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Dilemma 1

Who is the client?

A daughter accompanies her mother to an appointment for a hearing test. The daughter relates that her mother has had hearing difficulty for at least five years. The daughter is clearly pressuring her mother to try a hearing aid. You test the mother's hearing and find that she has a moderate hearing loss. The mother states that she has no need to improve her hearing. You realize that the mother is not willing to acknowledge her hearing loss or the difficulties it creates for her.

The daughter describes the situation: It is possible that the reason mum feels she does not need better hearing is because everyone tries to accommodate her hearing loss. We all speak to her in loud voices and turn the TV volume up to the highest level - even when it is too loud to be comfortable for others in the room. The mother is not socially active and her conversational situations are presently limited. During your discussion with her, you notice that the mother is somewhat withdrawn and unwilling to talk about her hearing problem. You believe her social isolation and possible depression are related to her hearing loss.

How would you deal with the situation?

Suggestions

  1. Ask the mother if there are any situations she avoids due to hearing difficulties, i.e., does she go to church, visit friends and family or join in social gatherings? Discuss feelings associated with avoidance behaviour
  2. Try to interview the mother without the daughter present so that you can better understand the mother's needs
  3. Explore whether the mother would be willing to participate in seniors' outreach programs
  4. Or...
Dilemma 2

Which way should I go?

A 45-year old woman presents with a diagnosis of Meniere's Disease and progressive hearing loss. In the 1980s, the patient was first seen with tinnitus, fluctuating hearing loss and vertigo attacks. In 1985, she underwent a saccotomy on her right ear and was fitted with a hearing aid on the left ear. The hearing loss on the left ear is probably due to recurrent otitis media in childhood.

Five years ago, she stopped wearing hearing aids and now requires an interpreter for communication. Due to her deteriorating speech discrimination and difficult hearing loss, she is requesting cochlear implantation. In the late 1990s, her ENT advised her that she was not a candidate for implantation. However, since 2000, she has been offered cochlear implantation at your clinic. The patient has not made up her mind. She always has an excuse for not scheduling the surgery.

How would you deal with the situation?

Suggestions

  1. Engage the patient in a discussion of the pros and cons of implantation
  2. Arrange to have a cochlear implant recipient (i.e., mentor) meet with the patient
  3. Try to motivate the patient to use a hearing aid until she feels sufficiently informed to make a decision about cochlear implants
  4. Or...
Dilemma 3

My new colleague - the internet

In general, you think it is a good idea that patients with cochlear implants seek information from the internet. However, many of your patients surf the internet extensively whenever they have a question.

You realize that you have a new 'colleague' - the internet. Unfortunately, some of your patients are receiving incorrect information and anxiety provoking answers from the internet. You spend an increasing amount of time correcting mis-informed patients. To make matters worse, your last patient chose to believe the internet over you!

How would you deal with the situation?

Suggestions

  1. Provide a list of reliable websites in your own information pack
  2. Explain that it is your role to evaluate each patient's unique hearing loss and lifestyle and personal communication needs, enabling you to provide relevant information that will empower patients to make informed decisions
  3. Point out that information on the internet is general, but your professional advice is specific to each person's unique hearing needs
  4. Or...
Dilemma 4

We don't accept your solution

Parents bring their 4-year-old son to your clinic for a second opinion. The mother reports that her son "doesn't hear certain sounds at all or if there is a lot of noise, he doesn't hear you. We have to speak loudly." The hearing test shows a sloping mild to severe sensorineural hearing loss.

The parents easily accept that their son has a hearing loss; they almost seem relieved. Accepting his need for hearing aids is much more difficult. They worry that people may respond negatively to their son when they see that he is wearing hearing aids. Initially the parents refuse hearing aids. Three months later they return, stating that their son's pre-school has advised them that their son's language development is significantly delayed. The parents are asking for communications strategies to address the problem but still refuse to consider hearing aids for their son.

How would you deal with the situation?

Suggestions

  1. Directly address the parents' fears about hearing aids and explain the impact of not hearing on the brain, learning, language and future academic outcome. Ensure that they understand the importance of the first five years of a child's life for language acquisition
  2. Explore the reasoning behind the parents' belief that a hearing loss is acceptable, but not a hearing aid. What are the family dynamics behind this?
  3. Suggest use of hearing aids for one or two months at school on a trial basis to demonstrate the benefit of amplification. Ask the teacher for a report on the change in the child's language, classroom participation, behavior, etc.
  4. Or...
Dilemma 5

Accepting a hearing loss is a process, not a destination

You first met Jackie 10 years ago when participating in a group called 'Living with Hearing Loss'. At that meeting, Jackie reveals that she feels like a failure. Later Jackie attends and graduates with honors from a local community college. She then applies to a teaching program at another college. The college discourages her from entering the teaching program stating that because of her severe hearing loss, she would be 'a danger' to the children! She is crushed.

