LICENTIATE THESIS IN TECHNOLOGY AND HEALTH, ERGONOMICSSTOCKHOLM, SWEDEN 2017

KTH ROYAL INSTITUTE OF TECHNOLOGYSCHOOL OF TECHNOLOGY AND HEALTHwww.kth.se

ISBN 978-91-7729-271-5TRITA-REPORT 2017:2ISSN 1653-3836ISRN KTH/2017:2-SE

Occupational health services in the prevention of musculoskeletal disordersProcesses, tools and organizational aspects

KRISTINA ELIASSON

Occupational health services in the prevention of

musculoskeletal disorders- Processes, tools and organizational aspects

Kristina Eliasson

Licentiate Thesis No. 2, 2017

KTH Royal Institute of Technology Technology and Health

Unit of Ergonomics SE -141 57 Huddinge, Sweden

i

Academic dissertation which with permission from Kungliga Tekniska Högskolan (Royal Institute of Technology) in Stockholm is presented for public review for passing the licentiate examination on

Friday 17 February 2017 at 13:15 in lecture hall 9504, School of Technology and Health, Hälsovägen 11C, Huddinge, Sweden.

TRITA-STH Report 2017:2 ISSN 1653-3836 ISRN/KTH/STH/2017:2-SE ISBN 978-91-7729-271-5

© Kristina Eliasson, 2017

ABSTRACT

i

Abstract

Work-related musculoskeletal disorders are associated with high costs and it is essential to prevent them before they occur. Occupational Health Services (OHS) provide expert services regarding work environment, health and rehabilitation of work related disorders. Risk assessments of the work environment can be an initial step for preventive measures, and ergonomists can be assigned by clients to assess exposures in the work environment. For such assignments different tools can be used as a support.

The aim of this thesis was to explore prerequisites, processes and practices of OHS consultants in Sweden within the domain of primary prevention of work-related musculoskeletal disorders. This was explored through the work of ergonomists in their role of assessing ergonomics risks.

The thesis is based on three papers and the research methodology was both quantitative and qualitative. Data collection includes a web questionnaire answered by 107 ergonomists, 12 semi-structured interviews and 21 inter- and 9 intra-observer reliability tests.

The results shows that ergonomics risk assessments were most commonly initiated reactively. Furthermore, a systematic work methodology for the risk assessment process was often lacking. Swedish ergonomists used only a few standardized tools for risk assessment. The Ergonomics provision from the Swedish Work Environment Authority, AFS-98, was widely used, but other tools based on standardized observation were used far less often. Ergonomics risks were often assessed solely by means of observation, based on ergonomists’ knowledge and experience. The results also pointed to that that the reliability was not acceptable when risk assessment was performed without any standardized tool. Furthermore, the results point towards that support from the OHS organizations is an important prerequisite for ergonomists to work with primary prevention, for example support the use of different risk assessment tools. Further, opportunities for specialization within a specific industry sector seem to facilitate ergonomic interventions. It is also important to have close relationships with clients and to make them aware about ergonomists competence.

Conclusively, this thesis identifies a numbers of areas in which OHS must develop to improve primary preventive services regarding work environment.

Keywords: Risk assessment, Ergonomists, Observation-based tools, Inter-observer reliability, Intra-observer reliability

SAMMANFATTNING

ii

Sammanfattning

Arbetsrelaterade muskuloskeletala besvär är förenade med höga kostnader och det är viktigt att de förebyggs. Företagshälsovården tillhandahåller experttjänster inom områden arbetsmiljö, hälsa samt rehabilitering av arbetsrelaterade sjukdomar och besvär. Riskbedömningar av arbetsmiljön kan vara ett inledande steg för olika preventiva åtgärder och ergonomer kan bli kontaktade av kunder för att bedöma exponeringar i arbetsmiljön. Vid sådana typer av uppdrag kan olika riskbedömningsverktyg användas som ett stöd för riskbedömningen.

Det övergripande syftet med avhandlingen var att undersöka förutsättningar, metodologi och processer bland svenska företagshälsovårdskonsulter för att förebygga arbetsrelaterade muskuloskeletala besvär. Detta undersöktes genom att undersöka ergonomers arbete och begränsades till deras roll gällande ergonomisk riskbedömning.

