Nursing Home Personnel Knowledge and Attitudes About Hearing Loss and Hearing Aids

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Nursing Home Personnel Knowledge and AttitudesAbout Hearing Loss and Hearing AidsLynn Norwood-Chapman MA, CCC-A a b & Samuel B. Burchfield PhD, CCC-A ca Department of Audiology and Speech Pathology , University of Tennessee-Knoxville , TN,USAb Lamar University , P.O. Box 10076 Lamar Station, Beaumont, TX, 77710, USAc Department of Audiology and Speech Pathology , University of Tennessee-Knoxville , 457South Stadium Hall, Knoxville, TN, 37996, USAPublished online: 25 Sep 2008.

To cite this article: Lynn Norwood-Chapman MA, CCC-A & Samuel B. Burchfield PhD, CCC-A (2000) Nursing Home PersonnelKnowledge and Attitudes About Hearing Loss and Hearing Aids, Gerontology & Geriatrics Education, 20:2, 37-47, DOI:10.1300/J021v20n02_04

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Nursing Home Personnel Knowledgeand Attitudes

About Hearing Loss and Hearing AidsLynn Norwood-Chapman, MA, CCC-A

Samuel B. Burchfield, PhD, CCC-A

ABSTRACT. A questionnaire study of registered nurses, licensedpractical nurses and nursing assistants in four nursing homes showedthat the majority felt inadequately trained to care for the hearing-im-paired. A measure of attitudes towards hearing loss and amplificationwas positive and not significantly different among the nursing person-nel groups. The licensed practical nurses did have a significantly higherknowledge score regarding hearing loss and amplification than theother two groups. Results suggest the need for additional training onhearing loss and the care of hearing aids among nursing home person-nel. An outline of an in-service training program for nursing homepersonnel is also described. [Article copies available for a fee from TheHaworth Document Delivery Service: 1-800-342-9678. E-mail address:[email protected] <Website: http://www.haworthpressinc.com>]

KEYWORDS. Amplification, hearing loss, nursing homes, nurseeducation

Lynn Norwood-Chapman is a doctoral candidate, Department of Audiology andSpeech Pathology, The University of Tennessee-Knoxville, and Assistant Profes-sor, Lamar University, P.O. Box 10076 Lamar Station, Beaumont, TX 77710.Samuel B. Burchfield is Associate Professor, Department of Audiology and SpeechPathology, The University of Tennessee-Knoxville, 457 South Stadium Hall,Knoxville, TN 37996.

The authors thank Bob Muenchen for his statistical expertise and Bill Terry forhis technical assistance in producing the companion video to this study. The au-thors gratefully acknowledge the nursing personnel and the nursing homes for theirparticipation.

Portions of this paper were presented at the American Academy of AudiologyConvention in Fort Lauderdale, Florida in April, 1997.

Gerontology & Geriatrics Education, Vol. 20(2) 1999E 1999 by The Haworth Press, Inc. All rights reserved. 37

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GERONTOLOGY & GERIATRICS EDUCATION38

INTRODUCTION

One of the most prevalent chronic conditions affecting the qualityof life in older persons is hearing impairment, which ranks secondonly to arthritis in frequency of occurrence (Sarvela, Sarvela & Odula-na, 1989). In a 1983 report regarding the prevalence of hearing impair-ment, it was reported that 25% of persons aged 65 to 74 years and 40%of persons 75 and older have some form of hearing impairment. Preva-lence figures for hearing loss in nursing home residents range up to90% (Palumbo, 1990; Taylor, 1993). The high prevalence of hearingimpairment among institutionalized elderly patients is known to affectthe daily care they receive and the quality of life for the patients(Mulrow, Aguilar, & Endicott, 1990).

Recent statistics indicate that the number of elderly is increasing.From 1960 to 1980, the 65 and older population increased from 9% to11% of the total population. This number is expected to reach near39% of the total population by the year 2000 (Estes & Lee, 1990). Asthe elderly population increases, so will the prevalence of problemsassociated with hearing impairment.

