growth in the elderly populations worldwide. An important consequence of this development is a drastic decrease in the number of workers per retiree in the society, putting high strains on national pension funds, government support, and health care systems. One of the measures taken by governments to manage this problem is increasing the retirement age for pensioners. This will unavoidably lead to larger number of adults who continue to work at a later age, which, in turn, will lead to a higher prevalence of hearing impairment in the workforce in the near future. Another change is related to a revolutionary shift in the labor tasks, which was observed during the last half of the 20th century. According to Ruben (2000), at the beginning of the 20th century, at least 80% of the American workforce was employed in tasks that depended on manual skills, whereas this proportion drastically decreased at the end of that century. By that time, the proportion of workers holding white collar jobs composed 62% of the U.S. workforce. Ruben argued that in the communication-age societies of today, occupations rely more and more on communication skills such as hearing, voice, and language. Other, more recent changes in the labor market include trends toward greater mobility and to more casual, freelance, and contract work (Punch, 2016). The increasing dependence on cloud-based technology has influenced the shift toward remote work and a more independent and self-motivated workforce. Whereas remote work may offer great opportunities for people with hearing loss, it also brings challenges. The skills and flexibility to manage and advance one’s own career, seek new work, and motivate and promote oneself are more important than ever before, and these issues may imply a greater burden on groups of people suffering from communication disorders (Punch, 2016). Several studies demonstrated that people with hearing impairment in the labor force comprise a vulnerable group for whom the conditions at work are more challenging than for normally hearing colleagues (for reviews, see Danermark, 2005, and Punch, 2016). Issues such as unemployment, underemployment, sick leave due to stress, low income, and early retirement seem to be more pervasive among workers with hearing difficulties than workers without this disability (Stam et al., 2013). The following paragraphs will discuss these work-related issues of hearing impairment.
Unemployment
Studies have found that hearing impairment is correlated to a greater likelihood of unemployment. Specifically, a study in Denmark revealed that about 30% of young adults (20–35 years of age) with hearing impairment were unemployed, whereas the level of unemployment was much lower (12%) in the age-matched reference group without hearing impairment (Parving & Christensen, 1993). Rydberg, Gellerstedt, and Danermark (2010) explored the position of deaf and hard-of-hearing people in the Swedish labor market and found a 63% employment rate for those who had attended a special school for the deaf (including hard-of-hearing adults), a rate significantly smaller than the employment rate for the normal hearing reference population (78%). Similar patterns were reported by Schroedel and Geyer (2000), with the deaf and hard-of-hearing alumni experiencing more unemployment (15%) than their similarly educated peers without hearing problems (10%) 15 years after college. Data from the U.S. Bureau of Labor Statistics (BLS) revealed an unemployment rate of 41.9% among adults with communication disorders as opposed to 29.5% for the working-age population without this disability (Ruben, 2000). Also Hogan, O’Loughlin, Davis, and Kendig (2009) in Australia found that people with all levels of measured hearing loss (mild, moderate, or severe) were less likely to be employed when compared to the general population. It must be noted, however, that the proportion of people without work in the Australian study was much larger for those reporting a main disability other than hearing loss (back problems, arthritis and related problems, and psychiatric disorders). When hearing loss itself was associated with employment difficulties, the effects appeared to be more prominent when people were also rendered more vulnerable in the labor market by other factors such as communication difficulties, older age, gender (being female), or low educational attainment (Hogan et al., 2009). In a longitudinal study among 1,888 adults, Stam et al. (2013) observed that participants with poorer hearing were less likely to have paid work and more likely to look for work or to be unfit for work.
Underemployment or Employment Restrictions
Whereas unemployment is shown to be prevalent among workers with hearing impairment, it is likely that issues such as underemployment or employment restrictions are even more common. Population survey data on the prevalence of underemployment are limited in availability. Clogg (1979) defined an underemployed person as “one whose abilities or educational credentials are higher than those usually required for the job in which he or she presently works” (pp. 222–223). Many of the professionals in the study performed by Tye-Murray, Spry, and Mauze (2009) indeed recognized this condition. The professionals with hearing impairment expressed a sense of having lost their competitive edge. They believed they had lost out on promotions or lost job opportunities due to their hearing loss. Maintaining job competency and/or a competitive edge emerged as a central component in their focus group data.
