Impact of a Cochlear Implant on Job Functioning.

Multichannel cochlear implants were first approved for use in adults with acquired profound hearing loss by the Food and Drug Administration (FDA) in 1985. Since that time patient selection criteria has been expanded by the FDA and manufacturer's recommendations to include adults with severe hearing loss, with limited benefit from hearing aids, and children with profound hearing losses. Cochlear implant devices are designed to electronically stimulate the auditory nerve to provide sound and speech information. Over 25,000 persons worldwide have received multichannel cochlear implants (Kirk, 2000). It is estimated that from 360,000 to 700,000 persons in the United States have profound hearing loss (Reis, 1982; Schow, Mercaldo, & Smedley, 1994). If persons with severe hearing loss are included in these estimates, these numbers are greatly increased.

The Nucleus mulitchannel cochlear implant system is the most commonly used system in the United States. It consists of an external headset with a microphone and transmitter, a battery-powered body worn speech processor approximately the size of a small beeper, and an internal receiver sugerically imbedded in the mastoid bone and electrode array that is implanted in the cochlea. The microphone picks up sound information and sends it to the speech processor that encodes the sound information into a digital signal. This digital signal is then sent back to the headset, and the transmitter sends the electrical signal through the skin via radio frequency waves to the internal receiver in the mastoid bone. The receiver sends the electrical impulses to the electrodes implanted in the cochlea thus stimulating the auditory nerve, and the person receives sound sensations (Estabrookes, 1998; Koch, 1996; Staller, Beiter, & Brimacombe, 1994).

Studies have shown cochlear implants to be successful in providing some auditory information to persons who receive minimal benefit from traditional hearing aids (National Institute of Health, 1995). Adults with post-lingual deafness have the best prognosis for success with cochlear implants. Post-lingual deafness is defined as having its onset after the development of speech and language (after approximately age six years). A wide range of benefits have been noted among patients, ranging from sound awareness and minimal help in speechreading to open-set speech perception without visual cues (National Institute of Health 1995; Skinner, et al., 1994; Skinner, Fourakis, Holden, Holden, & Demorest, 1996; Skinner, Holden, Holden, Demorest, & Fourakis, 1997).

One of the suggested benefits from the use of cochlear implants with adults is improvement of job satisfaction and placement. Dowler and Walls (1996) investigated 392 job-accommodation cases for individuals with hearing loss. The primary concerns of employers listed in these cases were in the areas of communication (62%) and safety (24%). The purpose of cochlear implants is to aid in both these areas by providing some auditory awareness and understanding. Studies have indicated that individuals with hearing impairment tend to have lower aspirations for vocational placements, higher unemployment rates, to be more underemployed and be paid less than their counterparts with normal hearing (Farrugia, 1982; MacLoed-Gallinger, 1992). Zain and Kelly (1996) found that attitudes about the employability of persons with hearing loss could be improved with prospective employer training. Their finding is positive in that employers may change their attitudes towards workers with hearing loss after they see successes with interventions such as the cochlear implant.

Saxon and Holmes (1996) completed a pilot study to determine the impact of a cochlear implant on the job functioning of a 60 year-old adult with profound hearing loss. A 20-item questionnaire was given to the cochlear implant patient and his two immediate work supervisors. The questions were designed to elicit information about the patient's performance prior to and after receiving his cochlear implant. The results of this study indicated that for this patient the cochlear implant has provided a positive impact in his work environment. Both the client and his supervisors stressed the improvement in his communication abilities and in his ability to hear and identify warning signals.

The purpose of this investigation was to evaluate the impact of cochlear implants on the job functioning of 21 adults with severe to profound sensorineural hearing loss. The questionnaire developed in a pilot study (Saxon & Holmes, 1996) was used to ascertain the vocational benefits of cochlear implants as perceived by the cochlear implant user and his/her direct supervisors on the job. The specific aim was to determine if clients with profound hearing loss and their employers perceive benefits in a vocational setting from the use of a cochlear implant.

Method

Participants

A 20-item questionnaire was sent to 21 cochlear implant clients from the University of Florida Cochlear Implant Program. Questionnaires were sent out to all of the adult implant clients who had acquired their hearing loss after they had developed speech and language and therefore were classified as post-lingually hearing impaired and had been implanted for at least six months. The clients agreed to participate by filling out the questionnaire, supplying names and addresses of employers and allowing us to send a questionnaire to these employers. Subjects were assured that their responses would be kept confidential and reported only as group data or using a subject number.

