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Abstract and Introduction

Abstract

Hearing loss affects 36 million people in the United States of America, including 17% of the adult population. This suggests

some nurses will have hearing losses that affect their communication skills and their ability to perform auscultation

assessments, potentially compromising patient care and safety. In this article, the authors begin by reviewing the hearing

process, describing various types of hearing loss, and discussing noise-induced hearing loss and noise levels in hospitals.

Next, they consider the role of hearing in nursing practice, review resources for hearing-impaired nurses, identify the many

costs associated with untreated hearing loss, and note nurses' responsibility for maintaining their hearing health. The

authors conclude that nurses need to be aware of their risk for hearing loss and have their hearing screened every five

years.

Introduction

Hearing loss is becoming a ubiquitous problem. In the adult population, hearing loss is one of the most common chronic

medical conditions, ranking third behind hypertension and arthritis (McCullagh & Frank, 2013). According to the United

States (U.S.) Department of Health and Human Service (DHHS), National Institute on Deafness and Other Communication

Disorders ([NIDCD], 2010), 18% of the adult population between the ages of 45 and 64, and 30% of adults between the

ages of 65 and 75, have hearing loss. Furthermore, estimates of diagnosed and undiagnosed hearing loss in Americans

between the ages of 20 and 69 could be between as much as 15 to 17 percent (Centers for Disease Control and Prevention

[CDC], 2013b; NIDCD, 2010).

Nurses comprise the largest segment of healthcare professionals in the US with more than 3 million licensed nurses in this

country (American Academy of Colleges of Nursing, 2011). If hearing loss statistics for nurses are similar to the 15 to 17%

prevalence rates of the general population, there are approximately 450,000 to more than half a million registered nurses

who are working with hearing loss. Currently, very limited research is available regarding hearing loss among practicing

nurses, a situation confirmed by the medical librarian who assisted with our literature search. The purposes of this article are

to discuss how hearing loss can influence both patient assessments and effective nurse-patient communication and to

explore accommodations available to the practicing nurse who has hearing loss. We will begin by reviewing the hearing

process, describing various types of hearing loss, and discussing noise-induced hearing loss and noise levels in hospitals.

Next, we will consider the role of hearing in nursing practice, review resources for hearing-impaired nurses, identify the many

costs associated with untreated hearing loss, and note nurses' responsibility for maintaining their hearing health. We will

conclude that nurses need to be aware of their risk for hearing loss and have their hearing screened every five years.

The Hearing Process

Ears are sensitive instruments that detect the mechanical forces of sound waves. These sound waves are picked up by the

pinna, the visible part of the ear, transferred into the external ear canal, and sent into the cochlea where stereocilia, also

known as hair cells, trigger neurotransmitters along the auditory nerve. The brain receives the stimulation, reconstructs the

information, interprets the sound recognition, conducts a speech analysis, and determines directional awareness if the

sound occurs from behind (Brownell, 1997).

Sound waves are described in decibels (dBs), which provide a measure of the volume of sound, and in hertz (Hz), which

provide a measure of the frequency or pitch of the sound. Audible volumes for humans range from zero to ten dBs as in soft

breathing; from 50 to 60 dBs as in normal conversation, to more than 110 dBs, a volume loud enough to elicit pain (Noise

Sources and their Effects, n.d.). Humans can hear frequencies between 20 Hz (low vibrations) up to 20,000 Hz (Cutnell &

Johnson, 1998).

Nurses With Undiagnosed Hearing Loss: Implications for PracticeCara S. Spencer, MSN, FNP-BC; Karen Pennington, PhD, RN

Online J Issues Nurs. 2015;20(1)

http://www.medscape.com/viewarticle/840915_print

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Types of Hearing Loss

Hearing loss is measured/presented by an audiogram, which compares the dB and the Hz levels heard during a hearing test

and configures the data graphically. In a normal hearing test, the Hz and the dB data points would fall into the normal range

of hearing. If a hearing loss exists, more volume (dBs) is needed to make the pitch audible and the data point will fall outside

the normal range of hearing (Rabinowitz, 2000). In other words, the louder the sound needs to be for audibility, the more

significant the hearing loss. A slight increase in volume could be an indication of a mild hearing loss. However, a significant

increase in volume could be categorized as a severe or profound hearing loss. An audiologist or other certified hearing

professional can conduct the audiograms and other hearing tests needed to determine hearing status.

