When the Task Force Says the Evidence Is Insufficient: Using the Iowa Model to Decide What a Primary Care Clinic Should Change About Hearing Loss in Older Adults
[Student Name]
University of Phoenix
NRP/513: Clinical Applications of Theory and Research
Week 6 Assignment
[Instructor Name]
[Date]
The clinic and team are composites written for a model paper.
In earlier weeks I framed untreated hearing loss in older adults as a nursing problem, applied Pender's model and self-efficacy theory to it and appraised evidence on hearing care and cognition. This week I use an evidence-based practice model to decide what my clinical site should actually change. I chose the revised Iowa Model because it is built for clinicians in practice settings and includes explicit decision points (Iowa Model Collaborative, 2017).
Step 1: The Triggering Issue
The Iowa Model begins with a triggering issue or opportunity, which may arise from clinical problems, data or new evidence (Iowa Model Collaborative, 2017). My trigger was a clinical observation, older patients who did not understand instructions, supported by informal data: in six weeks, fewer than a quarter of older patients who struggled to hear had hearing loss noted in their charts. Nationally, only about one in seven older adults with hearing loss uses hearing aids (Chien & Lin, 2012).
Step 2: The Purpose Statement
The model asks for a clear question or purpose. My initial purpose was: "Should our clinic screen all patients aged 65 and older for hearing loss at annual visits?"
Step 3: Is It a Priority?
Next comes the first of the model's forks: does the organization consider this worth its time? My preceptor and the clinic manager agreed that it is, for three reasons: many patients are older adults, misunderstood instructions contribute to medication errors and patient complaints and the clinic's quality committee is interested in communication. If they had not agreed, the model would direct me to consider other triggers.
Step 4: Forming a Team
A team includes my preceptor, a medical assistant who rooms patients, the clinic manager, a patient advisory member aged 74 who wears hearing aids and a local audiologist who agreed to advise. Including the medical assistant matters because any screening would happen during rooming.
Step 5: Assemble, Appraise and Synthesize the Evidence
The most important evidence for my original question is the U.S. Preventive Services Task Force recommendation. For adults 50 and older without symptoms, the Task Force found it could not weigh the benefits of screening against its harms because too little evidence exists, which it records as an I statement (U.S. Preventive Services Task Force et al., 2021). The Task Force noted that evidence is lacking on whether screening people who do not report hearing problems improves outcomes.
Other evidence is relevant. Hearing aids improve hearing-related function for people who seek help for hearing difficulty. The ACHIEVE trial, appraised in Week 5, did not show an overall cognitive benefit over three years.
Step 6: Is There Sufficient Evidence?
This is the model's key decision point. For universal screening of asymptomatic older adults, the answer is no. The evidence did not tell us to stop caring about hearing; it told us to change the question. The Iowa Model allows a team without sufficient evidence to conduct research or consider other types of evidence, but also to revise the purpose (Iowa Model Collaborative, 2017).
The Revised Purpose
The team revised the purpose: "In older adults who report or show difficulty hearing, does a structured case-finding and communication protocol increase recognition, referral and hearing aid uptake, and improve patients' understanding of visit instructions?" This question addresses patients with symptoms, for whom the benefit of evaluation and treatment is better established, and it adds communication practices that help all patients regardless of screening.
Step 7: Design and Pilot the Practice Change
The pilot has four parts. First, at rooming, the medical assistant asks every patient aged 65 and older one question: "Do you or your family think you have trouble hearing?" A yes, or observed difficulty, flags the chart. Second, for flagged patients, the nurse practitioner discusses hearing, performs a whispered voice test and offers referral to audiology or guidance on over-the-counter hearing aids for perceived mild to moderate loss. Third, all clinicians adopt communication practices: facing the patient, reducing background noise, using a pocket amplifier when needed and using teach-back. Fourth, a brief handout explains hearing options.
