71673851 62902636 ergonomics and the management of musculoskeletal disorders

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ERGONOMICS AND THE MANAGEMENT OF 0-7506-7409-1MUSCULOSKELETAL DISORDERS, SECONDEDITIONCopyright 2004, Elsevier (USA). All rights reserved.

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NOTICE

Occupational therapy and ergonomics are ever-changing elds. Standard safety precautions must befollowed, but as new research and clinical experience broaden our knowledge, changes in treatmentmay become necessary or appropriate.

CHERYL ATWOOD, BSYarns for EweBethlehem, Connecticut

NANCY BAKER, ScD, OTR/LAssistant ProfessorDepartment of Occupational TherapySchool of Health and Rehabilitation ScienceUniversity of PittsburghPittsburgh, Pennsylvania

DONALD CLARK, MS, PTPrivate PracticeWesterly, Rhode Island

CHARLES F. DILLON, MD, PhDResearch Medical OfcerDepartment of Health and Human ServicesCenters for Disease ControlDivision of Health Examination Statistics/NHANESHyattsville, Maryland

SUSAN V. DUFF, EdD, PT, OTR/L, CHT, BCPClinical Research DirectorClinical Research DepartmentShriners Hospitals for ChildrenPhiladelphia, PennsylvaniaClinical Faculty AssociatePhysical Therapy ProgramNew York Medical CollegeValhalla, New York

DOROTHY FARRAR EDWARDS, PhDProgram in Occupational TherapyWashington University School of MedicineSt. Louis, Missouri

MELANIE T. ELLEXSON, MBA, OTR/L, FAOTAAssistant ProfessorChicago State University Chicago, Illinois

ROBERT O. HANSSON, PhDProfessor of PsychologyUniversity of TulsaTulsa, Oklahoma

BARBARA J. HEADLEY, MS, PTInnovative Systems for Rehabilitation Inc.Boulder, Colorado

CARYL D. JOHNSON, OTR/L, CHTJohnson Hand Therapy ServicesNew York, New York

JAMES H. KILLIANGraduate StudentIndustrial-Organizational PsychologyUniversity of TulsaTulsa, Oklahoma

JAMES W. KING, MA, CHT, OTR/LRegional ManagerAlliance ImagingWaco,Texas

BRENDAN C. LYNCH, MAGraduate StudentClinical PsychologyUniversity of TulsaTulsa, Oklahoma

MICHAEL MELNIK, MS, OTRPrevention PlusMinneapolis, Minnesota

TIM MORSE, PhDTraining CoordinatorErgotechnology Center of ConnecticutDivision of Occupational and Environmental MedicineUniversity of Connecticut Health CenterFarmington, Connecticut

Contributors

CLAUDIA MICHALAK-TURCOTTE, CDA, RDH,MSDH, MSOSHAssociate ProfessorDepartment of Allied DentalTunxis CommunityTechnical CollegeFarmington, ConnecticutDepartment of Allied DentalDental HygieneUniversity of Connecticut School of Dental Medicine Farmington, Connecticut

NICK WARREN, ScD, MATCoordinator, Ergotechnology Center of ConnecticutDivision of Occupational and Environmental MedicineUniversity of Connecticut Health CenterFarmington, Connecticut

viii Contributors

RICHARD K. SCHWARTZ, MS, OTRRichard K. Schwartz Consulting Services, Inc.Industrial Medicine and Risk ManagementSan Antonio,Texas

JUDY SEHNAL, MS, OTR/L, CPEExecutive Technical ConsultantThe HartfordHartford, Connecticut

ROBYN STRICOFF, OTR/L, CHTOccupational SolutionsMonroe, Connecticut

The second edition of Ergonomics and theManagement of Musculoskeletal Disorders(previously, Management of CumulativeTrauma Disorders) has added much depth andbreadth to the rst edition to reflect the majorchanges in the political,medical, ergonomic,andresearch arenas relative to managing muscu-loskeletal disorders.The name of this book hasbeen changed to reflect the adoption of theterm musculoskeletal disorder (MSD) by theNational Institute of Occupational Safety andHealth.

Seven new chapters have been added andseven new expert contributors have addedincredible new information and experience tothe book. The context of work is now framed in the history of work, all the while maintaininga client-centered perspective. An update on the regulatory status and incidence of MSDssupports our need to continue our work towardpreventing such disorders. The medical chap-ters offer cutting-edge information on arthritis-related MSDs, heretofore rarely acknowledged in MSD literature. The entire context of ergo-nomics is expanded and discussed from a

contemporary perspective that incorporates notonly job design, but also the organization ofwork and characteristics of the individual.Ergonomics is taken out of the exclusive arenaof work and applied to home and leisure envi-ronments, acknowledging that MSD manage-ment is not limited to medical and industrialenvironments. Finally, special populations thatprovide challenges for MSD management, olderworkers and daycare workers, are presented inthis edition.

As before, Ergonomics and Management ofMusculoskeletal Disorders is organized topresent information in earlier chapters that issequentially developed and applied in laterchapters.

Although we should take pride that theoverall number of musculoskeletal disorders hasbegun to decline, much work still needs to bedone to prevent, minimize, and treat workerswho have developed MSDs in the workplace.Acollaborative approach of all disciplines is crucialto our further understanding and managementof MSDs.

Martha J. Sanders

Preface

This book is dedicated tothe families and colleagues of all contributors

whose support made this book possible.

More specicallymy family has been a great source of clarity and drive.

Thanks toDad

who instilled in us the self-fullling nature of workMom

whose compassion compels my quest for clients health and happinessPeter

whose focus allows us to plan and nish a projectJeffrey

whose balance makes us remember to have funWendy

whose creativity allows us to express ideas with new flairJimmy

whose broad scope allows us to expand into new horizonsPaul

whose breadth of knowledge invites new applications for traditional content.But a special thanks to

Addie and Taiwho taught us about perseverance.

Many individuals gave their time to thecreation of this second edition.Again, thanks tothe contributors for tting in this professionalwriting with daily life. A second thanks toNorma Keegan, Interlibrary Loan Director atQuinnipiac University, who gracefully suppliedme with reams of research studies for both therst and second editions. A special thanks toRuthanna Terreri and Cheryl Atwood, whoprovided the patience and expertise for many ofthe photos in this book.

Acknowledgements

Our society prides itself on the belief thattechnical advancements in information pro-cessing, manufacturing technology, and medicalscience will enhance the quality of life for allindividuals. Logic dictates that if we work moreefficiently, we will be more productive and,therefore,more satisfied with our personal work,our wages, and the use of our leisure time.Unfortunately, the basic assumptions that underliethis logic are gradually being undermined by thehidden costs of doing business in todays highlytechnical society. The hidden costs that weaddress are the escalating incidents of stress-related and musculoskeletal disorders (MSDs)for the thousands of workers responsible for oursoaring productivity.

Today,we are witnessing what has been termedan industrial epidemic (Schenck, 1989)thatis, an overwhelming increase in reports of work-related disorders that affect not only industryproductivity and labor costs but also the qualityof workers lives both inside and outside theworkplace. The problem has dramatic reper-cussions.As employment positions become lesssecure, workers are less willing to perform jobsthat jeopardize their health and limit futureearning potential. As businesses become in-creasingly competitive, employers complain thatthe cost of MSDs reduces profits by increasingworkerscompensation costs and decreasing pro-ductivity.The cost of managing these disordersreverberates from the factory or office floor tothe medical and often legal arenas, all of which

remove the employee farther from work anddrive our health care costs even higher.

The differences in focus among industrial,medical, insurance, and legal systems exacerbatesthe problem.Each system possesses a unique setof goals, languages, and procedures that canalienate other provider systems. Although eachprovider contributes a valuable perspective,oneprovider cannot effectively remediate MSDs tothe exclusion of other systems. Clearly, in themanagement of MSDs, the whole is truly greaterthan the sum of the parts.