Different types of hearing loss include conductive hearing loss, sensorineural hearing loss, and a combination of both types

known as mixed. In conductive hearing loss, the sound is prevented from traveling to the middle ear. An impaction of

cerumen in the canal or a middle ear mass from a cholesteatoma are possible causes of a conductive hearing loss. This

type of hearing loss is often reversible. A sensorineural hearing loss can result from damage to the inner ear or the neural

pathways to the brain. Possible causes of this type of hearing loss can include a genetic predisposition or medications, such

as aspirin, antibiotics, and chemotherapies (Wallhagen, Pettengill, & Whiteside, 2006).

Presbycusis is a form of sensorineural hearing loss often associated with age-related hearing loss (U.S. DHHS: NIDCD,

2013). This type of loss is usually bilateral, gradual, and characterized by an initial loss in the higher frequencies followed by

loss in the lower frequencies (Oyler, 2013; Wallhagen et al., 2006). This insidious problem is often without a known etiology;

it takes years to develop, causing many people to forgo screening and treatment and to ignore this type of hearing loss.

Noise Induced Hearing Loss

Noise induced hearing loss (NIHL) is a sensorineural loss resulting from the destruction of the hair cells within the cochlea.

These hair cells are very sensitive to noise damage caused, for example, by prolonged periods of noise, or sudden,

excessive noise levels. According to the CDC (2013a), damage to hearing can result from noises as low as 85 dBs for more

than eight hours.

Noise induced hearing loss and damage to the stereocilia is irreversible. From birth, there are a finite number of these cells.

Although the nickname 'hair cells' implies possible rejuvenation; once damaged, these cells do not re-grow and the loss is

permanent (NIDCD, 2013).

All ages are affected by NIHL. Young adults are at high risk for NIHL due to the use of personal listening devices (PLDs) and

earbuds. In studies investigating the use of PLDs and earbuds, 94% of college students own such devices and 75% use

them several times a week or daily. Punch, Elfenbein, and James (2011), found that 90% of these listeners reported a

volume level of medium to loud for one to three hours per usage. Although 85% of the users were concerned about NIHL,

77% of those surveyed thought the hearing loss was medically reversible (Punch et al., 2011).

Older nurses may also be at risk for NIHL and presbycusis. The Health Resources and Services Administration (HRSA) of

the U.S. Department of Health and Human Services has reported that the age of the registered nurse population has been

rising over the past two decades; nearly 45 percent of nurses are age 50 and older (U.S. DHHS, HRSA, 2010). If the

estimated rates of hearing loss in nurses are in line with those of the general population, then 18 percent of nurses who are

45 years of age and older may be practicing with hearing loss (U.S. DHHS, NIDCD, 2010b).

Noise Levels in Hospitals

Hospitals are noisy places (Pope, Galhun, & Kempel, 2013). Hospital noises are often a cacophonous mix of sounds.

Conversations, televisions, paging systems, and equipment noises from ventilation systems, alarms, and automatic doors

create the majority of the sounds. Other episodic noises, such as hand washing, telephones, pagers, and opening of

disposable packages, induce spikes in noise levels leading to patient dissatisfaction and a stressful work environment

(Konkani & Oakley, 2012; Konkani, Oakley, & Bauld, 2012; Pope et al., 2013).

Different areas of the hospital have different noise levels. Konkani and Oakley (2012) conducted a literature review of the


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noise levels in Intensive Care Units (ICUs) and neonatal intensive care units (NICUs). ICU noise level averaged 72 dBs and

the NICU average noise level was 85 dBs with a peak level of almost 140 dBs (Konkani & Oakley, 2012). Sustained over a

shift, NICU levels are above the recommended dB levels established by the National Institute for Occupational Safety and

Health (NIOSH), potentially leading to NIHL.