Restrictions in the type of work one can undertake and difficulty with changing jobs or getting the preferred job are also reported in the literature. Among the group of workers with reported hearing loss and communication difficulties, 33.8% reported being able to work only a restricted number of hours per week (Hogan et al., 2009). Studies of people who are deaf-blind also support the notion that having a physical disability is negatively associated with competitive employment (Ehn et al., 2016). Nachtegaal, Festen, and Kramer (2012) reported a significant association between hearing ability and experienced limitations in the kind or amount of work one can do. With every dB worsening of hearing ability, the odds of experiencing limitations at work increased significantly.
Sick Leave
A study by Kramer, Kapteyn, and Houtgast (2006a) revealed that normal hearing workers and employees with hearing impairment differed significantly in the amount of sick leave they take. In the group with hearing impairment, the proportion of employees reporting sick leave during a period of 12 months was significantly higher (77%) than in the normal hearing group (55%). This appeared to be exclusively due to a higher proportion of people reporting sick leave due to stress-related complaints (fatigue, strain, and burnout) in the group with hearing impairment (26%) than in the normally hearing group (7%). When examining the proportion of sick leave due to usual reasons (flu, a cold, or a hospital appointment) the proportions in both groups were equal, indicating that people with hearing impairment are not different from their normally hearing colleagues in that respect.
Low Income
In Australia, more than one-quarter (26%) of people with self-reported communication difficulties due to hearing loss reported being in the bottom three income groups (up to AUD$224 per week) compared with 16% of people without hearing loss (Hogan et al., 2009). Schroedel and Geyer (2000) noted that in all educational levels, the deaf and hard-of-hearing alumni in their survey earned less than the college graduates without hearing loss. According to Kochkin (2007), individuals with severe hearing loss earn USD$12,000 less per year than individuals with mild hearing loss. Stam et al. (2013) found that participants between 18 and 64 years old with poorer hearing ability were less likely to be found in the upper categories of educational level and income than people with better hearing.
Early Retirement
Finally, hearing impairment seems to be related to a greater likelihood of early retirement. In Sweden, the burden on groups of people with communication disorders led to a disproportionate percentage of employees taking early retirement. Danermark and Gellerstedt (2004) reported that, whereas only 5.4% of the general population reported having a hearing impairment, approximately 12% of those taking early retirement were hard of hearing. This indicates an overrepresentation of hearing impairment in that group. The option of early retirement from work as a way to overcome weariness and a marker for becoming resigned to the limitations imposed by hearing loss in the workplace was also seen as a real possibility by the participants in the studies by Fok et al. (2009) and Tye-Murray et al. (2009). In Stam et al.’s study (2013), however, a positive association between hearing impairment and taking early retirement was not found.
Costs
Aside from prevalence figures of hearing impairment in the workforce and the accompanying factors characterizing the vulnerable position of individuals with hearing loss in the workplace, there is the issue of societal and organizational costs of hearing impairment. The adverse work-related consequences of hearing impairment described in the previous paragraphs may be related to high costs for companies and for the society. A few studies provided data related to this issue. For example, Ruben (2000) estimated the combined costs of communication disorders (i.e., costs for special education for children with communication problems from birth to age 18, unemployment, and underemployment) as 2.5% to 3% of the Gross National Product in the United States, which means a significant loss to the U.S. economy. Mohr et al. (2000) demonstrated that the largest proportion of the societal costs related to hearing impairment is due to reduced work productivity.
The facts and numbers described above clearly illustrate the burden of hearing loss in the workforce. These data, together with the changes being observed in workforces, indicate that the number of clients in clinics requiring help for work-related difficulties may increase in the near future. The challenge for professionals in audiology is to foster better understanding of the specific barriers for workers with hearing loss and to provide rehabilitation services that address their specific needs. The next sections describe how hearing impairment may affect participation in work and present examples of rehabilitation programs to support workers with hearing loss, thereby improving their working situations.