The perspective of this book is that effectiveprevention and management programs for MSDsmust thoroughly integrate all professionalperspectives. The values of individual workersand worker cultures must be integrated with themedical, corporate, and insurance systems so thatlong-term solutions can be reached. Althoughhealth care practitioners and ergonomic con-sultants will enter the arena of MSD manage-ment from medical, insurance, industrial,or eveneducational systems, all practitioners will needto appreciate the contribution of other systemsand be prepared to work with representativesfrom those systems toward a thorough, com-prehensive MSD management plan.

This book systematically examines the meansby which health care practitioners and consult-ants can effect change to facilitate safer, moreproductive, and stimulating workplaces. Con-textual background from the individual worker,medical, and industrial/regulatory perspectives

3

C H A P T E R 1

Musculoskeletal Disorders: A Worldwide Dilemma

Martha J. Sanders

are presented to sensitize health care practi-tioners to the concerns of each participant.

From all perspectives, worker health is apriority in our efforts.If companies are to survive,managers need to maximize productivity andminimize medical costs. If workers are tomaintain quality of work and home life, workersneed to take responsibility for protecting theirhealth. If medicine is to alleviate disability,healthprofessionals must step beyond the clinics intothe real world of industry and business.Cooperatively, we must balance productivitywith health, consider long-term gains versusshort-term profit, and reexamine the value ofwork for todays worker.

From the high-speed assembly lines to thepropagating computer terminals, modern toolsof the trade certainly have improved ourstandard of living. But what about our quality ofwork life? Are we any better off than we were atthe turn of the century? As Eli Ginzberg (1982)eloquently stated,It remains to be seen whetheror not the potential of modern technology willturn out to be a blessing.

HISTORY OF MUSCULOSKELETALDISORDERSThe occurrence of MSDs in industry is not new.In 1717, Bernardo Ramazzini, the father ofoccupational medicine, first introduced tophysicians the common musculoskeletal disordersthat arose from eighteenth-century occupationsin his treatise De Morbis Artificum Diatriba(The Diseases of Workers) (translated byWright, 1940). Ramazzini observed that manydiseases or conditions appeared to be related tohis patients exposures to hazardous workenvironments.At that time, however, physiciansrarely asked patients about their jobs.Ramazzini,therefore, initiated one of the first systematicattempts to attribute specific diseases orconditions to factors in workers environments.Ramazzini documented the musculoskeletal,respiratory,dermatologic, and emotional problemsexhibited by his patients. He then observed

workers at their jobs and related specificaspects of the environment (such as hazardousmaterials, airborne toxins,and excessive physicaldemands) to these medical conditions.In essence,Ramazzini laid the foundation for occupationalhealth practices today. Ramazzini (1717) openshis treatise with the following overview.

Various and manifold is the harvest of diseasesreaped by certain workers from the crafts andtrades that they pursue; all the profit that they get isfatal injury to their health. That crop germinatesmostly, I think, from two causes.The first and mostpotent is the harmful character of the materialsthat they handle for these emit noxious vapors andvery fine particles inimical to human beings andinduce particular diseases; the second cause I ascribeto certain violent and irregular motions andunnatural postures of the body, by reason of whichthe natural structure of the vital machine is soimpaired that serious diseases gradually developtherefrom (p. 15).

Ramazzini poignantly describes the morbidityof many acquired conditions and the futile rewardof illnesses that many workers suffered as aresult of enduring hazardous work environments.He describes the conditions that resulted fromspecific occupations. He wrote the followingabout sedentary workers.

[M]en and women who sit while they work attheir jobs, become bent, hump-backed and holdtheir heads like people looking for something on theground; this is the effect of their sedentary life andthe bent posture as they sit and sew (p. 282).

He described scribes and notaries this way.[T]he maladies that afflict the clerks afore said

arise from three causes: First, constant sitting,secondly the incessant movement of the hand andalways in the same direction, thirdly the strain onthe mind from the effort not to disfigure the booksby errors or cause loss to their employers when theyadd, subtract, or do sums of arithmetic Further-more, incessant driving of the pen over papercauses intense fatigue of the hand and the wholearm because of the continuous and almost tonicstrain on the muscles and tendons, which in courseof time results in failure of power of the right hand(pp.421, 423).

4 Systems Involved in MSD Management: Worker, Medical, and Regulatory Perspectives

Of painters he reported that their sedentarylife and melancholic temperament may be partlyto blame, for they are almost entirely cut offfrom intercourse with other men and constantlyabsorbed in the creations of their imagination(p. 67). He noted of bakers,[N]ow and again, Ihave noticed bakers with swelled hands, andpainful, too; in fact, the hands of all such workersbecome thickened by the constant pressure ofkneading the dough(p. 229).

Ramazzini identified hazards in workersenvironments that we have come to associatewith the risk factors for MSDs today. Herecognized not only the physical demands suchas violent and irregular motions, bent pos-ture, incessant use of the hands, and tonicstrain on the muscles,but also the emotional ormental demands that contribute to work-relatedfatigue, such as melancholic temperament,sedentary life, and strain on the mind. Still,disorders of workers were treated on an in-dividual basis, and workers had relatively fewchoices about whether to work in the face ofsuch disorders.

MUSCULOSKELETAL DISORDERSIN THE TWENTIETH CENTURYAs the Industrial Revolution gained momentumand assembly-line pacing, predetermined motionand time standards, long hours at work, and theperformance of repetitive tasks became thenorm, the serious and problematic nature ofwork-related diseases became increasinglyapparent. When workers compensation lawswere introduced in 1911 and then amended in1914 and expanded to cover conditions such astenosynovitis, insurance companies began torecord and further examine these injuries asrelated to their clients occupations (Conn,1931; Hagan, Montgomery, & OReilly, 2001).

Physicians became instrumental in determiningwhether these disorders were actually related towork. Physicians therefore began to compiledata that equated musculoskeletal symptomswith workplace factors. Conn (1931) examined

rubber company workers who had tenosynovitisand determined that new high-speed handoperations, increased intensity of effort, andbeing new to the job clearly predisposedindividuals to disorders such as tenosynovitis.Hammer (1934),who attempted to delineate thetolerances, or number of repetitions that humantendons could withstand before tenosynovitisdeveloped, concluded that tenosynovitis wouldoccur in human tendons if repetitions exceeded30 to 40 per minute, or 1500 to 2000 manip-ulations per hour. Hammer noted certain handsymptoms consistent with carpal tunnel syn-drome, but this condition was not exploredfurther until Phalen reported on it in 1947.

Flowerdew and Bode (1942) raised the issueof improper training and physical conditioningas contributors to tenosynovitis in some workers.Among a group of 52 military personnel assignedto farm work in Great Britain, 16 developedtenosynovitis of the wrist and finger extensorsshortly after starting intensive manual work.Fourteen of these 16 individuals had no previousmanual labor experience.Blood (1942),a medicalofficer at a company in Great Britain,agreed thatnewcomers to a repetitive stereotyped job areparticularly vulnerable, but cases crop upamong employees who have had years ofexperience at these jobs, particularly afterreturning to work following a holiday or sickleave (p. 468). Blood attributed a 50% increasein cases of tenosynovitis from 1940 to 1941 toan influx of new workers in his industry.

As automation progressed and manual workbecame lighter and more efficient, muscu-loskeletal problems related specifically to officework became apparent. In the 1950s, new officeequipment such as high-speed typewriters andkeypunch operations streamlined tasks byeliminating movements not directly related tothe job (such as retrieving the typewriter car-riage after each line). Automation eliminatedboth the brief rest periods inherent in operatingthe old machinery and the need for workers touse several different muscle groups to accomplisha task. Physically, jobs became sedentary, static,

Musculoskeletal Disorders: A Worldwide Dilemma 5

and, unvarying; people relied on localizedmuscles to perform the work.Mentally, the workroutines became highly monotonous, althoughdetailed work demanded high levels of con-centration. Workers lost a sense of the overalltask to which they were contributing (Giuliano,1982).

By the mid-1950s, the musculoskeletal andmental fatigue problems associated with oper-ating new and repetitive machines were clear.The Fifth Session of the International LaborOrganization Advisory Committee on SalariedEmployees and Professional Workers reportedthe serious physical consequences created bymechanized work (ILO Advisory Committee,1960). Clerical workers complained of low-backand neck pain; keypunch operators complainedof painful nerves in the hands; accounting-machine operators complained of fatigue, eyestrain, pain and stiffness in cervical and lumbarregions, and numbness in the right hand(Maeda, Hunting, & Grandjean, 1980). Althoughthese disorders crossed national boundaries,peaks in reporting occurred at different timesfor each country.

