Overview

This study collected data via an anonymous, web-based survey of audiology and mental health leaders/clinicians across the VA. The survey was conducted in 2015 using the Research Electronic Data Capture (REDCap) web application behind the VA firewall. The conduct of this study was approved by the VA Portland Health Care System (VAPORHCS) Institutional Review Board (IRB).

Study population

The target population for this survey was audiology and mental health service chiefs (or similarly knowledgeable supervisors/clinicians) at all major VA medical center sites nationwide that provided both audiology and mental health services. We identified 144 sites with both clinic types in 2015. Our aim was to collect one audiology and one mental health survey from each site, in order to describe the implementation of PTM services on a site level across the country. While this sampling strategy would not include all clinicians potentially engaged in delivering PTM, we believed it would focus our sample on those individuals most involved in PTM delivery, whose responses would be most informative toward our goal of understanding and improving levels of PTM implementation in the VA. Contact information for survey recipients was assembled using a master list provided by the respective national service offices (Audiology and Speech Pathology, and Mental Health) in VA’s Central Office, supplemented with information from personal contacts, an internal VA global address book, and the internet. Because individual VA site organizational structure varies, emails to the identified service chiefs/supervisors requested that they or a clinician knowledgeable about tinnitus clinical services at their site complete the anonymous survey. The invitation acknowledged the study team’s collaboration with the national service offices and the VA Health Services Research and Development (HSR&D) Service Quality Enhancement Research Initiative (QUERI).

Informed consent

VA clinicians were asked to give consent to participate in research prior to completing the survey by indicating ‘yes’ to the first survey question, which included a description of the research. If the individual did not choose ‘yes’ to this question, the survey was terminated. Although the survey was anonymous, participants were asked to report their VA station/facility number and their Veterans Integrated Service Network (VISN) number, an administrative indicator of the geographic region in which each VA station/facility is located. These numbers were the only “identifying” information retained.

Survey development and data collection

Separate audiology and mental health surveys were designed by the study team and vetted with clinical and operations partners prior to fielding (S1 and S2 Appendices). Survey questions were developed to cover several domains of interest, including descriptive information about the clinician, clinic, facility, patient population, referrals, and tinnitus services available. Questions addressing an additional domain, namely training preferences, were added after being proposed by employee education partners within VA. The surveys were reviewed by the research team and colleagues within VA HSR&D for clarity, flow, and accessibility.

The audiology and mental health surveys contained nearly all of the same questions, though response options were structured according to discipline. The first section of the survey asked about participants’ facility characteristics and a second section focused on level of tinnitus management program implementation at their facility, including tinnitus patient characteristics and service use. The first section included five nominal, three ordinal, and one Likert-type question regarding characteristics and five interval, two nominal, and one Likert-type question regarding provider training. Additionally, the first section asked two open-ended questions regarding whether the respondent believes their clinic should provide tinnitus services and the respondent’s confidence in providing those services. The second section included four nominal, six ordinal, two interval, and one Likert-type question as well as one open-ended question asking the respondent to identify the main challenges to using tinnitus management services at their facility. The surveys were kept to a length that could be completed in 30 minutes or less.

The final audiology and mental health surveys were programmed into REDCap, with web links generated for each. These survey links were disseminated in invitation emails to the lists of 144 audiology service chiefs and 144 mental health service chiefs representing each VA facility with these services. The survey web page was open for approximately one month. After the initial invitation, weekly reminder emails were sent for four weeks.

Data analyses

Although our original intent was to link audiology and mental health survey responses from the same facility using the site code, this was not possible in most cases, as there was little overlap in site codes between audiology and mental health respondents. Thus, responses from the audiology and mental health surveys are presented separately.

Provision of tinnitus services (or PTM)

Respondents reported a wide variety of tinnitus services across their respective sites. The majority of audiology participants (83%) indicated that tinnitus services were available in their clinics, whereas few mental health participants (14%) reported the availability of tinnitus services in their clinic. Among the audiology participants, about 30% were classified as sites that offered full PTM, while 8% of mental health participants were categorized as offering full PTM. These and other results relating to the provision of care are presented in Table 2.

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Table 2. Provision of tinnitus care at respondents’ sites.

https://doi.org/10.1371/journal.pone.0242007.t002

In response to a question asking, “Do you feel that your clinic should provide tinnitus-management services to Veteran patients?” 100% of audiology respondents and 70% of mental health respondents replied, “Definitely yes” or “Probably yes.” Similarly, in response to a question asking, “How confident are you that your clinic can provide tinnitus-management services to Veteran patients?” fewer of the mental health respondents reported having confidence in their clinic’s ability to provide tinnitus services (40% very confident or somewhat confident) than audiology respondents (95% very confident or somewhat confident).