Avhandlingen baseras på två artiklar och ett konferensbidrag. Forskningsmetodologin har varit både kvalitativ och kvantitativ. Datainsamling har skett genom en webenkät som besvarades av 107 ergonomer, 12 intervjuer, samt genom 21 inter- och 9 intrabedömarreliabilitetstester.

Resultaten visar att ergonomiska riskbedömningsuppdrag oftast initieras reaktivt av kunderna, dvs efter att anställda fått besvär. Vidare saknas ofta en systematisk metodologi för riskbedömningsprocessen. Svenska ergonomer använder endast ett fåtal standardiserade verktyg vid riskbedömning. Föreskriften Belastningsergonomi från Arbetsmiljöverket, AFS-98, användes i hög utsträckning bland svenska ergonomer men däremot var användningen av flertalet andra standardiserade observationsverktyg begränsad. Riskbedömningar utfördes oftast genom observation av arbetet och intervjuer med anställda och baserades på ergonomens erfarenhet och expertkunskap. Vidare visar resultaten att det inte är reliabelt att utföra riskbedömning utan standardiserade riskbedömningsverktyg.

Resultaten indikerar även att företagshälsovårdsorganisationen är viktig för att stötta ergonomerna att arbeta primärpreventivt, till exempel genom att stötta i användning av olika riskbedömningsverktyg. Även möjligheten att specialisera sig inom en specifik bransch förefaller främja ergonomiska interventioner. Det är också viktigt att ha en nära relation med kunderna och att uppmärksamma dem på ergonomernas kompetensområden.

Sammanfattningsvis identifierar resultaten från avhandlingen ett antal områden där företagshälsovården bör utveckla sig för att förbättra sina primärpreventiva arbetsmiljötjänster.

Nyckelord: Riskbedömning, Ergonomer, Observationsverktyg, Interbedömarreliabilitet, Intrabedömarreliabilitet

PREFACE

iii

Preface

It began in 2011, when I had the privilege to become a part-time “Industrial PhD-student through a unique collaboration between Sensia Occupational Health Services and KTH Royal Institute of Technology. For a couple of years I had been working as an occupational ergonomist/registered physiotherapist (RPT) in OHS. Through the work I had seen a variety of different work environments and realized that many of these could be improved. I have always been interested in research and development and I started to think about how OHS could develop their work methods regarding primary preventive services. Through a series of coincidences, I got the opportunity to become a part of the newly founded research program “Future occupational health services – research for continuous evaluation, learning and improvement”.

In 2006, the Swedish government initiated an official investigation concerning the future competence of the OHS (SOU, 2007:91). This initiative resulted in the funding of a research program (2011-2016), “Future Occupational Health Services – research for continuous evaluation, learning and improvement”. The programme was hosted at KTH Royal Institute of Technology, in collaboration with three research institutions, Karolinska Institutet (KI), Uppsala University (UU) and the Swedish Environmental Research Institute (IVL).

The reason for starting the programme was simply that the research about Swedish OHS was scant. Already in 2003 it was pointed out in an investigation by the government (SOU, 2004:113) that the OHS did not meet the expectations as an independent expert with competence to identify and describe relationships between the working environment, organization, productivity and health. Furthermore, evaluations and research about benefits and effects of OHS service were lacking. However, it was not until after the investigation in 2007 (SOU, 2007:91) that actions were taken for the OHS to be developed as its own academic field. Eventually, this led to the first Swedish professorship in OHS research and two research programmes, one at KI and one at KTH, mentioned above.

Earlier research had traditionally focused on effects of deficient working environments, such as injuries, health impairments, absence due to illness and disability. Now there was also a need for research into the effects of OHS working methods and practices. Research in the KTH programme aimed to create scientifically based knowledge that would be applicable to OHS.

The programme focused on three areas:

1. Methods and tools for effective and efficient monitoring and improvement of the work environment and health.

2. Content and driving forces of OHS services provided.

3. Methodologies for continuous follow-up and evaluation of the effectiveness and efficiency of OHS interventions and other activities in relation to desired outcome.

The overall aim of the programme was to support the development of effective and efficient OHS through scientifically based research for continuous evaluation, learning and improvements.