Demographic information on the 13 clients who returned the questionnaire is reported in Table 1. Four of these clients were retired of self employed. The other nine clients provided names and addresses of their immediate work supervisors, who were then sent the same questionnaires about their employees. Seven of the nine employers returned completed questionnaires. The questions were designed to elicit information about the client's performance prior to and after receiving their cochlear implants.

Table 1 Client Demographics

Employment    Job Title               Length of time in
                                      current position

Full time     Dump-truck driver       Over 3 years
              & heavy equipment
              operator

Full time     Teacher of the          Over 3 years
              hearing impaired

Full time     Senior accountant       Over 3 years

Full time     Veterinary technician   Over 3 years

Full time     Special Education       Over 3 years
              teacher

Full Time     Lead Machinist          Over 3 years
              Tool Maker

Full Time     Auto Mechanic           Over 3 years

Retired

Retired

Homemaker

Part-time     Landlord/               Over 3 years
              Self Employed

Full time     Level II                Over 3 years
              Micro-Processor

Full time     Fourth Grade Teacher    Over 3 years

Employment    Length of deafness   Length of time
                                   as an implant user

Full time     Over 10 years        Over 3 years

Full time     Over 10 years        Over 3 years

Full time     Over 10 years        Over 3 years

Full time     Over 10 years        Over 3 years

Full time     Over 10 years        Over 3 years

Full Time     Over 10 years        6 months to 1 year

Full Time     Over 10 years        6 months to 1 year

Retired       3 to 5 years         1 to 3 years

Retired       Over 10 years        1 to 3 years

Homemaker     5 to 10 years        Over 3 years

Part-time     Over 10 years        Over 3 years

Full time     Over 10 Years        1 to 3 years

Full time     Over 10 years        Over 3 years

Instrument

A copy of the Abbreviated Profile of Hearing Aid Benefit Questionnaire (APHAB), developed by Cox, Gilmore, and Alexander (1995), was modified for this study. The APHAB is used extensively in clinical audiology and has been found to be both a reliable and valid measure of hearing aid benefit (Cox et al., 1995). Questions were modified to be relevant for cochlear implant patients and their supervisors. Four of the original questions on the APHAB that were unrelated to the work environment were deleted so that each resulting form consisted of 20 items, and the term cochlear implant was used in place of hearing aid throughout the questionnaire. The employer's form contained all the same items but was written in the third instead of first person. Each item was a statement in which the individual responded whether or not the statement was true on a scale from always (99% of the time) to never ([is less than or equal to] 1% of the time). They scored each item twice, once "before the cochlear implant" and once "after the cochlear implant." This questionnaire was used originally in the pilot study (Saxon & Holmes, 1996).

Results

The results of the entire survey are shown in Tables 2 and 3. Figures 1 and 2 present a graphical comparison for the before and after ratings for both the clients and supervisors. The questions were rated on a 7-point scale with higher numbers indicating a more positive response. Items 1, 8, 11, 14, 15, and 17 were reversed in scoring and therefore an inverse scoring strategy was used for these items. Comparisons were made between employer and employee and the pre- and post- implant information. Results indicated that the cochlear implant had a positive impact on the job functioning as perceived by the clients (T = 11, n' = 20, p [is less than] .01) and as perceived by their supervisors (T = 30.5, n' = 20, p [is less than] .01).

[GRAPHS OMITTED]

Table 2 Client Mean Item Ratings After and Before Implant

Questions                                            After      Before
                                                    Cochlear   Cochlear
                                                    Implant    Implant