Clinician interest in training

Although audiology respondents reported higher levels of readiness to provide PTM than mental health respondents, large proportions of both types of respondents (90% of audiology and 66% of mental health) indicated they would be interested in receiving training in tinnitus management if supported by a supervisor (Table 3). Fifty-eight percent of audiology survey respondents indicated willingness to invest 5–20 hours in training over the course of a year. Mental health survey respondents were more varied, with 35% indicating willingness to invest up to 3 hours of time for training, and 29% indicating willingness to invest 5–20 hours over a year. When asked about training method preferences, only about half of the audiology respondents (48%) and a quarter of mental health respondents (24%) were interested in training off-site requiring travel. Nine mental health providers suggested additional training preferences beyond those listed in the survey; seven of those nine suggestions were one-on-one and/or group telephone calls. Five audiologists suggested training preferences beyond those listed in the survey; three of those suggestions were options that would be compatible with training and ongoing telephone support from a mentor.

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Table 3. Respondents’ preferences for receiving tinnitus management training.

https://doi.org/10.1371/journal.pone.0242007.t003

Cross-tabulations by PTM category

Cross-tabulations of PTM category with respondent and/or site characteristics, training preferences and other variables resulted in many zero count cells, particularly for the mental health survey data. As there were only 4 full PTM and 1 partial PTM mental health survey responses, Chi-square analyses could not be run on those data using the PTM category variable. Chi-square analyses of audiology survey responses were also affected by some low or zero count cells, requiring that some response categories be combined.

Among audiology survey responses, there was a statistically significant relationship between PTM category and the number of full-time providers in the clinic (Chi-Square = 10.32, df = 4, p = 0.035), with the no PTM category distributed more toward sites with fewer clinicians, full PTM distributed symmetrically with the majority reporting 6–10 clinicians, and the partial PTM category showing more of a uniform distribution (Table 4). However, there was no significant relationship between PTM category and daily patient volume (Chi-Square = 0.63, df = 2, p = 0.73), nor with hospital facility (Chi-Square = 2.30, df = 2, p = 0.32). Other comparisons of interest could not be assessed due to cells with zero or low counts.

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Table 4. PTM category by number of full time equivalent (FTE) providers.

https://doi.org/10.1371/journal.pone.0242007.t004

Factors influencing implementation of tinnitus management services

Qualitative analysis of the open-ended survey responses identified seven thematic factors influencing providers’ abilities or desires to implement tinnitus management services. These were: 1) available resources, 2) service collaboration, 3) prioritization, 4) Veterans’ preferences and needs, 5) clinician training, 6) awareness of (evidence-based) options, and 7) perceptions of scope of practice. Table 5 describes these factors, with illustrative quotes and attention to differences between professional groups. Audiologists and mental health providers were closely aligned in their perceptions of needed resources and the benefits of service collaboration. Both audiologists and mental health providers mentioned difficulty finding space to hold group sessions, and staff shortages that prevented implementation of a new program. Lack of resources also factored into other themes in responses, such as prioritization (tinnitus is a lower priority given lack of time to address current top priorities). As groups, audiologists and mental health providers identified different Veteran needs and preferences influencing tinnitus management, different clinician training deficits, and different barriers to prioritizing tinnitus management. There were differences between provider groups in the salience of some thematic factors: notably, mental health providers exhibited wide within-group variation in their perceptions of whether tinnitus management fell within their scope, while audiologists expressed that tinnitus was within their scope of practice. Audiologists described variation among their colleagues’ awareness of evidence-based options as a factor that could hinder implementation, while mental health respondents were less aware of techniques to address tinnitus altogether.

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Table 5. Factors influencing implementation of Progressive Tinnitus Management (PTM).

https://doi.org/10.1371/journal.pone.0242007.t005

Available resources

As is common in implementation of new programs [19, 20], staffing shortages, lack of space, and limited availability of materials such as patient workbooks were identified as barriers for PTM implementation. Tuepker et al [16] found that administrative time and/or administrative support facilitated PTM implementation, and that lack of this resource was a barrier to implementation. Alternatives to PTM group sessions, including individual care and telehealth delivery, have good evidence of efficacy [11]. Encouraging use of these alternatives to group sessions may help overcome the issue of finding space for groups while providing more options to align with patient preferences. Additionally, telehealth delivery of PTM allows for flexibility during unexpected situations, such as the recent global pandemic, which may be of increasing importance in both the immediate and long-term future [21].

