THE OCCUPATIONAL STRESS INDEX An Approach Derived from Cognitive Ergonomics and Brain Research for Clinical Practice
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CAMBRIDGE INTERNATIONAL SCIENCE PUBLISHING
Contents
1
2
Acknowledgements
iv
Introduction
1
The Need for the Occupational Stress Index—An Approach Derived from Cognitive Ergonomics and Brain Research for Clinical Practice
1
The Impact of Stressful Work on Health
4
How research in this area has proceeded: The crucial role of models The Job Strain Model The Effort Reward Imbalance Model
4 4 5
Evidence concerning exposure to psychosocial work stressors and adverse health outcomes
5
Cardiovascular Disease Hypertension Musculo-Skeletal Disorders Mental Health Outcomes Occupations with Evidence of Risk for Adverse Stress-Related Health Outcomes Professional Drivers Health Care Professionals Teachers Air Transport Professionals Sea Pilots Other Occupational Groups
5 10 11 11
12 12 13 14 14 15 15
ii
3
4
5
How Insights from Cognitive Ergonomics and Brain Research Inform our Assessment of the Work Environment
16
How we handle Information: A Neurophysiologic View Levels of Information Transmission: High Demands versus Underload Knowledge-Based versus Skill-Based Information Processing Threat Avoidant Vigilance The Conflict Dimension Physically Aversive Exposures
16 22 27 30 34 36
Occupation-Specific versus Generic Self-Report Measures To Assess Workplace Exposures The Occupational Stress Index as an Additive Burden Model to Help Bridge The Gap
38 38
The Occupational Stress Index (OSI) Model – Revised Version
40
The Organization of the OSI Levels of Information Transmission Stressor Aspects The Two-Dimensional Matrix The OSI Summations
41 41 41 42 42
The Generic versus Specific OSI’s The Generic OSI Occupation Specific OSI’s OSI for Professional Drivers OSI for Physicians OSI for Clerical Workers OSI for Teachers Other Specific OSI’s in Development
43 43 44 44 49 50 50 51
The Occupational Stress Index In Clinical Practice Preparing a Narrative Occupational History, which includes Psychosocial Stressors as This Informs a Work-Related Diagnostic and Management Plan
53 53
The Clinician’s Challenge An Approach to taking a Work History which includes Psychosocial Stressors, Based upon the OSI
53 54
iii Part I—Pedagogical Occupational Histories based upon the OSI A. Physician Specialist in Neuropsychiatry--using the OSI for MD’s B. Long Route Truck Driver--using the OSI for professional drivers C. Administrative Assistant--using the OSI for those who work daily with computers D. Automobile Assembler—using the Generic OSI
58 58 79 92 120
Part II--Pedagogical Clinical Cases based upon the OSI-derived Occupational Histories 139 A. Physician with Paroxysmal Supraventricular Tachycardia 139 B. Truck Driver with silent myocardial ischemia & complex arrhythmias 142 C. Administrative Assistant with Angina Pectoris 146 D. Automobile Assembler – Status Post Acute Myocardial Infarction 150
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7
Assessment And Approach To Management: Answers To Questions From The Cases
154
The Revised OSI Questionnaires and Score Sheets
163
The Revised Version of the Generic OSI Questionnaire Score Sheet
165 180
The Revised Version of the OSI for Professional Drivers Questionnaire Score Sheet
197 206
The Revised Version of the OSI for Physicians Questionnaire Score Sheet
219 233
The OSI for Teachers Questionnaire Score Sheet
248 264
Conclusions and Future Perspectives
280
Bibliographic References
282
iv
Acknowledgements I would like to express my appreciation to family, teachers and colleagues for support, inspiration and dialogue. I also wish to thank my patients and participants in research projects, as well as many other working people who have shared their concerns and experiences. For their cooperation and help throughout the years, I thank many librarians. Thanks are also due to my students who have participated in these research and pedagogical endeavors. In the most recent period, I have had a chance to communicate electronically with numerous clinicians and researchers throughout the world about the Occupational Stress Index. I am grateful for their queries and interest – these have been a prime motivation for this work. The pedagogical cases and parts of Chapter 3 were prepared for Courses in Occupational Health Psychology and Occupational Cardiology at the University of California, Los Angeles and Irvine, respectively, and this was supported, in part, by a teaching grant from the U.S. National Institutes for Occupational Health and Safety (NIOSH). Permission to reproduce figures was granted by Elsevier Science Publishers for Fig 3.1 and 3.17; and by Taylor and Francis publishers (http://www.taylorandfrancis.com) for Fig. 3.12 and 3.13. Those who have participated in the development of the specific OSI’s are acknowledged in the corresponding sections of Chapter 4. This work is dedicated to the memory of Professor Ludwig Edinger, my great granduncle, whose neuroanatomic discoveries have been an impetus for inquiry.
Chapter 1
Introduction The Need for the Occupational Stress Index—An Approach Derived from Cognitive Ergonomics and Brain Research for Clinical Practice Paraphrasing the late Professor Bertil Gardell, a pioneer in the effort to develop multi-facetted strategies to humanize the work environment: work is one of the most important potential sources of social and psychological well-being, which can provide much of the meaning and structure in adult life (Gardell 1987). Unfortunately, however, for many working people, this potential is far from reality. Instead, the contemporary work environment has all too frequently become the locus in which employed adults spend the majority of their waking hours performing activities that are characterized as demanding, constraining, and otherwise stressful. Reflecting pressures of global competition, trends in working life are towards increasing job demands, working hours and job instability. Growing dependence on computer technology, which could improve working life, has de facto lead to greater workload and pressure. The toll taken by unhealthy work is enormous. Mental health problems and other stress-related disorders are recognized to be the largest overall cause of premature death in Europe (Levi 2002). Cardiovascular disease, the major cause of morbidity and mortality in the industrialized world, and for which the stressful work environment is increasingly recognized as an important risk factor (Belkic 2000a, Karasek 1990, Kristensen 1998, Schnall 2000), is projected within the next twenty years, to become the leading cause of death worldwide (Braunwald 1997). In purely economic terms, a recent estimate is that job-related cardiovascular disease costs for the U.S. alone amount to $22.5 billion annually (Leigh 2000). At the same time, there have been tremendous strides made in our understanding of the human nervous system. This knowledge could potentially be used to help create working conditions that are in harmony with human needs. As stated in the Tokyo Declaration on Work-Related Stress and Health (1998): “The growth of neuroscience and stress science has allowed elucidation of the links between social structures and processes (at work and outside it), the way in which these are perceived and appraised and the resulting interaction between the central nervous system and other organ systems to promote or counteract workers' health, based on a bio-psycho-social approach to all relevant aspects of the [human] – environment ecosystem and its dynamics” (p. 2). One of the critical stumbling blocks in this process has been confusion between the objective characteristics of a given set of working conditions, and how the individual perceives and responds to these. Rohmert’s formulation (1971) is a helpful starting point for clarification: “It seems to be an advantage to distinguish between the evaluation of work and the assessment of the human operator. The independent factors of work (or control tasks) affect as stressors, stress. The dependent physiological, psychological and social
2 reactions…[of a given individual] due to these stressors affect strain. The amount of strain always depends upon the given components of stressors and the individual capacities of [a given person] at work” (p. 546). This distinction becomes particularly important for occupations in which many of the most taxing stressors are not readily apparent, and it is here, as we will outline, that insights from brain research and cognitive ergonomics prove to be invaluable. Our basic motivation in this work is practical—to offer the reader a way to apply a methodology derived from cognitive ergonomics and brain research for assessing work stressors: the Occupational Stress Index (OSI) (Belkic 1989). In order to do so, we needed to present some basic information about how the brain receives and handles information: the aversions and affinities of the human nervous system in relation to the environment. This is done very briefly in Chapter 3, with illustrations to facilitate this aim, and, hopefully, to spark interest and curiosity to delve further. This also represents a unified vantage point from which various types of stressors: “mental”, physical, ergonomic and organizational can be considered in concert, with respect to their effect upon the central nervous system. Chapter 3 provides an introduction to the OSI framework, which is presented formally and in detail in Chapter 4, entitled, “Occupation-Specific Versus Generic Self-Report Measures To Assess Workplace Exposures: The Occupational Stress Index as an Additive Burden Model to Help Bridge the Gap.” Here, we discuss two divergent trends in occupational psychosocial research. One is represented by theory-based, generic approaches, which tend to be remote from actual work experiences, and therefore are often not helpful for assessing within-occupation variance, the very level at which intervention strategies are developed, in practice. The other trend has been that of occupation-specific inquiries, which provide rich, detailed information often useful for identifying key areas for intervention. These have usually been so focused upon a given occupation, that more generalizable conclusions based upon between-group analyses are often missed. This is precisely where the OSI can offer a potential solution, namely by providing a series of occupation-specific instruments that are all mutually compatible within the OSI framework: allowing betweenoccupation comparisons, but at the same time far more operationalized and streamlined than a single generic instrument. The utility of this approach is illustrated with respect to the OSI for professional drivers, which has been applied most widely, and for which within-group and between-group criterion validity have been demonstrated. We also present initial results from the OSI for Physicians, and describe the progress made in developing OSI’s for teachers, factory workers, those who work daily with computers, as well as for other occupational groups. We especially focus on the clinical arena, which has heretofore remained relatively isolated from the rapidly growing field of occupational psychosocial health. In Chapter 2, for that audience in particular, we describe the Job Strain (Karasek 1979) and Effort Reward Imbalance Models (Siegrist 1991, 1996), and how their evolution and wide application have represented a key turning point for this field of research. We then briefly summarize the large body of empirical evidence concerning exposure to Job Strain and to Effort Reward Imbalance and health outcomes including cardiovascular and cerebro-vascular disease, hypertension, musculo-skeletal problems (repetitive-motion disorders) and adverse mental health outcomes, especially burnout and depression. Data are also reviewed regarding specific occupations at
3 increased risk for deleterious stress-related disorders. Of note here are the limitations of the Job Strain Model as currently operationalized, e.g. for single occupation studies of ambulatory blood pressure responses during work, as well as for detecting the reasons why city mass transit drivers and other professional drivers are at such high risk for cardiovascular disease. Chapter 5 is devoted to the application of the OSI in clinical practice. The OSI provides the necessary information for obtaining a comprehensive occupational history, including not only psychosocial exposures, but also those of a physical and chemical nature, as well as considering other key stressors such as long work hours and shift work, inter alia. From each of four completed OSI’s: for a physician, a truck driver, an administrative clerical worker who works daily with computers, and an automobile assembler, we provide step-bystep instructions on how to prepare a narrative history. These can be viewed as examples of occupational histories that could be incorporated into the general medical history. In Part II of this Chapter, four complete clinical cases are presented, with diagnostic and management issues informed by each of the OSI’s and their corresponding narrative histories from Part I. This chapter was designed for pedagogical purposes1. We therefore pose a set of questions for each case, and provide some possible answers at the end of the Chapter. Perhaps the most important questions to ask oneself in reading Chapter 5 are: (1) what would have been missed if the occupational history were not included? (As is now very often the standard of care, particularly in clinical cardiology, which is the major domain of these clinical cases), and (2) how can the insights gained from the work history inform various possible diagnostic and management scenarios? The development of the OSI framework and the specific questionnaires has been a long-term process. In Chapter 6 we present for the first time, the revised versions of the generic OSI and of the specific OSI’s for professional drivers and physicians, as well as the newly developed OSI for teachers. Together with the questionnaires are explicit instructions for coding and data analysis. Permission to use any of the OSI instruments should be obtained from this author. Our policy is to provide permission free-of-charge for all research endeavors aimed at improving the job conditions and health of working people. We will be happy to answer questions concerning its application, and to discuss how the OSI might be best implemented in a given setting, and look forward to dialogue and feedback.
1
The cases are not based on any individual patient.
4
Chapter 2
The Impact Of Stressful Work On Health How research in this area has proceeded: The crucial role of models It has long been suspected that exposure to stressors of the modern work environment may be related to adverse health outcomes. Karasek and Theorell (1990), in discussing how this area originally developed, note that the question of whether the social organization of work caused serious physical illness would require scientific evidence of such associations, that evidence of subjective perceptions, such as job dissatisfaction, would not be sufficient to generate the political will to redress worker hazards related to psychosocial exposures. They pointed out (ibid) that this evidence would be far more difficult to accumulate, compared to that for physical or chemical work exposures, where the cause of injury was often obviously jobrelated. The critical obstacle was, in fact, the theoretical conceptualization, modeling and measurement of workplace stressors. The Job Strain Model A pioneering breakthrough came in 1979 with the introduction of the Job Strain (DemandControl) Model (Karasek 1979). The model was developed for work environments in which stressors are “chronic, not initially life-threatening and the product of sophisticated human organizational decision making. In decision making the controllability of the stressor is critical, and it becomes more important as increasingly complex and integrated social organizations develop, with ever more complex limitations on individual behavior”. The model has two components: “psychological demands, and a combined measure of task control and skill use, or decision latitude”. Job strain occurs when the human organism is overloaded psychologically and at the same time deprived of control over his or her work environment, a combination which is predicted to give rise to increased risk of stress-related illness (Karasek 2000, p.78). A second hypothesis of the model is that high demands together with high levels of decision-making latitude lead to the “active learning” of new, salutogenic behaviors, e.g. improved coping, and may thereby lead to improved health (Ibid). Later, Johnson and Hall (1988) added social support, as a third dimension of the Job Strain Model. When workers are faced with adverse working conditions, a dynamic process of improving these conditions via "collective control" emerges from joint, supportive efforts. This, and other forms of social support at work, can serve as an important buffer against ill health. On the other hand, workers who are faced with high psychological demands and low decision-latitude and who are also socially isolated at work are in the worst situation. This Demand-Control-Support model has high face validity. The model is readily embraced by working people, who tell us that these general concepts coincide very well with
5 their real life experience. As stated recently by Karasek and Theorell (2000): "The ... model is useful educationally when a worksite is being explored. The model has great face value, and the employees immediately grasp the importance of it in the practical exploration of the psychosocial work environment." (p. 78) Exposure to job strain can be assessed from self-report via questionnaire, with the dimensions operationalized in the form of short, general instruments, most frequently the Job Content Questionnaire (JCQ) or the Psychosocial Job Strain Questionnaire (PSJSQ) (Johnson 1988, Karasek 1998, Theorell 1988, Landsbergis 2000). These are feasibly administered in field and epidemiological studies. Data linkage methods have been developed in the U.S. and in Sweden, so that exposure to Job Strain (as well as “iso-strain” in Sweden) can also be inferred from occupational title alone, i.e. the imputation method (Johnson 1993, Schwartz 2000a). External assessment of job characteristics (e.g. by an expert observer) is yet another method for obtaining exposure data. (For an in-depth discussion of methodological issues, see Landsbergis, Theorell et al. (2000)). The Effort Reward Imbalance Model An alternative, yet complementary way of looking at psychosocial work stressors is embodied in the Effort-Reward Imbalance (ERI) Model (Siegrist 1991, 1996). This model emphasizes lack of reciprocity between efforts spent and rewards received. The latter include monetary rewards, as well as esteem, career opportunities and job security. Efforts can be both extrinsic (job demands and obligations) and intrinsic (over-commitment by the individual to work). Compared with the Job Strain Model, with its emphasis on moment-to-moment control over the work process (namely, decision-making latitude), the ERI Model focuses upon macrolevel, longer-term control as reflected in rewards such as income, recognition and chances for job advancement. As pointed out by Belkic, Schnall, Landsbergis and Baker (2000(a)): “Key dimensions are shared by the Job Strain and ERI Models: both control as well as challenge (demands) are an integral part of each. However, control varies—from micro (task) level in the former, to macro level in the latter. The nature of the challenge varies from model to model, but there is a challenge of some kind in each.” (p. 310) The components of each of these two models are shown in Table 2.1a and b, respectively. A burgeoning body of epidemiological studies has emerged examining these exposures in relation to a number of health outcomes. Evidence concerning exposure to Psychosocial Work Stressors and Health Outcomes Cardiovascular Disease The intimate connections between the social environment and the central nervous system (CNS) and the CNS and the cardiovascular system via the autonomic and neuroendocrine
6 systems, together with clinical observations, have long suggested that work stressors may impact upon cardiovascular morbidity and mortality.
TABLE 2.1A Components of the Job Strain Model ___________________________________________________________________________ Psychological job demands: Working very hard Working very fast Excessive Work Conflicting Demands Not having enough time to get the job done
Decision latitude: Skill Discretion Job requires learning new things Job provides opportunities to develop one’s skills Job requires a high level of skill Job requires creativity Job entails a variety of things to do Job does not involve a lot of repetitive work
Decision Authority Job allows making one’s own decision Job provides a lot of freedom as to how the work gets done Job provides a lot of say on the job Job allows taking part in decisions affecting oneself ____________________________________________________________________________________________ Derived from: Karasek RA, Russell RS, Theorell T. Physiology of stress and regeneration in job-related cardiovascular illness. J Hum Stress 1982; 8: 29-42.
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TABLE 2.1B Extrinsic Components of the Effort Reward Imbalance Model _______________________________________________________________ Extrinsic Effort Constant time pressure due to heavy workload Many interruptions and disturbances on the job Pressured to work overtime Physically demanding work Job has become increasingly demanding
Reward Esteem Respect from superiors Respect from colleagues Respect and prestige based on efforts and achievements Adequate support in difficult situations Not treated unfairly Monetary Gratification/Security and Career Opportunities Adequate salary/income given efforts and achievements No undesirable change at work Promotion prospects Job security Job reflects education and training Adequate work prospects given efforts and achievements
___________________________________________________________________ Derived from: Siegrist J, Peter J. Measuring effort-reward imbalance: Guidelines. University of Duesseldorf,1999.
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Job Strain and Cardiovascular Disease The Job Strain Model has been the most widely used means of evaluating the psychosocial work environment as it may impact upon cardiovascular disease (CVD), with some studies incorporating the third dimension of social isolation, as well. Since the introduction of the Model, a large number of empirical investigations have been published concerning the relation between job strain and CVD outcomes, including acute myocardial infarction (MI), other manifestations of ischemic heart disease and CVD-related mortality. Many of these studies report significant positive findings, and job strain is increasingly receiving attention as a potential contributor to CVD risk (Barsky 2001, Hemingway 1999, Kristensen 1998, Schnall 1994). On the other hand, however, there have been several non-confirmatory findings concerning job strain and CVD outcomes published from large-scale studies. These results spurred some questions concerning the strength and consistency of the evidence. Recently, using a pre-defined set of criteria, we systematically examined the empirical studies on job strain and CVD. The criteria2 were developed to assess the methodological issues affecting internal validity of studies on this topic, and, whenever possible, to identify the direction in which the results would most likely be affected. Other major elements of causal inference besides strength and consistency of the association were also reviewed. We thereby sought to provide a more definitive answer to the question: Is job strain a major CVD risk factor (Belkic 2002, 2003)? We found that notwithstanding their high methodological quality, in all but one of the fourteen examined longitudinal studies, biases towards the null were predominant, due most often to use of the imputation method and long follow-up times during which there was no assessment of exposure or even employment status. Viewed in this light, we considered that six investigations, including several of the largest, showing significant positive results, plus another three studies with positive, though not statistically significant findings, provide strong and consistent evidence, particularly among men, that exposure to job strain is associated with an increased risk of future cardiac events and death from cardiovascular disease. The magnitude of this association appears to have been substantially underestimated, since bias towards the null was present in nearly all of these longitudinal studies. We also concluded that the six of nine case-control studies with significant positive results, provide consistent evidence supporting an association between job strain and cardiovascular disease among men, 2
The empirical studies examining the relation between exposure to job strain and CVD outcomes were assessed using 15 criteria that could affect internal validity. Issues most likely creating bias to the null were: use of the imputation method and of a dichotomous variable to define job strain, both leading to non-differential misclassification; assessment of exposure to job strain temporally distant from outcome, e.g. from longitudinal studies with protracted follow-up periods without repeated assessment of exposure status; selection bias in assembly of the sample, if participants exposed to job strain but without CVD preferentially enter the study; selective attrition, if those exposed to job strain or related work stressors selectively stop working during the follow-up period; likely confounding by other factors, if the relationships were in the opposite direction of the tested association; and lack of gender-stratified analysis. Overestimation of association could occur with: information bias, if outcome and exposure were both self-reported; selection bias in assembly of the sample, if participants exposed to job strain and with CVD preferentially enter the study; selective attrition if those not exposed to job strain or related work stressors selectively stopped working during the follow-up period; and likely confounding by other factors, if the relationships were in the direction of association.
9 and some, though not as consistent, support for this association among women. The crosssectional studies provide further evidence of an association between job strain and CVD among men, although biases leading both to over-estimation, as well as to the null, may have been present in some of the studies. Based upon these analyses, the conclusion of the previous focused review on this topic (Schnall 1994), has been corroborated, namely that that there is strong and consistent evidence of an association between exposure to job strain and CVD, across study designs and across a somewhat limited number of examined populations. The data among women are much more sparse, and not quite as consistent, though, as is the case among men, the majority of the studies are likely to have underestimated existing effects. Several other elements of causal inference were also supportive of this hypothesis, particularly the biological plausibility of the association between job strain and risk of CVD (Belkic 2003). Effort Reward Imbalance and Combined Effects upon Cardiovascular Disease A substantial body of cross-sectional and longitudinal investigation, primarily among men, has also shown a significant positive association between Effort-Reward Imbalance and acute MI, as well as CVD-related mortality. The magnitudes of the effect have been found to be similar or even higher than for job strain studies. (For overviews, see Belkic, Landsbergis et al. (2000(b)) and Brisson (2000)). Peter and colleagues (2002) recently examined the combined effects of exposure to Job Strain and Effort Reward Imbalance upon risk of acute MI in the Stockholm Heart Epidemiology case-control study. Among men, exposure to job strain together with high extrinsic effort and low rewards, yielded a considerably higher adjusted effect estimate, Odds Ratio (OR) =2.02 (1.34 – 3.07), compared to being exposed only to job strain or only to ERI (1.42 and 1.30, respectively). This was a gender-specific finding: among women; it was only intrinsic effort (over-commitment) plus job strain, which yielded a combined effect. These authors point out that assessing the joint effects of the two models is much more informative than handling the alternative model as a confounder. Controlling one model for the other, in order to test independent effects did not result in systematically increased effect estimates in their study. Bosma and colleagues (1998a) found that although job control remained a significant independent predictor of self-reported CHD after adjusting for Effort-Reward Imbalance, the effect estimate diminished. They also reported a significant association between job control and effort-reward imbalance: those with low job control reported ERI more often than those with high job control. This association is not surprising, since the control dimension is integral to both models, though, as mentioned, for job strain this is mainly control over task performance, whereas ERI views control at the “macro-level”, over larger issues such as salary, career advancement, etc. The extrinsic effort and psychological demand dimensions have substantial similarity, and show moderate statistical correlation (Peter 2002). Thus, as we have noted above, while the two models have clear conceptual and operational differences, they also overlap. Most importantly, the “combination of information derived from the two models [captures] a broader range of stressful experience at work, and thus, result[s] in an improved risk estimate” (Ibid, p.294).
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Hypertension There is also strong empirical evidence linking job strain to hypertension. A sizable amount of data has accumulated, indicating that exposure to job strain is cross-sectionally and longitudinally associated with significant elevations in ambulatory blood pressure of clinically important magnitude, greatest at work, but also at home and during sleep among heterogeneous working populations (LaFlamme 1998, Melamed 1998, Schnall 1992, Schnall 1998). (For detailed numerical analyses and discussion of methodological issues regarding job strain in relation to ambulatory blood pressure, see Landsbergis et al. (1994), and for reviews of the empirical data, see Belkic et al. (2000b) and Brisson (2000)). One of the largest investigations, the Work Site Blood Pressure Study, which addresses this issue, includes longitudinal follow-up. Three-year follow-up of 195 men showed that those chronically to job strain had a +11.1/+9.1 mmHg adjusted difference in work systolic/diastolic ambulatory blood pressure, compared to the men unexposed at baseline and at follow-up (Schnall 1998). Increased ambulatory blood pressure, particularly during work, is closely linked to left ventricular hypertrophy (Devereux 1983, Liu 1999, Verdecchia 1994). Furthermore, exposure to job strain has been directly associated with increased left ventricular mass (Schnall 1990). It is therefore plausible that sustained exposure to job strain leads to sustained elevation in blood pressure, which in turn causes structural changes in the left ventricle. Considering the strong, independent relation between increased left ventricular mass and cardiac events, this pathway may account for a substantial part of the reported association between job strain and CVD-related morbidity and mortality (Schwartz 2000b).
Studies assessing the relationship between job strain and ambulatory blood pressure among single occupations have often yielded null results. These include studies among nurses (Goldstein 1999), firefighters (Steptoe 1995), and teachers3 (Steptoe 1999). An investigation by Theorell, Ahlberg-Hulten, Jodko and colleagues (1993) which included female registered and licensed vocational nurses as well as hospital aides, revealed a significant association between systolic and diastolic blood pressure at work and exposure to job strain, based upon selfreport. Two cross sectional studies (Peter 1997, 1998) show a significant positive association between exposure to Effort-Reward Imbalance and elevated blood pressure. At 6.5 year follow-up, an increased risk for the co-manifestation of elevated blood pressure and high LDL-cholesterol was found among blue-collar workers exposed to ERI, after adjusting for age, body mass index, smoking and exercise (Siegrist 1991, 1996). Repetitive Motion Injury/Musculo-Skeletal Disorders
3
Work ambulatory blood pressure did not differ significantly between teachers in the high strain versus low strain groups. However, the difference between day and evening blood pressure was significantly greater among those in the low strain group. The authors state that “failure of subjects with high job strain to show reduced blood pressure in the evening may be a manifestation of chronic allostatic load” (p. 193):
11 There has been substantial investigation of the relationship between adverse psychosocial work conditions and musculo-skeletal disorders. Toomingas and colleagues (1997) examined men and women in various occupations, and found that low social support at work, high psychological demands and high job strain were associated with soft tissue tenderness on physical examination in the central body regions. Analyses were stratified by age, gender and physical load at work. The authors conclude that their results are confirmatory of findings from earlier studies regarding associations with symptoms from the neck and back regions. Moreover, they note that studies not separating clinical signs and body regions may have attenuated risk estimates. Leslie and coworkers (1998) showed that lean production and changes in the layout of the shop floor lead to increased risk of injury, in particular repetitive strain injury. Exposure to job strain or its major dimensions has been associated with risk for musculoskeletal symptoms among nurses and nurses’ aides (Ahlberg-Hulten 1995, Josephson 1997), sales persons (Skov 1996), municipal workers (Myers 1999) and among public transit operators (Krause 1997a, 1998). In most of these studies, this association remained significant after adjusting for physical factors. In her review of workers who use video-display units (VDU), Punnett (1997) concluded that based both on self-reported symptoms, as well as objective findings, “For disorders of the hand and wrist, we found evidence that the use of the VDU or the keyboard was a direct causative agent, mediated primarily through repetitive finger motion and sustained muscle loading across the forearm and wrist” (p.1). Working four or more hours per day at a VDU carries an OR of about 2. High work demand and postural stress from poor workstation design were associated with upper extremity disorders (Ibid).
Adverse Mental Health Outcomes Exposure to job strain has been found to significantly predict depressive symptoms in a longitudinal study of over 10,000 electrical company employees (Niedhammer 1998). Crosssectional relationships between job strain and negative emotions have also been reported (Bourbonnais 1996, Williams 1997), though null findings have been seen, as well (Landsbergis 1992). Recent preliminary results from the Czech Republic, Russia and Poland reveal that exposure to Effort-Reward Imbalance, as well as to Job Strain, is associated with depressive symptoms in cross-sectional analyses (Pikhart 2002). There are also some data indicating a relationship between the main components of job strain and various psychological markers. In a 1.5 year follow up of 11,121 working men, psychological work load was associated with 1.4 times higher risk of a new visit for psychiatric treatment (Uehata 1993). In an Israeli study among female blue-collar workers, shortcycle repetitive work was significantly related to psychological distress (anxiety-irritability, depression and somatic complaints) (Melamed 1995). Low job control was significantly associated with negative affectivity among male civil servants studied by Bosma et al. (1998b). However, risk estimates of self-reported heart diseases due to low job control were not substantially changed in models with and without adjustment for negative affectivity in the paper of Bosma et al (1997), suggesting that this was not a mediator of the job control-CHD association.
12 Job strain has also been associated with burnout or vital exhaustion in cross-sectional studies among nurses (Amick 1998, Bourbonnais 1998) and teachers (Cropley 1999). Nurses in Germany exposed to Effort-Reward Imbalance were found to have high levels on two of the three core dimensions of burnout (Bakker 2000). Occupations With Evidence of Risk for Adverse Stress-Related Health Outcomes The burden of disease is unequally distributed across various occupations. Identification of occupational groups at increased risk for adverse, stress-related health outcomes can be helpful in generating etiological hypotheses (Tuchsen 2000). Here, we briefly summarize salient findings concerning occupational groups for whom there is some evidence of increased risk for one or more of these health outcomes. A number of methodological issues arise with this type of analysis. Of particular importance for cardiovascular disease is the very strong selection effect in hiring and periodic examination for many of these high stress occupations, leading to a bias towards the null. These issues are discussed by Tuchsen (Ibid). Professional Drivers Professional drivers, especially urban transit operators, are at exceptionally high risk for hypertension and ischemic heart disease (IHD). The data accumulated over three decades in various countries, despite “super-healthy worker” selection against these diseases at screening and follow-up. Compiling the focused reviews of Winkleby, Ragland, & Fisher et al. (1988), Belkic, Savic & Theorell et al. (1994), and van Amelsvoort (1995), Belkic, Emdad and Theorell (1998) reported that thirty-four of forty empirical studies on this topic showed a significant positive association. Such a consistent and large body of evidence concerning hypertension and ischemic heart disease cannot be found for any other occupational group. Of particular note is that the acute cardiac events often occur prematurely, such that professional drivers are over-represented among series of young myocardial infarction patients (Riecansky 1988, Villarem 1982). In the paper of Villarem, Thieleux, & LaBlanche et al (1982) of thirty-eight consecutive patients who had a first myocardial infarction before the age of thirty, 20% were long-route truck drivers. Riecansky, Milichercik & Kasper et al (1988) reported that 40% of their series of patients younger than forty with acute myocardial infarction were professional drivers. City mass transit drivers are especially prone to develop ischemic heart disease, as well as hypertension (Alfredsson 1993, Backman 1983, Gustavsson 1996, Michaels 1991, Morris 1966, Netterstrom 1988, Ragland 1987, Ragland 1997, Rosengren 1991). Standard cardiac risk factor prevalence has been found to be high among professional drivers, however, risk factor status does not consistently distinguish professional drivers from other groups at lower risk (Belkic 1994). Rosengren, Anderson & Wilhelmsen (1991) found that the increased risk of coronary heart disease among middle-aged bus and tram drivers compared to referents in Gothenburg was independent of standard risk factor status. After a mean of 11.8 years of prospective study, these authors reported an odds-ratio of 3.3 (95% Confidence Interval = 2.0 - 5.5) for coronary heart disease in 103 middle-aged male mass transit drivers in Gothenburg compared to 6596 men from other occupational groups. With accounting for the major standard cardiac risk factors (age, serum cholesterol, blood pressure, smoking, body mass index, diabetes, positive parental
13 history of CHD and physical activity) as well as socio-demographic factors, the risk decreased only slightly (OR=3.0, 95% CI=1.8-5.2). More recently, Bigert and colleagues (2002) showed that that increased risk for myocardial infarction among bus and taxi drivers, was only slightly diminished by adjusting for selfreported job strain. The authors conclude, “bus and taxi driving in urban areas is a highly stressful occupation and all aspects of the psychosocial stressors in this environment may not be reflected by the demand/control model”. This point is discussed in more detail in Chapters 3 and 4. Empirical studies have also revealed an increased risk among professional drivers for stroke musculoskeletal disorders (Backman 1983, Hedberg 1988, Krause 1997b), peptic ulcer disease (Netterstrom 1990), and psychological distress (Orris 1997). (Tuchsen 1997),
Health Care Professionals Physicians and nurses, particularly early in their careers, have been reported to have a high prevalence of adverse mental health findings, including depression and burnout (Baldwin 1995, Hisashige 1991, Schweitzer 1994). Olkinuora and colleagues (1992) in their study of a representative, random sample of 2671 Finnish physicians, found the highest burnout scores among nonspecialists, and also among those often dealing with chronic, incurable or dying patients. A total of 22% and 26% of male and female physicians, respectively, in their sample had either contemplated or attempted suicide. Gunnarsdottir and colleagues (1995) compared 2159 female Icelandic nurses who had worked more than or less than 20 years in their profession, with the general population, and found an excess risk of suicide in those with the shorter employment time. High rates of suicide among nurses have also been reported in the U.S. (Katz 1983) and among female physician consultants in the U.K. (Carpenter 1997). Tan (1991) states, “among all professional groups, nursing has one of the highest rates of suicide” (p. 227). According to Heim (1992) suicide rates are high among physicians, especially females, although he states that these findings are “surprisingly little observed and reflected by the medical community when compared with increasing preventive activities in other job situations” (p. 207). Low standardized mortality rates due to cardiovascular disease have been reported among physicians (Carpenter 1997). However, Nedic and colleagues (2001) followed two groups with hypertension: 160 physicians and nurses, and referents: 122 hospital employees of other profiles without clinical duties. The doctors and nurses were found to have a RR=3.7 (95% CI=1.6 - 8.6) for developing cardiovascular or cerebrovascular complications (MI, angina pectoris, stroke) at 7 year follow-up. Smoking, obesity and alcoholism were similar in the two groups, while lack of physical activity, positive family history of CVD, and hyperlipidemia were significantly higher among the referent group. High rates of back pain have been found among nurses in several countries (Harber 1985, Stubbs 1983, Videman 1984).
14 Teachers In a study from the U.S., Eaton and colleagues (1990) report that teachers and counselors at the non-college levels4, were one of four occupations with a significant adjusted odds ratio (2.85, 95%CI = 1.2 – 6.8) for major depression using DSM III criteria measured by the National Institute of Mental Health Diagnostic Interview Schedule. This was part of a case-control study among twenty-eight selected occupations examined in a five-site Epidemiologic Catchment Area Program of 11,789 persons who had been full-time employed. A longitudinal investigation of Schonfeld (1992) of 255 first-year female teachers in the New York metropolitan area revealed that CES-D-assessed depression was higher among those working in the most adverse conditions (episodic and ongoing stressors such as threat of personal injury, confrontation, vandalism, overcrowding, unmotivated pupils, lack of disciplinary enforcement against unruly pupils), after controlling for other risk factors. Among 352 nursery teachers and guidance workers in homes for mentally retarded children in Japan, Takeda (1994) found that labor-related problems: dissatisfaction and sense of being overburdened were significant multivariate predictors of depression, using the Zung scale. However, their sample was not found to have a higher prevalence of depression compared to the general population. Burnout among teachers has received increasing attention, as reviewed by van der Berghe (1999). Air Transport Professionals Air Traffic Controllers Cobb and Rose (1973) performed a detailed study in the U.S. of 4,325 air traffic controllers (ATC) and 8,435 second class airmen, with respect to hypertension, peptic ulcer disease and diabetes. Since the licensing regulations are far more stringent for the latter group with respect to hypertension, their findings of significantly greater prevalence and incidence of diagnosed hypertension among the controllers is somewhat difficult to interpret. More informative is the significant association between average traffic density and both hypertension and peptic ulcer disease among the ATC. Comparison of 80 male ATC working in Milan with an age-matched group of 240 male workers in a variety of occupations, revealed no significant differences in ambulatory blood pressure and heart rate on 24-hour periods that included working shifts, while casual clinic systolic but not diastolic blood pressures were significantly higher among the ATC (Sega 1998). The authors (Ibid) note the rigorous selection procedure, which applies to this occupational group. Potter (1987) cites air traffic controllers as one of the high-risk groups for burnout. Feelings of burnout among ATC have been associated with a number of work-related factors: having experienced a “near miss” in the past 3 years, number of years of work as an ATC, working at the highest level of air traffic (“Level 5”), poor work organization, and poor social support 4
Classified by most-recent full-time job.
15 from supervisors and co-workers (Landsbergis 1998). Air traffic controllers were among the occupational groups found to be at increased risk for acute myocardial infarction in the population-based study of Hammar, Alfredsson and colleagues (1992). Airline Pilots Airline piloting is clearly a highly stressful occupation. However, as indicated above, there are extremely rigorous selection and licensing standards, particularly with respect to cardiovascular disease, hypertension, psychiatric disorders and substance abuse (Dark 1987, Joy 1992). These limit the value of comparisons with other occupational groups. Little data is available on the relationship between stressful working conditions and health outcomes. A field study of pilots by Jorna (1993), however, indicates that a total loss of heart rate variability (HRV) occurs during the time of landing, and that when pilots learn to handle a new type of aircraft, there was a prolonged duration of attenuated HRV during the approach period, prior to touch down. Sea Pilots Harrington (1972) reported that over a 12-year period, in comparison with age-matched employed referents, 393 English sea pilots age 35 to 49 have 3.5 times more cardiac deaths (p<0.01). West German sea pilots aged 31 to 40 had a cardiac mortality rate of 3 per 1000, whereas male controls from the same city had 0.1/1000. The differences were similar, but less marked in the 41 to 50 age group. Thus, while having an overall mortality rate similar to the general population, the West German sea pilots had a markedly increased cardiac mortality (Zorn 1977). The authors note that sea pilots worked long, irregular hours (up to 60 hours per week, and 18 hours per shift) frequently without breaks, under harsh and dangerous weather conditions, in which they were required to maintain constant alertness as they guided vessels through long, twisting channels, while simultaneously communicating with other stations (Ibid). However, more recent studies did not reveal an increased mortality from circulatory disorders among sea pilots in Sweden (Nystrom 1990) or Finland (Saarni 1996), compared to the general male population. Other Occupational Groups Increased risk for acute myocardial infarction or IHD-related death has been reported in at least one empirical study5 among a number of other high stress occupational groups, including firefighters and lower-ranking police officers, though the evidence is sparse and somewhat conflicting (Belkic 1995a, Tuchsen 2000).
5
Lower level of 95% CI >1.
16
Chapter 3
How Can Insights From Cognitive Ergonomics And Brain Research Inform Our Assessment Of The Work Environment? Complementary to constructs such as the Job Strain Model and Effort-Reward Imbalance, that are based heavily upon sociological theory, are approaches derived from cognitive ergonomics and brain research. The domain of cognitive ergonomics encompasses questions about how the human being processes information, makes decisions and, on that basis, carries out actions (Singleton 1997). Spectacular advances have been made in our understanding of how the human being-via the Central Nervous System (CNS)--handles information, transforming it into productive output of various kinds. The question which we are now addressing is: How can that knowledge be harnessed to inform us in our quest to organize work so that it becomes in better harmony with human needs and capacities? This approach helps us understand what are the affinities and the aversions of the human being at work, and then to describe, in more objective and quantitative terms, the burden of work processes upon the central nervous system (CNS). Thus, e.g., when speaking of psychologically demanding work, we can go far beyond queries about “working hard” and “working fast”, to analyze tasks in terms of allocation of mental resources. In other words, cognitive ergonomics and brain research help us address in a concrete way, the very question of “how fast is too fast” or “how hard is too hard”. Approaches to quantifying the mental burden of occupational endeavor using objective means can help circumvent some of the difficulties inherent in self-report methods (Cacioppo 1990, Greiner 1998, Kristensen 1996, Sackett 1979, Schnall 1994). Ideally, this information would complement the worker's own perceptions of his or her occupational tasks and in that way help guide participatory intervention strategies. Unfortunately, however, the tremendous knowledge gained from this research has generally not been harnessed to inform and enrich Psychosocial Work Assessment. These methods, when applied in the context of the real-life work environment, have mainly been used to improve performance, although there are exciting developments for humanization of work, some of which we will discuss here. How we handle Information: A Neurophysiologic View Figure 3.1 is a schematic representation of how the organism handles information--mapped along the time axis, as developed by Ivanitsky (1980). We see that the incoming signal is evaluated first in terms of its physical attributes, and then with respect to its meaning for the individual. On that basis, a decision is made, which may result in some action.
17
Perception
Psychophysics of perception
Sensitivity Index
Criterion Index
Evoked Potential
Brain Informational Processing
Msec.
FIGURE 3.1
Sensory Stage
Stage of Synthesis
Decision Making
Analysis of the physical characteristics of the signal
Synthesis of the physical and biological characteristics of the stimulus Sensation
Decision-Making
0--------50--------100--------150--------200--------250--------300
Schematic Diagram of the Stages of Information Processing
From: Ivanitsky AM. Evoked potentials and mental processes. In Lechner H, Aranibar A. Electroencephaologr Clin Neurophysiol Amsterdam: Excerpta Medica, 1980, pp. 727-732. With permission.
18 As we view this process along the time axis, it can be seen that at least 300 milliseconds (0.3 seconds) are needed to arrive at this stage of decision-making, at which time the P300 wave of the evoked potential may be seen. The P300 is a positively oriented averaged electrocortical wave appearing 300 - 500 milliseconds after stimulus presentation, and is most commonly elicited when the subject's attention is focused upon an infrequently-occurring signal, especially if this signal has some motivational or emotional significance. The P300 will be produced by task-relevant stimuli that occur relatively unexpectedly, and require either some kind of motor response and/or cognitive decision (Ritter 1968). For more information about Event-Related Potentials, such as the P300, see (Chiappa 1989, Coles 1990, Cooper 1980). The study of “Event-Related Potentials” (ERP) provides us with insight into the higher nervous processing resources required by a given task. These can be a gauge of "mental chronometry" (McCarthy 1981) by assessing brain activity over time as it processes information, makes decisions and lays the basis for task execution. Using the concepts from cognitive ergonomics, Event-Related Potentials can help quantify mental burden using the time dimension.
Time FIGURE 3.2 Schematic illustration that the P300 wave has a longer latency (occurs later), as shown by the curve with dotted line, when more time is needed to evaluate a given signal.
The latency of the P300 ERP component is related to the time required to evaluate and correctly categorize a signal. For example, in the visual modality, when detection is made more complex or when contrast is diminished, the latency of the P300 becomes prolonged (Walton 1987). This is shown above in Figure 3.2.
19
Reaction Time (msec)
600
400
200
0
1
3
5
7
9
Number of Alternatives
FIGURE 3.3
The relation between number of alternatives and reaction time: The “Merkel” curve
Derived from: Merkel J. Die zeitlichen Verhaltrisse der Willenstatigkeit. Philosophie Studion 1885; 2: 73-127.
As the incoming information exacts a greater demand upon the brain’s processing resources, not only the electrocortical activity (e.g. P300) but also the reaction time (RT) takes longer. Here, as shown above in Figure 3.3, from the classical study by Merkel (1885), as the number of alternatives increases, there is a marked rise in the mean RT: from 200 milliseconds (msec) with 1 signal versus 600 msec. when the choice is among 9 alternatives.
20
↑ cognitive or emotional significance of signal
Time
↑ complexity of primary task
Time FIGURE 3.4 resources
Increased P300 amplitude (dotted line) with increased demands upon mental
The amplitude of ERP components, notably the P300 wave, also reflects allocation of mental resources to a given task. As the complexity of a task increases, not only is the latency prolonged, but also the amplitude of the P300 wave heightens. The amplitude of the P300 also increases as the cognitive or emotional significance of the signal increases, as shown above in Figure 3.4. However, when a person performs two tasks, the P300 amplitude to a subsidiary task diminishes as the primary task becomes more difficult, indicating withdrawal of processing
21 resources from a lower priority task as the primary one consumes progressively more of the subject's mental energy (Sirevaag 1984). On the other hand, as the load upon memory increases, P300 amplitude falls. This may similarly reflect competing demands upon mental resources, so that less are available for the specific task at hand; there may also be more uncertainty or equivocation with increasing memory load (Kok 1997). The effect of exacerbating stressors can also be seen with respect to the amplitude of the P300. Laboratory exposure to noise and to sleep deprivation elicited an attenuation of P300 amplitude (Gunter 1987, Polich 1995). Among professional drivers, an inverse relation was found between number of work hours behind the wheel and the P300 amplitude to a visual oddball reaction time task. This finding was considered to be related to fatigue (Belkic 1996), which is known to attenuate P300 amplitude, as well as prolonging its latency (Polich 1995).
TIME PRESSURE
↓ P300 Latency (CR sub-component)
No ∆ P300 Latency (Stimulus Assessment Sub-component)
+ Shortened Choice Reaction Time
PERFORMANCE ERRORS
FIGURE 3.5 A Neurophysiologic View of Time Pressure Derived from data of: Hohnsbein J, Falkenstein M, Hoormann J. Effects of attention and time-pressure on P300 subcomponents and implications for mental workload research Biol Psychol 1995; 40: 73-81.
22
Subcomponents of the ERP waves can be even more illustrative of how these exacerbating stressors deleteriously affect mental processes. Hohnsbein and colleagues (1995) found that when a person was placed under time pressure to perform two-choice reactions, the choice reaction subcomponent of the P300 shortened, even though the stimulus assessment time remained unchanged. The consequence was a greater number of performance errors. These findings are graphically represented in Figure 3.5. In other words, the subject was making a forced decision to react to stimuli that had not been properly evaluated, because the brain did not have sufficient time to do so! These neurophysiologic findings provide insight into the brain mechanisms that may mediate the compromise of safe performance, including the observed increase in accident rate, associated with high levels of time pressure (Gardell 1983, Green 1991, Greiner 1998).
Levels of Information Transmission: High Demands and Underload In line with the neurophysiologic scheme and data that we have just shown, the main phases involved in any kind of labor can be described in terms of Levels of Information Transmission, as formulated by Welford (1960): Sensory input, central decision-making and effecter output or task performance. TABLE 3.6
Levels of Information Transmission
___________________________________________________________________________
Sensory Input
Central decision-making: Information Processing
Effecter output: Task Performance
___________________________________________________________________________ Derived from: Welford AT. The measurement of sensory-motor performance: Survey and reappraisal of twelve years’ progress. Ergonomics 1960; 3: 189-230.
23 In the Occupational Stress Index (to be presented in full subsequently) we have attempted to quantify some of the elements of high demand, broken down by level of information transmission. On the input level besides the number of signals to be processed, we need to consider their modality, complexity, dynamics, sources, inter alia.
TABLE 3.7
High Demand on the Input Level
_________________________________________________________________________
Several sources of information Heterogeneous signals Heavy burden on the visual system High frequency of incoming signals Three sensory modalities Communication essential ___________________________________________________________________________ From the OSI
We know e.g. that the visual modality places the greatest demands upon attentional resources, as do heterogeneous signals, especially if from various sources. Then, we go to the level of central decision-making and consider how many elements are involved (complicated) and their interrelation (complexity), as well as decision-making involving the work of others, and how quickly the decision needs to be made. Next, we consider the nature, heterogeneity and time exigencies involved in actual task performance. We point out here that when people themselves report working hard and working fast, they mainly look at the task performance level, rather than the first two levels (sensory input and decision-making), that are often “invisible”. Finally, we have added a fourth level which goes beyond the levels of information transmission, to considering working conditions on a more general level, that contribute to demand: long hours, lack of rest breaks, irregular schedule or night work, working at a piece rate, lack of vacations and holding down more than one job.
24
TABLE 3.8
High demand among Professional Drivers vs. Subway Attendants according to the Job Strain Model versus the OSI Professional Drivers (Mean +/- sd)
Level of Significance Subway Attendants (Mean +/- sd)
Job Strain
(N=34)
(N=23)
High Demand
11.9 +/- 3.8
Non-significant
12.3 +/- 3.4
Total High Demand
16.1 +/- 2.1
p < 0.001
6.4 +/- 3.8
Input High Demand
9.1 +/- 1.2
p < 0.001
3.4 +/- 1.2
p < 0.01
1.3 +/- 1.4
p < 0.001
1.0 +/- 1.1
OSI
Central High Demand 2.0 +/- 0.2 Output High Demand
3.9 +/- 0.5
From: Belkic K, Emdad R, Theorell T, Cizinsky S, Wennberg A, Hagman M, Johansson L, Savic C, Olsson K. Neurocardiac mechanisms of heart disease risk among professional drivers. Stockholm: Swedish Fund for Working Life, 1996.
Table 3.8 provides an example of how a more detailed and operationalized approach to the demand dimension distinguishes professional drivers, whom we consider to be among the most highly strained of occupational groups, but for whom the standard 5 questions for the demand dimension from the Swedish Psychosocial Job Strain Questionnaire (Theorell 1988) actually scored lower than the subway attendant referents. Note especially, that the demands upon professional drivers are nearly three times greater than referents at the level of incoming signals. Notably, there is actually a reciprocal relation between what would be described as working fast (i.e. driving fast), and the actual demands on the input and central level. In other words, when traffic conditions are the most demanding, as in rush hour, the possibilities to proceed quickly with task performance are, in fact, the lowest.
25
TABLE 3.9
High Demand Among City Bus Drivers Versus Truck Drivers-Using the OSI City Bus Drivers (N=130)
Level of Significance
Truck Drivers (N=69)
Input High Demand
10.0 ± 0.9
Central High Demands
2.0 ± 0.0
Output High Demands
4.0 ± 0.1
P<0.001
3.0 ± 0.0
General High Demands
5.1 ± 1.6
P<0.01
4.4 ± 1.8
21.0 ± 2.0
P<0.001
17.2 ± 2.1
Total High Demands
P<0.001
7.9 ± 1.4 2.0 ± 0.0
From: Belkic K, Savic C, Theorell T, Cizinsky S. Work Stressors and Cardiovascular Risk: Assessment for Clinical Practice. Part I. Stockholm (Sweden): Stress Research Reports. National Institute for Psychosocial Factors and Health. Section for Stress Research, Karolinska Institute, WHO Psychosocial Center; 1995(a). Report No.: 256.
This approach also demonstrates within-occupational subgroup differences, particularly clear on the input level, where the higher demand upon city bus drivers is related to a more rapid flow of incoming signals and the fact that they are obliged to communicate with the public, as shown above in Table 3.9.
On the other hand, truck drivers, especially on long routes, face many elements of “underload”: low frequency of more homogeneous signals, often driving alone without any communication. Underload is another stressor dimension that we have included in the Occupational Stress Index.
26
TABLE 3.10
Underload
___________________________________________________________________________
Input Homogeneous signals Low frequency of incoming signals Working alone: without need for communication
Central Decisions automatic from input
Output Homogeneous tasks Simple tasks Nothing to do
General Fixed pay Inadequate pay No chances for upgrade Lack of recognition of good work ___________________________________________________________________________ From the OSI
We know, e.g. that not only will overly rapid, but also an exceedingly slow rate of incoming signals, especially if of prolonged duration, impair correct and timely action. This coincides with the well-known "U" shaped-curve, showing optimal performance associated with moderate arousal levels and a performance decrement, together with heightened catecholamine excretion, with both over- as well as under stimulation (Frankenhaeuser 1981, Hebb 1958).
27 Underload or monotony is characteristic of many branches of automatic production as well as long-distance transport work, in which a high level of vigilance must be maintained to detect infrequently or irregularly occurring signals. There is also a mental burden as well as safety risks in this type of work, due to which there is a need for frequent rest breaks and other protective measures (Levi l981, Braby 1993). Combinations, of underload and high demand can be very harmful (Ibid). Next, we will briefly present two cognitive ergonomic models developed by Anthony Gaillard from the Netherlands. These models help us better understand the nature of the demand dimension and also how it is related to control. Knowledge-Based versus Skill-Based Information Processing First, a critical point is to identify so-called “Controlled or Knowledge-based” processing, for which there are limitations in human capacity, since it demands attention and effort, and is performed in series. This is called into play, e.g., when new knowledge is acquired, when decisions require planning and in non-routine situations. Some examples of this type of processing are given in Table 3.11.
TABLE 3.11
Examples of Controlled/Knowledge based Activities
_______________________________________________________________________________
Complex human interactions Use of a new apparatus Emergency operations Apparatus failure Dealing with irregularities _______________________________________________________________________________ From: Gaillard, A.W.K. Comparing the concepts of mental load and stress. Ergonomics 1993; 36: 991-1005.
In contrast, the human capacity for automatic or "skill-based" processing is much less limited, and represents rapid, smooth, learned, highly integrated patterns, that can be performed in parallel (Gaillard 1993). Figure 3.12 provides a schematic representation of controlled versus automatic processing.
28
I N P U T
CONTROLLED
AUTOMATIC
O U T P U T
FIGURE 3.12 Controlled (Knowledge based) vs. Automatic (Skill-Based) Processing Gaillard, A.W.K. Comparing the concepts of mental load and stress. Ergonomics 1993; 36: 991-1005. With Permission.
The ratio between knowledge-based and skill based activity is extremely important, with the critical dimension being time. The former is most sensitive to time limitations, whereas a long stretch of solely skill-based processing will create underload. Neerincx and Griffioen (1996) formulated the following rule of thumb:
"The more actions to be executed in a period, the less knowledge-based actions are preferable” (p. 548)
This cognitive ergonomic approach was used to develop specific recommendations for harmonizing the tasks of railway traffic controllers, to eliminate both momentary overload and underload.
29
Cognitive Control
Feedback
Input
Central Processing
Output
Energy Regulation
FIGURE 3. 13 Energy Regulation—The Relation Between the Demand and Control Dimensions Gaillard, A.W.K.Comparing the concepts of mental load and stress. Ergonomics 1993; 36: 991-1005. With permission.
As illustrated above in Figure 3.13, Gaillard (1993) also integrated the concept of "Energy Regulation" into the levels of information transmission, and helps us better understand the interaction between the demand and control dimensions. He points out that as the processing demands become greater, there is an increased need for energy. This energy comes from arousal: partially involuntarily and in part related to voluntary mental effort. When mental processing demands increase, these resources are mobilized. But these human cognitive energy reserves have their limitations. Furthermore, the human being is constantly monitoring the output and on that basis, needs to exert cognitive control over the entire process. This requires feedback information and decision-latitude, so that one can decide whether the output is in line with his or her goals and intentions, and, if not, to make proper adjustments. Thus, from the vantage point of cognitive-ergonomics, we have convergent validation of the Job Strain Model, namely, that mental workload, is not synonymous with mental strain; that lack of control coupled to high psychological demands is crucial in creating strain conditions. With sufficient decision-latitude, or control, one can modulate even a fairly onerous, though not overwhelming, psychological workload to meets one's moment-tomoment needs, capacities and goals.
30
TIME PRESSURE
↓ P300 Latency (CR sub-component)
No ∆ P300 Latency (Stimulus Assessment Sub-component)
+ Shortened Choice Reaction Time
PERFORMANCE ERRORS FIGURE 3.14 A Neurophysiological View of Time pressure Revisited Derived from: Hohnsbein J, Falkenstein M, Hoormann J. Effects of attention and time-pressure on P300 subcomponents and implications for mental workload research Biol Psychol 1995; 40: 73-81.
Now, in this light, we revisit the Hohnsbein data (1995) on the neurophysiologic consequences of time pressure. We can now see that the “time” dimension in a critical part of control, that excessive time pressure is not only a demand, but it also undermines control, and is fundamentally incompatible with the way our nervous system should be working. Threat Avoidant Vigilance Another critical element of mental stress is the intervening variable of threat, meaning that one anticipates the possibility of encountering harm of some sort (Lazarus 1967). When the potential consequences of one's actions can include disaster, work becomes a "threatavoidant" activity whose primary goal is self-protection, and which is inevitably associated with negative emotion and often with untoward physiologic reactions, as well. The heaviest burden upon conscious attentional resources occurs when one must continuously follow a
31 barrage of predominantly visual signals and be prepared to rapidly respond, whereby a momentary lapse, error or delay could have serious, potentially fatal consequences. This can be termed "threat-avoidant vigilant activity", or ”disaster potential” (Fuller 1984, Belkic 1989).
______________________________________________________ THE HEAVIEST BURDEN UPON CONSCIOUS ATTENTIONAL RESOURCES OCCURS WHEN THE HUMAN OPERATOR MUST CONTINUOUSLY FOLLOW A BARRAGE OF INCOMING, PREDOMINANTLY VISUAL SIGNALS TO WHICH HE OR SHE MUST BE PREPARED TO RAPIDLY RESPOND, WHEREBY A MOMENTARY
LAPSE,
ERROR
OR
DELAY
COULD
HAVE
SERIOUS,
POTENTIALLY
FATAL
CONSEQUENCES
PANEL 3.15 Belkic, K; Savic, C; Djordjevic, M; Ugljesic, M; Mickovic, Lj. Event-related potentials in professional city drivers: heightened sensitivity to cognitively relevant visual signals. Physiol Behav. 1992(a); 52: 423-427.
______________________________________________________ Brain mechanisms exist which focus attention to potentially dangerous phenomena in one's surroundings; neocortical pathways have been identified in primates, that respond preferentially to danger-evoking signals. These pathways are of obvious survival benefit. Normal human subjects selectively attend to threatening visual stimuli such as snakes, spiders or angry faces even when presented subliminally (Ohman 1986)
______________________________________________________ PREFERENTIAL ATTENTION TO THREATENING STIMULI
SNAKES SPIDERS ANGRY FACES When presented subliminally to normal human subjects PANEL 3.16 Derived from: Ohman A. Face the beast and fear the face: animal and social fears as prototypes for evolutional analyses of emotion. Psychophysiology. 1986; 23: 123-145.
_____________________________________________________________________________
32
µV -15 -10 -5 0 +5 +10
CNV1
CNV2
CNV3
Professional Drivers Non-Driver Controls
FIGURE 3.17 Heightened Sensitivity To Cognitively Relevant Visual Signals: A Go:No-Go CNV Paradigm among Professional Drivers From: Belkic, K; Savic, C; Djordjevic, M; Ugljesic, M; Mickovic, Lj. Event-related potentials in professional city drivers: heightened sensitivity to cognitively relevant visual signals. Physiol Behav. 1992(a); 52: 423-427. With Permission
In Figure 3.17 we have a neurophysiologic example of the heightened expenditure of processing attentional resources among professional drivers whose jobs epitomize threat avoidant vigilant activity, when presented with warning stimuli that were linked to traffic accident avoidance tasks, compared to workers who had no driving experience whatsoever. This study used a GO-NOGO Contingent Negative Variation paradigm (Belkic 1992(a)). Figure 3.18 provides another view of how threat-avoidant vigilant activity such as driving, adds yet another burden to higher CNS resources. Martin and colleagues (1992) examined amateur drivers’ responses when faced with a choice reaction time task in response to pictures of imminent traffic accidents compared to those showing safe scenes. First, we see that their selective attention was so great that even under high signal probability, the P300
33 appears (as mentioned, P300 is typically elicited with rare events). Also, they hastened their motor response to such an extent that information processing was not yet complete (RT precedes P300 latency, similar to what we saw with the Hohnsbein data). Thus, the sudden appearance of this threatening stimulus, totally out of the driver’s control, demands rapid action and the burden on attention resources is tremendous. Here the control dimension related to time acquires an even greater importance.
Threat-Avoidant Stimulus (Imminent Traffic Accident)
AROUSAL
Attentional Resources Mobilized
P300 appears At 0.5 Probability
↑ Stimulus Assessment Time (↑ P300 latency)
Hastened Response Time
ERROR
FIGURE 3.18 P300 in Imminent Traffic Accident Paradigms Derived from: Martin F., Siddle, D.A.T., Gourley, M., Taylor, J., Dick, R. (1992). P300 and traffic scenes: The effect of temazepam. Biological Psychology, 33: 225-240.