Occupational Cervicobrachial Disorderin JapanIn Japan, a dramatic increase in musculoskeletaldisorders was reported between 1960 and 1980.Comparatively high prevalence of hand and armpain was first reported in keypunch operators(17% of the occupational sample). Later, typists(13%),telephone operators (16%),office keyboardoperators (14%), and assembly-line workers(16%) reported pain in the hands and arms thatinterfered with their abilities to perform theirjobs (Maeda,1977;Ohara, Itani,& Aoyama,1982).The claims rose to such a proportion that, in1964, the Japanese Ministry of Labour issuedguidelines for keyboard operators, demandingthat workers spend no more than 5 hours perday on the keyboard, take a 10-minute rest breakevery hour, and perform fewer than 40,000keystrokes per day. In companies that imple-mented these preventive measures, the preva-lence of arm and hand disorders decreased from

an overall prevalence of 10% to 20% down to 2%to 5% (Ohara et al., 1982). However, the overallnumber of individuals who received compen-sation for hand and arm disorders in the privatesector in Japan increased from 90 in 1970 to 546in 1975 (Maeda, 1977).

In 1971, Japan formed the Japanese Com-mittee on Cervicobrachial Syndrome to definethe syndrome and fully identify contributingfactors. The committee proposed the nameoccupational cervicobrachial disorder (OCD)and defined the problem as a functional ororganic disorder (or both) resulting from mentalstrain or neuromuscular fatigue due to per-forming jobs in a fixed position or withrepetitive movements of the upper extremity(Keikenenwan Shokogun Iinkai [JapaneseAssociation of Industrial Health], 1973).

The Japanese committee then conducted amass screening of individuals in private industryto further delineate the causative factors forOCD. Researchers concluded that how theworkers use their muscular and nervoussystems at work and how the task is organizedinto the work system as a whole underlie thecondition (Maeda, 1977, p. 200). Researchersspecifically identified static loading of thepostural muscles, dynamic loading of localizedarm and hand muscles, and lack of active restbreaks during the day as factors contributing to OCD. The condition was found to advancewith excessive workload and insufficientrecovery from fatigue.

The Japanese committee astutely regardedvisual eye strain and mental fatigue as beingrelated to OCD. It urged physicians to furtherinvestigate the relationship between sleepdisturbance, chronic fatigue, and symptoms ofOCD (Maeda, 1977). A 20-year review of thedisorder by Maeda analyzed the progression ofthe disease in Japan and posed questions aboutexposure or dose-effect relationships. Maeda,Horiguchi, and Hosokawa (1982) found thatOCD first peaked in individuals within 6 to 12months of starting a new job (possibly due tooverwork of untrained individuals) and thenpeaked again between 2 and 3 years (possibly


due to chronic fatigue of muscles). Maedaidentified the fundamental controversy thatexists today: whether OCD is caused by factorssolely within the workplace or by psychologicalfactors such as personal anxiety or workplacestress that becomes magnified by the physicalaspects of the workplace.

Other countries subsequently began toexamine the incidence of musculoskeletal dis-orders related to office work. In each country, agross rise in workers compensation claims formusculoskeletal disorders served as the catalystfor research of the problem. Specific task forceswere established in each country to study MSDswithin the socioeconomic context of that country.Most countries followed a similar chronologicpattern of first recognizing acute hand and armpain in workers, then identifying problemsrelated to static posturing of the shoulder andcervical regions, and finally relating specificmedical problems to workplace factors.

REPETITIVE STRAIN INJURY INAUSTRALIAIn the 1970s and 1980s, Australia observed adramatic increase in the number of telecom-munications workers who reported symptomsof arm pain or muscular fatigue (Chatterjee,1978; Ferguson, 1971a; McDermott, 1986).Ferguson (1971a) first investigated the prevalenceof telegraphists cramp in 517 male workers inthe Australian telegraph service and found that20% of the workers complained of an occupa-tional cramp or occupational myalgias. Fergusonreported that 75% of these workers had a historyof neurosis and complained of work overload orjob dissatisfaction.Ferguson therefore attributedthe cramp more to psychological and socialfactors within the workplace than to thephysical performance of the job.

In a later study of 77 female workers in anelectronics assembly plant who were diagnosedwith tendinitis, Ferguson (1971b) acknowledgedthe awkward and repetitive nature of electronicsjobs as contributing to workers symptoms.However, Ferguson questioned the validity of

the initial diagnosis of tendinitis and thenecessity for the excessive medical leave (morethan 4 months) for workers with this condition.Ferguson (1971b) advocated early return towork and medical surveillance in addition toergonomic changes.

The term repetitive strain injury (RSI) wasadopted among Australian medical investigatorsin the early 1980s,although most did not believethat the term adequately described the con-dition (Ireland, 1992; McDermott, 1986; Stone,1983). Within years, RSI had affected Australiantelegraphists and typists,tradesmen,and assembly-line,clerical,data-processing,and postal workers.McDermott (1986) explained that the numberof occupational claims for RSI in Australiaincreased generally from 300% to 400% in data-processing, accounting, and postal services from the mid-1970s to the early 1980s. TheCommonwealth Government of Australia, inresponse to the spiraling cost of RSI in thatcountry, set up a task force on RSI, seeking inputfrom the National Occupational Health andSafety Commission. This task force concludedthat a combination of ergonomic and psy-chological factors contributed to the problem(McDermott, 1986).

Clearly, investigators in Australia resistedrelating RSI to biomechanical factors within theworkplace and struggled with the definition ofRSI as a separate disease entity as opposed to agrouping of conditions with similar occu-pational etiologies. Ireland (1992), a researcherfrom Australia, still contends that musculoskele-tal pain relates only to workers psychologicalstress, because no objective medical tests (e.g.,nerve conduction or electromyography) candiagnose the condition definitively. Despite thestrong association of RSI with psychologicalfactors, few studies attempted to evaluate thepsychological aspects of RSI.

Occupational Disorders in EuropeThe Nordic countries have long been involvedin industrial health care. Whereas most of theresearch in musculoskeletal problems initiallyfocused on factors related to low-back pain,


Swedish researchers began to examine upper-extremity musculoskeletal disorders related to work in the 1980s in response to in-creasing complaints of neck and shoulder painamong blue-collar workers (Bjelle, Hagberg,& Michaelson, 1981; Dimberg et al., 1989;Kvarnstrom, 1983).

Kvarnstrom (1983) and Bjelle et al. (1981)examined the records of workers on long-termsick leave in large industrial plants in Swedenand noted the increasing magnitude of neck andshoulder problems. Kvarnstrom found that 48%of all workers on long-term sick leave hadmusculoskeletal conditions; neck and shoulderproblems were the most common disordersamong light-manufacturing workers. WhenKvarnstrom (1983) studied the demographic,work task, and social factors related to shoulderproblems in 112 workers, the variables relatedto the presence of shoulder pain were asfollows: older workers were affected moreoften; female workers were 10 times more likelythan male workers to suffer shoulder pain; light-manufacturing jobs were most often associatedwith shoulder pain; piece-rate incentives werepositively correlated with shoulder pain; andimmigrants were at higher risk than otherworkers for developing shoulder pain. Somefactors could be explained by the relationshipamong variables.For example,women tended tobe clustered in the higher-risk jobs, andimmigrant workers, because of their limitedlanguage skills, did not have the opportunity forproper training or job rotation.

When cases were matched with controls,Kvarnstrom (1983) found that a group piece-rate system, shift work, and regard for the workas repetitive, monotonous, and stressful weresignificant among case subjects. More casesubjects than controls cited a poor relationshipwith their supervisors, although no difference inrelationships with their peers was seen betweengroups. Finally, Kvarnstrom noted a significantassociation of shoulder pain with social factors,including being married, having a sick spouse,having children at home, working alternate

shifts from ones spouse, and having few leisureactivities. Researchers discussed the heavyburden placed on workers with both job andhome responsibilities (see Chapter 2). This study heralded the beginning of many futurestudies to systematically examine the relation-ship between physical and psychosocial factorsin the development of MSDs.

