International Journal of Audiology

ISSN: 1499-2027 (Print) 1708-8186 (Online) Journal homepage: http://www.tandfonline.com/loi/iija20

Conceptions of working life among employees

with mild-moderate aided hearing impairment: A
phenomenographic study

Håkan Hua, Agneta Anderzén-Carlsson, Stephen Widén, Claes Möller & Björn
Lyxell

To cite this article: Håkan Hua, Agneta Anderzén-Carlsson, Stephen Widén, Claes Möller &
Björn Lyxell (2015) Conceptions of working life among employees with mild-moderate aided
hearing impairment: A phenomenographic study, International Journal of Audiology, 54:11,
873-880, DOI: 10.3109/14992027.2015.1060640

To link to this article: http://dx.doi.org/10.3109/14992027.2015.1060640

Published online: 03 Jul 2015.

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 International Journal of Audiology 2015; 54: 873–880

Original Article

Conceptions of working life among employees with mild-

moderate aided hearing impairment: A phenomenographic study

Håkan Hua*,†, Agneta Anderzén-Carlsson*,‡,#, Stephen Widén*,‡, Claes Möller*,‡,# & Björn Lyxell*,†
*Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linköping University, Sweden, †Department of Behavioural Sciences and
Learning, Linköping University, Sweden, ‡School of Health and Medical Sciences, Örebro University, Sweden, and #Audiological Research Centre,
Downloaded by [University of Birmingham] at 20:37 05 November 2015

Örebro University Hospital, Sweden

Abstract
Objectives: The aim was to explore the conceptions of working life among employees with mild-moderate aided hearing impairment
(HI). Design: This study has a descriptive design, in which data was collected by means of semi-structured interviews. All interviews
were audio-recorded and transcribed verbatim. The text was analysed in accordance with the phenomenographic approach. Study sample:
Fifteen participants with mild-moderate aided HI were recruited to the current study. Results: The analysis of the interviews resulted in
four main categories describing the participants’ conceptions of working life: (1) diffiiculties in daily work, (2) communication strategies,
(3) facilitating factors in work environment, and (4) impact on daily life. The four identified descriptive categories show that the effects
of HI on the lives of working adults generate far-reaching psychosocial consequences for the individual. Conclusions: This study dem-
onstrates that difficulties and impact of having a HI interact with strategies used by the individual and contextual facilitators made in the
work environment. We argue that there is a need for extensive services in aural rehabilitation for this population. This includes identifying
the need of assistive listening devices, teaching the individual with HI about communication strategies and informing stakeholders about
the consequence of having a HI.

Key Words: Conceptions; employees; fatigue; hearing impairment; labor market; noise; phenomenography;
withdrawal

Health-care professionals are frequently consulted by individuals
with hearing impairment (HI) who experience difficulties at work,
and studies have shown that HI, regardless of type and degree of
hearing loss, is associated with a poorer quality of life (Grimby &
Ringdahl, 2000; Danermark & Gellerstedt, 2004; Hua et al, 2013).
Observations further indicate that individuals with HI are a vulner-
able group in the labor market. Statistics Sweden (2003) reports
that this group show increased unemployment, early health-related
retirement, and a higher degree of sick leave when compared to the
population at large. In a study by Danermark and Gellerstedt (2004),
445 employees with HI completed a questionnaire about psychoso-
cial work environment, health and wellbeing. A sample consisting
of 8000 respondents were used as a reference group. In this study,
demand and control were defined as requirements to do an indi-
vidual’s work and the employee’s degree of control over their work
situation and working tasks, respectively. The results indicated that
imbalances between demand and control were indeed experienced
to a higher degree among employees with HI than their normally-
hearing peers and that neck problems were most frequently reported.
The authors speculated that the physical tension for this group might
be generated by communicating and participating in difficult lis-
tening situations at work. The results further showed a gender dif-
ference in psychological wellbeing where women tended to report
a higher degree of feeling irritated and frustrated than men in the
workplace.
In a study by Nachtegaal et al (2009), hearing status in relationship
to psychosocial characteristics and the need for recovery after work
was assessed in 925 working adults with normal hearing, and with
HI, via an internet-based questionnaire. This questionnaire consisted
of 11 items assessing the short-term effects of fatigue caused by
work activities. Individual scores of the 11 items were added and
transformed into a scale ranging from 0 to 100, with a higher score
indicating a greater need for recovery. The results showed a signifi-
cant association between decreased hearing and need for recovery
after work. The results also showed that for every dB signal-to-noise
ratio worsening hearing status, the odds for showing a consider-
able need for recovery increased by 9%. The authors speculated that
the most likely explanation for an increased need for recovery in
employees with HI is the extra effort and concentration needed when
communicating under challenging situations.