34
_______________________________________________________________________________
ANTICIPATORY AVOIDANCE RESPONSES
CONTROL OVER THESE DEMANDS REQUIRES ENOUGH TIME TO MAKE “ANTICIPATORY AVOIDANCE RESPONSES”: TO RECOGNIZE THE PRECURSORS TO THE POTENTIALLY DISASTROUS SITUATION AND TO TAKE APPROPRIATE MEASURES. E.G. IN TRAFFIC: SLOWING DOWN AT A BLIND INTERSECTION TO CIRCUMVENT A POTENTIAL COLLISION WITH AN UNSEEN, APPROACHING VEHICLE. PANEL 3.19 Derived from: Fuller R. A conceptualization of driving behaviour as threat avoidance Ergonomics 1984: 27; 11391155.
_______________________________________________________________________________
In order to have control over these inevitable demands of the driving situation and other situations requiring TAV, there must be enough time to make “anticipatory avoidance response” whereby the experienced worker recognizes the precursors to the potentially disastrous stimulus and takes appropriate measures. For example, in traffic this would include slowing down at a blind intersection so as to circumvent a potential collision with an unseen, approaching vehicle (Fuller 1984). These anticipatory avoidance responses are vital to health and safety, but they consume a large share of these workers’ already overburdened attentional resources, and they also require enough time. Seen in this light, unrealistic pressures to stay on schedule could very well be the ”straw that breaks the camel’s back”, both in terms of accident risk and to the health of the worker. In order to avoid such situations, compensatory allowance, especially with respect to increased time allocation, must be included into the work planning “equation”. Now let us consider yet another burden that the human being faces at work. The Conflict Dimension From the point of view of cognitive ergonomics, conflict and uncertainty adds a qualitatively new dimension. As stated by Neerincx and Griffoen (1996) “task load is not a simple summation of the load of the individual processes. Interference between concurrent information processes increases task load” (p. 545). Thus, in contrast to a normal, smooth work routine, in which there is reinforcement of the correctness of work decisions and actions,
35 conflict or uncertainty arises when untimely or inaccurate correlations disrupt work and its rhythm. Pavlov (1951) has termed this the difficult meeting of excitation and inhibition in the brain. TABLE 3.20
Conflict / Uncertainty
________________________________________________________________________________
Input Signal/noise conflict Signal/signal conflict Central Missing information needed for decision Contradictory information Unexpected events change work plan Output Conflicting Demands Task Performance hampered by: Extrinsic Problems Interruptions from people General Emotionally charged work atmosphere Lack of help with work-related difficulties Opposition to career advancement Violations of behavioral norms/abuses of power Lack of mechanisms for redress of grievances Threat of job loss Job lacks coherence
__________________________________________________________ From the OSI
What would happen, for example, on the input level, if in a two-choice reaction-time task, the signals were both subtly different shades of green, or if they were imbedded in fog so as to be seen only with difficulty? The signal detection process would become more difficult,
36 normally leading to a longer reaction time, due to impaired discriminability. These are examples, respectively, of signal-signal and signal-noise conflict. These kinds of input conflicts are very common for physicians in clinical practice, for example trying to distinguish a T wave from a U wave or in interpreting the electrocardiogram with background noise. Lacking important information, getting contradictory information or being faced with unexpected events that require some kind of change in work plans would create conflict and uncertainty when making decisions. On the task performance level these would include conflicting demands in time and space, external problems and interruptions from people that hamper task performance. And finally, a tense work atmosphere with interpersonal conflicts, lack of help with work-related difficulties, opposition to career advancement, violations of norms of behavior/abuses of power, lack of redress for grievances, threat of job loss and lack of coherent work would contribute to conflict and uncertainty on the general level. Physically Aversive Exposures Noxious physical exposures also contribute to the stressfulness of the work environment. Neurophysiologic data indicate that these factors impact upon attentional resources. Exposure to hypoxia, turbulence or noise during task performance was associated with a prolongation of P300 latency (Kramer 1987, Gunter 1987, Polich 1995). Table 3.21 shows the physically aversive factors included in the OSI, according to levels of information transmission. TABLE 3.21
Physical Aversiveness/Noxious Exposures
________________________________________________________________________________
Input Glare Noise Output Isometric Lifting Vibration General Heat Cold Noxious gases, fumes, dusts ____________________________________________________________________________________________ From the OSI
37
In the Occupational Stress Index the stressor dimensions we have discussed are analyzed in relation to levels of information transmission, thus forming a two-dimensional matrix. Besides an overall assessment of burden, the OSI also provides insight into the nature of the stressors. This, in turn, often informs the direction needed for improvements in the work environment. The OSI, per se, will be the topic of our next Chapter.
38
Chapter 4
Occupation-Specific versus Generic Self-Report Measures To Assess Workplace Exposures The Occupational Stress Index: An Additive Burden Model To Help Bridge The Gap It is indisputable that etiologic research demonstrating the relationship between psychosocial workplace stressors, and a number of key health outcomes, would not have been possible without generic instruments to measure these exposures. The very success of this line of research, coupled with the global trends towards a deterioration in working conditions, oblige us to sharpen our tools, so that efforts to protect working people against these deleterious job exposures are maximally effective. As discussed in the previous chapter, cognitive ergonomics and brain research provide a complementary approach vis-à-vis constructs such as the Job Strain and Effort-Reward Imbalance Models that are based heavily upon sociological theory. We have seen that the burden of work processes upon the central nervous system (CNS) can be described in objective terms. This is particularly important for the dimension of psychologically demanding work, which has often been mired with problems of report bias (both over-report and denial), and insufficient internal consistency (Theorell 1996, Kristensen 2002). Kristensen and colleagues (Ibid), consider that this problem is due to poor conceptualization of work demands and suggest a more quantitative and dimensionalized approach. The psychological demand dimension of the Job Strain Model has not proven to be as robust a predictor of outcomes such as ischemic heart disease, in comparison to the control dimension. On that basis, some have even called into question the validity of the Job Strain Model itself. However, from the vantage point of cognitive ergonomics, we have seen that the indelible coupling between these two dimensions becomes eminently clear: with sufficient decision-latitude, or control, one can modulate even a fairly onerous, though not overwhelming, psychological workload to meet his or her needs and capacities. At the same time, the imperative to define and guard against exposure to overwhelming psychological demands becomes that much greater.
The Occupational Stress Index (OSI) (Belkic 1989, 1995a) is an additive burden model, in which we have sought to delineate work stressors, particularly those relevant to the cardiovascular system, including psychological demands, in terms of how the CNS receives, processes information and then directs productive action. Thus, we consider objective factors such as the nature and temporal density of incoming signals, the complexity and speed with which
39 these are processed, inter alia, as well as how much control the worker has in modulating these, and other, demanding factors. Taking this approach, the demand dimension of the OSI has shown not only good reliability6, but as discussed in the previous chapter, also clearly identifies occupational groups such as urban mass transit operators who face a heavy burden upon the CNS, but for whom this burden had been difficult to quantify from self-reports. The OSI incorporates elements of the leading psychosocial constructs: the Job Strain Model and Effort-Reward Imbalance Model (Siegrist 1991, 1996), as well as other formulations of how work exposures lead to cardiovascular disease, and includes salient features of work in high-risk occupations. In contrast to these more sociological models, the OSI is derived from cognitive ergonomics and brain research, attempting to describe, in quantitative terms, the burden of work processes upon the human being. The underlying motivation for developing such an approach is to help pinpoint areas for intervention, by striving to reflect actual work experiences.
(Karasek 1979),
There have been two major trends in occupational psychosocial research using self-report methods. One has been to develop occupation-specific questionnaires. These can provide rich, detailed information useful in identifying key areas for intervention. However, these job-specific questionnaires generally cannot measure job stressors across various occupations. As a consequence, research using these tools has often been focused on a single occupation, and much valuable experience has not yet been as widely appreciated as it could be. The other approach has been to measure generic job characteristics using questions of a general nature. However, “this approach is less useful for intervention studies, because questions are more ‘remote from actual work experiences“ (Landsbergis 2000, p. 164). The OSI represents a potential means of bridging these two divergent approaches. As stated by Landsbergis and Theorell (Ibid): “A recent innovative approach used occupation-specific questions (useful for workplace interventions), that are based on general questions. The Occupational Stress Index (OSI) can be tailored to specific occupations, thus allowing comparison among occupations of the stress burden faced by workers“ (p. 164). We can make comparisons regarding the total burden, as well as in the nature of the occupational stress burden. These questions are of interest not only in the research setting, but also are concerns articulated by working people themselves.
Since the Occupational Stress Index is questionnaire-based, it does not require on-the-job analysis. Insofar as these are available, direct work-site measurements and data about the workplace can be effectively incorporated into the OSI, and will improve its precision.
6
The Generic OSI in which all the factors are variable has a (Cronbach α=0.81)—see later text for further detail
40
TABLE 4.1: The Occupational Stress Index7
40
Levels of Information Aspect Transmission Input
7
Extrinsic Time Pressure
Under-load
High Demand
Strictness
•Homogeneous signals • Low frequency of incoming signals • Works alonewithout need for communication
• Several info. sources • Heterogeneous information • Heavy burden on visual system • High frequency of incoming signals • 3 sensory modalities • Communication essential
• Strict requirements for signal detection
• No control over speed of incoming signals
Central DecisionMaking
• Decisions automatic from input
• Strict problemsolving strategy • Strictly defined correct decision
• Decisions cannot be postponed
Output/ Task performance
• Homogenous tasks • Simple Tasks • Nothing to do
• Complex decisions • Complicated decisions • Decisions affect work of others • Rapid decisionmaking • Heterogeneous tasks • Simultaneous task performance • Complex tasks • Rapid task performance
• Work must meet a strictly defined standard
• No control over rate of task performance
General
• Fixed pay • Inadequate pay • No chances for upgrade • Lack of recognition of work
• Piece rate work • Long work hours • Holds 2+ jobs • Lack of rest breaks • Night shift/irregular work hours • Lack of paid vacations
• Fixed body position • Confined, windowless, workspace • Lack of autonomous workspace • Limited in taking time off from work Low influence over: • Schedule • Tasks • Policy • With whom one works
• Deadline pressure • Speed-up
Revised Version –Author: Dr. Karen Belkic 2002
Aversiveness/ Noxious Exposures • Glare • Noise
Avoidance/ Symbolic Aversivenss
Conflict/ Uncertainty
• High level of attention (Serious consequences of momentary lapse) • Visually-disturbing scenes • Listens to emotionallydisturbing occurrences
• Signal/noise conflict • Signal/signal conflict
• Serious consequences of a wrong decision
• Missing information needed for decision • Contradictory information • Unexpected events change work plan
• Isometric lifting • Vibration
• Hazardous task performance
• Conflicting demands Task performance hampered by: • Extrinsic problems • Interruptions from people
• Heat • Cold • Noxious gases, fumes, dusts
• Work Accident • Witnessed work accident • Work-related litigation/Testifying in court • Lack of functioning emergency system
• Emotionally-charged work atmosphere • Lack of help with workrelated difficulties • Opposition to career advancement • Violations of behavior norms/abuses of power • No grievance redress • Threat of job loss • Job lacks coherence
41
The Organization of the OSI Levels of Information Transmission As seen in Table (4.1), the OSI is arranged into a two-dimensional matrix, with the vertical axis comprised of “Levels of Information Transmission“. These levels are termed dimension (j). 1) Sensory input 2) Central decision-making 3) Effecter output (task performance) 4) General level These are the basic cognitive ergonomic processes, as outlined in the previous chapter according to the formulation of Welford (1960), that can be mapped over time using neurophysiologic methods as described in the model by Ivanitsky (1980). These provide a useful format for categorizing a broad range of occupational endeavor. Luczak (1971), e.g., employed this formulation in work simulation analysis. Recall that we have added a “General“, level for elements that are related to the overall work environment and not localized to a specific level of information transmission. Stressor Aspects The stressor aspects of the OSI are placed along the horizontal axis, as follows: 1) Underload 2) High demand 3) Strictness 4) Extrinsic Time Pressure 5) Aversive/Noxious Exposures 6) Threat-avoidant vigilance/disaster potential 7) Conflict/uncertainty These aspects are termed dimension (i). An in-depth discussion of each of the aspects and their constituent elements of the OSI as they relate to other psychosocial work stress models, to cognitive ergonomics, as well as to cardiac risk can be found in (Belkic 1989, Belkic 1995(a)). However, threat-avoidant vigilance warrants comment at this juncture, because it is often left out of job stress models, and yet is, in our opinion, an extremely important, albeit often unrecognized, aspect. As we have previously noted: when the potential consequences of one’s actions can include disaster, work can become a “threat-avoidant“ vigilant activity. Insofar as one anticipates the possibility of encountering harm of some sort, this is inevitably associated with negative emotions (Lazarus
42 There are epidemiological, human laboratory and experimental animal data that directly and indirectly link prolonged exposure to threat-avoidant vigilant activity with adverse cardiovascular outcomes, including cardiac electrical instability and even sudden cardiac death (Corley 1977, Lown 1990, Menotti 1985, Murphy 1991, Suurnakki 1987). Professional drivers, sea pilots, air traffic controllers and some other classes of workers, who perform primarily threatavoidant vigilant work are found to be at risk for hypertension and/or for ischemic heart disease (Winkleby 1988, Belkic 1998, Ragland 1997, Cobb 1973, Erikssen 1981, Tuchsen 2000, Zorn 1977). In the previous chapter we have noted that threat avoidant vigilant activity places the heaviest burden upon conscious attentional resources (Belkic 1992(a), Kalsbeek 1974, Levi 1981, Parasuraman 1984, Stroh 1971), and that for survival reasons, our nervous systems are constructed to selectively allocate mental resources to threatening stimuli, even if the threat is only of a symbolic nature. We reviewed a salient illustration of the importance of this hidden burden upon conscious attentional resources in a study of human electrocortical brain activity during a simulated traffic situation (Martin 1992). 1967).
The Two-dimensional Matrix Each element in the OSI has a set of coordinates, localizing it to the stressor aspects and the level at which it affects the human operator. Summations by levels and by stress aspects can be made, and a wide variety of combined effects can be assessed. The sum of the scores for each element comprises the total OSI score, which is an attempt to quantify the overall burden upon the human operator of a given set of working conditions. As mentioned above, using the OSI between-group comparisons regarding total burden can be made. Insight into the nature of the occupational stress burden can be gained, as well. For example, it may turn out that two very different jobs, such as work as a teacher and an assembly line worker, have similar total OSI scores. The OSI would help elucidate how these two jobs differ. As will be discussed subsequently, teachers have very high demand on the input and central decisionmaking levels, together with various degrees of extrinsic time pressure and conflict. In contrast, factory workers face under load (short-cycle, monotonous work), together with very strict constraints on the speed and content of the work they perform. The OSI can provide an in-depth profile of the relatively fixed, as well as potentially modifiable workplace stressors of a given job, identifying the level at which the burden primarily occurs, and the major contributing aspects. This information helps pinpoint where modifications in the work environment would be most beneficial.
The OSI Summations Each element, termed (k) of the OSI is scored on a scale from 0 to 2, with zero being “not present“ and 2 as “strongly present“. Summations are then made as follows:
43
a) All elements within a given aspect (i) at a given level (j) n
∑I
i.j.k
k =1
b) A given aspect (i) over all levels of information transmission: 4
n
j =1
k =1
∑ ∑I
i.j.k
c) A given level (j) of information transmission over all aspects: 7
n
i=1
k =1
∑ ∑I
i.j.k
d) An overall index of Occupational Stress as the grand sum of the entire matrix: (total OSI score): 7
4
n
i=1
j =1
k =1
∑ ∑ ∑I
i.j.k
The Generic versus Specific OSI’s The Generic OSI The Generic OSI Questionnaire is applicable to workers of any occupational profile. We have collected and analyzed data using this questionnaire among 345 workers of various occupations and of both genders, in several countries (Belkic 1989, 1995(a and b)). Our experience is that the generic OSI has good face validity, that working people consider the questions relevant to their daily life on-the-job, and that they understand quite well even the somewhat more abstract questions. The internal consistency of the total Generic OSI is within the desired range (Cronbach alpha = 0.81), as are most, but not all of the scales8. The Generic OSI Questionnaire can be used for between-occupation comparisons, especially when evaluating a heterogeneous working population with a wide range of profiles. However, as noted above, generic questionnaires have a common weakness in their remoteness from actual work experiences, and therefore, are often not helpful for assessing 8
The two scales from the Generic OSI, in which internal consistency is low, are: Extrinsic time pressure and Strictness. For more details, see Belkic 1995 (b), as well as Landsbergis (2000)
44 within-occupation variance, the very level at which intervention strategies are developed, in practice. The Generic OSI is no exception. On the other hand, the Generic OSI, having been designed to identify objective features of work, can be a bridge to the next step in the application of the OSI. Namely, Generic OSI data from workers in a single occupation can be used as the first phase for developing an occupation-specific questionnaire. Qualitative data from workers willing to put in the extra time to comment and explain their answers to the Generic OSI in relation to their actual work environment proves to be invaluable. This process is facilitated by a number of open-ended questions, and, whenever possible, by semistructured interviews and focus groups. Expert observers can also be of great help.
Occupation-Specific OSI’s Our aim with the OSI has been to develop a series of occupation-specific questionnaires that are all part of the OSI “umbrella“. In other words, these would all be compatible with each other, and with the Generic OSI, and thereby allow between-occupation comparisons. The advantage of the occupation-specific OSI’s is that they are far more operationalized and streamlined, and allow us to omit questions about the fixed aspects of a given line of work and to concentrate upon the variable features. Specific OSI’s are being designed for a broad range of occupational endeavor—from industrial, transport, to clerical and other white-collar sectors. OSI for Professional Drivers Our experience with the OSI for professional drivers illustrates these points. The OSI Questionnaire for professional drivers is about half the length of the General OSI, and the questions are very concrete and germane to this occupational group. Drs. Ljiljana Mickovic and Milena Gluhak provided input for the development of the OSI for Professional Drivers. In developing this specific OSI, we first identified those features of professional driving, which are relatively constant, such as: --The need to make and carry out rapid, non-deferrable, but somewhat automatic decisions (a combination of decision-making underload and high demand), --No possibility of ignoring incoming signals (strictness on the input level), --Fixed posture while behind the wheel (strictness on the general level), --No chance to influence the rate at which new signals are received (extrinsic time pressure on the input level). These and other features contribute to the high demand and low control of professional drivers, but because they are relatively fixed features of the occupation, queries in this regard would be superfluous. Furthermore, professional driving epitomizes threatavoidant vigilant activity, with requirements for high levels of vigilance and potentially fatal consequences from a momentary lapse or even a slight decision-making error. Again, there is no need to ask about this.
45
We then took the remaining, variable features of professional driving, and sought to operationalize these in relation to the traffic environment: road and vehicle conditions, type of routes, passengers, accidents, as well as work schedules, time table stringency, rest breaks, etc. These queries are presented in a neutral way, to minimize reporting bias, especially denial or repressive coping. Here are some examples of how this was done with respect to elements of input high demand versus under load. Frequency of incoming signals is scored by where driving predominantly takes place: within the city signifies high frequency of incoming signals (high demand), whereas driving mainly on long, inter-city routes is scored as low incoming signal frequency (under load). Heterogeneous signals (high demand) are encountered when driving on various routes and in various vehicles, while with driving on the same route day after day, relatively homogeneous signals are encountered (under load). The conflict between meeting a strict time schedule and fulfilling the other task requirements, as described by Gardell et al. (1983) is reflected in an item on conflict at the level of task performance. We have collected and analyzed data for 327 professional drivers using this instrument. Drivers tell us that it is easy for them to complete the questionnaire and it takes only a few minutes for them to do so. The Cronbach alpha for the variable features of the total OSI for professional drivers is 0.84. Between-group analyses reveal that professional drivers have approximately twice the mean total OSI scores compared to heterogeneous groups of workers of similar socio-economic status. (Table 4.2).
TABLE 4.2
Mean Total OSI scores for Professional Drivers versus Referent Groups
Professional drivers (mean +/- sd)
Level of Significance
Referents (mean +/- sd)
67.2 +/- 4.3 (N=258)
P < 0.001
33.0 +/- 7.9 (N=227)
63.6 +/- 4.0 (N=69)
P < 0.001
34.8 +/- 6.1 (N=23)
Derived from: Belkic et al. (1996) and Emdad et al. 1997
46 The next table (4.3) illustrates how a more detailed and operationalized approach to the demand and control dimensions helps identify professional drivers as a high strain occupational group. We found a significant, positive correlation between the demand/control ratio assessed using the Swedish Psychosocial Job Strain Questionnaire (Theorell 1988), and the total OSI score. (Belkic 1996, Emdad 1997). However, using the standard five questions for the demand dimension from the above-mentioned questionnaire (Theorell 1988), professional drivers scored non-significantly lower than the subway attendant referents, as described in Chapter 3. For decision latitude, skill discretion and for the demand/control ratio as a quotient term, there were also no significant differences. In contrast, the total scores for the high demand, strictness and extrinsic time pressure dimensions of the OSI all were significantly higher among the drivers. TABLE 4.3
The Demand and Control Dimensions using the Swedish Psychosocial Job Strain Questionnaire and the Occupational Stress Index: Comparisons between Professional Drivers and Subway Guard Attendants
Professional Drivers (Mean +/- sd)
Level of Significance
Subway Attendants (Mean +/- sd)
Job Strain
(N=34)
(N=23)
Skill Discretion
10.0 +/- 1.9
Non-significant
8.7 +/- 3.3
Decision latitude
3.7 +/- 1.5
Non-significant
4.4 +/- 2.2
ψ Demand
11.9 +/- 3.8
Non-significant
12.3 +/- 3.4
Demand/control
0.97 +/- 0.3
Non-significant
1.0 +/- 0.4
High Demand
16.1 +/- 2.1
p < 0.001
6.4 +/- 3.8
Strictness
9.0 +/- 0.0
p < 0.001
6.8 +/- 1.8
Extrinsic Time Pressure
6.6 +/-1.7
p < 0.001
4.8 +/- 1.1
OSI
Derived from: Belkic 1989, Belkic et al. (1996), Emdad et al. (1997)
47 The specific OSI for professional drivers has also shown utility in within-occupation analyses. As shown in Table 4.4, the total OSI scores significantly and independently predicted smoking intensity, indicating within-occupation criterion validity of this instrument. TABLE 4.4.
Significant Independent Predictors of Smoking Intensity among Professional Drivers who are Current Smokers (N=32)
Multiple Linear Regression
Independent Variables
Standardized Regression SE Coefficient
P
Number of smoking years
0.52
0.18
0.005
Total OSI
0.42
0.36
0.02
Adjusted R2 = 0.37
References: Belkic et al. (1996), Emdad et al. (1998(a)
As we have said, professional drivers as a group are exposed to very high levels of occupational stressors and all have much in common. However, each driver profile also faces a specific set of stressors. As shown in Table 4.5, we used the OSI to compare 130 city bus drivers and 69 truck drivers. The mean total OSI scores were very high for both groups (68.7±3.8 and 65.2±3.6, respectively)(Belkic 1989, Belkic 1995(a)). However, while these two groups share many features of their working environment, using the OSI, we were able to identify a number of important differences. As noted in Chapter 3, city bus drivers face predominantly overload, while truck drivers are exposed to a mixture of under load and overload. Our findings indicate that city bus drivers had a larger high demand score due to receiving a rapid flow of new information and having to communicate with the public, as well as performing more tasks simultaneously, often lacking rest breaks and working at night. In contrast, when driving on long routes, truck drivers have a relatively low flow of new information (monotony) and frequently drive alone, which is another source of under load, as well as social isolation. At the same time, they still must keep their sensory systems (especially visual) on full alert at all times ready to make rapid decisions and actions. This need for sustained vigilant monitoring, combined with monotonous road conditions, is recognized to be a very important contributor to fatigue during long-distance truck driving (Williamson 1996). An additional source of under load, which contributes to fatigue, is delays and long waiting times. We found these to be a frequent occurrence among the truck drivers. Another important difference is that the truck drivers worked significantly longer hours and were paid by the number of routes driven (two important sources of overload).
48 Truck drivers also performed heavy lifting significantly more often, and drove under more hazardous conditions (including carrying explosive cargo, and driving on narrow, winding roads). However, they reported fewer accidents. Extrinsic time pressure was greater for city bus drivers because they were obliged to follow a rigid schedule. They were exposed to more glare because of driving at night often on roads that were often undivided by the direction of traffic, and had more vibration exposure due to poorer shock absorbers, as well as poorer heating, cooling and isolation systems in their vehicles. City bus drivers had more conflict/uncertainty at various levels. Conflict on the input level was related to more difficult signal detection due to decreased visibility. They also had more vehicle breakdowns, other impediments to task performance, poorer interpersonal work atmosphere, as well as more conflicts between the need to arrive on time and traffic congestion which prevented them from doing so. These latter results coincide with the reports of Gardell (1983), Syme (1991) and Evans (1994), that the work environment of urban bus drivers frequently entails the need for rigid adherence to schedule, which is hampered by traffic congestion. This leads to conflict and even punitive consequences, as well as the loss of the rest breaks that are so badly needed. Threat of violence is yet another stressor which increases the cognitive aversiveness of the city mass transit drivers' work environment. As noted by Kompier and DiMartino (1995) in their review of bus drivers, this work "can be regarded as a classic example of a high-strain occupation...characterized by high demands, low control and low support...[Nevertheless] bus drivers often characterize themselves as boss of their own bus" (p. 255), although this power and decision-making latitude is greatly restricted in reality. The OSI for professional drivers provides a means to better reflect these high strain conditions. TABLE 4.5
Comparison of Mean Total OSI, Underload and High Demand Scores among City Bus Drivers and Truck Drivers
City Bus Drivers (mean +/- sd)
Level of Significance
(N=130) Total OSI
Truck Drivers (mean +/- sd) (N=69)
68.7 +/3.8
P < 0.001
65.2 +/- 3.6
Total Underload Score 5.0 +/- 1.3
P < 0.001
8.1 +/- 1.9
Total High Demand Score
P < 0.001
17.2 +/- 2.1
21.0 +/- 2.0
Reference: Belkic et al. (1995(a))
49
We have also developed multiple logistic regression models to find the set of independent factors that best identify professional drivers with hypertension and those who had suffered ischemic heart disease events, (Belkic 1996, Emdad 1997). Extrinsic time pressure on the general level was an independent predictor of hypertensive status among the drivers (beta coefficient = 2.24, p=0.04). Long work hours – an element of high demand on the general level was one of two significant factors that identified drivers who had suffered cardiac events (beta coefficient=2.91, p=0.03). Thus, two exacerbating stressors in the driver’s work environment, as assessed using the OSI, could be linked to hypertension and IHD in these groups of professional drivers. OSI for Physicians The OSI for Physicians has been pilot tested among our colleagues from various clinical specialties. Initial experience indicates good face validity and the Cronbach alpha was 0.77 for the variable features. Mean total OSI-MD scores were high (approximately at the levels of PD), and the demand levels9 about 1.5 times greater than among professional drivers. Analysis is underway for data collected from over 100 physicians. Since this instrument was developed by physicians themselves (this author together with the participation of Dr. Cedo Savic, with Dr. Michael Roybal as contributor), the first phase of development was based upon our own experience in a variety of clinical settings. As we began to pilot test the OSI for Physicians, we contextualized this as “by physicians for physicians“ within the framework of a “participatory action research“ (Israel 1992) approach. This point is emphasized here because of the pivotal position of physicians with respect to the work environment and health outcomes. Namely, physicians are often called upon to make decisions about fitness for work, and can potentially have an impact upon patients’ working conditions by making informed recommendations. At the same time, physicians increasingly face an infringement of decision-making latitude, increased demands, etc., especially within the context of managed care. The underlying burden of the work of physicians is a heavy one. Documenting and quantifying this burden is important for many reasons. As an empowerment tool for physicians, we hope this will help in efforts to improve the working conditions of our own profession. We also hope that this process can be translated into better insight by physicians into the working conditions of patients. The response of our colleagues during pilot testing has been very positive and we are grateful for the time they have taken to provide invaluable insights into their working life, and how it might be improved. There are several elements on the decision-making level, that are fixed features of work as a physician: --Need to make complex and complicated decisions (high demand on the decision-making level)
9
Cronbach alpha of the demand dimension of the Physician OSI = 0.77.
50 --Serious, potentially fatal consequences of a wrong decision (threat avoidance on the decision-making level) --Receiving contradictory information (conflicts/uncertainty on the decision-making level) Specific aspects of the physician’s work environment, that can vary to some extent, and that contribute to their stress burden, include: --Frequency of incoming signals: related to patient load and setting (emergency room or ICU versus outpatient) --Possibility to postpone decisions: related to setting (emergency room or ICU versus outpatient) --Need for rapid task execution: related to performance of invasive procedures or urgent care --Strictness on the decision making level: related to degree of control over areas such as indications for hospitalization and procedures --External time pressure on the output level / control over pace of task performance: related to control over number of patients, scheduling, and performance of non-clinical duties. OSI clerical workers – the human-computer interface Clerical work relies ever more heavily upon computer technology. While potentially increasing productivity; there are specific stressors that arise from the human-computer interaction, to which clerical workers are exposed (Smith 1999). Some examples of these stressors include: --Interruptions (a source of conflict), --High workload, lack of control related to electronic monitoring, --Slow down-wait time creating underload, --Disaster potential—(material or other type of damage)—sending wrong file, opening a virus-infected file, --Cumbersome – incompatible types of software -- hamper task performance, etc. We have developed a specific OSI for those who work daily with computers, mainly within the clerical / administrative capacity, this has been pilot tested among several such workers. Face validity appears to be good, and we have found this specific OSI useful in clinical practice (see next chapter).
OSI for teachers As discussed in Chapter 2, increasingly, adverse mental health outcomes, especially burnout (van der Berghe 1999) are being reported among teachers, in relation to an ever-greater stress burden. On the other hand, the null results described in Chapter 2, for the relationship between self-reported job strain and work ambulatory blood pressure suggest that an occupation-specific tool, within the OSI framework may offer further insights.
51
A number of fixed features of teachers’ work contribute to high demand: --Attention to several sources of information simultaneously (input high demand) --Communication essential for work (input high demand) --The need to make complex and complicated decisions (central high demand) A few examples of variable features in the teacher’s work environment that are cited as exacerbating stressors include: --Rapidity of new information, related to e.g. class size --Speed-up and deadline pressure (extrinsic time pressure on the general level) -- related to class size and curriculum demands, as well as the need to perform other duties such as administration --Conflict and uncertainty as well as threat-avoidant vigilant burden—related to e.g. to problematic pupils --Administrative task assignment – a source of high demand, extrinsic time pressure and conflict --Threat of violence We have just completed a specific OSI for teachers, with the participation of Dr. Haiou Yang, and of teachers in various settings and countries: Nancy Atwood, Charlotte Augustine, Susanna DeFalla, Iris Edinger, Lynne Kalmar, Karin Nordell, Susan Olsen and Claudia Padilla.
Other Specific OSI’s in development We have begun work on two specific OSI’s for air transport professionals: Air Traffic Controllers and Pilots, after having performed semi-structured interviews. These professions entail enormous responsibility, with maximum threat-avoidant vigilance on the input and decision-making level. They are also characterized by alternations between under load and extremely high demands, with requirements to generate peak attention levels at certain moments. As discussed by Levi (1981), generating these very high levels of attention creates a heavy burden upon the human nervous system. Requirements for judgment place an onerous load upon decision-making capacities. Variable features that affect burden upon Air Traffic Controllers include: --Average traffic density --Peak traffic density (highest attentional demand) --Latitude to alter decision-making strategy –considered a key buffer by Bisseret Sperandio (1971), and one that is compromised by time pressure and other constraints Descriptions of these stressors can be found in Costa (1993) and Landsbergis (1986).
(1971)
and
For pilots, maximum attentional demands occur during take-off and landing. Particularly during long flights, there are extended periods of relative under load with need to
52 continuously maintain high levels of vigilance. Pilots are under extremely strict control upon their performance, and must continuously fulfill rigorous licensing standards. Pressures to keep on schedule and at the same time to perform their jobs safely represent a key source of conflict. A descriptive summary of the stressors faced by pilots is provided by Green (1991). **************
Assembly line work can be considered as the epitome of job strain, as paced work with low control and high demands. However, there are variations that exacerbate or ameliorate the stress burden. Trends in the former direction, i.e. lean production, are reviewed in (Landsbergis 1999).
Some variable features of production line work include: -- High frequency of incoming signals – related to line speed -- Simple and homogeneous tasks – input and output under load related to short cycle time -- Strictness on the task performance level can be related to quality control procedures -- Physical exposures (noise, glare, vibration, lifting, chemicals, heat, cold) -- Extrinsic time pressure on the task performance level – whether working directly on assembly line An important element of control over task performance rate relates to whether the work is directly on the assembly line as opposed to those tasks that can be performed off the line (on a separate desk or work station). In the latter case, the worker would usually have more moment-to-moment control over speed of performance. An OSI for production-line workers is currently being developed. ************** An initial version of an OSI for nurses has been drafted and is ready to be pilot tested. *************************************************************************** It is a great and labor-intensive challenge to develop a set of occupation-specific instruments to assess work stressors, within a theory-based framework, and from which between-group, as well as within-group, analyses can be made. Progress and dilemmas will be explored in more detail in Chapter 6, in which each of the OSI questionnaires in their newest version is presented. In the next Chapter, we will focus upon the OSI as a clinical tool, for preparing a narrative occupational history and as part of a work-related diagnostic and management plan.
53
Chapter 5
The Occupational Stress Index In Clinical Practice Preparing A Narrative Occupational History, which includes Psychosocial Stressors As This Informs A Work-Related Diagnostic And Management Plan The Clinician’s Challenge Clinicians have long sensed that workplace stressors can have a profound impact upon their patients’ health. In 1958 Drs. Henry Russek and Burton Zohman published a seminal paper from their own medical practice, identifying “occupational stress and strain” as the factor which most sharply distinguished their young patients with ischemic heart disease from a group of healthy referents. Their analyses relied upon descriptive data obtained from patient histories. In the first international workshop on Occupational Cardiology, held in 1988 in Udine, Italy focusing upon return to work for patients after acute myocardial infarction or revascularization, Dr. Giorgio Maisano, the chairperson, eloquently summed up the challenges faced by clinicians: to offer the patient a style of life and of work that protects both his or her health and right to be productive. Dr. Maisano insisted that in order to achieve the aforementioned goal, understanding of the job and the work environment, in addition to a functional evaluation of the patient, is absolutely essential. In other words, taking this approach, when clinicians are called upon to make a judgment about the work fitness of their patients, they should also ask the fundamental question: is the work environment fit, or conducive to health? In this chapter, we will present a series of pedagogically constructed clinical cases that address this challenge. These are not based on any individual patient. We begin by presenting a completed OSI for the specific occupation, from which a fairly brief narrative history is developed. These provide examples of how an occupational history, which includes psychosocial factors, can offer insight into key work-place stressors that may impact upon a given patient. In part II of this chapter a complete clinical case is presented, including diagnostic and management issues that are informed by each of the OSI’s and the narrative histories from Part I. We pose a set of questions for each case, and provide some possible answers at the end of the Chapter. Perhaps the most important questions to ask oneself in reading this Chapter are: (1) what would have been missed if the occupational history were not included? (As is now very often the standard of care, particularly in clinical cardiology, which is the major domain of these clinical cases), and (2) how can the insights gained from the work history inform various possible diagnostic and management scenarios?
54
An Approach to taking a Work History which includes Psychosocial Stressors, Based upon the OSI In order to facilitate this process, we will present a flow sheet (Panel 5.1), which summarizes what such a narrative history should encompass. We also provide a set of “link sheets” which connect the flow sheet to the generic OSI, as well as to each of the specific OSI’s. Therein, each stressor on the summary flow sheet is linked to the corresponding question(s) in OSI. We illustrate how this is linkage is achieved with an example: The presence or absence of the job characteristic: socially isolated work (falling under the under load aspect) is evaluated as follows: ---------------------------------
Generic OSI Yes, if Question 49=a 49. Communication with other people during work: a. There is no need for work-related communication with others. b. From time to time, I must discuss with others in order to perform my work properly. c. Communication with other people is a major feature of my work. OSI for Professional Drivers: Yes, if Question 8=a 8. Do you drive most often? a. Alone in your vehicle? b. With 1 or 2 other persons in your vehicle? c. With many passengers in your vehicle? Physicians: No No need to ask: the work of all physicians requires at least some work-related communication OSI-Computer: This will not often be the case, unless Questions 49, 53, 56, and 45.2=a No email, telephone nor face-to-face work-related communications, and no teamwork. 45.2 Does performance of your work tasks require teamwork? a) Minimally or not at all. b) Sometimes. c) Definitely. ------------------------------------
From this example, it can be seen that while the generic OSI poses a generic question, the OSI for professional drivers directs this query to the driving milieu. For physicians, it is clear that no question is even needed here: the physician’s work cannot be performed without communication with others. The information can also be derived very concretely for the office milieu.
55 TABLE 5.1
Evaluation of The Workplace For Clinical Practice: Summary Flow Sheet
Step A: Type of Occupation-High Risk1 for CVD or other work-stress-related outcomes
Step B: Job Characteristics (Many, but not all of these, are fairly fixed within an occupation) Underload --Monotonous work --Little or no decision-making --Socially-isolated work --Doesn’t learn anything new
Hypertension or CVD --Professional Drivers --Air Traffic Controllers --Sea Pilots --Workers in the Explosives Industry High Psychological Demand --Smelter Workers --Rapid flow of new information --Chimney Sweeps --Receives and transmits important, job-related --Factory workers information to other people --Many things going on at once/divides attention --Must focus attention upon devices Burnout or other Adverse Mental --Complicated decision making and/or tasks Health Outcomes --Supervises work of others --Nurses --Physicians Low Control/Physical Constraints --Strict time schedule --Other health care professionals --Paced work --Teachers --No chance for creativity --No influence over work conditions --Works in a confined space/fixed body position Repetitive Motion Syndrome --Heavily Supervised --Factory workers --Workers sitting behind a computer Physically Aversive Exposures terminal --Glare --Noise --Nurses --Vibration --Heavy lifting --Professional Drivers --Heat --Cold --Chemical noxins
Disaster Potential-Symbolic Aversiveness --Threat-avoidant vigilance --Encountering visually disturbing scenes --Listening to emotionally-disturbing occurrences --Danger of serious accidents (hazardous tasks) --Threat of physical violence from other people
1
Based upon Empirical Evidence, as discussed in Chapter 2, and Reviews Referenced therein.
56 Step C: Specific Work Conditions (Likely to vary within an occupation) Work schedule and rest breaks --Number of work hours --Night shift work/irregular schedule --Rest breaks/mini-breaks --Vacation (Individual and collective control over these) Actual workload and its distribution over time Evaluate for specific occupation, e.g. --Teachers: # of classes, class size, # of challenged pupils, etc. --Air traffic controllers: average and peak traffic density, etc. --Total patient load, # admissions, % emergency or otherwise difficult patients, etc.
Step D: Exacerbating (new) conditions
Step E: Larger Questions
--More overtime work than usual
--Looming possibility of layoff or permanent unemployment
--New deadlines --Recent involvement in or witnessing serious work accident or other threatening situation --New interpersonal conflicts
--Need to change occupation or workplace Minority/refugee/ immigrant: Discrimination and/or status incongruity --Restructuring within the work organization --Additive burden from major non-work stressors --Low socio-economic status
Level of exposure to physical noxins --Usual and peak exposure intensity (How cold, how hot, how noisy, how heavy, etc.) --Duration & characteristics Work Accidents --# experienced and severity --Witnessed or heard about Barriers to task performance --Conflicting demands --Technical problems and breakdowns Interpersonal relations/Social climate --Conflicts with supervisor, colleagues workers of other profiles
Now let us review each of the steps in the Summary Flow Sheet.
57
Step (A) is to indicate the current occupation, and determine whether it falls into the high-risk category for adverse somatic and psychological outcomes. It is helpful to be as specific as possible; for example, rather than merely noting that the person works as a teacher, it would be much more informative to know e.g. whether he or she teaches in a private gymnasium versus in a poor, inner city elementary school versus in an adult education setting, etc. The number of years in the current job, as well as a list of all jobs held with approximate dates of employment should be obtained, with relevant details of past work conditions also noted. Next, in Step (B), the underlying work characteristics should be defined. These include many factors that are somewhat fixed features of a given job, and could require major organizational change in order to be modified. As one becomes more familiar with the occupations, this step can become shorter. In other words, many of the job attributes will be obvious, so that the number of queries posed will be minimized. In the specific OSI’s, the fixed and the relatively fixed features of the respective occupations are indicated. Included in Step (C) are the specific work conditions that are more likely to vary within an occupation, and may be more amenable to change. The exacerbating conditions are listed in Step D. Finally in Step E, the larger questions affecting the working individual are considered, such as threat of unemployment; work reorganization requiring change of occupational activity; minority, refugee or immigrant status which may result in discrimination and/or status incongruity. Some of these elements are part of the low reward dimension of the Effort-Reward Model (Siegrist 1991). A notation should also be made of non-work related stressors, keeping in mind the additive burden. The latter may be of particular importance to women workers.
58 Part I: Occupational Histories Based upon the OSI: In this first part of the Chapter, we present four occupational histories (A. for a physician, B. truck driver, C. clerical worker who daily works with computers, and D. an automobile assembler). Each case begins with a completed OSI, this is followed by a “link sheet” which connects the respective OSI to Table 5.1. Finally, the sample narrative history is presented. A. Physician Specialist –Neurologist/Psychiatrist Completed OSI for Physicians The answers to this questionnaire are pedagogically constructed, not based on any individual. THE WORKING CONDITIONS AND WELL-BEING OF PHYSICIANS This questionnaire is designed to assess the working conditions and well being of physicians. It is being applied in the international context and therefore, contains elements that are relevant in a broad range of settings. Please read each question carefully, and unless otherwise indicated, choose the best single answer. This questionnaire is handled entirely confidentially, without names or any other means of individual identification. This questionnaire has been approved by the regional Medical Ethics Committee Thank you for your Cooperation! ----------------------------------------------------------------------------------------------------------------GENERAL INFORMATION
Your age: 54 Gender: Male
X Female
Marital status: a) Single b) Married
c) Divorced X d) Widowed/widower
Number of children: One Do you consider that there are serious problems in your family? Yes
X No
If yes, what are these? _____________________________ Your housing question: a) Not solved, living in inadequate/ uncomfortable conditions b) Not solved, but living in adequate/comfortable conditions c) Solved in the sense of owning the property, but inadequate/uncomfortable conditions X d) Property owner, living in adequate/comfortable conditions Regular recreational physical activity? Yes
X No
59
Do you have any hobbies?
X No
Yes
How many cups of coffee do you drink per day? 4-5 b) Former Smoker Current smoking status: X a) Smoker smoker If currently smoking, number of cigarettes per day: 15-20 Number of drinks of alcohol /week: 0 Current medications:
c)
Never
Type(s)of alcohol:
Enalapril, 5 mg/d
X Yes Do you have any medical problems? Arterial hypertension Diagnoses: Hypercholesterolemia
No
What is your current height: 5’ 4” Weight: 120 lbs. When did you last weigh yourself ? Last week
YOUR WORK AS A PHYSICIAN
1.What is your Specialty? Neurology and Psychiatry Subspecialty? ________________________ 2.How long altogether have you worked as a physician? X e) Over 20 years a) Less than 5 years c) 11 to 15 years b) 6 to 10 years d) 16 to 20 years 3.How long altogether have you been employed? a) Less than 5 years c) 11 to 15 years b) 6 to 10 years d) 16 to 20 years 4.Type of practice: a) Solo Private Practice b) Group Private Practice c) Health maintenance organization (HMO)
X e) Over 20 years
X d) Public (non-private) clinic / hospital e) Physician in general training (intern) f) Physician in specialty training (resident)
5. What is the approximate percentage of inpatient work, which you handle? a) Less than 10% b) < 50% (but at least 10%) X c) > 50%
60 6. What is the percentage of patients for whom you care with end-stage/incurable disease or injury? c) Over 20% but less than 50% X a) Less than 10% b) Between 10 and 20% d) Fifty percent or more 7. What is the approximate percentage of emergency cases, which you handle? a) Less than 10% X b) Less than 50% (but at least 10%) than 50%
c)
More
8.At how many different institutions do you work? b) Two c) Three or more X a) Only one Work Hours, Scheduling and Payment 9.
How long is your ordinary workday? Eight hours
10. Do you ever work longer than that? X Yes 11. If yes, how many days per month (usually)? _10
No For how many hours per day? 2
12. How many days do you usually work per week? 6 How many weeks of paid vacation do you have per year? Four
13. Do you work at another job outside your regular one? Yes
X No
14.
If yes, how many hours per week? __________
15.
What do you do at your other job? While I do not have another paid job, I perform many hours of housework per week
16. Do you have the opportunity to take breaks during your workday? a) I almost always have a chance to take breaks during my workday. b) Sometimes work is so heavy that I have no breaks during my workday. X c) Usually not, mostly I work non-stop throughout the workday. 17. If you do have some breaks, are these usually: X a) Short ones (5-10 minutes) b) Long breaks (at least 30 min) c) Both short and long breaks 18. Do you take night call? a) Rarely (no more than once per month) or never X b) Less than weekly, but more than once per month. Twice/month
61 c) At least weekly, but not more than every fourth night d) Every third night or even more frequently e) I only work the night shift If you take night call, please answer the next 4 night shift related questions: 19. How much do you usually sleep during night call? a) At least 4 to 5 hours per night b) Mainly between 2 and 4 hours; the rest of the time I'm busy c) At the most I get 2 hours of sleep; I'm busy most of the night X d) I usually get only a couple of hours. Even when I'm not busy, I am too agitated to sleep 20. Are you obliged to be physically at the hospital during night call: X a) Yes b) No, I am on pager, and only occasionally must come in. 21. What kind of free time adjacent to night call do you have? (Please check all that apply) a) I come in for the night shift, having been free that day b) After the night shift, I go home in the morning X c) I go on call after having worked that day, and must work at least part (if not all) of the next day If you answered (c) immediately above: 22. Do you have guaranteed relief at a specified time after being on call? a) Yes, I can go home and be certain that the patients under my responsibility are cared for by colleagues X b) No, it can happen that I must stay late to be sure my patients are stable before I go home 23. Are you called at home during your free (not on-call) time regarding clinical care of X c) Often patients? a) Rarely or never b)Occasionally 24a. Upon what is your salary based? a) Upon my own work: number of patients, interventions, hours worked etc. b) Upon group work: number of patients, interventions, hours worked etc. X-c) Fixed pay, irrespective of the amount of work 24b. My salary is: X a) Totally inadequate to meet the basic needs of my family and myself. b) Just barely covers the basic needs of my family and myself. c) Covers more than the basic needs of my family and myself. Working Conditions and Exposures 25. Are you exposed to strong lights that create glare for you at work?
62 X c) Rarely or never
a) Often (in the Operating Room or elsewhere) b) Occasionally
26. Do you encounter any of the following visually disturbing scenes during work? (Mark all that apply) a) Severe burns c) Grotesque dermatological X d) Other (specify: b) Dismemberment or other severe trauma Coma, status epilepticus, delerium tremens, etc. 27. Do you listen to accounts of emotionally disturbing occurrences? X a) Often b) Occasionally c)Rarely or never If a or b, please briefly describe: Panic attacks, depression, and psychotic patients 28. Do you perform heavy lifting during work? a) Yes, I regularly must lift patients b) I do other heavy lifting, up to: _______kg or (_______lbs.) X c) No, I rarely do any heavy lifting during my workday 29. Are you exposed to vibration during work? a) Yes, I use vibrating hand tools (hours/week ) X b) No, only very rarely or not at all If yes, which tools: _________________________________
30. Concerning heat exposure during work? a) Rarely or never hotter than 25° C (77° F) at work b) Rarely or never hotter than 30° C (86° F) at work X c) It is occasionally or often hotter than 30° C (86° F) 31. Concerning cold exposure during work? a) Rarely or never colder than 18° C (64° F) at work X b) The heating system is poor, with temperatures <18° C (64° F) 32. Are you exposed to gases, mists or dusts at work? X a) No, only very rarely or not at all b) Yes, at least occasionally If yes, how many hours per week _______ to which substances: _________________________________________
33. Are you exposed to radiation during work? Yes If yes, do you wear a radiation badge? Yes No
X No
63 Specifics about your exposure: _____________________ 34. Acute hazards at work: (please check all which are applicable) X a) Threat of violence from psychotic or otherwise dangerous patients X b) Possible infection /close exposure to blood or other body fluids c) Work with flammable materials d) Other risk(s), (please specify: _____________________________) e) There are no special acute hazards where I work b) I share an office (with how many others? ____) 35. Workspace: X a) Own office Approximate size of your office: 81 square feet If you share an office, do you have your own desk? Yes No Must you sometimes look for an empty office in which to interview or examine patients? Yes No What approximate percent of your working day do you spend in your office? _________ Mishaps at or regarding work 36. Have you ever suffered physical harm or injury at work? Yes If yes, please briefly describe:
X No
37. Have colleagues and/or staff suffered physical harm or injury at your workplace? a) Yes, I witnessed such, with a fatal outcome b) Yes, I witnessed such, with a serious, but not fatal outcome X c) I’ve heard about serious or fatal injury, but never witnessed it d) No, I have never witnessed or heard about anyone’s serious injury at my workplace If you answered a, b or c, please briefly describe: 38. Has a patient under your care ever committed suicide? a) Yes, this has happened on several occasions X b) Yes, I have had one or two such patients c) No, but it has happened to colleague(s) with whom I work d) No, it has never happened to me or to colleague(s) with whom I work X Yes 39. Have you ever been obliged to testify in court as a physician? If yes, please mark all the following which apply: X a) I have testified as an expert witness about a patient b) I have been obliged to testify regarding a colleague or staff member c) I have been obliged to testify as a defendant in a malpractice case d) Other, please specify: _____________________________________ If yes to question 39,
No
64 40. Were any of these proceedings made public via the mass media? Yes
X No
Time pressure 41. Do you have a deadline by which any of your tasks must be completed? X a) Often b) Sometimes c) No, it happens only rarely or never 42. Are you obliged to speed-up your work tempo? X a) Yes, every day b) Yes, at least weekly, but not daily c) Yes, during certain periods every month
d) Yes, during certain periods every year e) No, it happens only rarely or never
43. With regard to your workload and time constraints a) It is usually possible complete everything X b) Even with maximal effort, it is sometimes objectively impossible to complete everything c) Even with maximal effort, it is often objectively impossible to complete everything How much influence do you have over: Major 44. Your own work hours and schedule 45. Number of patients under your care/ outpatient scheduling 46. The colleagues and staff with whom you work 47. Scheduling of vacation
Little/None X X
X X
48. Planning and policy of your institution(Including those regarding indications for medical procedures and for hospital admissions) 49. Whether and how much you will take on other, non-clinical duties
50. Is your work overseen by others? If yes, please check all which apply:
Some
X
X
Yes
X No
65 a) By more senior physicians b) Non-physician personnel (e.g. administrators, nurses) c) Physicians of your level or lower If yes, is your clinical judgment questioned? a) Often b) Sometimes c) Rarely or never Rules and regulations regarding: Very strict
Somewhat
Flexible
strict 51. Patient admissions
X
52. Patient scheduling
X
53. Are there problems that directly hamper your providing adequate patient care? X a) Yes, major ones b) Occasionally c) Rarely or never 54. If a or b, please check all which contribute to this problem X a) Lack of needed supplies (including medications) X b) Lack of hospital beds X c) Understaffing X d) Administrative constraints to ordering needed supplies X e) Language barriers with patients (lack of translators) X f) Infrastructural problems (lack of elevators, power failures etc.) X g) Need for frequent patient transport under tenuous conditions X h) Delay or inability to obtain medical records X i) Difficulty in obtaining laboratory results j) Limitations in ordering tests k) Limitations on sending patients for consult l) Other problems (_____________________________) Inter-personal relations with colleagues and staff 55. Can you get help from colleagues and/or supervisors for difficult cases and/or clinical dilemmas? a) Yes, I can almost always count on such help. c) I can’t really count on getting such help X b) Yes, more often than not. d) Rarely or never do I get the help, which I need. 56. How is cooperation with staff? a) Excellent, we get along well together and misunderstanding are rare.
66 X b) Fair, sometimes there are misunderstandings and tensions. c) Poor, there is a great deal on tension and conflict with the staff. 57. Do you receive support and encouragement for improvements in your knowledge and skills/career advancement? a) Definitely yes. b) Yes, to some extent. X c) Not really, but there is no active opposition to my efforts d) No, there is active opposition to my career advancement. 58.When obliged to display knowledge and/or skills in front of colleagues and/or supervisors (e.g. during rounds, journal club, other presentations, etc.): X a) The atmosphere is constructive and conducive to growth and learning b) There is some tension. Oversights and/or lack of knowledge will be noticed and commented upon. If these are of major importance, there may be adverse consequences. c) These occasions are highly unpleasant. Event the slightest oversight or lack of knowledge inevitably becomes a point of ridicule and/or chastisement
Workload and Activities
Do you handle patients who are? Frequently 59. Disturbed
X
60. Cannot provide a history
X
Occasionally
Rarely/Never
61. How many inpatients do you usually have under your direct care at one time? a) None d) Eleven to twenty X e) Over twenty b) One to five c) Six to ten 62. How many of these are in intensive care (including CCU)? a) None d) Six to ten b) One to two e) Over ten X c) Three to five 63. How many outpatients do you usually see during one work shift? a) None d) Twenty-one to thirty
67 X e) Thirty-one to forty b) One to ten c) Eleven to twenty f) Over forty How many of these are new patients?_____________ 64. How many patients do you usually admit during a working shift? a) None d) Eleven to twenty X b) One to five e) Over twenty c) Six to ten 65. Are you obliged to care for these newly admitted patients, or do you transfer them to other colleagues? a) I must care for all the patients whom I admit during a given shift X b) I must care for some of the patients whom I admit during a given shift c) The patients whom I admit are nearly always transferred fairly rapidly to other colleagues 66. Does it happen during work that several people seek your attention at the same time (including people on the telephone?) X c) Yes, but at most once or twice a day a) Yes, many times per day b) Yes, a few times per day d) No, rarely or never 67. If people simultaneously seek your attention, how many do so? c) Usually >3 a) Rarely > 2 X b) Usually two, but sometimes more
68. Does it happen that you are obliged to physically be at work, but there is not any real work to do? X c) No, rarely or never a) Yes, often b) Occasionally 69. Do you oversee or supervise the work of: (please check all which apply) a) Physicians at your level of training or higher c) Medical students X d) Other health professionals X b) Physicians with less training than yourself 70. Number of persons other than yourself, for whose work you must take responsibility: 16 71. Besides clinical work, other major work activities include: (please check all which apply) X a) Teaching in small groups (e.g. medical students) X d) Administrative duties X b) Lecturing to larger groups e) Other:____________________________ X c) Research 72. If you have other major work activities, is there special time set aside for these?
68 X No Yes If no, when do you perform these other activities? (Please check all that apply) X a) I perform these duties simultaneously with my clinical work X b) I work after normal work hours to complete these activities 73. Are you under pressure to publish/present new findings or results at Congresses or other meetings outside your Institution? a) Yes, if I fail to do so in sufficient quantity, my career will suffer and I may even lose my position b) Yes, but there are no major adverse consequences if I fail to do so. X c) No, such activity is entirely up to my own initiative and choice. Which of the following do you perform on a regular basis (please enumerate) 74. Non-invasive diagnostic procedures
Yes
Clinical evaluation of patients, mainly relying upon history and physical examination 75. Invasive procedures Lumbar puncture
Yes
76. Surgical interventions
No
77. Tasks outside the realm of a physician/work of other personnel:
Yes
Administrative work, admitting and discharging patients, inter alia 78. Do you regularly use a computer as part of your clinical work? X No Yes If yes: (please check all of the uses you have for the computer) a) To obtain data (lab, medical records, etc.) about my patients b) For patient write-ups (e.g. discharge summaries, etc.) c) For help in triaging to other departments and other institutions d) For statistical analyses that would be for clinical purposes e) For electronic communication (email) with colleagues (consults etc.) f) For electronic communication (email) with patients g) For searching the medical literature to elucidate a clinical question. h) Other, please describe:___________________________ In which of the above circumstances is the computer most helpful? In which of the above circumstances is the computer more of a burden than a help, and why?
69 79. In the past 6 months has any of the following occurred? (Please check all which apply) a) An increase in the length of you workday? b) A decrease in the length of your workday? X c) Increased time pressure/number of deadlines? X d) An increase in work responsibility? e) Demotion with pay cut? f) Promotion with pay raise? g) Threat of being laid off? h) Other changes, please specify: _________________________________
Open-Ended Questions: What is the hardest part of being a physician of your profile? --Lack of needed diagnostic equipment --Death of a patient and having to inform the family --Feelings of helplessness in caring for patients with endstage, terminal disease
What do you think could be done to improve work as a physician of your profile? Immediate/ very feasible --Increased financial resources allocated to diagnostic equipment and patient care --Increased salaries for health-care professionals (we are inadequately rewarded for the efforts that we devote More long-range changes requiring organizational modifications: --In addition to the above, improve our working conditions --Improve work organization What would be the most important immediate change to improve work as a physician? --Provide adequate salaries for physicians --Obtain medical equipment and other needed supplies If attempts were made to improve the conditions for your job, what would you suggest to preserve the good aspects of your work as it now stands? --Humanism and enthusiasm of our colleagues, their motivation and desire to acquire new knowledge via seminars and specialist meetings, and in other ways to exchange experience Additional comments about your work: --The continuous responsibility and care for patients leads to psychological and physical exhaustion. The emotional satisfaction is our reward. Being able to help in the
70 treatment and cure of patients represents a powerful buffering factor, and motivation for work.
