The issue of hearing screening in commercial settings, in particular hearing screening conducted by front-of-house non-clinical staff in shopping centres, has been a common theme in requests for information and complaints to the HPCCB.
Members’ ethical dilemmas regarding hearing screening
There appears to be widespread consensus amongst audiologist and audiometrist members of the professional bodies (Audiology Australia and the Australian College of Audiology Inc. HAASA) that hearing screening practices, in any setting, are a valuable community awareness activity that encourages people to think about, and respond to, their hearing needs.
However, sometimes the nature of these screening practices poses ethical dilemmas. Members have called the Ethics Officer seeking guidance on their clinical responsibility for front-of-house screening practices. They have raised the issue of not knowing if and how they should act on their concerns about:
- The reliability and/or clinical relevance of results (e.g. due to background noise, tester training, and test equipment settings).
- Who gets targeted for hearing screening (e.g. older people but not younger people who may be at risk of noise-related hearing loss).
- Messaging to older people during these screening practices (e.g. non-clinical staff offering opinions on the degree of hearing loss, the effects of hearing loss, and/or possible treatment options).
Concerns about screening practices by front-of-house staff often pose a difficult professional and ethical question for members. Item 19.2 of the Code of Conduct for audiologists and audiometrists holds members responsible for people conducting tests and procedures under their supervision, but in many cases front-of-house staff are not under the direct supervision of a member.
The ethical dilemmas faced by members when considering hearing screening practices were further highlighted during the COVID-19 pandemic. Members called with concerns that opportunistic hearing screening of people who happened to walk past a service was not an essential health service. The response by the HPCCB and Ethics Officer during the pandemic was to follow the relevant government guidelines regarding essential health services, and to remind members that hearing services were an important part of primary care.
Code of Conduct Responsibility 19.2
“Members may employ non-member staff to conduct a certain test or procedure provided they are competent to carry out those duties and are under the immediate and personal supervision of the member. Under these circumstances the non-member is bound by this Code of Conduct and the member must maintain full responsibility for the client’s welfare.”
As always, a good first step for members with concerns about how an employer may be providing hearing services is to discuss these concerns with an employer. Take the time before this discussion with your employer to jot down the key issues/contributing factors relating to your concerns, any evidence or regulations relating to the clinical issues to be discussed, and what you think could be done to address your concerns.
The public’s view
Many complaints and requests for information by clients of hearing services have raised issues relating to hearing screening performed by front-of-house non-clinical staff in shopping centres. However, these practices often fall outside the remit of the HPCCB due to the fact that the people conducting the screening are not members of the professional bodies or under the direct supervision of a member.
The types of concerns raised by clients include:
- Confusion about the qualifications of the person conducting the screening.
- A misunderstanding that the screening is a comprehensive diagnostic assessment.
- Being so overwhelmed after ‘failing my hearing test when I had no idea anything was wrong with me’ (i.e. ‘failing’ the screening) that they then ‘couldn’t take in what the doctor at the back said’ (i.e. the audiologist or audiometrist).
- Front-of-house staff commenting on their clinical prognosis based on the screening results.
These client concerns often escalate further if they have then Googled ‘hearing screening guidelines’ and found that their screening test did not adhere to the detailed testing equipment, testing environment, and tester qualification requirements of, for example, the government-funded hearing screening programmes in Australia and overseas.
Let’s continue the discussion
Perhaps it is time for a further exploration of the professional, clinical and ethical issues relating to hearing screening in different contexts and for different populations/needs groups by the members, together with their professional bodies. Taking the discussion back to first principles of health screening for each population/needs group could help to guide these discussions. The Australian Government’s 2018 Department of Health Population Based Screening Framework (the Australian Framework) states that:
“As screening has benefits, costs and harms, there is an ethical obligation to maximise benefits and minimise harm. The overall benefits should outweigh any harms that result from screening. […]” (1)
The Australian Framework builds on the World Health Organization (WHO) principles of screening for disease (2). It notes that benefits may include improving disease/condition outcomes and that harms include false positives, over-diagnosis and other physical and psychological harms resulting from the screening. Although these principles can be applied to the hearing screening context, it is important to note that the Australian Framework distinguishes between population screening and ‘case-finding or opportunistic screening’ describing this as “[…] where a test is offered to an individual with or without symptoms of the disease when they present to a health care practitioner for reasons unrelated to that disease (for example, when a GP orders blood tests when a patient presents for a flu shot).”.
Considering these first principles may assist the audiology and audiometry professions to define more clearly the various hearing screening activities they or their employer undertake. This would include a consideration of the relative benefits and harms, who is targeted for screening, and how the findings of the screening are communicated to clients.
References
(1) Department of Health, (2018) Population Based Screening
Framework. Commonwealth of Australia.
P2.
(2) Wilson J & Jungner G (1968) Principles and practice of screening
for disease. WHO Public Health Paper No 34.