The Workplace as a Challenging Context
The relationship between hearing and work is mostly associated with the risks of exposure to occupational noise and the effects on workers’ health. Loud noise can cause temporary or permanent hearing impairment. The underlying mechanisms of noise-induced hearing loss have been studied extensively, both in animal models and in human populations (Job et al., 2009; Ohlemiller, 2008). Ample knowledge and information exists on how to diagnose and monitor noise-induced hearing loss (e.g., Lutman, Coles, & Buffin, 2016), reduce excessive noise at work, institute hearing conversation programs, and provide hearing protection devices (Nelson et al., 2005). There is no doubt that attention to these issues is relevant because hazardous occupational noise levels remain a problem in all regions of the world (Concha-Barrientos, Campbell-Lendrum, & Steenland, 2004; Flamme et al., 2012; Tikka et al., 2017). However, the number of people with noise-induced hearing loss is relatively small compared to the number of employees with other types of hearing impairment.
Consequences of Hearing Impairment at the Workplace
Existing or acquired hearing impairment (even mild degrees), regardless of its origin, may adversely affect occupational performance and well-being. People with hearing impairment are more sensitive to background noise than people with normal hearing, predominantly due to a distorted peripheral processing of signals (Houtgast & Festen 2008; Plomp & Mimpen, 1979). This may lead to unfavorable outcomes in speech-in-noise testing with stationary maskers but also with more realistic fluctuating maskers (Soli et al., 2018). With any background noise, people with hearing impairment may experience greater difficulties understanding their colleagues than those with normal hearing do. It should be noted that this may occur in a lot of realistic workplace scenarios and not only in work environments where the ambient noise level exceeds the critical level of 80 dB(A) (Sorgdrager et al., 2006). More generally, the peripheral hearing impairment may lead to reduced monaural and binaural processing of sounds, which in turn may pose more strain on the top-down processing (Goverts & Houtgast, 2010). To date, the effect of hearing aids is evident in restoring audibility but is known to be limited in restoring processing of sounds in noise. Thus, individuals with hearing loss need enhanced signal-to-noise ratios at work. Unfavorable signal-to-noise rations may compromise their work performance or performance may be achieved at the cost of more mental effort (Pichora-Fuller et al., 2016). This is further discussed in the paragraph below entitled “Mental Distress, Fatigue, and Need for Recovery After Work.” In addition to these audiologic factors causing increased sensitivity to background noise and reverberation, there is a range of other factors that may cause difficulties for people with hearing loss in the workplace.
What Specific Difficulties Do Individuals With Hearing Loss Encounter in the Workplace?
The precise implications of hearing loss in the workplace are not fully understood yet (Jennings & Shaw, 2008), and remains a relatively unexplored area of research. With a growing number of studies in recent years, however, some evidence is beginning to emerge. Both qualitative and quantitative studies have been performed and evidence accumulated through repeated observations of phenomena. The most pertinent problems of workers with hearing loss relate to job control, mental distress, fatigue, need for recovery after work, and lack of knowledge. Results of studies on each of these issues are summarized in the following paragraphs.
Job Control
Kramer et al. (2006a) compared the occupational performance of a group of 151 employees with hearing impairment with that of a group of 60 workers with normal hearing. The groups were matched for age, gender, educational level, and type of job. A questionnaire was used to assess the participants’ self-reported environmental conditions at work: type of job, type of contract (permanent versus temporary; full-time versus part-time), general working conditions (job demand, control, support), and activities required for the performance of the job (including communication activities). An analysis of group differences revealed that the reported effort in hearing needed during listening was significantly higher in the group with hearing impairment. No differences between the two groups were found for the general working conditions (demand, support, career satisfaction), except for job control (the possibility to interrupt work or take breaks when wanted). Participants with hearing loss perceived themselves to have significantly less control at work compared to their normally hearing colleagues. It is worth noting that these findings very much support the results of comparable investigations, such as a study by Danermark and Gellerstedt (2004) in a group of 445 employees who completed a questionnaire on the psychosocial environment at work. The scores were compared with reference data obtained from more than 8,000 people employed by local municipalities. The results showed that the psychosocial environment at work was much more demanding for the hard-of-hearing group than for the normally hearing reference group. The most important difference appeared to be the lower self-assessed degree of control at work for those with hearing impairment.