Nordic researchers recognized the difficultyin comparing studies from country to countrybecause of a lack of uniform terminology and criteria for diagnosis (Kuorinka et al., 1987;Kvarnstrom, 1983). The Nordic Council ofMinisters therefore supported a project todevelop a standardized Nordic questionnaire for the purposes of collectively recording andcompiling information.The Standardized NordicQuestionnaire, now widely used and trans-lated into four Nordic languages, is meant as a screening for musculoskeletal disorders of the low back, neck, and shoulder complaintsrelated to ergonomic exposures (Kuorinka et al.,1987). Using this questionnaire, the estimatedprevalence of hand and wrist disorders inSweden ranged from 18% among Swedishscissor makers to 56% among Swedish packers(Luoparjrvi, Kuorinka,Virolainen, & Holmberg,1979).

Throughout Europe, the European Union has exerted strength in the formation ofOccupational Safety and Health laws thatemphasize social policy, improvements toquality of life, protection of the environment,and a minimum common standard for workingconditions in member countries (Batra &Hatzopoulou, 2001).

Musculoskeletal Disorders in NorthAmericaThe United States witnessed a gradual rise inMSDs from 1980 to 1986. The incidence thenrose tremendously from less than 50,000 in1985 to 330,000 in 1994 (BLS, 1992, 2002).Theincidence has fallen steadily over the past 6years to 241,800 in 2000, most likely because ofergonomic changes and early intervention. (See


Chapter 4 for a compete discussion.) In theUnited States,carpal tunnel syndrome (CTS) wasthe initial focus of investigation.The occupationalcauses of CTS were first investigated byArmstrong and Chaffin (1979) in two groups offemale seamstresses, one with a known historyof CTS and one with no previous history.Researchers found that women with a history ofCTS used more force and wrist deviation whenperforming the work tasks than those with nohistory of CTS. Researchers questioned whetherthe differences in work methods between thegroups was the cause or the effect of CTS in theaffected women.

In an effort to delineate risk factors in an in-dustrial population,Silverstein,Fine,& Armstrong(1987) investigated the relationship betweenforce and repetition in a job task and the preva-lence of CTS in 652 industrial workers. Resultsof a physical examination and interview indi-cated that workers in high-force, high-repetitionjobs were 15 times more likely to have CTS thanworkers in low-force, low-repetition jobs(Silverstein et al., 1987). (See Chapter 10 for acomplete discussion.) This study became thehallmark for identifying biomechanical risk factorsand drawing an association between exposuresand musculoskeletal conditions.

As the reported incidence of MSDs sky-rocketed, researchers began to document andexamine the prevalence of MSD in specific high-risk occupations. Self-reported studies indicatedupper-extremity symptoms among the fol-lowing occupational samples: 62.5% of femalesupermarket checkers (Margolis & Kraus,1987),63% to 95% of dental hygienists (Atwood &Michalak, 1992; Shenkar, Mann, Shevach, Ever-Hadani, & Weiss, 1998), and 82% of electricians(Hunting, Welch, Cuccerini, & Seiger, 1994), toname a few. A compilation of well-documentedresearch attributed the high prevalence of MSDsto job tasks involving postural loads at the neckand shoulders, awkward postures, and longhours of repetitive and static work along withorganizational factors (Bernard, 1997). (SeeChapter 10 for a complete discussion).

However, a group of physicians in the mid-1990s argued that solely psychosocial issues andthe sociopolitical climate were causal in theetiology of MSDs, particularly with regard to theincidence of CTS in keyboard users.This groupattributed the rise in CTS to workers frus-trations with their jobs, difficulty coping withnondescript, short-lived pain, and the contagionof inflammatory self-reports (Hadler, 1996).Hadler contended that typical exposures expe-rienced during keyboard tasks were not excessiveor hazardous to the worker and were unrelatedto health outcomes.

Silverstein, Silverstein, and Franklin (1996)countered this argument citing a well-researched body of evidence indicating dose-response relationships between biomechanicalrisk factors in the workplace and the devel-opment of MSDs. Although Silverstein et al.shared Hadlers concern for the management ofMSDs and some physicians preponderancetoward surgery, their distinct beliefs about thecauses of MSDs also represent divergent beliefson prevention.

Finally, in 1997 in the United States, theNational Institute for Occupational Health andSafety (NIOSH) adopted the term work-relatedmusculoskeletal disorder (WMSD), or MSD, toreplace the term cumulative trauma disorder(Bernard, 1997; NIOSH, 1997). This changerepresented an effort to accommodate the widerange of disorders associated with work expo-sures. Ongoing efforts continue to establish anergonomics standard as part of the federal OSHAlegislation. (See Chapter 4 for a completediscussion.)

GLOBAL APPRECIATION FOR THE IMPACT OF WORK-RELATED STRESSAs industrialized nations have identified thatstress is contributory to the overall MSDetiology, more global legislative efforts areaddressing the impact of stress on workers,identifying the sources of work-related stress,


and advocating that institutions take respon-sibility for minimizing stress by examining theirorganizational frameworks (Levi, Sauter, &Shimomitsu, 1999; Sanders, 2001).

In the United States, NIOSH (1999) publishedits monograph on stress prevention strategiesfor the workplace, stating that because work ischanging at whirlwind speed perhaps nowmore than ever, job stress poses a threat to thehealth of workers and in turn, to the health oforganizations (p. 10). NIOSH upholds thatworkplaces should address not only thebiomechanical aspects of a job but also thepsychosocial aspects focusing on providingworker control, skill-enhancing, and decision-making opportunities. Levi et al. (1999) contendthat the widely used routine of providing stressmanagement skills to help individual workerscope with stressful situations is merely a short-term approach to solving greater,more complexproblems for the entire organization (Levi et al.,1999). (See Chapters 8 and 12 for furtherdiscussions of work-related stress.)

Initiatives have been taken throughout theworld to encourage employers to look internallyto minimize stresses in work environments. Inthe United Kingdom, the reduction of work-related stress is part of a greater proposal by theHealth and Safety Commission to promotehealth across all industrial and governmentalsectors from line workers to administrativelevels (Health and Safety Commission, 1999).The European Parliament Resolution in 1999urged employers to adapt work to the workersabilities, thus minimizing the disparity betweenwork demands and workers capacities. Theinfluence of limited job autonomy, job variety,and worker participation on worker health hasrung loud and clear in current programming(Levi et al., 1999).

The culmination of these legislative efforts is the Tokyo Declaration, a treatise developed by worldwide experts on stress research inresponse to mounting evidence as to the pro-found influence of stress in industrializednations. Researchers expressed concern about

the effects of technological changes in worklife(i.e., increasing cognitive workloads) on indi-viduals and their abilities to function to theirmaximum potential given these demands. Thephilosophy of the Declaration, Investment forHealth, implies that a commitment to individualworkers will also bring about social benefits.The Declaration endorses developing measure-ment tools to measure psychosocial stress,examining health outcomes based on stressexposures,monitoring psychosocial health stress,providing education and training, and creating asystem for gathering and disseminating in-formation (Tokyo Declaration, 1999).

THE ROLE OF ERGONOMICS ININDUSTRIAL DEVELOPING COUNTRIESWhereas ergonomics has traditionally consultedwith businesses in industrially advanced coun-tries (IACs), the role of ergonomics in indus-trially developing countries (IDC) is beingexpanded with regard to productivity and healthand safety (Ahasan, Mohiuddin, Vayrynen,Ironkannas, & Quddus, 1999; Brunette, 2002;ONeill, 2000). An IDC is a country whoseexistence is based on either commercializingnatural resources or on simply surviving. In both cases, the infrastructure is rarely adequateto sustain the characteristically high populationgrowth. Although nutrition and basic safety are clearly lacking, it is suggested that muscu-loskeletal injuries in IDCs are also growing at ahigher rate than in IACs.This is not surprising,since legislation in IDCs is either nonexistent orineffective at controlling health and safety risks(ONeill, 2000; Stubbs, 2000). Arguments fordeveloping prevention programs for MSDs inIDCs will need incentives such as economicgrowth, social responsibility, or perhaps researchopportunities to advance quality of work andquality of life in these countries.