For the past ten years, Jackie has passionately devoted her time and talents to teaching others about hearing loss and the misconceptions that often accompany it. She is now involved with a number of hearing loss advocacy organizations and has taken on a leadership role with several of these groups. You often collaborate with Jackie when giving talks about hearing loss. You know that Jackie never tells normal-hearing people that she has a hearing loss. Consequently, they think she is rude, ignoring them, snobbish, or not very bright. When you gently suggest that it might be helpful to let people know that she has a hearing loss, she says it is awkward and embarrassing.

How would you deal with the situation?

Suggestions

  1. Acknowledge her feelings, but highlight how important it is for her communication partners to understand that she has a hearing loss. Point out that her reluctance to discuss her own hearing loss may undermine her continued efficacy as a hearing loss advocate
  2. Do nothing more at this time. As Jackie is actively speaking about hearing loss on a regular basis, the issue is most likely on her mind already
  3. Suggest 'overcoming the embarrassment of hearing loss' as a future topic at the self-help group in which she participates
  4. Or...
Dilemma 6

How much has to happen before the hearing aids are worn?

Your client has a long-standing mild to severe high frequency sensorineural hearing loss and possesses advanced technology hearing aids. However, because she is not wearing her hearing aids on a regular basis, she is experiencing communication problems with her family and colleagues on the job. Her communication problems with her husband eventually lead to their divorce. Now, she is also considering resigning from her job due to the high level of communication required.

How would you deal with the situation?

Suggestions

  1. Recommend counseling with a psychologist to help her reach a better level of acceptance of her hearing loss and its emotional impact
  2. Try to facilitate ownership of the hearing loss and increased hearing aid use by suggesting she attend self-help groups. Perhaps, she will be positively influenced by the experiences of others with hearing aids and the resulting improvements in their lives
  3. Explore her reasons for not wearing the hearing aids and explain the consequences of not wearing hearing aids compared to the benefit, in order to increase self-motivation
  4. Or...
Dilemma 7

Friendly professional advice

You are visiting your friend at a family party. The whole family is gathered in the kitchen. Your friend uses the occasion to bring up the subject of her father-in-law's (Mr. C) hearing loss, stressing how hearing aids have helped her husband.

Although Mr. C agrees that he has all the symptoms of hearing impairment, he is not interested in having his hearing tested. He appears to think that hearing loss is 'nature's way' of telling him that he is past his prime. He understands why it is frustrating for the family. However, he can live with it, so why can't they?

How would you deal with the situation?

Suggestions

  1. Privately, tell Mr. C that he can come in for an appointment with or without his family present
  2. If he shows interest, speak privately to Mr. C about the situations in which he may be experiencing hearing difficulty
  3. As this is a social setting, do not put pressure on Mr. C to pursue this discussion
  4. Or...
Dilemma 8

Understanding the parents' agenda

A 12-year-old boy arrives at your clinic with his mother, who would like a second opinion regarding her son's hearing loss. Although he was diagnosed with a bilateral sensorineural hearing loss at the age of 4, he wears only one hearing aid.

Your audiological investigations show the following results:

  • Pure tone Audiometry with average thresholds for speech frequencies of 40 dB HL
  • Impedance Audiometry normal in both ears
  • Transient Otoacoustic Emissions absents in both ears
  • BERA normal responses down to 50 dB nHL

You recommend bilateral hearing aids, but the mother insists on a unilateral hearing aid. This is her preference and is not due to financial constraints.

How would you deal with the situation?

Suggestions

  1. Explore why a second opinion is so important. What answer is the mother looking for that she has not already heard?
  2. Explore the mother's request for only one hearing aid. Does she believe that one hearing aid represents less of a handicap than two hearing aids?
  3. Suggest trial use of binaural hearing aids for 1-2 months. Ask the child's teacher, with the parents permission, for observations of the child's performance in school when wearing two versus one hearing aid
  4. Or...
Dilemma 9

Putting an end to the dissatisfaction dilemma

Your 70-year-old patient presents with a moderate sloping high-frequency sensorineural hearing loss. She seems to have a typical presbycusic hearing loss. You follow the usual rehabilitation structure in the public health care system, i.e., an initial consultation to discuss hearing test results and recommendations; a second visit for the hearing aid fitting, orientation and verification; and a third follow-up visit. However, the patient is not satisfied. She comes back once a month for nearly 9 months, always with a new list of questions and problems.