Correspondence: Håkan Hua, Department of Behavioral Sciences and Learning, Linköping University, SE-581 83 Linköping, Sweden. E-mail: huahakan@aol.com

(Received 29 August 2014; accepted 5 June 2015)

ISSN 1499-2027 print/ISSN 1708-8186 online © 2015 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society
DOI: 10.3109/14992027.2015.1060640
 874 H. Hua et al.
Abbreviations
HA Hearing aid
HI Hearing impairment
To date, research on occupational performance in adults with
HI has focused mostly on studies of health aspects using quanti-
tative questionnaires (Grimby & Ringdahl, 2000; Gellerstedt &
Danermark, 2004; Kramer et al, 2006; Nachtegaal et al, 2009; Hua
et al, 2013), with few studies describing the individual’s subjective
experiences of work. While the former approach has yielded valuable
information, qualitative research has provided a deepened knowl-
edge concerning interpersonal and psychosocial factors on hearing
disability, help-seeking, and aural rehabilitation (Hetú et al, 1988;
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Hallberg & Carlsson, 1991; Backenroth & Ahlner, 1998; Espmark
& Scherman, 2003; Laplante-Lévesque et al, 2012; Jennings et al,
2013; Southall et al, 2011).
In a recent qualitative study by Jennings et al (2013), social
identity management was examined in twelve employees with HI
and the participants were employed in a variety of settings and
occupations. As employees with hearing loss often avoid socially
demanding situations and might conceal signs of hearing loss from
colleagues, or even be hesitant to acknowledge their disability, the
authors speculated that this group is more likely to experience differ-
ent challenges in the work place. As a result, these difficulties could
lead to disruptions and communication breakdowns. Actions taken
or not taken in an attempt to resolve the communications break-
downs are thus a form of identity management by individuals with
hearing loss. Five recurrent themes were identified by the authors
as important considerations for identity-management strategies at
work: (1) managing the situation (e.g. moving to a quieter area),
(2) having a buddy system (e.g. colleagues providing support at
difficult listening situations), (3) feeling comfortable (e.g. when
revealing the hearing loss for colleagues), (4) using personal
resources (e.g. revealing the hearing loss in a positive manner
for colleagues), and (5) it gets easier with time (e.g. social identity
management strategies are learned by trial and error). This indicates
that employees with HI are aware of the effects of communication
breakdowns on the perception that others will have on them. The
authors therefore concluded that stakeholders, both professionals
and colleagues at the workplace need to be better informed about
the consequences of having a HI in order to provide comprehensive
services to improve workplace communication.
In another qualitative study by Southall et al (2011), the factors
that lead individuals to conceal or disclose their hearing loss in the
workplace were studied. Twelve employees with HI participated in
semi-structured interviews and content analyses were used in order
to extract information from verbatim transcripts. The authors iden-
tified five themes that influenced disclosing or concealing hearing
loss in the workplace: (1) perceived importance of the situation,
(2) perceived responsibility in the situation, (3) costs versus benefits
of disclosing hearing loss in the situation, (4) predictability of work
related tasks, and (5) balance of power between worker with hear-
ing loss and the co-worker. This shows that employees with HI are
conscious of the demands that HI place on co-workers. However,
the inclination to disclose a hearing loss in the workplace is likely
to be influenced by physical and social characteristics of the work-
place. Support may therefore come in the form of friendliness and
support from colleagues. The authors further concluded that there is
a need for occupation-specific aural rehabilitation and this type of
intervention program should focus on: supporting employees with
HI to increase their self-efficacy for managing their identity in the
workplace, communication strategies, hearing assistive technolo-
gies, strategies on disclosing hearing loss and stress management.
Taken together, both qualitative and quantitative studies have
shown that employees with HI can be regarded as a vulnerable
group. However, there is still paucity in knowledge of this popula-
tion regarding their conceptions of daily working life, and such
knowledge is important in planning interventions within this field
for health-care professionals, employers, and the employee with
HI. Therefore, the aim of the present study was to explore the
conceptions of working life among employees with mild-moderate
aided HI.
Method
Study design
This study has a descriptive design, in which data was collected
by means of semi-structured interviews which were analysed using
a phenomenographic approach. Phenomenography as an approach
in research was developed in the early 1970s in Gothenburg
University in Sweden by a group of researchers within the domain
of human learning (Marton, 1981). The fundamental characteris-
tic of phenomenography is based on the assumption that different
people perceive and experience a phenomenon in different ways.
Thus, analysis using this approach is carried out to capture and
describe the individuals’ way of understanding, perceiving and
experiencing a certain phenomenon. However, the intent of
phenomenography is not only to explore different ways in which a
certain phenomenon is understood by a specific group (Dahlgren &
Fallsberg, 1991; Stenfors-Hayes et al, 2013), but also to examine
how these ways of understanding are structurally related to one
another (Stenfors-Hayes et al, 2013).
Participants
Twenty participants who participated in Hua et al (2013) were
invited to take part in the current study. They were all initially
recruited from a department of Audiology at a university hospital
in Sweden, and had taken part of a larger experimental project
about hearing loss, noise and cognition (Hua et al, 2013, 2014a,
2014b). All participants were informed about the present study
18 months after participation in the previous studies. Fifteen par-
ticipants agreed to participate. In addition to the 15 participants,
one pilot interview was conducted and this interview was included
in the final data set. However, the final study sample still con-
sisted of 15 participants as one of the 16 recruited participants later
dropped out due to illness. The participants were selected based
on the following criteria: all were between 18–65 years old, had
mild-moderate binaural sensorineural hearing loss, had undergone
aural rehabilitation, and were experienced hearing-aid (HA) users
(⬎ 3 months). All participants were fitted with different HAs from
different manufacturers and a majority of the participants were
using open-fit HAs. Moreover, all participants were active to a
high degree in the labor market (working 80–100% of full time)
and they were employed in a variety of settings and occupations.
The participant in the pilot interview was recruited based on the
mentioned criteria and selected from the records of the audiology
department in the same hospital. Table 1 gives the demographic
information of the participants.
 Conceptions of working life among employees with aided HI 875