ONeill (2000) more specifically discussesergonomic issues currently at the forefront inIDC manufacturing, the agriculture industry, and


in transporting materials. In agriculture, thegreatest constraints to crop production are landpreparation and weeding. Both require high-energy activities and laborious work, usuallywithin a limited amount of time. Interventionsto reduce work intensity in IDCs have includedbetter hoe designs for weeding, and improveddesigns of animal-drawn equipment.

In factories, heat stresses, poor air quality(from fumes, dusts, and particulates), and awk-ward postures and noise are commonly found.Ahasan et al. (1999) illustrate these issues inexamining jobs at a metal working plant inBangladesh. Although many ergonomic inter-ventions have been employed, attitudinal bar-riers and access to adequate training resourcesand support from the international communityare still lacking. Finally, transporting materialsusing people as transporters takes its toll inhuman injury and energy costs. For example,head loading, a prevalent mode of transportinggoods over hilly terrain, involves carrying loadsup to 15 lb over distances of 10 miles severaltimes per week. The practices of transportinggoods and people are in dire need of inno-vations to increase efficiency.

To date, researchers have found that high-endergonomic interventions employed in indus-trially advanced countries (IAC) are rarelyfeasible in IDCs. In fact, simple interventionsmay have even greater potential to affect thehealth, productivity, and quality of life forworkers in such countries. The challenge todevising acceptable solutions and transferringtechnology to IDCs is to understand andintegrate the cultural dimensions into therecommendations.Cultural dimensions refer notonly to the physical attributes of the workers(such as anthropometrics, typical postures) butalso the cognitive, social, and conceptualaspects. For example, human factor informationusually conveyed by color must be reassessedrelative to the stereotypes of a country (e.g., inthe United States red means stop); attitudestoward wearing protective equipment must beaddressed,explained,and supported by workers.

Brunette (2002) suggests that corporatesocial responsibility should be a vehicle for pro-moting improved working conditions in develop-ing countries. Partnerships between universitiesand multinational corporations (MNC) mayincrease awareness of ergonomic factors andbegin to create an infrastructure that will allowimplementation of ergonomic recommenda-tions in IDCs. Above all, the recommendationsmust emanate from multidisciplinary teamswith close collaboration between ergonomicand occupational health practitioners in thecultural context (ONeill, 2000; Stubbs, 2000).

GLOBAL TRENDS IN THETWENTY-FIRST CENTURY ANDIMPLICATIONS FORERGONOMICSGlobalization has created large multinationalcompanies (MNC) whose strong occupationalhealth and safety programs have positivelyimpacted the working lives of their employeesin IDCs (Rantanen, 1999). It is hoped that thesecorporate standards along with the support fromthe international community may influence the future legislative development of nationalergonomic and safety standards in developingcountries (Ahasan et al, 1999).

Flexibility in Work StructureDecentralization of the large companies intosmaller networks creates a reliance on outsourcingor contracting work to smaller companies.Thispractice has created work organizations withincreasing numbers of temporary,e-lance, andtele- workers. Such variability in work struc-ture affects the ability to reach, train, and trackthe injury status of self-employed workers andworkers in small to midsize companies over along period of time (Rantanen, 1999).

The Aging PopulationAs a whole, the world is aging because ofincreasing life expectancy and decreasing pop-ulation growth in IACs. Since people will be


working longer to support themselves, re-searchers in both the United States and Europemust contend with new situations: How can wekeep an older population actively engaged andproductive in the workforce in light of the newjob demands? What are the effects of aging onphysical and mental work capacity? Can wedevelop age-related criteria for using infor-mation technology (Rantanen, 1999;Westgaard,2000)? Illmarinen (1997) has offered a model to promote and maintain work capacities ofolder employees. The model is based on factorsfrom the work environment, organization, andindividual functioning.

New TechnologyInformation and communication technologies(ICT) have become integral to the existence ofindustrialized countries in an astonishinglyshort time. Research has just begun to addressthe burgeoning questions of how the newtechnology will interact with and sustain thework ability, aspirations, and long-term produc-tivity of workers (Rantanen, 1999; Westgaard,2000). Critical areas for ergonomic growth andresearch will include understanding the ICTdemands on the visual and auditory systems,cognitive ergonomics for intensive computerwork, and physical demands and organization ofICT work.

CHALLENGES FOR RESEARCHINGMSDs IN THE TWENTY-FIRST CENTURYRapid and significant changes in work life overthe last decade have created new challenges forMSD research that will demand more innovativemeans to studying these conditions. In 1983,Kvarnstrom noted the existing epidemiologicstruggles in compiling and comparing databetween countries and occupational groups. Studies from different time periods are

difficult to compare because of differences inthe social roles of health and illness.

Socioeconomic differences between studygroups may invalidate comparisons.

The gender bias in different populations andoccupations affects results (e.g., women tendto be clustered in high-risk jobs).

Reporting systems for epidemiologic studiesdiffer among countries.

Inclusion criteria for diagnostic categoriesand the quantification of risk factors differamong studies.The preceding challenges have been surpassed

by even broader concerns created by ouraccelerated use of technology, globalization, andchanges in the structure of work and workerdemographics (also see Chapter 2 for furtherdiscussion). Research challenges exist not onlyin comparing data from country to country, butalso in gathering data, identifying exposures,andmeasuring health outcomes.

Research Baselines and Follow-UpThe process of establishing a baseline of occu-pational exposures as a means of measuring theimpact of exposures over time and the efficacyof interventions is more difficult than inprevious times (Rantanen, 1999; Stubbs, 2000).As indicated, the once stable core of homog-enous full-time workers who formed the basisfor epidemiological studies has been replacedby a population of workers who enjoy flexibilityin employment structures, patterns, and loca-tions. Even the regular monitoring of employeeswill demand new models. Research designs mayneed to include shorter periods of follow-up andaccommodations for diverse populations andinternational migration.Rantanen (1999) suggestsa smart card to follow the worker throughoutthe career irregardless of type and location ofemployment.

Exposure MeasuresErgonomic exposures typically include severaltypes of hazards based on physical demands and changes in work organization (i.e., workschedules, work teams, work locations). Newexposure concepts are surfacing related to ourprimarily service-oriented society and thecontinued prevalence of human-to-humaninteraction between service workers and clients


(Rantanen, 1999).The emotional load in caringoccupations, threat of violence, and dealing with anger are issues yet to be identified andaddressed in most classic MSD research designs.

Health OutcomesThe traditional means of measuring occupationaloutcomes have been the presence or absence of musculoskeletal injury. However, Rantanen(1999) suggests that our new work life hasspurred interest in the functional and behavioralaspects of the workplace such as functionalcapacities, innovation, work motivation, thecapacity to handle clients, and psychologicaloverload (to name a few). These outcomescannot easily be measured by traditional means;therefore,new methods will have to be identified.

SUMMARYIn summary, researchers throughout the worldhave come to recognize the contribution ofbiomechanical factors and psychosocial factors(including workplace stressors) to the overalldevelopment of MSDs in the individual worker.Research and legislation in industrialized coun-tries has demonstrated continued commitmentto minimizing ergonomic hazards for workersand has acknowledged the strength of multi-disciplinary, participative approaches to inter-ventions.As interested health care practitionerswe all must encourage both research and socialresponsibility to improve worker health through-out the world.

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Nick is a 47-year-old meat cutter whodeveloped a chronic lateral epicondylitis aftercutting meat for 25 years. After 3 years ofintermittent therapy that brought little relief,Nick nally underwent surgery and embarkedon a gradual return-to-work program. Within 3 months, the pain had returned. When thetherapist revisited Nick at his job, the therapistadvised Nick to stretch periodically and to slowdown. Nick stated, I cant. Thats what Imknown for. Im the best because Im fast, with or without a bum elbow.Well have to think ofsomething different.

