor repairs, screening interview (not case history), minor equipment maintenance, hearing aid cleaning, ea rmold tube replac ement, outcome me asure collectio n and analysis, da ily biological calibration, progress note writing with co-signature, screening auditory brainstem response (ABR) and assisting the audiologist with the vestibular test battery. There were two items assigned by th e author as audiology technician duties. These were reminder calls and equipment calibr ation. The pre-s urvey responden ts agreed with both assignments. Of the items assign ed by the author a s audiologist duties, the pre-survey respondents disagreed with four of these assignments. These included earmold impressions and patient preparation for ABR and electronystagmography (ENG) tests. Clearly, the respondents believed that these activities, once considered audiologist activities are now thought of as shared activities between the audiologist and the audiology technician. Earmold impressions and patient preparation for ABR and (ENG) tests were placed by the respondents in the either (audiologist or Audiology technician) category. The other assignment disagreement was hearing aid orientation (for nonprogrammable instruments). The author assigned both programmable and non-programmable he aring aid orienta tions as audiologist duties. The respondents placed the programmable HA O in the audiologist a rena but allowed for the non-prog rammable HAO to be accomplished by either (audiologist or audiology technician).

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John T. Berardino 18 Appendix B. (Continued) The respondents disagreed with eight of 18 items (44%) of the duties assigned by the author as either (audiologist or au diology technicia n) duties. Mostly, th e respondents indicated that certain duties should be handled primarily by the audiology technician ratherthan by either (audiologist or audiology technician). Some duties were a ssigned by the resp ondents as audiology technician only These included shipping, mailing and ordering and stocking of supplies. The respondents split fouritems assigned to either (audiologist or audiology technician) between either and audiology technician These include data entry, assisting the audiologist with programmable and nonprogrammable HA Os and assisting the audiologist with ce rumen managemen t. Two items that were assigned by the author as appropriate for either (audiologist or audiology technician) we re assigned by the respondents as audiologist duties. These include hearing aid outcome data collection and analysis and screening ABR. This finding was surprisingsince in many locations, pediatric screening ABRs are conducted by medical or nursing assistants. Furthermore, outcome measures seem to be an appropriate area for collaborationbetween the audiologist and the audiology technician. The main message gleaned from the responses to the pre-survey is that, based upon the author’s concept of traditional thinking regarding audiologist duties, the role of the audiology technic ian appears to be expanding. The r esponses to the mai n survey should reveal whether this view is shared among the remainder of audiologists in the VA.

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John T. Berardino 19 John Terry Berardino Mr. Berardino is Chief of the Audiology and Speech Pathology Service at the James A. Haley Veterans’ Hospital in Tampa, Florida. He has been a practicing audiologist for over20 years. He has also practiced a t a VA outpatient c linic and a multi-sp ecialty private practice. He holds a Master of Public Health and a Master of Science in Audiology.