Bess, Lichtenstein, Logan, Burger and Nelson (1989) studied theadverse functioning and psycho-social consequences imposed byhearing loss in older adults and found that hearing impairment was animportant determinant of functional level in elderly persons. The re-searchers expressed concern regarding the false labeling of institution-alized elderly patients as having dementia, when the true communica-tion disorder with many of these patients is the presence of significanthearing impairment. In addition to false labeling, unremediated hear-ing loss has been shown to be a contributing factor to many mentalhealth conditions in the elderly, such as loneliness, social isolation,and depression (Montano, 1993). It is crucial that hearing impairmentbe identified and treated effectively in older adults, including elderlynursing home residents.

Several recent studies have investigated nurses’ knowledge aboutcommunication disorders in a variety of professional settings, includ-ing hospitals (Johnson, Stein, Lyons, & Lass, 1995), rehabilitationsettings (Johnson, Clark-Lewis, Griffin, & Franklin, 1996), nursinghomes (Montano, 1993; Sarvela et al., 1989) and public schools (John-son, Stein & Lass, 1992). Most of these studies reported that, althoughthe nurses are knowledgeable in some areas of hearing impairment,

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Lynn Norwood-Chapman and Samuel B. Burchfield 39

there is a need for additional training, specifically in care and mainte-nance of hearing aids. Despite literature reports that suggest that com-munication disorders are a major problem for the elderly, few healthcare workers have received formal training regarding the identifica-tion, treatment, and special needs of patients with communicationdisorders.

Nurses and nursing assistants are likely to have the most directcontact with nursing home residents. Thus, they can serve as a vitallink in maintaining the ability of patients with hearing impairment tocommunicate by ensuring that hearing aids or assistive listening de-vices are working properly. To do so, however, they must have knowl-edge and skills in this area. The present study investigated the knowl-edge of, and attitudes about, hearing impairment and the basic skillsregarding hearing aids in a sample of nursing home nurses and nursingassistants.

METHOD

A questionnaire was developed by the authors, modified after Lasset al., 1989 and Johnson et al., 1992. The questionnaire contained sixitems concerning respondents’ experience with hearing impairment;nine items measured attitude towards hearing impairment and hearingaids using a modified Likert-type agreement scale; 14 yes/no itemsassessed knowledge of hearing impairment, as well as basic skills withhearing aids, hearing aid batteries, and earmolds. Additionally, therewere five true/false items that examined general knowledge of hearingimpairment.

An overall attitude score was derived by computing the mean agree-ment ratings for all attitude questions. A higher attitude score wasconsidered to reflect a more positive attitude regarding hearing im-pairment and amplification. An overall knowledge score was alsoobtained by computing the mean of the nineteen knowledge items. Ahigher knowledge score was considered to indicate a better under-standing of hearing loss and hearing aids.

Questionnaires were distributed to nurses and nursing assistants infour nursing homes in the Knoxville, Tennessee area by the Directorof Nursing at each facility. The Nursing Director was responsible fordistributing the questionnaires to the head nurse on each shift, who inturn distributed the questionnaires to the staff. All respondents com-

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pleted the questionnaire anonymously and voluntarily. All question-naires were collected by the Nursing Director and returned to thePrincipal Investigator in a postage-paid envelope. A total of 350 ques-tionnaires were distributed.

RESULTS

A total of 260 respondents provided information on the study ques-tionnaire, for a response rate of 74%. Respondents included 22 regis-tered nurses, 62 licensed practical nurses, and 153 nursing assistants.Twenty-three respondents did not provide information on their creden-tials, so their results could not be included in the analyses by nursingpersonnel group. The 260 respondents ranged in age from 18 years to76 years, with the mean age of 40.25 years (SD = 13.1 years). Therespondents had an average of 9.9 years of professional experience(SD = 10 years), with a range of less than one year to 45 years ofexperience.

Exposure to Hearing Aids and Hearing Aid Wearers

Table 1 reports the results on respondents’ exposure to hearing aidsand wearers. Twenty-seven (10.4%) of the respondents indicated thatthey have a hearing loss, but only four respondents reported wearing ahearing aid; three of these respondents were nurse assistants.