Perceived sense of control also appeared an important factor in the disclosure of hearing loss in the workplace (Southall, Jennings, & Gagné, 2011). This sense of control was mostly influenced by the predictability of work-related tasks and the balance of power between the worker with hearing impairment and his/her coworker. People with hearing impairment apparently feel a greater need to have control over their work (i.e., organizing their own schedules so as to be able to take breaks or interrupting work after having had auditory demanding activities) (Backenroth, Ohasko, Wennberg, & Klinteberg, 2003). Providing control over their work for employees with hearing impairment enhances their well-being.
Mental Distress, Fatigue, and Need for Recovery After Work
Higher sick leave rates among workers with hearing impairment in the study by Kramer et al. (2006a) appeared to be exclusively due to a higher prevalence of stress-related complaints (fatigue, strain, and burnout) in the group with hearing impairment (26%) compared to that in the normally hearing group (7%). Along the same line, Nachtegaal et al. (2009) observed higher levels of need for recovery after work among those with poor hearing ability compared to individuals with good hearing ability. Need for recovery is an indicator of mental distress. It refers to the degree to which employees are able to recover from fatigue and distress after a day of work. It is an important factor influencing an individual’s physical and mental health status. In occupational health care, need for recovery after work is seen as an acute short-term reaction to work. Exposure to stressful psychosocial working conditions, combined with repeated inadequate recovery after work, may lead to psychosomatic health problems (Sluiter, de Croon, Meijman, & Frings-Dresen, 2003). The extended Job Demand Control (JDC) model by Karasek and Theorell (1990) offers a helpful framework for understanding the mechanisms behind the development of stress, fatigue, and strain in the workplace. According to the JDC model, high psychological job demands combined with a lack of control are associated with psychological strain and health problems (Karasek et al., 1998). Nachtegaal et al. (2009) found that for every dB signal-to-noise ratio (dB SNR) point scored more poorly on a hearing test, the need for recovery increased by 1.4 percentage points in a group of 925 workers, of whom 430 had limited hearing ability. In their later study, Nachtegaal et al. (2012) found the need for recovery to be a mediator in the relationship between hearing ability and sick leave. Examples of items describing the need for recovery after work are “At the end of the day I am really feeling worn out” and “I find it hard to relax at the end of a working day.”
The findings of Nachtegaal et al. (2009, 2012) confirm what has been documented in a range of other studies. For example, the workers in the study by Backenroth et al. (2003) reported that they were striving to do a good job and felt that they did so to an even higher extent than did the normally hearing colleagues, but that this was at the cost of great fatigue at the end of the working day. Similarly, a few participants in the study by Tye-Murry et al. (2009) explicitly indicated they had to work twice as hard to compensate for having hearing loss and to “go above and beyond.” They described how tiring such a “double duty” can be. The participants in Grimby and Ringdahl’s (2000) study expressed their concern about stress and strain resulting from conversations in the coffee room or their offices that contributed to exhaustion both at and after work.
Hasson et al. (2011) used physiological measures to investigate the relation between stress and hearing loss. They found that symphony orchestra musicians with hearing problems exhibited lower heart rate variability than those without hearing problems. A lower heart rate variability indicates an impaired ability to unwind from stress due to the inability to activate the parasympathetic nervous system.
It is encouraging to see that the mounting number of studies all point in the same direction. Apparently, mental distress and fatigue among workers with hearing loss cannot be neglected in clinical practice and vocational rehabilitation services. All studies unanimously emphasized the relevance of addressing these matters. Stakeholders (e.g., occupational physicians, otolaryngologists, general practitioners, audiologists, employers, and the employees themselves) should also be aware of the fact that hearing loss may be the underlying cause of fatigue.
In most cases hearing loss develops gradually over time; therefore, monitoring an individual’s need for recovery after work in clinical practice or in the workplace may be considered a useful measure. Thus, if employees present themselves to their general practitioner (GP) or occupational physician with complaints of fatigue and mental distress, hearing loss should be considered as a possible cause. Early detection of enhanced levels of need for recovery will identify patients at risk and enable stakeholders to take timely actions. Such measures can contribute to the prevention of long-term sick leave.