Link between the Summary Flow Sheet and the OSI for Physicians High Risk Occupation Current occupation, total number of years in that occupation, work history OSI-MD Q. 1-4 Specialty, subspecialty and type of practice --------------------------------------------------------------------------------------------------Monotonous work Physicians: No No need to ask: the work of physicians is not monotonous. -------------------------------------------------Little or no decision-making Physicians: No No need to ask: the work of physicians requires decision-making. -----------------------------------------------------Socially isolated work Physicians: No No need to ask: the work of all physicians requires at least some work-related communication Learning new things. Physicians: Generally this will not be the case. If available, see answer to JCQ: Question 1 --------------------------------------------------------------------------------------------------------Rapid flow of new information OSI-MD Usually yes, especially if emergency cases (Q. 7=b or c) See also Q. 61-67. ----------------------------------------------------Receives and transmits important, job-related information to other people Physicians: Yes. No need to ask: the work of all physicians requires at least some work-related communication ----------------------------------------------------Many things going on simultaneously/must divide attention
71 OSI-MD: Usually yes, especially if emergency work (Q.7=b or c) or if Q.66=a or b (several people seek attention at the same time) Must focus attention upon devices OSI-MD: Most often yes, especially if emergency work (Q.7), ICU patients (Q.62), or noninvasive & invasive procedures and surgical interventions (Q. 74-76) -----------------------------------------------------
Complicated decision making and/or tasks Physicians: Yes. No need to ask, the work of all physicians entails complicated decision-making (complicated tasks can be assessed by Q. 74-76) ----------------------------------------------------Supervises work of others OSI-MD: Usually yes, see Q. 69. 69. Do you oversee or supervise the work of: (please check all which apply) a) Physicians at your level of training or higher c) Medical students b) Physicians with less training than yourself d) Other health professionals --------------------------------------------------------------------------------------------------------Strict time schedule Generic OSI Very much so, if Q. 24=a, & 25=a. 24. Do you have a deadline by which a given job or task must be completed? a. Often b. Sometimes c. Rarely of never 25. Do you face speed-up? a. Every day b. At least once a week, but not every day. c. At certain periods of every month d. At certain periods of the year e. Rarely of never OSI-MD: Very much so, if Q. 41=a, & 42=a. (These are identical to Generic OSI Q. 24 & 25) ----------------------------------------------Paced Work OSI-MD: Cannot ever be truly paced work, but if extreme time pressure, almost like paced work. -----------------------------------------------
No chance for Creativity OSI-MD: Some creative problem solving is usually part of the work of physicians. This can be compromised if patient-care related rules and regulations are very strict (Q. 51 & 52), if discussion is stifled (q. 58) or if supervision is overly heavy (q. 50) ----------------------------------------------No influence over work conditions OSI-MD: Q. 44-49 indicate little or no influence over the cited work conditions ----------------------------------------------
72 Works in confined space/fixed body position OSI-MD: Yes if many invasive/surgical procedures during which the body position is fixed (See Q. 1 and 75-76), and/or in very cramped office space especially without one’s own desk, Q.35) ----------------------------------------------
Heavily Supervised OSI-MD: Yes, if Q. 50=yes, with clinical judgment often questioned and Q. 58=c 50. Is your work overseen by others? Yes No If yes, please check all which apply: a) By more senior physicians b) Non-physician personnel (e.g. administrators, nurses) c) Physicians of your level or lower If yes, is your clinical judgment questioned? a) Often b) Sometimes c) Rarely or never 58.When obliged to display knowledge and/or skills in front of colleagues and/or supervisors (e.g. during rounds, journal club, other presentations, etc.): a) The atmosphere is constructive and conducive to growth and learning b) There is some tension. Oversights and/or lack of knowledge will be noticed and commented upon. If these are of major importance, there may be adverse consequences c) These occasions are highly unpleasant. Event the slightest oversight or lack of knowledge inevitably becomes a point of ridicule and/or chastisement ------------------------------------------------------------------------------------------Glare exposure OSI-MD: Yes, if Q. 25=a or b. 25. Are you exposed to strong lights that create glare for you at work? a) Often (in the Operating Room or elsewhere) b) Occasionally c) Rarely or never ---------------------------------------------Noise exposure OSI-MD: If working mainly in the Emergency Room (Q. 7), moderate noise exposure is likely, otherwise less likely. ---------------------------------------------Vibration exposure OSI-MD: Usually not, unless Q.29=a, which may be the case, e.g. for orthopedic surgeons. 29. Are you exposed to vibration during work? a) Yes, I use vibrating hand tools (hours/week ______) b) No, only very rarely or not at all ----------------------------------------------
Heavy lifting OSI-MD: Yes, if Q.28=a or b
73 28. Do you perform heavy lifting during work? a) Yes, I regularly must lift patients b) I do other heavy lifting, up to: _______kg or (_______lbs.) c) No, I rarely do any heavy lifting during my workday ---------------------------------------------Heat OSI-MD: Yes, if Q.30. 30. Concerning heat exposure during work? a) Rarely or never hotter than 25° C (77° F) at work b) Rarely or never hotter than 30° C (86° F) at work c) It is occasionally or often hotter than 30° C (86° F) ---------------------------------------------Cold OSI-MD Yes, if Q.31=b. 31. Concerning cold exposure during work? a) Rarely or never colder than 18° C (64° F) at work b) The heating system is poor, with temperatures <18° C (64° F) ---------------------------------------------Chemical exposures: Fumes, Dusts and Gases OSI-MD: Yes, if Q.32=b (Most often, surgeons, anesthesiologists, trauma and ER, performance of invasive procedures) 32. Are you exposed to gases, mists or dusts at work? a) No, only very rarely or not at all b) Yes, at least occasionally If yes, how many hours per week _______ To which substances?_________________________________________ Also note radiation exposure ------------------------------------------------------------------------------------------Threat Avoidant Vigilant Work OSI-MD : Yes. No need to ask, this is fundamental to the occupation. ---------------------------------------------Encountering Visually Disturbing Scenes OSI-MD (Q.26 if yes to any of these) 26. Do you encounter any of the following visually disturbing scenes during work? a) Severe burns c)Grotesque dermatological disorders b) Dismemberment or other severe trauma d) Other ----------------------------------------------
Listening to Emotionally-disturbing occurrences OSI-MD: Likely yes. Q. 27=a or b. 27. Do you listen to accounts of emotionally disturbing occurrences? a) Often b) Occasionally c) Rarely or never ----------------------------------------------
74 Hazardous tasks/Danger of serious accidents -- harm OSI-MD : Yes, if Q.34 a – d 34. Acute hazards at work: (please check all which are applicable) a) Threat of violence from psychotic or otherwise dangerous patients b) Possible infection /close exposure to blood or other body fluids c) Work with flammable materials d) Other risk(s), (please specify: _____________________________) e) There are no special acute hazards where I work ---------------------------------------------Threat of physical violence /assault OSI-MD: Yes, if Q.34=a. ------------------------------------------------------------------------------------------Number of work hours Hours /day, Days/week, Overtime OSI-MD: Q. 9 -12 ---------------------------------------------Night shift work OSI-MD: Often yes, see Q.18 regarding frequency. ---------------------------------------------Irregular work hours OSI-MD Yes, if rotating night (Q. 18=b, c or d), and especially if no guaranteed relief after being on call (Q. 22=b). ---------------------------------------------Rest breaks: scheduled and unscheduled, Minibreaks OSI-MD: See Q. 16-17 ---------------------------------------------Vacations OSI-MD See Q. 12 Part II. ------------------------------------------------------------------------------------------Workload and distribution over time OSI-MD Questions 61-65, 74-77 Number of patients (Inpatient, ICU, outpatient & new admissions), clinical tasks and other duties. ------------------------------------------------------------------------------------------Level of exposure to physical noxins
75 For any of these physical noxins (Glare, noise, vibration, isometric stress, heat, cold, chemical agents) to which a worker is exposed, obtain more information about level and type of exposure. ------------------------------------------------------------------------------------------Number and Severity of Work Accidents OSI-MD: Q. 36 ---------------------------------------------Work accidents witnessed or heard about OSI-MD: Q. 37 ------------------------------------------------------------------------------------------Conflicting demands in time and space OSI-MD: Yes, if Q. 43=b or c 43. With regard to your workload and time constraints a) It is usually possible complete everything b) Even with maximal effort, it is sometimes objectively impossible to complete everything c) Even with maximal effort, it is often objectively impossible to complete everything ---------------------------------------------Technical Problems and Breakdowns OSI-MD: Yes, if Q.53=a or b. (See Q.54 for a description) 53. Are there problems that directly hamper your providing adequate patient care a) Yes, major ones b) Occasionally c) Rarely or never 54. If a or b, please check all which contribute to this problem a) Lack of needed supplies (including medications) b) Lack of hospital beds c) Understaffing d) Administrative constraints to ordering needed supplies e) Language barriers with patients (lack of translators) f) Infra-structural problems (lack of elevators, power failures etc.) g) Need for frequent patient transport under tenuous conditions h) Delay or inability to obtain medical records i) Difficulty in obtaining laboratory results j) Limitations in ordering tests k) Limitations on sending patients for consult l) Other problems (_____________________________) ------------------------------------------------------------------------------------------Inter-personal relations OSI-MI: Q. 55-58 give a more detailed view of the aspects of interpersonal relations specifically relevant to physicians: 55. Can you get help from colleagues and/or supervisors for difficult cases and/or clinical dilemmas?
76 a) Yes, I can almost always count on such help. c) I can’t really count on getting such help b) Yes, more often than not. d) Rarely or never do I get the help, I need. 56. How is cooperation with staff? a) Excellent, we get along well together and misunderstanding are rare. b) Fair, sometimes there are misunderstandings and tensions. c) Poor, there is a great deal on tension and conflict with the staff. 57. Do you receive support and encouragement for improvements in your knowledge and skills/career advancement? a) Definitely yes. b) Yes, to some extent. c) Not really, but there is no active opposition to my efforts d) No, there is active opposition to my career advancement. 58.When obliged to display knowledge and/or skills in front of colleagues and/or supervisors (e.g. during rounds, journal club, other presentations, etc.): a) The atmosphere is constructive and conducive to growth and learning b) There is some tension. Oversights and/or lack of knowledge will be noticed and commented upon. If these are of major importance, there may be adverse consequences c) These occasions are highly unpleasant. Event the slightest oversight or lack of knowledge inevitably becomes a point of ridicule and/or chastisement ------------------------------------------------------------------------------------------Recent increase in Work hours/more overtime OSI-MD: Yes, if Q. 79 a ---------------------------------------------New Deadlines OSI-MD: Yes, if Q. 79c ---------------------------------------------Recent Experiencing or Witnessing Accident OSI-MD: If Q. 36 yes or Q. 37 a-c, ask whether this was recent. ---------------------------------------------New Interpersonal Conflicts OSI-MD: If any of the answers to Q. 55-58 indicate that interpersonal problems, ask whether any of these have gotten worse recently. ------------------------------------------------------------------------------------------Looming possibility of Lay-off OSI-MI: Yes, if Q. 79 g
77
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Physician Narrative History derived from the OSI for Physicians This narrative occupational history is pedagogically constructed, not based on any individual. The patient is a widow with a grown daughter, and her entire working life (24 years) has been as a physician, the last 20 of these as a neurologist-psychiatrist in a public hospital. On the average she has clinical responsibility for at least 20 in-patients, usually with 3-5 patients in the ICU, and examines 30 to 40 outpatients per day, with an average of 1-5 admissions, several of whom remain under her care. Up to half of these patients are emergency cases. Other than lumbar punctures, she does not perform invasive procedures. Policy concerning patient care issues is flexible and she has substantial autonomy in this regard. However, she describes numerous problems (shortages and the like) that seriously hamper patient care. She has her own small office in which she does much of her work; heating and air conditioning are inadequate. Acute hazards include risk of violence from psychotic or otherwise dangerous patients, and risk of infection related to work with blood and other body fluids. She has not, however, ever suffered any physical harm at work, and has heard about (but never witnessed) such incidences at her workplace. Recently, she has had an increase in non-clinical responsibilities: supervising the work of house-staff, teaching medical students, as well as increased administrative responsibilities and clerical duties. No special time is allocated to perform these latter activities. She has also recently had a prolongation in work hours: her workday now lasts 8 – 10 hours, 6 days / week. She has no scheduled rest breaks, and manages only to take occasional 5 – 10 minute pauses. She takes night call about twice per month, usually on a weekday after having worked the usual day shift. Unless she has very unstable patients, she can usually go home in the morning after having been on call. She has little say about her work schedule, nor about institution-level policy and planning. Her pay is fixed, and she describes it as inadequate to meet her basic needs. The social climate, however, is good; in particular, she notes that there is a constructive atmosphere for learning, and enthusiasm and devotion by colleagues to patient care, despite the above-described difficulties. She has not taken any vacation for 2 years, and has not missed a day of work. Physicians are an at-risk group for burnout, as well as for other mental health outcomes such as depression, anxiety and suicide. The work of physicians is characterized by very high demands, symbolic aversiveness (threat avoidant vigilance, hearing about and seeing disturbing things) and dilemmas and uncertainty. Numerous potentially modifiable stressors are identified above that further add to the demand level, but without concomitant increases in decision-latitude. The mean total OSI score is very high indicating a heavy total burden of occupational stressors. On the other hand, the JCQ scores fall within the “active” quadrant, and the ratio does not indicate job strain. We would suggest that the levels of decisionlatitude are not sufficient to compensate for the psychological demands, and that a more
78 detailed assessment of the latter dimension would indicate that many physicians (including this one) are indeed exposed to job strain. Having fixed and totally inadequate pay compromises the reward dimension, such that in combination with the enormous effort of this job, Effort-Reward Imbalance is present. Additional Relevant Information from the Patient: The patient says that the hardest part of her work is dealing with the death of patients, having to tell the family and feelings of helplessness in these situations. She states that the continuous responsibility and worry about patients leads her to “psychophysiologic exhaustion”. But she also says that the emotional gratification of this work represents the key reward, which not only eases this tremendous burden, but also motivates her to continue. She considers that increased availability of medications and other supplies for critical diagnostic and therapeutic procedures to be the most important way to improve her working life and that of her colleagues. She also cites the need for improved economic rewards as a key to increasing the motivation of physicians and other health-care workers. ------------------------------------------------------------------------------------------------------------------------------------------
Quantitative Assessment of Work Stress
Physicians (N=12) Mean
Sd
This Patient Total OSI
73.8
76.3
6.3
--Total Underload --High Demand --Strictness --Extrinsic Time Pressure --Noxious Exposures --Symbolic Aversiveness --Conflict/Uncertainty
4 26.25 6.5 9 1.5 12.5 15.5
4.2 27.3 7.9 8.6 3.3 11.4 14.2
0 3.9 1.1 0.9 2.1 1.3 1.9
Job Content Questionnaire:
Psychological demands Skill discretion Decision making authority
National Average
35 39 39
30.9 33.5 36.8
8.5 8. 9.9
Active Quadrant — above average psychological demands, skill discretion and decision-making authority. Job Strain Ratio: 0.9, which implies that job strain is not present. Extrinsic Effort/Reward Imbalance: Present
79
B. Truck Driver Completed OSI for Professional Drivers The answers to this questionnaire are pedagogically constructed, not based on any individual. INFORMATION ABOUT THE WORKPLACE: FOR PROFESSIONAL DRIVERS Unless otherwise specified, all of the questions refer to driving on the job. Please choose the single answer which best applies to your working situation, unless otherwise specified. Feel free to write your comments.
1. Total number of working years: 18 2. Total number of years as a professional drivers:10 3. Have you worked at other jobs besides being a professional driver? Yes If yes, please list the jobs you've had number of years at each: Cabinet Maker From (year): 1982 To (year): 1990 4. Type of vehicle which you currently drive at work: a. Crane of forklift d. Official car e. City bus b. Truck c.Tramcar f. Suburban bus
g. Trolley car h. Intercity bus i. Subway j. Taxi k. Other:_________
5. Which other vehicles have you previously driven at work? None 6. Do you drive mainly on one particular route?
Yes
7. Do you drive mostly: a. In the city? b. On long routes (suburban and inter-city routes included here )? 8.Do you drive most often: a. Alone in your vehicle? b. With 1 or 2 other persons in your vehicle? c. With many passengers in your vehicle? 9. Is driving your only task on the job? a. Yes
No
No
80 b. No, during my driving tours, I also have other tasks such as checking or selling tickets, opening and closing the doors, giving information, etc. c. No, I have tasks other than those during the driving tours. My other tasks outside driving tours are: Loading and unloading 10. Does it occur that during you work hours, you have nothing to do? a. Yes, often b. Occasionally c. Rarely or never. I always have something to do during my work hours 11a. My pay is: a. Based upon how much I myself work b. Based upon how much my group or collective, as whole, works c. Fixed 11b.My salary is: a) Totally inadequate to meet the basic needs of my family and myself. b) Just barely covers the basic needs of my family and myself. c) Covers more than the basic needs of my family and myself. 12. How long does your workday usually last? 12_hours Yes Do you ever work longer than that? If yes, how often? It varies and for how many hours/day? It varies 13. How many work hours to you actually spend driving per day?
No
8
14a. How many days do you work per week? 6 14b. How many weeks of paid vacation to you have per year? 2 No 15. Do you work at another job outside your regular one? Yes If yes, how many hours per week? What do you do? 16. Do you always have at least one break during your workday? If yes, how many breaks do you usually have? It varies How long is your usual break? It varies 17. The times at which you drive / your work schedule: *Do you have a regular work schedule? Yes *If yes, when do you begin work? End work:
No
* Do you drive the split shift (early morning and afternoon rush hours) a. Yes, I constantly work the split shift
Yes
No
81 b. Sometimes c. Rarely or never
*Do you drive in the dark/at night ? a. No, I work (drive) only during the daylight hours. b. Yes, I drive in the city at night, and/or when it's dark. c. Yes, I drive inter-city (long routes) at night, and/or when it's dark. (If no, continue with question 18) *If you drive on the job at night, No Are the roads well lit? Yes Are the roads divided according to the direction of traffic?
Yes
No
Yes *Do you drive after midnight (third/night shift)? No If yes, do you drive the night shift: a. Constantly b. On a rotating basis (describe please how this rotates It varies, but at least twice a week 18. With respect to time pressure at work: a. I don't experience any substantial time pressure at work. It is only important that I arrive at my destination within a reasonable amount of time. b. Sometimes I must arrive at a given time c. I have an extremely tight schedule. If I arrive late, I face unpleasantness or even penalty. However, I can usually arrive on schedule. d. I have an extremely tight schedule. If I arrive late, I face unpleasantness or even penalty. It happens, that despite my efforts, and for objective reasons, I sometimes or often arrive late. 19. Do you perform heavy lifting at work? a. Yes, often times during the day, I must lift 50 kg ( 110 lbs), or more. b. Yes, I lift from 20 to 50 kg loads (44 - 110 lbs) during my usual workday. c. Yes, I lift up to 20 kg (44 lbs) during my usual workday. d. No, I rarely or never lift anything heavy during work. 20. What are the physical conditions like in your vehicle cabin? a. I have good shock absorbers and isolation. I don't usually feel much vibration or gases/fumes. b. I have poor shock absorbers, but good isolation. I feel vibration but not much gases/fumes c. I have good shock absorbers but poor isolation. I don't usually feel much vibration but I do feel gases/fumes because the isolation is poor. d. I have poor shock absorbers and poor isolation. I feel vibration and also gases/fumes. 21. What is the temperature like in your vehicle cabin?
82 a. I have proper ventilation/air conditioning, as well as adequate heating. It never gets extremely hot (over 30 degrees C/ 86 degrees F) nor very cold in my cabin (not less than 15 degrees C/ 60 degrees F) b. I have good heating, so it never gets too cold in my cabin. However, I don't have a proper ventilation/air conditioning system. Especially in the summer, it gets very hot (over 30 degrees C/86 F) c. I don't have proper ventilation/air conditioning, nor is the heating system adequate. Especially in the summer, it gets very hot (over 30 degrees C/ 86 F) and especially in the winter is can get cold(below 15 degrees C/ 60 degrees F) 22. Do you drive under especially hazardous conditions (check all answers that apply) a. Yes, I carry flammable/explosive material in my vehicle. b. Yes, I drive along winding, narrow roads c. Yes, I face threat of violence from passengers d. Yes, for another reason(s): ______________________________________________ e. No, I face ordinary traffic conditions, but no special hazards. 23. Have you even had an accident or been injured (including assault) at work? a. No b. Yes, only of a minor nature c. Yes, I have had one or more serious accidents or have suffered serious physical harm at work: Please briefly describe all serious accidents or injuries I swerved off the road once to avoid another truck coming at me, it was about 3 A.M. But I only had a few cuts and bruises (I was wearing my seatbelt). 24. Have you ever witnessed a serious accident at work? a. Yes, I have observed one or more accidents with a fatal outcome b. Yes, I have observed one or more serious accidents, but I have never witnessed a fatal outcome. c. I have heard about serious or fatal accidents at work, but never seen this. d. No, I have never witnessed or heard about a serious accident at work. 25. With regard to on-the-job driving and weather conditions: a. I drive under all weather conditions, without exception. b. I drive under various weather conditions, but when visibility is decreased substantially (e.g. snowstorms, heavy fog, etc.) I don't drive. 26. My work vehicle: a. Often breaks down. b. Sometimes breaks down c. Very rarely or never breaks down.
83 27. Objectively, how are interpersonal relations at your workplace? a. Excellent, we all get along together and misunderstandings are rare. b. Fair, sometimes there are misunderstandings and tension among us. c. Poor, there is a lot of tension and conflict among us. Recent changes in your working conditions 28. In the past six months has there been: (Please check all which apply) a. An increase in the length of your workday? b. A decrease in the length of your workday? c. Increased time pressure/number of deadlines? d. An increase in work responsibility? e. Demotion with pay cut? f. Promotion with pay raise? g. Threat of being laid off? h. Other changes, please specify:_________________________________________ Some open-ended questions about your work as a professional driver: 29. What could be done to improve working conditions as a professional driver of your profile? Improve our pay for each tour, so we can work fewer hours 30. Which of the above suggestions do you consider to be the most important? 31. What is the most difficult aspect of being a professional driver of your profile? Having to keep very alert at all times, especially late at night when I am exhausted. Driving the triple-A dolly trailer. 32. What do you think could be done to make that difficulty less of a burden? Don’t drive at night, drive fewer hours. Cut down on waiting times, so I could get home at a decent hour. 33. What is the best part(s) about being a professional driver of your profile? --Meeting my friends at the truck stops and sometimes during waiting times (when I’m lucky enough for that to happen) --Not having someone boss me around all the time 34. If attempts were made to improve the working conditions of professional drivers of your profile, what would you suggest to preserve the good aspects of your work? If we had more efficient scheduling and shorter hours, I might not get to see my friends at much, unless we had more control ourselves about the scheduling.
35. Other comments: It’s a really tough job, but I basically like it.
84
Link between the Summary Flow Sheet and the OSI for Professional Drivers STEP A: HIGH RISK OCCUPATION Current occupation, total number of years in that occupation, work history OSI-PD: Q. 2-4 Type of vehicle, urban, suburban or inter-city --------------------------------------------------------------------------------------------------STEP B: JOB CHARACTERISTICS Underload --Monotonous work OSI-PD: Yes, unless Q. 9c, indicates otherwise Monotonous work is a relatively fixed feature of professional driving unless they do other, more complex tasks (e.g. mechanical work on their vehicles). 9. Is driving your only task on the job? a. Yes b. No, during my driving tours, I also have other tasks such as checking or selling tickets, opening and closing the doors, giving information, etc. c. No, I have tasks other than those during the driving tours. My other tasks outside driving tours are: ---------------------------------------------------Little or no decision-making OSI-PD: To some extent, unless Q. 9c, indicates otherwise Unless indicated otherwise, professional drivers are all scored as 44(b) from Generic OSI. -------------------------------------------------------Socially isolated work OSI-PD Yes, if Q. 8=a 8. Do you drive most often: a. Alone in your vehicle? b. With 1 or 2 other persons in your vehicle? c. With many passengers in your vehicle? -----------------------------------------------------
----------------------------------------------------High Psychological Demand --Rapid flow of new information OSI-PD Yes, if Q.7=a, drives mostly in the city -----------------------------------------------------
--Receives and transmits important, job-related information to other people OSI-PD Yes, if Q. 8=c (and to a lesser extent if b) 8. Do you drive most often: a. Alone in your vehicle? b. With 1 or 2 other persons in your vehicle? c. With many passengers in your vehicle?
85 Also see Q. 9 about other tasks, and consider whether they use a cell-phone or transmitter to communicate job-related information to other people. ------------------------------------------------------Many things going on simultaneously/must divide attention OSI-PD: Yes, especially if Q.7=a (drives in the city) and Q.9=b (performs other tasks, during driving tours) ------------------------------------------------------Must focus attention upon devices Professional Drivers: Yes No need to ask: Professional drivers must be paying attention to their vehicles ------------------------------------------------------Complicated decision making and/or tasks OSI-PD: Unless Question 9=c and indicates otherwise, the answer will be no. ------------------------------------------------------Supervises work of others OSI-PD: Unless Question 9=c and indicates that they have supervisory duties, the answer will be no. --------------------------------------------------------------------------------------------------------Low Control/Physical Constraints --Strict time schedule OSI-PD: Very much so, if Q. 18=c or d. 18. With respect to time pressure at work: a. I don't experience any substantial time pressure at work. It is only important that I arrive at my destination within a reasonable amount of time. b. Sometimes I must arrive at a given time c. I have an extremely tight schedule. If I arrive late, I face unpleasantness or even penalty. However, I can usually arrive on schedule. d. I have an extremely tight schedule. If I arrive late, I face unpleasantness or even penalty. It happens, that despite my efforts, and for objective reasons, I sometimes or often arrive late. ------------------------------------------------Paced Work Professional Drivers: Not truly paced work, but the driver has only partial control over speed of work. No need to ask. Bear in mind that if a very tight schedule, this becomes almost like paced work. ------------------------------------------------No chance for Creativity Professional Drivers: There is usually not much chance for creativity. See 9=c to assess whether tasks besides driving might be somewhat creative. ------------------------------------------------No influence over work conditions Professional Drivers: This is best assessed from the decision-latitude dimension of the JCQ (having a lot of say on the job, take part in decisions that affect me)
86 ----------------------------------------------
--Works in confined space/fixed body position Professional Drivers: Yes No need to ask, driving obviously requires working in a confined space with a fixed body position ----------------------------------------------- Heavily Supervised Professional Drivers: Usually not heavily supervised. No need to ask, notwithstanding law enforcement (and sometimes passengers), continuous heavy supervision of performance is unlikely. Bear in mind, however, that with new monitoring techniques, this could be changing. ------------------------------------------------------------------------------------------Physically Aversive Exposure --Glare exposure OSI-PD: Yes, if Q. 17 b or c, especially if poorly lit and undivided roads. 17. Do you drive in the dark/at night ? a. No, I work (drive) only during the daylight hours. b. Yes, I drive in the city at night, and/or when it's dark. c. Yes, I drive inter-city (long routes) at night, and/or when it's dark. If you drive on the job at night, Are the roads well lit? Yes No Are the roads divided according to the direction of traffic? Yes No -----------------------------------------------Noise exposure Professional Drivers: Yes, based upon average road noise level estimates of 85dB, a conservative estimate is that drivers are exposed to at least moderate noise levels. -----------------------------------------------Vibration exposure OSI-PD: All professional drivers are exposed to some whole body vibration. Q. 20 provides an estimate of severity: 20. What are the physical conditions like in your vehicle cabin? I have good shock absorbers and isolation. I don't usually feel much vibration or gases/fumes. b. I have poor shock absorbers, but good isolation. I feel vibration but not much gases/fumes c. I have good shock absorbers but poor isolation. I don't usually feel much vibration but I do feel gases/fumes because the isolation is poor. d. I have poor shock absorbers and poor isolation. I feel vibration and also gases/fumes. -----------------------------------------------Heavy lifting OSI-PD: Yes, if Q. 19=a-c. (Same Question as for Generic OSI above) ---------------------------------------------
--Heat OSI-PD: Yes, if Q. 21=b or c. (Consider the climate).
87 21. What is the temperature like in your vehicle cabin? a. I have proper ventilation/air conditioning, as well as adequate heating. It never gets extremely hot (over 30 C/ 86 F) nor very cold in my cabin (not less than 15 C/ 60 F) b. I have good heating, so it never gets too cold in my cabin. However, I don't have a proper ventilation/air conditioning system. Especially in the summer, it gets very hot (over 30 C/ 86 F) c. I don't have proper ventilation/air conditioning, nor is the heating system adequate. Especially in the summer, it gets very hot (>30 C/ 86 F) and especially in the winter is can get cold (< 15 C/ 60 F) ----------------------------------------------
--Cold OSI-PD: Yes, if Q. 21=c. ----------------------------------------------
--Chemical exposures: Fumes, Dusts and Gases OSI-PD: All professional drivers are exposed to some gases and fumes. Q. 20 provides a rough estimate of severity. -------------------------------------------------------------------------------------------
Disaster Potential-Symbolic Aversiveness --Threat Avoidant Vigilant Work Professional Drivers : Yes. No need to ask, this is the fundamental to the occupation. ----------------------------------------------
--Encountering Visually Disturbing Scenes OSI-PD Some indication if Q. 24=a or b ----------------------------------------------
--Listening to Emotionally-disturbing occurrences OSI-PD Some indication, if Q. 24= c. -----------------------------------------------Hazardous tasks/Danger of serious accidents -- harm OSI-PD: Truly hazardous if Q. 22=a – d, otherwise professional driving is somewhat, but not acutely, hazardous. 22. Do you drive under especially hazardous conditions (check all answers that apply) a. Yes, I carry flammable/explosive material in my vehicle. b. Yes, I drive along winding, narrow roads c. Yes, I face threat of violence from passengers d. Yes, for another reason(s): ______________________________________________ e. No, I face ordinary traffic conditions, but no special hazards. ----------------------------------------------
--Threat of physical violence /assault OSI-PD: Yes, if Q.22=c. -------------------------------------------------------------------------------------------
88 STEP C: SPECIFIC WORK CONDITIONS Work Schedule and Rest Breaks -- Number of work hours Hours /day, Days/week, Overtime OSI-PD: Q. 12- 14 -----------------------------------------------Night shift work OSI-PD: Yes, if Q. 17 part V = yes -----------------------------------------------Irregular work hours OSI-PD: Yes, if Q. 17 part II=no or part V=b (rotating night shift work) -----------------------------------------------Rest breaks: scheduled and unscheduled, Minibreaks OSI-PD: See Q. 16 -----------------------------------------------Vacations OSI-PD: See Q. 14 Number of weeks of paid vacation --------------------------------------------------------------------------------------------Workload and distribution over time OSI-PD: Estimate by number of hours behind the wheel + Q. 9b + c (other tasks besides driving) ------------------------------------------------------------------------------------------Level of exposure to physical noxins For any of these physical noxins (Glare, noise, vibration, isometric stress, heat, cold, chemical agents) to which a worker is exposed, obtain more information about level and type of exposure. ------------------------------------------------------------------------------------------Work Accidents --Number and Severity of Work Accidents OSI-PD: Q. 23 -----------------------------------------------Work accidents witnessed or heard about OSI-PD: Q. 24 --Conflicting demands in time and space OSI-PD: Yes, if Q. 18=d. 18. With respect to time pressure at work: a. I don't experience any substantial time pressure at work. It is only important that I arrive at my destination within a reasonable amount of time. b. Sometimes I must arrive at a given time
89 c. I have an extremely tight schedule. If I arrive late, I face unpleasantness or even penalty. However, I can usually arrive on schedule. d. I have an extremely tight schedule. If I arrive late, I face unpleasantness or even penalty. It happens, that despite my efforts, and for objective reasons, I sometimes or often arrive late. ----------------------------------------------
--Technical Problems and Breakdowns OSI-PD: Yes, if Q. 25=a, or Q. 26=a or b. 25. With regard to on-the-job driving and weather conditions: a. I drive under all weather conditions, without exception. b. I drive under various weather conditions, but when visibility is decreased substantially (e.g. snowstorms, heavy fog, etc.) I don't drive. 26. My work vehicle: a. Often breaks down. b. Sometimes breaks down c. Very rarely or never breaks down. ------------------------------------------------------------------------------------------Inter-personal relations OSI-PD: Q. 27 is identical to Q. 35 of the Generic OSI ------------------------------------------------------------------------------------------STEPS D AND E: EXACERBATING (NEW) CONDITIONS AND LARGER ISSUES --Recent increase in Work hours/more overtime OSI-PD: Yes, if Q. 28 a -----------------------------------------------New Deadlines OSI-PD: Yes, if Q. 28 c -----------------------------------------------Recent Experiencing or Witnessing Accident OSI-PD: If Q. 23 c or Q. 24 a-c, ask whether this was recent. -----------------------------------------------New Interpersonal Conflicts OSI-PD: If Q. 27=b or c, ask whether there have been new interpersonal conflicts or worsening situation., ask whether this was recent. --------------------------------------------------------------------------------------------Looming possibility of Lay-off OSI-PD: Yes, if Q. 28 g
Narrative History—Truck Driver—Derived from the OSI for Professional Drivers This narrative occupational history is pedagogically constructed, not based on any individual.
90
The patient has worked for the past ten years in his current occupation, prior to which he was a self-employed cabinetmaker for eight years. He began long-route truck driving for economic reasons after the birth of his first child. He and his wife now have three children. His work schedule is irregular, and includes frequent after-midnight night driving. At least twice per week he sleeps (3-4 hours) in his truck cabin. His working time totals over 72 hours per week, with an average of 8 hours behind the wheel per 24h. He faces considerable time pressure with each delivery, but once arriving at the destination has an uncertain waiting time of up to several hours, until delivery. During that time he lifts crates of up to 50 kg. He takes rest breaks irregularly to eat at truck stops. He drives a triple trailer A-dolly, often on poorly lit, undivided roads. He drives various routes, but always with the same vehicle that is in good mechanical condition, and has adequate shock absorbers and heating, but no airconditioning. Cabin isolation is poor, however. He drives under all weather conditions, including heavy rain and fog, that compromise visibility. He has had one accident that occurred during late night driving (swerving off the road after facing an on-coming truck, and sustained minor injuries), and has seen numerous road accidents, many with fatal outcomes. He drives alone in his cabin. Interpersonal relations among the employed truck drivers and with the company manager and other personnel are good. The occupational history reveals that, as a professional driver, this patient’s job falls into the high-risk category for hypertension and ischemic heart disease, as well as for repetitive motion syndrome. The work is a characteristic threat-avoidant vigilant occupation. Thus, not only are high levels of sustained attention required for reasons of safety, but this exigency, in turn, appears to have an untoward effect upon the cardiovascular system. This patient faces extra hazards by driving on poorly lit undivided roads, under untoward weather conditions, and he has been in a night driving accident related to glare exposure. Having witnessed many fatal accidents further heightens the threat-avoidant vigilance of his work. He drives long, irregular hours, including night shift and early A.M.; these are key, potentially modifiable workplace risk factors. Due to poor cabin isolation, he is likely exposed to increased levels of carbon monoxide. The psychological demands of the job are further increased by having to drive the triple A-dolly trailer. The overall burden of work stressors is very high, even for a professional driver, as quantified by the total OSI score of 72. Other quantitative assessments of psychosocial workplace stressors reveal the presence of Effort Reward Imbalance and a borderline finding concerning exposure to self-reported job strain. The latter reflects the discrepancy between the objective nature of professional driving (clearly high strain), but the difficulty by which the high demands and low control are operationalized using generic versions of self-report instruments to assess job strain. He experiences both under-load and high demands: a deleterious combination. Additional Relevant Information from the Patient: This truck driver identified always having to be watchful as the most difficult aspect of his job. He, as well as several of his colleagues, identified the long and irregular work hours and night driving together with excessive waiting times as key modifiable stressors at this workplace. A team of occupational health psychologists, and cardiologists proposed a plan to regularize and shorten the work hours and improve organization to minimize the long waiting
91 times. This is coordinated with health promotion efforts aimed at smoking cessation, exercise and nutrition. Discount tickets for the local swimming pool are made available, and groups of coworkers, and their families make this a regular part of their weekly activity. ____________________________________________________________________________________________
Quantitative Assessment of Work Stressors Truck Drivers (N=69) This Patient
Total OSI --Total Underload --High Demand --Strictness --Extrinsic Time Pressure --Noxious Exposures --Symbolic Aversiveness --Conflict/Uncertainty
72 10 15 9 9 9 10 10
Mean 65.2 8.1 17.2 9 6.8 6.3 6.8 11.1
Sd 3.6 1. 2.1 0 0.8 1.5 0.9 1.3
Job Content Questionnaire: National Average
Psychological demands Skill discretion Decision making authority
31 25 35
Mean 30.9 33.5 36.8
Sd 8.5 8. 9.9
Quadrant On the borderline between the passive and high strain quadrants: clearly below average skill discretion and low decision-making authority, and very slightly above average psychological demands. Ratio: 1.03, job strain is present. Extrinsic Effort Reward Imbalance:
Present
92 C. Administrative Assistant Completed OSI For those who work daily with Computers The answers to this questionnaire are pedagogically constructed, not based on any individual. Please note: The descriptive answers in Courier font. INFORMATION ABOUT YOUR WORKPLACE FOR THOSE WHO WORK DAILY WITH COMPUTERS
Please, choose the best single answer which best applies to your working situation unless otherwise specified. Feel free to add any comments or clarification, and use as much space as you wish. Your answers are confidential. 1.Total number of working years: 15 2. Current job title (please be as precise as possible): Assistant to the Director of the Cancer Research Division of a University Department of Applied Molecular Biology 3.Total number of years in current job: 7 4. Have you worked at other jobs besides your current one?
X Yes
No
If yes, please list the previous jobs you’ve had and the number of years at each: Translator for a Medical Publishing Company From 1987 to 1994. --I worked on translation into and from French and German (I was a language major), and some translation from these languages into English. The Publishing Company was bought up by a multi-national corporation, which considered that the foreign publishing activity was not sufficiently profitable, such that this division was eliminated. Work Hours, Scheduling and Payment 5.1. How long is your ordinary workday? 8 Hours No Do you ever work longer than that? X Yes If yes, how often? 1-2/week For how many hours per day? 2-3 hours /day 5.2. How many hours per day do you usually spend in front of a computer terminal? 8 Hours/day (?!) --Let me explain: The computer is on, right in front of me, all the working day. I get pulled away from it to do other tasks (like photocopying), or I am answering the phone, but it’s always there waiting for me to come back to work on it.
93 X Yes 5.3. Do you have a regular work schedule? No If yes, when do you begin work? 9 A.M. End work: 5 P.M. 5.4 Who decides about your work schedule? a) Myself alone. b) I have some choice about my schedule, but I must also agree with others (supervisor, coworkers). X c) Others decide about my schedule, I have no voice in the matter at all. 6.a How many days do you usually work per week? 5 6.b How many weeks of paid vacation do you have per year? 2
Weeks/year
No 7. Do you work at another job outside your regular one? Yes X If yes, how many hours per week? Lots!!! What do you do at your other job? --I don’t have another paid job, but as a wife and the mother of two school-aged children, what I consider to be my second work-shift begins as soon as I get home from this job. Also, I commute and drive at least 1 hour in each direction daily, often in heavy traffic. 8.1 Do you have guaranteed, scheduled rest breaks during your workday? X Yes If yes, how many? 1 How long do these last? 1 hour Can you completely rest from work during that time (no phone calls, etc.)? Yes X No It depends on whether others cover the phones, since Director insists that someone always answers the phone. are not allowed to use the answering machine.
No the We
8.2 Are breaks taken by: a) A few or several workers at the same time, so there is a chance, if one so wishes to chat or socialize with others. X b) One person at a time, so that there is no chance to chat or socialize with coworkers. 8.3 How many times per day do you take a “minibreak” (get away from your desk for a few minutes)? 1-2 times per day, but sometimes not at all if it gets very busy. X No 8.4 Can you decide to take a mini-break when you need it? Yes --It seems like whenever I was just beginning to take a couple of minutes of rest, the Director or one of the other professors invariably comes by and thinks I’m not busy, so they come up with some work-related question, or some more work to do. The bottom line is: I get back to work to avoid this. At other times, when I need to take a few minutes, the phone rings and I must answer it. 9. Do you work the late night shift (after midnight?)? Yes If yes, do you work the night shift:
X No
94 a) Constantly b) On a rotating basis (please describe how this rotates): ______________________________ Mode of Payment, Evaluation and Monitoring 10. Upon what is your salary based? X c) Fixed pay, irrespective of the a) Only own work. b) My group’s work amount of work. The only time I get more pay is when I put in overtime hours 11.My salary is: a) Totally inadequate to meet the basic needs of my family and myself. X b) Just barely covers the basic needs of my family and myself. c) Covers more than the basic needs of my family and myself. 12. How is your work evaluated? a) No one but me evaluates my work X b) A supervisor or other responsible person evaluates my work, there are no rigid standards and generally if it is done properly, it is accepted c) A supervisor or other responsible person evaluates my work according to a strict standard. If, for any reason, even a minor one, it does not fully meet these standards, my work may be rejected. 13. Is there an external monitoring system at your workplace? X Yes No If yes, please check all that apply: a) My telephone conversations are monitored X b) My email communication is monitored --We are not allowed to use email for personal communication. It’s not that someone’s checking on us every day, but our emails can be monitored at any time. I think there is some spot-checking. c) There is a camera monitoring me during work d) Other type of monitoring, please describe: Physical Working Conditions and Exposures 14. Are you exposed to glare at work? X c) Rarely or never a) Yes, often b) Occasionally 15. Is your workplace noisy? a) Yes, it gets so noisy that I must raise my voice to be heard by someone right next to me X b) Somewhat, but I can speak normally and be heard by someone next to me. c) No, my workplace is not noisy. 16. Do you perform heavy lifting during work? X Yes If yes, what is the usual weight that you lift? 10 pounds. How often do you do so? 1-2x/day
No
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17. Do you have properly functioning air conditioning at your workplace? X Yes
No
X No 18. Do you have a properly functioning heating system at your workplace? Yes If you answered “No” to either of the above questions, How hot and/or cold does it typically become in your workspace? --It gets pretty chilly here sometimes in the winter, and I have to wear a couple of sweaters. About the lowest is around 60 – 65 degrees F. 19. Workspace: a) I have my own office X b) I share an office (with how many others? --Two other secretaries share the office. Approximate size of your office: It’s long and narrow, about 20’ x 9’. --I work in the front office, so my coworkers and I are the first persons to see any visitor to the chairman of the department. There are no windows in the office. -------------------20. Computer-related physical working conditions: X Yes No I sit in a comfortable chair Yes
X No
X Yes No Yes
X No
X Yes No
The keyboard is placed so that my hand position is comfortable Image clarity and contrast are adequate Desk space is adequate The lighting is appropriate
Screen-size: a) < 20 cm. Wide (small-laptop screen) X b) 20 – 30 cm wide (medium-large laptop screen or small stationary computer screen) c) >30 cm wide (medium to large stationary computer screen) Your assessment of the overall computer-related physical working conditions: X b) Fair c) Poor a) Good 21.Do you work on: a) Only one computer, for which you are the only user. X b) Only one computer, but which you share with other users (Visitors, occasionally) c) More than one computer. 22. Specific comments about computer-related, or other, physical working conditions: --I get eyestrain after long hours at computer, and sometimes have headaches. Also, I find it really frustrating to have papers piled all over, I need more desk-space. When visitors come to the Department for a day or so, they sometimes ask to use my computer to check their email.
96 --------------------Time pressure 23. Do you have a deadline by which any of your tasks must be completed? X a) Often b) Sometimes c) No, it happens only rarely or never 24. Are you obliged to speed-up your work tempo? X d) Yes, during certain periods every year a) Yes, every day X b) Yes, at least weekly, but not daily e) No, it happens only rarely or never c) Yes, during certain periods every month During the times before grant proposals are due, the time pressure gets really heavy! 25. With regard to your workload and time constraints a) It is usually possible to complete everything X b) Even with maximal effort, it is sometimes objectively impossible to complete everything c) Even with maximal effort, it is often objectively impossible to complete everything Problems at Work 26. Remembering and retrieving work-related information: a) I can quickly and easily retrieve just about any needed information. X b) Needed information can be retrieved, but this may require quite a bit of time and energy. Thus, there is important information, which I must keep track of in my head. c) It often happens that important information cannot be retrieved. I must therefore be very careful to register and remember information when it is first presented. 27. If you encounter some dilemma during work, and are not certain how to proceed: a) I can usually postpone a decision until the situation is clarified. X b) Sometimes I must act based upon the information I have at a given moment, and can’t postpone the decision. c) Most of the time I must act based upon the information I have at a given moment, and can’t postpone the decision. --Whether or not to triage a phone call to the Director versus taking a message. 28. What is the likelihood that you could make a work-related mistake, e.g. sending a file or attachment to the wrong person, which would have serious, irreparable consequences? a) There is a substantial risk that I could make an error that would have serious consequences. X b) It is fairly unlikely, but it is possible that I could make an error that would have serious consequences. c) Minimal, under normal circumstances, just about any conceivable error is correctable and would not have serious consequences. If you answered ”a” or “b”, what are the mistakes that could happen:
97 --I could attach the wrong file to someone. It happened once a couple of years ago, when by mistake (due to how the files were labeled) on a very hectic day, I sent a confidential editorial review to the person being reviewed, and who collaborates with our department. Fortunately, it was a pretty positive report, so there were no hard feelings or repercussions, but I felt awful and from then on I became aware of how easy it could be to make a really terrible mistake. Now I am extra careful to check this. But the Director and the other professors sometimes get impatient with me for all my double-checking, and they sometimes subtly imply that I work too slowly. --Also, I could make a mistake in triaging (see Q. 27 above), and especially if I didn’t put through an important call, that might be a problem. ----------------------------
29. How effective is the anti-virus system on the computer/system upon which you work? a) Excellent. It is continuously and automatically updated so that virus-related computer problems are not a worry for me. X b) Fair to good. I must be careful in certain situations, e.g. opening unknown emails, etc. but, in general, virus-related problems are unusual. c) Unsatisfactory. Virus-related problems are a major concern for me. --It’s never happened to me (thank goodness!), but one of the other secretaries once opened an email from an unknown sender and her system crashed. I worry about this, with all the frightening news about these viruses, and especially because my email address is used for lots of Department related communication, and I don’t always know the sender. 30.a If you have to work with a new computer-related feature, e.g. a new system, a new software program, is the procedure explained properly? a) Yes. X b) No, sometimes when this happens, there are details that are unclear or confusing. c) No, this can be a big problem, since there is often important information, which is lacking. For that reason, it is very difficult to work with the new computer-related feature. 30.b In general, do you receive clear instructions and information concerning your work? a) Yes, usually or always. X b) No, sometimes these are unclear. c) No, often these are unclear. 31. Does it happen that you don’t receive all the needed instructions and information concerning your work? a) Yes, there is often missing information. X b) Occasionally there is missing information. c) No, rarely or never is there is missing information.
98 32. Do you receive conflicting/contradictory information or instructions concerning your work? X Yes, often. b) Yes, sometimes. c) No, rarely or never. 33. Does it happen that due to unforeseen circumstances the plan of work changes? X Yes, often. b) Yes, sometimes. c) No, rarely or never. --One of the biggest problems involves both Q. 32 and 33 and that is in preparing files for submitting manuscripts and proposals. There are always lots of last-minute changes and I have to keep track of what is the most recent version. Also, the Chairman and other professors and researchers keep adding or deleting figures and they forget to renumber, so I have to go through all the files and make sure everything is correct. It gets really confusing when there are several authors and each makes changes without checking with the other. Sometimes I feel like I don’t know what I’m doing, when this happens.
34. Are there computer-related problems or inadequacies that directly hamper your work? X Occasionally a) Yes, major ones c) Rarely or never If you answered a or b, please check all which contribute to this problem: X Slow access to the Internet or to the sites that you often need (A big problem) X Computer breakdown (Rare, but when it happens, it’s chaos!) Power failures Limited number of phone lines, so that Internet and telephone access cannot be obtained simultaneously. X The computer is being used by someone else when you need it. --A couple of times per month, one of the scientific visitors asks to use my computer, usually to check their email. I usually don’t mind since they are pretty brief and are always very appreciative. The exception is at the end of the day when I would like to go home, and I can’t until I’ve made sure my computer is properly shut off. Someone else has used the computer, after which a problem arises: X Having to use new systems or software that are unfamiliar to you. X Disruption of work when new software is installed for purposes of upgrading --I find this the most troublesome. It seems to me that we should be more selective in deciding what’s absolutely essential, rather than trying to keep up with all the latest software. This is especially important since the new software
99 may not be sufficiently well tested before it comes onto the market. X Poor compatibility of various programs/software. --A big problem is that various versions of programs have different symbols, and I have to check that they are correct. Tedious!!! X Lack of needed software that could help you avoid doing a tedious task --If we had a scanner, it would free me up from numerical data entry, which is incredibly boring and requires meticulous checking of numbers that don’t mean anything to me. X Cumbersome or otherwise inadequate software: Please describe the problems / “glitches” that are most troublesome: --Downloading files using various software programs. Often, it just doesn’t work, and I have to write back to the sender. Also, sometimes this causes the computer to “freeze” and I have to re-boot it, which I find very disconcerting. --I wish we had a spell and grammar check with a memory. As it now stands, each time there is a new version of a manuscript, I have to start at the very beginning. --One more comment about computers: I know how much they help us, but even after many years working at the computer, I still feel some nervousness that something might go wrong. Other computer-related problems:
35. Are there non-computer related problems that directly hamper your work? X b) Occasionally c) Rarely or never a) Yes, major ones If a or b, please describe: --Having to do phone calling and waiting through recorded messages—I think it’s just a fancy way of being put on hold!!! --Photocopy machine gets jammed. Work Accidents and Injuries 36. Have you ever suffered an accident or been injured (including assault) at work? X No Yes 37. Have you ever witnessed physical harm or injury at your workplace? a) Yes, I witnessed such, with a fatal outcome b) Yes, I witnessed such, with a serious, but not fatal outcome c) I’ve heard about serious or fatal injury, but never witnessed it X d) No, I have never witnessed or heard about anyone’s serious injury at my workplace Inter-personal relations with coworkers and supervisors
100 38. Can you get help from coworkers or supervisors when computer-related questions or problems arise? a) Yes, I can almost always count on getting the help that I need. X b) Often, but not always, do I get the help that I need. c) No, I cannot count on getting the help that I need. 39. How are your questions and efforts to improve your knowledge received? (But I don’t have enough time to do this as much as I would like) X a) Very well. We have a work atmosphere that encourages us to ask questions and improve our knowledge. b) Fair. Sometimes asking questions or trying to improve knowledge can provoke criticism or ridicule. c) Very poorly. Asking questions and trying to improve our knowledge is clearly discouraged. 40. How is cooperation with your coworkers? X a) Excellent, we get along well together and misunderstanding are rare. b) Fair, sometimes there are misunderstandings and tensions. c) Poor, there is a great deal on tension and conflict. 41.1 How supportive is your supervisor(s)? a) Very much so. I can freely discuss problems with him/her. X b) Somewhat. c) Not at all. My supervisor is unsupportive; I cannot discuss problems with him/her. 41.2 How flexible is your supervisor(s)? a) Very much so. He/she is willing to listen to my ideas and suggestions, as well as those of my coworkers, and really takes them seriously. X b) Somewhat. c) Not at all. He/she is rigid, and unwilling to listen to my ideas or suggestions, as well as those of my coworkers. --Comment: “C” is sometimes the case when the Chairman is in a bad mood, usually around the time when big grant proposals need to get turned in—right now we are in one of those periods!!! Workload and Activities 42. Please list and very briefly describe each of the main work tasks that you perform (Fill in as many lines as you need, use more space if necessary) --Reception (answering the telephone, triaging and receiving visitors to the Department) --Keeping track of the Chairman’s schedule, making his travel arrangements, sorting communication to him (letters, faxes, emails) --Technical preparation of manuscripts, grant proposals
101 --Downloading files and printing them --Photocopying --Taking dictation to write up official letters --Numerical data entry --Translation --Routine email and phone communications (mainly administrative matters) --Miscellaneous
about
43.1 Are your work tasks monotonous? a) No, a given task always has its particular and interesting qualities, so it’s never exactly the same. X b) Some of my tasks are monotonous, basically the same thing over and over again. c) Most of my tasks are monotonous, basically the same thing over and over again. --This is especially true about numerical data entry. Also, repeated spell-checks and grammar checks. Photocopying is totally boring. So is downloading files and printing them and sending faxes. 43.2 Looking at all your work tasks together: a) I can see how they fit together and how they relate to the work of others, and the overall goals of my workplace. X b) Some of my tasks fit together, but not all. I can vaguely see how they relate to the work of others, and to an overall goal of my workplace. c) My work tasks seem to be disconnected from each other, and I don’t see how they relate to the work of others, nor to the overall goals of my workplace. --I wish this were (a)!!! 44. Do your work tasks require uninterrupted attention? a) No, most or all of my work tasks can be interrupted and it is easy for me to resume where I left off, without much “back tracking”. X b) Sometimes my work tasks require continuous attention, such that an interruption requires a bit of “back tracking” to continue with the work task. c) Yes, many or most of my work tasks require continuous attention, such that an interruption requires a lot of “back tracking” and is therefore very disturbing. If you answered b or c, on the average, how many times per day are you interrupted so that to resume your work you have had to back track? At least 5 times /day 45.1 How much can you control the speed at which you perform your work tasks? a) Completely, since I work independently from others. X b) Only partially, since others depend upon the work which I perform. 45.2 Does performance of your work tasks require teamwork? X b) Sometimes. a) Minimally or not at all.
c) Definitely.
102
46. Does it happen that you are obliged to physically be at work, but there is not any real work to do? a) Yes, often b) Occasionally X c) No, rarely or never. I always or almost always have something to do during my work hours. 47. Do you have the option of working on a computer from your home or other location outside the office? a) Yes, and I do so regularly. b) The option exists, but I don’t often do so for the following reason(s): X c) No, I must be physically present in the office during work hours. 48. For how many people at your workplace do you perform tasks? a) None d) Four to ten X e) Over ten b) One c) Two to three If you perform tasks for others, what are their positions? --My responsibility is first to the Chairman of the Department, but I also perform work for other professors and some of the other researchers. Communication Electronic communication - email 49. How many new work-related email messages do you usually receive per day? X d) Over twenty, but less than forty a) None b) One to ten e) Forty or more per day c) Eleven to twenty --Several times per week I must check the chairman’s email as well as my own, because he often doesn’t. When he is away on an official trip, I have to triage his email and even answer some of it (in a very routine way). 50. How many of these messages (per day) must be answered promptly (within a few hours)? a) None d) Over twenty, but less than forty X b) One to ten e) Forty or more per day c) Eleven to twenty 51. How many of these messages (per day) are of a non-routine nature, requiring deliberation, consultation, etc. a) None d) Over twenty, but less than forty X b) One to ten e) Forty or more per day c) Eleven to twenty
103 52. Are you immediately notified when you receive a new email? a) No, I must deliberately check my email. b) I can be, if I so choose. X c) Yes, each new incoming email is always immediately signaled to me; I cannot shut off this function. --I find this distracting, since I feel obliged to check and see whether this is something urgent. Telephone communication 53. How many work-related telephone calls do you usually receive or make per day? a) None X d) Over twenty, but less than forty b) One to ten e) Forty or more per day c) Eleven to twenty 54. How many of these (per day) must be answered right away when the person calls? a) None X d) Over twenty, but less than forty b) One to ten e) Forty or more per day c) Eleven to twenty 55. How many of these calls (per day) are of a non-routine nature, requiring deliberation, consultation, etc. a) None d) Over twenty but less than forty e) Forty or more per day X b) One to ten c) Eleven to twenty Face-to-face work-related communication (both with employees and with the public) 56. How many face-to-face work-related interactions do you usually have per day? a) None X d) Over twenty, but less than forty b) One to ten e) Forty or more per day c) Eleven to twenty 57. How many of these persons (per day) must be addressed immediately (cannot be postponed if e.g. you are in the middle of your work)? a) None d) Over twenty but less than forty X b) One to ten e) Forty or more per day c) Eleven to twenty 58. How many of these interactions (per day) are of a non-routine nature, requiring intense concentration, consultation, etc. a) None d) Over twenty, but less than forty X b) One to ten e) Forty or more per day c) Eleven to twenty
104 59. Does it happen during work that several people seek your attention at the same time? (Including people on the telephone) X a) Yes, many times per day c) Yes, but at most once or twice a day b) Yes, a few times per day d) No, rarely or never 60. If people seek your attention at the same time, how many do so? a) Rarely more than 2 X b) Usually two, but sometimes more c) Usually more than 3 Decision-making at work 61. Do you make work-related decisions that affect the work of others? X a) No b) Yes, I work as a supervisor or in a similar capacity, and must oversee the work of others. c) I am not a supervisor, but sometimes I must oversee the work of others. 62. Do you make decisions at your workplace or do you mainly carry out the decisions made by others? a) All the decisions have been made by others, I only carry out the tasks given to me, and make no decisions, not even about the smallest details. X b) The decisions have been made by others. I don’t decide even about the details. But my judgment is necessary during work. c) The major decisions have been made by others, but I can decide on my own about the details. d) Sometimes I must make major decisions, and take the responsibility for these. e) My job is mainly comprised of making major decisions. --I thought quite a bit about this question, and realized that I don’t decide about much of anything, but I am continuously called upon to use my judgment. 63. If you make decisions in your work, describe, as best you can, by an example, how you go about it? Example of a decision: --Whether or not to triage a call to the Chairman. Steps in the decision-making process: --I’ve got to consider who’s calling, from where (we get a lot of international calls). I have to weigh whether or not to ask what the subject matter is (sometimes people are offended by this question). I also have to think about the Chairman’s schedule and what he is involved with at the moment and I should even take into consideration his mood. It’s particularly hard if he’s told me explicitly not to interrupt him and he’s in a bad mood when an overseas call comes in, which is said to be urgent. If I don’t put the call through, it could have been really important, but if I do, sometimes it ties the Chairman up for too long. It’s tough, and really it’s not my decision to make, but I try to use good judgment.
105 64. Must you make rapid decisions or quickly assess a given situation? a) Yes, often X b) Occasionally (triaging—See my answer to Q.63) c) No, rarely or never. 65.a Concerning conclusions that are decided upon: a) There is usually only one correct decision to be made. X b) There are a limited number of correct decisions to be made. c) There are many possible correct decisions to be made. 65.b Do you have a way influencing the policies of your workplace? X a) Not at all. b) Somewhat. c) Definitely yes. 66. Is there a defined way of solving problems in your work? a) No, I must think up the strategy myself in order to solve problems, and that often requires imagination and creativity. This also means that I can vary the order in which tasks get done. X b) There are a few variations, but the basic strategy has already been defined. This also means that I can make a few modifications in the order in which tasks get done. c) There is a strictly defined strategy to solve problems for my work. This also means that the order in which tasks get done is pre-defined. 67. Which of the following computer-related activities do you perform regularly? (Please check all that apply) --Computer programming --Installation of software --System management X Proof-reading/language editing Original writing/word processing(I do some translation, but according to a pre-defined text) If yes, is the spell-check and grammatical checking system on your computer: a) Good. These functions help me a great deal. X b) Fair. These functions are sometimes, but not always helpful. c) Poor or non-existent. --Each professor has his or her own writing style, and the grammar function seems too stereotyped. When I make changes according to the computer, the professors often disagree. On the other hand, it’s useful to have it as a check. --When I write in French, the spell-check gets crazy and a couple of times the computer froze and I lost some work. Also, I have to put in the accents by hand—-that is tedious! X Numerical data entry Statistical analysis
106 X Preparation of graphics X Technical preparation, e.g. for Website, of materials created by others X Transferring information from various files/collation Plus: Organizing & Keeping Backup files Electronic commercial transactions: X Purchasing X Sales and distribution X Searching for information on the Internet. If yes, do you encounter distracting, extraneous material: a) Rarely, since I use non-commercial search engines with which I am familiar b) Sometimes. X c) Often there are advertisements, or other distracting material 68. In the past six months has there been: (please check all which apply) X An increase in the length of you workday? A decrease in the length of your workday? X Increased time pressure/number of deadlines? An increase in work responsibility? Demotion with pay cut? Promotion with pay raise? Threat of being laid off? What do you think could be done to improve your current work? (Take as much space as you need, and try to be as complete and detailed as possible) --Define our hours as 9-12 A.M. and 1 P.M. to 5 PM. Then we could all take a real lunch hour. Use the answering machine during the lunch hour. I know that there are lunch meetings for the researchers and professors. I’d like to be able to attend these, at least sometimes, so that I could learn more about the work of the Division. --It seems to me that I do two kinds of work, which are in constant collision with each other: communication-reception and computer related work such as numerical data entry, preparation of graphics, proof-reading of texts, collation of files etc. The latter needs peace and quiet, and I find the interruptions disturbing. I have a computer at home. I’d like to be able to work at home on these latter tasks 1-2 days per week, and then be in the office doing the communication the other working days. The three of us in the front office could then cover for each other. I’ve been thinking about this for a long time, and I’ve talked with my coworkers in the front office who really like the idea. But I’m a little scared about how the Chairman and other professors might take this suggestion. Would they think we’re trying to slack off? --Get more office space and more computers, so that visiting scientists can have a room in which to work. --We need regular meetings (at least once a month) to inform us about policy and let us all have some input into what’s going on in the Department.