You feel very strongly that you will never meet her expectations.

How would you deal with the situation?

Suggestions

  1. Encourage her to identify and prioritize her goals and expectations with a questionnaire such as the COSI
  2. Recommend that she keep a hearing aid diary of successful experiences as well as areas of challenge
  3. Enroll her in an aural rehabilitation group where she can benefit from others' experiences and the weekly social interaction
  4. Or...
Dilemma 10

Getting to the root of the problem

You inherited an 88-year-old client that your colleague has been unable to satisfy. You have cared for her for four years with an average of ten visits a year. She has seen a speech therapist a few times to improve communication strategies.

Most sessions start with getting the hearing aids to work again, as there is always some problem such as a dead battery, a cleaning or a minor repair.

Despite her multiple visits, she seems dissatisfied with the performance of her hearing aids. She has tried several different styles and brands of hearing instruments over the years and no one, including you, has ever achieved a satisfactory fitting for the client.

You are beginning to feel this will be a never-ending story.

How would you deal with the situation?

Suggestions

  1. Revise the hearing aid orientation, ensuring that instructions are clear and easy to remember. Include significant others in the patient's environment who can help to check that the hearing instruments are being used correctly
  2. Schedule her to return in 6 weeks. Set a goal that the hearing aids will be in working order and the batteries will be functional when she arrives. Do not proceed on further adjustments of the aids until she comes in with working aids and batteries. She will never be happy with the sound of the hearing aids until she has them functioning correctly
  3. Recommend that she takes part in a self-help group for ongoing support and encouragement
  4. Or...
Dilemma 11

Who defines the problem?

A 42-year-old male is referred to you for aural rehabilitation focused on tinnitus counseling. The referring specialist would also like your assessment of the viability of the client's continued employment.

The client has a severe to profound sensorineural hearing loss bilaterally and has worn hearing aids since the age of three. He is experiencing increased difficulty understanding speech. Previous assessments have shown a gradual decrease of speech recognition scores over time.

The client arrives for the first session with no amplification but with an interpreter present.

During the consultation, the client expresses concern only about his tinnitus. He also mentions that for the past few years, he has primarily worn one hearing aid. He reports receiving confusing information from previous hearing care professionals. Your advice is a referral for a cochlear implant assessment.

How would you deal with the situation?

Suggestions

  1. Seek clarity regarding the client's employment needs and expectations (amplification, compensation, CI, help for his tinnitus)
  2. Explore why the patient is not wearing his hearing instrument for this consultation
  3. Provide advice about technology, e.g., improvements in amplification, assistive listening devices such as FM and CI, and tinnitus therapy
  4. Or...
Dilemma 12

I want it fixed, not improved!

Mr. L has a long history of conductive hearing problems, and his left ear canal has been surgically closed. He wears an ITE aid on the right ear with reasonable success. He wants more gain but refuses a BTE, insisting on an ITE. Due to severe infections, Mr. L's hearing has deteriorated dramatically in both ears and he has a bilateral profound loss. He attends appointments with his wife who handles the majority of the interaction. The only goal he wants is "to hear like I used to." He is not interested in understanding more realistic goals. Since he has a 1 kHz BC threshold at 65, you suggest he try a bone conduction aid.

Over several follow-up appointments, Mr. L's wife reports that he rarely wears the b/c aid as it is "too much of a bother." Mr. L's ENT refers him for a cochlear implant evaluation for his 'closed' ear. The ENT feels it is unlikely that Mr. L can return to using an aid in his right ear due to copious discharge and chronic infection. The implant centre indicates that given his very poor motivation, Mr. L is not a good candidate. After 6 or 7 appointments over 12 months, you consider no longer working with Mr. L. It is clear he is not motivated to use any compensatory strategies or devices.

How would you deal with the situation?

Suggestions

  1. Gently refer him to a psychologist to help him deal with his loss and accept his disability
  2. Openly discuss your concern that you are not able to satisfy his needs and that perhaps you should no longer see him
  3. Encourage his wife to take less action in order to get Mr. L to do more for himself
  4. Or...
Dilemma 13

New technology, new hopes

Mrs. F, who has a moderate to severe mixed hearing loss, is anxious to upgrade from a high-gain hearing aid to a new frequency-compression hearing aid. She is accompanied by her husband, who is very well read on the newest hearing aid technology.