Nearly half of the respondents (117) reported receiving previoustraining in ‘‘the use and care of hearing aids,’’ however, only 44 ofthem felt they were adequately prepared to care for hearing-impairedpatients. One-quarter of the respondents (55) reported that they were‘‘somewhat’’ prepared and 18 felt that they were not adequately pre-pared to care for hearing impaired patients. Approximately half, 128(49.2%) of the 260 respondents believed that 51% to 75% of theirnursing home patients are hearing-impaired, yet less than 25% of thesepatients wore hearing aids.

Attitudes

Table 2 reports the means and standard deviations of scores reflect-ing the nurses and nursing assistants’ attitudes toward persons with

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TABLE 1. Nursing Home Personnel Experience with Hearing Impairment andAmplification

LicensedTotal Registered Practical NursingRespondents* Nurses Nurses Assistants(N = 260) (n = 22) (n = 62) (n = 153)

Questionnaire Item No. (%) No. (%) No. (%) No. (%)

Do you have a hearing loss? NO: 232 (89.2) 20 (90.9) 57 (91.7) 135 (88.2)YES: 27 (10.4) 2 (9.1) 5 (8.1) 17 (11.1)

If Yes, do you wear ahearing aid? YES: 4 (1.5) 0 0 3 (2.0)

Have you had any training in theuse and care of hearing aids? NO: 144 (55.4) 15 (68.2) 34 (54.8) 82 (53.6)

YES: 98 (37.7) 6 (27.3) 26 (41.9) 57 (37.3)

If Yes, did this training adequatelyprepare you to care forhearing impaired patients? NO: 18 (6.9) 0 6 (9.7) 11 (7.2)

SOMEWHAT: 55 (21.2) 2 (9.1) 19 (30.6) 29 (19.0)YES: 44 (16.9) 5 (22.7) 6 (9.7) 29 (19.0)

What percentage of your patients do youthink are hearing impaired?

0-25%: 26 (10.0) 0 5 (8.1) 20 (13.1)26-50%: 65 (25.0) 7 (31.8) 13 (21.0) 40 (26.1)51-75%: 128 (49.2) 12 (54.5) 30 (48.4) 73 (47.7)76-100%: 32 (12.3) 3 (13.6) 11 (17.7) 15 (9.8)

What percentage of these hearing impairedpatients own or wear hearing aids?

0-25%: 188 (72.3) 17 (77.3) 51 (82.3) 109 (71.2)26-50%: 46 (17.7) 5 (22.7) 8 (12.9) 28 (18.3)51-75%: 16 (6.2) 0 2 (3.2) 7 (4.6)76-100%: 5 (1.9) 0 0 5 (3.3)

*Twenty-three respondents did not specify certification level.

hearing impairment. The attitude score was derived by computing themean agreement ratings for the nine attitude items, with reverse scor-ing carried out for four items. The attitude score was calculated suchthat a rating of ‘‘1’’ was given to the most negative response to an itemand a rating of ‘‘6’’ to the most positive response. Thus, the higher theattitude score, the more positive the attitude towards hearing loss andhearing aids. The group mean attitude score was 4.78 (SD = .69) witha range of scores from 3.55 to 6.0.

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TABLE 2. Mean and Standard Deviation of Attitude Scores on Hearing Impair-ment and Amplification



I am comfortable talkingto people who wearhearing aids.+ 5.51 (0.28) 5.45 (0.27) 5.60 (0.29) 5.54 (0.27)

I am uncomfortable handling hearing aidsfor fear I might damage it. 3.72 (0.09) 4.27 (0.13) 3.77 (0.11) 3.65 (0.10)

Hearing aids are a worthwhile expense.+ 4.97 (0.24) 5.09 (0.22) 5.26 (0.27) 4.94 (0.24)

People who wear hearing aids tend to feelsorry for themselves. 4.60 (0.16) 5.86 (0.25) 4.84 (0.18) 4.41 (0.14)

People who wear hearing aids tend to beembarrassed about their hearing aids. 3.77 (0.07) 4.27 (0.13) 3.55 (0.06) 3.72 (0.07)

People who wear hearing aids are sociallymore restricted than those who do notwear hearing aids. 4.47 (0.15) 5.14 (0.21) 4.52 (0.14) 4.31 (0.13)

People look older when they wearhearing aids. 5.15 (0.28) 6.0 (0.27) 4.98 (0.27) 5.19 (0.29)

People who wear hearing aids are equallyintelligent as those who do not wearhearing aids.+ 5.30 (0.31) 5.95 (0.39) 5.68 (0.36) 5.18 (0.29)

I would wear a hearing aid if it wererecommended for me.+ 5.54 (0.32) 5.73 (0.31) 5.55 (0.32) 5.54 (0.31)

Overall Attitude Score 4.78 (0.69) 5.30 (0.69) 4.86 (0.78) 4.72 (0.73)

Note: Scores calculated such that 1 = most negative response to an item and 6 = most positive response.*Twenty-three respondents did not specify certification level.+Denotes items reverse scored.