Lack of Knowledge or Understanding
Whereas mental distress and auditory fatigue are critical correlates of hearing loss in the workplace, employees with auditory difficulties expressed additional factors that limit their participation in work. One is the lack of knowledge among colleagues, supervisors, employers, and others about the manifestations and impact of hearing loss in the workplace or appropriate workplace accommodations (Detaille, Haafkens, & van Dijk, 2003; Hétu & Getty, 1991; Hétu, Getty, & Waridel, 1994; Punch, 2016; Schoffstall, Cawthon, Tarantolo-Leppo, & Wendel, 2015). This phenomenon is aptly expressed in an article by Southall et al. (2011). One of the interviewees in that study reported a profound social exclusion in the workplace due to the fact that the general population does not understand the concept of partial hearing loss. While both normal hearing and clinical severe to profound deafness are apparent, partial hearing loss is not. Additionally, interviewees reported that coworkers simply do not know intuitively how to communicate with people who have a hearing loss. They easily forget about the hearing loss, partly because it is invisible.
Lack of knowledge or awareness of suitable workplace accommodations also exist among workers with hearing loss themselves. This was one of the outcomes of an integrative review of the literature on experiences of barriers, accommodations, and stress in the workplace (Punch, 2016), as also found by Tye-Murray et al. (2009). In some of the focus groups in the latter study, asking the question “What services are available to you through work?” led participants to talk about the Americans With Disability Act (ADA). Twenty of the 48 interviewees indicated they were familiar with the ADA. However, when they were asked the follow-up question “What do you know about the ADA?” many of them knew little about it or were misinformed about its provisions. Furthermore, a survey among workers with hearing impairment in the United States revealed that most consumers lack information regarding available technology (Mascia & Mascia, 2008). It must be noted that reluctance to request accommodations on the part of workers with hearing loss has also been reported, particularly among those who are older, those with lesser degree of hearing loss, those who perceive their work environment to be unsupportive, and those in part-time work (Punch, 2016). Reluctance to request appropriate accommodation may also occur when persons prefer not to disclose their hearing loss at work because they fear being stigmatized and perceived as incompetent.
Stigmatization
Data on stigmatization in the workplace are less straightforward or unanimous than those on mental effort. According to Southall et al. (2010), stigma is defined as “the possession of, or belief that one possesses an attribute or characteristic that conveys a social identity that is devalued in a particular social context” (p. 804). Hétu (1996) and Hétu et al. (1994) have extensively studied stigma in the workplace. Stigma may be related to embarrassment, lack of confidence, a sense of inferiority, and shame. Focus group interviews of Hétu et al. (1994) revealed that at least some coworkers of people with noise-induced hearing loss perceived hearing impairment as a weakness and associated it with a lack of capacity. Whereas most of the coworkers in that study showed compassionate understanding about the difficulties posed by the hearing impairment, they appeared to be unfamiliar with the manifestations and consequences of it (see previous paragraph). In contrast to the results of Hétu et al. (1994), Tye-Murray and colleagues (2009) did not find much evidence that the professionals in their study were experiencing stigmatization in the workplace. (For further information on stigma, the reader is referred to Chapter 4 of this text.)
A recent study of Koerber, Jennings, Shaw, and Cheesman (2017) is also relevant to mention in this context. The goal of this study was to analyze how the Canadian newspapers frame workers with hearing loss. The results of their thematic analysis revealed a rather positive framing. Newspapers writing about workers with hearing loss most frequently presented an image of workers cheerfully striving toward a good work life.
Lack of Support or Adequate Services
Another barrier that people with hearing impairment frequently experience in the workplace is an overall lack of timely coordination of services. Using narratives describing the lived experiences of persons in their 50s with hearing loss, Jennings and Shaw (2008) identified the lack of support to help workers with hearing loss manage barriers and the lack of recognition of the extent of the hearing problem due to its invisibility. Just as in Kramer’s study (2008), lack of recognition of the multidimensional needs and lack of timely coordination of services was reported. In identifying the gaps in existing services, Jennings and Shaw (2008) emphasized the need to begin questioning traditional approaches in aural rehabilitation for workers with hearing loss. A similar conclusion was drawn by de Graaf and van Bijl (2002), who conducted a large survey among Dutch deaf and severely hearing-impaired people on the use and need of health care. Counseling on how to handle one’s own hearing loss in the workplace was one of the most frequently reported care needs.