107 --Buy a scanner to free us up from numerical data entry. --Renovate the heating system --More desk space
Which of the above suggestions do you consider to be the most important? --I think they’re all important! What is the most difficult aspect of your job? --Stress!!! What do you think could be done to make that difficulty less of a burden? --I’m not sure where to start. I’ve made some suggestions (see above), but I wish an expert, who has the interest of workers at heart, would help! What is the best part(s) about your job? --At the end of the day, I do feel that I am appreciated. It feels especially good that the Chairman and the other professors acknowledge my help in every published paper and book. Even though I don’t have the chance to learn much about the research subjects per se, it’s exciting and rewarding to feel that I have been able to facilitate this work, in some way. That’s what keeps me going! Also, I like my coworkers and we have a good espirit de corp! --I also enjoy it when we have French-speaking visitors, then my skills as a translator really are an asset. If attempts were made to improve the conditions for your job, what would you suggest to preserve the good aspects of your work as it now stands? --Despite all its problems, I still like the academic environment better the private companies. At least people are concerned about something besides profits, and their goals are humanistic. I would be really sad if our department started to be run strictly “according to market principles”. Maybe we’d have fancier equipment and more “efficiency”, but everyone would be out for him- or herself. The professors and other researchers would be worrying about patents and ownership, instead of trying to make break-throughs that might someday really help in the fight against cancer. Numerical OSI Scores:
(N=60 women2 without manifest ischemic heart disease, mainly white and “pink” collar workers, using the Generic OSI) This Patient Mean
2
Sd
Belkic K. Psychosocial triggers of myocardial ischemia in women. Final Report to the Swedish Medical Research Council 1995.
108 Total OSI
43.5
31.4
10.2
--Underload
5.5
3.4
1.8
--High Demand
11
12.8
5.4
--Strictness
6
3.7
1.8
--Extrinsic Time Pressure
7
4.6
1.9
--Noxious Exposures
2
0.9
1.6
--Symbolic Aversiveness
1.5
1.1
1.5
--Conflict/Uncertainty
10.5
5.8
3.2
Link between the Summary Flow Sheet and the OSI for those who work daily with computers STEP A: HIGH RISK OCCUPATION Current occupation, total number of years in that occupation, work history OSI Computer: Q. 2-4 Current occupation (as precise as possible) --------------------------------------------------------------------------------------------------STEP B: JOB CHARACTERISTICS Underload --Monotonous work OSI-Computer: Yes, if Q. 42 indicates a small number of simple work tasks & Question 43.1=b or c. 43.1 Are your work tasks monotonous? a. No, a given task always has its particular qualities, so it's never exactly the same. b. Some of my tasks are monotonous, the same thing over and over again. c. Most of my tasks are monotonous, the same thing over and over again. See also, Q. 34: Computer-related problems: Lack of needed software that could help avoid doing a tedious task, and Q.67 about computer-related tasks. ---------------------------------------------------Little or no decision-making OSI-Computer. Yes, if Q. 62=a or b, and Q. 65.2=a
109 62.a Do you make decisions at your workplace or mainly carry out the decisions made by others? a. All the decisions have been made by others, I only carry out the tasks given to me, and make no decisions, not even about the smallest details. b. The decisions have been made by others. I don't decide even about the details. But my judgment is necessary during work. c. The major decisions have been made by others, but I can decide on my own about the details. d. Sometimes I must make major decisions, and take the responsibility for these. e. My job is mainly comprised of making major decisions. Q. 65.b Do you have a way influencing the policies of your workplace? a) Not at all. b) Somewhat. c) Definitely yes. -------------------------------------------------------Socially isolated work OSI-Computer: This will not often be the case, unless Q. 49, 53, 56 =a, and Q. 45.2=a) (No email, telephone nor face-to-face work-related communications, and no teamwork. 45.2 Does performance of your work tasks require teamwork? a) Minimally or not at all. b) Sometimes. c) Definitely. -------------------------------------------------------Doesn’t learn new things Best assessed using JCQ Q. 1. See also work tasks (q. 42) and increase in responsibility (q. 68) as an indirect assessment. --------------------------------------------------------------------------------------------------------High Psychological Demand --Rapid flow of new information OSI- Computer: Yes, if there is a high rate of communication via the various modes. Q. 49-60. ------------------------------------------------------Receives and transmits important, job-related information to other people OSI- Computer: Most likely yes, unless there is no email, telephone nor face-to-face workrelated communications and no team work: Q. 49, 53, 56 =a and Q. 45.2=a ------------------------------------------------------Many things going on simultaneously/must divide attention OSI- Computer: Yes, if 59=a or b, especially if many telephone or face-to-face communications (Q. 53 and 56). --Must focus attention upon devices OSI-Computer: Working with a computer always requires some attention upon the device. See also Q. 42 to assess tasks. and Q.67 about the computer-related tasks.
110
--Complicated decision making and/or tasks OSI: Computer: . Yes, if Q. 62=d or e. See also Q 63(description of decision-making) and Q. 42 to assess tasks, and Q.67 about the computer-related tasks. 62. Do you make decisions at your workplace or mainly carry out the decisions made by others? a. All the decisions have been made by others, I only carry out the tasks given to me, and make no decisions, not even about the smallest details. b. The decisions have been made by others. I don't decide even about the details. But my judgment is necessary during work. c. The major decisions have been made by others, but I can decide on my own about the details. d. Sometimes I must make major decisions, and take the responsibility for these. e. My job is mainly comprised of making major decisions. ------------------------------------------------------Supervises work of others OSI: Computer: Yes, if Q. 61= b, and to some extent if c. 61. Do you make decisions that affect the work of others? a. No. b. Yes, I work as a supervisor or in a similar capacity, and must oversee the work of others. c. I am not a supervisor, but sometimes I must oversee the work of others. --------------------------------------------------------------------------------------------------------Low Control/Physical Constraints --Strict time schedule OSI—Computer: Very much so if Q. 23=a & 24=a. 23. Do you have a deadline by which a given job or task must be completed? a. Often b. Sometimes c. Rarely of never 24. Do you face speed-up? a. Every day c. At certain periods of every month
b. At least once a week, but not every day. d. At certain periods of the year e. Rarely of never
------------------------------------------------Paced Work OSI Computer: Cannot ever be truly paced work like on an assembly line, but if Q. 45.1=b & extreme time pressure, almost like paced work. 45.1 How much can you control the speed at which you perform your work tasks? a) Completely, since I work independently from others. b) Only partially, since others depend upon the work which I perform. ------------------------------------------------No chance for Creativity
111 OSI Computer: Yes, if Q. 65.a=a, Q.67 about the computer-related tasks & Q.66=c. 65.a Concerning conclusions that are decided upon: a) There is usually only one correct decision to be made. b) There are a limited number of correct decisions to be made. c) There are many possible correct decisions to be made. 66. Is there a defined way of solving problems in your work? a) No, I must think up the strategy myself in order to solve problems, and that often requires imagination and creativity. This also means that I can vary the order in which tasks get done. b) There are a few variations, but the basic strategy has already been defined. This also means that I can make a few modifications in the order in which tasks get done. c) There is a strictly defined strategy to solve problems for my work. This also means that the order in which tasks get done is pre-defined. ------------------------------------------------No influence over work conditions OSI Computer: True, if Q. 5.4=c, Q. 8.4=no, Q.47=c, Q.65.2=a. See also JCQ decisionlatitude dimension (having a lot of say on the job, take part in decisions that affect me) ------------------------------------------------Works in confined space/fixed body position OSI: Computer: Work with a computer is obviously sedentary. See Q. 19 for the officespace, and Q. 8.1-8.3 regarding breaks and mini-breaks. ----------------------------------------------- Heavily Supervised OSI—Computer Yes, if Q. 12=c, Q.13=yes (external monitoring). Especially if 41.2=c (rigid supervisor). See also Q.19, regarding the physical layout of the office. 12. How is your work evaluated? a. No one but me evaluates my work b. A supervisor or other responsible person evaluates my work, there are no rigid standards and generally if it is done properly, it is accepted c. A supervisor or other responsible person evaluates my work very carefully according to a strict standard. If, for any reason, even a minor one, it does not fully meet these standards, my work may be rejected. ------------------------------------------------------------------------------------------Physically Aversive Exposure --Glare exposure OSI Computer: Yes, if Q. 14=a or b. 14. Are you exposed to glare at work? a) Yes, often b) Occasionally c) Rarely or never -----------------------------------------------Noise exposure OSI—Computer: Yes, if Q.15=a or b. (If a assume ≥ 90 dB)
112 15. Is your workplace noisy? a) Yes, it gets so noisy that I must raise my voice to be heard by someone right next to me b) Somewhat, but I can speak normally and be heard by someone next to me. c) No, my workplace is not noisy. -----------------------------------------------Vibration exposure OSI Computer: Unlikely to be the case, unless Q.42 indicates a major work task entailing vibration exposure. -----------------------------------------------Heavy lifting OSI Computer: Yes, if Q.16=yes. See the weight. -----------------------------------------------Heat OSI Computer: Yes, if Q. 17=no (inadequate air conditioning), see how high the temperature can get. -----------------------------------------------Cold OSI Computer: Yes, if Q. 18=no (inadequate heating system), see temperature nadir. ----------------------------------------------
--Chemical exposures: Fumes, Dusts and Gases OSI—Computer: Fairly unlikely, but see tasks Q.42, which might involve use of chemicals ------------------------------------------------------------------------------------------Disaster Potential-Symbolic Aversiveness --Threat Avoidant Vigilant Work OSI Computer: To some extent, if Q.28=a or b (see what the mistakes might be), also Q. 29 about anti-virus system. See also q.67 (computer programming, installation of software and system management could entail the possibility of serious errors). 28. What is the likelihood that you could make a work-related mistake, e.g. sending a file or attachment to the wrong person, which would have serious, irreparable consequences? a) There is a substantial risk that I could make an error that would have serious consequences. b) It is fairly unlikely, but it is possible that I could make an error that would have serious consequences. c) Minimal, under normal circumstances, just about any conceivable error is correctable and would not have serious consequences. -----------------------------------------------Encountering Visually Disturbing Scenes OSI Computer: Unlikely for these workers, unless Q. 37(witnessed work accidents) or Q.42 (work tasks) suggests that this might be the case. -----------------------------------------------Listening to Emotionally-disturbing occurrences OSI—Computer: Unlikely for these workers, unless Q. 37(witnessed work accidents)or Q.42 (work tasks) suggests that this might be the case.
113 -----------------------------------------------Hazardous tasks/Danger of serious accidents -- harm OSI—Computer: See Q.36-37 -----------------------------------------------Threat of physical violence /assault OSI—Computer: See Q. 36-37 ------------------------------------------------------------------------------------------STEP C: SPECIFIC WORK CONDITIONS Work Schedule and Rest Breaks -- Number of work hours Hours /day, Days/week, Overtime OSI Computer: Q. 5.1, 6.1 & 7. -----------------------------------------------Night shift work OSI—Computer: Yes, if Q. 9=yes. -----------------------------------------------Irregular work hours OSI-- Computer Yes, if Q. 5.3=no or if Q.9=b (rotating night shift work) -----------------------------------------------Rest breaks: scheduled and unscheduled, Mini-breaks OSI Computer: Q. 8.1 and Q.8.3 (mini-breaks) 8.1 Do you have guaranteed, scheduled rest breaks during your workday? Yes No If yes, how many? How long do these last? Can you completely rest from work during that time (no phone calls, etc.)? Yes No 8.3 How many times per day do you take a “mini-break” (get away from your desk for a few minutes)? -----------------------------------------------Vacations OSI—Computer: Q. 6.2 Number of weeks of paid vacation -------------------------------------------------------------------------------------------Workload and distribution over time OSI Computer See Q. 42, and 67 for tasks and computer-related activities, and Q. 49-58 concerning people-related activities. ------------------------------------------------------------------------------------------Level of exposure to physical noxins For any of these physical noxins (Glare, noise, vibration, isometric stress, heat, cold, chemical agents) to which a worker is exposed, obtain more information about level and type of exposure. ----------------------------------------------
114 ---------------------------------------------Work Accidents --Number and Severity of Work Accidents OSI Computer Q.36 -----------------------------------------------Work accidents witnessed or heard about OSI Computer: Q. 37 --------------------------------------------------------------------------------------------Conflicting demands in time and space OSI Computer Yes, if Q.25=b or c See also Q.44=b or c (tasks require uninterrupted attention) but Lots of demands on attention (telephone and face-to-face) and no email blocking 25. When there are several work tasks to perform: a. It is usually possible to complete everything without much trouble. b. Even with maximal efforts, it is sometimes impossible to complete everything. c. Even with maximal efforts, it is often impossible to complete everything. -----------------------------------------------Technical Problems and Breakdowns OSI—Computer: Yes, if Q.34=a or b, or Q. 35=a or b. 34. Are there computer-related problems or inadequacies that directly hamper your work? a) Yes, major ones b) Occasionally c) Rarely or never (A long checklist of possible computer-related problems is given) 35. Are there non-computer related problems that directly hamper your work? a) Yes, major ones b) Occasionally c) Rarely or never ------------------------------------------------------------------------------------------Inter-personal relations See also JCQ Q. 17-24. OSI Computer: See Q. 38-41.2 regarding interpersonal relations with coworkers and supervisors, with specific relevance to work with computers. Also, Q. 38 is assesses instrumental support with respect to computer-related issues. 38. Can you get help from coworkers or supervisors when computer-related questions or problems arise? a) Yes, I can almost always count on getting the help that I need. b) Often, but not always, do I get the help that I need. c) No, I cannot count on getting the help that I need. 39. How are your questions and efforts to improve your knowledge received? a) Very well. We have a work atmosphere that encourages us to ask questions and improve our knowledge. b) Fair. Sometimes asking questions or trying to improve knowledge can provoke criticism or ridicule.
115 c) Very poorly. discouraged.
Asking questions and trying to improve our knowledge is clearly
40. How is cooperation with your coworkers? a) Excellent, we get along well together and misunderstanding are rare. b) Fair, sometimes there are misunderstandings and tensions. c) Poor, there is a great deal on tension and conflict. 41.1 How supportive is your supervisor(s)? a) Very much so. I can freely discuss problems with him/her. b) Somewhat. c) Not at all. My supervisor is unsupportive; I cannot discuss problems with him/her. 41.2 How flexible is your supervisor(s)? a) Very much so. He/she is willing to listen to my ideas and suggestions, as well as those of my coworkers, and really takes them seriously. b) Somewhat. c) Not at all. He/she is rigid, and unwilling to listen to my ideas or suggestions, as well as those of my coworkers. ------------------------------------------------------------------------------------------STEPS D & E: EXACERBATING (NEW) CONDITIONS & LARGER ISSUES --Recent increase in Work hours/more overtime OSI—Computer Yes, if Q. 68 indicates that this is the case. -----------------------------------------------New Deadlines OSI—Computer Yes, if Q. 68 indicates that this is the case. -----------------------------------------------Recent Experiencing or Witnessing Accident OSI Computer If Q. 36 c, or 37a-c, ask whether this was recent. -----------------------------------------------New Interpersonal Conflicts OSI Computer If Q. 38=c, 39=c, 40=b or c, or 41.1=c, 41.2=c, ask whether there have been new interpersonal conflicts or worsening situation. --------------------------------------------------------------------------------------------Looming possibility of Lay-off
116 OSI—Computer: Yes, if Q. 68 indicates that this is the case. ---------------------------------------------See open-ended questions in OSI, demographic and ERI questionnaires for: --Need to change occupation or Workplace --Minority/refugee/immigrant: Discrimination and/or status incongruity --Restructuring within the work organization --Additive burden from major non-work stressors (also, sometimes OSI Q.7 will be answered for the non-paid work at home) --Low SES
Narrative Occupational History: Derived from the Computer OSI This narrative occupational history is pedagogically constructed, not based on any individual. This patient has worked as an assistant to the Director of the Cancer Research Division of a University Department of Applied Molecular Biology for the past 7 years, prior to which she worked as a translator for a division of a medical publishing company (8 years). She started her current job after the translation division was eliminated due to a company merger. While her current job requires her to perform many, varied tasks, a good number of these are, in themselves, monotonous. Her decision-making authority is low, even though she must sometimes rapidly decide about matters such as triaging calls to the Director, which requires taking many elements into consideration. As she herself correctly states: this is not really her decision to make, but instead requires judgment on her part. On the other hand, she receives a high volume of new information, much of which entails communication with other people, and her attention seems to be almost constantly divided. The vast majority of her work time is behind the computer; she also uses the fax and photocopy machine. Her work pace is rapid, with frequent deadline pressure and requirements to speed-up her work at least weekly, as well as at certain times of the year (when grant proposals are due). There is little room for creativity in her work, nor does she have an influence over her working conditions. She works in a fairly confined office space (without windows), and since this is the thoroughfare to the Director, her freedom of activity is thereby further constrained, and this represents another de facto means of control over her. Her job clearly falls into the strain category, with high demand and low decision latitude (especially low decision authority), based both upon qualitative and quantitative assessment. Her work entails a combination of high
117 psychological demand, especially related to time pressure and rapid information flow, but also has elements of under load, since the tasks are repetitive and require little creativity, and it is not entirely clear to her how these are integrated into the overall goals of the Department for which she works. Noxious physical exposures at her workplace are fairly minimal; these include: some noise-not exceeding 90 dB, minor lifting and occasionally the winter temperatures in the office fall below the comfort zone. Threat-avoidant vigilant aspects of her work are not extreme, but she is aware of the possibility that an error could have serious consequences. Her resulting vigilance and careful checking is not fully appreciated by those for whom she works. She works the day shift, with a fairly regular schedule, 5 days/week with a 42-46 hour workweek (the latter includes overtime), and two weeks of paid vacation. She has a one-hour lunch break but is not always free from answering the telephone during that time. Shorter breaks, including mini-breaks are sporadic and frequently not taken, at all. Her workload is heavy, entailing nearly continuous communication via phone, email and faceto-face (from 60-120 communications per day), plus many computer-related tasks: proofreading/language editing, translation, according to a pre-defined text, numerical data entry, preparation of graphics, technical preparation, e.g. for Website, of materials created by others, transferring information from various files/collation, organizing & keeping backup files, electronic commercial transactions: purchasing, sales and distribution, searching for information on the Internet; as well as non-computer related tasks such as photocopying, faxing, reception (answering the telephone, triaging and receiving visitors to the Department) and keeping track of the Chairman’s schedule, making his travel arrangements, sorting communication to him, inter alia. She works primarily for the Chairman of the Division, but also performs tasks for over ten professors and other researchers. There are clearly conflicting demands in time and space. In particular, the demands on her attention from the telephone and face-to-face communications, as well as new emails, conflict with performance of computer-related tasks that often require continuous attention (e.g. numerical data entry, file transfer, etc.). She lists numerous computer- and non-computer related technical problems and barriers, which she states occur “occasionally”. She considers the most troublesome of these to be: installation of new software, as well as poor compatibility of various programs and software, problems in downloading files, long telephone waiting times, and problems with the photocopy machine. Interpersonal relations with coworkers are consistently described as positive. Those in supervisory positions appear to be concerned about the well being of those for whom they are responsible, and somewhat flexible except when there is pressure of a grant proposal deadline, which is now the case. She now works more overtime than usual, for that reason. She faces the additional burden of unpaid work at home, as a wife and the mother of 2 teen-aged children. She also drives 2 hours/day as a commute, often in heavy traffic. With three years of university education, this job appears to be status incongruent for her, even though she considered that her current occupational position adequately reflects her education and training.
118 Continuous work at the computer represents a high-risk category for repetitive motion disorders. She notes that keyboard placement renders her hand position uncomfortable, risk of carpal tunnel syndrome may therefore be especially high. She also experiences eyestrain and headaches. Exposure to job strain is much more common among women workers (compared to men), and is associated with adverse psychological outcomes, inter alia. When combined with a high family burden, exposure to job strain is associated with increased risk of elevated blood pressure among white-collar women workers. While extrinsic effort is present, job security and esteem reward scores are high, so the Effort-Reward Imbalance is not present. However, it should be noted that salary and promotions prospects are not considered adequate. Compared to workingwomen in similar job profiles, the overall burden of occupational stressors, as additively assessed with the OSI, is very high. This patient shows evidence of psychological distress, with a GHQ score of 21. She describes therein feeling: under much more strain than usual, losing sleep over worry, and feeling less capable of making decisions, inter alia. On the other hand, she has made many suggestions as to how her workplace could be improved, as well as describing satisfaction in being appreciated for her work, and being part of an academic department doing cancer research. She also expresses motivation to learn more about the actual research and how her work fits into the whole, and she would like to make greater use of her language skills.
Quantitative Assessment of Work Stressors National Average Job Content Questionnaire: Psychological demands
This patient 42
Z (+1.31)
Mean 30.9
Sd 8.5
Skill discretion
30
(-0.41)
33.5
8.5
Decision making authority
20
(-1.70)
36.8
9.9
Decision Latitude
50
(-1.30)
70.3
15.6
Co-worker support
13
(+0.11)
12.73
2.53
119 Supervisor support
10
(-0.40)
11.94
4.85
Total social support
23
(-0.38)
24.6
4.26
Job insecurity
5
(+0.05)
4.91
1.97
Quadrant: Job strain Above average scores for demands, below average scores for decision latitude Ratio: 1.68 (Demands * 2 / Decision latitude) Extrinsic Effort Reward Imbalance: Extrinsic Effort = 4 Rewards = 8 Extrinsic effort is present ( > 3), but low reward is not present (score not below <7 which is the defined cutpoint ). Therefore, ERI is not present. General Health Questionnaire (GHQ): 21 (>20 suggests severe problems and psychological distress) ******************************************************************************************* *******************************************************************************************
120 D. Automobile Assembler Completed Generic OSI The answers to this questionnaire are pedagogically constructed, not based on any individual. INFORMATION ABOUT YOUR WORKPLACE
Unless otherwise specified, all of the questions refer to driving on the job. Please choose the single answer which best applies to your working situation, unless otherwise specified. Feel free to write your comments. 1. Total number of working years: 29 2. What is your current occupation (please be as precise as possible)? Automobile Assembler 3. What is the total number of years that you worked in your current occupation? 17 years 4.Have you worked at other jobs besides your current one? If yes, please list the jobs you've had number of years at each: Brick Layer From (year):1972_ To (year):1984
Yes
No
Work hours and scheduling 8 hours 5. How long does your workday usually last? Yes No Do you ever work longer than that? If yes, how often? Twice a week_______ and for how many hours/day?_4 *Do you have a regular work schedule? Yes No *If yes, when do you begin work? 7A.M. End work: 3:30 P.M. (30 minutes for lunch—not included in work hours) 6. How many days do you work per week? Usually 5, but once per month 6 *How many weeks of paid vacation to you have per year? 2 weeks
7. Do you work at another job outside your regular one? Yes If yes, how many hours per week? What do you do?
No
8. Do you always have at least one break during your workday? Yes If yes, how many breaks do you usually have? How long is your usual break?
No
121
9. Do you work the late night shift (after midnight?) If yes, do you work the night shift: a. Constantly b. On a rotating basis (describe please how this rotates
Yes
No
Mode of Payment and Evaluation 10. My pay is: a. Based upon how much I myself work b. Based upon how much my group or collective, as whole, works c. Fixed Our pay used to be fixed, but about a year ago the company introduced something they call “the team concept” so we have to produce more to keep up our wages.
10 a. My salary is: a) Totally inadequate to meet the basic needs of myself and my family. b) Just barely covers the basic needs of myself and my family. c) Covers more than the basic needs of myself and my family. 11. How is your work evaluated? a. No one but me evaluates my work b. A supervisor or other responsible person evaluates my work, there are no rigid standards and generally if it is done properly, it is accepted c. A supervisor or other responsible person evaluates my work very carefully according to a strict standard. If, for any reason, even a minor one, it does not fully meet these standards, my work may be rejected. Physical Working Conditions 12. Are you exposed to welding or any other strong lights during work? a. Yes, often (though I wear a mask when I weld, others do welding around me and the light is very strong) b. Sometimes c. Rarely or never 13.Are you exposed to noise at your workplace? a. Yes, it's very noisy and I must raise my voice to be heard by someone right next to me. b. Somewhat, but I can speak normally and be heard by someone next to me. c. No, my workplace is not noisy. 14. Do you perform heavy lifting at work? a. Yes, often times during the day lift 50 kg.(110 lbs) or more. (I also push heavy crates) b. Yes, I lift from 20 to 50 kg loads (44 - 110 lbs) during my usual workday.
122 c. Yes, I lift up to 20 kg (44 lbs) during my usual workday. d. No, I rarely or never lift anything heavy during work. 15. Are you exposed to vibration at work? Approximate number of hours/day: 1-2 a. Yes. Source: Hand drill b. Rarely or never 16. Does it get hot at your workplace? a. Not more than 30 degrees C (86 degrees F) b. It gets hotter than 30 degrees C (86 degrees Ft), but not >40C (103 F) In the summer, no air conditioning c. Extremely. It can get hotter than >40 C(103 F). 17. Does it get cold at your workplace? a. Not less than 15 degrees C (60 degrees F). b. It can get colder than 15 degrees C/ 60 degrees F, but not less than 10 degrees C/ 50 degrees F. The heating system is terrible and it’s also very drafty c. I work outside in the wintertime where it is often less than 10 degrees C/ 50 degrees F. 18.Are you exposed to gases, mists or dusts at your workplace? a. No b. Yes, occasionally c. Yes, often. If you answered (b) or (c), please list the chemicals to which you are exposed: Paint, turpentine, other solvents but I don’t know exactly what they are 19. What is your body position and activity during work? a. I am constantly in motion, with no fixed body position. b. I mainly work in a single position, but I am free to move about. c. My body position is fixed during work, and my motion is restricted. If you answered (b) or (c), please describe your body position during work: Standing, except when doing lifting or moving crates 20. Do you work in a: a. Hall, large office or outside? b. Small office or workshop? c. Very confined space? If you answered (b) or (c), please state the dimensions:___________________________
21. Do you work in dangerous conditions? (please check all that apply to you)
123 a. Yes, I work on heights or in a workplace in which objects can fall on us, can lose fingers in the machinery b. Yes, I work with flammable material. c. Yes, I am in danger of being physically assaulted. d. Yes, I am exposed to danger at work due to:___________________________ e. No Work Accidents and Injuries 22. Have you ever had an accident or been injured (including assault) at work? a. No b. Yes, only of a minor nature c. Yes, I have had one or more serious accidents or have suffered serious physical harm at work: Please briefly describe all serious accidents or injuries: 23. Have you ever witnessed a serious accident at work? a. Yes, I have observed one or more accidents with a fatal outcome. b. Yes, I have observed one or more serious accidents, but I have never witnessed a fatal outcome. c. I have heard about serious or fatal accidents at work, but never seen this. d. No, I have never witnessed or heard about a serious accident at work. My coworker lost two fingers Time Pressure at Work 24. Do you have a deadline by which a given job or task must be completed? a. Often b. Sometimes c. Rarely of never 25. Do you face speed-up? a. Every day b. At least once a week, but not every day. c. At certain periods of every month d. At certain periods of the year e. Rarely of never Problems at Work 26. If you don't manage to remember some work-related information: a. I can fairly easily retrieve the information. b. The information can't be retrieved, and sometimes it could have been important. c. The information can't be retrieved, and often the information is very important. I must therefore be very careful to register and remember the information when it is first presented.
124
27. If you encounter some dilemma during work, and are not certain how to proceed: a. I can usually postpone a decision until the situation is clarified. b. Sometimes I must act based upon the information I have at a given moment, and can't postpone the decision. c. Most of the time I must act based upon the information I have at a given moment, and can't postpone the decision. 28. If you were to make a mistake during work, what are the most serious possible consequences: a. I can usually correct the error. b. There could be irreparable material or other damage. c. The outcome could be fatal. 29. Do you receive clear instructions and information concerning your work? a. Yes, usually or always. b. No, sometimes these are unclear. c. No, often these are unclear. 30. Does it happen that you don't receive all the needed instructions and information concerning your work? a. Yes, there is often missing information. b. Occasionally there is missing information. c. No, rarely or never is there missing information. 31. Do you receive conflicting/contradictory information or instructions about the work you should be doing? a. Yes, often. b. Yes, sometimes. c. No, rarely or never. 32. Does it happen that due to unforeseen circumstances the plan of work changes? a. Yes, often. b. Yes, sometimes. c. No, rarely or never. 33. When there are several work tasks to perform: a. It is usually possible to complete everything without much trouble. b. Even with maximal efforts, it is sometimes impossible to complete everything. c. Even with maximal efforts, it is often impossible to complete everything. 34. Regarding technical problems that prevent you from proceeding with your work (e.g. computer breakdown, power failure, faulty parts, lack of needed supplies, etc.) a. We have a lot of those problems.
125 b. Occasionally such technical problems happen. c. Such problems are rare at my workplace, usually I can proceed with my work without disturbances of that kind. 35. Objectively, how are interpersonal relations at your workplace? a. Excellent, we all get along together and misunderstandings are rare. b. Fair, sometimes there are misunderstandings and tension among us. c. Poor, there is a lot of tension and conflict among us. My coworkers and I all get along really well, but we are always having trouble with supervisors and management who push us around a lot Description of your work tasks 36. Please list each of the main work tasks that you perform (Fill in as many lines as you need) Auto assembly—I am assigned to assembly of doors on car models that are practically all the same 37. Please list the tools/equipment/apparatus that you use during work: (Fill in as many lines as you need) Hand drill, screwdriver, welding arc 38. Are your work tasks monotonous? a. No, a given task always has its particular qualities, so it's never exactly the same. b. Some of my tasks are monotonous, the same thing over and over again. c. Most of my tasks are monotonous, the same thing over and over again. 39. Does it occur that during your work hours, you have nothing to do? a. Yes, often b. Occasionally c. Rarely or never. I always have something to do during my work hours We used to sometimes have some slack time, which was nice because we could kid around a little, and relax. But now, it’s just work, work, work all the time. 40. How many different tasks or operations do you perform simultaneously? a. One, or at the most two tasks. b. Occasionally three or more. c. Often three or more. If you answered (b) or (c), please list these: 41. Do any of your tasks have to be performed with a particular speed? a. No. b. Some tasks require speed. c. Many or most of the tasks that I perform require speed:
126 If you answered (b) or (c), please list these: Welding 42. Can you control the speed at which you work? a. Yes, completely since I work independently from others. b. Only partially, since the speed at which I work affects the work of others in my work group. c. Not at all. I work on an assembly or other paced system, and I have no control over the speed at which I work. Decision-making at work 43. Do you make decisions that affect the work of others? a. No. b. Yes, I work as a supervisor or in a similar capacity, and must oversee the work of others. c. I am not a supervisor, but sometimes I must oversee the work of others. If you answered (b) or (c), how many people to you oversee?______ What are the job profiles of the people whom you oversee? ________________________ ______________________________ ________________________ ______________________________ ________________________ ______________________________ 44. Do you make decisions at your workplace or mainly carry out the decisions made by others? a. All the decisions have been made by others, I only carry out the tasks given to me, and make no decisions, not even about the smallest details. b. The decisions have been made by others. I don't decide even about the details. But my judgment is necessary during work. c. The major decisions have been made by others, but I can decide on my own about the details. d. Sometimes I must make major decisions, and take the responsibility for these. e. My job is mainly comprised of making major decisions. 45. If you make decisions in your work, describe, as best you can, by an example, how you go about it: Example of a decision: I don’t really make any decisions at work. Steps in the decision-making process: 46. Must you make rapid decisions or quickly assess a given situation? a. Yes, often b. Occasionally c. No, rarely or never. If you answered (a) or (b), please briefly describe these situations: If an emergency situation arises. 47. Concerning conclusions that are decided upon: a. There is usually only one correct decision to be made.
127 b. There are a limited number of correct decisions to be made. c. There are many possible correct decisions to be made. 48. Is there a defined way of solving problems in your work? a. No, I must think up the strategy myself in order to solve problems, and that often requires imagination and creativity. b. There are a few variations, but the basic strategy has already been defined. c. There is a strictly defined strategy to solve problems for my work. Interactions with People and with Machines 49. Communication with other people during work: a. There is no need for work-related communication with others. b. From time to time, I must discuss with others in order to perform my work properly. c. Communication with other people is a major feature of my work. 50. If you use gauges, meters or other such devices at your job: How many measuring devices do you use? Not really Please list these:_________________________________ 51. Do you oversee the work of one or more machines or automatic devices? No Yes If yes, how many devices do you follow simultaneously?___________ Can you control the speed at which these devices operate? Yes
No
52. How many people do you have under your on-going care/responsibility at work? (e.g. pupils, patients, clients) a. None b. One to five c. Six to ten d. Eleven to twenty e. Over twenty 53. With how many people do you interact daily at work (both fellow employees and the public)? a. None b. One to five c. Six to ten d. Eleven to twenty e. Over twenty
54. How many telephone calls do you receive during a normal working day? (including calls that are meant for others)
128 a. None b. One to five c. Six to ten d. Eleven to twenty e. Over twenty 55. Does it happen during your workday that several people seek your attention at the same time? (including people on the telephone) a. Yes, many times each day b. Yes, a few times each day c. Yes, but only once or twice each day d. No, rarely or never. 56. If several people seek your attention at the same time, how many are they? a. Two at the most b. Usually two, but sometimes more. c. Usually three or more 57. For how many people at your workplace to you perform tasks? Not applicable a. None b. One c. Two to three d. Four to ten e. Over ten Recent changes in your working conditions 58. In the past six months has there been: (Please check all which apply) a. An increase in the length of your workday? b. A decrease in the length of your workday? c. Increased time pressure/number of deadlines? d. An increase in work responsibility? e. Demotion with pay cut? f. Promotion with pay raise? g. Threat of being laid off? h. Other changes, please specify:_________________________________________
129
Some open-ended questions about your current work: 59. What could be done to improve working conditions at your current job? Make the machinery safer and stop the pressure to work faster and faster
60. Which of the above suggestions do you consider to be the most important? Make the machinery safer and stop the pressure to work faster and faster
61. What is the most difficult aspect of your job? It’s boring but I have to keep alert to avoid an accident or making a mistake
62. What do you think could be done to make that difficulty less of a burden? Learn different operations and change around, and again stop the time pressure which, it seems to me, is the biggest reason why accidents happen
63. What is the best part(s) about being your job? My coworkers—they’re my good friends!
64. If attempts were made to improve the conditions for your job, what would you suggest to preserve the good aspects of your work as it now stands? Let us assemblers together have more say in how things get done. 65. Other comments: We also need to have job security, and better hourly wages so that we don’t work overtime which is really exhausting.
Link between the Summary Flow Sheet and the Generic OSI High Risk Occupation
130 Current occupation, total number of years in that occupation, work history Generic OSI Q. 2-4 Current occupation (as precise as possible) --------------------------------------------------------------------------------------------------Monotonous work Generic OSI: Yes, if Q. 36-37 indicate A small number of simple work tasks & Question 38=b or c) 38. Are your work tasks monotonous? a. No, a given task always has its particular qualities, so it's never exactly the same. b. Some of my tasks are monotonous, the same thing over and over again. c. Most of my tasks are monotonous, the same thing over and over again. -------------------------------------------------Little or no decision-making Generic OSI Yes, if Q. 44=a or b. 44. Do you make decisions at your workplace or mainly carry out the decisions made by others? a. All the decisions have been made by others, I only carry out the tasks given to me, and make no decisions, not even about the smallest details. b. The decisions have been made by others. I don't decide even about the details. But my judgment is necessary during work. c. The major decisions have been made by others, but I can decide on my own about the details. d. Sometimes I must make major decisions, and take the responsibility for these. e. My job is mainly comprised of making major decisions. -----------------------------------------------------Socially isolated work Generic OSI Yes, if Q.49=a 49. Communication with other people during work: a. There is no need for work-related communication with others. b. From time to time, I must discuss with others in order to perform my work properly. c. Communication with other people is a major feature of my work. -----------------------------------------------------Learning new things. Generic: See answer to JCQ Question 1, and consider also answer to monotonous work, above. --------------------------------------------------------------------------------------------------------Rapid flow of new information Generic OSI: Yes, if people-related or machine-related information cannot be controlled and occurs rapidly. Q. 42=b or c, Q.51 (part II)=no, see also Q. 51-57 -----------------------------------------------------
Receives and transmits important, job-related information to other people
131 Generic OSI: Yes, if Q. 49=c (and to a lesser extent if b) 49. Communication with other people during work: a. There is no need for work-related communication with others. b. From time to time, I must discuss with others in order to perform my work properly. c. Communication with other people is a major feature of my work. ----------------------------------------------------Many things going on simultaneously/must divide attention Generic OSI: Yes, if Q.40=b or c, Q.55=a or b. Usually yes, if many people-related or machine-related interactions; see Q. 49-54, 56-57. ----------------------------------------------------Must focus attention upon devices Generic OSI: Yes, if Q. 50 and 51 indicates use of gauges, meters or other such devices / oversees the work of devices ----------------------------------------------------Complicated decision making and/or tasks Generic OSI: Yes, if Q. 44=d or e. See also Q. 45 (description of decision-making) and Q. 36-37 to assess tasks 44. Do you make decisions at your workplace or mainly carry out the decisions made by others? a. All the decisions have been made by others, I only carry out the tasks given to me, and make no decisions, not even about the smallest details. b. The decisions have been made by others. I don't decide even about the details. But my judgment is necessary during work. c. The major decisions have been made by others, but I can decide on my own about the details. d. Sometimes I must make major decisions, and take the responsibility for these. e. My job is mainly comprised of making major decisions. ----------------------------------------------------Supervises work of others Generic OSI Yes, if Q. 43=b, and to some extent if c 43. Do you make decisions that affect the work of others? a. No. b. Yes, I work as a supervisor or in a similar capacity, and must oversee the work of others. c. I am not a supervisor, but sometimes I must oversee the work of others. --------------------------------------------------------------------------------------------------------Strict time schedule Generic OSI Very much so, if Q. 24=a, & 25=a. 24. Do you have a deadline by which a given job or task must be completed? a. Often b. Sometimes c. Rarely of never 25. Do you face speed-up? a. Every day b. At least once a week, but not every day. c. At certain periods of every month d. At certain periods of the year e. Rarely of never -----------------------------------------------
132 Paced Work Generic OSI Yes, if Q. 42=c. 42. Can you control the speed at which you work? a. Yes, completely since I work independently from others. b. Only partially, since the speed at which I work affects the work of others in my work group. c. Not at all. I work on an assembly or other paced system, and I have no control over the speed at which I work. ----------------------------------------------No chance for Creativity Generic OSI Yes, if Q. 47=a and 48=c 47. Concerning conclusions that are decided upon: a. There is usually only one correct decision to be made. b. There are a limited number of correct decisions to be made. c. There are many possible correct decisions to be made. 48. Is there a defined way of solving problems in your work? a. No, I must think up the strategy myself in order to solve problems, and that often requires imagination and creativity. b. There are a few variations, but the basic strategy has already been defined. c. There is a strictly defined strategy to solve problems for my work. -----------------------------------------------
No influence over work conditions Generic OSI: This is best assessed from the decision-latitude dimension of the JCQ (having a lot of say on the job, take part in decisions that affect me) ---------------------------------------------Works in confined space/fixed body position Generic OSI: Yes, if Q. 19=c and 20=c. 19. What is your body position and activity during work? a. I am constantly in motion, with no fixed body position. b. I mainly work in a single position, but I am free to move about. c. My body position is fixed during work, and my motion is restricted. 20. Do you work in a: a. Hall, large office or outside? b. Small office or workshop? c. Very confined space? ---------------------------------------------– Heavily Supervised Generic OSI Yes, if Q. 11=c 11. How is your work evaluated? a. No one but me evaluates my work b. A supervisor or other responsible person evaluates my work, there are no rigid standards and generally if it is done properly, it is accepted
133 c. A supervisor or other responsible person evaluates my work very carefully according to a strict standard. If, for any reason, even a minor one, it does not fully meet these standards, my work may be rejected. ------------------------------------------------------------------------------------------Glare exposure Generic OSI: Yes, if Q.12=a or b 12. Are you exposed to welding or any other strong lights during work? a. Yes, often b. Sometimes c. Rarely or never ---------------------------------------------Noise exposure Generic OSI: Yes, if Q.13=a or b. (If a assume ≥ 90 dB) 13.Are you exposed to noise at your workplace? a. Yes, it's very noisy and I must raise my voice to be heard by someone right next to me. b. Somewhat, but I can speak normally and be heard by someone next to me. c. No, my workplace is not noisy. ---------------------------------------------Vibration exposure Generic OSI Yes, if Q.15=a. 15. Are you exposed to vibration at work? a. Yes. Source:___________ Approximate number of hours/day:__________ b. Rarely or never ---------------------------------------------Heavy lifting Generic OSI Yes, if Q.14=a-c. 14. Do you perform heavy lifting at work? a. Yes, often times during the day lift at least 50 kg. (=110 lbs.). b. Yes, I lift from 20 to 50 kg loads (44 - 110 lbs) during my usual workday. c. Yes, I lift up to 20 kg (44 lbs) during my usual workday. d. No, I rarely or never lift anything heavy during work. ---------------------------------------------Heat Generic OSI Yes, if Q.16=b or c. Especially c (smelter-workers, some other factory conditions or outside in very hot climate) 16. Does it get hot at your workplace? a. Not more than 30 degrees C (86 degrees F) b. It gets hotter than 30 degrees C (86 degrees Ft), but not >40C (103 F). c. Extremely. It can get hotter than >40 C(103 F). ---------------------------------------------Cold Generic OSI: Yes, if Q. 17=b or c (especially c). 17. Does it get cold at your workplace? a. Not less than 15 degrees C (60 degrees F).
134 b. It can get colder than 15 degrees C/ 60 degrees F, but not less than 10 degrees C/ 50 degrees F. c. I work outside in the wintertime where it is often less than 10 degrees C/ 50 degrees F. ---------------------------------------------Chemical exposures: Fumes, Dusts and Gases Generic OSI: Yes, if Q.18=b or c. 18.Are you exposed to gases, mists or dusts at your workplace? a. No b. Yes, occasionally c. Yes, often. If you answered (b) or (c), please list the chemicals to which you are exposed: ------------------------------------------------------------------------------------------Threat Avoidant Vigilant Work Generic OSI: Yes, if Q.28=c, and to some extent if b. See also tasks performed (q. 36-37) 28. If you were to make a mistake during work, what are the most serious possible consequences: a. I can usually correct the error. b. There could be irreparable material or other damage. c. The outcome could be fatal. ---------------------------------------------Encountering Visually Disturbing Scenes Generic OSI Some indication, if Q. 23=a or b. ---------------------------------------------Listening to Emotionally-disturbing occurrences Generic OSI (Q.) Some indication, if Q. 23=c. ---------------------------------------------Hazardous tasks/Danger of serious accidents -- harm Generic OSI Yes, if Q. 21=a – d. 21. Do you work in dangerous conditions? (please check all that apply to you) a. Yes, I work on heights or in a workplace in which objects can fall on us. b. Yes, I work with flammable material. c. Yes, I am in danger of being physically assaulted. d. Yes, I am exposed to danger at work due to:___________________________ e. No ---------------------------------------------Threat of physical violence /assault Generic OSI Yes, if Q. 21=c. ------------------------------------------------------------------------------------------STEP C: SPECIFIC WORKING CONDITIONS Number of work hours Hours /day, Days/week, Overtime Generic OSI: Q. 5-7
135 ---------------------------------------------Night shift work Generic OSI: Yes, if Q. 9=yes ---------------------------------------------Irregular work hours Generic OSI: Yes, if Q. 5 part II=no or if Q.9=b (rotating night shift work) ---------------------------------------------Rest breaks: scheduled and unscheduled, Minibreaks Generic OSI: See Q. 8. 8. Do you always have at least one break during your workday? Yes No If yes, how many breaks do you usually have?_______ How long is your usual break?___________ ---------------------------------------------Vacations Generic OSI: See Q. 6 Number of weeks of paid vacation ------------------------------------------------------------------------------------------Workload and distribution over time Generic OSI Use Q. 36, 50-57 for assessment of machine-related and people-related tasks, asking more specific questions as needed. ------------------------------------------------------------------------------------------Level of exposure to physical noxins For any of these physical noxins (Glare, noise, vibration, isometric stress, heat, cold, chemical agents) to which a worker is exposed, obtain more information about level and type of exposure. ------------------------------------------------------------------------------------------Number and Severity of Work Accidents Generic OSI Q.22 ---------------------------------------------Work accidents witnessed or heard about Generic OSI: Q.23 ------------------------------------------------------------------------------------------Conflicting demands in time and space Generic OSI Yes, if Q. 33=b or c. When there are several work tasks to perform: a. It is usually possible to complete everything without much trouble. b. Even with maximal efforts, it is sometimes impossible to complete everything. c. Even with maximal efforts, it is often impossible to complete everything.
136 ---------------------------------------------Technical Problems and Breakdowns Generic OSI: Yes, if Q. 34=a or b. 34. Regarding technical problems that prevent you from proceeding with your work (e.g. computer breakdown, power failure, faulty parts, lack of needed supplies, etc.) a. We have a lot of those problems. b. Occasionally such technical problems happen. c. Such problems are rare at my workplace, usually I can proceed with my work without disturbances of that kind. ------------------------------------------------------------------------------------------Inter-personal relations See also JCQ Q. 17-24. Generic OSI: If Q. 35=b or c, there are problems in interpersonal relations, that can be explored. 35. Objectively, how are interpersonal relations at your workplace? a. Excellent, we all get along together and misunderstandings are rare. b. Fair, sometimes there are misunderstandings and tension among us. c. Poor, there is a lot of tension and conflict among us. ------------------------------------------------------------------------------------------STEP D: EXACERBATING CONDITIONS AND LARGER ISSUES Recent increase in Work hours/more overtime Generic OSI= Yes, if Q. 58=a ---------------------------------------------New Deadlines Generic OSI: Yes, if Q. 58=c ---------------------------------------------Recent Experiencing or Witnessing Accident Generic OSI If Q. 22 c, or 23a-c, ask whether this was recent. ---------------------------------------------New Interpersonal Conflicts Generic OSI: If Q. 35=b or c, ask whether there have been new interpersonal conflicts or worsening situation. ---------------------------------------------Looming possibility of Lay-off Generic OSI: Yes, if Q. 58 g
Narrative History Automobile Assembler--Derived from the Generic OSI This narrative occupational history is pedagogically constructed, not based on any individual.
137
This patient has worked as an auto assembler for the past seventeen years; prior to which he was employed for twelve years as a bricklayer in the building trades. His current job is on a paced, assembly line, the speed of which has recently been accelerated with group piece rate pay system introduced. Management has recently attempted to pressure the workers to accept a lower piecework rate, with the alternative being layoffs. As a consequence, the work-pace has increased in order to maintain previous pay levels. There is also very heavy supervision, so that any piece of work will be rejected if it does not meet the strict quality control standards. The tasks are fairly complex requiring concentration especially with welding and drilling but at the same time are monotonous since he is assigned exclusively to assembly of the car doors of nearly identical models. There is minimal decision-making, and the job does not require communication with other workers, i.e., a job with high demand but also under-load. Physical exposures include noise (likely >90 dB), hand-arm vibration from hand drilling performed daily, repeated lifting and pushing of loads up to 44 lbs, and other than which he works with a fairly fixed body position: standing, welding glare, heat (often > 86 but never >103 F) in the summer, cold and drafty in the winter (10–15 degrees C), as well as fumes from paint, turpentine and other solvents. There is risk of objects falling and from heavy machinery; the patient has suffered one minor accident, and saw his coworker lose 2 fingers. The basic workweek is 42 hours, on a regular schedule starting at 7 A.M., but with an average of 8 hours of overtime per week. There are no guaranteed rest breaks (a 30 minute pause for lunch is unpaid). Paid vacation is 2 weeks/year. Pay is described as barely adequate to meet basic needs. Interpersonal relations are described as fair, with tension between the supervisors and management, while coworkers are said to get along very well. Assembly-line factory jobs are a high-risk category for hypertension and CVD as well as repetitive motion disorders. Using the JCQ, because of the low levels of decision-making authority, coupled with high pressure to work hard and fast, this job is clearly in the high strain category, based upon both the ratio calculation and quadrant term. There are low rewards: both financial and in terms of career opportunities. Piece rate work and speed up contribute to high effort, such that Effort-Reward Imbalance is present. These conditions have recently worsened, and there is a threat of unemployment. The total OSI is over two standard deviations above that found for industrial and building trade workers; the patient is exposed to a large number of job stressors that can be harmful to the cardiovascular system. Quantitative Assessment of Work Stressors
Male-Industrial/Building Trade Workers (N=227) This Patient
Total OSI --Underload --High Demand --Strictness --Extrinsic Time Pressure --Noxious Exposures
51.5 6 11 7 8 12
Mean 33.0 3.8 9.0 3.5 3.2 6.3
Sd 7.9 3. 3.7 1.6 1.5 2.6
138 --Symbolic Aversiveness --Conflict/Uncertainty
5.5 2
3.9 5.2
1.5 2.8
National Average Job Content Questionnaire:
Psychological demands Skill discretion Decision making authority
36 32 30
Mean 30.9 33.5 36.8
Sd 8.5 8.5 9.9
Quadrant: High strain: clearly above average psychological demand and below average decision-making authority with borderline low skill discretion. Ratio: 1.16, job strain is present. Extrinsic Effort Reward Imbalance Present
139
Part II: Clinical Cases Based upon the OSI-derived Occupational Histories A. A 54-Year Old Neurologist-Psychiatrist Working In A Public Hospital This is a pedagogically constructed case, not based on any individual. Chief Complaint: Palpitations, clinic diagnosed hypertension, hypercholesterolemia History of the Present Illness: For the last year, the patient complains of episodes of sudden onset of palpitations occurring most often during or after a difficult work shift, especially when taking night call. The episodes typically last about 1-2 minutes but occasionally last up to 5 minutes. These usually, but not always, respond to carotid sinus massage, which she initiates. During an episode she feels slightly lightheaded and nauseated. On a few occasions the palpitations have been accompanied by a non-radiating left-sided pressure type chest pain, which lasted for the duration of the episode. She has not undergone any medical work-up for these arrhythmias (nor the chest pain), because she states she has been ”too busy”, but also admits her reluctance to have an ECG recorded by colleagues and staff with whom she works. Initially, she experienced approximately 1-2 episodes per week, but they recently have become more frequent so that now she has the minimum 5-6 daily. Two years ago during a mandatory health examination (at a nearby clinic), her BP was 160/100. Repeat clinic measurements on two subsequent occasions were 150/95 and 145/93. She then began to take Enalapril, and on a dose of 5 mg/d, after which clinic BP ranged from 130-135/80-85mmHg. She has continued on that dose ever since. During the same examination, an abnormal lipid profile with elevated plasma LDL cholesterol was found (3.8 mmol/L), and she was given dietary advice with which she partially complies. A repeat measure last year was 3.5 mmol/L. The patient has been smoking 15-20 cigarettes/D for the past two years, prior to which she had smoked between 5-10 cigarettes/D for 25 years. She drinks 4-5 cups of coffee per day. She does not consume alcoholic beverages. Physical activity outside the workplace is confined to that related to housework. Past Medical History and Review of Systems: Two years post-menopause, takes calcium supplements only. Gravida 1, para 1. Occasional dry cough. The patient admits to feelings of emptiness and apathy, and sometime is melancholic and has crying spells. Occupational History See Part I of this Chapter (p. 77) Family History: Parents both living and in good health, as are her siblings and children. Breast cancer in mother’s sister and paternal grandmother.
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Social History: Widowed two years ago. Her daughter, son-in-law and 2 year-old grandson live with the patient in a comfortable home. The patient performs most of the household chores. Clinic Physical Examination: Slender, subdued, cooperative female --Grade II hypertensive and arteriosclerotic retinal arteriolar changes --Pulmonary: Prolonged expiratory phase, occasional wheezes on forced expiration --Cor: Increased apical impulse, frequent extra-systoles, increased second heart sound (S2) --BP=130/85 in both arms --HR=90/min, somewhat irregular Otherwise, unremarkable. Laboratory: Total plasma cholesterol: 7.4 mmol/L, LDL=4.3 mmol/L Serum triglycerides = 1.5 mmol/L HbA1C = 4% of total hemoglobin (normal to 6%) Normal TSH, T3, T4 24-hour Holter and Ambulatory BP monitoring (1) Recording during a period at home (prior to working a night shift) Sinus rhythm, average HR=85/min, minimum HR=65/min, maximum HR=150/min. Average waking BP=135/85 mmHg, minimum 100/60mmHg, maximum 150/100 mmHg Average BP during sleep=125/80 mmHg, minimum 90/60mmHg, maximum 130/85 mmHg Frequent premature atrial contractions (PAC), average 20/hour, maximum 50/hour (after vacuuming the house) Two episodes of paroxysmal supraventricular tachycardia (PSVT), maximum rate = 150/min, narrow QRS complexes, initiated by PACs, lasting 1-2 minutes. Both of these stopped spontaneously. Two cups of coffee and 10 cigarettes smoked during the recording period. Medication: Enalapril 5 mg/day. *****************************************************
(2) Recording during work (day shift-plus night call in-hospital) Sinus rhythm, average HR=95/min, minimum HR=75/min, maximum HR=150/min. Average BP=155/95 mmHg, minimum 100/60mmHg, maximum 160/105 mmHg Frequent PAC, average 50/hour, maximum 250/hour (occurring from 4-5 A.M). Five episodes of PSVT, maximum rate = 150/min, narrow QRS complexes, initiated by PACs, lasting 1-5 minutes. Three episodes occurred during the night shift. Two of these stopped spontaneously, and the remainder after carotid sinus message. One episode of left-sided pressure type chest pain lasting 3 minutes immediately after PSVT, without STT changes, at 5 P.M.
141 The patient slept from midnight to 3 A.M., whereupon she was called to admit and care for a case of status epilepticus, until 5 A.M. At 4:30 A.M. immediately after she had an episode of PSVT, which subsided spontaneously, horizontal ST depression to 1.2 mm with T wave inversion was recorded in CMV5, the latter lasted 5 minutes. BP was 100/60 mmHg. No chest pain reported at that time. Five cups of coffee were consumed, and 20 cigarettes smoked during the recording period. Medication: Enalapril 5 mg/day. The patient described as a typical 24-hour on-call period. Heart rate variability could not be reliably assessed because of frequent atrial arrhythmias. Bicycle Exercise Text to 120 Watts --PSVT triggered at 120 Watts, accompanied by lightheadedness, testing stopped. --BP at 110 Watts=160/100mmHg --T wave inversion during the recovery period. Otherwise, unremarkable findings. Echocardiogram at rest -- Posterior left ventricular and intraventricular wall thickness = 1.3 cm (Upper Limit of Normal = 1.1), all other chamber dimensions, valves and wall motion normal. Chest X-ray: --Unremarkable Pulmonary Function: --FEF25-75% slightly reduced, otherwise within normal limits Psychosocial Interview: Discussion of Problems with ECG and Ambulatory BP recording During neutral conversation at the beginning of the recording period: BP=130-135/85, HR= 85/min, occasional PAC. BP rises to 150-160/110-115 mmHg and episodes of PSVT to 150/min. when discussing very difficult patients, including those who have committed suicide, as well as when discussing her husband’s illness. *************************************************************************** Questions: What is your assessment of this patient? How would you manage this patient? What are some possible scenarios that might ensue, and what would be your next therapeutic steps for each of the outcomes that you foresee? Basic Readings: Adams SL, Roxe DM, Weiss J, Zhang F, Rosenthal JE. Ambulatory blood pressure and Holter monitoring of emergency physicians before, during, and after a night shift. Academic Emergency Medicine 1998; 5: 871-877.
142 Belkic K, Schnall P. Paroxysmal supraventricular tachycardia and the workplace: Need for an occupational cardiologic approach. The Job Stress Network Website (www.workhealth.org), 2000. Josephson ME, Zimetbaum P, Buxton A, Marchlinski FE, Paroxysmal Supreventricular Tachycardia. In Fauci AS, Braunwald E, Isselbacher K, et al. (eds). Harrison’s Principles of Internal Medicine. McGraw-Hill, New York, 1998, pp. 1265-1268. Supplementary Readings: On physicians’ working conditions and health outcomes: Agius RM, Blenkin H, Deary IJ, Zealley HE, Wood RA. Survey of perceived stress and work demands of consultant doctors. Occup Environ Med 1996; 53: 217-224 Arnetz B. Physicians’ views of their work environment and organization. Psychother Psychosom1997; 66:155-62. Baldwin DS, Rudge SE. Depression and suicide in doctors and medical students. In: P Litchfield (ed.) Health risks to the health care professional. 1995, Royal College of Physicians of London, London, pp. 77-89. Chambers R, Belcher J. Predicting mental health problems in general practitioners. Occup Med 1994; 44: 212-6. Firth-Cozens J. Sources of stress in women junior house officers. BMJ 1990; 301: 89-91. Green MJ. What (if anything) is wrong with residency overwork? Ann Intern Med 1995; 123: 512-517. Heim E. Stressors in medical professions. Do women bear the greater risks for their health? Zsch psychosom Med 1992; 38: 207-226. Johnson JV, Hall EM, Ford DE, Mead LA, Levine DM, Wang N-Y, Klag MJ. The psychosocial work environment of physicians. JOEM 1995; 37: 1151-1159. Kamal A-A M, Dammak M, Caillard J-F, Couzinet M, Paris C, Ragazzini I. Relative cardiac cost and physical, mental and psychological workload among a group of post-operative care personnel. Int Arch Occup Environ Health 1991, 63: 353-358. Olkinuora M, Asp S, Juntunen J, Kauttu K, Strid L, Äärimaa M. Stress symptoms, burnout and suicidal thoughts of Finnish physicians. Scand J Work Environ Health 1992; 18 Suppl 2: 110-112. Revicki DA, Gershon RRM. Work-related stress and psychological distress in emergency medical technicians. J Occup Health Psychol. 1996; 1: 301-396 Rubin R, Orris P, Lau SL, Hryhorczuk DO, Furner S, Letz R. Neurobehavioral effects of the on-call experience in housestaff physicians. J Occup Med. 1991; 33: 13-18. Waldron HA. Sickness in the medical profession. Ann Occup Hyg 1996; 40: 391-396.