The causes of musculoskeletal disorders(MSD) are complex and include personal, bio-mechanical, and psychosocial factors. Althoughan initial evaluation of a job may involveidentifying factors in the workplace design oradministrative procedures that can contributeto the development of MSDs, these are not theonly areas that need assessment. We mustconsider that the worker is an individual in thework environment, an individual with uniquebeliefs and values about work. Workers beliefsand values about work and what work requiresof them have been associated with muscu-loskeletal discomfort at work (Baker, Jacobs, &Tickle-Degnen, 2003) and may well influence a workers choice to accept and implementrecommendations to improve the workplace.Understanding workersbeliefs and values aboutwork may be one way to identify appropriate

interventions and facilitate the acceptance byworkers of appropriate workplace interventions.

This chapter presents an overview of thetheoretical and practical constructs that underliethe beliefs and values associated with work inthe United States. In this chapter we denework, identify how historical context hasshaped present work beliefs, and discuss somework beliefs and values. The chapter alsoaddresses the concept of work groups asminicultures that shape workers values, skills,and behaviors relative to work. Finally, trends inthe social context of work, such as workerdemographics, worker aging, downsizing, andjob security issues, are addressed.

DEFINITION OF WORKWhat is work? Many denitions of work exist,but there is no comprehensive denition thatsuits all purposes. At its most basic level, theterm work refers to any activity in which anindividual expends energy (Oxford EnglishDictionary, 1989). However, this denition is too broad to clarify the nature of work. Work is frequently dened as an activity that is donefor nancial recompense (Ruiz-Quintanilla &England, 1996). Unfortunately, this denitionignores the importance of nonnancial workroles as well as people who work for little or no pay (Friedson, 1990). Another denition ofwork describes it as an activity that is obligatory,

15

C H A P T E R 2

The Individual Worker Perspective

Nancy A. BakerMartha J. Sanders

directed by others, and done in a specic placeand at a specic time (Hearnshaw, 1954).Work,therefore, is the opposite of leisure; it is anactivity that must be done and, by implication, isonerous.Yet work can be creative, self-fullling,and even enjoyable. Work has been described as a means to contribute to society (Ruiz-Quintanilla & England, 1996; Jahoda, 1981). It isalso a strong role identity that provides rewardsbeyond income (Burke, 1991; Jahoda, 1981;Roberson, 1990). What becomes obvious fromall these specications of work is that work isdifcult to dene because it has many aspects.Each person will, therefore, dene work dif-ferently based on the beliefs and values that heor she most identies with it.

A Historical Perspective of WorkOur present beliefs and values about work havetheir antecedents in the history of work.Americans have a love-hate relationship withwork (Tausky, 1992).This attitude can be tracedback through the varied historical beliefs aboutworking. (See Applebaum, 1992 for a completehistory of working.) The nature of work hasshifted radically throughout the centuries, fromthat of performing daily tasks engaged in forsurvival to the modern exchange economy in which work is perceived as a means to an end (Applebaum, 1992; Primeau, 1996; Ruiz-Quintanilla & England, 1996; Wilcock, 1998).The dichotomous nature of work, however, hasbeen present in all but the earliest agrariansocieties.Work began as a means of survival andbecame at various times throughout the ages ameans of categorizing social class, of monetaryexchange, of fullling spiritual obligations, andof developing personal growth and self-esteem.

The concept of the type of work as distinct to social classes was evident with the Greek andRoman aristocrats. Aristocrats did no manuallabor, instead participating in government, war,and leisure pursuits. They viewed all manuallabor, except farming, as degrading (Applebaum,1992; Wilcock, 1998). With the advent ofChristianity, manual work was viewed as

spiritual, a way to serve God (Applebaum, 1992;Ruiz-Quintanilla & England, 1996), and also as apunishment for original sin (Thomas, 1999). Allwere expected to perform manual tasks regard-less of class structure.The social class structurewas gradually reintroduced in the Middle Ages ascommerce and the formation of guilds gainedmomentum.In general,however,work was still asubsistence undertaking.

The idea of working hard to achieve materialwealth and salvation was introduced in themid-1500s with the advent of Protestantism,particularly Calvinism. Protestants believed thateach person had a calling, or a specic workrole within Gods scheme. If that work wasperformed well, one was worshiping God. If the person did well nancially, it demonstratedthat the individual was one of the chosen.Hence, individuals worked long hours and accu-mulated wealth for wealths sake in order todemonstrate that they had achieved salvation(Hill, 1996). Calvinist Protestants beliefs aboutwork eventually became known as the Protestantwork ethic (Weber, 1958). These beliefs includ-ed concepts that work was itself good, that hardwork would overcome all obstacles, that successwas measured by both effort and material wealth,and that frugality was a virtue (Buchholz, 1978).The belief that work, in and of itself, was goodand linked to success was an idea that wouldshape many modern work beliefs.

During the Industrial Revolution (early1700s) the nature of work changed dramatically.Prior to the Industrial Revolution, craftsmenworked alone or in small conclaves dedicated to the production of a product. They primarilyworked at home, used hand tools to craft thegoods, and paced their work based on their own abilities. After the Industrial Revolution,workers were essentially machine tenders and paced their work to match the pace of themachine (Applebaum, 1992; Primeau, 1996; Ruiz-Quintanilla & England, 1996). Men, women, andchildren worked outside the home and werepaid a wage for their labor. Each worker did onlyone small aspect of the job, since, according to


Frederick Taylors Principles of ScienticManagement, production was more efcientwhen jobs were divided into small, repetitivesubdivisions (Liebler & McConnell, 1999; Parker,Wall, & Cordery, 2001). Workers lives werestructured around the time clock with limitedleisure time.

In the 1940s, behavioral and organizationaltheorists initiated a shift in industrial focus fromemphasis on work tasks to emphasis on theworker. The Human Relations Approach tomanagement identied work as a means to fulllworkers social and motivational needs (Liebler& McConnell, 1999).Thus, jobs became increas-ingly enriched, and work became associatedwith self-actualization and personal growth(Parker et al., 2001).

Over the last 50 years, the perception andstructure of work has been shifting again (Ryan,1995). The information age has caused manyworkers to move from manufacturing to theservice arena. Because the products of servicework are often intangible, intellectual propertyand consumer satisfaction become the endproduct rather than manufactured goods. Assuch, work is often not proscribed by time orplace. Work can now occur virtually anywherethat one is able to think.The strict demarcationbetween working time and home time has alsoblurred, with telecommuting becoming analternative to onsite work. Rapid communi-cation allows workers to work not only outsidethe ofce but also across the globe fromcorporate headquarters. Finally, workers rarelystay at one job for their entire careers but shiftfrom position to position (Ryan, 1995). Thesenew working parameters are likely to changemany of the beliefs about working, particularlythose associated with work as a constrainedactivity.

BELIEFS AND VALUES ABOUTWORKBeliefs are statements that individuals hold astrue. Beliefs shape the values of an individual

and culture; these values, in turn, form the basisfor individual behavior and opinions (OToole,1992). Our present-day beliefs and values aboutwork are grounded both in the historical per-spective of work and in socialization experiences(Hasselkus & Rosa, 1997; Trombly, 1995). Thehistorical perspective provides the ontologicalbackground from which we develop our beliefsand expectations about work and what theworker role will bring to us.Examples of specicbeliefs about working based on historical expe-riences include work as a burden, a constraint,a reciprocal arrangement, a means of self-actualization, and a means to contribute tosociety (Ruiz-Quintanilla & England, 1996). Earlysocialization experiences draw upon whatworkers have learned about working from theirparents, friends, and society and what they haveexperienced in the working role.

Workers also develop values that relate to theproper way to perform work and execute theworker role.These values are also influenced byearly socialization and become rmly embeddedin a workers role performance and self-perception as a worker. The introductory case of Nick illustrates the powerful influence ofthese behavioral values on work performance.Nick believed that he was a model worker. Hefelt that he was respected among his fellowworkers because he valued efcient work andwas the speediest, most efcient meat cutter.Although pacing himself at work might havedecreased his elbow pain, admiration from hisfellow workers and the ability to execute hisvalues was integral to his self-esteem andidentity as a meat cutter and therefore not anacceptable mode of intervention.