Concern and Anxiety
Throughout the range of studies focusing on the consequences of hearing impairment in the workplace and the possible barriers that professionals with hearing loss experience, there was one overriding factor: concern. It seems as if a troubled or anxious state of mind is predominant among workers with hearing loss. Backenroth et al. (2003) observed significantly higher levels of anxiety among workers with hearing loss compared to their control group. Concern about a range of issues was expressed. To illustrate, in Tye-Murray et al. (2009), the participants expressed concern about maintaining their job competency. The employees’ primary concerns in Morata et al. (2005) were about job safety as the result of a reduced ability to hear ambient sounds and warning signals in a noisy environment. Also, their inability to monitor essential equipment sounds was a concern. Other concerns encountered in the literature and through personal observation are about future employability, perceptions of coworkers and supervisors, stress and fatigue, reduced work productivity, reduced communication abilities, and social isolation in the workplace (Grimby & Ringdahl, 2000; Kramer, 2008; Morata et al., 2005; Tye-Murray et al., 2009).
Implications for Vocational Adult Aural Rehabilitation
As outlined in the previous paragraphs, the research findings so far indicate that, for many workers with hearing impairment, even after hearing rehabilitation, the conditions at work are more challenging than for normally hearing colleagues. This brings us to the question of what is needed to accommodate people with hearing loss in the workplace. Several issues that ought to be addressed in vocational rehabilitation for workers with hearing impairment have already been mentioned in this chapter and include the following examples:
1. Equipment and environmental management:
■ Appropriate hearing aid fitting
■ Appropriate hearing-assistive technology
■ Environment management strategies, including reducing background noise and reverberation
■ Timely and integrated approach
2. Awareness for hearing colleagues:
■ Lack of knowledge among employers, employees, and coworkers
■ Support from employers, employees, and coworkers
■ Strategies on disclosing hearing loss in the workplace
3. Psychosocial issues:
■ Need for some time off from work
■ Ongoing supervision or assistance
■ Need for control over work
■ Mental distress and fatigue
■ Maintaining and building self-esteem, self-confidence, and self-advocacy skills
■ Empowerment and assertiveness training
■ Communication strategies
4. Information on current legislation
The list above clearly illustrates that the suggested issues requiring attention in vocational rehabilitation refer not only to the content of care, but also to its logistics and management. It is an illustration of the complexity of vocational rehabilitation. To handle vocational problems successfully for persons with hearing loss, a multidisciplinary, integrated approach is needed.
What Is Needed Is a Multilevel, Interdisciplinary, Integrated Approach
The workplace is a very complex environment with many different actors and factors playing a role. Hence, for an adequate assessment of a hard-of-hearing employee’s limitations and the consequences for work performance, a multifactorial understanding is required, just as outlined in the International Classification of Functioning Disability and Health (ICF) framework (WHO, 2001) and applied to the domain of vocational auditory adult rehabilitation in Figure 25–1 (Kramer et al., 2009). A person’s disability and functioning should always be evaluated within context. In other words, functioning and disability are viewed as outcomes of interactions between an individual’s health condition (e.g., hearing impairment) and contextual factors. Among contextual factors are environmental factors (e.g., room acoustics, colleagues, tasks, schedules) and personal factors (e.g., age, cognitive capacities, visual ability, coping styles, education). A compelling example showing the importance of taking personal factors into account is the case of Dual Sensory Loss (DSL). Lacking visual information reduces the amount of nonauditory information that may be needed to reconstruct the auditory scene; specifically, speechreading is hampered.
Figure 25–1. ICF framework illustrating factors acting on work functioning. Note. The figure illustrates how the functioning at work of a person with hearing loss is viewed as an outcome of interactions between the person’s health condition and contextual factors according to the ICF framework.
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