Service collaboration

Although the traditional home of tinnitus care is audiology, both audiology and mental health expertise are critical to the successful implementation of PTM. A much larger proportion of audiology respondents than mental health respondents reported provision of PTM at their sites. It is likely that PTM is provided at some sites with little or no involvement from mental health. As PTM is typically initiated in audiology, it is often left up to audiologists to make efforts to connect with mental health. However, there is no established pathway or clear guidance for audiology partnering with mental health. As mental health clinicians may not understand their role with respect to provision of tinnitus care and are already stretched thin, these efforts at establishing collaboration may not be successful. Further research is needed to understand how audiology and mental health collaborate to provide PTM at sites that have successfully implemented the program. Stories describing successful collaboration between audiology and mental health can help inspire those starting PTM.

One survey respondent suggested that PTM could be done in primary care within Primary Care-Mental Health Integration (PCMHI) services, which are common throughout the VA. PCMHI programs assist patients with a wide range of behavioral health assessments, brief interventions, and referrals to higher levels of mental health care as needed. Because PCMHI providers are familiar with the role of a mental health provider in helping patients to cope with physical problems such as pain, PCMHI may well be a way to help Veterans in coping with tinnitus. The authors are aware of some VA sites experimenting with adapting PTM for use within PCMHI; however, further research is needed to develop and test a well-informed PCMHI version of PTM. In the meantime, PCMHI providers could be educated about PTM so that they can help to connect patients to these services where available.

Due to the recent COVID-19 global pandemic, use of telehealth services has become more predominant. It is possible that increased use of telemental health services may serve to reduce perceived barriers to contributing to a Tele-PTM program. A mental health provider who is already providing telehealth services will not have the barrier of lack of space or inability to coordinate the use of space with audiology—they can remain in the same space and use the same telehealth technology used with other patients. Also, when seeking out a mental health provider to collaborate with in providing Tele-PTM, there are fewer restrictions in terms of location of provider, as telehealth may be provided from other locations.

Prioritization

Mental health providers treat patients with many serious conditions, and tinnitus likely is not a top priority for many. Prioritization can be linked to availability of resources for particular programs, and also can be linked to buy-in from supervisors or senior management on where clinicians should focus their attention. Tuepker et al [16] provided examples of ways supervisors can signal their buy-in to PTM implementation, including mandatory training and dedicated provider time. Improvement in the availability of resources (for example) may also benefit prioritization.

A large proportion of tinnitus patients have comorbid mental health diagnoses [7]. One pathway to improve prioritization of care for tinnitus within mental health could involve education about the impact of care for tinnitus on comorbid mental health conditions. There is some evidence that symptoms of anxiety and depression improve when people are provided with care for tinnitus, even when that care is not focused on anxiety or depression [22]. For example, in the prior RCTs of PTM, statistically significant improvements in anxiety and depression symptoms were documented in addition to tinnitus-related quality of life [11].

Veteran preferences and needs

Audiologist survey responses noted that Veterans may object to traveling to the VA for multiple PTM group sessions due to the logistical challenges involved (e.g., distance of travel required, number of appointments, parking, time off work, etc.). In addition to these stated challenges, other events (e.g., the COVID-19 global pandemic) can create barriers to providing in-person care, and to care in groups. Availability of telehealth options can help sites overcome some of these issues, as travel is not required to receive care remotely, and individual appointments can be made with more flexibility around the Veteran’s schedule compared to group sessions on a pre-set schedule. Henry et al [11] found that one-on-one telephone administration of PTM resulted in better attendance rates and better outcomes when compared to a study of in-person group PTM [3]. Mental health survey responses suggested that Veterans may not be aware that their mental health provider could help with their tinnitus, and may not bring up tinnitus during mental health appointments for that reason. These providers clearly value the perspective of Veterans, though it is unknown whether their speculation correctly represents Veterans. Input collected directly from Veterans is required to ensure VA programs meet their needs.

Clinician training

The majority of audiology survey respondents and well over half of mental health survey respondents indicated an interest in receiving training in tinnitus management. Given the stated preferences for duration of training, audiologists may be more receptive to longer training opportunities (i.e., 5–20 hours). Nearly a third of mental health respondents were willing to invest in equally long training opportunities; however, more than one third of mental health respondents preferred training of 3 hours or fewer. It may be helpful to offer both shorter and longer versions of training opportunities to meet the needs and preferences of both audiology and mental health providers.