VALUES OF A WORK CULTUREThe concept of work values relates not only toindividual workers but also to groups ofworkers in the same job or profession (referredto as work groups). Work groups share similarvalues or ideas about the right way to do thejob. These ideas may relate to the quality of

The Individual Worker Perspective 17

the job, how the job is performed, the prioritiesfor performing tasks, or even to the unspokenrules of conduct that govern how and whenworkers ask each other for help or complainabout pain. Social networks between workersare believed to have a signicant impact onindividuals attitudes toward work and on theirtendency to report symptoms or painfulconditions arising from work-related tasks(Finholt, 1994).

In addition to sharing similar values, workgroups share similar tools, daily routines,language, and symbols that reflect their jobs. Inother words, work groups are miniculturesthat develop from shared work experiencesamong their members. In the context of work,institutions that shape culture include the work-place environment, supervisor and peer rela-tionships, roles, and work-related responsibilities.The culture of the work group influences andgradually shapes workers perspectives onperforming or modifying their jobs (Hosteded,1996).

The ability of group culture to shapeworkers attitudes toward work is clearly shownin Ashforth and Keiners (1999) analysis ofworkers who do dirty work (i.e., work that isphysically, socially, or morally repugnant to mostof society). They reported that although mostliterature would suggest that dirty work should cause its members to have low self-esteem and a poor social identity, the oppositetends to be true. They hypothesized that dirty workers develop a strong work culture,which has a strong element of us versus them.This strong culture allows them to reframe theirwork to emphasize its importance to society,recalibrate the job to change the values that areviewed as important, and reframe the job tofocus on its positive aspects. By the end of anindoctrination period, most dirtyworkers whoremain on the job have attained the commonlanguage and attitude that allows them to per-form the work. The worker is assimilated intothe culture of the job.


WORK CULTURE ASSIMILATIONIndividuals become assimilated into a work culturethrough various channels, including technicaltraining, formal orientations, and informalexperiences. New workers learn technical skillsthrough educational programs, vocational train-ing, on-the-job training, and trial and error.They learn the formal workplace rules such aspunctuality, work quality, and productivitystandards through company orientations, policyand procedure manuals, and yearly performancereviews. New workers learn the important, yetunspoken, informal dos and donts of the jobthrough conversation with seasoned workers,by modeling others, and by observing usual andunusual events (Van Maanen, 1976). These in-formal channels may exert the greatest impacton work attitudes as demonstrated by the dirtyjobs study (Ashforth & Kreiner, 1999).

Initially, new workers are concerned withperforming and complying with work roleexpectations. However, over time, individualscontribute their own talents and perspectives toboth the task and to interactive aspects of thejob, so that the work culture subtly changeswith the input of new workers (Jablin, 1987;Van Maanen, 1976). (For further reading aboutorganizational socialization, see Van Maanen,1976 and Jablin, 1987.)

Cultural assimilation is so insidious that indi-viduals are generally unaware of the elements oftheir own culture (Hall,1973).However,workersattitudes toward injury prevention can beaffected at every step of the assimilation processthrough establishing a safety culture that pro-vides positive feedback, injury awareness, andsupport from management and peers (Krause,1997). (See Chapter 15 for a complete dis-cussion.) The better we understand the workculture,work role assimilation,workersroutines,daily priorities,and relationships with other workgroups, the better will we understand workersattitudes and behaviors toward accepting orrejecting intervention strategies.

An ethnographic interview is one means tolearn about workers cultures, including theirenvironments, daily routines, and tools. Anethnographic interview enables health care andergonomic practitioners to answer such questionsas the following. Can one worker realistically ask another

worker for help, or is this considered to be acop-out?

Can workers be expected to slow down orpace themselves if pay depends on piece-rateincentives?

What determines quality for certain workgroups both personally and professionally?

What aspects of a particular job should notbe changed?These seemingly simple questions offer

much information about workers values andhow they perceive their work role.

Appendix 2-1 offers a semistructured inter-view that seeks to understand workers cul-tures on the basis of the interview techniquesdescribed by Spradley (1979). The interviewbegins with a grand tour of the workersphysical environment, then narrows the scopeto the workers specic work area and worktasks. Next, the interview addresses such jobassimilation issues as training and learning the ropes and ends with a discussion of hisemployers response to a work-related injury,the workers social relationships, and workvalues. The goal of the interview is to provide a context for understanding the workplacedemands. Ultimately, health care practitionersseek to understand aspects of the job that areimportant to the worker.

Spradley (1979) advocates that interviewersuse the technical words or jargon particular to a work group to encourage workers to explaintheir jobs more vividly. Although the interviewwas designed for an individual worker, it can be adapted for a group interview format.Readers will nd that stories relative to un-expected events at work add particular insightinto understanding a workers perspectives.

THE CHANGING SOCIAL CONTEXT OF WORK:TRENDS IN WORKAs discussed earlier, beliefs and values aboutworking are not static; they shift and changedepending on social and historic events thatframe a workers career. The social context re-flects not only the attitudes or values of societytoward work during a certain period but alsothe worker demographics, the industry or tech-nology trends that shape employees jobs, andthe public policy mandates that affect managingwork-related conditions. The following sectiondiscusses changes in the social context of workthat will influence our understanding of workersvalues, roles, and services needed.

Worker DemographicsWorker demographics have been changingsince the 1950s. In the 1950s the workforce was predominately male (70.4%), white (essen-tially 100%), and older (87% of men between 55and 64 worked). Job categories were as follows:41% worked in manufacturing,mining,construc-tion, or transportation; 13% worked in govern-ment; and 37% worked in areas such as trade,nance, or service (Kutscher, 1993). By 1992,46% of the workforce was female and 22% of theworkforce was a minority; 27% worked inmanufacturing, mining, construction, or trans-portation; 17% worked in the government; and62% worked in areas such as trade, nance, orservice (see Figure 2-1). Only 67% of men be-tween 55 and 64 worked (Kutscher, 1993),although this trend seems to be slowing. Withthe baby boom population aging, there will begreater numbers of older workers in the work-force over the next few years. Another demo-graphic characteristic of the present workforceis that a higher percentage has a collegeeducation. In 1960, 9.7% of males and 5.8% offemales had a college education; in 2000, 27.8%of all males and 23.6% of all females had acollege education (U.S. Census Bureau, 2001).This level of education is becoming more nec-


essary for a service-based working force (Hill,1996; Ryan, 1995).

The Aging WorkforceThe trend in aging baby boomers suggests that older workers are a growing percentage ofthe workforce. Older workers can contribute astrong work ethic, good judgment, and valuableinsights about job safety and training. However,employers must acknowledge that older workersmay need environmental modications to main-tain productivity (e.g., brighter lighting, lessbackground noise, a temperature-controlledatmosphere, and flexible working parameters)(Connolly 1991; Coy & Davenport 1991).Employers must also realize that although olderworkers as a group have fewer injuries, theypresent a higher risk for injuries because ofrepeated exposure over time and changes in thebodys resilience, reaction time, and depth per-ception. They generally take a longer time torecover from injuries. Isernhagen (1991) suggestsergonomic job task modications for olderworkers that demand less lifting and impact on

joints and slower reaction times as well as envi-ronmental modications (see Chapter 21 for acomplete discussion).

The Culturally Diverse WorkforceAs we approach a global economy, there will beincreasing numbers of companies owned byforeign subsidiaries with a greater percentage of workers coming from diverse ethnic back-grounds (Naisbitt & Aburdene, 1990). Thisdiversity brings creativity and manpower to acompany. However, it also brings a need tounderstand other ethnic culturesperceptions ofthe worker role, work environment, and thebeliefs and values of individuals.