PREFACE

iv

This thesis focuses on how the practical work in OHS is performed, with an emphasis on the work process and use of systematic methodology and tools for primary prevention of WMSDs. Increased knowledge in this area is a prerequisite to knowing how and what type of supports are needed within OHS to achieve effective and efficient services.

The studies included in this thesis are based on the practical work of OHS companies in Sweden and exemplifies the work conducted by ergonomists regarding primary preventive ergonomic assignments, for example risk assessment. It is important for me that I can contribute with research which can be practically applicable for OHS companies and promote their primary preventive services regarding work environment.

Sala, December 2016

Kristina Eliasson

LIST OF APPENDED PAPERS

v

List of appended papers

Paper A

Eliasson, K., Lind, C., Nyman, T. (2016). Ergonomics Risk Assessment: Tool Use and Processes.

(Manuscript).

Paper B

Eliasson, K., Palm, P., Nyman, T., Forsman, M. (2016). Inter- and Intra-Observer Reliability of Risk Assessment of Repetitive Work without an Explicit Method.

(Accepted for publication in Applied Ergonomics)

Paper C

Eliasson, K., Lind, C., & Nyman, T. (2015). Facilitators for the Implementation of Ergonomic Interventions. Proceedings from the NES 2015 Nordic Ergonomics Society 47th Annual Conference, K. I. Fostervold, et al., Editors. 2015, NEHF (Norwegian society for Ergonomics and Human Factors): Lillehammer, Norway.

LIST OF ABBREVIATIONS ANS GLOSSARY OF TERMS

vi

List of abbreviations and glossary of terms

Client Refers to e.g. different industries or different companies in various sectors that are clients of OHS companies.

OBRAT Observation-based risk assessment tool.

OHS Occupational health services. Companies that provide services in the domains of the work environment, health promotion and rehabilitation.

OHSM Systematic occupational health and safety management. Involves different activities that in a systematic manner involve inventory, analysis and measures to prevent various types of risk within a company.

Risk assessment A series of logical steps to enable, in a systematic way, identification, analysis and evaluation of risks.

SWEA Swedish Work Environment Authority

Standardized risk assessment tools

Tools that are used in a systematic methodology, as in assessing different risk factors, e.g. OBRAT.

Systematic methodology

A work methodology that includes a series of logical steps in which different facts are collected and analysed and often evaluated.

Proactive Taking the initiative by making things happen or by preparing for possible future problems.

Prevention

Includes a wide range of activities (interventions) which are aimed at reducing risk or threats to health.

Primary prevention Aims to prevent disease or injury before it occurs.

Secondary prevention Aims to reduce the impact of a disease or injury that has already occurred.

WMSD

Work-related musculoskeletal disorders are pain, injuries and disorders in the human musculoskeletal system.