Table 1. Demographic data of the participants. 1. Familiarization. Transcriptions of the interviews were read
through carefully and an acquaintance of the data was
Demographic variable N Mean (SD) achieved.
Age 47.4 (14.0) 2. Condensation. Significant statements or meaning units made by
Education level the informants were selected for further scrutiny.
Junior high school 1 3. Comparison. The selected statements were compared in order to
High school 7 find sources of agreement or variation.
University 7 4. Grouping. Answers which appeared to be similar (of understand-
Work status ing the phenomenon) were allocated in the same category.
Part-time 3 5. Articulating. A first attempt to describe the essential meaning of
Full-time 12 each category was made.
Occupation setting
6. Labelling. The core meaning of each category was denoted a
School 3
Health care 2
suitable linguistic expression.
Industry 4 7. Contrasting. Comparisons between the obtained categories, in
Office 6 regard to similarities and differences, were made in order to
PTA reach a higher level of abstraction.
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Right ear 39.6 (6.4)*

Left ear 34.0 (4.3)*
PTA: Pure-tone average; *Based on data collected 2011–2012.
Procedure
In order to evaluate whether the interview guide was clear, under-
standable, and capable of capturing the research questions, a pilot
interview was conducted prior to the data collection. In phenom-
enographic research, the researcher strives to hold back their own
pre-understanding and theories in order to capture the participants’
understanding of the phenomenon. It is also important for the
researcher to focus on describing the way a phenomenon is under-
stood rather than explaining why the participants would have such
understanding (Stenfors-Hayes et al, 2013). The first author who
conducted all interviews intentionally adapted to these standpoints
during the interviews. All interviews were conducted individually
within a four-week period and they all proceeded in an informal,
conversational style based on an interview guide (Appendix 1).
Initially, all participants were asked about their demographics, such
as age, current job, work status, and whether they felt their hearing
had changed significantly during the 18 months since the question-
naire study. After the initial questions, the participants were encour-
aged to describe their overall experiences of working with a HI and
their thoughts on their working tasks, relationships with colleagues,
and of what importance HAs had during working hours. Moreover,
they were also asked about their positive and negative experiences
of these topics, and whether they perceived any complicating and/or
facilitating factors at their workplace in general. Follow-up questions
were asked for clarification purposes (Bowden & Green, 2005). All
interviews were conducted in Swedish at an Audiological Research
Centre and each interview lasted 30–45 minutes. In the results
section, quotations have been used to illustrate the participants’
voice. The interviews were conducted in Swedish and translated into
English by a native English speaker with experience of translation
in qualitative studies.
Data analysis
All interviews were audio-recorded using a dictaphone and tran-
scribed verbatim. Analyses of the text were performed in accordance
to the phenomenographic approach outlined by Dahlgren and Falls-
berg (1991). Aiming at a description of how working life among
employees with mild-moderate aided HI was conceived, the analysis
process followed the seven steps:
In line with Dahlgren and Fallsberg (1991), the analysis did not
precisely follow the described sequence, but rather occurred as a
constant interplay between the various steps. Generally in steps 1–3,
one participant’s data set was analysed before moving to the next
participant’s interview. However, in steps 4–7, in order to compare,
group, and contrast the different categories and statements with each
other, all data sets were analysed together. Three authors (HH, AAC,
& SW) continuously discussed the analysis process. Following these
preliminary discussions, consensus was reached by all five authors
regarding the significant statements made by the participants for each
category.
Ethics
Informed consent was obtained prior to the interviews. The study
was approved by the Regional Ethics Committee in Uppsala
(Dnr: 2010/072/1).
Results
The analysis of the 15 interviews resulted in four main
categories describing the participants’ conceptions of working
life: (1) diffiiculties in daily work, (2) communication strategies,
(3) facilitating factors in work environment, and (4) impact on
daily life. Table 2 shows the identified categories and the varia-
tion within each category. In general, all participants stated that
they benefitted from using HAs at work and the majority of them
were frequent HA users. Nevertheless, all participants perceived
difficulties and these mainly originated from noise at the work
environment, including competing speech and loud non-verbal
noises. As most participants perceived difficulties, all of them
also described communication strategies as something they used
in order to facilitate communication. Moreover, a majority of
them also perceived environmental facilitators as something that
could make work easier. These facilitators ranged from acoustical
and technical adjustments in the work environment to colleagues
showing understanding and support towards the individual.
However, despite these factors, perceived difficulties due to HI
could still have a direct negative impact on the participants’ daily
life in form of a sense of exclusion, withdrawal and fatigue. In
the following sections, each category, with significant statements
made by the participants, will be presented. The number within
brackets after the excerpts represents the individual participant.
 876 H. Hua et al.