Differences in language and cultural morespresent a challenge to professionals who striveto provide health care, work incentives, andopportunities for career growth. For example,traditional Japanese workers work in cohesivegroups that collectively solve problems. Hence,they are rarely singled out for individual praiseor punishment. Japanese workers develop strongsocial bonds with supervisors and are accus-


Gender Ethnicity Job categories

Perc

ent

male

0

female

white

ethnic

100

90

80

70

60

50

40

30

20

10

man

ufactu

ring

governmen

t

service

19501990

Figure 2-1 Changes in worker characteristics from the 1950s to the 1990s. (Data from Kutscher, R.(1993). Historical trends, 19501992 and current uncertainties. Monthly Labor Review online.Retrieved November 10, 2001 from http://stats.bls.gov/opub/mlr/1993/11/art1full.pdf.)

tomed to more personal,paternal,and supervisorystyles of management than the strictly businessrelationship common with supervisors in theUnited States. Evidence exists that Japaneseworkers have a higher sense of organizationalcommitment that may be partly due to theirsystem that rewards workers based on seniorityrather than job content (Lincoln,1996). Japaneseworkers tend to view working as more of aneconomic exchange through life commitment,whereas a greater percent of those in the UnitedStates are more inclined to view working as ameans to contribute to society and develop asense of identity (England & Whitely, 1990). U.S.managers may encounter workers from a varietyof ethnic backgrounds and must realize thatclassically American rewards based on individualachievement and ambition may be ignoring thegreater human needs and work potential of theiremployees.

Salimbene (2000) presents guidelines forsuccessful interactions with individuals fromdifferent ethnic backgrounds when discussingwork-related health care issues. These tips arebroad and not specic to any one ethnicbackground (see Box 2-1).

Use of Self-Managed and Self-LeadingWork TeamsSelf-managed work teams are those that havethe direct responsibility for product set-up,process, and outcome (Manz, 1996).Workers inself-managed teams perform a variety of worktasks and are given discretion over their workmethods, task scheduling, and task assignment.General goals for self-managed teams are toincrease production for the company whileincreasing quality of life for the employees. Infact, self-managed teams bear a resemblance to the job design in preassembly-line days inwhich each individual clearly influenced thenal product. Self-leading teams furtherincrease worker control by making workersresponsible for strategically dening goals andestablishing process and productivity standardsthat govern the system (Manz, 1996).The skills

and capacities of each worker in self-managedand self-leading work teams ultimately affect theentire team and work process. Therefore, aninjured worker in such an environment mayperceive different work values and perspectiveson returning to work than those of a worker in amore typical work environment. This conceptneeds to be understood for workers returning towork after an injury.

Americans with Disabilities Act andthe Culture of AblenessThe Americans with Disabilities Act (ADA) wasdesigned to present opportunities for qualiedworkers with disabilities to enter or return toworkplaces provided with the necessary jobaccommodations.The ADA focuses on providingreasonable accommodationsand making publicbuildings accessible for workers with physical oremotional disabilities (U.S. Department of Justice,


BOX 2-1Guidelines for Successful Interactions withIndividuals from Varied Ethnic BackgroundsRegarding Health Care Issues

Begin the interaction more formally with workerswho were born in another country. Use the lastname when initially addressing workers. It is auniquely American tradition to address individualsby their rst names.

Dont automatically treat someone as you wouldlike to be treated. Culture determines the norms forpolite, caring behaviors.

Dont be put off if the worker fails to give eyecontact. In some countries it is disrespectful to lookdirectly at another person.

Dont make any assumptions regarding theworkers beliefs regarding illness and health.Encourage individuals to share their beliefs.

Present information in a succinct manner. Provideonly essential information at rst so as not toconfuse the worker.

Recheck workers understandings of your words. Aworker may interpret instructions in a radicallydifferent manner than you intended.

Compiled from Salimbene, S. (2000). What language does yourpatient hurt in? A practical guide to culturally competent patientcare. St. Paul, MN: EMC Paradigm.

1991) (See Chapters 13 and 15 for further dis-cussion.) Although critics were initially con-cerned about the ADAs cost to companies,research has suggested that about two thirds ofall job accommodations cost less than $500 andthat these costs were often more than recoupedthrough lower job training costs, insuranceclaims, increased worker productivity, andreduced rehabilitation costs after injury on thejob. The estimated savings was $50 for every $1 spent (Blanck, 2000).

Despite the success of many interventions,there are still issues with developing reasonableaccommodations within companies. Harlan and Robert (1998) have suggested that someemployers and managers still have a standard of ableness that is not related to actual ability.This standard is related to beliefs about therightway to work,which has its underpinningsin the historical concepts of working discussedpreviously. They report that some employershave prevented workers with disabilities fromreceiving reasonable accommodations througha variety of strategies: denying the need foraccommodation; renouncing responsibility foraccommodation; withholding legal informationabout the ADA; and using intimidation to forcethe worker to work within the able-bodied workculture. Health care practitioners should famil-iarize themselves with the ADA and advocateimplementation of the law for qualied workers.

Job SecurityTodays workers are rightfully skeptical abouttheir job futures.Few organizations are insulatedfrom economic pressures, and the potential forlayoffs is real in many companies.For this reason,some workers may be hesitant to report injuriesfor fear of losing their jobs, or they may notreport work-related injuries because they do notget reimbursed their total salary (or the totalcosts of an injury) (Morse, Dillon, Warren,Levenstein,& Warren,1998). In fact,when Morseet al. (1998) examined the incidence of chronicupper extremity pain in a random Connecticutsample, they found that only 10.6% of those

who reported a work-related injury had led aworkers compensation claim. Thus, under-reporting may be a common practice.

DownsizingBusiness has become more competitive. One re-sult of this competition is the increase of organ-izational restructuring and downsizing (Ryan,1995). The process of downsizing companieshas affected workers from high-performing,high-salaried executives to loyal, skilled machin-ists. For those remaining on the job, downsizingcan create a grossly overworked and stressedworkforce. Production workers are forced toincrease the speed of their tasks withoutsacricing quality, and managers are respon-sible for a multitude of departmental respon-sibilities and tasks. Open communication,however, may be the buffer for the negativeeffects of downsizing. A recent large-scale studyon the effect of downsizing (Pepper &Messinger, 2001) found that workers who feltthat the process was equitable and that com-munication was open had fewer symptoms and health problems. Workers who remainedand who had low-decision/high-demand jobsreported increased symptoms. These resultssuggest that during downsizing, employersshould emphasize fair proceedings and com-municate openly about what is going on. It alsosuggests that managers need to monitor workdemands carefully after downsizing. Health carepractitioners can assist with this process andencourage employers to acknowledge that bothwhite-collar and blue-collar workers are at riskof developing a stress-related disorder or MSD.

SUMMARYThis chapter has provided an overview of thebeliefs and values associated with work and hasalso discussed how these beliefs and values maybe integral to managing workers with injuries.Although individuals beliefs and values aboutwork may vary, there are underlying themes thatare common to many workers. These beliefs


will shape workers perceptions and interactionswithin the working environment.Clinicians mustbe sensitive to a workers beliefs and values inorder to shape an intervention that can bestreduce disability and return that worker toproductive work.

The following case exemplies the strongbonds and self-identity some workers associatewith work. Health care professionals need tounderstand this relationship in order to provideclient-centered treatment and vocational planning(Sanders, 1994).

Barbara Ann was a 59-year-old woman whoworked at a steel mill for 17 years prior todeveloping carpal tunnel syndrome and degen-erative changes in her right thumb carpo-metacarpal joint. Her job as a Z-mill operatordemanded that she perform repetitive pinchingand grasping of tight machine controls, lifting of 50-pound metal cylinders, and operating 40-pound shears. After undergoing surgery anddeveloping reflex sympathetic dystrophy, it was clear that Barbara Ann would not be able toreturn to this physically demanding job. Al-though she had described the work environ-ment as noisy, hot, and awful smelling, whenshe was given the option of being retrained as atravel agent (her avocational passion), shedeclined. Well have to nd something at themill. I was the rst female Z-mill operator in theUnited States, and a steel worker is who I am.Mill life was central to her identity.

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Baker, N.A., Jacobs, K., & Tickle-Degnen, L. (2003).Theassociation between the meaning of working andmusculoskeletal discomfort. International Journal ofIndustrial Ergonomics, 31, 235247.

Blanck, P. D. (2000). Economics of the employmentprovisions of the ADA. In P. D. Blanck (Ed.), Employment,disability, and the Americans with Disabilities Act (pp.201227). Evanston, IL: Northwestern University Press.

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Connolly, J. K. (1991). Consideration for the visuallyimpaired older worker. Work, 2(1), 1928.

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