Mrs. F's initial response to the sound with the new hearing aids is positive, and both the patient and husband are pleased with the improvement. You discuss in great detail the difference in sound quality to be expected in moving from high-gain hearing aids to the new frequency-compression hearing aids, and also mention adaptation to new sound and the limitations of any hearing aid when a patient has severe hearing loss.

Within 48 hours, Mrs. F returns. At this visit it becomes clear that she is disappointed with the new technology, perhaps having anticipated more significant benefits based on her husband's expectations of what technological advances can accomplish. It is clear she expected a cure from the new technology and feels quite deflated.

How would you deal with the situation?

Suggestions

  1. Try to clarify the expectations of both the husband and wife. Are they in agreement, and are their expectations realistic?
  2. Explain that Mrs. F may need to adapt to the new sound. Proceed with small adjustments, allowing the patient time to acclimate between adjustments.
  3. Ask Mrs. F if the hearing aid helped in any situations. Suggest that she build up the time she uses the hearing aid, starting with situations that are successful and progressively adding situations that are acoustically similar.
  4. Or...
Dilemma 14

Big hair

Julia is 16 and has a flat moderate sensorineural bilateral hearing loss. She wears her hearing aids consistently but reluctantly at school and immediately removes them when she gets home. She has beautiful dark curly hair that is always styled to cover her hearing aids. Her parents support her covering her hearing aids and hiding all aspects of her hearing loss.

As she grows up, she resists using an FM system at school. Over time the school accommodates her hearing loss, allowing her to have lunch in the guidance office because the cafeteria is "too loud," for example. Julia works diligently and excels academically, but she is shy and withdrawn and has problems with social interaction. In the seven years you work with her, the family never appears to make any step forward with acceptance of the hearing loss, have any concern about etiology or show any interest in changing their behavior. You are frustrated with the family and with yourself.

How would you deal with the situation?

Suggestions

  1. Speak with Julia separately and see how she feels about eating apart from her classmates. Is this really how she wants to deal with the situation?
  2. Speak with the parents alone. Why do they want to hide their daughter's hearing loss? Introduce them to social welfare to talk about the situation and their daughter's future.
  3. Ask Julia to wear her hearing aids for one complete day and to count the number of people who comment on the fact that she is wearing hearing aids.
  4. Or...
Dilemma 15

Work-related hearing loss... or not?

Mr. J, a 45-year-old man with a history of noise exposure during more than 20 years of work in underground coal mines, visits your office. He reports difficulty in understanding conversation, especially when multiple talkers are present, such as at a restaurant or party. The hearing loss is affecting his emotional and psychological well-being, causing him to withdraw from social events. Prior to the audiological evaluation, the patient completes the Hearing Handicap Inventory with a score of 88%, consistent with a significant hearing disability.

Mr. J is referred as required by the state for evaluation of claims for work-related hearing loss. The patient undergoes a series of tests, including an audiogram and the Synthetic Sentence Index. The hearing loss is not as great as would be expected based on his report. The SSI suggests that Mr. J did not exaggerate his hearing loss. Further testing suggests a central auditory component to his hearing loss.

How would you deal with the situation?

Suggestions

  1. Arrange for Mr. J to be examined by an ENT for further diagnosis of his hearing difficulty.
  2. Conduct speech audiometry in silence and in noise to further identify his communication difficulty.
  3. Ask Mr. J what he expects his evaluation to accomplish. For example, does he want recognition of his problem? Is he seeking possible solutions?
  4. Or...
Dilemma 16

Who knows best?

A 34-year-old man with a congenital hearing loss returns repeatedly to the clinic over a period of years with a series of complaints, usually related to sound quality, about his hearing aids.

It appears that previous audiologists have always made any changes requested. At each return visit, he comes in and tells you exactly what is wrong and how you should fix it. He does not give himself any time to acclimate to the new sound quality.

How would you deal with the situation?