Alarms in the hospital not only contribute to the noise level, but also pose their own challenges. Hospital codes and

standards require that alarms on pumps and monitors are loud enough to be heard above the background noise (Solet &

Barach, 2012). One study found the sound range of most medical alarms are set between 60 to 70 dBs with some

exceeding 80 dBs (Konkani et al., 2012). Additionally, the frequency of the tone used can vary depending upon the

manufacturer; and a single machine can have multiple alarms. Alarm frequency ranges vary and can be pre-set between

150 to 4000 Hz which can exceed the ability of those personnel with presbycusis or NIHL to hear these sounds (Wallace,

Ashman, & Matjasko, 1994). Some machines now allow staff to set the alarm tones to lower frequencies, thus allowing

nurses to program the alarms to accommodate the needs of both a specific agency, and/or nurses with high frequency

hearing losses.

The Role of Hearing in Nursing Practice

Nurses view communication as a vital part of their role. Interpersonal communication, multidisciplinary communication, and

patient education are basic nursing responsibilities. When communication challenges occur, 82% of nurses report a 'high to

very high' impact on their ability to work efficiently, and 92% of nurses report lapses in communication that affect patient

safety (Dare, 2009). Additionally, The Joint Commission (TJC) has identified ineffective communication as the leading root

cause of sentinel events in all categories investigated between 1995 and 2006 (Joint Commission Center for Transforming

Healthcare, 2013). This section will address difficulty hearing both human speech and auscultation.

Difficulty Hearing Human Speech

Hearing loss greatly impacts the ability to communicate efficiently and effectively. Although human beings have the ability to

hear a wide range of frequencies as measured in hertz (Hz), most normal conversation frequencies occur between 250 to

6000 Hz. It is in the 1000 to 2000 Hz range that the best speech discrimination and intelligibility occurs (Shindler, 2007). A

disruption within this Hz range could impact speech recognition as words are spoken.

Although the English language contains many sounds, the sounds most crucial to speech intelligibility are the sounds within

the high frequencies. These include the voiceless consonants, such as 'f,' 's,' 'h,' 'sh,' and 'th' as in the word "with." These

sounds are the first to be lost with presbycusis and NIHL. Further progression of hearing loss into the 1000 to 2000 Hz range

includes the loss of the consonants sounds, such as 't,' 'k,' 'p,' and the blends of 'ch.' It is with the loss of these sounds that

the person complains of hearing but not understanding the words that are spoken (CDC, 2012; Ross, 2009).

Ambient and background noises within a noisy hospital environment create added difficulty for those with hearing loss as

they mask and distort sounds. Listening and speech recognition is significantly poorer for those with hearing loss in a noisy

environment (Jin & Nelson, 2010). Neubert (2012) found that in people with hearing loss, the temporal lobes of the brain had

difficulty coding the sounds of speech. Working in noisy environments and trying to carry on a conversation is like "turning on

a dozen television screens and asking someone to focus on one program" (Hear-It, 2012, para 2). A nurse with undiagnosed

hearing loss, performing the multitude of necessary duties during a shift, may have difficulty communicating effectively in the

noisy environment.

Challenges Related to Auscultation

Hearing loss also impacts the role of the nurse to perform accurate auscultation during patient assessments. Hearing loss

also impacts the role of the nurse to perform accurate auscultation during patient assessments. Heart sounds are in the

lower frequencies and thus generally easier to hear for those with the high frequency hearing losses of NIHL or presbycusis.

Normal heart sounds (S1 and S2) vary from 50 to 500 Hz. Heart sounds S3 and S4 occur at lower frequencies, ranging from

20 Hz to 200 Hz, with S3 occurring at the lowest frequency. Other cardiac sounds, including murmurs and ejection clicks,

also occur most often below 300 Hz. To hear the required sounds, however, does require a decibel (dB) level that is high

enough for adequate detection with the stethoscope and the assessor's auditory ability (Debbal & Bereksi-Reguig, 2008).


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Lung sounds vary in frequency depending upon the structure and location of the auscultated sound. Normal lung sounds

range from 100 to 1,000 Hz. Although rhonchi or crackles are typically below 300 Hz, they do require an amplitude loud

enough for audible detection with the stethoscope. Other adventitious lung sounds require more astute hearing. Tracheal

restrictive sounds, such as occurs with croup in pediatric patients, can occur as high as 3,000 Hz, and wheezes as high as

1,000 Hz. These levels are potentially out of range for those with presbycusis or other upper frequency hearing loss

(Pasterkamp, Kraman, & Wodicka, 1997).