CONTENTS

vii

Table of contents

Abstract i

Sammanfattning ii

Preface iii

List of appended papers v

List of abbreviations and glossary of terms vi

Table of contents vii

1 Background 1

1.1 Work environment and risk assessments 1

1.2 Occupational health services in Sweden 3

1.3 Work-related musculoskeletal disorders and prevention 4

1.4 Primary prevention and occupational health services 5

1.5 Ergonomists within occupational health services 7

1.6 Ergonomic risk assessment - a tool in primary prevention? 8

2 Aim 10

3 Method 11

3.1 Research design 11

3.2 Data collection methods 12

3.3 Data analysis 14

3.4 Preconceptions of the author 17

3.5 Ethical considerations 17

4 Summary of results 18

4.1 Paper A - Ergonomic Risk Assessment: Tool Use and Process 18

4.2 Paper B - Inter- and Intra-Observer Reliability of Risk Assessment of Repetitive Work without an Explicit Method 19

4.3 Paper C - Facilitators for the Implementation of Ergonomic Interventions 20

CONTENTS

viii

5 Discussion 21

5.1 Results discussion 21

5.2 Methodological discussion 24

5.3 General reflections 26

6 Conclusions and further research 27

6.1 Practical implications 27

6.2 Further research 27

7 Acknowledgments 28

8 References 29

BACKGROUND

3

1.2 Occupational health services in SwedenThe industrialisation contributed to the development of the Swedish OHS. During the mid-1800s new work-related health and safety problems arose. This resulted in a need for medical care adjacent to workplaces (Josefsson & Kindenberg, 2004). Initially, the focus was on health care and treatment. The modern OHS, which included both technical and medical expertise, originated from the mid-1960s. Somewhat later, psychosocial and ergonomics competence was also included and the OHS began to focus on preventing work-related ill health. During the 1980s, the OHS sector in Sweden expanded rapidly and about 75% of the employees had access to OHS. Between the years 1986 and 1992, the government provided indirect funding to OHS companies. At the beginning of the 1990s, the collective agreement regulating OHS between the employers and the union was terminated. According to the former collective agreement, all employers were obliged to provide OHS; after the termination it was not mandatory for an employer to have a contract with OHS and the access to OHS varies between industry sectors and size of companies. However, “the employer shall be responsible for the availability of the occupational health services which the working conditions require” (the Swedish Work Environment Act, chapter 3, § 2c) (AML, 2015). All these events led to a decline of the Swedish OHS during the late 20th century. Today approximately 65% of Swedish employees have access to OHS through their employer (Företagshälsor, 2016). This can be compared to France, the Netherlands, Finland, Belgium and Luxembourg where 75–100% of employees have access to OHS (Hämäläinen, Husman, Räsänen, Westerholm, & Rantanen, 2001). According to Axelsdotter Hök (2009), it also seems that there has been a shift in requested services from the Swedish OHS. Focus has shifted from prevention of work environmental risk factors towards rehabilitation and health promotion.

Today the Swedish OHS operates on the free market and the Swedish Work Environment Act describes and defines the function of OHS as follows:

“The OHS company is an independent expert resource in the domains of the work environment and rehabilitation. OHS shall in particular work for the prevention and elimination of health risks at workplaces, and shall have the competence to identify and describe connections between the working environment, organization, productivity and health” (the Swedish Work Environment Act, chapter 3, § 2c) (AML, 2015).

The Swedish OHS are among the least regulated OHS in Europe (Hämäläinen et al., 2001)

The most common organization of OHS is “private external OHS”. They are privately owned and have contracts with several clients who pay for ordered services, often per hour or alternative per service assignment. A handful of large OHS corporations with OHS units nationwide are the main actors in the Swedish OHS market. Another, much less common, organization of OHS is the “in-house OHS”, which is an internal OHS unit/department incorporated into a larger company/industry, municipality or county council.

The Swedish OHS market employs about 4000 people. Nurses comprise about a third of the OHS employees, followed by behavioral scientists, physicians, ergonomists, work environment engineers, administrators and others (Svenska Företagshälsor, 2016).

BACKGROUND

4

Schmidt, Gunnarsson, Dellve, & Antonsson (2016), has claimed that the OHS do not fulfil their function as impartial OHSM experts. Clients do not use them as an expert resource to prevent occupational health and safety risk. Instead, the services often are focused on individual issues such as rehabilitation, curative services and wellness activities (Schmidt & Sjöström, 2015). Hence, according to the law, the OHS overall objective to be an expert within work environment correlations and to offer primary preventive service is not fulfilled.

1.3 Work-related musculoskeletal disorders and preventionHealth hazards resulting in WMSD are a major problem worldwide, entailing expenses and suffering for society, employers and the affected individual (Breivik, Eisenberg, & O’Brien, 2013; Cimmino, Ferrone, & Cutolo, 2011). Work-related musculoskeletal disorders is one of the most common causes to ill-health relating to the work environment (Arbetsmiljöverket, 2014; Punnett, 2014). Exposures in the work environment that affect these tissues are biomechanical exposure, such as awkward postures, repetitive work, forceful exertions, static loads and vibrations, but also work-related psychosocial and organizational factors (Bovenzi, 2006; da Costa & Vieira, 2010; Lang, Ochsmann, Kraus, & Lang, 2012). WMSD can be acute – for example, acute back pain in connection with lifting activities when a heavy load leads to a sudden failure in both the structure and function of the locomotor system (Luttman et al., 2003). However, usually it takes several years to develop WMSD because they are the result of a long-term load (Cimmino et al., 2011; Luttman et al., 2003). The long incubation period and other contributing factors (such as lifestyle factors) might lead to WMSD not being prevented in time.

