Part I: Factors inflencing professional functioning 51 & Zijlstra, 2006; Van der Hulst et al., 2006). Third, receiving collegial support did neither influence ‘the feeling that something should change at work’, nor NFR as was earlier reported (Kraaijeveld et al., 2014). This might be explained by the small variance in collegial support reported by our population. Only a few employees reported having problems in their relationship with colleagues. We have derived work-related factors from the QEEW and ACHW, because these questionnaires are routinely performed in the ENT-Audiology clinic. Therefore, we may have missed other work-related factors that influence NFR in hearing-impaired employees, such as job control, job demand, and social support. The included scale score of collegial support does not reflect all aspects of the construct social support, since this construct also refers to helpful social interactions from supervisors (Nachtegaal et al., 2009). For future research, we recommend to include the Job Content Questionnaire whenmeasuring psychosocial work characteristics (Karasek et al., 1998). Some study limitations should be noted. First, the retrospective character of the study implicates a risk for measurement bias. For example, the hearing tests were performed by multiple clinicians following clinical protocols, rather than a research protocol, which may have caused differences in measurement settings. Despite this limitation, the four identified factors accounted for 46.1 percent of the variance in NFR and 43.1 percent of LE. Second, the cross-sectional design is a limitation of this study, since it does not allow drawing conclusions about causality. Constructing a directed acyclic graph allowed for visualization of the relationship of a broad spectrum of factors influencing NFR. Since the evidence on factors influencing NFR in hearing-impaired employees was limited, this explorative method is considered to be appropriate. A prospective study is needed to verify and validate the findings of this study. To gain further understanding in the difficulties of hearing-impaired employees and the efficacy of intervention strategies that aim to reduce these difficulties, future clinical trials are recommended to assess the efficacy of audiological, speech therapeutic, and social interventions on both LE and NFR.
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