The majority (91.9%) of the nursing home personnel reported thatthey felt comfortable talking with the hearing-impaired, yet 52% wereuncomfortable handling hearing aids for fear of damaging the device.When categorized by nursing certification level, the registered nursegroup (M = 5.3, SD = .69) tended to have the more positive attitudethan either the licensed practical nurse group (M = 4.86, SD = .78) or

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the nurse assistant group (M = 4.72, SD = .73); however, an analysis ofvariance did not indicate a significant difference among the total atti-tude scores for the three groups.

Knowledge

Table 3 presents the results from the fifteen items regarding theknowledge about hearing aids and earmolds from the three categoriesof nursing home personnel. Among all nurses, more than half of therespondents (58%) could identify the parts of a hearing aid and 70%understood how a hearing aid works; however, only 21% knew howlong batteries should last. The majority of the respondents (87.7%) feltthey could properly insert/remove a hearing aid from someone’s ear,yet 24% thought that hearing aids could be washed and 40% did notknow what causes ‘‘feedback.’’

Table 4 describes the results for the five true/false items. A com-bined knowledge score was obtained by taking the mean of all 19knowledge questions. A higher knowledge score was considered tobe indicative of a better understanding of hearing loss and hearingaids. The overall mean score for all nursing personnel groups was12.7 (SD = 3.14) with a range of scores from 5 to 19. An analysis ofvariance of the nursing personnel group means indicated a signifi-cant difference between the three groups (F (2, 236) = 11.8, p <.01). Licensed practical nurses had a significantly higher knowl-edge score (M = 14.3, SD = 2.5) than either the registered nurses(M = 13.1, SD = 3.2) or the nursing assistant group (M = 12.2, SD =3.0). A Pearson product moment correlation coefficient failed to showa relationship between the attitude score and the knowledge score (r =.073). This suggests that, for these nursing home workers, there is nota relationship between a positive attitude regarding hearing loss andamplification and their knowledge about hearing loss and hearing aids.

DISCUSSION

The results of this study indicate the majority of the nursing homepersonnel surveyed expressed a positive attitude about hearing loss,the hearing impaired, and amplification. Although the attitude scoreswere not significantly different among the three groups, the registered

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TABLE 3. Nursing Home Personnel Knowledge About Hearing Aids



Could you identify the parts(microphone, volume control,receiver) of a hearing aid? NO: 102 (39.2) 10 (45.5) 20 (32.3) 63 (41.2)

YES: 151 58.1) 11 (50.0) 41 (66.1) 86 (56.2)

Do you have a rough understandingof how a hearing aid works? NO: 76 (29.2) 8 (36.4) 11 (17.7) 50 (32.7)

YES: 183 (70.4) 14 (63.6) 51 (82.3) 102 (66.7)

Could you remove a hearing aidfrom and insert a hearing aidinto someone’s ear? NO: 31 (11.9) 4 (18.2) 3 (4.8) 20 (13.1)

YES: 228 (87.7) 18 (81.8) 59 (95.2) 132 (86.3)

Can hearing aids be washed? NO: 179 (68.8) 15 (68.2) 37 (59.7) 110 (71.9)YES: 18 (24.2) 6 (27.3) 24 (38.7) 30 (19.6)

Do you know what NO: 61 (23.5) 3 (13.6) 5 (8.1) 46 (30.1)feedback is? YES: 198 (76.2) 19 (86.4) 57 (91.9) 107 (69.9)

Do you know whatcauses feedback? NO: 106 (40.8) 10 (45.5) 25 (40.3) 60 (39.2)