B. A
43 Year-Old Male Long-Route Truck Driver
This is a pedagogically constructed Case, not based on any individual. Chief Complaint: Asymptomatic. Elevated BP and episodes of ST segment depression and complex ventricular arrhythmias, all appearing during work hours.
143
Medical History: These findings were detected as part of a surveillance field study of professional drivers. The patient has no current or past medical diagnoses, takes no medication and his tri-annual mandated cardiologic screening examinations have all been normal. (Casual clinic BP has been 130/80, HR=90, resting ECG was otherwise normal). The patient currently smokes on the average 20 cigarettes per day, (30 on work days, 10 on non-workdays), has no sport or physical activity, and consumes a diet high in saturated fat. He has a strong family history of hypertension among the males in his family (father and both grandfathers with onset in their mid-forties, and who also have all been professional drivers). He drinks 3-5 cups of coffee on workdays, and denies use of other stimulant substances. When at home on weekends and after work hours, he drinks 2-3 beers per day. Occupational History: See Part I of this Chapter.(p. 89) Physical Examination: Moderately obese and slightly anxious, cooperative male. Grade I hypertensive and atherosclerotic retinal arteriolar changes. Normal cardiopulmonary findings, and otherwise unremarkable physical examination. Casual Clinic Blood Pressure=135/85, in both arms. Body Mass Index (BMI)=30 (Weight=90 kg, Height 170 cm.) Laboratory: Total plasma cholesterol: 6.8 mmol/L , LDL=3.4 mmol/L (borderline normal) Serum triglycerides = 1.8 mmol/L (upper limit of normal) HbA1C = 5% of total hemoglobin (normal to 6%) Ambulatory BP and Holter monitoring during two 24-h periods: A workday and a non-work day: Work The work-recording period was fairly typical, driving time was between 22:00 and 01:00, from 6:00 to 10:00, and from 13:00 to 15:00. Sleep was between 1:30 and 5:00 in the cabin. Mean blood pressure (BP) during the entire recording period was 145/95 with minimal variation. Mean heart rate (HR) was 85/min. Horizontal ST segment depression >1.0 mm was recorded intermittently from 5:30 to 11:00; the total duration was 100 minutes, and the maximum depression was 1.5 mm in CMV5 occurring at 7:00, with HR of 95/min. During this episode of ST depression lasting 15 minutes, twenty multi-focal (mainly singlets, but three pairs) ventricular extrasystoles (VES) including R on T phenomena were recorded, and there was T wave inversion. 24-hour mean Heart Rate Variability (HRV) analysis reveals 80.2% low frequency (LF). In the 5-minute epoch immediately preceding the episode of ST segment
144 depression, there was 95% LF. The patient had drunk 2 cups of coffee at 5:30 and had smoked 5 cigarettes between 6:00 and 7:00. During heavy lifting between 11:00 and 12:00, blood pressure rose to 150/105, HR=85, maximum ST depression 1.0 mm in CMV5 with occasional unifocal VES. The patient had smoked three cigarettes during the waiting period prior to performing the heavy lifting. HRV index=17 (normal values – mean +/- sd = 37 +/- 15)
Non-work Non-work 24-hour recording, mean BP=140/85mmHg, 15 minutes total of ST segment depression to maximum of 1.0 mmHg, upon waking. Occasional single, unifocal VES (total number 21). HRV index=27 (normal values – mean +/- sd = 37 +/- 15) Bicycle Exercise to 175 Watts to HR=180/min. No STT changes or ventricular arrhythmias. BP at maximum exercise was 200/110 mmHg. Test stopped due to muscle fatigue. Echocardiogram at rest and during bicycle exercise: No wall motion abnormalities, posterior left ventricular and intra-ventricular wall thickness = 1.2 cm (Upper Limit of Normal=1.1), otherwise unremarkable. Glare Pressor Test: 10 mmHg increase in diastolic BP to 145/95mmHg, persists at Glare 1 and Glare 5, with progressively increased number of VES with consecutive glare impulses, no ST segment depression, mild flattening of T wave. Heart rate fell by 15 beats per minute to 70/min during the test. There were strongly positive Galvanic skin responses to each glare impulse. Behavioral Indices Spielberger Trait Anxiety Score= Type A Questionnaire Score= Type A Interview Score=
Healthy Professional Drivers 40 16 9
32.5 +/- 9.0 12.6 +/- 3.4 7.9 +/- 1.4
Questions: What are your diagnoses for this patient? What do you consider to be key modifiable workplace stressor(s) for this patient?
145 Describe some possible scenarios for this patient, if you were able to ameliorate these stressors, and what your next eventual steps would be for each. Is this patient at risk for sudden cardiac death? If yes, what are the potential environmental triggers and pathophysiologic mechanisms? If no, why not? Basic reading: Belkic K. Questions and answers concerning working life and health among truck drivers. The job stress network website: Center for Social Epidemiology (www.workhealth.org), 2000. Belkic K, Schnall P, Landsbergis P, Schwartz JE, Gerber LM, Baker D, Pickering TG. Hypertension at the Workplace—An occult disease? The need for work site surveillance. Theorell T (ed.) Biological Stress Mechanisms. Advances in Psychosomatic Medicine, Basel, Karger, 2001; 22: 116-138. Landau C, Nordlander R, Nyquist O, Schenck K. Coronary artery spasm—A case with fatal outcome. Scand J Thor CV Surg 1979; 13: 129-132 Supplementary Reading Akhras F, Jackson G. Raised exercise diastolic blood pressure as indicator of ischaemic left ventricular function. Lancet. 1991; 337:899-900. Apparies RJ, Rinolo TC, Porges SW. A psychophysiological investigation of the effects of driving longercombination vehicles. Ergonomics 1998; 41: 581-592. Belkic, K; Ercegovac, D; Savic, C; Panic, B; Djordjevic, M; Savic S. EEG arousal and cardiovascular reactivity in professional drivers. The glare pressor test. Eur Heart J. 1992; 13: 304-309. Belkic K, Emdad R, Theorell T. Occupational profile and cardiac risk: possible mechanisms and implications for professional drivers. International Journal of Occupational Medicine and Environmental Health. 1998; 11: 37-57. Belkic K. Cardiac electrical stability and environmental stress. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15 (1): 117-120. Belkic K. Myocardial oxygen supply and demand: Environmental triggers of imbalance. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15 (1):132-136. Belkic K. Ambulatory electrocardiographic monitoring: Stress-mediated, clinically relevant endpoints. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15 (1): 196-203. Devereux RB, Pickering TG, Harshfield GA, Kleinert HD, Denby L, Clark L, Pregibon D, Jason MN, Kleiner B, Borer JS, Laragh JH. Left ventricular hypertrophy in patients with hypertension: Importance of blood pressure response to regularly recurring stress. Circulation. 1983; 68: 476-479. Dilaveris PE, Zervopoulos GA, Psomadaki ZD, Michaelides AP, Gialofos JE, Toutouzas PK. Assessment of time domain and spectral components of heart rate variability immediately before ischemic ST segment depression episodes. PACE 1996; 19: 1337-1345
146 Emdad R, Belkic K, Theorell T, Cizinsky S, Savic C, Olsson K. Work environment, neurophysiologic and psychophysiologic models among professional drivers with and without cardiovascular disease: Seeking an integrative neurocardiologic approach. Stress Med 1997; 13: 7-21. Emdad R, Belkic K, Theorell T, Cizinsky S, Savic C, Olsson K. Psychophysiologic sensitization to headlight glare among professional drivers with and without cardiovascular disease. Journal of Occupational Health Psychology 1998; 3: 147-160. Emdad R, Belkic K, Theorell T, Cizinsky S. What prevents professional drivers from following physicians' cardiologic advice? Psychoth Psychosom 1998; 67: 226-240. Greiner BA, Ragland DR, Krause N, Syme SL, Fisher JM. Objective measurement of occupational stress factors-An example with San Francisco urban transit operators. J Occup Health Psychol. 1997; 2: 325-342. Kompier M, Di Martino V. Review of bus drivers' occupational stress and stress prevention. Stress Medicine 1995; 11: 253-262. Kremser CB, Rajfer SI. The normal cardiovascular response to exercise. In AR Leff (ed.) Cardiopulmonary exercise testing. Grune & Stratton, Orlando, 1986, pp. 107-121. Muller JE, Ludmer PL, Willich SN, Tofler GH, Aylmer G, Klangos I, Stone PH. Circadian variation in the frequency of sudden cardiac death. Circulation 1987; 75: 131-138. Nelson DE, Emont SL, Brackbill RM, Cameron LL, Piddicord J, Fiore MC. Cigarette smoking prevalence by occupation in the United States. J Occup Med 1994; 36: 516-525. Schnall PL, Landsbergis PA, Baker D. Job strain and cardiovascular disease. Annu Rev Public Health 1994; 15: 381-411. Schnall PS, Pieper C, Schwartz JE, Karasek RA, Schlussel Y, Devereux RB, Ganau A, Alderman M, Warren K, Pickering T. The relationship between "job strain", workplace diastolic blood pressure, and left ventricular mass index. Results of a case-control study. JAMA. 1990; 263: 1929-1935. Selwyn AP, Braunwald E. Ischemic heart disease. In: Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, Hauser DL, Longo D. Harrison’s Principles of Internal Medicine. 14th Edition. New York, McGraw-Hill, Inc., 1998, pp. 1365-1375. Ugljesic M, Belkic K, Boskovic D, Boskovic S, Ilic M. Exercise testing of young, apparently healthy professional drivers. Scand J Work Environ Health 1996; 22: 211-215. Winkleby, MA; Ragland, DR; Fisher, JM; Syme SL. Excess Risk of Sickness and Disease in Bus Drivers: A Review and Synthesis of Epidemiological Studies Int J Epidemiol 1988; 17: 255-262.
A 51-Year Old Clerical Assistant To The Director Of A University Cancer Research Division This is a pedagogically constructed Case, not based on any individual. C.
Chief Complaint: Chest pain
147 History of the Present Illness: About 3 years ago, the patient began to experience mid-sternal, post-prandial chest pain, accompanied by some regurgitation of food. Increased esophageal tone was found on motility study. She was treated with H2 receptor blockers and dietary advice was given. For about 1 year thereafter she was free of these episodes. However, despite following the medical and dietary regimen, and avoiding heavy evening meals, the chest pain recurred especially when she became upset. For the past year, episodes have become more frequent, up to 2-3 times per day, usually lasting about 30 minutes, and are also provoked by physical exertion. The quality of the chest pain has changed somewhat and is now described as heavy and pressure-like, radiating to the jaw. Past Medical History and Review of Systems: The patient has used oral contraceptives for 15 years (mainly progestogen-only) until two years ago when these were discontinued for sporadically high BP at Planned Parenthood Clinic Visits (range 130-150/85-95mmHg). She now uses an intra-uterine device, and still has regular menses. Occupational History: See Part I of this Chapter, p. 116 Family History: The patient’s mother has had high blood pressure since her early fifties. Social History: The patient is married, a non-smoker, and lives with her husband and two teenage boys, in a comfortable suburban home. She has no recreational physical activity, even walking is minimal; distances oblige her to drive for all errands. She performs most of the housework. Clinic Physical Examination: Moderately obese, somewhat anxious female. Arcus senilis. Funduscopic exam reveals grade II hypertensive and atherosclerotic retinal vascular changes. BP=150/95mmHg in both arms HR=90/min. Cardiopulmonary and remainder of the physical exam, except for abdominal obesity, were unremarkable. Laboratory: Total plasma cholesterol: 7.4 mmol/L, LDL=4.3 mmol/L (elevated) Serum triglycerides = 2.8 mmol/L (elevated) HbA1C = 8% of total hemoglobin (normal to 6%) Height=5’4” Weight=170 BMI=30 (moderately obese) T4=66 nmol/L (lower limit of normal), TSH=5.1mU/L (upper limit of normal). Bicycle Exercise Text to 150 Watts 1.3 mm horizontal ST depression in the anterior and lateral chest leads at maximal exercise accompanied by typical angina pain.
148 Coronary Angiography Morphologically normal epicardial vessels, ergonovine test shows no signs of epicardial coronary artery spasm Echocardiogram at rest and exercise Ejection fraction = 0.55 (lower limit of normal), Posterior left ventricular and intra-ventricular wall thickness = 1.4 cm (Upper limit of Normal = 1.1), all other chamber dimensions normal. 24-hour Holter and Ambulatory BP (AmBP) monitoring Paid working 24-hour period Normal sinus rhythm, average HR=85/min, minimum=55/min at 3 A.M., maximum 105/min at 7 P.M. Mean work AmBP=150/100, home=140/90, sleep=130/82 mmHg In CMV5 horizontal ST segment depression > 1.0 mm, was present during waking hours, on the average of 10 minutes per hour, with a maximum of 30 min/hour at 7PM, at which time the maximum depression was also seen (1.5 mm). This occurred while driving home in a traffic jam. There was an average of 10 ventricular extrasystoles/hour, maximum 30/hour, mainly singular, unifocal, but occasional VES pairs and multifocal VES, occurring together with ST segment depression. Two episodes of angina type chest pain at maximum and sub maximum ST depression. The patient had a typical workday. She awoke at 6:30 A.M., prepared breakfast for her family, drove 1 hour to work, which began at 9:00, and lasted until 6P.M. Heart rate index (HRV)=22 (normal values – mean +/- sd = 37 +/- 15) Home Normal sinus rhythm, average HR=78/min, minimum=52/min at 4 A.M., maximum 88/min at 3P.M. Mean waking AmBP=135/85, sleep=128/77 mmHg In CMV5 horizontal ST segment depression > 1.0 mm was present during waking hours, on the average of 2 min/hour, maximum 10 min/hour at 3 PM, at which time the maximum depression was also seen (1.1mm). There was an average of 5 ventricular extrasystoles/hour, maximum 12/hour, exclusively singular, unifocal. One episode of angina type chest pain occurred with maximum ST depression. The patient had a typical day at home with a minimum of driving around her neighborhood, and all exclusively outside rush hours. She awoke at 8 A.M fairly calm except in the midafternoon when she became upset with her son who wanted to borrow her car to go out with his friends about whom she did not have a good opinion. HRV index=25 (normal values – mean +/- sd = 37 +/- 15) Psychosocial Interview: Discussion of Problems with ECG and AmBP recording During neutral conversation at the beginning of the recording period: BP=130-135/85, HR= 85/min, horizontal ST depression no greater than 1 mm in V3 and V5. When describing how she felt when she learned that she had sent the wrong file (see narrative occupational history), horizontal ST depression to 1.5 mm, with T wave depression, BP 160/110 mmHg, HR=105/min. accompanied by chest pain. Similar findings were seen when discussing worries about her teenage son.
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Questions: 1.Which two syndromes would best account for the findings described? 2.How important do work-related stressors seem to be in the etiology and manifestations seen in this patient ? (Justify your answer). 3. Which findings are of particular concern? 4. Develop an integrated management plan for this patient, including workplace modifications, lifestyle changes, in addition to any pharmacological measures. 5. Which neuroendocrine marker(s) might be helpful to follow? Basic Readings: Belkic K, Landsbergis P, Schnall P, Baker D, Theorell T, Siegrist J, Peter R, Karasek R. Psychosocial factors: Review of the empirical data among men. . In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15 (1): 24-40. Fossum E, Hoieggen A, Moan A, Rostrup M, Kjeldsen SE. The cardiovascular metabolic syndrome. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15 (1): 146-150. Hlatky MA, Lam LC, Lee KL, Clapp-Channing NE, Williams RB, Pryor DB, Califf RM, Mark DB. Job strain and the prevalence and outcome of coronary artery disease. Circulation 1995; 92: 327-333. Kleiman NS. Angina pectoris in patients with normal coronary angiograms. In: Willerson JT, Cohn JN (eds.) Cardiovascular medicine. Churchill Livingstone, New York, 1995, pp. 375-389. Supplementary Readings: Brisson C, LaFlamme N, Moisan J, Milot A, Masse B, Vezina M. Effect of family responsibilities and job strain on ambulatory blood pressure among white-collar women. Pyschosom Med 1999; 61: 205-213. Laflamme N, Brisson C, Moisan J, Milot A, Mâsse B, Vézina M. Job strain and ambulatory blood pressure among female white-collar workers. Scand J Work Environ Health 1998; 25: 334-343. Siegrist J, Peter R, Georg W, Cremer P, Seidel D. Psychosocial and biobehavioral characteristics of hypertensive men with elevated atherogenic lipids. Atherosclerosis 1991; 86: 211-218. Taggart P, Gibbons D, Somerville W. Some effects of motor-car driving on the normal and abnormal heart. Br Med J. 1969; 4: 130-134
150 D. 47 year-old Male Auto Assembler This is a pedagogically constructed Case, not based on any individual. Two-weeks status post non-Q wave acute inferior myocardial infarction Medical History: The patient was previously in apparently good health, until 2 weeks ago, when on a Monday morning, at 9 A.M. at work after pushing heavy crates, he experienced a sudden onset of crushing substernal chest pain, which radiated down his left arm, associated with sweating and weakness. He was taken immediately to the nearest hospital (10 minutes away) and admitted to the coronary care unit. At that time there was marked ST segment elevation in the inferior leads and the MB fraction of CK was over two times greater than the upper limit of normal. Blood pressure was 165/110 mmHg, HR was 95/min, and there were frequent multifocal VES, mainly singular, but with occasional couplets. The patient was acutely treated with morphine and metropolol. Streptokinase was initiated 30 minutes after admission, and reperfusion ventricular tachycardia occurred 20 minutes thereafter, controlled with Lidocaine, which was continued for 2 hours thereafter. He was transferred out of the CCU after 24 hours, and remained hemodynamically stable throughout (Killip I--no signs of pulmonary or venous congestion), BP=125-130/75-85mmHg, with ambulation on Day 3. Overall, he had an unremarkable post-infarction 7-day hospital course without subjective complaints, on a regimen of Aspirin. Family history reveals that his father died suddenly at age 46. His mother is 90 years old, without major medical problems; he has no siblings. His four school-aged children are in good health. He lives with them and his wife in a 2 bedroom rented house. He has smoked 1 pack of cigarettes/day for 25 years, drinks 4-5 beers on the weekend, and does not engage in recreational physical activity. He finished 2 years of high school and is employed as a factory worker. Occupational History: See Part I of this Chapter, p. 136. Coronary Angiography performed on Day 5 of Hospitalization: Findings at site of presumed MI: TIMI grade 2.5 (nearly complete reperfusion of the Left ventricular branch of the Right coronary artery). Otherwise, there was insignificant coronary artery disease, (no luminal narrowing >75% in the major coronary arteries, nor >50% in the LAD). Radionuclide ventriculography at rest and exercise performed on Day 6 of Hospitalization: Ejection fraction =0.65, no perfusion defects, normal wall motion. 24-hour Ambulatory Monitoring Day 6 of Hospitalization:
151 Three lead ECG reveals normal sinus rhythm, average HR=75/min, maximum = 90/min, minimum =50/min, rare single, unifocal VES (maximum 10/hour). No STT changes. Heart Rate Variability Index = 22 (Normal +/- sd = 37 +/- 15)
Clinical Examination Day 7 of Hospitalization: Physical exam: Moderately obese, cooperative patient who looks somewhat older than his stated age. Grade II atherosclerotic retinal changes Increased expiratory phase of respiration and occasional expiratory wheezes, Normal cardiac findings Mild discomfort elicited by range of motion of the right elbow and wrist, superficial varicose veins in both lower extremities, without signs of inflammation. Otherwise normal physical exam, BP=130/80 mmHg in both arms. Height=5’5”, Weight=180 lbs., BMI=30 Resting 12 lead ECG: Sinus rhythm HR=70, Entirely normal. Signal averaged ECG: Root mean square voltage of the terminal 40 ms = 20 microV. (Borderline finding with respect to late potentials)
Laboratory: --Fibrinogen 500 mg/dL (normal to 400) --HDL Cholesterol = 0.8 mmol/L (undesirable <0.9mmol/L) --LDL=4.1 mmol/L (borderline elevated 3.4-4.1 mmol/L) --Triglycerides=2.0 mmol/L (normal < 1.8 mmol/L) --Hemoglobin A1c= 7% of total Hb, (normal to 6%) Chest X-Ray Increased broncho-vascular markings at the bases, otherwise normal. Pulmonary Function: --Reduced FEF25-75% Exercise test Day 7: Bicycle exercise to 150 Watts, with BP=180/80mmHg, HR=150/min. no STT changes, arrhythmias or chest pain. Stopped due to leg fatigue.
152 The patient was discharged on aspirin, and was referred to a smoking cessation clinic, and to a cardiac rehabilitation program with graded physical exercise and dietary counseling. The patient presents to the Occupational Medicine Department to obtain approval for return to work. Questions: 1. How do you interpret the patient’s clinical / risk status based upon the information presented thus far? 2. Review the occupational history and enumerate the potentially cardionoxious factors to which the patient is exposed. 3. How would you proceed with the evaluation? 4. Describe a number of possible outcome scenarios, and how you would proceed for each of these. 5. Should this patient return to the same working conditions as prior to the MI? How would you justify your decision to colleagues, supervisors and administrators, insofar as it deviates from usual clinical practice? Can you draw a parallel with the established approach to a patient with occupational lung disease, which would strengthen your argument?
Basic Readings: de Gaudemaris R. Clinical issues: Return to work and public safety. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15 (1): 223-230. Theorell T, Perski A, Orth-Gomér K et al. The effects of the strain of returning to work on the risk of death after a first myocardial infarction before age of 45. Int J Cardiol. 1991; 30: 61-67.
Supplementary Readings: Belkic K, Savic C, Theorell T, Cizinsky S. Work stressors and cardiovascular risk: Assessment for Clinical Practice. Stress Research Report Number 256, IPM, Section for Stress Research Karolinska Institute and WHO Psychosocial Center, Stockholm, 1995. Belkic K. Ambulatory electrocardiographic monitoring: Stress-mediated, clinically relevant endpoints. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15 (1): 196-203. Blake LM, Goldschlager N. Risk stratification of potential sudden death victms after myocardial infarction. Prim Cardiol 1995; 21: 8-15.
153 Denolin H, Feruglio GA, Gobbato F, Maisano G. Guidelines for return to work after myocardial infarction and/or revascularization. Eur Heart J 1988; 9 (Suppl. L): 130-131. Dilaveris PE, Zervopoulos GA, Psomadaki ZD, Michaelides AP, Gialofos JE, Toutouzas PK. Assessment of time domain and spectral components of heart rate variability immediately before ischemic ST segment depression episodes. PACE 1996; 19: 1337-1345 Fine L. Chemical and physical factors. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15 (1): 18-24. Hoffmann A, Pfiffner D, Hornung R, Niederhauser H. Psychosocial factors predict medical outcome following a first myocardial infarction. Working Group on Cardiac Rehabilitation of the Swiss Society of Cardiology. Coronary Artery Disease 1995; 6: 147-152. Kavanagh T, Matosevic V. Assessment of work capacity in patients with ischaemic heart disease: methods and practices. Eur Heart J 1988; 9 (Suppl L): 67-73 Landsbergis PA, Cahill J, Schnall PL. The impact of lean production and related new systems of work organization on worker health. J Occup Health Psychol 1999; 4: 1-23.
Peters RW, McQuillan S, Resnick SK, Gold MR: Increased Monday incidence of life-threatening ventricular arrhythmias: Experience with a third-generation implantable defibrillator. Circulation 1996: 94: 1346-1349. Rozanski A, Bairey CN, Krantz DS, Friedman J et al. Mental stress and the induction of silent myocardial ischemia in patients with coronary artery disease. N Engl J Med. 1988; 318: 1005-1012 Russell RO, Abi-Mansour P, Wenger NK. Return to work after coronary bypass surgery and percutaneous transluminal angioplasty: Issues and potential solutions. Cardiology 1986; 73: 306-322.
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Assessment And Approach To Management: Answers To Questions From The Cases A. A 54-Year Old Neurologist-Psychiatrist Working In A Public Hospital Assessment: Paroxysmal Supraventricular Tachycardia (PSVT) (likely AV nodal reentrant type), and work-related elevated BP (not controlled by current medication although clinic BP is within normal limits), some signs of burn-out and depression, likely precipitated by life event (death of spouse), and exacerbated by exposure to severe psychiatric pathology, together with heavy additive burden of exposure to work stressors, plus performing a large amount of un-paid work at home. The single episode of post-arrhythmic ST depression was likely triggered by hypo-perfusion.
Possible Management Scenarios and outcomes for this patient Clinical Treatment and Standard Risk Factor Intervention only Long work hours with heavy total burden of paid and unpaid labor leave no time for recreational physical activity. The patient admits using smoking and coffee in order to be able to function and also to combat feelings of depression. Her own efforts to quit smoking are ineffective, creating frustration and further exacerbate psychological distress. Enalapril is replaced by Beta-blockers (propranolol), but these exacerbate lipid status, depression, and bronchospasm. Amelioration of total burden, life style changes and medication optimization Work related changes are suggested by the clinician together with the patient, and are implemented. These include devoting more time to teaching, with a lowered case burden, avoiding severe psychiatric trauma cases, and emergency work. Her work is limited to the daytime shift, maximum of 7-8 hours per day, 5 days per week, and regular, scheduled rest breaks are included. While she does not take on a leadership role in efforts to improve the overall work environment, she participates in discussions with and encourages those colleagues who do so. She also schedules short vacations at regular intervals, and takes 1 to 2 free days periodically. She is encouraged to allow her daughter and son-in-law to take on a greater load of the household chores. Beta-blockers are tapered off and replaced by slow-release Verapamil 120 mg/day p.o. on non-work days, 180/mg/day p.o. on workdays.
155 She joins a hospital-based folk dance group, to improve social life, physical activity, mood and a smoking-cessation group for professional women (on work time) and limits coffee intake to 1-2 cups in the morning. Scenario A: (BEST CASE) Repeat Holter and AmBP monitoring on a working day, with the new work and medication regimen and life-style changes, reveals 1 run of PSVT lasting 90 seconds, which subsides spontaneously. Mean PAC 25/hour. No other ECG abnormalities, average HR=84/min. Mean work AmBP=130/83, home=125/80, sleep=120/78mmHg. Scenario B: Cardiovascular changes persist despite medication, during work only: The patient needs to eliminate clinical work, and do teaching exclusively. Signs of depression and burnout worsen: short-term cognitive-behavioral psychotherapy and selective serotonin reuptake inhibitor medication are initiated. Scenario C: PSVT during work and non-work, worsen after interventions of B. The patient is referred to an cardiac electrophysiologist, who diagnoses AV nodal reentrant tachycardia and recommends catheter ablation, to which the patient consents. The procedure is successful; AV nodal conduction is maintained. With the workplace and life style changes outlined for scenario A, and treatment with Enalapril 5mg/d, average work AmBP work is 133/84, home=130/82, sleep=125/80 mmHg, and there are no episodes of PSVT, despite the occurrence of occasional PAC. Recommendations to the Hospital and Policy Makers: Surveillance reveals that many other physicians and health professionals are also showing occult workplace hypertension and signs of burnout. A task force to improve patient care and working conditions is established, with policy-making authority. Physicians, nurses and other health professionals together with hospital administrators and policy makers are included. Priorities are to increase financial resources allocated for diagnostic equipment and patient care, improve salaries for health-care professionals and to work organization. ********************************************************************* B. 43 Year-Old Male Long-Route Truck Driver This patient was referred to the cardiologist because of electrocardiographic and hemodynamic abnormalities indicative of occult workplace hypertension (Belkic 2001) with signs suggesting transient myocardial ischemia together with possible cardiac electrical instability. These were detected during ambulatory monitoring on a working day. Being asymptomatic, had he not been part of a worksite surveillance program, it is unlikely that a person such as this would have come to the attention of a cardiologist. This underscores the fundamental importance of recognizing and screening high-risk occupations and worksites. The occupational history reveals that, as a professional driver, this patient’s job falls into the high-risk category for hypertension and for ischemic heart disease (Belkic 1998, van Amelsvoort 1995). The work is a characteristic threat-avoidant vigilant occupation. Thus, not only are high levels of sustained attention required for reasons of safety, but this exigency, in
156 turn, appears to have an untoward effect upon the cardiovascular system. This patient faces extra hazards by driving on poorly lit undivided roads, under untoward weather conditions, and he has been in a night driving accident related to glare exposure. Having witnessed many fatal accidents further heightens the threat-avoidant vigilance of his work. He drives long, irregular hours, including night shift and early A.M.; these are key, potentially modifiable workplace risk factors. Due to poor cabin isolation, he is likely to be exposed to increased levels of carbon monoxide. The psychological demands of the job are further increased by having to drive the triple A-dolly trailer (Apparies 1998). The overall burden of potentially cardio-noxious work stressors is very high, even for a professional driver, as quantified by the total OSI score of 72. Other quantitative assessments of psychosocial workplace stressors relevant to the cardiovascular system, reveal the presence of Effort Reward Imbalance and a borderline finding concerning exposure to self-reported job strain. The latter reflects the discrepancy between the objective nature of professional driving (clearly high strain), but the difficulty by which the high demands and low control are operationalized using generic versions of self-report instruments to assess job strain (Belkic 1996, Emdad 1997). The finding of greatest clinical concern is the early morning episode of ST segment depression to 1.5 mm and T wave inversion, with a large number of multifocal VES showing R on T phenomena. The acute triggers to this episode are most likely smoking and caffeine during the vulnerable early morning period (Muller 1987), after sleep deprivation and fatigue from night driving. A milder degree of ST segment depression with occasional unifocal VES, was also seen during heavy lifting, again after smoking. The underlying substrate for these abnormalities is an increased myocardial oxygen demand due to work-related elevated BP and HR, together with a borderline increase in left ventricular mass, also likely related to elevated work AmBP (Devereux 1983, Belkic 2001, Schnall 1990, Schwartz 2000b). Besides elevated BP and smoking, several other modifiable cardiac risk factors are present in this patient, including obesity, sedentary leisure activity, and high fat diet. The lipid profile indicates borderline elevations of triglycerides and LDL cholesterol. The patient has a strong positive family history of hypertension, but also a shared exposure to professional driving among these family members. There are no clear signs on functional diagnostic testing indicative of coronary artery disease. Bicycle exercise testing is remarkable only for the elevated diastolic BP, a frequent finding among professional drivers (Ugljesic 1996), whose precise significance is as yet undetermined, but which according to some authors may be associated may be associated with risk of hypertension (16) and risk of IHD (Akhras 1991). It should also be recalled that the overall sensitivity of exercise stress electrocardiography is approximately 75%, although triple-vessel disease or left main coronary artery disease is highly unlikely in the face of a negative exercise test (Selwyn 1998). Wall motion at rest and during exercise is normal on echocardiogram. The glare pressor test suggests sensitization to glare, with a marked rise in diastolic BP and conditioned ventricular arrhythmias (Belkic 1992(b), Emdad 1998(b). The galvanic skin response, together with the clinical observation and the behavioral indices, suggests behavioral arousal with some degree of anxiety and coronary-prone attributes; the scores being quite typical for professional drivers (Belkic 1998).
157 Overall, it can be said that this is an at-risk patient, possibly a candidate for becoming a victim of Karoshi (Shimomitsu 2000), but as yet seemingly in a “pre-pathologic state”, and for whom an intensive preventive program could be of substantial benefit. Without insight into his occupational endeavor, this would be aimed at standard cardiac risk factors (SCRF): smoking cessation, weight control, exercise etc. However, it is of crucial importance to understand that, particularly among this cohort, these standard risk factors are intimately linked to the occupational burden, and that efforts to modify the SCRF have shown modest success without concomitant amelioration of that occupational burden (Belkic 1996, Emdad 1998a, Fisher 2000, Ugljesic 1992). Truck drivers are among the occupational groups in the U.S. with the highest smoking prevalence (Nelson 1994). In this patient, we have several specific indications of the strong relation between SCRF and work activity: He smokes three times as many cigarettes on work compared to non-work days, his meals on work days are eaten at irregular intervals and his long and irregular work hours make an exercise program difficult to follow. It should also be noted that, while randomized controlled intervention studies are still lacking, observational data indicate that improvements in the work environment i.e. amelioration of job strain, are associated with a significant drop in ambulatory blood pressure at work, especially among those with work-related hypertension (Schnall 1998). Possible management scenarios and outcomes for this patient: Interventions aimed only at the standard cardiac risk factors Health promotion efforts aimed at smoking cessation, exercise and low-fat diet are undertaken, but are ineffective. The patient fully understands the importance of these measures, but is unable to carry of them out while continuing with the above-described work regimen. He explicitly states that without smoking, he would be unable to drive for these long and irregular hours. An integrated intervention program with amelioration of work stressors coupled to SCRF Scenario (a) (BEST CASE) A regular, early afternoon shift lasting no longer than 6 hours becomes available. This is a shift that the patient prefers, and would entail driving on shorter routes with a smaller truck, and without heavy lifting. A trial of these new working conditions is begun and 24-h monitoring reveals that mean work BP is 138/90 mmHg; there are no STT changes and occasional singular, unifocal VES are recorded. The patient is enrolled in a smoking cessation program on company time. Family dietary advice is implemented, and the patient eats his meals at home at regular times, with a light breakfast, an early lunch and a light dinner after work. He carries with him a low calorie, low fat snack for break time during work. He begins a regular physical exercise routine, including swimming twice per week. The patient has a solid network of family, friends and colleagues, who support (and often join) him in these health promotion efforts. At 6-month follow-up, he had lost 5 kg. and had quit smoking. Ambulatory monitoring which included a working day revealed a mean BP of 135/85.
158 Scenario (b) The measures described in Scenario (a) are implemented, but the blood pressure and STT changes persist. A more aggressive medical work-up is undertaken. A thallium 201exercise test reveals a small reversible apical perfusion defect. Coronary angiography reveals a subtotal mid-proximal stenotic lesion of the Left Anterior Descending (LAD) coronary artery. Ergonovine test is negative. Percutaneous transluminal coronary angioplasty (PTCA) is performed. With careful, regular medical follow-up and pharmacologic measures, the patient returns to work according to conditions described in (a). Findings on ambulatory monitoring during work are normalized. Scenario (c) The scenario described in (b) above, except that the ergonovine test during coronary angiography provokes coronary artery spasm at multiple sites of the LAD and circumflex arteries. One month after PTCA, ambulatory monitoring on a workday, with the patient on aspirin and calcium antagonists, reveals several episodes of ST segment depression to 1.5 mm in CMV5, coupled with complex ventricular arrhythmias. The patient admits that he feels uncomfortable and anxious when driving a truck, and prefers his earlier work as a cabinetmaker. The clinician supports the patient’s suggestion to change to a lower risk job. Recommendations to the Company:
This case, together with others from the surveillance program, indicates that long, unphysiologic and irregular work hours with excessive waiting times are associated with untoward cardiovascular changes, including a high prevalence of occult workplace hypertension. A team of truck drivers from the trade union together with management, occupational health psychologists, and cardiologists propose a plan to regularize and shorten the work hours and improve organization to minimize the long waiting times. This is coordinated with health promotion efforts aimed at smoking cessation, exercise and nutrition. Discount tickets for the local swimming pool are made available, and groups of coworkers, and their families make this a regular part of their weekly activity. ***********************************************************************************
C. A 51-Year Old Adminstrative Assistant At A University Cancer Research Division The findings are consistent with Syndrome X (microvascular angina pectoris with likely subendocardial ischemia) (Kleiman 1995) and Cardiovascular Metabolic Syndrome. Evidence for the former include: --the occurrence of esophageal spasm, which is part of the syndrome, --chest pain with electrocardiographic signs of ischemia during exercise and emotional stress, but without epicardial coronary artery stenosis --borderline low ejection fraction, which is typical and of concern. Abdominal obesity, hypertension, glucose intolerance and hyperlipidemia are clearly present as typical of the Cardiovascular Metabolic Syndrome (Fossum 2000). Increased blood viscosity might be contributing to the episodes of myocardial ischemia. The increased left ventricular
159 mass index is of particular concern. Ambulatory blood pressure is highest during work, as are the severity of ischemic episodes. The psychosocial interview indicates that work-related problems and mistakes (subtlely present threat-avoidant vigilance) are potent triggers of untoward hemodynamic changes leading to myocardial ischemia in this patient, as are family problems to a slightly lesser extent. The patient is exposed to job strain and a heavy total burden; these are likely to be both directly and indirectly (sedentary lifestyle, obesity) affecting her clinical status. Interventions are needed in both the domains of paid and unpaid work. A number of reasonable suggestions have been made by the patient. A carefully graded exercise program and weight reduction are also needed. Calcium-channel antagonists together with nitrates would be reasonable pharmacologic measures. Since the key mechanism for the Metabolic Syndrome is increased sympathetic outflow, catecholamine excretion could be followed as a marker of the stress response. Finally, the stress of commuting should be taken into account (note triggering of the most severe ischemic episode), and could justify telecommuting, carpooling or use of public transportation if available, as possible options. ***********************************************************************************
D. 47 year-old Male Auto Assembler The patient had an excellent outcome from the acute episode. He is clinically stable, and the extent of damage to the myocardium appears to be minimal. However, risk parameters of concern include: --The presence of multiple standard cardiac risk factors: smoking, obesity, adverse lipid profile, evidence of glucose intolerance, sedentary leisure activity, and positive family history--father’s sudden cardiac death at age 46. In-hospital blood pressure, however, apart from BP on admission, was normal. --Low HRV index and possible presence of late potentials, associated with increased risk of life threatening ventricular tachyarrhythmias and sudden death post-myocardial infarction. --High fibrinogen level --History of father’s sudden cardiac death at age 46 Furthermore, his socio-economic level appears to be quite low, and this, in itself is associated with increased risk of CHD, independently of the SCRF (Marmot 2000). The patient could not benefit from the protective effects of beta-blockade, as these would not be appropriate due to his metabolic status, and a possible tendency towards bronchospasm. (The lipid profile should be repeated several weeks post-MI, since these will still have been depressed on Day 7.) His job is likely to have played an important etiologic role in the development of an acute myocardial infarction at a relatively young age. Potential contributory factors include: paced factory work with exposure to job strain exacerbated by the introduction of lean production with speed up and group piece rate pay, job insecurity and effort-reward imbalance, long work hours, exposure to cardio-noxious physical and chemical agents, and some requirements for threat avoidant vigilance.
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In addition to the standard cardiologic work-up (as performed during the hospitalization), an occupational cardiologic approach to evaluating return to work after myocardial infarction may be appropriate. A possible approach is outlined in Figure 5.2. This could begin by performing Functional Diagnostic Testing in the laboratory. This could entail continuous electrocardiographic recording and blood pressure measurement during exposure to as many of the relevant physical factors as possible. For this patient these include: --Heavy lifting or isometric handgrip --Noise --Heat --Cold --Solvents and other acutely cardionoxious chemicals --Hand-arm vibration In addition, cardiovascular monitoring could be performed during a psychosocial interview while the patient discusses and reenacts painful, difficult or dangerous aspects of work. The results of the laboratory testing may help identify cardio-deleterious factors for this patient, and might thereby help guide a decision about return to work. Insofar as Functional Diagnostic Testing were normal, a monitored trial of return to work might be undertaken, if the patient so desires and which is the case here. Holter and AmBP monitoring would best be performed on the hardest working day, as well as on the 24-hours from Sunday to the Monday working day. (In shift workers, we recommend recording on the night shift and all non-standard schedules). Given the circumstantial evidence that isometric stress may have triggered the patient’s MI, it seems prudent to limit that kind of activity for this patient, even if the functional diagnostic testing were normal. Furthermore, the patient should not work overtime. The monitoring record should be carefully reviewed with respect to occult workplace hypertension, increased double product, signs of myocardial ischemia and
FIGURE 5.2 A New View for Considering Return to Work after Acute Myocardial Infarction in Patients with a Stable Clinical Profile Evaluation of Work-Place Exposures using Continuous ECG and BP monitoring
161
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162 163 cardiac electrical instability, and the temporal course of HRV and of the QT interval evaluated. Combined abnormalities are particularly important. The patient diary of symptoms and activities (including transient work exposures) is invaluable. Even if all the findings on ambulatory monitoring are entirely normal, regular follow-up with repeat monitoring at work is imperative. This approach is still not part of the standard of cardiologic care. However, it is quite analogous to that taken in some sub-specialties, most notably, pulmonary medicine with respect to airborne workplace exposures. Dialog and cooperation among occupational medicine specialists, pulmonologists and cardiology, together with randomized clinical trials could help determine whether this approach could be helpful for working patients with respect to return to work after an acute myocardial infarction.
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Chapter 6
The Revised OSI Questionnaires and Score Sheets In this Chapter, we present the revised version of the Generic OSI, as well as the revised versions of the OSI for Professional Drivers and for Physicians. We also present the OSI for teachers, which is entirely compatible with the other three. The questionnaires are accompanied by scoring sheets that provide detailed instructions as to how to code each element of the respective OSI1. We have strived to make these instructions as standardized as possible, and as such, for most of the elements, automatic or computerized scoring can be done. However, there are a few circumstances for which the rater’s judgment is required. In such cases, we describe in detail the items to be taken into consideration. Nevertheless, there could be some, albeit fairly minor, disagreement as to the score for a given element. Obviously, principles of good research, such as blinded rating, if possible by more than one observer, should be applied in these cases. The process of revising the OSI model has been on-going over several years, and is the result of multi-facetted considerations. The development of the specific OSI’s has been one of the most important of these, whereby new questions relevant to a certain occupation are found to reflect issues of general relevance. For example, in reviewing major stressors for physicians: the possibility of malpractice litigation, or the need to appear in court as an expert witness, it became clear that while the likelihood is perhaps less for many other occupations than for physicians, testifying in court in relation to work, either as a defendant or as a witness should be included as an element in general symbolic aversiveness (GAVOI3). Several key general or macro-level stressors were not in the earlier version of the OSI model. These include job security, adequacy of pay, as well as influence over larger issues such as institutional policy and lack of buffers such as unions/collective control (Johnson 1995, Karasek 1979, Siegrist 1996). We have now added lack of monetary reward, of possibilities for upgrades or promotion, and lack of recognition for good work as general factors contributing to under load. We have also expanded the number of items for strictness2 on the general level, to include influence over work schedule, taking time off, with whom one will work, what one’s work tasks will be, as well as over policy. The number of elements in the conflict aspect on the general level has also been expanded, and includes considerations of job security, opposition to career advancement, violations of norms of behavior/abuses of power, lack of redress for grievances 1
The reader should note that the narrative histories and clinical cases presented in the previous chapter were based upon older versions of the OSI’s. The revised questionnaires and scoring sheets are presented for the first time here. 2 Recall, as noted in Ch. 4 that the strictness dimension had previously shown quite low internal consistency. This may be remedied by a more comprehensive assessment of areas in which the worker has influence.
164 and lack of instrumental support and coherence of work tasks. It should however, be pointed out that queries are phrased somewhat differently from those e.g. in the Effort-Reward Imbalance instrument (Siegrist 1999). For example, in the OSI the respondent is asked whether good work is recognized at the workplace (GU4), not whether one’s own good work is recognized. In this way, an attempt is made to obtain a more neutral assessment of the workplace by avoiding the use of the first person. All the elements that have been added to the revised OSI are indicated on the Generic OSI scoring sheet. We have also revised a number of the questions to correspond to a 4-point Likert scale, still keeping to the original scoring from 0 to 2 for all elements. The coding scheme has been changed in other ways for a few of the elements, such as lack of rest breaks and irregular schedules and night shift work, as noted on the Generic OSI scoring sheet. There are three major ways in which the scoring of the Generic and the specific OSI’s, differ. We have previously mentioned two of these: the unchanging characteristics of a given occupation that are assigned a fixed score, and those variable features that can be operationalized according to the specificities of the occupation. The third is that the range of possible scores could be narrowed. For example, there is some variation in the degree to which professional drivers perform hazardous tasks, e.g. carrying explosive cargo, driving on winding narrow roads, or in areas where the threat of violence is high, but even without these extra dangers, there is a certain amount of underlying hazard inherent in driving itself. Therefore, the possible range for OAVOIT is from 1 to 2 in the Driver OSI. The reader will also notice that the questionnaires contain more information than is incorporated into the OSI framework. This can be used for more detailed analyses, especially in identifying modifiable stressors specific for a given occupation. The open-ended questions at the end of each questionnaire fall into this category, and, in our experience, provide invaluable insights when reviewed systematically using content analysis (Belkic 1996, Emdad 1998(a)). Needleman and Needleman (1996) have emphasized the particular utility of qualitative methods in occupational intervention research.
*************************************************************************** Permission to use any of the OSI instruments should be obtained from this author3. This can be done electronically, to:
[email protected]. Our policy is to provide permission free-ofcharge for all research endeavors aimed at improving the job conditions and health of working people. We will be happy to answer questions concerning its application, and to discuss how the OSI might be best implemented in a given setting. All emerging publications using the OSI should acknowledge permission from the author and should cite the appropriate bibliographic references. *************************************************************************** 3
Insofar as the language to be used is other than English, please apply the Translation-Back-Translation methodology (Brislin 1973), and inform this author, when requesting permission.
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Revised Version of the Generic OSI, 2002-2003. Use of this questionnaire requires the permission of the author, Dr. Karen Belkic. This was granted to: ___________________ (Investigator) on _______________________
(Date)
INFORMATION ABOUT THE WORKPLACE
*************************************************************************** This questionnaire is designed to assess working conditions on your job, with the aim of finding ways to create a healthier work environment. It is being applied in the international context and therefore, contains elements that are relevant in a broad range of settings. Please read each question carefully, and unless otherwise indicated, choose the best single answer. Feel free to write any comments that you may have, and to use as much space as you would like. This questionnaire is handled entirely confidentially, without names or any other means of individual identification. Thank you for your Cooperation! Approval by the Regional Medical Ethics Committee/Institutional Review Board: Date________________ *************************************************************************** A. Length, Location and Terms of Work A1. What is your current job title? (Please be as precise as possible) _____________________________________________________ A 2. How long have you worked at your current job at the present site? _____ Years A 3. In which capacity are you employed? a) Full time position b) Part time position c) Temporary capacity d) Other capacity, please specify: _______________________________________
A 4. What is the total number of years that you have worked in your current occupation? ___________Years A 5.How long altogether have you been employed (in any type of work)? ________ Years
166 A 6. Have you worked in other occupations besides your current one? Yes If yes, what were your other jobs? (Please list these in chronological order with approximate dates) _____________________________ _____________________________ _____________________________
No
_____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________
*************************************************************************** Please answer the following for your work in the past year for your main job, unless otherwise specified B. Work hours and scheduling B1. How long does your workday usually last? ________ Hours Do you ever work longer than that? Yes No If yes, how days per month (usually)? ________ How many hours/day? ________ B 2. How many days do you work per week? _________ Days B 3. Do you have a regular work schedule? Yes No If yes, when do usually you begin work? _____________ End work: ________________ B 4. Are you called at home regarding your work? a) Never b) Rarely c) Occasionally d) Frequently B 5. How many weeks of paid vacation do you have per year? _______________ B 6. Do you work at another job outside your regular one? Yes No If yes, how many hours per week? _________ What do you do? ___________________ B 7. Do you have the opportunity to take breaks during your workday? a) Never b) Rarely c) Occasionally d) Frequently B 8. If you do have some breaks, are these usually: a) Short ones (less than 15 minutes) b) Long breaks (at least 30 minutes) c) Both short and long breaks
167 B 9. If you have some breaks, are these true rest breaks so that you can completely be free from work obligations? Yes No If no, why not: ___________________________________________ B 10. How long do you typically work, without being able to take at least a short, 5-10 minute break? _____ B 11. Do you work the late night shift (after midnight)? Yes No If yes, do you work the late night shift: a) Constantly. b) On a rotating basis. If b, how many nightshifts do you usually work per month? _____________/month How many free days do you usually have after working a rotating night shift? ____________ Days B 12. How difficult is it for you to take time off from work? a) Not at all b) A little c) Somewhat d) Very much B 13. How much say do you have about your work schedule? a) Complete, it is entirely up to me. b) To a large extent, I mainly decide on my work schedule. c) A little, but mainly my schedule depends on others, or is decided by others. d) None at all, my schedule depends on others or is decided by others; I have no say about it. B 14. Do you perform work for your job at home? a) Never b) Rarely c) Sometimes d) Frequently If c or d, did you include this time in calculating your work hours when you answered Questions B1-2 above? Yes No
C. Mode of Payment, Upgrading Possibilities and Evaluation of your Work C 1. My pay is: a) Based upon how much I myself work. b) Based upon how much my group or collective, as a whole, works. c) Fixed.
168 C 2. My salary: a) Covers substantially more than my basic needs and those of my family. b) Covers a bit more than my basic needs and those of my family. c) Just barely covers my basic needs and those of my family. d) Totally inadequate to meet my basic needs and those of my family. C 3. Are there possibilities for you to upgrade your job title/advance your career? Yes If yes, do you receive support and encouragement to do so? a) Definitely yes. b) Yes, to some extent. c) Not really, but there is no active opposition to such efforts. d) No, there is active opposition to such efforts.
No
C 4. How is your work evaluated? a) No one but me evaluates my work. b) A supervisor or other responsible person evaluates my work; there are no rigid standards and generally if it is done properly, it is accepted. c) A supervisor or other responsible person evaluates my work very carefully according to a strict standard. If, for any reason, even a minor one, it does not fully meet these standards, my work may be rejected. C 5. Is good work recognized at your workplace? a) Definitely yes b) Yes, to some extent. c) Not very much. d) Not at all.
D. Working Conditions D 1. Are you exposed to welding or any other strong lights / glare during work? a) Never b) Rarely c) Occasionally d) Frequently D 2. Is it noisy at your workplace? a) Yes, it is often very noisy so that I must raise my voice to be heard by someone right next to me. b) Sometimes it’s so noisy, that I must raise my voice to be heard by someone right next to me. c) It can be a bit noisy, but I can usually speak normally and be heard by someone next to me. d) No, my workplace is not noisy.
169 D 3. Do you perform heavy lifting during work? a) Never b) Rarely c) Occasionally d) Frequently If b-d, up to how many _______ kg. or (_______lbs.)? D 4. Are you exposed to vibration at work? a) Never b) Rarely c) Occasionally d) Frequently If b-d, what is the source of vibration? ________________________ D 5. How hot does it get at your workplace? a) Rarely or never hotter than 25° C (77°F) at work b) Rarely or never hotter than 30° C (86° F) at work c) It can get hotter than 30° C (86° F)(either working inside or outdoors), but never over 40° C (103°F) d) Extremely. It can get hotter than 40° C (103° F). D 6. How cold does it get at your workplace? a) Rarely or never colder than 20 ° C (68° F) at work b) Rarely or never colder than 18° C (64° F) at work c) It can get colder than 18° C (64° F) but not below 50° F (10° C) (either working inside or outdoors) d) It can get colder than 10° C (50° F) (either working outdoors or inside). D 7.Are you exposed to gases, mists or dusts at your workplace? a) Never b) Rarely c) Occasionally d) Frequently If (b-d), please list the chemicals to which you are exposed: __________ ______________ ______________ ___________ D 8. What is your body position and activity during work? a) I am constantly in motion, with no fixed body position. b) I mainly work in a single position, but I am free to move about. c) My body position is fixed during work, and my motion is restricted. If b or c, what is your body position during work? ________________________ D 9. Do you have your own desk or workspace?
Yes
No
170
D 10. Do you mainly work? a) Outside b) Indoors, but in more than one place or location c) Indoors, in one place or location If “c”, please answer the next five questions (D11- D15) about the work area: D 11. Are there windows at your workplace? a) Yes, there’s a window next to me, so I can look outside from where I work. b) Yes, but not next to me, so I can’t look outside from where I am working. c) No, I work in an office or work area without windows. D 12. Do you work in a a) Hall or large office? b) Small office or workshop? c) Cabin, or other very confined/closed area? D 13. Do other people, beside yourself, work in your office or workshop? a) No, I have my own office, workshop or cabin. b) Yes, I share my office, workshop or cabin with one other person. c) Yes, two to five other people work in same office or workshop. d) Yes, five to ten other people work in the office or workshop. e) Yes, more than ten other people work in the office, workshop or hall, where I work. D 14. How is the ventilation in your work area? a) Adequate b) Inadequate D 15. Is it drafty in your work area? Yes No ************************************************ D 16. Do you work in dangerous conditions? (Please check all that apply) a) Yes, I work on heights or in a workplace in which objects can fall on us. b) Yes, I work with flammable material. c) Yes, I am in danger of being physically assaulted. d) Yes, I am exposed to danger at work due to: ___________________________ e) No D 17. Do you see any visually disturbing scenes during work? a) Never b) Rarely c) Occasionally d) Frequently If b-d, what are these scenes? ______________________
171
E. Work Accidents, Injuries and Mishaps Please answer the following three questions (E1-E3) for all work experience in your current occupation E 1. Have you suffered physical harm or injury at work? Yes If yes, was this a serious injury? Yes
No No
What happened (very briefly)? ________________________________ E 2. Have you ever witnessed a serious accident at work? a) Yes, I have observed one or more accidents with a fatal outcome. b) Yes, I have observed one or more serious accidents, but I never witnessed a fatal outcome. c) I have heard about serious or fatal accidents at work, but never seen this. d) No, I have never witnessed or heard about a serious accident at work. E 3. Have you ever been obliged to testify in court in relation to your workplace? Yes If yes, was this (please check all that apply): a) As a witness b) As a defendant ********************************************************************* E 4. Is there a system in place at work in case of emergency? a) Yes, and I know that it functions properly. b) Yes, but I do not know how well it actually functions. c) No, there is not a functioning system in place in case of emergency.
No
F. Time Pressure at Work F 1. Do you have a deadline by which a given job or task must be completed? a) Never. b) Rarely c) Occasionally d) Frequently F 2. Must you speed-up your work tempo? a) No, it happens only rarely or never. b) Yes, during certain periods of the month or year. c) Yes, at least weekly, but not daily. d) Yes, every day. F 3. Can you control the speed at which you work? a) Absolutely, since I work completely independently. b) Mainly yes, since the speed at which I work doesn’t affect others very much. c) Only partially, since my work speed affects the work of others in my group. d) Not at all. I work on an assembly line/other paced system,without control over work speed.
172
F 4. With regard to your workload and time constraints: a) It is always possible to complete everything. b) It is usually possible to complete everything. c) It is sometimes impossible to complete everything, even with maximal effort. d) It is often objectively impossible to complete everything, even with maximal effort.
G. Problems, Constraints and Influence at Work G 1. If you encounter some dilemma during work, and are not certain how to proceed: a) I can always postpone a decision until the situation is clarified. b) I can usually postpone a decision until the situation is clarified. c) Sometimes I must act based upon the information I have at a given moment, and can't postpone the decision. d) Usually or always I must act based upon the information I have at a given moment, and can't postpone the decision. G 2. Can you get help for handling difficult situations or dilemmas? a) Yes, I can nearly always count on such help. b) Yes, more often than not. c) I can’t really count on getting such help. d) Rarely or never do I get the help, which I need. G 3. Do you listen to things that are emotionally disturbing as part of your work? a) Never b) Rarely c) Occasionally d) Frequently If b-d, what are these? ______________________ G 4. If you were to make a mistake during work, what are the most serious possible consequences? a) None at all. I can always correct the error. b) Fairly minor. I can usually correct the error. c) There could be irreparable material or other damage. d) The outcome could be fatal. G 5. Do you receive clear instructions and/or information concerning your work? a) Always. b) Usually c) Sometimes not. d) Frequently work instructions or needed information are unclear.
173 G 6. Does it happen that you don't receive all the needed instructions and/or information concerning your work? a) Never b) Rarely c) Occasionally d) Frequently G 7. What happens if you don't manage to remember or register some work-related information? a) No problem whatsoever. I can always easily find/retrieve the information. b) It’s usually not a problem; in most cases I can find/retrieve the information fairly easily. c) The information can't be retrieved, and sometimes it could have been important. d) The information can't be retrieved, and often the information is very important. I must therefore be very careful to register and remember the information when it is first presented. G 8. Do you receive conflicting/contradictory information or instructions about the work you should be doing? a) Never b) Rarely c) Occasionally d) Frequently G 9. Does it happen that due to unforeseen circumstances the plan of work changes? a) Never b) Rarely c) Occasionally d) Frequently G 10. Are you prevented from proceeding with your work because of external problems/glitches? (E.g. computer breakdown, faulty parts, lack of supplies, power failure.) a) Never b) Rarely c) Occasionally d) Frequently If c or d, what are the main problems that occur? ______________ __________________ _____________________ G 11. Do interruptions from other people (including work-related phone calls) prevent you from proceeding with your work? a) Never b) Rarely c) Occasionally d) Frequently
174 H. Description of your work tasks H 1. Please list each of the main work tasks that you perform (Fill in as many lines as you need) _______________________________________ _________________________________ _______________________________________ _________________________________ _______________________________________ _________________________________ _______________________________________ _________________________________ H 2. Please list the tools/equipment/apparatus (including computer) that you use during work. (Fill in as many lines as you need) _______________________________________ _________________________________ _______________________________________ _________________________________ _______________________________________ _________________________________ _______________________________________ _________________________________ H 3. Are your work tasks monotonous? a) Not at all. b) Mainly no, a given task usually has its particular qualities, so it's not exactly the same. c) Some of my tasks are monotonous, the same thing over and over again. d) Most of my tasks are monotonous, the same thing over and over again. H 4. Does it occur that during your work hours, you must be physically at work, but there is nothing to do? a) Never b) Rarely c) Occasionally d) Frequently H 5. How often do you perform different tasks simultaneously? a) Never b) Rarely c) Occasionally d) Frequently H 6. Do any of your tasks have to be performed with a particular speed? a) Not at all. b) Rarely. c) Some tasks require speed. d) Many or most of the tasks that I perform require speed: If (c) or (d), please list these: _________________________ __________________ ______________________ ________________________ __________________
175 H 7. Looking at all your work tasks together: a) I can see how they fit together and how they relate to the work of others, and the overall goals of my workplace. b) Some of my tasks fit together, but not all. I can vaguely see how they relate to the work of others, and to an overall goal of my workplace. c) My work tasks seem to be disconnected from each other, and I don’t see how they relate to the work of others, nor to the overall goals of my workplace. I. Supervising, Decision-making and Influence at work I.1 Do you supervise or oversee the work of others? a) Never b) Rarely c) Occasionally d) Frequently If (c) or (d), how many people do you oversee? ______ I.2. Do you make decisions at work or mainly carry out the decisions made by others? a) All the decisions have been made by others, I only carry out the tasks given to me, and make no decisions, not even about the smallest details. b) The decisions have been made by others. I don't decide even about the details. But my judgment is necessary during work. c) The major decisions have been made by others, but I can decide about the details. d) Sometimes I must make major decisions, and take the responsibility for these. e) My job is mainly comprised of making major decisions. I.3. If you answered d or e, give a typical example of a decision to be made: _______________________________ Describe (very briefly) the usual steps you take in the decision-making process: ________________________________________________________________ ________________________________________________________________ I 4. Must you make rapid decisions or quickly assess a given situation? a) Never b) Rarely c) Occasionally d) Frequently If (c) or (d), please very briefly describe these situations: ______________________ _____________________________ ___________________________________
176 I 5. Concerning conclusions that are decided upon at work: a) There is a very wide range of possible decisions that would be correct—lots of flexibility. b) There are several possible decisions that would be correct—some flexibility. c) There is a limited number of decisions that would be correct—limited flexibility d) There is usually only one correct decision to be made—no flexibility whatsoever. I 6. Is there a defined way of solving problems in your work? a) Not at all. I must think up the strategy myself in order to solve problems, and that always requires imagination and creativity. b) Basically not. I must often come up with a strategy on my own. c) Pretty much so. There are a few variations, but the basic strategy has already been defined. d) Very much so. There is a strictly defined strategy, which I must follow to solve problems for my work. How much influence do you have over: Major
Some
A little
None
I 7. Deciding with whom you work? I 8. What your work tasks will be? I.9. Planning and policy issues at your workplace? J. Interactions with People and with Machines J 1. Communication with other people during work: a) There is no need for work-related communication with others. b) From time to time, I must discuss or communicate with others in relation to my work. c) Communication with other people is a major feature of my work. J 2. Do you use gauges, meters or other such devices at your job? Yes No If yes, how many measuring devices do you use? ___ Please list these: ________________ _________________ ______________________ J 3. Do you oversee the work of one or more machines or automatic devices? Yes If yes, how many devices do you follow simultaneously? _____ Can you control the speed at which these devices operate? Yes No J 4. How many people do you have under your on-going care/responsibility at work? (e.g. pupils, patients, clients) a. None (or not applicable) b) One to five c) Six to ten d) Eleven to twenty e) Over twenty
No
177
J 5. With how many people do you interact daily at work (both fellow employees and the public)? a) None b) One to five c) Six to ten d) Eleven to twenty e) Over twenty J 6. How many work-related telephone calls do you receive during a normal working day? (Including calls that are meant for others) a) None b) One to five c) Six to ten d) Eleven to twenty e) Over twenty J 7. Does it happen during your workday that several people seek your attention at the same time? (Including people on the telephone) a) Yes, many times each day b) Yes, a few times each day c) Yes, but only once or twice each day d) No, rarely or never. J 8. If more than 1 person seeks your attention at the same time, how many persons do so? a) Two at the most b) Usually two, but sometimes more. c) Usually three or more J 9. For how many people at your workplace to you perform tasks? a) None b) One c) Two to three d) Four to ten e) Over ten J 10. In general, how is the social climate at your workplace? a) Excellent, we all get along very well together and misunderstanding are very rare. b) Good, most the time we get along well, with few misunderstandings and tensions. c) Fair, we have our ups-and-downs; sometimes there are misunderstandings and tensions. d) Poor, there is a great deal of tension and conflict.