Table 2. Descriptive categories and variation within each descriptive loud when the lockers are opened and closed and I find it
category. extremely difficult to remain there. I’m almost unable to hear
what people are saying.’ (No. 4).
Descriptive category Variation within descriptive category

Difficulties in daily work Communication in groups

Loud non-verbal noise
Inconvenience with hearing aids
Tinnitus
Communication strategies Guessing/making sense of missing words
using contexts
Asking for repetition
Move closer to speaker
Avoid challenging listening situations
Inform colleagues about hearing
impairment
Adjust hearing aids
Speech reading
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INCONVENIENCE WITH HEARING AID
A third major difficulty the participants perceived at work was
inconvenience with their HAs. This could range from using HAs
in conjunction with other equipment, such as telephones, safety
glasses, and hearing protectors, to acoustic feedback in the HAs.
Doing outside work and exposing the HAs to moisture (sweat, rain,
etc.) could also be perceived as a complication. These difficulties
often resulted in the majority of the participants not using their HAs
at work even when there was a desire to use them:
‘They’re in the way when I wear hearing protectors at work as
it’s uncomfortable to wear them inside the protectors. I might

Facilitating factors in work Support and understanding from
environment colleagues
Assistive listening devices
Adjustment of room acoustics
Impact on daily life Sense of exclusion
Withdrawal
Fatigue
Difficulties in daily work
All participants stated that they had some form of difficulty they
encountered on a daily basis at work due to the HI. The most obvi-
ous difficulty was during communication in groups. However, there
could also be instances where loud non-verbal noise and inconve-
niences with HAs where perceived as complicating factors. A few
of the participants also experienced mild-moderate tinnitus every
now and then, which in turn could make certain working tasks even
more difficult.
COMMUNICATION IN GROUPS
All participants stressed that they had difficulties communicating
during group activities at work. In addition to feeling confused, this
type of difficulty was also perceived as bothersome by the partici-
pants, and it could happen regardless of whether they used HAs in
that certain situation. This type of difficulty was not only appar-
ent during work hours in big meetings, but could also occur during
smaller events, such as lunch and coffee breaks, with fewer people
attending. One of the participants stated:
‘Sometimes it gets a bit crowded in the coffee room and it’s
very loud and noisy. When it’s like that I find it very difficult to
hear and join in conversations. It’s a difficult environment for
me when it’s crowded and therefore hard for me to join in the
discussions.’ (No. 12).
LOUD NON-VERBAL NOISE
Another major difficulty the participants perceived, especially those
working in an industrial or school environment, was loud non-verbal
noises at the workplace. These loud noises could both complicate
communication between the participants and their colleagues and/or
be painfully loud. Participant number four said:
‘Loud noises cause me physical pain. Chairs and everything
metallic hurt my ears. Unfortunately we have metal lockers,
which they refuse to remove for fire safety reasons. It’s really
wear them inside for a while, but not for very long, so I take
them out. If somebody comes over and talks to me I cannot
hear anything which means that I have to put them [hearing
aids] in and then take them out again. Such situations are dis-
turbing. I would also like to turn the volume up when I cannot
hear, but I don’t do so because they start to beep and squeal
when I smile. So I have to explain that ‘it’s my HAs’ and that
really bothers me.’ (No. 1).
TINNITUS
Three of the participants had mild-moderate tinnitus that occurred
every now and then, and having tinnitus in combination with HI
could also be perceived as an additional difficulty. One of the
participants described it as having an extra noise inside the ears:
‘I have tinnitus. So sometimes my ears and all the whistling
sounds are really difficult. It feels as if I have a bucket over my
head and all sounds go straight into my ears. Usually I only
get tinnitus in one ear, so I put an earplug into that ear. But
then I cannot hear what people are saying and become afraid
of missing something important.’ (No. 15).
Communication strategies
The second identified descriptive category was communication
strategies where all participants stated that they used a variety of
strategies in order to prevent or repair communication breakdowns.
This category showed most variation among the identified categories
as each participant tended to use the strategies that they were most
comfortable with.
GUESSING/MAKING SENSE OF MISSING WORDS USING CONTEXT
Six participants said that they actively tried to fill in words that they
might have missed during conversations or just simply guess what
has been said during communication breakdowns. Many of them
also perceived it to be easier to guess when they knew the topic of
the conversation. For example, respondent number 2, who worked
in the health-care sector, described:
‘It’s a bit problematic when they come and say something and
I cannot hear, because sometimes we cannot talk loudly in my
profession. For example, when we’re sitting in the reception
area and have to speak quietly to each other, I think I miss
every second word, so I have to guess what they are saying.’
(No. 2).
 Conceptions of working life among employees with aided HI
ASKING FOR REPETITION
Asking their colleagues for repetition could also help the participants
to understand what they could have missed in noisy situations:
‘Yes, it’s a bit tough, I think. I cannot hear exactly what they say,
so I have to ask them to repeat several times until I catch what