Based on survey results, it appears there may be reluctance from audiologists and mental health providers to engage in training that requires travel. Although audio- or video-recording sessions would allow for training and ongoing mentorship with no travel for provider or trainer, these options were not popular with either set of providers. Assessing willingness to travel when developing educational opportunities for clinicians may be important. Write-in suggestions from both disciplines favored more mentoring support (e.g., going over difficult cases by phone) than direct oversight and feedback. Training and ongoing mentorship by telephone may be palatable for both trainers and trainees. Such ‘hub-and-spoke’ or ‘train-the-trainer’ models of dissemination have been used to implement other evidence-based practices across the VA nationally [23–28]. Similarly, a centralized tinnitus education and resource hub, into which clinicians could call for support as needed, could be an effective delivery model to meet the education and mentorship needs of audiologists and mental health providers who work with patients with tinnitus.

Knowledge of evidence-based options

Most VA mental health providers are trained in CBT as there is a strong focus on providing this evidence-based practice for relevant mental health disorders. Although mental health providers regularly use CBT for various conditions, they are not necessarily aware that there is good evidence for the use of CBT for tinnitus. There is also support in the literature, though not as robust, for other mental health strategies with tinnitus such as Acceptance and Commitment Therapy (ACT) [29]. These methods are not unknown to mental health providers; rather, the barrier is connecting these particular methods to tinnitus management specifically. Outreach is needed to help raise awareness and make the connection between existing evidence-based practices and their application to tinnitus care. Mental health providers already offering care with patients coping with other chronic health problems (pain, cancer, etc.) would be obvious initial targets for such training.

Our survey indicated that audiologists perceive a fair amount of inconsistency in their field regarding awareness and use of evidence-based methods for tinnitus. Audiologists predominantly reported that they can and should provide care for tinnitus. However, to date, there is no evidence-based therapy for tinnitus that involves audiology alone. In interviews with VA audiologists and mental health providers conducted by Tuepker et al [16], providers identified as clinical champions of PTM tended to be audiologists. Thus, although audiologists are willing to champion PTM, they cannot provide this evidence-based care for tinnitus without mental health providers to deliver the CBT portion of the care. As discussed further below, future research that examines audiologists’ use of key elements of CBT to help patients with tinnitus could change this dynamic. Until this possibility is explored further, it may be most helpful to support audiologists in championing evidence-based practices, while simultaneously supporting them in efforts to collaborate with mental health providers.

Perception of scope

Most audiologists view tinnitus as within their scope of practice, though they recognize that comorbidities such as anxiety and depression lie outside their scope. However, mental health providers tend not to see tinnitus as part of their scope of practice, which aligns with the reported lack of knowledge of evidence-based options for tinnitus among mental health providers. Drawing parallels between tinnitus and chronic pain [30, 31], which is recognized as within the scope of mental health, can aid the argument that tinnitus is worthy of attention from mental health as well. As discussed above, CBT is an effective approach for improving quality of life for people with chronic conditions, and there is evidence supporting use of CBT in treating both tinnitus and chronic pain [30, 31]. Increased collaboration with audiology, and prioritization of tinnitus within mental health, would also underscore the perception that tinnitus falls within the scope of mental health.

Audiologists and CBT

When mental health providers are not engaged in providing care for tinnitus within a PTM program, audiologists will sometimes consider conducting the CBT portion of PTM themselves. However, providing CBT is not typically considered to be within an audiologist’s scope of practice. Mental health providers receive extensive training and supervision to become proficient in CBT, and most audiologists do not have opportunities for equally stringent training and supervision. More importantly, mental health providers have a breadth and depth of knowledge that is relevant to people struggling with any chronic condition that audiologists do not have. It is in the best interest of patients struggling with tinnitus to have access to a mental health provider as part of the team of clinicians providing care for tinnitus.

When it is not possible to include a mental health provider in providing tinnitus care, audiologists may leverage some key elements of CBT without going outside their scope of practice. Relaxation techniques and planning pleasant activities are mind-body practices that overlap with CBT. The VA system is advancing a Whole Health program [32, 33] that endorses VA health care providers of any discipline teaching mind-body practices to their patients. In accordance with these guidelines, it would be acceptable for audiologists to teach deep breathing, imagery, and other mind-body approaches to coping. It is possible that these mind-body approaches, along with the sound therapy elements of PTM coping skills education, could be delivered to patients with tinnitus entirely by audiologists. Future research to evaluate the efficacy and effectiveness of this option is warranted. Audiologists teaching mind-body approaches to coping with tinnitus does not eliminate the need for behavioral health involvement; it may, however, improve the quality of care provided by audiologists when they are unable to partner with behavioral health.