178 J 11. Are there abuses of power or violations of norms of behavior at work? a) Never b) Rarely c) Occasionally d) Frequently J 12. Is there the possibility to redress grievances at work? a) Yes, this can be done in an efficient and confidential manner. b) In principle, yes, but this is either not effective or cannot be done confidentially. c) No, there is no possibility to redress grievances at work. K. Recent changes at work (Please answer the following questions for the last 6 months) Yes
No
Yes
No
K 1) Has there been an increase in the length of your workday? K 2) Has there been increased time pressure/deadlines? K 3) Have you had an increase in work responsibility? K 4) Have you been demoted? K 5) Has your pay been cut? K 6) Have you been promoted? K 7) Is there a threat that you will be laid off? K 8) Have there been other recent changes at work? If yes, please specify: L. Other Questions about your workplace:
L 1) Is there a trade union at your workplace? L 2) Are you employed at an equal opportunity workplace? L 3) Is there a pension-plan available at your workplace? L 4) Is health care coverage provided by your workplace
179 M. Some open-ended questions about your current work: M 1. What is the best part(s) about your job?
M 2. What is the most difficult aspect of your job?
M 3. What do you think could be done to make that difficulty less of a burden?
M 4. What could be done to improve working life at your current job? a) Immediately:
b) Long-term:
M 5. Which of these do you consider to be the most important?
M 6. If attempts were made to improve the conditions for your job, what would you suggest to preserve the good aspects of your work as it now stands?
M 7. Other comments:
180
REVISED GENERIC OSI SCORE SHEET
ID#: ______________________ A1.Job title4: ___________________ A2. ____ Years in current job at present site A3. Employment capacity 1=Full time position 2=Part time position 3=Temporary capacity 4=Other capacity: _____________________ A4. ____Years in occupation A5. ____Years employed A6. Former Jobs: __________________ _________________
_____ _________________
UNDERLOAD Homogeneous Information IU1 0 Heterogeneous information (H3=a or b (no monotonous tasks)) OR (H1=several tasks) OR (J2-9=interacts with persons or several machines) 1 Moderately homogeneous information (H3=c or d) AND [(H1= a few tasks) OR (J2-9=limited interactions with persons / few machines)] 2 Maximally homogeneous information (H3=d (monotonous tasks)) AND (H1=very few, simple tasks) AND (J2-9=minimal interactions with persons/few machines) Low frequency of incoming signals IU2 0 Controls speed him or herself (F3=a or b AND if J3=yes, controls speed of devices)) OR >1 new signal/minute (overall assessment, see especially J3-9) 2 Doesn’t control speed (F3=c or d, OR J3=yes and doesn’t control speed of devices) AND <1 new signal per minute (overall assessment, see especially J1-9) No need for communication IU3 0 J1=b or c (works with others)(Verify with J4-9) 4
Other items outside the explicit OSI framework (e.g. parts of K and L, as well as the open-ended questions) should be analyzed though not summed into the total OSI score
181 2 J1=a (No need for communication with others)((Verify with J4-9) Input underload total: IU1 + IU2 + IU3 Automatic decision-making CUT 0 Decisions not automatic (I2=c, d or e) OR some supervisory work (I1=b, c or d) 1 Fairly automatic decisions but judgment required (I2=b) AND No supervisory work (I1=a) 2 Fully automatic decisions (I2=a) AND no supervisory work (I1=a) Central Underload Total: CUT Homogeneous Tasks OU1 0 H3=a or b (Heterogeneous tasks) 1 H3=c (Fairly homogeneous tasks) 1.5 H3= H3=d (Homogeneous tasks) AND H1=three or more tasks] 2 H3=d (Homogeneous tasks) AND H1=two or fewer tasks Simple Tasks OU2 0 Several steps (assessed from H1 & H2) 2 Few steps in tasks (assessed from H1 & H2) Nothing to do OU3 0 H4=a (Always something to do) 0.5 H4=b (Rarely nothing to do) 1 H4=c (Occasionally nothing to do) 2 H4=d (Frequently nothing to do) Output Underload Total: OU1 + OU2 + OU3 Fixed Pay GU1 0 C1=a or b (Based upon amount of individual or group work) 2 C1=c (Fixed pay) Inadequate Pay5 GU2 0 C2=a (Covers substantially more than basic needs) 0.5 C2=b (Covers a bit more than basic needs) 1 C2=c (Just barely covers expenses) 5
Added as new element to general under-load
182 2 C2=d (Totally inadequate) Lack of Promotion Prospects6 GU3 0 C3=Yes + a, b, or c (There are possibilities to upgrade job title or advance one’s career, and no active opposition) 1 C3=Yes + d (There are upgrade possibilities, but active opposition) 2 C3=No Lack of Recognition of Good Work7 GU4 0 C5=a (Definitely yes) 0.5 C5=b (Yes, to some extent) 1.5 C5=c (Not very much) 2 C5=d (Not at all) General Underload Total: GU1+GU2 + GU3 + GU4 Input Underload Total + Central Underload Total + Output Underload Total + General Underload Total = Total Underload Score HIGH DEMAND Three or more information sources simultaneously IH1 0 Not >2 sources simultaneously (H5=a or b AND I1=a or b, see also J3-9, and make an overall assessment) 2 Three or more sources simultaneously (H5=c or d OR I1=c or d, see also J3-9, and make an overall assessment) Heterogeneous information IH2 0 Homogeneous information (H3=c or d) AND [(H1=a few, simple tasks) AND J2-9=Limited or minimal interactions with persons or few machines)] 1 Moderately heterogeneous information (H3=a or b) AND [(H1=up to 5 tasks) OR (J2-9=some interactions with persons or machines)] 2 Maximally Heterogeneous information (H3=a or b) AND [(H1=over 5 tasks) OR (J2-9=many interactions with persons or several machines)] Heavy Burden on Visual System 6 7
Added as new element to general under-load Added as new element to general under-load
183 IH3 0 Visual input minor modality (H1 and H2=few visual tasks) 1 Visual input primary (H1 and H2=primarily visual tasks) AND (J1, J4-9 = some interactions with people) 2 Visual input sole modality (H1 and H2=only visual tasks) AND (J1, J4-9 = minimal interactions with people) More than five new signals per minute IH4 0 Controls speed him or herself (F3=a or b AND if J3=yes, controls speed of devices) OR < 5 new signals/minute (overall assessment, see especially J3-9) 2 Doesn’t control speed (F3= c or d, OR J3=no, doesn’t control speed) AND > 5 new signals/ minute (overall assessment, see especially J3-9) Three sensory modalities simultaneously IH5 0 Not the case (H5=a or b) AND (Make an overall assessment, based on H1-2, and J2-9) 2 Three modalities simultaneously (H5=c or d) AND (make an overall assessment, based on H1-2, and J2-9) Communication necessary for work IH6 0 J1=a (no need for communication with others, verify with J4-9) 1 J1=b (sometimes communication needed, verify with J4-9) 2 J1=c (communication essential part of work, verify with J4-9) Input High Demand Total=IH1+IH2+IH3 + IH4 + IH5 + IH6 Complex Decisions/Interrelated Elements CH1 0 I2=a, b or c (no major decisions) AND I1=a or b (no supervisory work) 1 I2= d or e (makes major decisions) AND (I1=supervises at most 1-3 persons) AND (I3=fairly complex decisions--some interconnected information) 2 I2=d or e (makes major decisions) AND (I1=c or d, supervises >3 people) OR (I3=clearly complex decisions--lots of inter-connected information) Complicated Decisions/Many Elements CH2 0 I2=a, b or c (no major decisions) AND I1=a or b (no supervisory work) 1 I2= d or e (makes major decisions) AND (I1= supervises at most 1-3 persons) AND (I3=somewhat complicated decisions—moderate amount of information) 2 I2=d or e (makes major decisions) AND (I1= c or d, supervises >3 people) OR (I3=clearly complicated decisions—large amount of information)
184 Decisions affect the work of others CH3 0 I1=a (no supervisory work) 0.5 I1=b (rarely supervisory work) 1 I1= c (occasional supervising) 2 I1= d (frequent supervising) Rapid Decisions CH4 0 I4 = a (never) 0.5 I4 = b (rarely) 1 I4 = c (occasionally) 2 I4 = d (frequently) Central High Demand Total=CHI + CH2 + CH3 + CH4 Heterogeneous Tasks OH1 0 H3=c or d (Homogeneous tasks) 1 H3=a or b (Heterogeneous tasks) AND (H1=1-2 tasks) 1.5 H3=b (Quite heterogeneous tasks) AND (H1=3 or more tasks) 2 H3=a (Very heterogeneous tasks) AND (H1=3 or more tasks) Simultaneous Task Performance OH2 0 H5=a (never) 0.5 H5=b (rarely) 1 H5=c (occasionally) 2 H5=d (frequently) Complex Tasks OH3 0 Simple tasks (see H1 and H2) 1 A few steps in tasks (see H1 and H2) 2 Many stepped tasks (see H1 and H2) Rapid Task Execution OH4 0 H6= a (never) 0.5 H6= b (rarely) 1 H6= c (occasionally) 2 H6= d (frequently) (If c or d, check that the tasks themselves must be rapidly carried out, i.e. that this is not just a matter of working fast)
185 Output High Demand Total=OHI + OH2 + OH3 + OH4 Piece Rate GH1 0 C1=c (Fixed pay) 1 C1=b (Group work) 2 C1=a (By individual work) Long work hours GH2 (Calculate from B1-3, add 0.5 points if B4=c or d (called at home) or B14=c or d (works at home and hours not included) to a maximum of 2 points) 0 Not more than 40h/week 0.5 40 to 42h/week 1 Frequently > 42h/week or occasionally >48h/week 2 Frequently > 48h/week, or occasionally > 60h/week Two or more jobs GH3 0 B6=no 2 B6=yes
Other job: __________________
Lack of Rest breaks8 GH4 0 B7=d (frequently) 1 B7=c (occasionally) 1.5 B7=b (rarely) 2 B7=a (never) (Add 0.5 points if B8=a, B9=no, or if B10 > 2 hours, to a maximum of 2 points) Reason for not true break: _________________________ Night shift / irregular work9 GH5 0 B3=regular work schedule AND B11=no late night shift work 0.5 B3=irregular work schedule AND B11=no late night shift work 1 B11=yes, a (late night shift only) 1.5 B11=yes, b (rotating late night shift, up to four night shifts/month) 1.75 B11=yes, b (rotating late night shift, at least once per week but not > every fourth night) 2 B11=yes, b (rotating late night shift, at least every third night) (Add 0.5 points if < 24 free time after working a rotating late night shift, or if irregular schedule (B3=no) up to max. 2 points) 8 9
Coding somewhat modified Coding somewhat revised
186 If B3=regular work schedule, Morning start time: _________ Lack of Paid Vacation10 GH6 0 B5= Over four weeks 1 B5=Three to four weeks 1.5 B5=Two weeks 2 B5=Less than two weeks General High Demand Total=GHI + GH2 + GH3 + GH4 + GH5 + GH6 Input High Demand Total + Central High Demand Total + Output High Demand Total + General High Demand Total = Total High Demand Score STRICTNESS Strict requirements for signal detection IST 0 G7=a (not strict at all, can retrieve information easily) 0.5 G7=b (usually not strict, can retrieve information) 1 G7=c (somewhat strict) 2 G7=d (very strict) Input Strictness Total=IST Strict problem solving strategy CS1 0 I6=a (no, needs to be creative) 0.5 I6=b (basically not) 1 I6=c (limited freedom in problem-solving) 2 I6=d (strictly defined strategy must be followed) Strictly defined correct decision CS2 0 I5=a (wide range of possible correct decisions, very flexible) 0.5 I5=b (several possible correct decisions, somewhat flexible) 1 I5=c (limited number of correct decisions, limited flexibility) 2 I5=d (only one correct decision, no flexibility whatsoever) Central Strictness Total=CS1 + CS2
10
Added as new element to general high demand
187 Strict evaluation of performance OST 0 C4=a (primarily self-evaluation) 1 C4=b (some evaluation by others) 2 C4=c (strict evaluation by others) Output Strictness Total=OST Fixed Posture GS1 0 D8=a (mobile) 1 D8=b (mainly single posture, but free to move) 2 D8=c (fixed body position, constrained motion) Confined, window-less, poorly ventilated work area11 GS2 0 Works outside, or indoors in >1 location (D10=a or b) 0.5 Non-confined work area, with a direct window (D11=a) AND [(D12=b and D13=a or b) OR (D12=a and D13=a, b or c)] 1 Non-confined work area, with an indirect window (D11=b) AND [(D12=b and D13=a or b) OR (D12=a and D13=a, b or c)] 1.5 Non-confined work area without a window (D11=c) AND [(D12=b and D13=a or b) OR (D12=a and D13=a, b or c)] 1.5 Confined or crowded space with an indirect window (D11=b) AND [(D12=c) or (D12=b AND D13=c, d or e) or D12=a and D13=d or e) 2 Windowless and confined/crowded space (D11=c) AND [(D12=c) or (D12=b AND D13=c, d or e) or D12=a and D13=d or e) Add 0.5 points if D14=no, inadequate ventilation, to a maximum of 2 points. Lack of autonomous workspace12 GS3 0 Has own desk/workspace and either has own office or works outside (D9=yes) AND (D13=a or D10=a)) 1 Has own desk or workspace but shares an office (D9=yes) AND (D13=b, c, d or e) 2 No autonomous workspace (D9=no) Limited chance to take time off from work13 GS4 0 B12=a (no problem to take time off) 1 B12=b (a little difficult to take time off) 1.5 B12=c (somewhat difficult to take time off) 11
Coding substantially revised Added as new element to general strictness 13 Added as new element to general strictness 12
188 2 B12=d (very difficult to take time off) Limited influence over work schedule GS5 0 B13=a (complete influence) 0.5 B13=b (major influence) 1.5 B13=c (a little influence) 2 B13=d (no influence)
14
Limited influence over deciding with whom he or she works15 GS6 0 I7= Major 0.5 I7= Some 1.5 I7= A little 2 I7= None Limited influence over what the work tasks will be16 GS7 0 I8= Major 0.5 I8=Some 1.5 I8=A little 2 I8=None Limited influence over policy17 GS8 0 I9= Major 0.5 I9= Some 1.5 I9= A little 2 I9= None General Strictness Total=GS1 + GS2 + GS3 + GS4 + GS5 + GS6 + GS7 + GS8 Input Strictness Total + Central Strictness Total + Output Strictness Total + General Strictness Total = Total Strictness Score EXTRINSIC TIME PRESSURE Control of speed incoming signals IEPT
14
Added as new element to general strictness Added as new element to general strictness 16 Added as new element to general strictness 17 Added as new element to general strictness 15
189 0 Full control over work speed (F3=a) AND J4-9 few interactions, AND if J3=yes, controls speed of devices 0.5 F3=b (major control over work speed) 1 F3=c (partial control over work speed) 2 F3=d (no control over work speed) Add 0.5 up to 2 maximum if many interpersonal interactions (J4-9) or if J3=cannot control speed of devices Input Extrinsic Time Pressure Total=IEPT Decisions cannot be postponed CEPT 0 G1=a (decisions can always be postponed) 0.5 G1=b (decisions can usually be postponed) 1 G1=c (sometimes decisions cannot be postponed) 2 G1=d (decisions often cannot be postponed) Central Extrinsic Time Pressure Total=CEPT Control of Task Performance Rate OEPT 0 F3=a (full control over rate of task performance) 0.5 F3=b (major control over rate of task performance) 1 F3=c (partial control over rate of task performance) 2 F3=d (no control over rate of task performance) Output Extrinsic Time Pressure Total=OEPT Deadline Pressure GEP1 0 F1=a (never) 0.5 F1=b (rarely) 1 F1=c (occasionally) 2 F1=d (frequently) Speedup GEP2 0 F2=a (rarely or never) 1 F2=b (certain periods of the month or year) 1,5 F2=c (at least weekly but not daily) 2 F2=d (daily) General Extrinsic Time Pressure Total=GEP1 + GEP2
190 Input Extrinsic Time Pressure Total + Central Extrinsic Time Pressure Total + Output Extrinsic Time Pressure Total + General Extrinsic Time Pressure Total = Total Extrinsic Time Pressure Score AVERSIVENESS/NOXIOUS EXPOSURES Glare INOX1 0 D1=a (never) 0.5 D1=b (rarely) 1 D1=c (occasionally) 2 D1=d (frequently) Noise INOX2 0 D2=d (not noisy) 1 D2=c (moderate noise, not > 90 dB) 1.5 D2=b (sometimes likely 90dB or more) 2 D2=a (often likely 90dB or more) Input Noxious Exposure Total=INOX1 + INOX2 Isometric lifting ONOX1 0 D3=a (never) 0.5 D3=b (rarely) 1 D3=c (occasionally) 2 D3=d (frequently) Add 0.5 points if > 30kg or 50 lbs., up to maximum of 2 points Vibration exposure ONOX2 0 D4=a (never) 0.5 D4=b (rarely) 1 D4=c (occasionally) 2 D4=d (frequently) Source: ________________________ Output Noxious Exposure Total=ONOX1 + ONOX2 Heat Exposure18 GNOX1 18
Coding slightly modified
191 0 D5=a (not over 25 degrees C) 0.5 D5=b (not over 30 degrees) 1 D5=c (30 to 40 degrees C) 2 D5=d (over 40 degrees C) Add 0.5 points, to maximum of 2, if D 14=b (inadequate ventilation) Cold Exposure19 GNOX2 0 D6=a (at least 20 degrees C) 0.5 D6=b (at least 18) 1 D6=c (10 -18 degrees C) 2 D6=d (under 10 degrees C) Add 0.5 points, to maximum of 2, if D15=yes (drafty) Exposure to fumes, gases &/or dusts GNOX3 0 D7=a (never) 0.5 D7=b (rarely) 1 D7=c (occasionally) 2 D7=d (frequently) Exposures: ____________________ ____________________ ____________________ General Noxious Exposure Total=GNOX1 + GNOX2 + GNOX3 Input Noxious Exposure Total + Output Noxious Exposure Total + General Noxious Exposure Total = Total Noxious Exposure Score AVOIDANCE (SYMBOLIC AVERSIVENESS/DISASTER POTENTIAL) Need for sustained alertness to avoid serious consequences IAVOI1 Do an overall assessment (job title (A.1), also H.1) 0 D16=e and some controlled lapses of attention can be tolerated 1 D16=a, b, c or d, or sustained alertness required but not primary task 2 Vigilance is primary task (e.g. security guard, police, air traffic controller) Visually disturbing scenes20 IAVOI2 0 D17=a (never) 0.5 D17=b (rarely) 1 D17=c (occasionally) 2 D17=d (frequently) 19 20
Coding slightly modified Added as new element to input avoidance
Scenes: ________________________
192
Listens to emotionally disturbing occurrences21 IAVOI3 0 G3=a (never) 0.5 G3=b (rarely) 1 G3=c (occasionally) Occurrences: ________________________ 2 G3=d (frequently) Input Symbolic Aversiveness Total = IAVOI1 + IAVOI2 + IAVOI3 Serious consequences of wrong decisions CAVOIT 0 G4=a (None at all, correctable) 0.5 G4=b (Fairly minor, usually correctable) 1 G4=c (potential material or other serious damage from error) 2 G4=d (potential fatality from error) Central Symbolic Aversiveness Total = CAVOIT Hazardous Task Performance OAVOIT See job title (A1), H1 and H2, do overall assessment 0 D16=e, and no other indication of risk or danger 1 D16=e, but performs tasks with some risk e.g. welding, driving, drilling 2 D16=a, b, c or d (dangerous work) Output Symbolic Aversiveness Total = OAVOIT Experienced Accident or Injury at Work GAVOI1 0 E1 (none) 1 E1 (not serious) 2 E1 (serious) Witnessed Accident or Injury at Work GAVOI2 0 E2=d (never heard about or witnessed a serious accident at work) 0.5 E2=c (heard about but never witnessed a serious accident at work) 1 E2=b (witnessed a serious accident at work) 2 E2=a (witnessed fatal accident at work)
21
Added as new element to input avoidance
193 22
Litigation/Testifying in Court GAVOI3 0 E3 (No) 1 E3 (Yes, (a) As a witness) 2 E3 (Yes, (b) As a defendant) Lack of functioning emergency system23 GAVOI4 0 E4 =a (Yes and knows that it functions properly) 1 E4=b (Yes, but does not know whether it functions properly) 2 E4=c (No) General Symbolic Aversiveness Total = GAVOI1 + GAVOI2 + GAVOI3 + GVOI4 Input Symbolic Aversiveness Total + Central Symbolic Aversiveness Total + Output Symbolic Aversiveness Total + General Symbolic Aversiveness Total = Total Symbolic Aversiveness Score CONFLICT/UNCERTAINTY Signal/noise conflict ICNFL1 See also job title (A1), work tasks (H1-2), technical problems and glitches (G10), make overall assessment 0 Clear instructions and information (G5=a or b), no evidence of signal/noise conflict 1 Sometimes unclear instruction and information (G5=c) or other possible signal/noise conflict 2 Frequent unclear instruction and information (G5=d) or otherwise, likely signal/noise conflict Signal/signal conflict ICNFL2 See also job title (A1), work tasks (H1-2), make overall assessment 0 Clear instructions and information (G5=a or b), no evidence of signal/signal conflict 1 Sometimes unclear instruction and information (G5=c) or other possible signal/signal conflict 2 Frequent unclear instruction and information (G5=d) or otherwise, likely signal/signal conflict Input Conflict Total = ICNFL1 + ICNFL2
22 23
Added as new element to general avoidance Added as new element to general avoidance
194 Missing information needed for decision-making CCNFL1 0 G6=a (never) 0.5 G6=b (rarely) 1 G6=c (occasionally) 2 G6=d (frequently) Contradictory information CCNFL2 0 G8=a (never) 0.5 G8=b (rarely) 1 G8=c (occasionally) 2 G8=d (frequently) Unforeseeable events require new plan CCNFL3 0 G9=a (never) 0.5 G9=b (rarely) 1 G9=c (occasionally) 2 G9=d (frequently) Central Conflict Total = CCNFL1 + CCNFL2 + CCNFL3 Conflicting demands in time and space OCNFL1 0 F4=a (Always possible to complete everything) 0.5 F4=b (Usually possible to complete everything) 1 F4=c (Sometimes impossible to complete everything) 2 F4=d (Often impossible to complete everything) Technical problems hamper task performance OCNFL2 0 G10=a (never) 0.5 G10=b (rarely) 1 G10=c (occasionally) 2 G10=d (frequently) Sources: __________________ Interruptions from people hamper task performance24 OCNFL3 0 G11=a (never) AND J7=d 0.5 G11=b (rarely) 1 G11=c (occasionally) 24
Added as new element to external conflict
195 2 G11=d (frequently) Add 0.5 point, to a maximum of 2, if J6=e or J7=a or J8=c or J9=d or e Output Conflict Total = OCNFL1 + OCNFL2 + OCNFL3 Emotionally charged work atmosphere GCNFL1 0 J10=a (no) 0.5 J10=b (minimal) 1 J10=c (occasionally) 2 J10=d (great deal of tension) Lack of help with difficulties25 GCNFL2 0 G2=a (Can count on help) 0.5 G2=b (More often than not, can get help) 1.5 G2=c (Can’t really count on help) 2 G2=d (rarely of never can get help) Opposition to career advancement26 GCNFL3 0 C3 (No=no opportunities) OR [(Yes) AND (a or b = support for advancement)] 1 C3 (Yes) AND (c = not really support, but not active opposition) 2 C3 (Yes) AND (d = active opposition) Violations of behavior norms/abuses of power27 GCNFL4 0 J11=a (Never) 0.5 J11=b (Rarely) 1.5 J11=c (Occasionally) 2 J11=d (Frequently) Lack of redress of grievances28 GCNFL5 0 J12=a (Redress can be done and is efficient and confidential) 1 J12=b (In principle yes but not effective or not confidential) 2 J12=c, (No possibility to redress grievances) Threat of Job Loss29 25
Added as new element to general conflict Added as new element to general conflict 27 Added as new element to general conflict 28 Added as new element to general conflict 29 Added as new element to general conflict 26
196 GCNFL6 0 A3=a or b (Full time or part time position) AND K7=no 1 A3=c (Temporary work) AND K7=no 2 K7=yes, (threat of job loss present) If K7=no and A3=d, evaluate whether this is basically temporary versus stable employment 30
Job lacks coherence GCNFL7 0 H7=a (work tasks fit together and it is clear how they relate to the goals of the work organization) 1 H7=b (some of the work tasks fit together, vaguely can see how they related to the goals of the work organization) 2 H7=c (disconnected work tasks, unclear how they relate to the goals of the workplace) General Conflict Total = GCNFL1 + GCNFL2 + GCNFL3 + GCNFL4 + GCNFL5 + GCNFL6 + GCNFL7 Input Conflict Total + Central Conflict Total + Output Conflict Total + General Conflict Total = Total Conflict Score ***************************************************************************
Total Underload + Total High Demand + Total Strictness + Total Extrinsic Time Pressure + Total Noxious Exposure + Total Symbolic Aversiveness + Total Conflict = Total OSI Score
30
Added as new element to general conflict
197
Revised Version of the OSI for Professional Drivers 2002-2003 Use of this questionnaire requires the permission of the author, Dr. Karen Belkic. This was granted to: ___________________ (Investigator) on ____________(Date) INFORMATION ABOUT THE WORKPLACE FOR PROFESSIONAL DRIVERS
*************************************************************************** This questionnaire is designed to assess working conditions on your job, with the aim of finding ways to create a healthier work environment for professional drivers. It is being applied in the international context and therefore, contains elements that are relevant in a broad range of settings. Please read each question carefully, and unless otherwise indicated, choose the best single answer. Feel free to write any comments that you may have, and to use as much space as you would like. This questionnaire is handled entirely confidentially, without names or any other means of individual identification. Thank you for your Cooperation! Approval by the Regional Medical Ethics Committee/Institutional Review Board: Date________________ *************************************************************************** A. Length, Location and Terms of Work A1. How long have you worked at your current job at the present site? ____ Years A2. Total number of years as a professional driver: _______ A3 .Are you employed in a a) Full time position b) Part time position c) Temporary capacity d) Other capacity, please specify: _______________________________ A4. Total number of working years: _________ A5. Have you worked at other jobs besides being a professional driver? Yes No If yes, what were your other jobs?(Please list all these in with approximate dates __________________ __________________ ___________________________________ __________________ __________________ ___________________________________ A6. Type of vehicle, which you currently drive at work: a) Crane d) Official car g)Trolley car j) Local train b) Truck e) City bus h) Inter-city bus k) Taxi c) Tram f) Suburban bus i)Subway l.) Other: _______
198
A7. Which other vehicles have you previously driven at work? __________________ __________________ __________________ *************************************************************************** Please answer the following for your working conditions in the past year for your main job, unless otherwise specified B. Work hours and scheduling B1. How long does your workday usually last? ________ Hours Do you ever work longer than that? Yes No If yes, how many days/month? ________For how many hours/day? ________ B2. Do you have a regular work schedule? Yes No If yes, when do usually you begin work? _____________ End work: ________________ B3. How many work hours to you actually spend driving per day? _________ B4. How many days do you work per week? _________ B5. Do you work at another job outside your regular one? Yes No If yes, how many hours per week? ____ What do you do? __________________ B6. Do you have the opportunity to take breaks during your workday? a) Never c) Occasionally b) Rarely d) Frequently B7. If you do have some breaks, are these usually: a) Short ones (less than 15 minutes) b) Long breaks (at least 30 minutes) c) Both short and long breaks B8. If you have some breaks, are these true rest breaks so that you can completely be free from work obligations? Yes No If no, why not: _______________________ B9. How long do you typically work, without being able to take at least a short, 5-10 minute break? _____ B10. Do you work the late night shift (after midnight)? Yes If yes, do you work the late night shift: a) Constantly. b) On a rotating basis. If b, How many nightshifts do you usually work per month? ______/month
No
199 How many free days do you usually have after working a rotating night shift? ______ Days B11 Do you drive the split shift (early morning and afternoon rush hours) a). Yes, I constantly work the split shift b). Sometimes c). Rarely or never If a or b, how do you usually spend the time between the two shifts? a) I can either go home or take care of personal business: in other words this is useful time. b) Usually just waiting around. I don’t have enough time to go home nor is it possible to use the time for personal business. B12. How difficult is it for you to take time off from work? a) Not at all b) A little c) Somewhat d) Very much B13. How much say do you have about your work schedule? a) Complete, it is entirely up to me. b) To a large extent, I mainly decide on my work schedule. c) A little, but mainly my schedule depends on others, or is decided by others. d) None at all, my schedule depends on others or is decided by others; I have no say about it. B14. How many weeks of paid vacation do you have per year? _______________ C. Mode of Payment, Upgrading Possibilities and Evaluation of your Work C1. My pay is: a) Based upon how much I myself work. b) Based upon how much my group or collective, as a whole, works. c) Fixed. C2. My salary: a) Covers substantially more than my basic needs and those of my family. b) Covers a bit more than my basic needs and those of my family. c) Just barely covers my basic needs and those of my family. d) Totally inadequate to meet my basic needs and those of my family. C3. Are there possibilities for you to upgrade your job title/advance your career? Yes If yes, do you receive support and encouragement to do so? a) Definitely yes. b) Yes, to some extent. c) Not really, but there is no active opposition to such efforts. d) No, there is active opposition to such efforts.
No
200 C4. Is good work recognized by your workplace? a) Yes, drivers with a good safety record or other merits are recognized by my workplace. b) No, there is no recognition for good work. D. Working Conditions D1. What are the physical conditions like in your vehicle cabin? a) I have good shock absorbers and isolation. I don't feel much vibration or gases/fumes. b) I have poor shock absorbers, but good isolation. I feel vibration but not much gases/fumes c) I have good shock absorbers but poor isolation. I don't usually feel much vibration but I do feel gases/fumes because the isolation is poor. d) I have poor shock absorbers and poor isolation. I feel vibration and also gases/fumes. D2. What is the temperature like in your vehicle cabin? a) I have proper ventilation/air conditioning, as well as adequate heating. It never gets extremely hot (over 30 degrees C/ 86 degrees F) nor very cold in my cabin (not less than 15 degrees C/ 60 degrees F) b) I have good heating, so it never gets too cold in my cabin. However, I don't have a proper ventilation--air conditioning system. Especially in the summer, it gets very hot (over 30 degrees C/86 F) c) I don't have proper ventilation--air conditioning, nor is the heating system adequate. Especially in the summer, it gets very hot (over 30 degrees C/ 86 F) and especially in the winter is can get cold (below 15 degrees C/ 60 degrees F) D3. Do you perform heavy lifting at work? a) Yes, often times during the day, I must lift 50 kg (110 lbs), or more. b) Yes, I lift from 20 to 50 kg loads (44 - 110 lbs) during my usual workday. c) Yes, I lift up to 20 kg (44 lbs) during my usual workday. d) No, I rarely or never lift anything heavy during work. D4. Do you drive on the job when it is dark? a) No, I work (drive) only during the daylight hours. b) Yes, I drive mainly in the city when it's dark. c) Yes, I drive mainly inter-city (long routes) when it's dark. If you drive on the job when it’s dark, please answer the following 2 questions Are the roads well lit? Yes No Are the roads divided according to the direction of traffic? Yes
No
D5. Do you drive mainly on one particular route?
No
Yes
D6. Do you drive mostly: a) In the city? b) On suburban or inter-city routes with moderate to high traffic density? c) On long routes with low traffic density?
201
D7.Do you drive most often: a) Alone in your vehicle? b) With 1 or 2 other persons in your vehicle? c) With many passengers in your vehicle? If (b), can you decide who that person(s) will be? Yes
No
D8. Is driving your only task on the job? a) Yes b) No, during my driving tours, I also have other tasks such as checking or selling tickets, opening and closing the doors, giving information, etc. c) No, I have tasks other than those during the driving tours. My other tasks outside driving tours are: ____________________ _______________________________ If you answered c, that you perform tasks outside driving tours: D9. Do you have any say over whether or not you will perform these other tasks? Yes
No
D10. How do you see all the tasks that you perform at work? a) I can see how they fit together and how they relate to the work of others, and the overall goals of my workplace. b) Some of my tasks fit together, but not all. I can vaguely see how they relate to the work of others, and to an overall goal of my workplace. c) My work tasks seem to be disconnected from each other, and I don’t see how they relate to the work of others, nor to the overall goals of my workplace D11. With regard to on-the-job driving and weather conditions: a) I drive under all weather conditions, without exception. b) I drive under various weather conditions, but when visibility is decreased substantially (e.g. snowstorms, heavy fog, etc.) I don't drive. D12. Are you the only person who drives your vehicle? Yes No Do you always drive the same vehicle? Yes No If no to either of the above, do you have a desk or some other space of your own at work? Yes No D13. With respect to time pressure at work: a) I don't experience any substantial time pressure at work. It is only important that I arrive at my destination within a reasonable amount of time. b) Sometimes I must arrive at a given time c) I have an extremely tight schedule. If I arrive late, I face unpleasantness or even penalty. However, I can usually arrive on schedule. d) I have an extremely tight schedule. If I arrive late, I face unpleasantness or even penalty. It happens, that despite my efforts, and for objective reasons, I sometimes or often arrive late.
202 D14. Does it occur that during your work hours, you must be physically at work, but there is nothing to do? (Include waiting times, in answering this question) a) Never b) Rarely c) Occasionally d) Frequently D15. Do you drive under especially hazardous conditions (check all answers that apply)? a) Yes, I carry flammable/explosive material in my vehicle. b) Yes, I drive along winding, narrow roads c) Yes, I face threat of violence from passengers d) Yes, for another reason(s): ______________________________________________ e) No, I face ordinary traffic conditions, but no special hazards. D16. Is there a system in place in your vehicle in case of emergency? a) Yes, and I know that it functions properly. b) Yes, but I do not know how well it actually functions. c) No, there is not a functioning system in place in case of emergency. E. Work Accidents, Injuries and Mishaps Please answer the following 3 questions (E1-E3) for all experience as a professional driver. E1. Have you ever had an accident or been injured (including assault) at work? a) No b) Yes, only of a minor nature c) Yes, I have had one or more serious accidents or have suffered serious physical harm at work: Please briefly describe all serious accidents or injuries ________________________ ____________________________________ E2. Have you ever witnessed a serious traffic or other accident, or assault at work? a) Yes, I have observed one or more accidents or assaults with a fatal outcome b) Yes, I have observed one or more serious accidents or assaults, but I have never witnessed a fatal outcome. c) I have heard about serious or fatal accidents or assaults at work, but never seen this. d) No, I have never witnessed or heard about a serious accident at work. If you answered (a) or (b), how many serious accidents or assaults have you seen? _____ If you answered (a), (b) or (c), how many times have you heard about serious accidents or assaults? _______ E3. Have you ever had to testify in court in relation to your workplace? Yes If yes, was this (please check all that apply): a) As a witness b) As a defendant
No
203
F. Problems, Influence and Interpersonal Relations at Work F1. The vehicle(s), which I drive at work: a) Often break(s) down. b) Sometimes break(s) down c) Rarely or never break(s) down. F2. Do interruptions from passengers (e.g. disruptive behavior, standing so as to block your view) prevent you from proceeding with driving? a) Never b) Rarely c) Occasionally d) Frequently F3. Can you get help from people at your workplace for handling difficult situations? a) Yes, I can nearly always count on such help. b) Yes, more often than not. c) I can’t really count on getting such help. d) Rarely or never do I get the help, which I need. F4. How much influence do you have over planning and policy at your workplace? a) A great deal b) Some c) A little d) None F5. In general, how is the social climate at your workplace? a) Excellent, we all get along very well together and misunderstanding are very rare. b) Good, most the time we get along well, with few misunderstandings and tensions. c) Fair, we have our ups-and-downs; sometimes there are misunderstandings and tensions. d) Poor, there is a great deal of tension and conflict. F6. Are there abuses of power or violations of norms of behavior at work? a) Never b) Rarely c) Occasionally d) Frequently F7. Is there the possibility to redress grievances at work? a) Yes, this can be done in an efficient and confidential manner. b) In principle, yes, but this is either not effective or cannot be done confidentially. c) No, there is no possibility to redress grievances at work.
204
G. Recent changes at work (Please answer the following questions for the last 6 months) Yes
No
Yes
No
G 1) Has there been an increase in the length of your workday? G 2) Has there been increased time pressure/number of deadlines? G 3) Have you had an increase in work responsibility? G 4) Have you been demoted? G 5) Has your pay been cut? G 6) Have you been promoted? G 7) Is there a threat that you will be laid off? G 8) Have there been other recent changes at work? If yes, please specify:
H. Other Questions about your workplace:
H1) Is there a trade union at your workplace? H 2) Are you employed at an equal opportunity workplace? H 3) Is there a pension-plan available at your workplace? H 4) Is health care coverage provided by your workplace
I. Some open-ended questions about your work as a professional driver: I1. What is the best part(s) about being a professional driver of your profile?
205 I2. What is the most difficult part of being a professional driver of your profile?
I3. What do you think could be done to make that difficulty less of a burden?
I4. What could be done to improve working conditions as a professional driver of your profile? a) Immediately:
b) Long-term:
I5. Which of the above suggestions do you consider to be the most important?
I6. If attempts were made to improve the working conditions of professional drivers of your profile, what would you suggest to keep the good aspects of your work?
I7. Other comments:
206
REVISED DRIVER OSI SCORE SHEET: 2002-2003
A1. ____ Years in current job at present site A2. ____Years as a professional driver A3. Employment capacity 1=Full time position 2=Part time position 3=Temporary capacity 4=Other capacity: _____________________ A4. ____Years employed A5. Former Jobs: __________________
_________________
______________________
A6. Type of vehicle currently: _________ A7. Previous vehicles: __________________ _________________
______________________
UNDERLOAD Homogeneous Information IU1 0 D5=no (drives on various routes) 1 D5=yes (drives on a fixed route) Low frequency of incoming signals (<1 signal/minute) IU2 0 D6=a or b (drives in suburb or city/high flow of information) 2 D6=c (long route driver with low traffic density/<1 new signal/minute) No need for communication/Works alone IU3 0 D7=b or c (others are in the vehicle) 2 D7=a (drives alone) (see also D8) Input Underload Total : IU1 + IU2 + IU3 Automatic decision-making CUT 1 Decisions follow from input, but require judgment (Essential feature of driving) (Unless D8 indicates another task with substantial decision-making)
207 Central Underload Total : CUT Homogeneous Tasks OU1 2 D8=a (homogeneous tasks and few in number) 1 D8=b (homogeneous tasks and more numerous) D8=c (score this based on answer to c: the number and nature of non-driving tasks) Simple Tasks OU2 2 D8=a or b (simple tasks) D8=c (score this based on answer to c: the nature of non-driving tasks) Nothing to do OU3 0 D14=a (Always something to do) 0.5 D14=b (Rarely nothing to do) 1 D14=c (Occasionally nothing to do) 2 D14=d (Frequently nothing to do) Output Underload Total: OU1 + OU2 + OU3 Fixed Pay GU1 0 C1=a or b (based on individual or group norm) 2 C1=c (fixed pay) Inadequate Pay GU2 0 C2=a (Covers substantially more than basic needs) 0.5 C2=b (Covers a bit more than basic needs) 1 C2=c (Just barely covers expenses) 2 C2=d (Totally inadequate) Lack of Promotion Prospects GU3 0 C3=Yes + a, b, or c (There are possibilities to upgrade job title or advance one’s career, and no active opposition) 1 C3=Yes + d (There are upgrade possibilities, but active opposition) 2 C3=No Lack of Recognition of Good Work GU4 0 C4=a (Drivers with good safety records or other merits are recognized)
208 2 C4=b (No recognition for good work) General Underload Total: GU1+GU2 + GU3 + GU4 Input Underload Total + Central Underload Total + Output Underload Total + General Underload Total = Total Underload Score HIGH DEMAND Three or more information sources simultaneously IH1 2 Essential feature of driving Heterogeneous information IH2 0 D5=yes (drives on a fixed route/homogeneous information) 1 D5=no (drives on various routes (fairly heterogeneous information)) Add 0.5 points if D12 (pt. II)=doesn’t drive same vehicle Visual Input Primary IH3 1 Visual input primary but not only modality (essential feature of driving) High frequency of incoming signals (> 5 new signals per minute) IH4 0 D6=c (long route driver / low traffic density/ <1 new signal/minute) 1 D6=b (drives in intercity or suburbs / moderate to high traffic density / often > 5 new signals per minute) 2 D6=a (drives in city / high flow of information / always > 5 new signals per minute) Three sensory modalities simultaneously IH5 2 Can receive visual, auditory & somatosensory signals simultaneously (essential feature) Communication necessary for work IH6 0 D7=a (drives alone) 1 D7=b (1-2 persons in vehicle) 1 D7=c (many passengers) AND (D8=a) 2 D7=c (many passengers) AND (D8=b) Input High Demand Total=IH1+IH2+IH3 + IH4 + IH5 + IH6 Complex Decisions/Interrelated Elements CH1 0 Fairly automatic decisions /essential feature of driving
209 (Unless D8=c and indicates otherwise) Complicated Decisions/Many Elements CH2 0 Fairly automatic decisions / essential feature of driving (Unless D8=c and indicates otherwise) Decisions affect the work of others CH3 0 D8=a, b or c (if no supervisory work) 2 D8=c (if supervisory work) Rapid Decisions CH4 2 Essential feature of driving Central High Demand Total=CHI + CH2 + CH3 + CH4 Heterogeneous Tasks OH1 0 D8=a or b (homogeneous tasks) __ D8=c (score this based on review of the qualitative answer to c) Simultaneous Task Performance OH2 2 A6 =c, e or g AND D8=b (Urban mass transit-driver AND checks and/or sells tickets, gives information, opens and closes doors) 1 A6=a, b, d, h, i, j or k, OR D8=a or c (Some simultaneous task performance, but less than above) Complex Tasks OH3 0 D8=a or b (simple tasks) __D8=c (score this based on answer to c: the nature of non-driving tasks) Rapid Task Execution OH4 2 Essential feature of driving Output High Demand Total=OHI + OH2 + OH3 + OH4 Piece Rate GH1 0 C1=c (Fixed pay)
210 1 C1=b (Group work) 2 C1=a (By individual work) Long work hours GH2 Calculate from B1 & 4. Add 0.5 if B11=b (sometimes split shift) AND pt. II=b (can’t use the time) and 1.0 if B11=a (always split shift) AND pt. II=b (can’t use the time) to a maximum of 2 points 0 Not more than 40h/week 0.5 40 to 42h/week 1 Frequently > 42h/week or occasionally >48h/week 2 Frequently > 48h/week, or occasionally > 60h/week Number of hours behind the wheel (B3):__________ Split shift (B11): (2) a=always, (1) b=sometimes, (0) c=rarely or never Two or more jobs GH3 0 B5=no 2 B5=yes
Other job: _________________________
Rest breaks GH4 0 B6=d (frequently) 1 B6=c (occasionally) 1.5 B6=b (rarely) 2 B6=a (never) Add 0.5 points if B7=a, B8=no, or if B9 > 2 hours, to a maximum of 2 points Reason for not true break: _________________________ Night shift work GH5 0 B2=regular work schedule AND B10=no night shift work 0.5 B2=irregular work schedule AND B10=no night shift work 1 B10=yes, a (night shift only) 1.5 B10=yes, b (rotating night shift, up to four night shifts/month) 1.75 B10=yes, b (rotating night shift, at least once per week but not more than every fourth night) 2 B10=yes, b (rotating night shift, at least every third night) (Add 0.5 points if < 24 free time after working a rotating night shift, or if irregular schedule (B2=no) up to max. 2 points) If B3=regular work schedule, Morning start time: _________ Lack of Paid Vacation
211 GH6 0 B14= Over four weeks 1 B14=Three to four weeks 1.5 B14=Two weeks 2 B14=Less than two weeks General High Demand Total=GHI + GH2 + GH3 + GH4 + GH5 + GH6 Input High Demand Total + Central High Demand Total + Output High Demand Total + General High Demand Total = Total High Demand Score STRICTNESS Strict requirements for signal detection IST 2 Essential feature of driving Input Strictness Total=IST Strict problem solving strategy CS1 1 For drivers there are a few, but limited number of problem-solving strategies Strictly defined correct decision CS2 1 For drivers there are a limited number of correct decisions Central Strictness Total=CS1 + CS2 Strict evaluation of performance OST 1 Others (especially law enforcement) evaluate performance. Output Strictness Total=OST Fixed Posture GS1 2 Drivers are essentially constrained during driving Confined, window-less, poorly ventilated work area GS2 1.5 D2=a (adequate ventilation) (Drivers work in a confined space but with a direct window) 2 D2=b or c (inadequate ventilation) Lack of autonomous workspace
212 GS3 0 D12=the only one who drives the vehicle 1 D12= has own desk or workspace, but is not the only one to drive the vehicle 2 D12= is not the only one to drive the vehicle and doesn’t have own desk or workspace Limited chance to take time off from work GS4 0 B12=a (no problem to take time off) 1 B12=b (a little difficult to take time off) 1.5 B12=c (somewhat difficult to take time off) 2 B12=d (very difficult to take time off) Limited influence over work schedule GS5 0 B13=a (complete influence) 0.5 B13=b (major influence) 1.5 B13=c (a little influence) 2 B13=d (no influence) Limited influence over deciding with whom he or she works GS6 0 D7=a OR (D7=b AND decides who else will be in the vehicle) 2 D7=c OR (D7=b AND doesn’t decide who else will be in the vehicle) Limited influence over what the work tasks will be GS7 1 D8=c AND D9=yes (performs non-driving tasks and decides whether or not to do so) 2 D8=a or b (only driving related tasks) OR [D8=c AND D9=no (performs non-driving tasks and does not decide whether or not to do so)] Limited influence over policy GS8 0 F4=a (has a great deal of influence) 0.5 F4=b (some influence) 1.5 F4=c (a little influence) 2 F4=d (no influence) General Strictness Total=GS1 + GS2 + GS3 + GS4 + GS5 + GS6 + GS7 + GS8 Input Strictness Total + Central Strictness Total + Output Strictness Total + General Strictness Total = Total Strictness Score EXTRINSIC TIME PRESSURE Control of incoming signals
213 IEPT 2 Drivers have no control over the speed of incoming signals Input Extrinsic Time Pressure Total=IEPT Decisions cannot be postponed CEPT 2 Essential feature of driving Central Extrinsic Time Pressure Total=CEPT Control of Task Performance Rate OEPT 1 Drivers have only partial control over this Output Extrinsic Time Pressure Total=OEPT Deadline Pressure GEP1 0 D13 =a (no deadline pressure) 1 D13=b (occasional deadline pressure) 2 D13=c or d (frequent deadline pressure) Speedup GEP2 0 D13=a (no speed-up pressure) 1 D13=b (occasional speed-up pressure) 2 D13=c or d (frequent speed-up pressure) General Extrinsic Time Pressure Total=GEP1 + GEP2 Input Extrinsic Time Pressure Total + Central Extrinsic Time Pressure Total + Output Extrinsic Time Pressure Total + General Extrinsic Time Pressure Total = Total Extrinsic Time Pressure Score AVERSIVENESS/NOXIOUS EXPOSURES Glare INOX1 1 D4 =a, (drives only in daylight hours, glare may occur in early AM or late afternoon) 2 D4 =b or c (drives at night) Noise INOX2 1 Based on road noise measurements (85dB) (If there are more specific data available on cabin noise levels, then score as per general OSI: 90dB or more =2, moderate noise level 80 90dB = 1, minimal noise exposure = 0)
214 Input Noxious Exposure Total=INOX1 + INOX2 Isometric lifting ONOX1 0 D3=d (No noteworthy lifting) 0.5 D3=c (Up to 20 kg.) 1 D3=b (20-50 kg.) 2 D3=a (Over 50 kg. regularly) Vibration exposure ONOX2 1 D1=a or c (good shock absorbers) 2 D1=b or d (poor shock absorbers) See also D8 (whether performing tasks with exposure to hand-arm vibration) Output Noxious Exposure Total=ONOX1 + ONOX2 Heat Exposure GNOX1 0 D2=a (adequate ventilation or air-conditioning) 1 D2 =b or c (inadequate ventilation or air conditioning, exposed to heat > 30 °) Cold Exposure GNOX2 0 D2=a or b (adequate heating) 1 D2 =c (inadequate heating) Add 0.5 points if D1=c or d, poor isolation Exposure to fumes, gases &/or dusts GNOX3 1 D1=a or b (good isolation, doesn’t feel fumes) 2 D1=c or d (poor isolation, often feels fumes) General Noxious Exposure Total=GNOX1 + GNOX2 + GNOX3 Input Noxious Exposure Total + Output Noxious Exposure Total + General Noxious Exposure Total = Total Noxious Exposure Score AVOIDANCE (SYMBOLIC AVERSIVENESS/DISASTER POTENTIAL) Need for sustained alertness to avoid serious consequences IAVOIT 2 Vigilance is the driver’s primary task
215 Visually disturbing scenes IAVOI2 0 E2=c or d (never witnessed serious accident or assault) 1 E2= b (witnessed 1-2 non-fatal accidents or assaults) 1.5 E2=a (witnessed 1-2 fatal accidents or assaults) 2 E2=a (witnessed 3 or more fatal accidents or assaults) Listens to emotionally disturbing occurrences IAVOI3 0 E2=d (never heard about a serious work-related accident or assault) 1 E2=a, b or c (heard about 1-2 accidents or assaults) 1.5 E2=a, b or c (heard about 3-4 accidents or assaults) 2 E2=a, b or c (heard about 5 or more accidents or assaults) Input Symbolic Aversiveness Total = IAVOI1 + IAVOI2 + IAVOI3 Serious consequences of wrong decisions CAVOIT 2 Wrong decision by a driver can obviously have fatal consequences Central Symbolic Aversiveness Total = CAVOIT Hazardous Task Performance OAVOIT 1 D15 2= e (usual traffic conditions) 2 D15 = a-d (special hazards present) Output Symbolic Aversiveness Total = OAVOIT Work Accidents or Injuries GAVOI1 0 E1 = a (none) 1 E1 = b (minor) 2 E1 = c (serious) Witnessed Physical Harm/Injury at Work GAVOI2 0 E2 = d (never witnessed a serious accident at work) 0.5 E2 = c (heard about but never witnessed a serious accident at work) 1 E2= b (witnessed serious accident at work) 2 E2 = a (witnessed fatal accident at work)
216 Litigation/Testifying in Court GAVOI3 0 E3 (No) 1 E3 (Yes, (a) As a witness) 2 E3 (Yes, (b) As a defendant) Lack of functioning emergency system GAVOI4 0 D16 =a (Yes and knows that it functions properly) 1 D16=b (Yes, but does not know whether it functions properly) 2 D16=c (No) General Symbolic Aversiveness Total = GAVOI1 + GAVOI2 + GAVOI3 + GVOI4 Input Symbolic Aversiveness Total + Central Symbolic Aversiveness Total + Output Symbolic Aversiveness Total + General Symbolic Aversiveness Total = Total Symbolic Aversiveness Score CONFLICT/UNCERTAINTY Signal/noise conflict ICNFL1 0 D4=a (drives only during daylight) AND D11=b (drives only with good visibility) 1 D4=b or c (drives at night or dark) OR D11=a (drives under all weather conditions) (but not both) 2 D4=b or c (drives at night or dark) AND D11=a (drives under all weather conditions) Signal/signal conflict ICNFL2 1 Occurs occasionally for drivers with road signs, information from other participants in traffic, etc. Input Conflict Total = ICNFL1 + ICNFL2 Missing information needed for decision-making CCNFL1 2 This is often the case for drivers Contradictory information CCNFL2 2 This is often the case for drivers Unforeseeable events require new plan CCNFL3 2 Drivers must continually adjust their plan of action based on traffic conditions
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Central Conflict Total = CCNFL1 + CCNFL2 + CCNFL3 Conflicting demands in time and space OCNFL1 0 D13=a, b or c (no) 2 D13 =d (yes) External conditions hamper task performance OCNFL2 0 D11=b (drives only under good visibility) AND F1=c (rare vehicle breakdown) 1 D11 =a (drives under all weather conditions) OR F1=b (occasional vehicle breakdown) (but not both conditions) 1.5 D11 =a (drives under all weather conditions) AND F1=b (occasional vehicle breakdown) 2 F1=a (frequent vehicle breakdown) Interruptions from people hamper task performance OCNFL3 0 F2=a (never) 0.5 F2=b (rarely) 1 F2=c (occasionally) 2 F2=d (frequently) Output Conflict Total = OCNFL1 + OCNFL2 + OCNFL3 Emotionally charged work atmosphere GCNFL1 0 F5=a (no) 0.5 F5=b (minimal) 1 F5=c (occasionally) 2 F5=d (great deal of tension) Help with difficulties GCNFL2 0 F3=a (Can count on help) 0.5 F3=b (More often than not, can get help) 1.5 F3=c (Can’t really count on help) 2 F3=d (rarely of never can get help) Opposition to career advancement GCNFL3 0 C3 (No=no opportunities) OR [(Yes) AND (a or b = support for advancement)] 1 C3 (Yes) AND (c = not really support, but not active opposition) 2 C3 (Yes) AND (d = active opposition)
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Violations of behavior norms/abuses of power GCNFL4 0 F6=a (Never) 0.5 F6=b (Rarely) 1.5 F6=c (Occasionally) 2 F6=d (Frequently) Lack of redress of grievances GCNFL5 0 F7=a (Redress can be done and is efficient and confidential) 1 F7=b (In principle yes but not effective or not confidential) 2 F7=c, (No possibility to redress grievances) Threat of Job Loss GCNFL6 0 A.3=a or b (Full time or part time position) AND G7=no 1 A 3=c (Temporary work) AND G7=no 2 G7=yes, (threat of job loss present) If G7=no and A3=d, evaluate whether this is basically temporary versus stable employment Job lacks coherence GCNFL7 0 D10=a (work tasks fit together and it is clear how they relate to the goals of the work organization) 1 D10=b (some of the work tasks fit together, vaguely can see how they related to the goals of the work organization) 2 D10=c (disconnected work tasks, unclear how they relate to the goals of the workplace) General Conflict Total = GCNFL1 + GCNFL2 + GCNFL3 + GCNFL4 + GCNFL5 + GCNFL6 + GCNFL7 Input Conflict Total + Central Conflict Total + Output Conflict Total + General Conflict Total = Total Conflict Score Total Underload + Total High Demand + Total Strictness + Total Extrinsic Time Pressure + Total Noxious Exposure + Total Symbolic Aversiveness + Total Conflict = Total OSI Score
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Revised Version: OSI for Physicians 2002-2003 Use of this questionnaire requires the permission of the author, Dr. Karen Belkic. This was granted to: ___________________ (Investigator) on _________ (Date) THE WORKING CONDITIONS OF PHYSICIANS
*************************************************************************** This questionnaire is designed to assess working conditions on your job, with the aim of finding ways to create a healthier work environment for physicians. It is being applied in the international context and therefore, contains elements that are relevant in a broad range of settings. Please read each question carefully, and unless otherwise indicated, choose the best single answer. Feel free to write any comments that you may have, and to use as much space as you would like. This questionnaire is handled entirely confidentially, without names or any other means of individual identification. Thank you for your Cooperation! Approval by the Regional Medical Ethics Committee/Institutional Review Board: Date________________ *************************************************************************** A. Length and Location of Work A.1.What is your position? _______________________ A.2. How long have you worked at your current position at the present site? _____ Years A.3 .Are you employed in a a) Full time position b) Part time position c) Temporary capacity d) Other capacity, please specify: _______________________________________ A.4. What is the total number of years that you worked as a physician? _________Years A.5. How long altogether have you been employed (in any type of work)? _______ Years A.6. Have you worked in other occupations besides as a physician? Yes No If yes, what were your other jobs? (Please list these in chronological order with dates) ____________________ ____________________ ____________________ ____________________ ____________________ ____________________
220 Please answer the following for your working conditions in the past year for your main job as a physician, unless otherwise specified B. Type of Practice and Setting B.1. Are you a: a) General Practitioner? b) Specialist? If b, what is your specialty? __________________ Subspecialty? _____________________ B.2. What is the setting of your practice? a) Solo Private Practice b) Group Private Practice c) Health maintenance organization (HMO)
d) Public (non-private) clinic / hospital e) Physician in general training (intern) f) Physician in specialty training (resident)
B.3. What is the approximate percentage of inpatient work, which you handle? a) Less than 10% b) Less than 50% (but at least 10%) c) More than 50% B.4. What is the percentage of patients for whom you care with end-stage/incurable disease or injury? a) Less than 10% b) Between 10 and 20% c) Over 20% but less than 50% d) 50% or more B.5. What is the approximate percentage of emergency cases, which you handle? a) Less than 10% b) Not over 50% (but at least 10%) c) >50% B.6.At how many different institutions do you work? a) Only one b) Two c) Three or more C. Work Hours and Scheduling C.1.How long is your ordinary workday? ___________ Hours Do you ever work longer than that? Yes No If yes, how many days per month (usually)? ____ How many hours per day? ______
C.2. How many days do you usually work per week? __________ C.3. Do you have a regular work schedule? Yes No If yes, when do you usually begin work? _____________ End work? ________________
221 C.4. Are you called at home regarding during your free (not on-call) time regarding clinical care of patients? a) Never b) Rarely c) Occasionally d) Frequently C.5. How many weeks of paid vacation do you have per year? _________________ C.6. Do you work at another job outside your regular one? Yes No If yes, how many hours per week? ______ What do you do? ___________________ C.7. Do you have the opportunity to take breaks during your workday? a) Never b) Rarely c) Occasionally d) Frequently C.8. If you do have some breaks, are these usually? a) Short ones (less than 15 minutes) b) Long breaks (at least 30 minutes) c) Both short and long breaks C.9. If you have some breaks, are these true rest breaks so that you can completely be free If no, why not: _____________________ from work obligations? Yes No C.10.How long do you typically work, without being able to take at least a short, (5-10 minute) break? _____ C.11. Do you take night call? Yes No If yes, do you work the late night shift: a) Constantly. b) On a rotating basis. If b, how many nightshifts do you usually work per month? _____________/month If you have night call, please answer the next 4 night shift related questions (C.12-C.15): C.12. How much do you usually sleep during night call? a) At least 4 to 5 hours per night b) Mainly between 2 and 4 hours, the rest of the time I'm busy c) At the most I get 2 hours of sleep; I'm busy most of the night d) I usually get only a couple of hours. Even when I'm not busy, I am too agitated to sleep C.13. Are you obliged to be physically at the hospital during night call: a) Yes b) No, I am on pager, and only occasionally must come in.