they have said. It becomes annoying for them too.’ (No. 10).
MOVE CLOSER TO THE SPEAKER
Another communication strategy the participants used in order to
hear better was simply to move closer to the target speaker.
‘At a conference I try to sit close to the speaker where I can
both see and hear him/her clearly. In that way I can follow the
speech better. If I sit at the back of the hall and other people
talk, it’s more difficult’ (No. 5).
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AVOID CHALLENGING LISTENING SITUATIONS
Some of the participant stressed that they avoided coffee rooms or
lunch areas during certain hours of the day. They waited until these
areas were not as crowded and would take a coffee break when it
was quieter. Moreover, some of them could even avoid these areas
completely and go and eat in a different location on a daily basis.
For example, participant number 8 described:
‘We have a small staff room in the basement with a tiny window
and ten or twelve chairs. I think there are four tables, but no one
really wants to eat there because it’s such a boring place. Most
people take their lunch boxes to the school canteen, heat
their lunch and eat with the pupils. I don’t because it’s utterly
impossible for me due to the noise. It doesn’t really bother me. It’s
not worth going there because of the high noise level.’ (No. 8).
INFORM COLLEAGUES ABOUT HEARING IMPAIRMENT
Seven participants said that they informed their colleagues about
their HI. Most of them thought that informing them made it easier
to communicate at work. However, this strategy was not always
optimal for everyone as some colleagues had a tendency to forget
about the HI.
‘Yes, I just tell them that I misheard because it’s true. I don’t
know what else I can do. Some people even get a bit irritated
because I cannot hear properly, but there’s nothing I can do
about it. A colleague might have repeated something a couple
of times and I still did not understand exactly what he said.
Then he might [think] ‘what’s wrong with him?’ (No. 13).
ADJUST HEARING AIDS
A few participants prevented communication breakdowns by
adjusting the gain of their HAs if they knew they would get into a
challenging listening situation:
‘For example, I can prevent it by turning up the volume when
I go to the reception area. In that way I can prepare myself
[for receiving guests].’ (No. 1).
SPEECH READING
One of the participants stated that speech reading was a very helpful
strategy for her during conversations with her colleagues:
‘I’m very good at lip reading. But if someone talks like this
[puts her hands in front of her mouth and mumbles] then it’s
877
much more difficult for me to understand what has been said
but I’m generally good at lip reading.’ (No. 15).
Facilitating factors in the work environment
In addition to using their individual communication strategies, many
of the participants also emphasized the importance of environmental
facilitators at work. This could be in form of colleagues showing
support and understanding for the individual, adjustments of room
acoustics, and using assistive listening devices.
SUPPORT AND UNDERSTANDING FROM COLLEAGUES
Six participants expressed that colleagues showing them understand-
ing and support of having a HI could make it easier for them. This
made the participants feel better in general and could also reduce
some of the anxiety of having a HI. One participant worked in very
loud industrial environment also said that colleagues who knew
about the HI sometimes could take over some of his tasks when
they could not contact him:
‘Those on my shift know that I do not hear very well, so they
are understanding about it. If they are unable to contact me
when something critical happens, there’s another colleague
who can run out and take care of things instead.’ (No. 9).
ASSISTIVE LISTENING DEVICES
Assistive listening devices were something nine participants
stressed was important and facilitated communication at work. This
could be devices such as using FM-systems, telecoils, streamer
devices, and headsets. Some individuals working in industries
required electronic hearing protectors that could both enhance
environmental awareness while also protecting their ears from
loud noises. Among the individuals doing office work, there was a
special need for equipment that made it easier for them, for
example to talk on the phone:
‘If I have my Bluetooth device I can sit like this in my office
and talk on the phone. There’s really no need for me to do
anything else because the sound goes straight into my ears and
I wear the microphone around my neck. It’s also easier for me
to hear [during seminars] when there’s an audio system in the
hall.’ (No. 3).
ADJUSTMENT OF ROOM ACOUSTICS
Adjustment of room acoustics was described as an important
factor in the work environment. Many of the participants described
that going into a room that had been sound treated was a positive
experience compared to a room that had not been sound treated.
Moreover, some of the participants stated that sound treatment of
room acoustics did not only benefit the individual with HI, but
normally-hearing individuals as well. One participant worked in
a school said:
‘They put new insulation on the ceiling that is very absorbent.
They also put down a large mat that absorbs quite a lot of
noise. I feel that there’s a huge difference between working in
my classroom and going into somebody else’s classroom that
has not been sound proofed. I think the pupils think so too.
There is a big difference between being in a facilitating
environment and an aggravating one.’ (No. 4).
 878 H. Hua et al.
Impact on daily life
A majority of the participants stated that their HI at work had a
major impact on their situations both during work hours, as well as
on their daily lives. The most common feeling described was a sense
of exclusion, especially during conversations in groups. However,