The pilot will run for three months with two clinicians, and measures include the percentage of older patients asked the question, the percentage flagged who receive a discussion and referral, the percentage referred who obtain hearing aids by three months and teach-back success rates.
Step 8: Decide Whether to Adopt
After the pilot, the team will decide whether to adopt the change, modify it or stop. Criteria include whether the question is asked consistently, whether it adds acceptable time to rooming and whether referral and uptake increase.
Step 9: Integrate, Sustain and Disseminate
If adopted, the question will be built into the electronic record's rooming template, the communication practices into staff orientation and the measures into the quality committee's quarterly report. Results will be shared at a regional nurse practitioner meeting.
What the Patient Advisor Changed
The patient advisory member reshaped two parts of the pilot. She pointed out that the handout's small print would defeat its purpose for many older readers and that the words hearing loss felt harsh to her; the team changed the question to ask about trouble hearing and enlarged the handout's type. She also suggested that patients be told why the question is asked, so it does not feel like a test. Her input reflects the Iowa Model's attention to stakeholders and makes the change more likely to be accepted.
Barriers to Expect
The team anticipates three barriers. Medical assistants already have a long rooming checklist, so the question must be quick and built into the template. Some clinicians may see hearing as outside the visit's purpose; sharing the Week 1 data on how rarely hearing is documented should help. And patients referred to audiology may face long waits; the team will track time to appointment and consider over-the-counter guidance for those with perceived mild to moderate loss.
Why the Iowa Model Fit
The model's explicit decision points prevented me from implementing a screening program the evidence did not support. Its emphasis on organizational priority and team formation fits a small clinic where change depends on the people doing the work.
Ethical Review
Because the pilot is a quality improvement project within usual care, not research intended to produce generalizable knowledge, the clinic's leadership approved it without institutional review board submission, and no identifiable data will leave the clinic.
Conclusion
The Iowa Model guided the move from a clinical observation to a practice change. At the decision point on sufficient evidence, the Task Force's I statement on screening redirected the purpose from universal screening to case-finding and better communication for older adults with hearing difficulty. The result is a pilot the evidence can support, with clear measures and a plan to adopt, adapt or stop.
References
Chien, W., & Lin, F. R. (2012). Prevalence of hearing aid use among older adults in the United States. Archives of Internal Medicine, 172(3), 292-293. https://doi.org/10.1001/archinternmed.2011.1408
Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223
U.S. Preventive Services Task Force, Krist, A. H., Davidson, K. W., Mangione, C. M., Cabana, M., Caughey, A. B., Davis, E. M., Donahue, K. E., Doubeni, C. A., Epling, J. W., Jr., Kubik, M., Li, L., Ogedegbe, G., Pbert, L., Silverstein, M., Stevermer, J., Tseng, C.-W., & Wong, J. B. (2021). Screening for hearing loss in older adults: US Preventive Services Task Force recommendation statement. JAMA, 325(12), 1196-1201. https://doi.org/10.1001/jama.2021.2566
How this NRP 513 Week 6 example is structured
The NRP/513 Week 6 work usually asks students to examine an evidence-based practice model and apply it to a practice change. This paper walks through the Iowa Model's steps in order, showing the decision made at each one, and gives particular attention to the point where the evidence does not support the change first imagined. Students search this week as NRP 513 Week 6, NRP513 Wk 6 or NRP/513 Wk 6; all three are the same assignment.
NRP/513 Week 6 questions, answered
What does NRP/513 Week 6 usually ask for?
Many sections ask students to describe an evidence-based practice model and apply its steps to a clinical practice change.
What is the Iowa Model?
An evidence-based practice model that guides clinicians from a triggering issue or opportunity through a clear question, priority, team formation, evidence review, piloting, adoption and sustaining a change, with decision points along the way.
What does a USPSTF I statement mean?
The Task Force concluded that the current evidence is insufficient to assess the balance of benefits and harms of a service, so it neither recommends for nor against it.
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