For nurses with undetected or untreated hearing loss, deficits could have an impact on the accuracy of their assessments,

thus compromising patient care. Nurses with mild hearing loss in the lower frequencies could be missing heart and lung

sounds that occur at lower volumes. For nurses with losses of the higher frequencies, as with presbycusis, undetected

wheezes or other adventitious lung sounds could be missed, thus impacting patient safety. To date there is limited research

establishing how nurses with hearing impairment affect the safety and quality of patient care.

Resources for Hearing-impaired Nurses

A variety of resources are available to support hearing-impaired nurses in giving care to their patients. These resources

include assistive devices, the Americans with Disabilities Act, advocacy groups, and the American Nurses Association. Each

of these resources will be described below.

Assistive Devices

Amplified stethoscopes are readily available for use by hearing-impaired healthcare professionals. Amplified stethoscopes

are readily available for use by hearing-impaired healthcare professionals. These stethoscopes, available in many forms, are

made by several different companies. Traditional stethoscopes with ear tips are available for nurses who have mild hearing

loss not requiring the use of hearing aids, or who wear hearing aids placed deep in the ear canal. Amplified stethoscopes

are also available with headphones to be placed over hearing aids, including hearing aids that fit either behind the ear or are

molded in the ear. Still other stethoscopes can be plugged directly into the hearing aid for sound transmission. See Figure 1

for examples of amplified stethoscopes.


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Figure 1.

Amplified stethoscopes

The latest technologies for stethoscopes are amplified stethoscopes with a visual display. Some companies make visual

stethoscopes with their own hand-held device designed specifically for the healthcare professional with hearing loss. Others

make a visual stethoscope that plugs into a smartphone. These devices are very sensitive to the frequencies beyond human

hearing; many healthcare clinicians even without hearing loss are using them in their practice. See Figure 2 for visual

stethoscope examples.


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Figure 2.

Visual Stethoscope

The Americans With Disabilities Act

The Americans with Disabilities Act (ADA) was instituted in 1990 to address discrimination against individuals with

disabilities and to provide clear and enforceable standards against discrimination as determined by the U. S. Federal

Government under the 14th amendment of the U. S. Constitution (ADA, 2009). Hearing loss is not a disability specifically

named by the ADA. However, the ADA uses a general definition of disability, stating the person has a disability if "he/she has

a physical or mental impairment that substantially limits one or more major life activity, a record of such impairment, or is

regarded as having an impairment" (Job Accommodation Network [JAN], 2013, para. 13). Nurses with hearing loss may or

may not meet this definition.

Under the ADA, employers of those with hearing loss are required to provide a reasonable accommodation that enables

effective communication, barring undue hardship. These accommodations only relate to the work setting. Assistive devices

needed for personal use, such as hearing aids or cochlear implants, are not an employer- required accommodation. The use

of a sign language interpreter or the use of communication access real-time translation (CART) could be considered an

appropriate employer accommodation barring undue hardship (JAN, 2013, para. 16–19).

Advocacy Groups

Many advocacy groups are available to those healthcare professionals with hearing loss. The Association of Medical

Professionals with Hearing Losses (amphl.org/) is a web-based advocacy, mentorship network for all healthcare

professionals with a hearing loss. Although this organization is based in the Unites States, it has an active international

membership. Nursing-specific organizations, such as Exceptional Nurse (www.exceptionalnurse.com/), help to share

information and resources about nursing students with disabilities. The National Organization of Nurses with Disabilities

(www.nond.org/) works to promote equity for people with disabilities and chronic health conditions in nursing. The Society of

Nurses with Disabilities (www.nursingwithdisabilities.org/) is a branch of the larger Society of Healthcare Professionals with

Disabilities (www.disabilitysociety.org/). This is a free membership group that provides resources and tools for those who are

students or who work in the healthcare arena.