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C.14. What kind of free time adjacent to night call do you have? (Please check all that apply) a) I come in for the night shift, having been free that day b) After the night shift, I go home in the morning c) I go on call after having worked that day, and must work at least part of the next day If you answered (c) immediately above: C.15. Do you have guaranteed relief at a specified time after being on call? a) Yes, I can go home being certain that my patients are cared for by colleagues. b) No, it can happen that I must stay late to be sure my patients are stable before I go home. C.16. How difficult is it for you to take time off from work? a) Not at all b) A little c) Somewhat d) Very much C.17. How much say do you have about your work schedule? a) Complete, it is entirely up to me. b) To a large extent, I mainly decide on my work schedule. c) A little, but mainly my schedule depends on others, or is decided by others. d) None at all, my schedule depends on others or is decided by others; I have no say about it. C.18. Do you perform work for your job at home? a) Never b) Rarely c) Sometimes d) Frequently If c or d,did you include that time in calculating your work hours(Questions. B1-2)? Yes
D. Salary, Possibilities for Advancement and Recognition D.1. Upon what is your salary based? a) Upon my own work: number of patients, interventions, hours worked etc. b) Upon group work: number of patients, interventions, hours worked etc. c) Fixed pay, irrespective of the amount of work. D.2. My salary: a) Covers substantially more than my basic needs and those of my family. b) Covers a bit more than my basic needs and those of my family. c) Just barely covers my basic needs and those of my family. d) Totally inadequate to meet my basic needs and those of my family.
No
223 D.3. Are there possibilities to upgrade your job title/advance your career? Yes If yes, do you receive support and encouragement to do so? a) Definitely yes. b) Yes, to some extent. c) Not really, but there is no active opposition to such efforts. d) No, there is active opposition to such efforts.
No
D.4. Is good work recognized at your workplace? a) Definitely yes b) Yes, to some extent. c) Not very much. d) Not at all. E. Working Conditions and Exposures E.1. Are you exposed to strong lights that create glare for you at work? a) Never b) Rarely c) Occasionally (in the Operating Room or elsewhere) d) Frequently (in the Operating Room or elsewhere) E.2. Do you encounter visually disturbing scenes (e.g. severe burns, trauma, grotesque dermatological pathology)? a) Never b) Rarely c) Occasionally d) Frequently E.3. Do you listen to accounts of emotionally disturbing occurrences? a) Never b) Rarely c) Occasionally d) Frequently E.4. Do you perform heavy lifting during work? a) Yes, I regularly must lift patients b) I do other heavy lifting, up to: _______ kg or (_______ lbs.) c) No, I rarely do any heavy lifting during my workday E.5. Are you exposed to vibration during work? a) Yes, I use vibrating hand tools (hours/week ______) b) No, only very rarely or not at all If yes, which tools: ______________________ E.6. Concerning heat exposure during work:
224 a) It rarely or never gets hotter than 25° C (77° F) at work b) It rarely or never gets hotter than 30° C (86° F) at work c) It occasionally or often gets hotter than 30° C (86° F) E.7. Concerning cold exposure during work: a) It rarely or never gets colder than 20° C (68° F) at work b) It rarely or never gets colder than 18° C (64° F) at work c) The heating system is poor, with temperatures <18° C (64° F) E.8. Are you exposed to gases, mists or dusts at work? a) No, only very rarely or not at all b) Yes, at least occasionally If yes, how many hours per week _______ to which substances: _________________________________________ E.9. Are you exposed to radiation during work? Yes If yes, do you wear a radiation badge? Yes No Specifics about your exposure: _____________________
No
E.10. Acute hazards at work: (please check all which are applicable) a) Threat of violence from psychotic or otherwise dangerous patients b) Possible infection /close exposure to blood or other body fluids c) Work with flammable materials d) Other risk(s), (please specify: _____________________________) e) There are no special acute hazards where I work E.11. Workspace: a) I have my own office b) I share an office (with how many others? ________) Approximate size of your office: ______________ If you share an office, do you have your own desk? Yes No Must you sometimes look for an empty office in which to see patients? Yes No What approximate percent of your working day do you spend in your office? _________ E.12. Are there windows in the office in which you work? a) Yes, there is a window at my immediate workspace, so that I can look outside from where I am working. b) Yes, but not next to me, so I can’t look outside from where I am working. c) No, I work in a window-less office. E. 13. How is the ventilation in the area in which you work? a) Adequate b) Inadequate E.14. Is it drafty in the area in which you work? Yes
No
225 F. Mishaps at or regarding work Please answer the following 5 questions (F1-F5) for your entire experience as a physician F. 1. Have you suffered physical harm or injury at work? Yes If yes, was this a serious injury? Yes No What happened (very briefly)? ________________________________
No
F. 2. Have colleagues and/or staff suffered physical harm or injury at your workplace? a) Yes, I witnessed such, with a fatal outcome b) Yes, I witnessed such, with a serious, but not fatal outcome c) I’ve heard about serious or fatal injury, but never witnessed it d) No, I have never witnessed or heard about anyone’s serious injury at my workplace If you answered a, b or c, please briefly describe: _______________________________________________ F. 3. Has a patient under your care ever committed suicide? a) Yes, this has happened on several occasions b) Yes, I have had one or two such patients c) No, but it has happened to colleague(s) with whom I work d) No, it has never happened to me or to colleague(s) with whom I work F. 4. Have you ever been obliged to testify in court as a physician? Yes If yes, please mark all the following which apply: a) I have testified as an expert witness about a patient b) I have been obliged to testify regarding a colleague or staff member c) I have been obliged to testify as a defendant in a malpractice case d) Other, please specify: _____________________________________ If yes, F. 5. Were any of these proceedings made public via the mass media? Yes ****************************
F. 6. Is there a system in place at work in case of non-medical emergencies? a) Yes, and I know that it functions properly b) Yes, but I do not know how well it actually functions c) No, there is not a functioning system in place in case of non-medical emergencies. G. Time Pressure G.1. Do you have a deadline by which a given job or task must be completed? a) Never. b) Rarely c) Occasionally d) Frequently
No
No
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G.2. Are you obliged to speed-up your work tempo? a) No, it happens only rarely or never. b) Yes, during certain periods of the month or year. c) Yes, at least weekly, but not daily. d) Yes, every day. G.3. With regard to your workload and time constraints: a) It is always possible to complete everything. b) It is usually possible to complete everything. c) It is sometimes impossible to complete everything, even with maximal effort. d) It is often objectively impossible to complete everything, even with maximal effort. H. Problems, Constraints and Influence at Work
Please indicate the degree of influence do you have over: Major
Some
H.1. Number of patients under your care/ outpatient scheduling H.2. Which clinical tasks or procedures you perform H.3. Whether and how much you will take on other, non-clinical duties H.4. Colleagues and staff with whom you work H.5. Planning and policy of your institution (Including indications for medical procedures and for hospital admissions)
H.6. Is your work overseen by others? Yes No If yes, please check all that apply: a) By more senior physicians b) By non-physician personnel (e.g. administrators, nurses) c) By physicians of your level or lower H.7. If yes, is your clinical judgment questioned? a) Often b) Sometimes c) Rarely or never
A Little
None
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Please indicate the degree of strictness of rules and regulations regarding: Very strict
Somewhat strict
Flexible
H.8. Patient admissions H.9. Patient scheduling H.10. Are there problems that directly hamper your providing adequate patient care a) Never b) Rarely c) Occasionally d) Frequently If c or d, please check all which contribute to this problem a) Lack of needed supplies (including medications) b) Lack of hospital beds c) Understaffing d) Administrative constraints to ordering needed supplies e) Language barriers with patients (lack of translators) f) Infra-structural problems (lack of elevators, power failures etc.) g) Need for frequent patient transport under tenuous conditions h) Delay or inability to obtain medical records i) Difficulty in obtaining laboratory results j) Limitations in ordering tests k) Limitations on sending patients for consult l) Other problems (_____________________________) H.11. Do interruptions from other people (including work-related phone calls) prevent you from proceeding with your work? a) Never b) Rarely c) Occasionally d) Frequently
I. Inter-personal interactions and social climate I. 1. Can you get help for difficult cases and/or clinical dilemmas? a) Yes, I can almost always count on such help. c) I can’t really count on getting such help b) Yes, more often than not. d) Rarely or never do I get the help I need.
228 I. 2. In general, how is the social climate at your workplace? a) Excellent, we all get along very well together and misunderstanding are very rare. b) Good, most the time we get along well, with few misunderstandings and tensions. c) Fair, we have our ups-and-downs; sometimes there are misunderstandings and tensions. d) Poor, there is a great deal of tension and conflict. I.3 When obliged to display knowledge and/or skills in front of colleagues and/or supervisors (e.g. during rounds, journal club, other presentations, etc.): a) The atmosphere is constructive and conducive to growth and learning. b) There is some tension. Oversights and/or lack of knowledge will be noticed and commented upon. If these are of major importance, there may be adverse consequences. c) These occasions are highly unpleasant. Event the slightest oversight or lack of knowledge inevitably becomes a point of ridicule and/or chastisement. 1.4 Are there abuses of power or violations of norms of behavior at work? a) Never b) Rarely c) Occasionally d) Frequently 1.5. Is there the possibility to redress grievances at work? a) Yes, this can be done in an efficient and confidential manner. b) In principle, yes, but this is either not effective or cannot be done confidentially. c) No, there is no possibility to redress grievances at work. J. Workload and Activities Please indicate how often you handle patients who are: Frequently
Occasionally
Rarely/Never
J.1. Disturbed J.2. Cannot provide a history J.3. How many inpatients do you usually have under your direct care at one time? a) None d) Eleven to twenty b) One to five e) Over twenty c) Six to ten J.4. How many of these are in intensive care (including CCU)? a) None d) Six to ten b) One to two e) Over ten c) Three to five
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J.5. How many outpatients do you usually see during one work shift? a) None d) Twenty-one to thirty b) One to ten e) Thirty-one to forty c) Eleven to twenty f) Over forty How many of these are new patients? _____________ J.6. How many patients do you usually admit during a working shift? a) None d) Eleven to twenty b) One to five e) Over twenty c) Six to ten J.7. Are you obliged to care for these newly admitted patients, or do you transfer them to other colleagues? a) I must care for all the patients whom I admit during a given shift. b) I must care for some of the patients whom I admit during a given shift. c) The patients whom I admit are nearly always transferred fairly rapidly to other colleagues. J.8. During your workday do several people seek your attention at the same time? (Including people on the telephone) a) Yes, many times each day b) Yes, a few times each day c) Yes, but only once or twice each day d) No, rarely or never. J.9. If people simultaneously seek your attention, how many do so? a) Rarely > 2 b) Usually two, but sometimes more c) Usually >3 J.10. Does it occur that during your work hours, you must be physically at work, but there is nothing to do? a) Never b) Rarely c) Occasionally d) Frequently J.11. Do you oversee or supervise the work of: (please check all which apply) a) Physicians at your level of training or higher c) Medical students b) Physicians with less training than yourself d) Other health professionals e) Others: _____________ J.12.Number of persons other than yourself, for whose work you take responsibility: _______
230 J.13. Besides clinical work, other major work activities include: (please check all that apply): a) Teaching in small groups (e.g. medical students) d) Administrative duties b) Lecturing to larger groups e)Other: __________________ c) Research J.14.If you have other major work activities, is there special time set aside for these? Yes No If no, please check all which apply: a) I perform these duties simultaneously with my clinical work b) I work after normal work hours to complete these activities. J.15. Are you under pressure to publish/present new findings or results at Congresses or other meetings outside your Institution? a) Yes, if I fail to do so in sufficient quantity, my career will suffer and I could even lose my position. b) Yes, but there are no major adverse consequences if I fail to do so. c) No, such activity is entirely up to my own initiative and choice. Which of the following do you perform on a regular basis? (please enumerate)
J.16. Non-invasive diagnostic procedures:
Yes
No
_____________________ _____________________ _____________________ _____________________ _____________________ _____________________ J.17. Invasive procedures: Yes No _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ J.18. Surgical interventions: Yes No _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ J.19. Tasks outside the realm of a physician: work of other personnel: Yes No _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ J.20. Are there work tasks that you are obliged to perform that you consider pointless? Yes No
231 J.21. Do you regularly use a computer as part of your clinical work? Yes No If yes, please check all of the uses you have for the computer: a) To obtain data (lab, medical records, etc.) about my patients b) For patient write-ups (e.g. discharge summaries, etc.) c) For help in triaging to other departments and other institutions d) For statistical analyses that would be for clinical purposes e) For electronic communication (email) with colleagues (consults etc.) f) For electronic communication (email) with patients g) For searching the medical literature to elucidate a clinical question. h) Other, please describe: ___________________________ In which of the above circumstances is the computer most helpful? ________________________________________________ In which of the above circumstances is the computer more of a burden than a help, and why? ________________________________________________ K. Recent changes at work (Please answer the following questions for the last 6 months) Yes K 1) Has there been an increase in the length of your workday? K 2) Has there been increased time pressure/number of deadlines? K 3) Have you had an increase in work responsibility? K 4) Have you been demoted? K 5) Has your pay been cut? K 6) Have you been promoted? K 7) Is there a threat that you will be laid off? K 8) Have there been other recent changes at work? If yes, please specify:
No
232 L. Other Questions about your workplace: Yes
No
L 1) Is there a trade union at your workplace? L 2) Are you employed at an equal opportunity workplace? L 3) Is there a pension-plan available at your workplace? L 4) Is health care coverage provided by your workplace M. Some open-ended questions about your current work: M 1. What is the best part(s) about your present work? ________________________________________________________________ ________________________________________________________________ M 2. What is the hardest part of being a physician of your profile? ________________________________________________________________ ________________________________________________________________ M 3. What do you think could be done to make that difficulty less of a burden? ________________________________________________________________ ________________________________________________________________ M. 4. What do you think could be done to improve work as a physician of your profile? a) Immediate/ very feasible: ____________________________________________ ________________________________________________________________ b) More long-range changes requiring organizational modifications: ________________________________________________________________ ________________________________________________________________ c) What would be the most important immediate change to improve work as a physician of your profile? ________________________________________________________________ ________________________________________________________________ M. 5. If attempts were made to improve the conditions for your job, what would you suggest to preserve the good aspects of your work as it now stands? ________________________________________________________________ ________________________________________________________________ M .6 Additional comments about your work:
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REVISED OSI MD SCORE SHEET: 2002-2003
ID#: ______________________ A1.General practitioner or specialty: ___________________ A2. ____ Years in current job at present site A3. Employment capacity 1=Full time position 2=Part time position 3=Temporary capacity 4=Other capacity: _____________________ A4. ____Years as physician A5. ____Years employed A6. Former Jobs: __________________ _________________ __________________ B2. Setting 1=a, Private Solo 2=b, Private Group 3=c, HMO 4=d, Public Hospital 5=e, Intern 6=f, Resident B3. Inpatient Load 0 =a (<10%) 1 =b (10 – 50 %) 2 =c (>50 %) B4. Terminal (Patients with end-stage disease) 0 =a (<10%) 1 =b (10 – 20 %) 1.5 =c (20 - 50 %) 2 =d (>50 %) B5.Emergency 0 =a (<10%) 1 =b (10 – 50 %) 2 =c (>50 %) B6. Number of Institutions 0 =a (1) 1 =b (2) 2 =c (3+)
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UNDERLOAD Homogeneous Information IU1 0 Heterogeneous information (Essential feature for MD's) Low frequency of incoming signals IU2 0 Always >1 new signal/minute or control (Essential feature for MD's) No need for communication IU3 0 Works with others (Essential feature for most MD's) Input Underload Total : IU1 + IU2 + IU3 Automatic decision-making CUT 0 Not automatic (Essential feature for MD's) Central Underload Total : CUT Homogeneous Tasks OU1 0 Heterogeneous tasks (Essential feature for MD's) Simple Tasks OU2 0 Several tasks (Essential feature for MD's) Nothing to do OU3 0 J.10=a (Always something to do) 0.5 J.10=b (Rarely nothing to do) 1 J.10=c (Occasionally nothing to do) 2 J.10=d (Frequently nothing to do) Output Underload Total: OU1 + OU2 + OU3 Fixed Pay GU1 0 D.1=a or b (By individual work) 2 D.1=c (Fixed pay)
235 Inadequate Pay GU2 0 D.2=a (Covers substantially more than basic needs) 0.5 D.2=b (Covers a bit more than basic needs) 1 D.2=c (Just barely covers expenses) 2 D.2=d (Totally inadequate) Lack of Promotion Prospects GU3 0 D.3=Yes (Possibilities to upgrade job title or advance one’s career; no active opposition) 1 D.3=Yes + d (There are upgrade possibilities, but active opposition) 2 D.3 =No Lack of Recognition of Good Work GU4 (GOSI) 0 D.4=a (Definitely yes) 0.5 D.4=b (Yes, to some extent) 1.5 D.4=c (Not very much) 2 D.4=d (Not at all) General Underload Total: GU1+GU2 + GU3 + GU4 Input Underload Total + Central Underload Total + Output Underload Total + General Underload Total = Total Underload Score HIGH DEMAND Three or more information sources simultaneously IH1 Range= 1→ 2 (based on ER work: B.5 and number of people seeking attention: J.8-J.9) Heterogeneous information IH2 ___ Range= 1.5→ 2 (based on tasks: J.13, J.16 – J. 19) Heavy Burden on Visual System IH3 0.5 B.1=General or family practice, primary care, psychiatrist, non-invasive cardiologist 1 B.1=Surgeon, radiologist, pathologist, dermatologist or J.16 – J. 18 (many procedures) More than five new signals per minute IH4 ___Range= 1→ 2 (based on burden - B.5.ER work, workload: J.3 – J. 6, J.11-J.13) and (Control over workload: H.1 – H.3))
236 Three sensory modalities simultaneously IH5 0 (B.1=Pathologist, radiologist) 1 (B.1=Clinician,not surgeon or anesthesiologist) AND (J.17-J.18=no invasive procedures) 2 (B.1=Surgeon, anesthesiologist) OR (J.17 – J.18= invasive procedures) Communication necessary for work IH6 1 B.1=Pathologists, radiologists 2 B.1=Physicians involved in patient care Input High Demand Total=IH1+IH2+IH3 + IH4 + IH5 + IH6 Complex Decisions/Interrelated Elements CH1 2 Essential feature for MD's Complicated Decisions/Many Elements CH2 2 Essential feature for MD's Decisions affect the work of others CH3 1 J.11-J.12=no direct supervision (but some implicit) 1.5 J.11-J.12=supervises 1 to 2 others 2 J.11-J.12 =supervises 3 or more others Rapid Decisions CH4 1.5 B.3, B.5, J.4 = mainly outpatient work 2 B.3, B.5, J.4 = substantial ER and/or inpatient and/or ICU work Central High Demand Total=CHI + CH2 + CH3 + CH4 Heterogeneous Tasks OH1 __Range= 1→ 2 (based on tasks – J.13, J.16- J.19) Simultaneous Task Performance OH2 0 B.5 =a AND J.4=a AND J.8=c or d 1 B.5=b, OR J.4=b OR J.8=b 2 B.5=c, OR J.4=c-e OR J.8=a (Based on ER work, ICU patients and simultaneous attention sought, add 0.5 points if J.7=a or b, cares for newly admitted patients during work shift)
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Complex Tasks OH3 __Range= 1→ 2 (based on profile B.1, & tasks – J.13, J.16-J.19) Rapid Task Execution OH4 0.5 J.17-J.18=no invasive procedures, AND (B3=a or b AND B.5=a AND J.4=a) (mainly outpatient, no ER) 1 J.17-J.18=no invasive procedures, AND (B3=c or B.5=b or c or J.4=b through e) 2 J.17-J.18=performs invasive procedures Output High Demand Total=OHI + OH2 + OH3 + OH4 Piece Rate GH1 0 D.1. = c (Fixed pay) 1 D.1. = b (Group work) 2 D.1. = a (By individual work) Long work hours GH2 Calculate from C.1-C.3, add 0.5 points if C.4=c or d (called at home) or C.18=c or d (works at home) and hours not included, to a maximum of 2 points 0 Not more than 40h/week 0.5 40 to 42h/week 1 Frequently > 42h/week or occasionally >48h/week 2 Frequently > 48h/week, or occasionally > 60h/week Two or more jobs GH3 0 C.6 = No 2 C.6 = Yes Other job: ____________________________________ Lack of Rest breaks GH4 0 C.7 =d (frequently) 1 C.7 =c (occasionally) 1.5 C.7 =b (rarely) 2 C.7 =a (never) Add 0.5 points if C.8=a, C.9=no, or if C.10 > 2 hours, to a maximum of 2 points Reason for not true break: _________________________
238 Night shift work GH5 0 C.3=regular work schedule AND C.11=no night shift work 0.5 C.3=irregular work schedule AND C.11=no night shift work 1 C.11=yes, a (night shift only) 1.5 C.11=yes, b (rotating night shift, up to four night shifts/month) 1.75 C.11=yes, b (rotating night shift, at least once per week but not > every fourth night) 2 C.11=yes, b (rotating night shift, at least every third night) Add 0.5 points if < 24 free time after working a rotating night shift (C.14), or if irregular schedule (C.3=no), or no guaranteed relief (C15=b), up to max. 2 points If C3=regular work schedule, Morning start time: _________ Lack of Paid Vacation GH6 0 C5= Over four weeks 1 C5=Three to four weeks 1.5 C5=Two weeks 2 C5=Less than two weeks General High Demand Total=GHI + GH2 + GH3 + GH4 + GH5 + GH6 Input High Demand Total + Central High Demand Total + Output High Demand Total + General High Demand Total = Total High Demand Score STRICTNESS Strict requirements for signal detection IST 1.5 B.5=a AND J.4 =a AND J.17-18=no (minimal ER work, no ICU patients, no invasive procedures) 1.75 B.1=(not surgeon or anesthesiologist) AND (B.5=b OR J.4=b or c, some ER or ICU patients) AND (J.17-18=no invasive procedures) 2 (B.1= surgeon or anesthesiologist) OR (B.5=c over 50% ER work) OR (J.17J.18=performs invasive procedures) Input Strictness Total=IST Strict problem solving strategy CS1 __ Range= 0→ 1 (based on H.5 and H.8-H.9 maximum (1) if very strict rules and regulations) Strictly defined correct decision CS2 Range= 1→ 1.5, based on H.5 – H.9, maximum (1.5) if very strict rules &/or overseen)
239 Central Strictness Total=CS1 + CS2 Strict evaluation of performance OST ____Range= 1→ 2, based on H.6 and I.3, maximum (2) if overseen & slight oversight noted) Output Strictness Total=OST Fixed Posture GS1 0.5 B.1, E.11, J.3, J.16-19: (fairly mobile, in office < 50% of the time) 1 B.1, B.3=a, E.11, J.3, J.16-19: (mainly single posture, but free to move - mainly outpatient work, in office) 1.5 B.1, E.11, J.3, J.16-19: (lots on procedures, anesthesiologists) 2 B.1, E.11, J.3, J.16-19: (Surgeons performing long operations) Confined, window-less, poorly ventilated work area GS2 0 Works in >1 location (E.11 part IV < 50% in office) 0.5 Spends over 50% of time in a non-confined work area, with a direct window (E12=a) AND (E11 indicates non-confined work area) 1 Spends over 50% of time in a non-confined work area, with an indirect window (E12=b) AND (E11 indicates non-confined work area) 1.5 Non-confined work area without a window (E12=c) AND (E11 indicates non-confined work area-shares with at most 1 other colleagues) 1.5 Confined or crowded space with an indirect window (E12=b) AND (E11 indicates very crowded work area or 2+ colleagues in an office) 2 Windowless and confined/crowded space (E12=c) AND (E11 indicates very crowded work area or 2+ colleagues in an office) Add 0.5 points if E13=no, inadequate ventilation, to a maximum of 2 points. Lack of autonomous workspace GS3 0 E.11 (Has own desk/workspace and has own office) 1 E.11 (Has own desk or workspace but shares an office 2 E.11 (No autonomous workspace) Add 1 point to a maximum of 2 if (E.11) seeks free office space to see patients Limited chance to take time off from work GS4 0 C.16=a (no problem to take time off) 1 C.16=b (a little difficult to take time off) 1.5 C.16=c (somewhat difficult to take time off) 2 C.16=d (very difficult to take time off)
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Limited influence over work schedule GS5 0 C.17=a (complete influence) 0.5 C.17=b (major influence) 1 C.17=c (a little influence) _2_ C.17=d (no influence) Limited influence over deciding with whom he or she works GS6 0 B.1=pathologist or radiologist and H.4=major influence 1 B.1=patient care profile AND H.1, H.4 =major influence, H9=flexible 1.5 B.1=patient care profile AND H.1, H.4 =some influence, H9=somewhat strict 2 B.1=patient care profile AND H.1, H.4 =little or no influence, H9=very strict If combined answers, choose worst profile
Limited influence on what work tasks will be GS7 H2 AND H3 =major influence 1 1.25 H2 AND H3 =some influence 1.5 H2 AND H3 =a little H2 AND H3 =none 2 If combined answers, choose worst profile. Add 0.5 points to 2 maximum, if J.15=a or b Limited influence over policy GS8 0 H.5= (Major) 0.5 H.5= (Some) 1.5 H.5= (A little) 2 H.5= (None) General Strictness Total=GS1 + GS2 + GS3 + GS4 + GS5 + GS6 + GS7 + GS8
Input Strictness Total + Central Strictness Total + Output Strictness Total + General Strictness Total = Total Strictness Score
EXTRINSIC TIME PRESSURE Control of incoming signals IEPT
241 1 B.1 = pathologist, radiologist 1.5 B.1 = patient care work , H.1 and H.9: major control of number of patients under care/outpatient scheduling 1.75 B.1 = patient care work, H.1 and H.9: some control of number of patients under care/outpatient scheduling 2 B.1= patient care work , H.1 and H.9: little or no control of number of patients under care/outpatient scheduling If combined answers, choose worst profile Input Extrinsic Time Pressure Total=IEPT Decisions cannot be postponed CEPT 1 B.1, B.3, B.5 & J.4 = Mainly outpatient or non-clinical, no emergency or ICU patients 1.5 B.5 & J.4 = 10-50% emergency patients OR some ICU patients 2 B.5 & J.4 = predominantly emergency patients OR many ICU patients Central Extrinsic Time Pressure Total=CEPT Control of Task Performance Rate OEPT 1 H.1, H.2 & H.3 =major control over # patients, clinical tasks performed & of other duties 1.5 H.1, H.2 & H.3 =some control over #patients, clinical tasks performed & of other duties 2 H.1, H.2 & H.3 = little or no control over # patients, clinical tasks & of other duties If combined answers, choose worst profile Output Extrinsic Time Pressure Total=OEPT Deadline Pressure GEP1 0 G1=a (never) 0.5 G1=b (rarely) 1 G1=c (occasionally) 2 G1=d (frequently) Speedup GEP2 0 G2=a (rarely or never) 1 G2=b (certain periods of the month or year) 1,5 G2=c (at least weekly but not daily) 2 G2=d (daily) Add 0.5 points if B.5=c, to a maximum of 2, if mainly emergency work General Extrinsic Time Pressure Total=GEP1 + GEP2
242 Input Extrinsic Time P Total + Central Extrinsic Time P Total + Output Extrinsic Time P Total + General Extrinsic Time P Total = Total Extrinsic Time Pressure Score AVERSIVENESS/NOXIOUS EXPOSURES Glare INOX1 0 E1=a (never) 0.5 E1=b (rarely) 1 E1=c (occasionally) 2 E1=d (frequently) Noise INOX2 0 B.5=less than 50% in the ER (B.5) 0.5 B.5=works primarily in the ER (B.5) Input Noxious Exposure Total=INOX1 + INOX2 Isometric lifting ONOX1 0 E4=c 1 E4= Lifts less than 50 kg. 2 E.4=Over 50 kg. regularly Vibration exposure ONOX2 0 E.5=Minimal or no vibration exposure 0.5 E.5=a (unless over 5 hours per week) 1 E.5=a (over 5 hours per week) Output Noxious Exposure Total=ONOX1 + ONOX2 Heat Exposure GNOX1 0 E.6.=a (<25 °) 0.5 E.6=b(25 to 30 °) 1 E.6=c (30 to 40 °) Add 0.5 points, to maximum of 2, if E.13=b (inadequate ventilation) Cold Exposure GNOX 0 E7=a (at least 20 degrees C) 0.5 E7=b (at least 18) 1 E7=c (10–18 degrees C) Add 0.5 points, to maximum of 2, if E.14 =yes (drafty)
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Exposure to fumes, gases &/or dusts GNOX3 0 E.8=a (no) 1 E.8=b (at least occasionally) Exposures: ____________________ ____________________ General Noxious Exposure Total=GNOX1 + GNOX2 + GNOX3 Input Noxious Exposure Total + Output Noxious Exposure Total + General Noxious Exposure Total = Total Noxious Exposure Score AVOIDANCE (SYMBOLIC AVERSIVENESS/DISASTER POTENTIAL) Need for sustained alertness to avoid serious consequences IAVOI1 1.5 B.3=a AND B.5=a, (non-emergency, outpatient) or B.1=pathologist 2 B.3=(b or c) OR B.5=(b or c) (substantial emergency and/or inpatient work) Visually disturbing scenes IAVOI2 0 E.2 =a (never) 0.5 E.2 =b (rarely) 1 E.2. =c (occasionally) 2 E.2 =d (frequently) Listen to accounts of emotionally disturbing occurrences IAVOI3 0 E3=a (never) 0.5 E3=b (rarely) 1 E3=c (occasionally) 2 E3=d (frequently) Add 1 point if B4=c or d (large percentage of patients with end-stage or incurable disease), 0.5 points if B4=b, add 1 point if F.3 =a or b (patient suicide), and 0.5 if F.3=c (heard about patient suicide), to a maximum of 2 points Input Symbolic Aversiveness Total = IAVOI1 + IAVOI2 + IAVOI3 Serious consequences of wrong decisions CAVOIT 2 Potential human injury or fatality from error = Essential feature for M.D.) Central Symbolic Aversiveness Total = CAVOIT
244 Hazardous Task Performance OAVOIT 1 Question E.10= e (No acute hazards reported) 2 Question E.10 = a-d (Acute hazards present) Add 1 to a maximum of 2 points, for Radiation exposure, E.9 Output Symbolic Aversiveness Total = OAVOIT Experienced Physical Harm/Injury at Work GAVOI1 0 F. 1 = No 1 F. 1 = Yes, if not serious 2 F. 1 = Yes, if serious Witnessed Physical Harm/Injury at Work GAVOI2 0 F. 2 = d (never heard about or witnessed a serious accident at work) 0.5 F. 2 = c (heard about but never witnessed a serious accident at work) 1 F. 2 = b (witnessed serious accident at work) 2 F. 2 = a (witnessed fatal accident at work) Litigation/Testifying in Court GAVOI3 0 F. 4. = no 1 F. 4. = yes, a (Expert witness) 1.5 F. 4. = yes, b (Testified about a colleague or staff member) 2 F. 4. = yes, c (Defendant in a malpractice case) Add 0.5 points if F.5=yes, mass media coverage, to maximum 2 points Lack of functioning emergency system GAVOI4 0 F. 6 =a (Yes and knows that it functions properly) 1 F. 6 =b (Yes, but does not know whether it functions properly) 2 F. 6 =c (No) General Symbolic Aversiveness Total = GAVOI1 + GAVOI2 + GAVOI3 + GVOI4 Input Symb. Aversive Total + Central Symb. Aversive Total + Output Symb. Aversive Total + General Symb. Aversive Total = Total Symbolic Aversiveness Score CONFLICT/UNCERTAINTY Signal/noise conflict ICNFL1 2 Frequent signal/noise conflict (Essential feature for MD's)
245
Signal/signal conflict ICNFL2 2 Frequent signal/signal conflict (Essential feature for MD's) Input Conflict Total = ICNFL1 + ICNFL2 Missing information needed for decision-making CCNFL1 _2_ H.10. = e, h, i (language barriers, delay with medical records, difficulty in getting lab), OR J.1 or J.2 =frequent (disturbed patient, can’t get history) 1.5 Otherwise Contradictory information CCNFL2 2 (Essential feature for MD's) Unforeseeable events require new plan CCNFL3 _2_ B.5=c (>50%ER) OR J.4 =c, d or e(≥3 ICU patients) 1.5 B.5=b (10-50% ER) OR J.4 =b (at least 1 ICU patient) 1 Otherwise Central Conflict Total = CCNFL1 + CCNFL2 + CCNFL3 Conflicting demands in time and space OCNFL1 0 G.3 =a (never) 0.5 G.3 =b (rarely) 1 G.3 =c (occasionally) 2 G.3 =d (frequently) Add 0.5 points each for J.14= (no special time set aside for non-clinical tasks) and J.7=a or b (cares for newly admitted patients during shift) External conditions hamper task performance OCNFL2 0 H.10. =a (never) 0.5 H.10. =b (rarely) 1 H.10. =c (occasionally) 2 H.10. =d (frequently) Main sources: ________________________ ________________________
246 Interruptions from people hamper task performance OCNFL3 0 H11=a (never) 0.5 H11=b (rarely) 1 H11=c (occasionally) 2 H11=d (frequently) Output Conflict Total = OCNFL1 + OCNFL2 + OCNFL3 Emotionally charged work atmosphere GCNFL1 0 I. 2. =a (no) AND Question I.3=a (Constructive learning atmosphere) 0.5 I. 2. =b (minimal) 1 I. 2. =c (occasionally) 2 I. 2. =d (great deal of tension) Add 0.5 points if I.3 = b (some tension with display of knowledge) and 1 point if I.3=c (high tension with display of knowledge) to a maximum of 2 points. Help with difficulties GCNFL2 0 I.1 =a (Can count on help) 0.5 I.1 =b (Usually) 1.5 I.1 =c (Can’t count on it) 2 I.1 =d (Little or no help) Opposition to career advancement GCNFL3 0 D.3. =Yes + a or b (Support or advancement) OR (no possibilities for advancement) 1 D.3. =Yes, and c (No Active Opposition) 2 D.3. =Yes, and d (Active Opposition) Violations of behavior norms/abuses of power GCNFL4 0 1.4 =a (Never) 0.5 1.4 =b (Rarely) 1.5 1.4 =c (Occasionally) 2 1.4 =d (Frequently) Lack of redress of grievances GCNFL5 0 1.5=a (Redress can be done and is efficient and confidential) 1 1.5=b (In principle yes but not effective or not confidential) 2 1.5=c, (No possibility to redress grievances)
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Threat of Job Loss GCNFL6 0 A3=a or b (Full time or part-time position) AND K7=no 1 A3=c (Temporary work) AND K7=no 2 K7=yes, (threat of job loss present) If K7=no and A3=d, evaluate whether this is basically temporary versus stable employment. Add 0.5 points if J.15=a. Job lacks coherence GCNFL7 0 J.20 =no (no performance of pointless tasks) 1 J.20 =yes (performance of pointless tasks)
General Conflict Total = GCNFL1 + GCNFL2 + GCNFL3 + GCNFL4 + GCNFL5 + GCNFL6 + GCNFL7
Input Conflict Total + Central Conflict Total + Output Conflict Total + General Conflict Total = Total Conflict Score
Total Under load + Total High Demand + Total Strictness + Total Extrinsic Time Pressure + Total Noxious Exposure + Total Symbolic Aversiveness + Total Conflict = Total OSI Score
248 The OSI for Teachers—2002-2003 Use of this questionnaire requires the permission of the author, Dr. Karen Belkic. This was granted to: ___________________ (Investigator) on _____________ (Date) THE WORKING CONDITIONS OF TEACHERS
*************************************************************************** This questionnaire is designed to assess working conditions on your job, with the aim of finding ways to create a healthier work environment for teachers. It is being applied in the international context and therefore, contains elements that are relevant in a broad range of settings. Please read each question carefully, and unless otherwise indicated, choose the best single answer. Feel free to write any comments that you may have, and to use as much space as you would like. This questionnaire is handled entirely confidentially, without names or any other means of individual identification. Thank you for your Cooperation! Approval by the Regional Medical Ethics Committee/Institutional Review Board: Date________________ *************************************************************************** A. Length and location of work A.1.How long have you worked at your present site as a teacher? _______________ Years A. 2 .Are you employed as a: a) Full time teacher b) Part time teacher c) Temporary capacity d) Other capacity, please specify: ________________________________ A 3. What is the total number of years that you have worked as a teacher? _________ A 4.How long altogether have you been employed (in any type of work)? __________ Years A 5. Have you worked in other occupations besides as a teacher? Yes No If yes, what were your other jobs? (Please list these in chronological order with approximate dates) _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________
249 Please answer the following for your working conditions in the past year, unless otherwise specified B. Teaching Setting and Content B.1.In which type of school do you teach? a) Public c) Parochial b) Private-secular d) Other, please specify____________________________
B.2. (i) Do you teach: a) Elementary school b) Middle school c) High school (gymnasium) d) Adult education e) Community College f) University g) Other, please specify: ______________________ (ii) If you answered a, b or c (i.e. k – 12) which grade(s) do you teach? ___________ (iii) If more than 1 grade, which is the main one? _______ B.3. Which subject areas do you teach? Please indicate all that apply a) Mathematics b) Natural Sciences c) Social Sciences d) English (or the primary language of the country or region in which you are working) e) Foreign languages f) Technical training g) Music h) Fine arts (other than music) i) Physical education / sports j) Computer sciences k) Other, please specify: _______________________________________ B.3b. Do you teach bilingual education classes? a) Yes b) No
B.4. How many different subjects do you teach? a) 1 d) 4 b) 2 e) 5 c) 3 f) 6 or more
250 B.5.To what extent do students in a given class vary in their abilities towards the subject(s) that you teach? a) Not at all b) A little c) Somewhat d) Very much B.6. (I) Are the classes in your school divided (“tracked”) according to student abilities? Yes No (ii) If yes, which of the following do you teach? Please check all that apply. a) Advanced placement/accelerated/gifted and/or magnet school type programs b) Remedial classes c) General level (not college preparatory) d) Special education B.7. What is the main socio-economic background of your students’ families? a) Upper class/affluent b) Middle-class c) Employed blue-collar/working class d) Poor/high unemployment rate e) Combination of ___________ and _________________. B.8. (i) Do you teach students who are not fluent in the language in which the classes are taught? Yes No (ii) If yes, what is the approximate percentage of such students? a) Less than 10% b) Less than 50% (but at least 10%) c) More than 50% B.9. (i) Do you teach students who are substantially behind their grade level? Yes (ii) If yes, what is the approximate percentage of such students? a) Less than 10% b) Less than 50% (but at least 10%)
No
c) More than 50%
B.10. (i) Do you teach students with individual special needs? a) Yes If yes, please answer the following 2 questions: (ii) Does this include any of the following? (Please check all that apply) a) Learning disability b) Behavioral disorders c) Visual impairment d) Hearing impairment e) Speech impairment (hearing intact) f) Other, please specify: _______________________________________
b) No
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(iii) Approximately what percentage of your teaching activity is with students having special needs? a) Less than 10% b) Less than 50% (but at least 10%) c) More than 50% B.11.At how many different schools do you work? a) Only one b) Two c) Three or more C. Work Hours, Scheduling and Salary Please consider the actual length of time used for work-related activity, in answering questions # C.1-6 C.1. How long is your ordinary workday? ___________ Hours C.2. (i) Do you ever work longer than that? Yes No (ii) If yes, how many days per month (usually)? ____ For how many hours per day? ______ C.3. How many days do you usually work per week? __________ C.4. (i) Do you have a regular work schedule? Yes No (ii) If yes, when do you begin work? ___________ End work? ____________________ (iii) If no, please describe how your schedule varies: ____________________________ C.5. How many hours/week do you spend in the following activities? ________________ (a) Actively teaching/in the classroom ________________ (b) Grading homework and/or exams ________________ (c) Performing administrative duties (including related paperwork) ________________ (d) Preparing course plans, curriculum ________________ (e) Communicating with parents ________________ (f) Preparing for special events ________________ (g) Meeting with colleagues/staff ________________ (h) Extra, student-related duties (e.g. recess supervision) ________________ (i) Development and training ________________ (j) Required civic duties (e.g. leading scout groups, athletic coaching) ________________ (j) Other, please specify C.6. Is separate, adequate work time allocated to perform tasks other than classroom teaching? Yes No
252 C.7. If no, when do you perform these other duties? Please check all that apply a) In the classroom, interspersed with active teaching b) During lunch and break time, within normal work hours. c) After normal work hours C.8. Are you called at home regarding your students or other work duties? a) Never b) Rarely c) Occasionally d) Frequently C.9a. During the regular school year, do you have another job aside from your regular one? Yes No If yes, how many hours per week? ____ What do you do at the other job(s)? _____________ C.9b. During the summer time, do you have another job aside from your regular one? Yes No If yes, how many hours per week? ____ What do you do at the other job(s)? _____________ C.10. How many weeks of paid vacation do you have per year? _________ C.11. How difficult is it for you to take time off during the school year: a) Not at all b) A little c) Somewhat d) Very much C 12. Do you have the opportunity to take breaks during your workday? a) Never b) Rarely c) Occasionally d) Frequently C 13. If you do have some breaks, are these usually? a) Short ones (less than 15 minutes) b) Long breaks (at least 30 minutes) c) Both short and long breaks C 14. (i) If you do have some breaks, are these true rest breaks? Yes No
253 (ii) If no, what prevents this time from being a true rest break? Please indicate all that apply a) There are always work-related interruptions b) My students are not being supervised by colleagues or staff who can take full responsibility c) There is no adequate place to rest d) That is the only time when full staff & faculty are available to me for consultation. e) Other, please specify: ________________________________________ C 15. How long do you typically work, without being able to take at least a short, 5-10 minute break? _____ C.16. Upon what is your salary based? a) The amount of work I, as an individual, perform (number of classes, etc.). b) The amount of work my group or collective, as a whole, performs. c) Fixed. C.17 My salary: a) Covers substantially more than my basic needs and those of my family. b) Covers a bit more than my basic needs and those of my family. c) Just barely covers my basic needs and those of my family. d) Totally inadequate to meet my basic needs and those of my family.
D. Working Conditions D.1. How often is there glare (from indoor lights or outside) for you at work? a) Never b) Rarely c) Occasionally d) Frequently D.2. How often do you listen to accounts of emotionally disturbing occurrences? a) Never b) Rarely c) Occasionally d) Frequently D.3. Is it noisy in your classroom? a) Never b) Rarely c) Occasionally d) Frequently
254 D.4. Do you perform heavy lifting during work? a) Never b) Rarely c) Occasionally d) Frequently If b-d, up to: _______kg or (_______lbs.) D.5. Does it get hot during work? a) Rarely or never hotter than 25° C (77° F) at work. b) Rarely or never hotter than 30° C (86° F) at work. c) It is occasionally or often hotter than 30° C (86° F)(either working inside or outdoors). D.6. Does it get cold at your workplace? a) Rarely or never colder than 20 ° C (68° F) at work. b) Rarely or never colder than 18° C (64° F) at work. c) Temperatures can get <18° C (64° F) but not < 10° C (50° F) (working inside or outdoors). d) Temperatures can be colder than < 10° C (50° F) (either working outdoors or inside). D.7a. Do you have your own desk at work? D.7b. Do you have a safe place to store your personal belongings?
Yes Yes
No No
If you work indoors, please answer questions D.8 – 14 about the classroom(s) in which you work, otherwise continue with question D.12: D.8a. Is there adequate space in the classroom(s) in which you teach? D.8b. Do you have your own classroom(s)?
Yes Yes
No No
D.9. Do you change the classroom in which you teach? a) Rarely or never b) Once or twice per year c) Once a week d) Once or twice per day e) Several times per day D.10. Do (does) the classroom(s) in which you teach have any of the following problems? (Please check all that apply): Yes No a) Leaky ceiling, other water leakage h) Poor ventilation b) Needs painting i) No windows c) Poor electrical installation d) Worn out desks or chairs e) Moldy/mildew f) Poor isolation/drafty g) Dusty
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Are there other physical problems in your classroom that were not mentioned in question If yes, please specify:_____________________ D.10? Yes No D.11. What is the type of floor in your classroom(s)? a) Concrete d) Carpeted b) Hard wood e) Other, please specify____________________________ c) Linoleum *************************************************************************** D.12. Do you have a teachers’ lounge?
Yes
No
D.13. Are restroom facilities adequate?
Yes
No
D.14. What is your body position and activity during work? a) I am constantly in motion, with no fixed body position. b) Mainly sitting c) Mainly standing d) Other, please specify____________________________ D.15. (i) Does your teaching entail laboratory or technical instruction?
Yes
No
(ii) If yes, is there risk of accident/injury?
Yes
No
If so, is this from? (Please check all that apply) a) Chemicals b) Machines c) Heat/burns d) Other, please specify____________________________ (iii) If you answered yes to (b), do these machines include vibrating tools such as drills? Yes No D.16. With regard to the risk of violence from or among students at the school at which you work: a) The risk is negligible c) Substantial b) Fairly small, but present d) High/imminent D.17. Is there an adequate communication device for emergencies in your classroom? a) Yes, and I know that it functions properly. b) Yes, but I do not know how well it actually functions. c) No, there is not a functioning system in place in case of emergency.
256 E. Mishaps at or regarding work Please answer the following three questions (E1-E3) for all work experience as a teacher E.1. Have you ever suffered physical harm or injury at work? If yes, was this a serious injury? If yes, was this violence related?
Yes Yes Yes
No No No
E.2. Have colleagues, staff or students suffered physical harm or injury at your workplace? a) Yes, I witnessed such, with a fatal outcome. b) Yes, I witnessed such, with a serious, but not fatal outcome. c) I’ve heard about serious or fatal injury, but never witnessed it. d) No, I have never witnessed or heard about anyone’s serious injury at my workplace. E.3. Have you ever been obliged to testify in court as a teacher? Yes If yes, in which capacity? a) As a witness b) As a defendant
No
F. Problems, Constraints and Influence at Work F.1. How strict are deadlines by which your work tasks must be completed? a) Very strict b) Somewhat strict c) Not very strict. d) Not at all strict. F.2. Are you obliged to speed-up your work tempo? a) Yes, every day b) Yes, at least weekly, but not daily c) Yes, during certain periods of the month or year d) No, it happens only rarely or never. F.3. With regard to your workload and time constraints: a) It is always possible to complete everything. b) It is usually possible to complete everything. c) It is sometimes impossible to complete everything, even with maximal effort. d) It is often objectively impossible to complete everything, even with maximal effort. F.4. Does it happen that due to unforeseen circumstances the plan of work changes? a) Never b) Rarely c) Occasionally d) Frequently
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F.5. How often does your required (administratively-defined) curriculum change? a) Yearly, or more often b) About every 2-3 years c) About every 4-5 years d) About every 6-10 years e) It hasn’t changed nor are changes foreseen in the future F.6. (i) Are there problems that directly hamper your providing quality teaching? a) Never b) Rarely c) Occasionally d) Frequently (ii) If yes, please check all that contribute to this problem a) Large class size b) Lack of appropriate textbooks c) Infrastructural problems/physically-poor classroom conditions d) Administrative constraints e) Language barriers with students f) Language barriers with parents g) Lack of teaching assistants h) Lack of other supporting staff i) Lack of support from parents j) Lack of equipment and supplies k) Lack of supplementary teaching materials l) Interruption from outside messengers, phone calls or administrative public announcements m) Students checking in and out during the term n) Required time for administrative tasks (e.g. processing student absences) o) Other problems (_____________________________) (iii) Which of the above are the biggest problems (List up to 3): _________________ _________________ _________________ F.7. (i) Are there students in your classes who disrupt classroom teaching? Yes No (ii) If yes, how frequently does this occur, typically? a) Less than once a week b) At least weekly, but not daily c) About once or twice per day d) Usually three or more times per day
258 F.8. Do you teach students with any of the following problems? Yes No If yes, please check all that apply: a) Behaviors that could be an immediate threat to the student, him or herself, or to others b) Substance abuse c) Teenage pregnancy d) Gang members e) Major family problems f) Inadequate sleep, food or parental/home care F.9. If you meet with parents, can you do so without being interrupted by students or personnel? Yes No How much influence do you have over each of the following areas? A great deal
To Some Degree
A Little
None
F.10 Your work hours and schedule F.11 Number of students per class F.12 Number of classes that you teach F.13 Your supporting staff— including who they will be F.14 Scheduling absences when needed F.15 Course curriculum (including choice of textbook(s)) F.16 Other planning and policy issues of your school or school district F.17 Whether and how much you will take on other, non-teaching duties F.18. (i) Is your work overseen? Yes No If yes, by whom? Please check all that apply: a) Teachers at your level of experience and training, or less b) Teachers with more training or teaching experience c) Administrates who have previously been teachers d) Non-teachers, persons without teaching experience, e.g. administrators who have never been teachers
259
(ii) If your work is overseen by others, is your judgment questioned? a) Often b) Sometimes c) Rarely d) Never Please answer the questions F.19-22 concerning rules and regulations about the following: Very strict
Somewhat strict
Somewhat Flexible
Very Flexible
F. 19 Curriculum F. 20 Sick leave and absences F.21 Grading F.22 Qualifying examinations F.23 Do you receive conflicting/contradictory information or instructions about the work you should be doing? a) Never b) Rarely c) Occasionally d) Frequently G. Inter-personal relations: G.1. In general, how is the social climate at your workplace? a) Excellent, we all get along very well together and misunderstanding are very rare. b) Good, most the time we get along well, with few misunderstandings and tensions. c) Fair, we have our ups-and-downs; sometimes there are misunderstandings and tensions. d) Poor, there is a great deal of tension and conflict. G.2. Can you get help for handling difficult students and/or dilemmas? a) Yes, I can almost always count on such help. c) I can’t really count on getting such help b) Yes, more often than not. d) Rarely or never do I get the help I need. G.3. Do you interact/communicate with colleagues or staff? a) Usually on a daily basis. b) A few times per week. c) About once per week. d) Rarely, I mainly interact with my students. G.4. Are there possibilities for you to upgrade your job title/advance your career? Yes No
260 If yes, do you receive support and encouragement for career advancement? a) Definitely yes. b) Yes, to some extent. c) Not really, but there is no active opposition to such efforts. d) No, there is active opposition to such efforts. G.5. Is good work recognized at your workplace? a) Definitely yes b) Yes, to some extent. c) Not very much. d) Not at all. G.6 Are there abuses of power or violations of norms of behavior at work? a) Never b) Rarely c) Occasionally d) Frequently G.7 Is there a possibility to redress grievances at work? a) Yes, this can be done in an efficient and confidential manner. b) In principle, yes, but this is either not effective or cannot be done confidentially. c) No, there is no possibility to redress grievances at work. H. Workload and Activities H.1. How many students do you usually have in each class? a) Less than 10 d) 21-25 b) 11-15 e) 26-30 c) 16 - 20 f) 31-35 g) >35 H.2. Do you have any class with over 40 students?
Yes
No
H.3. Are there any possibilities for students to receive one-on-one attention? a) No, but it is only rarely or never needed. b) No, this is often needed, but unrealizable. c) Yes, from assistants or volunteers. d) Yes, during scheduled office hours. H.4. Does it happen during work that several people seek your attention at the same time? a) Many times per day b) A few times per day c) At most once or twice a day d) Rarely or never
261 H.5. If people simultaneously seek your attention, how many do so? a) Rarely more than 2 b) Usually two, but sometimes more c) Usually more than 3 H.6. How often do you perform different tasks simultaneously? a) Never b) Rarely c) Occasionally d) Frequently H.7. Do you oversee or supervise the work of any of the following? (Please check all that apply) a) Teachers at your level of training or higher b) Teachers with less training than yourself c) Teachers’ aides d) Other ___________________ H.8. Number of persons other than students, whom you supervise: ________ H.9. Are you obliged to physically be at work, but there is no work to do or activities (e.g. work-related meetings) in which you are participating? a) Never, there is always work to do or activities in which I participate. b) Rarely do I sit out work time with nothing to do. c) Occasionally I sit out work time with nothing to do. d) Frequently I sit out work time with nothing to do. H.10. (i) Are any of your work tasks monotonous? Yes (ii) If yes, what are these? _______________________________
No
H.11. (i) How often do you use a computer as part of your work? a) Daily b) Weekly, but not daily c) Less than weekly. d) Rarely or never. (ii) If you answered a-c, do you encounter problems with using the computer?
Yes
H.12. Are there work tasks that you are obliged to perform, that you consider pointless? Yes No
No
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I. Recent Changes at Work: (Please answer the following questions for the last 6 months) Yes
No
Yes
No
I 1) Has there been an increase in the length of your workday? I 2) Has there been increased time pressure/number of deadlines? I 3) Have you had an increase in work responsibility? I 4) Have you been demoted? I 5) Has your pay been cut? I 6) Have you been promoted? I 7) Is there a threat that you will be laid off? I 8) Have there been other recent changes at work? If yes, please specify:
J. Other Questions about your workplace:
J 1) Is there a trade union at your workplace? J 2) Are you employed at an equal opportunity workplace? J 3) Is there a pension-plan available at your workplace? J 4) Is health care coverage provided by your workplace
K. Open-ended Questions about Teaching K.1. What is the best part of being a teacher of your profile? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ K.2. What is the hardest part of being a teacher of your profile?