Comparison to other research

Several other studies have examined factors affecting implementation of tinnitus strategies. Cima [34] also identified the availability of resources as a factor, which impacted the involvement of psychologists in tinnitus care and the presence of multidisciplinary care teams. They also identified lack of clinician knowledge and lack of consensus on treatment options as barriers, which relate to our themes of clinician training and knowledge of evidence-based options. Martin et al [35] noted the impact of using evidence-based intervention and providing high-level training on the long-term sustainability of a program. Beck et al [36] identified close collaboration between an audiologist and a psychologist as an important factor in providing tinnitus care (specifically PTM). They attributed the success of the program, in part, to the transdisciplinary approach of the clinicians involved, whereby the boundaries between disciplines are blurred. This finding illustrates the importance of our theme of service collaboration, and its importance to a PTM program. Additionally, Beck et al identified the lack of administrative time and support as a challenge to their program, which fits under our theme of availability of resources. Finally, Beck et al paid close attention to Veteran needs by adapting the program to better fit Veteran preferences and noting that participation may have been limited at one site due to Veterans’ reluctance to travel long distances for multiple group sessions. Further, they noted that telehealth options would increase the potential reach of their program. These views align well with our study findings. Another study of clinical implementation of PTM by Edmonds et al [37] highlighted the importance of interdisciplinary care, but also described the challenge of achieving this model of care (one site did not have mental health involvement in the PTM program). Edmonds et al also reported successful provision of PTM via video conferencing.

Limitations

This survey was conducted in 2015, and results reported here represent an estimation of the clinical provision of tinnitus services and PTM at that time. It is likely that changes have occurred in these areas since the administration of the survey. However, as no large-scale PTM implementation efforts have occurred since this survey, it is likely these data are still largely representative of VA clinical practices for tinnitus.

As with any voluntary survey, response bias may influence the results presented here. The participation rate was approximately 60% for audiology and 46% for mental health and, although this is similar to response rates of other studies involving VA clinicians [38–40], these respondents may not be representative of all eligible providers. Those electing to respond to a survey about tinnitus may be more likely to have strong feelings (either positive or negative) about tinnitus, providing care for tinnitus, or tinnitus patients. In particular, responses among audiologists may not be contrastable to those among mental health providers, as there could be systematic differences between those who participated from each discipline and the sites at which they work. Our purposive sampling strategy attempted to gather data from those who were most “hands on” in their sites’ tinnitus programs, but in taking this approach we did not gather data from administrators or others whose decisions about service management may also critically influence the implementation of PTM.

Additionally, responses between the disciplines could not be linked between sites due to little overlap. Dyadic surveys or interviews, where clinicians who work together across disciplinary lines provide joint responses, could have yielded a more comprehensive, integrated picture of each site’s program; however, these approaches were not feasible due to the additional clinician burden they would impose. Future work that can assess the consistency of responses between audiologists and mental health providers from the same sites would help inform efforts to increase collaboration between these two disciplines.

Future directions

The results of this study, though informative, are now five years old. Our next effort includes conducting a follow-up survey to measure potential changes in PTM implementation in the intervening years. This follow-up survey is a joint effort between the VA and the Department of Defense (DoD), and will collect responses from audiologists, mental health providers, ear, nose, and throat physicians, and primary care physicians from both VA and DoD. The content of the follow-up survey is influenced by the results of the first survey reported in this manuscript. New training materials continue to be developed, and a series of online courses has recently been launched for both VA and DoD providers. Partnerships with VA health initiatives such as PCMHI, the Whole Health movement, and Clinical Resource Hubs will continue to be explored. Finally, as the landscape of care continues to change with the expansion of telehealth options, in particular the advent of telehealth services into the home, the focus will be on Tele-PTM to allow provision of PTM with minimal use of clinical space, and little to no travel for Veterans. Implementing Tele-PTM will require attention to access for disadvantaged groups (poor, computer challenged, rural, deaf, visually impaired, etc.) due to the need for devices and access to a reliable internet signal in a private location. The VA, for example, provides a tablet device and a paid data plan as needed to ensure appropriate access. Investing in Tele-PTM also provides for a relatively seamless transition to remote care when situations such as global pandemics preclude the provision of in-person PTM.