To prevent WMSD, it is most important to have balance between the load at work and the capacity of the working person. This can be done by the work design adapting the working conditions to the worker or by developing the capacity of the workers through training and vocational adjustment. However, preventive measures should strive for the adaption of the working conditions (Luttman et al., 2003). Changes in the work design can involve job rotation, job enlargement and enrichment, team work, as well as changes in the workplace design and the development of tools and equipment to better fit the worker.

Primary prevention aims at preventing the onset of injuries and disorders in a healthy working population (Driessen et al., 2010). This includes successful and effective work methodology to improve work environment and to reduce sick leave, such as workplace interventions, organizational interventions and multidisciplinary interventions (Arnetz, Sjogren, Rydehn, & Meisel, 2003; de Boer, van Beek, Durinck, Verbeek, & van Dijk, 2004; Goine, Knutsson, Marklund, & Karlsson, 2004; Jensen, Bergstrom, Ljungquist, & Bodin, 2005; Karsh, Moro, & Smith, 2001; Rivilis et al., 2008; Silverstein & Clark, 2004). “Multiple component intervention” is one of the most effective types of intervention to controlling WMSD (Karsh et al. 2001, Silverstein et al. 2004). “Multiple component intervention” refers to some combination of organizational changes (e.g. work rotation), technical changes (e.g. new tools, new workstation) and individual changes (e.g. training, education) (Karsh et al. 2001). Another important factor for successful WMSD interventions is a participative approach, meaning that the intervention takes place in cooperation with managers and employees (Karsh et al. 2001, Rivilis et al. 2008).

BACKGROUND

5

1.4 Primary prevention and occupational health servicesAll these primary preventive activities described in the previous section are within the expertise of OHS. However, instead of primary preventive activities, research reveals that OHS focus on individual rehabilitation after occurrences of WMSD (Axelsdotter Hök & Tege, 2009). Nevertheless, a primary preventive perspective is more cost effective and affects more people. The proactive initiative for implementation of, for example primary preventive measures, is the responsibility of the employer (client) (SWEA, 2001). Research has shown that organizations with a proactive OHSM report higher profits and fewer accidents; furthermore, they have significantly more positive safety climate perceptions which are associated with better self-reported physical and mental health (Haslam, O’Hara, Kazi, Twumasi, & Haslam, 2016). Since the OHS would have the competence to know what measures are needed for primary prevention (AML, 2015), they also would have the ability to take a role as a proactive partner towards their clients which have a less developed OHSM and actively support them to prevent WMSD.

The research about how OHS use a systematic work methodology for services that aims to be primary preventive is very limited (Eliasson, 2016). Table 1 presents three studies which describe primary preventive work methodologies used by OHS. Menckel, Hagberg, Engkvist, & Wigaeus Hjelm (1997) described feedback models used by occupational physiotherapists to prevent back injuries in health care. The models tested were feedback to work groups and supervisor, and feedback solely to supervisors. Both models generated a considerable number of accident-prevention proposals and the work method was perceived as favourable (Menckel et al., 1997). In a case study, Godderis, Vanhaecht, Masschelein, Sermeus, & Veulemans (2004) described, developed and evaluated a methodology for OHS companies to work preventively with chemical risks. The model could be transferred to other work environmental risks and the methodology was evaluated to be promising. Another primary preventive work method for OHS, described by Mattila & Kivi (1991), is called job load and hazard analysis and is a risk assessment methodology. This methodology was considered to be good and effective by both the OHS company and its client (Mattila & Kivi, 1991).

BA

CKG

ROU

ND

6

Tabl

e 1.

Prim

ary

prev

entiv

e w

ork

met

hods

use

d by

OH

S c

ompa

nies

.

Aim

Stud

y de

sign

Met

hods

Stud

y po

pula

tion

Impo

rtan

t fin

ding

s

The

Prev

entio

n of

Bac

k In

jurie

s in

Swed

ish

Hea

lth C

are

–a

Com

paris

on b

etw

een

Two

Mod

els

for A

ctio

n-O

rient

ed

Feed

back

. (M

enck

el e

t al.,

199

7)

Eva

luat

e tw

o di

ffere

nt m

odel

s fo

r act

ion-

orie

nted

feed

back

to

pre

vent

bac

k in

jurie

s.