YES: 154 (59.2) 12 (54.5) 37 (59.7) 93 (60.8)

Do all hearing aids NO: 47 (18.1) 5 (22.7) 3 (4.8) 34 (22.2)use batteries? YES: 207 (79.6) 17 (77.3) 58 (93.5) 115 (75.2)

Are there different sizesof batteries? NO: 30 (11.5) 3 (13.6) 1 (1.6) 23 (15.0)

YES: 224 (86.2) 19 (86.4) 60 (96.8) 126 (82.4)

Do you know where to purchasehearing aid batteries? NO: 51 (19.6) 4 (18.2) 7 (11.3) 32 (20.9)

YES: 207 (79.6) 18 (81.8) 55 (88.7) 119 (77.8)

Do you know how longhearing aid batteries last? NO: 204 (78.5) 18 (81.8) 46 (74.2) 122 (79.7)

YES: 55 (21.2) 4 (18.2) 16 (25.8) 30 (19.6)

Are hearing aid batteriespoisonous if swallowed? NO: 31 (11.9) 3 (13.6) 6 (9.7) 17 (11.1)

YES: 219 (84.2) 19 (86.4) 54 (87.1) 130 (85.0)

Do you know what NO: 95 (36.5) 6 (27.3) 15 (24.2) 64 (41.8)an earmold is? YES: 162 (62.3) 16 (72.7) 47 (75.8) 86 (56.2)

Are you able to attach an ear-mold to a hearing aid? NO: 131 (50.4) 10 (45.5) 29 (46.8) 79 (51.6)

YES: 116 (44.6) 11 (50.0) 30 (48.4) 67 (43.8)

Can earmolds be washed? NO: 92 (35.4) 7 (31.8) 20 (32.3) 57 (37.3)YES: 136 (52.3) 14 (63.6) 36 (58.1) 76 (49.7)

*Twenty-three respondents did not specify certification level.

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TABLE 4. Responses to True/False Knowledge Items Regarding Hearing Im-pairment



Anyone with a hearing loss canbenefit from a hearing aid. TRUE: 83 (31.9) 2 (9.1) 51 (82.3) 60 (39.2)

FALSE: 174 (66.9) 20 (90.9) 11 (17.7) 92 (60.1)

The larger the hearing aid, thelouder it makes sounds. TRUE: 11 (4.2) 0 0 8 (5.2)

FALSE: 246 (94.6) 22 (100) 62(100) 145 (94.8)

Hearing aids are not usefulto individuals over 65 years old. TRUE: 5 (1.9) 0 0 3 (2.0)

FALSE: 252 (96.9) 22 (100) 62(100) 149 (97.4)

The more expensive the hearingaid, the better it will improve aperson’s hearing. TRUE: 17 (6.5) 0 0 14 (9.2)

FALSE: 238 (91.5) 22 (100) 62(100) 136 (88.9)

It is difficult and frustrating totalk to hearing-impaired patients. TRUE: 82 (31.5) 5 (22.7) 25 (40.3) 45 (29.4)

FALSE: 170 (65.4) 17 (77.3) 35 (56.5) 106 (69.3)

* Twenty-three respondents did not specify certification level.

nurses had higher scores and a greater variability of scores than thelicensed practical nurses and nursing assistants. In terms of knowledgeabout hearing impairment, there are several areas of incomplete orincorrect information revealed. Licensed practical nurses indicatedgreater knowledge of hearing loss and hearing aids than either theregistered nurses or the nursing assistants. Again, there was a widerange of variability in the registered nurses’ knowledge scores, indi-cating that while some are very knowledgeable about hearing loss andhearing aids, others lack adequate information.

In-Service Education and Companion Video

It is apparent that basic information about hearing impairmentand hearing aids could assist nursing home personnel in caring fortheir patients. Providing this information to the nursing home per-sonnel could be incorporated into a staff in-service program forexisting personnel or as part of the new employee orientation pro-gram.