withdrawal and fatigue occurring both during and after work were
also perceived as direct negative consequences of having a HI.
SENSE OF EXCLUSION
A sense of exclusion was observed in all occupation settings, regard-
less of age and gender, and ranged from feeling insecure and inad-
equate in certain situations to feeling frustration and sadness. One
participant had taken a couple of courses and described a classroom
situation:
‘What’s most difficult is when someone makes a joke during
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class and everyone laughs except me. Or when I ask someone
to repeat what they said for the third time and I still cannot
hear because there is too much noise. It’s embarrassing.
I often believe that people might think I’m stupid, but I know
I’m not. Otherwise I would not be sitting here and doing
advanced level maths, passing all the exams and stuff like
that.’ (No. 6).
WITHDRAWAL
Another impact the participants’ perceived the HI could generate
was withdrawal, including activities during and after work. This
could be withdrawal in form of them not attending social activi-
ties with colleagues, even though they wanted to, or participating
in meetings but not being fully and mentally present due to too
much noise. However, despite withdrawal, it should be noted that a
majority of the participants said that the HI did not directly affect
their professional relationship with their colleagues. Many of the
participants expressed a desire to socialize with colleagues outside
of work, but did not do so because of the difficulties they know
they might experience:
‘I think it’s a bit sad. Socializing after work is something I
enjoy. Meeting people, hanging out and having a beer together.
I don’t do it very often now because of my HI. I made a
conscious decision not to meet up because I find communi-
cating difficult. I used to talk a lot with people, even those I
didn’t know but I don’t anymore.’ (No.11).
FATIGUE
A third major impact most participants perceived as direct negative
consequence of having a HI was fatigue. None of the participants
could really describe whether the fatigue was mental or physical,
but some of them expressed it as no clear boundary between these
two types. Instead, they expressed it as interplay of effort, where
too much sounds could affect them mentally whereas concentrating
to listen in noisy situation could generate physical tension in neck,
shoulders, and back. However, regardless of type, a majority of the
participants expressed that they did feel tired and pointed out the
need for recovery after work due to the HI:
‘It’s an ongoing process and it’s difficult to know how it affects
you. But I realized afterwards that it’s very tiring and, having
spoken to others who have a hearing impairment, they say that
it’s very tiring and drains you of energy. Maybe it’s more men-
tal than physical, as you have to concentrate and remain
focused for a long time, which makes you even more mentally
exhausted. However, when I’m tired I usually lie down and rest,
so it’s physical tiredness as well.’ (No. 3).
One participant described that her engagement in leisure activities
would suffer as a result of her feeling that recovering from work
was a higher priority during spare time. The participants also stated
that the way they recovered included a need for rest, peace and quiet
after a day’s work, and in some cases, even requests to children and
spouses at home not to make any noise.
Discussion
The aim of the present study was to explore the conceptions of work-
ing life among employees with mild-moderate aided HI. The four
identified descriptive categories show that the effects of HI on the
lives of working adults are far reaching and generate psychosocial
consequences for the individual. Even though all participant were
experienced HA users and a few of them adjusted their HAs in order
to cope with challenging listening situations, HAs could still be per-
ceived as inconvenient at work, resulting in the participants not using
them. A majority of the participants were aware that the difficulties
perceived at work due to the HI had a direct negative impact on
daily life such as a sense of exclusion during work hours, and both
physical and mental fatigue after work. Withdrawal was a third major
impact that could occur during work and affect after work activities.
This shows that difficulties and impact of having a HI also interact
with communication strategies used by the individual and contextual
facilitators in the work environment.
When comparing our results with another qualitative study, the
identified communication strategies used by the participants are
similar to the results obtained by Hallberg & Carlsson (1991). They
classified strategies into two management patterns: (1) to control the
social scene, or (2) to avoid the social scene. The latter is in line with
our findings where some of the participants avoided coffee and lunch
rooms when it was crowded or chose to sit in a quiet location during
lunch hours in order to hear better. Communication strategies as a
category further showed most variation when compared to the other
descriptive categories and there might be a couple of explanations
for this. Firstly, all participants worked in a variety of work settings
which means that they were all exposed to different listening situ-
ations. Secondly, all of them tended to use their individual prefer-
ence of one of the identified strategies for a specific situation. For
example, during a lecture it would be natural for some of them to
sit or move closer to the speaker, but this strategy is not something
they practiced in a lunch situation when all colleagues were already
seated at the table. Thus, the combination of different occupations
settings and preferences for individual strategies during certain situ-
ation generated a greater variation. At this stage, little is still known