Suggestions

  1. What problems does he seem to be encountering with his hearing aids? What issues does he have around "sound quality"? Explore these questions in detail.
  2. You may need to go back to basics. What does he know and understand about his hearing loss? Explore this topic in depth. What does the patient expect of the hearing aids?
  3. Explore with him where, when and why communication breakdowns are occurring. Try to move the burden of the breakdown from him onto the situation. Once you have established this, you can suggest some form of intervention to address the issues.
  4. Or...
Dilemma 17

ITBs, or in-the-bag hearing aids

Ms. S is a 42-year-old woman with a mild sloping to moderately severe bilateral hearing loss that was diagnosed seven years ago. She is experiencing difficulty at her job, which is 100% phone-based. She feels that she needs better hearing aids. Given that she works full-time and her job relies significantly on her hearing, Ms. S is eligible for government funding toward the cost of her hearing aids. She requests something "discreet" and is fitted with in-the-ear hearing aids.

In a follow-up visit, she reports that she does not like the echolike sound that she hears when she talks to people while wearing her hearing aids. She also complains that when she wears the hearing aids with a headset at work, sound is too loud. She often has a headache by the end of the day. In further discussion, it becomes apparent that the patient is not wearing her hearing aids consistently and in fact keeps them in her handbag because she is embarrassed that people might see them.

How would you deal with the situation?

Suggestions

  1. Seek clarity regarding Ms. S's employment needs and expectations. Explain strategies for coping with situations that are especially challenging for her.
  2. Give her a six-week trial period during which she can decide if the new hearing aids work. Enlist her agreement that she will wear them consistently during that period.
  3. Recommend participation in an aural rehabilitation group to help her gain a positive perspective and benefit from the experiences of others.
  4. Or...
Dilemma 18

Service above and beyond

Mrs. H, a 70-year-old patient with a moderate flat sensory bilateral hearing loss, initially appears to be an easy patient, as she is eager to do what she can to relieve her hearing disability. She insists on CIC hearing aids despite being counseled about the difficulty of handling CICs with her arthritis and monocular blindness. Your practice offers three free follow-up consultations. Unfortunately, Mrs. H comes in more often on numerous, unscheduled visits for adjustments.

You want her to be satisfied and keep allowing her to come back. Soon she is coming back when there isn't a problem with her hearing aids, often making up problems about battery consumption or fine-tuning. You wonder whether this is a lonely woman who wants the personal attention and interaction you are giving her. You also feel you may be encouraging her and giving her unrealistic expectations regarding her hearing aids and your ability to make them perfect in every way.

How would you deal with the situation?

Suggestions

  1. Set clear limits. Explain that you have extended service well beyond the three free follow-up appointments and will need to charge her for subsequent appointments.
  2. Ask Mrs. H why she continues to request appointments. If she reveals unrealistic expectations, correct them.
  3. Ask Mrs. H how she is coping with her hearing aids, the batteries and the filters in light of her arthritis and monocular blindness. Attempt to help Mrs. H see what she realistically can and cannot expect from her hearing instruments. Explore whether she might require help and/or retraining in handling the hearing aids at home.
  4. Or...
Dilemma 19

Nothing to shout about

A 52-year-old woman accompanied by her husband comes to your clinic prepared to purchase hearing aids. Earlier she was diagnosed with sensorineural hearing loss, moderate in her left ear and severe in her right ear. This is her second visit to see you. She wants to wear only one ITC hearing aid. As is appropriate, the referring ENT has recommended hearing aids for both ears. She and her husband want to understand why she is not a candidate for ITCs and why she should use hearing aids in both ears.

They have many questions and doubts regarding the most minute details of hearing loss and hearing aids. They also have questions on care, maintenance and battery use. It is a busy day with numerous appointments, and the visit is taking longer than allotted. She is not ready to understand this and begins shouting at you.

How would you deal with the situation?

Suggestions

  1. Help her to consider the pros and cons of one or two hearing aids and the pros and cons of the different models.
  2. Explain that you do not want her to feel pressured, and suggest scheduling another appointment to continue the discussion. This will give her time to consider the options and the benefits of various instruments, and it will give you time to reflect on the reason for and source of the tension.
  3. Take a moment to speak with the next client to assess how long you have to conclude the appointment. This will indicate to the couple that another patient is waiting for a scheduled appointment and provide a nonconfrontational way to end the appointment.
  4. Or...
Dilemma 20

Getting the story straight

Ms. D is referred to you in desperate need of new hearing aids and an FM system to return to work. She tells you that her hearing aids were stolen during an MRI at a hospital. You find it particularly difficult to obtain consistent information from Ms. D. Her history is complicated, and there are a number of issues: sudden onset of hearing loss, poor speech discrimination and suspicion from referring audiologists that she is exaggerating the degree of her hearing loss. She is not a reliable informant about her previous hearing aids, the FM system she used and financial coverage for her new equipment. Ms. D has a long history of anxiety issues.