1.  When I am in a job setting, talking
    with the office staff, I can follow the
    conversation.                                     5.25       2.20
2.  I miss a lot of information when conversing
    with my supervisor and work peers.                5.33       2.70
3.  I can identify warning signals such
    as smoke detectors and alarms.                    6.31       1.40
4.  I have difficulty hearing
    a conversation one-on-one.                        5.69       2.55
5.  I have trouble understanding the
    radio or TV without caption.                      3.23       1.80
6.  When I am with several people, and
    trying to have a conversation
    with one person, understanding speech
    is difficult.                                     4.00       1.91
7.  Traffic noises are bothersome.                    4.00       6.73
8.  When I am talking with someone
    across a large empty room,
    I understand the words.                           4.25       2.20
9.  When I am in a small office,
    interviewing or answering
    questions, I have difficulty
    following the conversation.                       5.46       2.80
10. When I am having a quiet conversation
    with a friend, I have difficulty
    understanding.                                    6.23       2.60
11. I can identify the sounds of running
    water, such as a toilet of a shower.              5.85       1.20
12. When a speaker is addressing a small
    group, and everyone is listening quietly, I
    have difficulty understanding.                    5.08       1.80
13. When I am in a quiet conversation with
    my supervisor in a quiet room, it is hard to
    follow the conversation.                          6.23       2.90
14. I can understand conversations even
    when several people are talking.                  3.85       1.30
15. I can identify the sounds of
    construction work and/or
    equipment on the job.                             5.58       2.89
16. It is hard for me to understand what
    is being said at lectures.                        3.54       1.40
17. I can communicate with others
    when in a crowd.                                  4.39       2.67
18. I have to ask people to repeat themselves
    in one-on-one conversation in a quiet room.       5.85       2.60
19. I have trouble understanding others
    when an air conditioner or fan is on.             5.23       2.44
20. I have trouble understanding others
    when shop or office equipment is running.         4.59       2.11

Questions                                            Change

1.  When I am in a job setting, talking
    with the office staff, I can follow the
    conversation.                                    +3.05
2.  I miss a lot of information when conversing
    with my supervisor and work peers.               +2.63
3.  I can identify warning signals such
    as smoke detectors and alarms.                   +4.91
4.  I have difficulty hearing
    a conversation one-on-one.                       +3.14
5.  I have trouble understanding the
    radio or TV without caption.                     +1.43
6.  When I am with several people, and
    trying to have a conversation
    with one person, understanding speech
    is difficult.                                    +2.09
7.  Traffic noises are bothersome.                   -2.73
8.  When I am talking with someone
    across a large empty room,
    I understand the words.                          +2.05
9.  When I am in a small office,
    interviewing or answering
    questions, I have difficulty
    following the conversation.                      +2.66
10. When I am having a quiet conversation
    with a friend, I have difficulty
    understanding.                                   +3.63
11. I can identify the sounds of running
    water, such as a toilet of a shower.             +4.65
12. When a speaker is addressing a small
    group, and everyone is listening quietly, I
    have difficulty understanding.                   +3.28
13. When I am in a quiet conversation with
    my supervisor in a quiet room, it is hard to
    follow the conversation.                         +3.33
14. I can understand conversations even
    when several people are talking.                 +2.55
15. I can identify the sounds of
    construction work and/or
    equipment on the job.                            +2.69
16. It is hard for me to understand what
    is being said at lectures.                       +2.14
17. I can communicate with others
    when in a crowd.                                 +1.72
18. I have to ask people to repeat themselves
    in one-on-one conversation in a quiet room.      +3.25
19. I have trouble understanding others
    when an air conditioner or fan is on.            +2.79
20. I have trouble understanding others
    when shop or office equipment is running.        +2.48
Table 3 Supervisor Mean Ratings After and Before Implant

Questions                                           After      Before
                                                    Cochlear   Cochlear
                                                    Implant    Implant

1.  When he/she is in a job setting,
    talking with the office staff, he/she
    can follow the conversation.                      5.43       3.67
2.  He/she misses a lot of information when
    conversing with a supervisor and work peers.      5.00       3.67
3.  He/she can identify warning signals
    such as smoke detectors and alarms.               5.00       2.40
4.  He/she has difficulty
    hearing a conversation one-on-one.                5.43       3.20
5.  He/she has trouble understanding
    the radio or TV without caption.                  4.75       3.50
6.  When he/she is with several people, and is
    trying to have a conversation with one
    person, understanding speech is difficult.        4.86       3.00
7.  Traffic noises are bothersome.                    3.67       6.50
8.  When he/she is talking with someone across a
    large empty room, he/she understands
    the words.                                        3.80       2.75
9.  When he/she is in a small office,
    interviewing or answering
    questions, he/she has difficulty
    following the conversation.                       5.43       4.20
10. When he/she is having a quiet conversation
    with a friend, he/she has difficulty
    understanding.                                    5.57       4.40
11. He/she can identify the sounds of
    running water, such as a toilet or a shower.      6.00       1.00
12. When a speaker is addressing a small
    group, and everyone is listening quietly,
    he/she has difficulty understanding.              4.60       3.33
13. When he/she is in a quiet conversation
    with his/her supervisor in a
    quiet room, it is hard to follow
    the conversation.                                 5.57       4.40
14. He/she can understand conversations even
    when several people are talking.                  2.86       2.80
15. He/she can identify the sounds of
    construction work and/or equipment
    on the job.                                       5.60       2.33
16. It is hard for him/her to understand
    what is being said at lectures.                   4.50       3.25
17. He/she can communicate with
    others when in a crowd.                           4.86       4.00
18. He/she has to ask people to repeat
    themselves in one-on-one
    conversation in a quiet room.                     5.29       3.60
19. He/she has trouble understanding
    others when an air conditioner or fan is on.      5.00       5.25
20. He/she has trouble understanding others
    when shop or office equipment is running.         4.50       4.40