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Based on the results of this study, the authors developed an in-service education program and companion video for the nursinghome personnel. The in-service program and video were dividedinto two topic areas: hearing loss and amplification devices. Apracticum section was also included in the in-service program for‘‘hands-on’’ experience. The topic area regarding hearing loss in-cluded information about: (1) anatomy and physiology of the ear,(including outer ear, middle ear, inner ear, and the auditory nervoussystem; (2) causes and treatments for hearing loss; (3) audiograminterpretation and familiar sounds; (4) signs of hearing impairment;and (5) communication strategies for family members and for med-ical personnel. The topic area regarding amplification devices in-cluded information about: (1) parts and operation of four hearingaid styles and sizes; (2) insertion and removal techniques for eachhearing aid style; (3) care and maintenance of the hearing aids; (4)trouble-shooting tips for malfunctioning hearing aids; and (5) assistivelistening devices and systems (ALDS).

A companion video was developed to assist the in-service programsince many nurses would not be able to attend the in-service due tovaried work schedules and other attendance restraints. The video wasproduced by the authors and recorded by the TelecommunicationsDepartment at The University of Tennessee. It was included in thein-service program information that was distributed. There are othercommercially available videos on this topic; however, the informationpresented in many of the commercial videos is not specific to nursinghome personnel as in the companion video produced for this in-ser-vice program.

CONCLUSION

The results of this study indicate that although many of the nursinghome personnel who participated had not received any formal trainingregarding hearing loss and hearing aids, there tended to be a positiveattitude towards the hearing impaired and some basic knowledge ofhearing aids. Additional training of the nursing personnel about hear-ing loss and audiologic devices is vital to providing quality audiologicrehabilitation to patients with hearing impairment, especially in nurs-

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ing home settings. An in-service education program and accompany-ing video on hearing loss and amplification devices was developed toaddress this need for training. Program information and the compan-ion video are available by contacting the first author at the addressprovided.

REFERENCES

Bess, F., Lichtenstein, J., Logan, S., Burger, J., & Nelson, E. (1989). Hearingimpairment as a determinant of function in the elderly. Journal of the AmericanGeriatrics Society, 37, 123-128.

Estes, C. L., & Lee, P. R. (1990). Health problems and policy issues of old age. InL. H. Aiken & D. Mechanic (Eds.), Applications of Social Science to Clinical Medi-cine and Health Policy (pp. 174-200). New Brunswick, NJ: Rutgers University Press.

Johnson, C. E., Clark-Lewis, S. Griffin, D., & Franklin, C. (1996). Multi-skillingand amplification: OTs, PTs and nurses in rehabilitation settings. Poster presented atSixth Annual American Academy of Audiology Convention, Salt Lake City.

Johnson, C. E., Stein, R. L., & Lass, N. J. (1992). Public school nurses’ prepared-ness for a hearing aid monitoring program. Language, Speech and Hearing Servicesin Schools, 23, 141-144.

Johnson, C. E., Stein, R. L., Lyons, R., & Lass, N. J. (1995). Study surveys viewsof nurses on hearing aids, hearing aid wearers. Hearing Journal, 48(2), 29-31.

Lass, N. J., Woodford, C. M., Pannbackerm M. D., Carlin, M. F., Sangia, R. D.,Schmitt, J. F., & Everly-Myers, D. S. (1989). Speech-language pathologists’ knowl-edge of, exposure to, and attitude toward hearing aids and hearing aid wearers.Language, Speech and Hearing Services in Schools, 20, 115-132.

Montano, J. J. (1993). Knowledge and needs of nursing personnel regardinghearing impairment and hearing rehabilitation of long-term patients. Unpublisheddoctoral dissertation, Columbia University Teachers College, Boston.

Mulrow, C., Aguilar, C., & Endicott, J. (1990). Association between hearingimpairment and the quality of life of elderly individuals. Journal of the AmericanGeriatrics Society, 38, 45-50.

Palumbo, M. V. (1990). Hearing access 2000: Increasing awareness of the hearingimpaired. Journal of Gerontological Nursing, 16(9), 26-31.

Sarvela, P. D., Sarvela, J. L., & Odulana, J. (1989). Knowledge of communicationdisorders among nursing home employees. Nursing Homes, 38, 21-24.

Taylor, K. S. (1993). Geriatric hearing loss: Management strategies for nurses.Geriatric Nursing, 14(2), 74-76.

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Nursing Home Personnel Knowledge and Attitudes About Hearing Loss and Hearing Aids