Cas

e st

udy

Form

s, w

ritte

n re

ports

, in

terv

iew

s w

ith

phys

ioth

erap

ists

.

11 p

hysi

othe

rapi

sts,

5 O

HS

un

its. 1

22 c

ases

. Th

e ac

tion-

orie

nted

fe

edba

ck m

etho

dolo

gy w

as

rega

rded

favo

urab

ly,

espe

cial

ly fe

edba

ck to

bot

h su

perv

isor

and

ent

ire w

ork

grou

p.

Prev

entio

n Pa

thw

ays:

A

pplic

atio

n of

the

Crit

ical

Pat

h M

etho

dolo

gy in

Occ

upat

iona

l H

ealth

Ser

vice

s. (G

odde

ris e

t al

., 20

04)

Dev

elop

, im

plem

ent a

nd

eval

uate

a w

ork

met

hodo

logy

fo

r OH

S to

wor

k pr

even

tivel

y.

In th

is c

ase,

rega

rdin

g ch

emic

al ri

sks.

Cas

e st

udy

Invo

lvem

ent o

f a

mul

tidis

cipl

inar

y te

am

(act

ion

rese

arch

)

A m

ultid

isci

plin

ary

team

from

an

OH

S c

ompa

ny in

Bel

gium

. Th

e te

am c

onsi

sted

of a

hy

gien

ist,

safe

ty e

ngin

eer,

nurs

e, p

hysi

cian

and

clie

nt

com

pany

.

The

PP

-met

hodo

logy

was

co

nsid

ered

a p

rom

isin

g m

etho

dolo

gy to

impr

ove

the

OH

S s

ervi

ces

rega

rdin

g pr

even

tive

wor

k en

viro

nmen

t ser

vice

.

Haz

ard

Scre

enin

g an

d Pr

opos

als

for P

reve

ntio

n by

O

ccup

atio

nalH

ealth

Serv

ice:

An

Expe

rimen

t with

Job

Loa

d an

d H

azar

d A

naly

sis

at a

Fin

nish

C

onst

ruct

ion

Com

pany

. (M

attil

a &

Kiv

i, 19

91)

Eva

luat

e th

e ef

fect

iven

ess

of

a sy

stem

atic

tool

for r

isk

asse

ssm

ent (

job

load

and

ha

zard

ana

lysi

s) a

nd w

heth

er

it co

uld

be a

wor

k m

etho

dolo

gy fo

r OH

S to

wor

k m

ore

prev

entiv

ely.

Cas

e st

udy,

Act

ion

rese

arch

Inte

rvie

ws,

com

paris

on

betw

een

OH

S p

rogr

amm

e be

fore

and

afte

r the

im

plem

ente

d w

ork

met

hodo

logy

.

Larg

e co

nstru

ctio

n co

mpa

ny,

over

200

0 em

ploy

ees.

OH

S

com

pany

.

The

met

hod

wor

ked

wel

l as

a ce

ntra

l com

pone

nt o

f pr

even

tive

occu

patio

nal

heal

th c

are.

BACKGROUND

7

1.5 Ergonomists within occupational health servicesThe International Ergonomics Association (IEA) defines ergonomics as:

Ergonomics (or human factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance (IEA, 2016).

Furthermore the IEA describes the role of ergonomics practitioners as follows:

Practitioners of ergonomics and ergonomists contribute to the design and evaluation of tasks, jobs, products, environments and systems in order to make them compatible with the needs, abilities and limitations of people (IEA, 2016).