You fit her with new hearing aids and ear molds. The molds are remade multiple times, and the aids are replaced because she is convinced that they are defective. You later learn that she has had similar problems with her previous hearing aids. In addition, her hearing aid settings are not consistent with the degree of hearing loss indicated by the audiogram.

How would you deal with the situation?

Suggestions

  1. Ask Ms. D to describe her everyday issues with hearing loss and pick out any inconsistencies with her test results, highlighting reasons she should be tested again so that appropriate amplification can be offered.
  2. Attempt to understand why she is anxious by asking her why she thinks the hearing aids are defective.
  3. Counsel Mrs. D regarding her poor speech discrimination, sudden loss and the need to adjust to any new settings. Discuss specific social issues, such as her need for an FM system at work.
  4. Or...
Dilemma 21

Family member - friend or foe?

A 70-year-old gentleman has been wearing binaural hearing aids successfully for about 10 years. He is currently wearing a pair of large ITE hearing aids. He is accompanied by his wife, who is very vocal about the fact that her husband drives her crazy. She complains that he can't hear anything she says and embarrasses her with his big, bulky hearing aids.

You show them a small power BTE and traditional mold and briefly review technology. Although you will fit basic hearing aids because of his price concerns, they will be better acoustically than his current aids. The couple agrees to this, and impressions are taken.

At the fitting, he is obviously dismayed when he sees the BTEs. However, he confirms that he is hearing well and the fit is comfortable, and he appears to go away happy. The next day he returns with his wife, who says that the new devices look terrible and he refuses to wear them at home. She rants about what an awful husband she has. New impressions are taken to make smaller earmolds. Two days later the wife returns alone with the hearing aids and demands a full refund.

How would you deal with the situation?

Suggestions

  1. Speak with the wife when she returns the hearing aids and try to understand her issues with the fitting.
  2. Provide a full refund, offer a future appointment and send batteries for the ITE hearing aids the patient has previously been happy with to keep the lines of communication open.
  3. Suggest that since it is her husband who has the hearing loss, it might be best to discuss the return of the hearing instruments with him. Make an appointment for both to come back.
  4. Or...
Dilemma 22

Refusing to hear better

A 60-year-old man is urged by his wife to consult you. His opening comment is, "I don't know why I'm here. My hearing is pretty much perfect!" Having managed to get her husband to agree to the test, his wife is now quiet and noncommittal, looking to her husband for answers.

Testing indicates that he has a mild to moderate bilateral sensorineural hearing loss. He appears to be interested when you explain his hearing loss but remains skeptical. You then proceed to demonstrate the benefits of hearing aids by programming a system setup for his loss and placing them in his ears. He simply says that they make no difference to the volume or quality of sound around him. You check the hearing aids twice to be sure they are working, but he again simply states, "No, it all sounds the same."

How would you deal with the situation?

Suggestions

  1. Ask him to discuss his social interactions and reflect upon any areas in which he might notice improvements if he wore hearing aids. Pick an event he is attending soon and loan him hearing aids to try there.
  2. Give him an open invitation to come back anytime if he or others near him feel that he is missing out on conversation in different situations. Put him on the one-year recall list.
  3. Discuss other options instead of hearing aids, such as hearing tactics and additional assistive equipment that may be suitable for the difficulty in the situations he describes.
  4. Or...
Dilemma Game

About

The Dilemma Game is a practical tool designed to better prepare hearing healthcare professionals to deal with difficult and challenging clinical situations. The game consists of a series of dilemma cards that each describe a challenging scenario in a clinical setting. Three possible solutions are given - with the understanding that the 'perfect' solution might not exist. With no right or wrong answers, game play encourages reflection, critical thinking and analysis of the potential consequences that a practitioner's choices may have on a patient and a variety of stakeholders. Players use problem-solving skills to make sound decisions based on a thorough and thoughtful analysis of the situation and the individuals involved.

The Dilemma Game is developed for use with colleagues, within a larger training group, in student training or as an individual exercise. The dilemma cards are also applicable for role playing and other learning exercises. Developed in collaboration with ida institute seminar participants, the dilemmas are based on actual clinical situations. New dilemma cards will be created on a regular basis.

The cards are color-coded to align with the phases of a Possible Patient Journey - another tool developed by ida institute and available online at www.idainstitute.dk. Two additional Ida Institute tools - Motivation Tools and Reflective Journal - are also available online.