Questions                                            Change

1.  When he/she is in a job setting,
    talking with the office staff, he/she
    can follow the conversation.                     +1.76
2.  He/she misses a lot of information when
    conversing with a supervisor and work peers.     +1.33
3.  He/she can identify warning signals
    such as smoke detectors and alarms.              +2.60
4.  He/she has difficulty
    hearing a conversation one-on-one.               +2.23
5.  He/she has trouble understanding
    the radio or TV without caption.                 -1.25
6.  When he/she is with several people, and is
    trying to have a conversation with one
    person, understanding speech is difficult.       +1.86
7.  Traffic noises are bothersome.                   -2.83
8.  When he/she is talking with someone across a
    large empty room, he/she understands
    the words.                                       +1.05
9.  When he/she is in a small office,
    interviewing or answering
    questions, he/she has difficulty
    following the conversation.                      +1.23
10. When he/she is having a quiet conversation
    with a friend, he/she has difficulty
    understanding.                                   +1.17
11. He/she can identify the sounds of
    running water, such as a toilet or a shower.     +5.00
12. When a speaker is addressing a small
    group, and everyone is listening quietly,
    he/she has difficulty understanding.             +1.27
13. When he/she is in a quiet conversation
    with his/her supervisor in a
    quiet room, it is hard to follow
    the conversation.                                +1.17
14. He/she can understand conversations even
    when several people are talking.                  +.06
15. He/she can identify the sounds of
    construction work and/or equipment
    on the job.                                      +3.27
16. It is hard for him/her to understand
    what is being said at lectures.                  +1.25
17. He/she can communicate with
    others when in a crowd.                           +.86
18. He/she has to ask people to repeat
    themselves in one-on-one
    conversation in a quiet room.                    +1.69
19. He/she has trouble understanding
    others when an air conditioner or fan is on.      -.25
20. He/she has trouble understanding others
    when shop or office equipment is running.         +.10

Discussion

Both the supervisors and cochlear implant users indicated the clients were more aware of warning signals, more able to understand conversations in most environments, and were able to identify sounds in their environment after receiving their implants. These findings are congruent with the case study findings by Saxon and Holmes (1996). The only negative effect of the cochlear implants indicated by both the clients and their supervisors was that traffic noises were more bothersome than before surgery. This makes sense since prior to surgery they reported inability to hear traffic noises. The supervisors differed from the clients in the pre-implant assessments on issues relating to understanding in difficult listening situations. The supervisors tended to over rate in comparison to clients rating their own abilities to comprehend in these environments. Their post ratings were more congruent.

An individual with a cochlear implant will overcome some hearing loss that will decrease negative functional impairment previously experienced. At the same time the person must compensate for being accustomed to varying degrees of visual communication (Watson, 1990). In order for the person with the cochlear implant to maximize the use of the technology provided, a vocational evaluation is strongly suggested at this point.