about the effectiveness of certain strategies during certain situations,
and future studies examining this topic would have a great value in
clinical practice and for individuals with HI.
As stated before, all participants were HA users and a majority
experienced a great benefit of them both at work and at home.
Nevertheless, many of them perceived inconveniences with their
HAs. Using a HA in conjunction with other technical equipment,
doing outside work and constantly shifting between a quiet and
noisy sound environment were perceived as intricacies. This was
experienced by participants working in all occupation settings, and
often resulted in most of them not using their HAs even when they
were needed. These reports regarding inconveniences with HAs
are somewhat related to the finding about the use and benefit of
 Conceptions of working life among employees with aided HI
assistive listening devices in the work environment. Participants who
used additional listening equipment stressed that it was much easier
for them to do certain tasks. For example, talking on the phone via
streamer devices and having extra-large technical ear protectors that
could both fit their HAs while also enhancing sounds and protect-
ing their ears from loud noises were perceived as very helpful. In
addition to the emphasis on assistive listening devices, acoustical
adjustments were also perceived as a facilitating factor in the work
environment. Interestingly, despite using different methodology, in a
focus group study by Tye-Murray et al (2009) similar findings were
obtained. In their study, 48 employees with a wide range of hearing
loss (range: 12–120 dB HL) using either HAs or cochlear implants
and working in office-like environments were recruited. The authors
reported four (out of five) factors in their study that seem to be very
similar to the four factors reported in the present study: (1) use of
hearing assistive technology, (2) supervisors and co-workers’ per-
Downloaded by [University of Birmingham] at 20:37 05 November 2015
ceptions and the provision of accommodations in the workplace,
(3) use of effective coping strategies, and (4) communication dif-
ficulties. In the current study we can extend these findings showing
that they are applicable even at a mild-moderate level of hearing
loss, including different types of work settings. The current study,
along with the findings of Tye-Murray et al (2009), also shows that
employees with HI, regardless of profession, nowadays are aware
about the effects of HI and what could be done to facilitate their
situation, for example adjustments in room acoustics.
Some of the participants described that having linen table cloths,
carpeting and drapery in the work environment improves room
acoustics and decreases reverberation. These reports seem to be
most apparent when the participants worked in an office or school
setting. In the current study, the three participants who worked in
a school environment were younger women and they all reported
more difficulties and greater impact on daily life compared to the
other participants. They emphasized the need of adjustments of room
acoustics at work. Many of the participants also stated that these
adjustments did not only benefit the individual with HI, but their
normally-hearing peers as well. From a clinical perspective, the
current findings indicate that there is a need of extensive services
for employees with HI even after a HA fitting. This study further
emphasizes the importance of identifying the need for assistive
listening devices, examining room acoustics of the individual’s work
setting, and providing the individual with communication strategies
in order to facilitate communication at work, even if the degree of
the hearing loss is considered as mild-moderate.
The current findings regarding fatigue, extra strain during
challenging listening conditions, and need for recovery after work
are in line with previous studies (Danermark & Gellerstedt, 2004;
Nachtegaal et al, 2009; Hua et al, 2013). In a previous study con-
ducted by our research group health-related quality of life and
perceived effort in noise was examined in a group of employees with
aided HI and normal hearing. In this study, the participants under-
went an experiment where they had to sit in an anechoic chamber
and perform certain working tasks in a sound environment consisting
of office noise. Furthermore, a questionnaire was also used to mea-
sure health-related quality of life. The results of the study showed
that employees with HI report a significantly lower physical health
status and a higher perceived effort in noise than their normally-
hearing peers (Hua et al, 2013). However, one limitation when using
a quantitative questionnaire and employing this type of experimental
design is that it was difficult to identify the underlying cause of
the self-reported lower physical health status and higher perceived
effort. In the current results, all participants stressed that they felt an
879
increased fatigue both mentally and physically after work and many
of them did indeed express that this was due to listening and partici-
pating in challenging listening conditions at work. Although most
of them could not differentiate between mental or physical fatigue,
they agreed that there was an extra need for recovery after work.
Three participants further stated that they had issues with tinnitus.
The impact of tinnitus on these participants were somewhat expected
as all three of them described that the tinnitus distorted incoming
sounds and consequently affected hearing negatively. Hetú et al
(1988) investigated hearing difficulties among 61 employees with
HI. Similar to our findings, problems perceived by this group also
included tinnitus which generated stress and anxiety for the individu-
als and that communication problems lead to extra effort, negative
self-image, withdrawal and changes in social activities. Moreover,