The American Nurses Association

The American Nurses Association (ANA) does not currently have a position statement or policy on nurses with disabilities, or

specifically a statement on hearing loss. Rather all registered nurses have an obligation to maintain their health and to be

aware of health issues including hearing health (C. Bickford, personal communication, July 31, 2013). To help nurses


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maintain their health, the ANA has a division called 'HealthyNurse' which addresses myriad health issues important to

nurses, including choosing nutritious foods, managing stress, maintaining an active lifestyle, living tobacco-free, getting

preventative immunizations, and other appropriate health advice and screening information (HealthyNurse, 2013). Healthy

People 2020 recommends hearing screening every five years for those over the age of 12 (U.S. Department of Health and

Human Services, Healthy People, 2013). Because hearing loss is not age discriminatory, nurses below age 50 who have

been exposed to excessive noise levels, including nurses in the military, could be at risk for hearing loss. Therefore, nurses

should be screened every five years to ensure their ability to safely and effectively function as a nurse without

accommodations.

Costs of Untreated Hearing Loss

Untreated hearing loss has emotional, social, and financial costs. The American Academy of Audiology (2013) has reported

that persons with hearing loss experience strained familial and personal relations, depression, and paranoia. They are also

less likely to participate in social engagements compared to those who treat their hearing loss with aids. The financial impact

of hearing loss on employment and wages is significant. A study of 40,000 individuals with hearing loss found these

individuals to have a lower wage, averaging $8,000 per year lower, a 25% decrease from the survey average; they were also

more likely to be unemployed (adjusted odds ratio, 2.2; p < 0.001) (Jung & Bhattacharyya, 2012). The executive director of

the Better Hearing Institute, Dr. Sergei Kochkin, has written that "delaying hearing loss treatment … negatively affects

individuals and their families for the rest of their lives in the form of lost wages, lost promotions, lost opportunities, lost

retirement income, and unrealized dreams" (Study Demonstrates Financial Dangers, 2011, para 5).

The Nurse's Responsibility for Hearing Health

Hearing health is the individual nurse's responsibility. Maintaining optimal health, including hearing health, is critical to

providing professional patient care. Nurses need to follow the Healthy People 2020 health screening recommendation that

nurses are screened every five years or sooner if needed. Nurses themselves may initiate hearing screening if they detect

hearing issues, such as difficulty with speech recognition especially in noisy settings, and/or an inability to hear patient

alarms or paging systems, to name a few important sounds. If the nurse becomes aware of a hearing loss and begins to

wear hearing aids while performing duties, the nurse is not obligated to inform his or her employer. However, the nurse must

inform the employer of a hearing deficit if the nurse is requesting accommodations.

Managers and employers are obligated to follow regulations as established by the ADA and the U.S. Equal Employment

Opportunity Commission (EEOC). Pre-employment, an employer may not ask questions about medical history, physical

impairments, or recent health screenings. After an offer is made, however, the employer may require a physical exam or

other health screenings to ensure the potential hire is able to perform duties of the role. The employer may require these

physicals or other health screenings only if the health screenings are performed on all potential hires for the same position.

An offer of employment cannot be withdrawn unless it has been determined that the individual with hearing loss is unable to

perform the essential duties of the job without reasonable accommodation. After hire, if a manager becomes aware of a

hearing loss that might impact performance issues or safety issues related to self, patients, or other employees, the

employer may ask for information about the hearing loss. If it becomes apparent that hearing accommodations are

necessary, each nurse's needs may be addressed on a case-by-case basis. Managers and employers are not required to

monitor the use of hearing aids or other assistive devices of their employees requesting (JAN, 2013; U.S. EEOC, 2006).

Conclusion

Nurses, as with the general population, need to be aware of their risk for hearing loss. Nurses, as with the general

population, need to be aware of their risk for hearing loss. Nursing is a noisy profession. Additionally, noise exposure at a

young age, as well as the increasing age of the nurses in the profession, can put nurses at risk for hearing loss. Nurses

working with an unknown hearing deficit could negatively impact healthcare-related communication, nurse efficacy, and

patient safety. Nurses should have their hearing screened every five years and accommodate any deficits as needed.

Accommodations for hearing deficits can generally be managed, and can keep experienced nurses as vibrant and effective

professionals.


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