263 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ K 3. What do you think could be done to make that difficulty less of a burden? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
K.4. What do you think could be done to improve work as a teacher of your profile? (i) Immediate/ very feasible: ___________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
(ii) Long-range changes: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ K.5. What would be the most important immediate change to improve work as a teacher of your profile? ________________________________________________________________ ________________________________________________________________ K.6. If attempts were made to improve the conditions for your job, what would you suggest to preserve the good aspects of your work as it now stands? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ K.7. Additional comments about your work:
264 OSI FOR TEACHERS SCORE SHEET
ID#: ______________________ A1. ____ Years in current job at present site A2. Employment capacity 1=Full time position 2=Part time position 3=Temporary capacity 4=other capacity: _____________________ A3. ____Years as a teacher A4. ____Years employed A5. Former Jobs: __________________
_________________
B.1 Type of School 1=a. Public 2=b. Private-secular 3=c. Parochial 4=d. Other: ________________________ B.2 Level of School 1=a. Elementary school 2=b. Middle school 3=c. High school (gymnasium) 4=d. Adult education 5=e. Community College 6=f. University 7=g. Other B.7 Main Socioeconomic background of students 1=a. Affluent 2=b. Middle class 3=c. Blue collar/working class 4=d. Poor 5=e. Combination: ___________ & __________________ B.11 Number of schools 1=a (one) 2=b (two) 3=c (three or more)
______________________
265 UNDERLOAD Homogeneous Information IU1 0 Heterogeneous information (for most teachers), unless ALL of the following apply: 0.5 Teaches only 1 grade (B.2), only 1-2 different subjects (B.4=a or b), students not of discrepant abilities (B.5=a), with no special needs (B.10=no), with minimal or no change in curriculum (F.5=d or e), AND H.10=yes (monotonous tasks) Low frequency of incoming signals IU2 0 Always >1 new signal/minute or control (Essential feature for teachers) No need for communication IU3 0 Works with others (for most teachers, if some communication with adults), unless: 0.5 Minimal communication with adults (teaches high school or younger (B.2=a, b or c) AND minimal communication with colleagues and staff (G.3=d) Input Under load Total: IU1 + IU2 + IU3 Automatic decision-making CUT 0 Not automatic (Essential feature for teachers) Central Under load Total: CUT Homogeneous Tasks OU1 1 H.10=yes (monotonous tasks) 0.5 H.10=no (no monotonous tasks) but teaches only 1-2 subjects (B.4=a or b), with no change in curriculum (F.5=d or e), and few tasks (C.5), otherwise: Heterogeneous tasks 0 Simple Tasks OU2 Heterogeneous tasks (Usually the case for teachers, unless C.5 clearly indicates 0 otherwise) C.5 clearly indicates that the tasks are simple and few in number (unlikely), maximum score could be 1 Nothing to do OU3 0 H9=a (Always something to do) 0.5 H9=b (Rarely nothing to do) 1 H9=c (Occasionally nothing to do) 2 H9=d (Frequently nothing to do)
266
Output Under load Total: OU1 + OU2 + OU3 Fixed Pay GU1 0 C.16=a or b (By individual work) 2 C.16=c (Fixed pay) Inadequate Pay GU2 0 C17=a (Covers substantially more than basic needs) 0.5 C17=b (Covers a bit more than basic needs) 1 C17=c (Just barely covers expenses) 2 C17=d (Totally inadequate) Lack of Promotion Prospects GU3 0 G.4=Yes + a, b, or c (Possibilities to upgrade job title or advance one’s career, and no active opposition) 1 G.4=Yes + d (There are upgrade possibilities, but active opposition) 2 G.4=No Lack of Recognition of Good Work GU4 0 G5=a (Definitely yes) 0.5 G5=b (Yes, to some extent) 1.5 G5=c (Not very much) 2 G5=d (Not at all) General Under load Total: GU1+GU2 + GU3 + GU4 Input Under load Total + Central Under load Total + Output Under load Total + General Under load Total = Total Under load Score HIGH DEMAND Three or more information sources simultaneously IH1 2 Usually the case for teachers, unless: 1 University teacher (B.2=f) with <10 students in a class (H.1=a) AND rarely or never do several people seek your attention at the same time (H.4=d)
267 Heterogeneous information IH2 ___ Usual range=1.0→ 2 (based upon number of different classes & subjects (B 3-4), various student backgrounds B.5 and B.10), changing curriculum (F.5), unless: 0 Teaches only 1-2 subjects (B.4=a or b), students not of widely discrepant abilities (B.5=a), not accelerated (B.6), or special needs (B.10=no), AND with little change in curriculum (F.5=d or e), Visual Input Primary IH3 0 Language or music teachers (B.3=d, e or g): Auditory modality primary 0.5 Auditory and visual input of about equal importance (most other teachers) 1 Visual input primary (e.g. computer sciences, B.3=j) More than five new signals per minute IH4 __ Range= 1→ 2 (based on burden - workload: (H.1-2, H.7-8) and control over workload (F.11-12 & F.17) Three sensory modalities simultaneously IH5 2 Teaches technical training or physical education (B.3=f or i) 1 Others Communication necessary for work IH6 2 (Essential feature for teachers) Input High Demand Total=IH1+IH2+IH3 + IH4 + IH5 + IH6 Complex Decisions/Interrelated Elements CH1 2 (Essential feature for teachers) Complicated Decisions/Many Elements CH2 2 (Essential feature for teachers) Decisions affect the work of others CH3 1 H.7-8 = no direct supervision, other than of students 1.5 H.8 =1 to 2 others, besides students 2 H.8 = 3 or more others, besides students
268 Rapid Decisions CH4 2 If special needs (B.10=yes), accident (D.15=yes), violence risk (D.16=b, c or d), disruption (F.7=yes) OR behavior threat (F.8=a), 1 Students of elementary school age (B.2=a), but otherwise as immediately below 0.5 Students of middle school age or older (B.2), no special needs (B.10), no accident or violence risk (D.15=no, and D.16=a), no classroom disruption (F.7=no) AND no behaviors that could be an immediate threat to the student or others (F.8) Central High Demand Total=CHI + CH2 + CH3 + CH4 Heterogeneous Tasks OH1 0 H.10=yes, (monotonous tasks), teaches only 1-2 subjects (B.4=a or b), with no change in curriculum (F.5=d or e), AND few tasks (C.5) 1 H.10=no (no monotonous tasks), but otherwise as immediately above 2 Several tasks (C.5) AND not monotonous (H.10=no) Simultaneous Task Performance OH2 0 H6=a (never) 0.5 H6=b (rarely) 1 H6=c (occasionally) 2 H6=d (frequently) Complex Tasks OH3 Usual range= 1→ 2 (based upon q. C.5) Rapid Task Execution OH4 2 B.3=f, g or .i; technical, music or physical education teaching, OR D.15=yes (laboratory or technical instruction) 1 If none of the above, but either teaches elementary school (B.2=a) or students with behavioral disorders or visual impairment (B.10 b or c) 0.5 If none of the above. Output High Demand Total=OHI + OH2 + OH3 + OH4 Piece Rate GH1 0 C.16=c (Fixed pay, regardless of workload) 1 C.16=b (Group work) 2 C.16=a (By individual work)
269
Long work hours GH2 0 C. 1-5= Not over 40h/week) 0.5 C 1-5 =40 to 42h/week 1 C. 1-5= frequently over 42h/week, &/or occasionally over 48h/week) 2 C. 1-5= frequently over 48h/week, &/or occasionally over 60h/week) (Add 0.5 points if C.8=c or d (called at home) to a maximum of 2 points) Two or more jobs GH3 0 C.9 (a and b) =no 1 C.9 (b)= yes (another job during summer) AND C.9(a)=no (not during school year) 2 C.9 (a)= yes (has another job besides teaching during the regular school year) Other job: ________________________ Rest breaks GH4 0 C.12=d (frequently) 1 C.12=c (occasionally) 1.5 C.12=b (rarely) 2 C.12=a (never) (Add 0.5 points if C.13=a, C.14=no, or if C.15 > 2 hours, to a maximum of 2 points) Reason(s) for lack of break: ________________________ Night shift or irregular work GH5 0 C.4 = yes (regular work schedule) 0.5 C.4=no (irregular work schedule) If C4=regular work schedule, Morning start time: _________ Lack of Paid Vacation GH6 0 C.10= Over four weeks 1 C.10=Three to four weeks 1.5 C.10=Two weeks 2 C.10=Less than two weeks General High Demand Total=GHI + GH2 + GH3 + GH4 + GH5 + GH6 Input High Demand Total + Central High Demand Total + Output High Demand Total + General High Demand Total = Total High Demand Score
270
STRICTNESS Strict requirements for signal detection IST 0.5 Students of middle school age or older (B.2), no special needs (B.10), no accident or violence risk (D.15ii=no, and D.16=a), no disruption (F.7=no) AND no behaviors that could be an immediate threat to the student or others (F.8≠ a), 1 Elementary school teacher (B.2=a), but otherwise as immediately above 2 If any of the following: special needs (B.10), accident or violence risk (D.15ii=yes), D.16=b, c or d, disruption (F.7=yes) OR behavior threat (F.8=a) Input Strictness Total=IST Strict problem solving strategy CS1 0 F.15 & F.16: major influence on curriculum & planning 0.5 F.15 & F.16: some influence on curriculum & planning 1 F.15 & F.16: little or no influence on curriculum & planning (If mixed answers, choose the worse option) Strictly defined correct decision CS2 0 F.19 & F.21: flexible rules on curriculum and grading 1 F.19 & F.21: somewhat strict rules on curriculum and grading 2 F.19 & F.21: very strict rules on curriculum and grading (If mixed answers, choose the worse option) Central Strictness Total=CS1 + CS2 Strict evaluation of performance OST 0 F.18=no, work not overseen by others 0.5 F.18=yes, work overseen by others; judgment rarely or never questioned, iii=c or d 1 F.18=yes, work overseen by others; judgment sometimes questioned, iii =b 2 F.18=yes, work overseen by others; judgment often questioned, iii =a Output Strictness Total=OST Fixed Posture GS1 0 D.14=a, constantly in motion, with no fixed body position 1 D.14=b or c, mainly sitting or standing
271 Confined, window-less, poorly ventilated work area GS2 0 Works outside, or indoors in >1 location (D9=d or e) 1 Has own classroom (D.8b=yes) or doesn’t change classroom daily (D.9=a, b or c) Add 0.5 points if D10=h, inadequate ventilation or if H.2 = yes (more than 40 students) and add 1 point if D.8a=no (inadequate space) to a maximum of 2 points. Lack of autonomous workspace GS3 0 Has own desk/workspace (D7a=yes) AND (has own classroom (D8b=yes)) AND [(D.9=a or b, doesn’t change classroom frequently) OR (works outside)] 1 Has own desk or workspace (D7a=yes), but doesn’t have own classroom (D8b=no) or changes classroom frequently (D.9=c, d or e) 2 No autonomous workspace (D7a=no) Add 0.5 point if no safe place for belongings (D.7b=no), to a maximum of 2 points Limited chance to take time off from work GS4 0 C.11=a (no problem to take time off) 1 C.11=b (a little difficult to take time off) 1.5 C.11=c (somewhat difficult to take time off) 2 C.11=d (very difficult to take time off) Limited influence over work schedule GS5 0 F10 & F14 = A great deal of influence 0.5 F10 & F14 =some influence 1.5F10 & F14 =A little influence 2 F10 & F14 =No influence If mixed answers, choose the worse option Limited influence over deciding with whom he or she works GS6 1 F11 & F.13=Great deal of influence over #of students per class and supporting staff 1.5 F11 & F13= some or a little influence over # of students per class and supporting staff 2 F11 & F13= No influence over number of students per class and supporting staff If mixed answers, choose worse profile Limited influence over what the work tasks will be GS7 1 F.12 & F.17= Major or influence over # of classes and taking on non-teaching duties 1.5 F.12 & F.17=A little influence over # of classes and taking on non-teaching duties 2 F.12 & F.17= A little influence over # of classes and taking on non-teaching duties If mixed answers, choose worse profile
272 Limited influence over policy GS8 0 F16= Major 0.5 F16= Some 1.5 F16= A little 2 F16= None General Strictness Total=GS1 + GS2 + GS3 + GS4 + GS5 + GS6 + GS7 + GS8 Input Strictness Total + Central Strictness Total + Output Strictness Total + General Strictness Total = Total Strictness Score EXTRINSIC TIME PRESSURE Control of incoming signals IEPT 1 Major or some control over # students/class (F.11) AND no classroom disruption (F.7) AND no behavioral problems (F.8≠a) 1.5 Little or no control over # students/class (F.11) OR classroom disruption (F.7) OR behavioral problems (F.8=a) 2 Little or no control over # students/class (F.11) AND [classroom disruption (F.7) OR behavioral problems (F.8=a)] If mixed answers, choose worst profile Input Extrinsic Time Pressure Total=IEPT Decisions cannot be postponed CEPT 2 F.8 =a (students with behaviors immediately threatening to self or others) or D.15=accident risk or D.16=c or d (threat of violence) 1 Above is not the case, but F.7=yes (students disrupt classroom teaching) 0 None of the above are the case. Central Extrinsic Time Pressure Total=CEPT Control of Task Performance Rate OEPT 1 F.11, F.12 & F.17=Major control over # of students and classes and of other duties 1.5 F.11, F.12 & F.17= Some control over # of students and classes and of other duties 2 F.11, F.12 & F.17=Little or no control over # of students and classes and of other duties (If mixed answers, choose the worst option) Output Extrinsic Time Pressure Total=OEPT
273 Deadline Pressure GEP1 0 F1=d (not at all strict deadlines) 0.5 F1=c (not very strict deadlines) 1 F1=b (somewhat strict deadlines) 2 F1=a (very strict deadlines) Speedup GEP2 0 F.2 =d, rarely or never 1 F.2 =c (certain periods of the month or year) 1.5 F.2 =b (at least weekly) 2 F.2 =a (every day) General Extrinsic Time Pressure Total=GEP1 + GEP2 Input Extrinsic Time P Total + Central Extrinsic Time P Total + Output Extrinsic Time P Total + General Extrinsic Time P Total = Total Extrinsic Time Pressure Score AVERSIVENESS/NOXIOUS EXPOSURES Glare INOX1 0 D1=a (never) 0.5 D1=b (rarely) 1 D1=c (occasionally) 2 D1=d (frequently) Noise INOX2 0 D3=a (not noisy) 1 D3=b (rarely) 1.5 D3=c (occasionally) 2 D3=d (frequently) Input Noxious Exposure Total=INOX1 + INOX2 Isometric lifting ONOX1 0 D4=a (never) 0.5 D4=b (rarely) 1 D4=c (occasionally) 2 D4=d (frequently) Add 0.5 points if > 30kg or 50 lbs., up to maximum of 2 points
274 Vibration exposure ONOX2 0 D.15iii=no 1 D.15iii=yes Output Noxious Exposure Total=ONOX1 + ONOX2 Heat Exposure GNOX1 0 D.5=a (<25 °) 0.5 D.5=b (25 to 30 °) 1 D.5=c (30 to 40 °) or D.15=c (heat during laboratory instruction) Add 0.5 points, to maximum of 2, if D 10=h (poor ventilation) Cold Exposure GNOX2 0 D.6=a (at least 20 ° C) 0.5 D.6=b (at last 18 ° C) 1 D.6=c (10 - 18°) 2 D.6=d (<10 ° C) Add 0.5 points to a maximum of 2, if D.10=a or f (leaky ceiling or poor isolation/drafty) or D.11=a or c (concrete or linoleum floor) Exposure to fumes, gases &/or dusts GNOX3 1 D.10 = e or g (mold or mildew) or D.15=a (chemistry laboratory) 0 D.10 ≠ e or g and D.15 ≠ a Exposures: ____________________ ____________________ ____________________ General Noxious Exposure Total=GNOX1 + GNOX2 + GNOX3 Input Noxious Exposure Total + Output Noxious Exposure Total + General Noxious Exposure Total = Total Noxious Exposure Score AVOIDANCE (SYMBOLIC AVERSIVENESS/DISASTER POTENTIAL) Need for sustained alertness to avoid serious consequences IAVOI1 2 D.15ii=yes (accident risk) OR D.16=c or d (substantial or imminent risk of violence) OR F.8=a (student behaviors that could immediately threaten self or others) 1.5 D.16=b (small, but present risk of violence) OR B.2 (teaches elementary school) OR B.10 =b or c (behavioral or visual impairment) 1 None of the above, but non-adult students (B.2=b or c) 0.5 None of the above, adult students (B.2=d, e or f) (minimum TAV of the teaching profession)
275
Visually disturbing scenes IAVOI2 0 E.1 = no and E.2 = c or d (has not seen or experienced injury) Score by severity and number (maximum=2, if witnessed several fatal injuries) Add 0.5 point to maximum of 2 if these were violence related Listen to accounts of emotionally disturbing occurrences IAVOI3 0 D.2=a (never) 0.5 D.2=b (rarely) 1 D.2=c (occasionally) 2 D.2=d (frequently) Occurrences: ________________________ Input Symbolic Aversiveness Total = IAVOI1 + IAVOI2 + IAVOI3 Serious consequences of wrong decisions CAVOIT 2 D.15ii=yes (accident risk) OR (D.16=c or d, substantial or imminent risk of violence), OR (F.8=a, student behaviors that could immediately threaten self or others) 1.5 D.16=b (small, but present risk of violence) OR (B.2=a, teaches elementary school) OR (B.10=b or c, behavioral or visual impairment) 1 None of the above, but non-adult students (B.2=b or c) 0.5 None of the above, adult students (B.2=d, e or f) (minimum TAV of teaching) Central Symbolic Aversiveness Total = CAVOIT Hazardous Task Performance OAVOIT 0 D15ii=no accident risk, AND D.16=a, negligible violence risk, AND D.10≠c 1 D15ii=yes, accident risk, OR (D.16=b or c, some violence risk) OR (D.10=c, poor electrical installation) 2 D.16=d, imminent risk of violence OR [D.15ii=yes, accident risk AND D.10=c poor electrical installation] Output Symbolic Aversiveness Total = OAVOIT Experienced Physical Harm/Injury at Work GAVOI1 0 E.1 = No 1 E.1 = Yes, if minor and accidental 2 E.1 = Yes, if serious or violence-related
276 Witnessed Physical Harm/Injury at Work GAVOI2 0 E.2 = d (never heard about or witnessed a serious accident at work) 0.5 E.2 = c (heard about but never witnessed a serious accident at work) 1 E.2 = b (witnessed serious accident at work) 2 E.2 = a (witnessed fatal accident at work) Litigation/Testifying in Court GAVOI3 0 E3 (No) 1 E3 (Yes, (a) As a witness) 2 E3 (Yes, (b) As a defendant) Lack of functioning emergency system GAVOI4 0 D.17 =a (Yes and knows that it functions properly) 1 D.17 =b (Yes, but does not know whether it functions properly) 2 D.17 =c (No) General Symbolic Aversiveness Total = GAVOI1 + GAVOI2 + GAVOI3 + GVOI4 Input Symbolic Aversiveness Total + Central Symbolic Aversiveness Total + Output Symbolic Aversiveness Total + General Symbolic Aversiveness Total = Total Symbolic Aversiveness Score CONFLICT/UNCERTAINTY Signal/noise conflict ICNFL1 0 D.3=a or b (not noisy in classroom) AND F.7=no or a or b (less than daily disruption of classroom teaching) 1 D.3 = c (occasionally noisy in classroom) OR F.7 = c (disruption of classroom teaching 1-2 times/d) 1.5 D.3 = d (frequently noisy in classroom) OR F.7 = d (disruption of classroom teaching 3+ times/d) 2 D.3 = d (frequently noisy in classroom) AND F.7 = d (disruption of classroom teaching 3+ times/d) Signal/signal conflict ICNFL2 2 B.8=yes (lack of language fluency) c= (>50%) 1 B.8=yes (lack of language fluency) b= (10 to 50%) 0.5 B.8=yes (lack of language fluency) a= (<10%) or F.6=f (language barriers with parents) 0 None of the above
277 Input Conflict Total = ICNFL1 + ICNFL2 Missing information needed for decision-making CCNFL1 2 B.8=yes (lack of language fluency) 1 B.8=yes (lack of language fluency) 0.5 B.8=yes (lack of language fluency), or F.6=f (language barriers with parents) 0 None of the above Contradictory information CCNFL2 0 F.23=a (never) 0.5 F.23=b (rarely) 1 F.23=c (occasionally) 2 F.23=d (frequently) Unforeseeable events require new plan CCNFL3 0 F.4=a 0.5 F.4=b 1.5 F.4=c 2 F.4=d Add 0.5 points to a maximum of 2 if F.5=a or b (curriculum change fairly frequent) Central Conflict Total = CCNFL1 + CCNFL2 + CCNFL3 Conflicting demands in time and space OCNFL1 0 F3=a (Always possible to complete everything) 0.5 F3=b (Usually possible to complete everything) 1 F3=c (Sometimes impossible to complete everything) 2 F3=d (Often impossible to complete everything) Add 0.5 points to a maximum of 2 if inadequate time for performing tasks other than classroom teaching External Conditions hamper task performance OCNFL2 0 F.6i =a (never) 0.5 F.6i =b (rarely) 1 F.6i =c (occasionally) 2 F.6i =d (frequently) Sources: ________________
278 Interruptions from people hamper task performance OCNFL3 0 F.7i =no 0.5 F.7i =yes, F.7ii=a 1 F.7i =yes, F.7ii=b 1.5 F.7i =yes, F.7ii=c 2 F.7i =yes, F.7ii=d Add 0.5 point, to a maximum of 2, if F.9=no, interruption during meetings with parents Output Conflict Total = OCNFL1 + OCNFL2 + OCNFL3 Emotionally charged work atmosphere GCNFL1 0 G.1=a (no) 0.5 G.1=b (minimal) 1 G.1=c (occasionally) 2 G.1=d (great deal of tension) Lack of help with difficulties GCNFL2 0 G.2=a (Can count on help) 0.5 G.2=b (Usually) 1.5 G.2=c (Can’t count on it) 2 G.2=d (Little or no help) Opposition to career advancement GCNFL3 0 G.4 (No=no opportunities) OR ((Yes) AND (a or b = support for advancement)) 1 G.4 (Yes) AND (c = not really support, but not active opposition) 2 G.4 (Yes) AND (d = active opposition) Violations of behavior norms/abuses of power GCNFL4 0 G.6=a (Never) 0.5 G.6=b (Rarely) 1.5 G.6=c (Occasionally) 2 G.6=d (Frequently) Lack of redress of grievances GCNFL5 0 G.7=a (Redress can be done and is efficient and confidential) 1 G.7=b (In principle yes but not effective or not confidential) 2 G.7=c, (No possibility to redress grievances)
279 Threat of Job Loss GCNFL6 0 A2=a or b (Full time or part time position) AND I7=no 1 A2=c (Temporary work) AND I7=no 2 I7=yes, (threat of job loss present) If I7=no and A2=d, evaluate whether this is basically temporary versus stable employment Job lacks coherence GCNFL7 0 H.12 =no (no performance of pointless tasks) 1 H.12 =yes (performance of pointless tasks) General Conflict Total = GCNFL1 + GCNFL2 + GCNFL3 + GCNFL4 + GCNFL5 + GCNFL6 + GCNFL7 Input Conflict Total + Central Conflict Total + Output Conflict Total + General Conflict Total = Total Conflict Score
Total Under load + Total High Demand + Total Strictness + Total Extrinsic Time Pressure + Total Noxious Exposure + Total Symbolic Aversiveness + Total Conflict = Total OSI Score
280
Chapter 7
Conclusions and Future Perspectives We have presented a multi-facetted view of the Occupational Stress Index (OSI). Its roots come from basic principles of cognitive ergonomics and insights from brain research, while also incorporating the perspectives and experience of the leading occupational psychosocial models. The OSI offers a complementary approach to these more sociological models, and actually helps to confirm the validity of the Job Strain construct, by operationalizing the less apparent features of mental load upon the central nervous system, as well as the often interrelated constraining and limiting conditions that can create “strain”. Of critical importance in this process has been the development of occupation-specific OSI instruments that are germane to a given line of work, and yet mutually compatible, as part of a unified theoretical framework. The OSI views the work environment as a whole, and includes “mental”, physical, ergonomic and organizational factors, as these all impact upon the central nervous system, so that the additive burden effect can be assessed. The often unrecognized, yet vital dimension of threat-avoidant vigilant activity is also included in the OSI. The practical utility of the OSI is demonstrated in the clinical arena, where it provides the basis for preparing a comprehensive occupational history that could be incorporated into the general medical records. We have shown how insights gained from the OSI can inform diagnostic and management strategies, including the identification of key modifiable work stressors. This clearly illustrates why the workplace needs to become an integral consideration in those clinical domains, most notably cardiology and neuro-psychiatry, as well as rheumatology, inter alia, where work-stress related health outcomes are the most prevalent. This approach could help pave the way for the formulation and implementation of randomized clinical trials, in which workplace modifications are tested as a potential adjunct therapeutic modality for patients with e.g. hypertension, ischemic heart disease, depression, anxiety, musculoskeletal disorders and perhaps other stress-triggered disorders affecting large numbers of working people, such as migraine headaches. This experience might also inform broader intervention strategies for job redesign, as suggested by Fisher and Belkic (2000). The revised versions of the OSI plus the newly presented OSI for teachers, together with the detailed instructions for data analysis, provide the possibility for a wider application of the Occupational Stress Index in a variety of settings. As mentioned, it was the on-going dialog and large number of requests for use of the OSI, that motivated preparation of this work. This author will consider this effort most worthwhile insofar as this dialog and feedback are hereby facilitated, including the process of developing new specific OSI’s.
281 A limitation of the Occupational Stress Index, as applied heretofore, has been the linear nature of the analyses that have been performed. There is a need to explore possibilities for multiplicative or other interactions and higher-level terms, especially in relation to existing models such as Job Strain. Eventually, weighting factors might be developed to reflect the relative contribution of the various factors to the total burden. The extrinsic time pressure and strictness dimensions that had a low internal consistency for the earlier version of the generic OSI, need retesting with the revised OSI’s. It may be worthwhile to perform factor analysis. There could be, e.g., one factor related to general and task performance elements, and another related to the input and central decision-making levels. Integration could be performed with objective measurements (part of triangulation, as described by Kristensen (1996)). For example, for urban mass transit operators there could be finer gradations to the scoring of high frequency of incoming signals based upon traffic density measures. By a similar logic, data about the average number of passengers on a given route could improve quantification of the burden of communicating with the public. Information obtained from expert-observer assessment of job characteristics, as outlined by Greiner and Krause (2000), could likewise be integrated with the OSI, and would also improve its precision. On the other hand, the OSI could detect areas for which in-depth observational analysis is needed, especially with a view to possibilities for practical improvements in the work environment.
282 BIBLIOGRAPHIC REFERENCES
Ahlberg-Hulten GK, Theorell T, Sigala F. Social support, job strain and musculoskeletal pain among female health care personnel. Scand J Work Environ Health 1995; 21: 435-439. Akhras F, Jackson G. Raised exercise diastolic blood pressure as indicator of ischaemic left ventricular function. Lancet. 1991; 337:899-900. Adams SL, Roxe DM, Weiss J, Zhang F, Rosenthal JE. Ambulatory blood pressure and Holter monitoring of emergency physicians before, during, and after a night shift. Academic Emergency Medicine 1998; 5: 871-877. Alfredsson L, Hammar N, Hogstedt C. Incidence of myocardial infarction and mortality from specific causes among bus drivers in Sweden. Int J Epidemiol. 1993; 22: 57-61. Amick B, Kawachi I, Coakley E, Lerner D, Levine S, Colditz G. Relationship between job strain and iso-strain to health status in a cohort of women in the United States. Scand J Work Environ Health 1998; 24:54-61. Apparies RJ, Rinolo TC, Porges SW. A psychophysiological investigation of the effects of driving longercombination vehicles. Ergonomics 1998; 41: 581-592. Backman AL. Health survey of professional drivers. Scand J Work Environ Health. 1983; 9: 30-35. Bakker AB, Killmer CH, Siegrist J, Schaufeli WB. Effort-reward imbalance and burnout among nurses. J Adv Nursing 2000; 31:884-891. Baldwin DS, Rudge SE. Depression and suicide in doctors and medical students. In: P Litchfield (ed.) Health risks to the health care professional. 1995, Royal College of Physicians of London, London, pp.77-89. Barsky AJ. Psychiatric and behavioral aspects of cardiovascular disease. In: E. Braunwald, DP Zipes, Libby P. (eds). Heart Disease. A Textbook of Cardiovascular Medicine. WB Saunders Co., Philadelphia, 2001, pp. 22442261. Belkic K. Neural mechanisms and risk of sudden cardiac death. An epidemiologic approach. Doctoral Dissertation. University of Belgrade, Center for Multidisciplinary Studies, 1989. Belkic K. Psychosocial triggers of myocardial ischemia in women. Research Report to the Swedish Medical Research Council. 1995(b). Belkic K, Emdad R, Theorell T, Cizinsky S, Wennberg A, Hagman M, Johansson L, Savic C, Olsson K. Neurocardiac mechanisms of heart disease risk among professional drivers. Stockholm: Swedish Fund for Working Life, 1996. Belkic K, Emdad R, Theorell T. Occupational profile and cardiac risk: possible mechanisms and implications for professional drivers. International Journal of Occupational Medicine and Environmental Health. 1998; 11: 37-57. Belkic, K; Ercegovac, D; Savic, C; Panic, B; Djordjevic, M; Savic S. EEG arousal and cardiovascular reactivity in professional drivers. The glare pressor test. Eur Heart J. 1992(b); 13: 304-309. Belkic K, Landsbergis P, Schnall P, Baker D, Theorell T, Siegrist J, Peter R, Karasek R. Psychosocial factors: Review of the empirical data among men. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000b; 15: 24-40.
283 Belkic K, Landsbergis P, Schnall P, Baker D. Is job strain a major risk factor for cardiovascular disease? A critical review of the published longitudinal studies. Third International Conference on the Work Environment and Cardiovascular Diseases—International Commission on Occupational Health. Dusseldorf, March 2002. Belkic K, Landsbergis P, Schnall P, Baker D. Is Job Strain A Major Source Of Cardiovasculardisease Risk? A Critical Review of the Empirical Evidence, with a Clinical Perspective 2003. Submitted Manuscript. Belkic, K; Savic, C; Djordjevic, M; Ugljesic, M; Mickovic, Lj. Event-related potentials in professional city drivers: heightened sensitivity to cognitively relevant visual signals. Physiol Behav. 1992(a); 52: 423-427. Belkic K, Savic C, Theorell T, Cizinsky S. Work Stressors and Cardiovascular Risk: Assessment for Clinical Practice. Part I. Stockholm (Sweden): Stress Research Reports. National Institute for Psychosocial Factors and Health. Section for Stress Research, Karolinska Institute, WHO Psychosocial Center; 1995(a). Report No.: 256. Belkic, K; Savic, C; Theorell, T; Rakic, Lj; Ercegovac, D; Djordjevic, M. Mechanisms of cardiac risk among professional drivers. Scand J Work Environ Health 20:73-86; 1994. Belkic K, Schnall P, Landsbergis P, Baker D. The workplace and cardiovascular health: Conclusions and thoughts for a future agenda. In: : Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000(a); 15: 307-321. Belkic K, Schnall P, Landsbergis P, Schwartz JE, Gerber LM, Baker D, Pickering TG. Hypertension at the Workplace—An occult disease? The need for work site surveillance. Theorell T (ed.) Biological Stress Mechanisms. Advances in Psychosomatic Medicine, Basel, Karger, 2001; 22: 116-138. Bigert C, Gustavsson P, Hallqvist J, Hogstedt C, Lewne M, Plato N, Reuterwall C, Scheele P. Myocardial infarction among professional drivers—A population-based case-referent study. Third International Conference on the Work Environment and Cardiovascular Diseases—International Commission on Occupational Health. Dusseldorf, March 2002. Bisseret A. Analysis of processes involved in air traffic control. Ergonomics. 1971; 14: 565-570. Bosma H, Marmot M, Hemingway H. et al. Low job control and risk of coronary heart disease in Whitehall II (prospective cohort) study. BMJ 1997; 314: 558-565. Bosma H, Peter R, Siegrist J, Marmot M. Two alternative job stress models and the risk of coronary heart disease. Am J Publ Health 1998a; 88: 68-74. Bosma H, Stansfeld SA, Marmot MG. Job control, personal characteristics and heart disease. Occupational Health Psychology 1998b; 3: 402-409.
Journal of
Bourbonnais R, Brisson C, Moisan J, Vezina M. Job strain and psychological distress in white-collar workers. Scand J Work Environ Health 1996; 22: 139-45. Bourbonnais R, Comeau M, Vezina M, Dion G. Job strain, psychological distress, and burnout in nurses. Am J Industrial Med 1998; 34: 20-28. Braby CD, Harris D, Muir HC. Ergonomics 1993; 36: 1035-1042.
A psychophysiological approach to the assessment of work underload.
Braunwald E. Cardiovascular medicine at the turn of the millennium: Triumphs, concerns and opportunities. New Engl J Med 1997; 337: 1360-1369. Brislin R, Lower W, Thorndike R. Crosscultural research methods. New York: John Wiley, 1973.
284
Brisson C, LaFlamme N, Moisan J, Milot A, Masse B, Vezina M. Effect of family responsibilities and job strain on ambulatory blood pressure among white-collar women. Pyschosom Med 1999; 61: 205-213. Brisson C. Women, work and CVD. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease.2000; 15: 49-57. Cacioppo JT, Tassinary LG. Psychophysiology and psychophysiological inference. In: (Eds.) Cacioppo JT, Tassinary LG. Principles of psychophysiology. Physical, social and inferential elements. Cambridge: Cambridge University Press, 1990, pp. 3-33. Carpenter LM, Swerdlow AJ, Fear NT. Mortality of doctors in different specialties: findings from a cohort of 20 000 NHS hospital consultants. Occup Environ Med 1997; 54: 388-395. Chiappa K.H Evoked Potentials in Clinical Neurology. 2nd Edition. New York, Raven Press, 1989. Cobb S, Rose RM. Hypertension, peptic ulcer disease and diabetes in air traffic controllers. JAMA 1973; 224: 489-492. Coles, G.H., Gratton, G., Fabiani, M. Event-related potentials. In J.T. Cacioppo, L.G.Tassinary (Eds.). Principles of psychophysiology. Physical, social and inferential elements. Cambridge: Cambridge University Press, 1990, pp. 413-455. Cooper R, Osselton JW, Shaw JC. EEG Technology. 3’d Ed. London: Butterworth’s, 1980. Corley KC , O’Shiel F, Mauck HP. Myocardial degeneration and cardiac arrest in squirrel monkeys. Physiologic and psychologic correlates. Psychophysiology 1977; 14: 322-328. Costa G Evaluation of workload in air traffic controllers. Ergonomics. 1993; 36: 1111-1120. Cropley M, Steptoe A, Joekes K. Job strain and psychiatric morbidity. Psychosom Med 1999; 29: 1411-1466. Dark SJ. Characteristics of medically disqualified airman applicants in calendar years 1982 and 1983. Aviat Space Environ Med. 1987; 58: 452-460. de Gaudemaris R. Clinical issues: Return to work and public safety. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15: 223-230. Devereux RB, Pickering TG, Harshfield GA, Kleinert HD, Denby L, Clark L, Pregibon D, Jason MN, Kleiner B, Borer JS, Laragh JH. Left ventricular hypertrophy in patients with hypertension: Importance of blood pressure response to regularly recurring stress. Circulation. 1983; 68: 476-479. Eaton WW, Anthony JC, Mandel W, Garrison R. Occupations and the prevalence of major depressive disorder. J Occup Med. 1990; 32: 1079-1087. Emdad R, Belkic K, Theorell T, Cizinsky S, Savic C, Olsson K. Work environment, neurophysiologic and psychophysiologic models among professional drivers with and without cardiovascular disease: Seeking an integrative neurocardiologic approach. Stress Med 1997; 13: 7-21. Emdad R, Belkic K, Theorell T, Cizinsky S, Savic C, Olsson K. Psychophysiologic sensitization to headlight glare among professional drivers with and without cardiovascular disease. Journal of Occupational Health Psychology 1998(b); 3: 147-160.
285
Emdad R, Belkic K, Theorell T, Cizinsky S. What prevents professional drivers from following physicians' cardiologic advice? Psychoth Psychosom 1998(a); 67: 226-240. Erikssen J, Johansen AH, Rodahl K. Coronary heart disease in Norwegian sea-pilots: part of the occupational hazard? Acta Med Scand Suppl. 1981; 645: 79-83 Evans GW. Working on the hot seat: urban bus operators. Accid Anal Prev 1994; 22: 181-193. Fisher J, Belkic K. A public health approach in clinical practice. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15: 245-253. Fossum E, Hoieggen A, Moan A, Rostrup M, Kjeldsen SE. The cardiovascular metabolic syndrome. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15: 146-150. Frankenhaeuser M, Johansson G. On the psychophysiologic consequences of understimulation and overstimulation. In Levi L. Society, Stress and Disease. Vol. 4 Working life. New York: Oxford University Press, 1981. Fuller R. A conceptualization of driving behaviour as threat avoidance. Ergonomics 1984: 27; 1139-1155. Gaillard, A.W.K. (1993). Comparing the concepts of mental load and stress. Ergonomics 1993; 36: 991-1005. Gardell B. Work organization and Human Nature. The Swedish Work Environment Fund, Stockholm, 1987. Gardell B, Aronsson G, Barklof K. The working environment for local public transport personnel. Stockholm: The Swedish Work Environment Fund, 1983. Goldstein IB, Shapiro D, Chicz-DeMet A, Guthrie D. Ambulatory blood pressure, heart rate and neuroendocrine responses in women nurses during work and off work days. Psychosom Med 1999; 61: 387-396. Green, R.G., Muir, H., James, M., Gradwell, D., Green, R.L. Human Factors for Pilots. Hampshire: Avebury Technical, 1991. Greiner BA, Krause N. Expert-observer assessment of job characteristics. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15: 175-183. Greiner BA, Krause N, Ragland DR, Fisher JM. Objective stress factors, accidents, and absenteeism in transit operators: A theoretical framework and empirical evidence. J Occup Health Psychol. 1998; 3: 130-146. Gunnarsdottir H, Rafnsson V. Mortality among Icelandic nurses. Scand J Work Environ Health 1995; 21:24-29. Gunter TC, Van der Zande RD, Wiethoff M, Mulder G, Mulder LJM. Visual selective attention during meaningful noise and after sleep deprivation. In R. Johnson, Jr., J.W. Rohrbaugh, R. Parasuraman. Current Trends in EventRelated Potential Research (EEG Supplement 40) Amsterdam: Elsevier Science Publishers B.V., 1987, pp. 99-107. Gustavsson P, Alfredsson L, Brunnberg I, Hammar N, Jakobsson R, Reuterwall C, Ostlin P. Myocardial infarction among male bus, taxi, and lorry drivers in middle Sweden. Occupational and Environmental Medicine 1996; 53: 235-240.
286 Hammar N, Alfredsson L, Smedberg M, Ahlbom A. Differences in the incidence of myocardial infarction among occupational groups. Scand J Work Environ Health 1992; 18: 178-185. Harber P, Billet E, Gutowski M, SooHoo K, Lew M, Roman A. Occupational low-back pain in hospital nurses. J Occup Med 1985; 27:518-524. Harrington JM. Mortality from coronary artery disease of English and Hamburg sea pilots. Trans Soc Occup Med 1972; 22: 19-23. Hebb, D.O. A Textbook of Psychology. Philadelphia: Sanders, 1958. Hedberg GE. The period prevalence of musculoskeletal complaints among Swedish professional drivers. Scand J Soc Med. 1988 ; 16: 5-13 Heim E. Stressors in medical professions. Do women bear the greater risks for their health? Zsch psychosom Med 1992; 38: 207-226. Hemingway H, Marmot M. Psychosocial factors in the aetiology and prognosis of coronary heart disease: systematic review of prospective cohort studies. BMJ 1999; 318: 1460-1467. Hishashige A. Burnout phenomenon and its occupational risk factors among Japanese Hospital Nurses. J Hum Ergol 1991; 20: 123-136. Hohnsbein J, Falkenstein M, Hoormann J. Effects of attention and time-pressure on P300 subcomponents and implications for mental workload research Biol Psychol 1995; 40: 73-81. Israel B, Schurman SJ, Hugentobler M. Conducting action research: Relationships between organization members and researchers. J Appl Behav Science 1992; 28: 74-101. Ivanitsky AM. Evoked potentials and mental processes. In Lechner H, Aranibar A. Electroencephaologr Clin Neurophysiol. Amsterdam, Excerpta Medica, 1980, pp. 727-732. Johnson JV, Hall EM. Job strain, workplace social support and cardiovascular disease: A cross-sectional study of a random sample of the Swedish working population. Am J Public Health 1988; 78:1336-1342 Johnson JV, Hall EM. Class, work, and health. In: Amick B, Levine S, Tarlov AR, Walsh DC (eds.): Society and Health. New York, Oxford University Press, 1995, pp. 247-271. Johnson JV, Stewart W. Measuring work organization exposure over the life course with a job-exposure matrix. Scand J Work Environ Health 1993; 19:21-28. Jorna PGAM. Heart rate and workload variation in actual and simulated flight. Ergonomics 1993; 36: 1043-1054. Josephson M, Lagerstrom M, Hagberg M, Wigaeus Hjelm E. Musculoskeletal symptoms and job strain among nursing personnel: a study over a three year period. Occup Environ Med 1997; 54: 681-685. Josephson ME, Zimetbaum P, Buxton A, Marchlinski FE, Paroxysmal Supreventricular Tachycardia. In Fauci AS, Braunwald E, Isselbacher K, et al. (eds). Harrison’s Principles of Internal Medicine. McGraw-Hill, New York, 1998, pp. 1265-1268. Joy M. Introduction and summary of principal conclusions to the first European workshop in aviation cardiology. Eur Heart J 1992; 13: Suppl H: 1-9.
287 Kalsbeek JWH. Prevention of excessive mental load, and how can the industrial engineer and the ergonomist cooperate. Laboratorium voor ergonomische psychologie van de gezondheidarganisatie, TNP. pres., Conference of the European Federation of Productivity Service, Berlin, 1974. Karasek RA. Job demands, job decision latitude and mental strain: Implications for job redesign. Adm Sci Q 1979; 24: 285-307. Karasek RA, Russell RS, Theorell T. Physiology of stress and regeneration in job-related cardiovasular illness. J Hum Stress 1982; 8: 29-42. Karasek RA, Theorell T. Healthy Work: Stress, productivity and the reconstruction of working life. New York. Basic Books, Inc., 1990. Karasek R, Brisson C, Kawakami N, Houtman I, Bongers P, Amick B. The Job Content Questionnaire (JCQ): An instrument for internationally comparative assessments of psychosocial job characteristics. J Occup Health Psychology 1998; 3: 322-355. Karasek RA, Theorell T. The Demand-Control-Support Model and CVD. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15:78- 83. Katz RM. Causes of death among registered nurses. J Occup Med 1983; 251: 760-762. Kleiman NS. Angina pectoris in patients with normal coronary angiograms. In: Willerson JT, Cohn JN (eds.) Cardiovascular medicine. Churchill Livingstone, New York, 1995, pp. 375-389. Kok A, Kramer A. Event-related-potential (ERP) reflections of mental resources: a review and synthesis. Biological Psychology 1997; 45: 19-56. Kompier M, Di Martino V. Review of bus drivers' occupational stress and stress prevention. Stress Medicine 1995; 11: 253-262. Kramer, A.F., Sirevaag, E., Braune, R. A psychophysiological assessment of operator workload during simulated flight missions. Human Factors 1987; 29: 145-160. Krause N, Ragland DR, Greiner BA, Syme SL, Fisher JM. Psychosocial job factors associated with back and neck pain in public transit operators. Scand J Work Environ Health 1997a; 23:179-186, Krause N, Ragland DR, Greiner BA, Fisher JM, Holman BL, Selvin S. Physical workload and ergonomic factors associated with prevalence of back and neck pain in urban transit operators. Spine 1997b; 22: 2117-2127. Krause N, Ragland DR, Fisher JM, Syme SL. Psychosocial job factors, physical workload, and incidence of workrelated spinal injuries. Spine 1998; 23: 2507-2516. Kristensen TS. Job stress and cardiovascular disease: A theoretic critical review. J Occup Health Psychol 1996; 1:246-260. Kristensen TS, Christensen KB, Borg V. How to measure quantitative psychosocial demands at work. An analyses based on the Copenhagen Psychosocial Questionnaire (COPSOQ). Third International Conference on the Work Environment and Cardiovascular Diseases—International Commission on Occupational Health. Dusseldorf, March 2002.
288 Kristensen TS, Kornitzer M, Alfredsson L. Social factors, work, stress and cardiovascular disease prevention. Brussels, The European Heart Network, 1998. Laflamme N, Brisson C, Moisan J, Milot A, Mâsse B, Vezina M. Job strain and ambulatory blood pressure among female white-collar workers. Scand J Work Environ Health 1998; 25: 334-343. Landau C, Nordlander R, Nyquist O, Schenck K. Coronary artery spasm—A case with fatal outcome. Scand J Thor CV Surg 1979; 13: 129-132 Landsbergis P. Is air traffic control a stressful occupation? Labor Studies Journal. 1986; 117-134. Landsbergis PA, Cahill J, Schnall PL. The impact of lean production and related new systems of work organization on worker health. J Occup Health Psychol 1999; 4: 1-23. Landsbergis PA, Schnall PL, Dietz DK, Friedman R, Pickering TG. The patterning of psychological attributes and distress by ’job strain’ and social support in a sample of working men. J Behav Med 1992; 15: 379-405. Landsbergis PA, Schnall PL, Schwartz JE, Warren K, Pickering TG, Schwartz JE. Association between ambulatory blood pressure and alternative formulations of job strain Scand J Work Environ Health. 1994; 20: 349363. Landsbergis P. Case studies of air traffic controllers in the United States and Italy. Encyclopaedia of Occupational Health and Safety, 4th Edition. Geneva, 1998, pp. 102.9.
In: J. Stellman (Ed.)
Landsbergis PA, Theorell T, Schwartz J, Greiner BA, Krause N. Measurement of psychosocial workplace exposure variables. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15: 163-188. Lazarus, R.S. Stress theory and psychophysiological research. In L. Levi (Ed.), Emotional Stress Physiological and Psychological Reactions Medical, Industrial and Military Implications. Forsvarsmedicin 3, 1967, pp. 152-177. Leigh P, Schnall P. Costs of occupational circulatory disease. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15: 257-267. Leslie D, Butz D. GM suicide: flexibility, space, and the injured body. Economic Geography 1998; 74: 360-378. Levi L. Preventing Work Stress. Reading: Addison-Wesley Publishing Co., 1981. Levi L. More jobs, better jobs and health-policy. Challenges to science. Third International Conference on the Work Environment and Cardiovascular Diseases—International Commission on Occupational Health. Dusseldorf, March 2002. Liu J, Roman MJ, Pini R, et al. Cardiac and arterial target organ damage in adults with elevated ambulatory and normal office blood pressure. Ann Intern Med 1999; 131:564-572. Lown B. Role of higher nervous activity in sudden cardiac death. Jpn Circ J. 1990; 54: 581-602. Luczak H. The use of simulators for testing individual mental working capacity. Ergonomics 1971; 14: 651-660. Maisano G. Summary and conclusions towards guidelines for return to work after myocardial infarction and myocardial revascularization. Eur Heart J 1988 (Suppl. L); 9: 120-122.
289 Marmot M. Social class, occupational status and cardiovascular disease. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15: 46-49. Martin F., Siddle, D.A.T., Gourley, M., Taylor, J., Dick, R. P300 and traffic scenes: The effect of temazepam. Biological Psychology 1992; 33: 225-240. McCarthy G, Donchin E. A metric for thought: A comparison of P300 latency and reaction time. Science 1981; 211:77-80. Melamed S, Ben-Avi I, Luz J, Green MS. Objective and subjective work monotony: Effects of job satisfaction, psychological distress and absenteeism in blue-collar workers. J Appl Psychology 1995; 80: 29-42. Melamed S, Kristal-Boneh E, Harari G, Froom P, Ribak J. Variation in the ambulatory blood pressure response to daily work load--the moderating role of job control. Scand J Work Environ Health 1998; 24: 190-196. Menotti A, Seccareccia F. Physical activity at work and job responsibility as risk factors for fatal coronary heart disease and other causes of death. J Epidemiol Commun Health 1985; 39: 325-329. Merkel J. Die zeitlichen Verhaltrisse der Willenstatigkeit. Philosophie Studion 1885; 2: 73-127. Michaels D, Zoloth SR. Mortality among urban bus drivers. Int J Epidemiol 1991; 20: 399-404. Morris JN, Kagan A, Pattison D, Gardner MJ, Raffle PAB. Incidence and prediction of ischaemic heart disease in London busmen. Lancet 1966; 2: 553-559. Muller JE, Ludmer PL, Willich SN, Tofler GH, Aylmer G, Klangos I, Stone PH. Circadian variation in the frequency of sudden cardiac death. Circulation 1987; 75: 131-138. Murphy LR. Job dimensions associated with severe disability due to cardiovascular disease. J Clin Epidemiol 1991; 44: 155-166. Myers AH, Baker SP, Li G, Smith GS, Wiker S, Liang K-Y, Johnson JV. Back injury in municipal workers: A case-control study. Am J Public Health 1999; 89: 1036-1041. Nedic O, Filipovic D, Solak Z. Job stress and cardiovascular diseases among health workers. Med Pregl 2001; 423-431. Needleman C, Needleman ML. Qualitative methods for intervention research. Am J Industrial Med 1996; 29:329337. Neerincx MA, Griffioen E. Cognitive task analysis: harmonizing tasks to human capacities. Ergonomics 1996; 39: 543-561. Nelson DE, Emont SL, Brackbill RM, Cameron LL, Piddicord J, Fiore MC. Cigarette smoking prevalence by occupation in the United States. J Occup Med 1994; 36: 516-525. Netterstrom, B., Juel, K. Impact of work-related and psychosocial factors on the development of ischemic heart disease among urban bus drivers in Denmark. Scand J Work Environ Health 1988; 14: 231-238. Netterstrom, B., Juel, K. Peptic ulcer among urban bus drivers in Denmark. Scand J Soc Med 1990; 18:97-102.
290 Niedhammer I, Goldberg M, Leclerc A, Bugel I, Landre MF. Psychosocial work environment and cardiovascular risk factors in an occupational cohort in France. J Epidemiol Commun Health 1998; 52: 93-100. Nystrom L, Kolmodin-Hedman B, Jonsson E, Thomasson L. Mortality from circulatory diseases, especially ischaemic heart disease in sea pilots and boatmen in Sweden 1951-1984: a retrospective cohort study. Br J Indust Med. 1990; 47: 122-126. Ohman A. Face the beast and fear the face: animal and social fears as prototypes for evolutional analyses of emotion. Psychophysiology. 1986; 23: 123-145. Olkinuora M, Asp S, Juntunen J, Kauttu K, Strid L, Äärimaa M. Stress symptoms, burnout and suicidal thoughts of Finnish physicians. Scand J Work Environ Health 1992; 18 Suppl 2: 110-112. Orris P, Hartman DE, Strauss P, et al. Stress among package truck drivers. Am J Indust Med 1997; 31:202-210. Parasuraman, R. Sustained attention in detection and discrimination. In R. Parasuraman & D.R. Davies (Eds.), Varieties of Attention. Orlando: Academic Press, Inc., 1984, pp. 243-271. Pavlov IP. Complete collected works. Moscow-Leningrad, 1951. Peter R, Siegrist J. Chronic work stress, sickness absence, and hypertension in middle managers: General and specific sociological explanations? Soc Sci Med 1997; 45: 1111-1120. Peter R, Alfredsson L, Hammar N, et al. High effort, low reward and cardiovascular risk factors in employed Swedish men and women: Baseline results from the WOLF study. J Epidemiol Community Health 1998; 52:540547. Peter R, Siegrist J, Hallqvist J, Reuterwall C, Theorell T, and the SHEEP Study Group. Psychosocial work environment and myocardial infarction: improving risk estimation by combining two complementary job stress models in the SHEEP study. J Epidemiol Community Health 2002; 56:294-300. Pikhart H, Bobak M, Pajak A, Malyutina S, Kubinova R, Marmot M. An association between depression, effortreward imbalance and job demand-control model in three post-Communist Countries. Third International Conference on the Work Environment and Cardiovascular Diseases—International Commission on Occupational Health. Dusseldorf, March 2002. Polich J, Kok A. cognitive and biological determinants of P300: an integrative review. Biol Psychol 1995; 41: 103-146. Potter BA. Preventing job burnout. Transforming work pressure into productivity. Crisp Publications, Inc., Menlo Park, 1987. Punnett L, Bergqvist U. Visual display unit work and upper extremity musculoskeletal disorders. A review of epidemiological findings. National Institute for Working Life—Ergonomic Expert Committee Document No. 1, 1997, 10. Ragland D, Winkleby MA, Schwalbe J, Holman BL, Morse L, Syme SL, et al. Prevalence of hypertension in bus drivers. Int J Epidemiol 1987; 16:208-14. Ragland DR, Greiner BA, Holman BL, Fisher JM. Hypertension and years of driving in transit vehicle operators. Scand J Soc Med 1997; 25: 271-279. Riecansky J, Milichercik J, Kasper J, Zelenay J, Havlinova K. Myocardial infarction at young age. Czech Med 1988; 11: 123-130.
291
Ritter W, Vaughan HG, Costa LD. Orienting and habituation to auditory stimuli: A study of short term changes in averaged evoked responses. Electroencephalogr Clin Neurophysiol 1968;25:550-556. Rohmert W. An International symposium on Objective Assessment of Workload in Air Traffic Control Tasks. Introduction. 1971; 14:545-547. Rosengren A, Anderson K, Wilhelmsen L. Risk of coronary heart disease in middle-aged male bus and tram drivers compared to men in other occupations: A prospective study. Int J Epidemiol 1991; 20: 82-87. Russek HI, Zohman BL. Relative significance of heredity, diet, and occupational stress in coronary heart disease of young adults. Am J Med Sci 1958; 235: 266-275. Russell RO, Abi-Mansour P, Wenger NK. Return to work after coronary bypass surgery and percutaneous transluminal angioplasty: Issues and potential solutions. Cardiology 1986; 73: 306-322. Saarni H, Niemi L, Koskela RS, Pentti J, Hartiala J, Kuusela A. Cardiac status and cardiovascular risk factors among Finnish sea pilots. Int J Occup Med Environ Health 1996; 9: 53-58 Sackett DL. Bias in analytic research. J Chron Dis. 1979; 32: 51-63. Schnall PL, Belkic K, Landsbergis P, Baker D. Why the workplace and cardiovascular disease? In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15: 1-5. Schnall PL, Landsbergis PA, Baker D. Job strain and cardiovascular disease. Annu Rev Public Health 1994; 15: 381-411. Schnall PL, Schwartz JE, Landsbergis PA, Warren K, Pickering TG. Relation between job strain, alcohol and ambulatory blood pressure. Hypertension. 1992; 19: 488-494. Schnall PL, Schwartz J, Landsbergis PA, Warren K, Pickering TG. A longitudinal study of job strain and ambulatory blood pressure: results of a three year follow-up. Psychosom Med 1998; 60: 697-706. Schnall PS, Pieper C, Schwartz JE, Karasek RA, Schlussel Y, Devereux RB, Ganau A, Alderman M, Warren K, Pickering T. The relationship between "job strain", workplace diastolic blood pressure, and left ventricular mass index. Results of a case-control study. JAMA. 1990; 263: 1929-1935. Schonfeld IS. A longitudinal study of occupational stressors and depressive symptoms in first-year female teachers. Teaching and Teacher Education. 1992; 31: 151-158. Schwartz JE. Imputation of job characteristics scores. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000a; 15: 172-175. Schwartz JE, Belkic K, Schnall PL, Pickering TG. Evidence for mediating econeurocardiologic mechanisms: Mechanisms leading to hypertension and CV morbidity. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000b; 15: 121-132. Schweitzer B. Stress and burnout in junior doctors. So African Med J. 1994; 84.352-354. Sega R, Cesana GC, Costa G, Ferrario M, Bombelli M, Mancia G. Ambulatory blood pressure in air traffic controllers. Am J Hypertens 1998; 11: 208-212
292 Selwyn AP, Braunwald E. Ischemic heart disease. In: Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, Hauser DL, Longo D. Harrison’s Principles of Internal Medicine. 14th Edition. New York, McGraw-Hill, Inc., 1998, pp. 1365-1375. Shimomitsu T, Odagiri Y. Working life in Japan. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15: 280-281. Siegrist J, Peter R, Georg W, Cremer P, Seidel D. Psychosocial and biobehavioral characteristics of hypertensive men with elevated atherogenic lipids. Atherosclerosis 1991; 86: 211-218. Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol. 1996; 1: 27-41. Siegrist J, Peter J. Measuring effort-reward imbalance: Guidelines. University of Duesseldorf, 1999. Singleton WT. AT Welford—a commemorative review. Ergonomics 1997; 40: 125-140. Sirevaag E, Kramer A, Coles M, Donchin E. P300 amplitude and resource allocation. Psychophysiology 1984; 21:598-599. Skov T, Borg V, Orhede E. Psychosocial and physical risk factors for musculoskeletal disorders of the neck, shoulders, and lower back in salespeople. Occup Environ Med 1996; 53: 351-356. Smith MJ, Conway FT, Harsh B-T. Occupational stress in human computer interaction. Industrial Health 1999; 37: 157-173. Sperandio JC. Variation of operator's strategies and regulating effects in workload. Ergonomics 1971; 14: 571577. Steptoe A, Roy MP, Evans O, Snashall D. Cardiovascular stress reactivity and job strain as determinants of ambulatory blood pressure at work. J Hypertension. 1995; 13: 201-210. Steptoe A, Cropley M, Joekes K. Job strain, blood pressure and response to uncontrollable stress. J Hypertension 1999; 17: 193-200. Stroh, C.M. Vigilance: The Problem of Sustained Attention. Oxford: Pergamon Press, 1971. Stubbs DA, Buckle PW, Hudson MP, Rivers PM, Worringham CJ. Back pain in the nursing profession: I. Epidemiology and pilot methodology. Ergonomics 1983; 26: 755-765. Suurnakki T, Ilmarinen J, Wagar G, Jarvinen E, Landau K. Municipal employees' cardiovascular disease and occupational stress factors in Finland. Int Arch Occup Environ Health 1987; 59: 107-114. Syme L. Social epidemiology and the work environment. In Johnson J, Johansson G. The psychosocial work environment. Amityville, New York: Baywood, 1991, pp. 21-32. Taggart P, Gibbons D, Somerville W. Some effects of motor-car driving on the normal and abnormal heart. Br Med J. 1969; 4: 130-134 Takeda F. Depressive state and related factors in nursery teachers and guidance workers in homes for mentally retarded children. Japanese J Indust Health 1994; 36: 183-193. Tan CH. Occupational health problems among nurses. Scand J Work Environ Health 1991; 17: 221-230.
293 Theorell T, Ahlberg-Hultén G, Jodko M, Sigala F, de la Torre B. Influence of job strain and emotion on blood pressure in female hospital personnel during work hours. Scand J Work Environ Health 1993; 19:313-318. Theorell T, Karasek R. Current issues relating to psychosocial job strain and cardiovascular disease research. J Occup Health Psychol 1996; 1: 9-26. Theorell T, Perski A, Åkerstedt T, Sigala F, Ahlberg-Hulten G, Svensson J, et al. Changes in job strain in relation to changes in physiological states A longitudinal study. Scand J Work Environ Health 1988; 14: 189-196. Theorell T, Perski A, Orth-Gomer K et al. The effects of the strain of returning to work on the risk of death after a first myocardial infarction before age of 45. Int J Cardiol. 1991; 30: 61-67. The Tokyo Declaration. J Tokyo Med Univ 1998; 56: 760-767. Toomingas A, Theorell T, Michelsen H, Nordemar R. Associations between self-rated psychosocial work conditions and musculoskeletal symptoms and signs. Scand J Work Environ Health 1997; 23: 130-139. Tuchsen F. Stroke morbidity in professional drivers in Denmark 1981-1990. Int J Epidemiology. 1997; 26: 989994. Tuchsen F. High-risk occupations for cardiovascular disease. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15: 5760. Uehata T. Stress, daily habits and health: from the epidemiologic survey on work stress and health. Bulletin of Institute of Public Health. 1993; 42:385-401. (In Japanese: As cited by: Kawakami N. and Haratani T. Epidemiology of job stress and health in Japan: Review of current evidence and future direction. Industrial Health 1999; 37: 174-186. Ugljesic M, Belkic K, Boskovic D, Boskovic S, Ilic M. Exercise testing of young, apparently healthy professional drivers. Scand J Work Environ Health 1996; 22: 211-215. Ugljesic M, Belkic K, Simeunovic-Mickovic Lj. Vukajlovic M. Implementation of a plan for cardiac prevention among professional drivers as a high risk group. Srpski Arhivi Lekarstva. 1992; 120 (Suppl. 1): 49-51. van Amelsvoort LGPM. Coronary heart disease among truck drivers. Report of the International Workshop on the Epidemiology of Coronary Heart Disease among European Truck Drivers. Bilthoven, European Commission, 1995. van der Berghe R, Huberman AM (eds.). Understanding and preventing teacher burnout. A Sourcebook of International Research and Practice. Cambridge University Press, Cambridge, 1999. Verdecchia P, Schillaci G, Guerrieri M, et al. Circadian blood pressure changes and left ventricular hypertrophy in essential hypertension. Circulation 1990; 81: 528-536. Videman T, Nurminen T, Tola S, Kuorinka I, Vanharanta H, Troup JD. Low-back pain in nurses and some loading factors of work. Spine 1984; 9: 400-404. Villarem D, Thieuleux FP, LaBlanche JM, Tilmant PY, Bertrand M. L'infarctus du myocarde chez les sujets de moins de 30 ans (Myocardial infarction in subjects less than 30 years of age). Ann Cardiol Angeiol 1982; 31: 263268.
294 Walton P, Callaway E, Halliday R, Naylor H. Stimulus intensity, contrast, and complexity have additive effects on P300 latency. In R. Johnson, Jr., J.W. Rohrbaugh, R. Parasuraman (Eds.). Current Trends in Event-Related Potentials. Electroencephalography and Clinical Neurophysiology. Supplement No.40. Amsterdam: Elsevier Science Publishers B.V. Company, 1987, pp. 284-292. Welford AT. The measurement of sensory-motor performance: Survey and reappraisal of twelve years’ progress. Ergonomics 1960; 3: 189-230. Williams RB, Barefoot JC, Blumenthal JA, Helms MJ, Luecken L, Pieper CF, Siegler IC, Suarez EC. Psychosocial correlates of job strain in a sample of working women. Arch Gen Psychiatry 1997; 54: 543-548. Williamson AM, Feyer A-M, Friswell R. The impact of work practices on fatigue in long distance truck drivers. Accid Anal Prev 1996; 28: 709-719. Winkleby, MA; Ragland, DR; Fisher, JM; Syme SL. Excess Risk of Sickness and Disease in Bus Drivers: A Review and Synthesis of Epidemiological Studies Int J Epidemiol 1988; 17: 255-262. Zorn EW, Harrington JM, Goethe H. Ischaemic heart disease and stress in West German sea pilots. J Occup Med 1977; 19:752-755.