The evaluator must understand the background of the individual as regards the history of hearing impairment. Thus, it becomes extremely urgent that the evaluator obtains as many pertinent records concerning the client as possible, especially any past testing results. These results need to be reviewed very carefully to determine any inherent discrimination when the testing was conducted (Herbert & Melick, 1993; Holm, 1987; Lane, 1988; National Institute of Handicapped Research [NIHR], 1983). In the preliminary assessment of the individual referred, one definite area to discover is the preferred client's communication style and accompanying competence level whether the style be reading, writing, speech, or sign (Herbert & Melick, 1993). Most adults with acquired hearing loss have little to no experience with manual communication. This basic knowledge will afford the evaluator critical information and form the foundation for the diagnostic vocational interview as well as the planning session. The results will determine what will take place in the evaluation. In addition to learning of the client's communication style, the evaluator must also take into consideration the physical environment. Such variables as level of room lighting, "noise" level, and seating location are substantial factors in evaluating a person with a hearing impairment with a recent cochlear implant. This person will undoubtedly be confused with the new levels of "noise" of sound entering into the receptive organ. Also, this person may rely on past communication skills to make the transition successfully between a severe hearing impairment and the situation where sounds take on more and more meaning. Distracting noises, ordinary to most and dismissed into the background, become strong distracters to the client in work-related situations such as instructions, on-job social interaction, and so on. Such "noises" as peripheral talking by others, telephone rings, hallway noises are to be kept to a minimum in the evaluation situation if the evaluator is to obtain meaningful information. For this reason the evaluator will necessarily need to be cognizant of the client's body language that may indicate if "noise" is interfering with the client's communication.

To facilitate the evaluation the evaluator will have to decide upon the tools to be used. Ziezuila (1982) recommends four questions to ask before choosing a particular test: 1) Is the test (instrument) composed of verbal or performance items? 2) Are verbal instructions required? 3) Are any of the items discriminatory toward a person with a hearing impairment? and 4) Are there norms based on a population with hearing impairment associated with the instrument? Once the instruments have been chosen the administration of the instruments can be more practical for the individual and obtain truer results by allowing for greater practice time, more in-depth instruction, one-on-one administration, and using norms based on hearing impaired population. It is suggested that to obtain the highest level of potential, that the evaluator allow the person to finish a particular task. This "power" testing will give useful information, even though norms cannot be used, and can be used in the final recommendations and possible suggestions for modifications and/or accommodations. A full evaluation would include a situational assessment where the client would be placed at an actual job site and work through two or three days to determine appropriateness of a possible placement. Three of these situational assessments would present both the evaluator and the client critical information for future decision making.

Since an individual with a cochlear implant may have had difficulty before in obtaining and/or maintaining a job, it may be very appropriate to consider some in-depth investigation on the client's career development. The expertise of the vocational evaluator in determining this will enhance the person's future success on the job. Many times the individual with a hearing loss has been missing out on much career development information. Field trips to actual work sites may help the client make some decisions about career choices (Herbert & Melick, 1993).

Once the evaluation has been completed the evaluator necessarily makes recommendations which ought to include training how a prospective employer might work with this individual with the cochlear implant. It is necessary to alert the employer that this individual has the skills and abilities to perform the job in question. The evaluator has to list the ways (accommodations) in which the employer will need to temporarily work with the client in order that this person be successful on the job.

Conclusion

The results of this study indicate that for clients and supervisors the cochlear implant has provided a positive impact in the work environments. Both the clients and supervisors stressed the improvement in communication abilities and in the clients' ability to hear and identify warning signals. Most of the previous research on the benefits of cochlear implants has been on communication improvements. This investigation also highlights the importance of alerting to warning signals that are primarily auditory to the job functioning of cochlear implant users. This was particularly evident in the supervisors' questionnaire results.

The small subject number in this study allowed for limited statistical evaluation. Further studies using larger subject samples could provide additional information on the vocational benefits of cochlear implants. In addition, objective measures such analysis of work performance reviews with and without the cochlear implant could be used along with subjective measures of performance.

Both clients and supervisors should be counseled on the potential benefits and limitations of cochlear implants in the workplace. Appropriate expectations as to improvements in speech communication and the ability to detect warning signals should be covered. At the same time they should be aware of the negative effects of noisy backgrounds to cochlear implant users. Cochlear implants can have a very positive impact on adults with post-lingual hearing impairment. It is recommended that rehabilitation counselors be part of cochlear implant teams.

Acknowledgement

This study was supported, in part, by a grant from the Florida Association of Speech-Language Pathologists and Audiologists Foundation.

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John P. Saxon, Ph.D., CRC, Professor, Department of Rehabilitation Counseling, Health Science Center, P.O. Box 100175, University of Florida, Gainesville, FL 32610-0175.