Southall et al (2011) also described that tinnitus could be perceived
as a complicating factor in the workplace in the form of the employ-
ees with HI experiencing it as an additional difficulty.
Hygge et al (2002) have previously shown that involuntarily exclu-
sion to noise indicated impaired memory performance and learning
with increasing noise levels in a group of schoolchildren. Further-
more, Sjödin et al (2012) have shown that stress and energy output
is more pronounced in pre-school employees with normal hearing
and that 30% of this population experience burnout syndromes. With
these and the current results in mind, an even higher risk for worse
health could exist for personnel with HI working in a school environ-
ment. At this stage, this study cannot state whether younger women
with HI in general or simply working in a school environment with
HI could pose a higher risk for worse health compared to individu-
als with other professions. Therefore, we argue that it is important
to identify the need for technical and acoustical adjustments in the
workplace environment for individuals with normal hearing and HI.
Future research identifying high-risk groups with HI in the labor
market would therefore be of interest in clinical practice. In addi-
tion, in the present study, a majority of the participants stated that
colleagues did provide meaningful social support and understanding,
and that HI did not affect the professional relationships with co-
workers negatively. Similar findings were further emphasized in the
studies by Southall et al (2011) and Jennings et al (2013), where the
authors observed that having a buddy system in the workplace and
organizational support could influence one’s inclination to disclose
the hearing loss in the workplace, even though these studies included
participants with moderate-profound levels of hearing impairment.
Therefore, from a clinical perspective, informing colleagues and
employers about the consequences of having a HI could be of value
for employees with HI and this objective should be included in
occupation-specific aural-rehabilitation, regardless of the severity
of the hearing loss.
A phenomenographic approach was used to analyse the data in
the current study. The reason for using this type of approach is that
the quantitative data in our previous studies (Hua et al, 2013, 2014a,
2014b) consistently showed a greater variation in the different out-
come measures (questionnaires, cognitive and general working tasks,
subjective ratings of effort, and disturbance, etc.) for the group with
mild-moderate HI compared to a well-matched normally-hearing
group. In phenomenography, the focus is capturing the variation
of conceptions of certain phenomenon and was thus an appropriate
method approach that supported good credibility (Stenfors-Hayes
et al, 2013). Credibility was further strengthened by the use of the
semi-structured interview guide that was developed to guarantee that
all participants were asked the same questions (Bowden & Green,
2005). A pilot interview was conducted by the first author in order to
 880 H. Hua et al.
make sure that the interview guide was understandable and capable
of capturing the research questions. All participants were asked to
reflect on their experiences of working with a HI, follow-up ques-
tions were posed in order to clarify statements, and they were all
encouraged to talk openly to the interviewer. To obtain confirmabil-
ity, the coding and classification of the interviews were continuously
discussed by the second (AAC) and third (SW) authors who both
had different professional backgrounds than the first author (HH), a
reliability and validity assessment in qualitative research known as
co-judging. Following classification by these three authors, the find-
ings were then discussed by all five authors and consensus regard-
ing classifications was reached. In no case was there disagreement
between authors. Lastly, in the current study, none of the participants
were asked for member checking and the length of the interviews
could be considered short as they lasted 30–45 minutes. However,
the general impression was that all participants gave rich and detailed
Downloaded by [University of Birmingham] at 20:37 05 November 2015
information according to the interview questions, and saturation of
data was obtained after eleven interviews.
Conclusion
Taken together, the present study is important because it shows that
although employees with mild-moderate HI have been fitted with
HAs, there is still need for extensive services in aural rehabilitation
for this population. This includes identifying the need of assistive
listening devices, teaching the individual with HI about communi-
cation strategies, and informing stakeholders, including employers
and colleagues, about the consequence of having a HI. The latter
is especially important as colleagues showing support and employ-
ers making adjustments (technically or acoustically) are facilitating
factors that would benefit employees with HI and as well as those
with normal hearing. Future studies investigating the use of assistive
listening devices and their effects, and identifying the effectiveness
of certain communication strategies and high-risk group with HI
would provide valuable knowledge.
Acknowledgements
The study would not have been possible without the study partici-
pants who generously gave their time to participate in the current
study. The authors would also like to thank Jonas Birkelöf, Ann-
Marie Helgstedt, Jennie Hjaldahl, Tobias Åslund, and Rachel Ellis
for providing assistance and help during the study. Thanks are also
due to two anonymous reviewers for providing valuable comments
on an earlier version of the manuscript. This study was funded by
AFA Insurance.
Declaration of interest: The authors report no conflicts of interest.
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