The ergonomics discipline is broad and there are several domains of specialization, such as physical ergonomics, cognitive ergonomics and organizational ergonomics. Ergonomists’ backgrounds may vary widely, from technical or medical disciplines (Piegorsch et al., 2006). In Sweden, ergonomists employed in OHS usually have a background as a registered physiotherapist (RPT) with additional education in physical ergonomics. The role is often complex and the work in OHS can include, for example, treating patients, rehabilitation, health examinations, risk assessments, education (Laring, Neumann, Nagdee, Wells, & Theberge, 2007). The title “ergonomist” is, in Sweden, unprotected, this means that anyone can use the title. However, the Swedish Association of Physiotherapists can promulgate RPT´s the title “specialist in ergonomics”. The process includes an application and special requirements regarding for example education, research and practical experience of ergonomics (Fysioterapeuterna, 2014). Furthermore, in Europe, ergonomists can apply for the protected title “European Ergonomist”, the minimum requirements are three years of education at university level, whereof at least one is dedicated to ergonomics. Furthermore, at least three years of practical experience and continuous development within the discipline are required. The application and certification is associated with a fee. In Sweden, 40 ergonomists are registered European Ergonomists (CREE, 2016).

In recent years, there has been a growing focus on ergonomists work and their consultative role (Laring et al., 2007; Wells, Neumann, Nagdee, & Theberge, 2013; Whysall, Haslam, & Haslam, 2004). Furthermore, some of the ergonomics research emphasizes the importance of how ergonomists should “navigate” within the client organization and how to make the client aware of the ergonomics issues (Berlin, 2011; Broberg & Hermund, 2004; Ege, 2006; Theberge & Neumann, 2010). However, the ergonomists’ role and work are not only affected by the organization and management of the client company in which the ergonomists provide their service, but are also affected to a high degree by the OHS organization in which the ergonomists are employed – and the research is scarce in this area.

BACKGROUND

8

1.6 Ergonomic risk assessment - a tool in primary prevention?As described above, multiple component interventions are an effective way to prevent WMSD (Karsh et al., 2001, Rivilis et al., 2008). Since WMSD can be affected by different work environmental factors (biomechanical, environmental, psychosocial and organizational) an intervention should be preceded by a thorough mapping/risk assessment. A systematic methodology for OHS has shown to be a good basis for preventing health hazards (Mattila & Kivi, 1991). The ergonomic risk assessments include assessment of the exposure of ergonomic risk factors. The risk assessment of WMSD can involve different standardized tools, such as direct technical measurements tools, which includes inclinometry, heart rate monitors and electromyography (David, 2005; Neumann, 2007). However, observational-based risk assessment tools (OBRATs) are often mentioned to be useful due to the fact that they are time-efficient, flexible and considered less costly compared with technical measurement tools (Chiasson, Imbeau, Aubry, & Delisle, 2012; David, 2005; David, 2005). This makes them suitable for OHS ergonomists since assignments often are restricted in time by the client.

There are several OBRATs reported in the literature (David, 2005; Neumann, 2007; Takala et al., 2010). An overview of a number of OBRATs and what sort of exposure and outcome they are developed for is presented in Table 2. To conduct a qualitative risk assessment/exposure assessment, use of several specific tools may be required. This means that ergonomists must have knowledge of a range of tools and the situations for which they are applicable.

OBRATs are structured in a manner such that one can rather easily conclude whether the elevated risk level found is due to the duration, force, repetition of the work task or other exposures. This may simplify the prioritizing process for ergonomists when determining which exposures should be targeted in an intervention. The standardized approach in OBRATs makes these tools also suitable for use in evaluation of risk reduction measures taken at a workplace which should be of interest to both the OHS providing the service and the client receiving the service. The use of OBRATs is described in few studies (Dempsey, McGorry, & Maynard, 2005; Diego-Mas, Poveda-Bautista, & Garzon-Leal, 2015; Pascual & Naqvi, 2008; Wells et al., 2013), and information concerning use among ergonomists with a background as physioterapists is even more limited. Studies of tools used by Swedish ergonomists have included a small number of respondents, about twenty (Laring et al., 2007; Sturesson, 2006), or a respondent rate of less than twenty percent (Sturesson, 2006). However, these studies indicate that the Ergonomics provision AFS-98 from the SWEA (SWEA, 1998) was widely used, as well as methods that were developed within the respondents’ own organizations.

As previously described, there is published research about ergonomists’ practice and their work with standardized tools. However, there is not much research regarding whether and how OHS-companies work with systematic methodology for primary preventive services, and information is scarce about how the OHS organization affects the work of their consultants (e.g. ergonomists).

BA

CKG

ROU

ND

9

Tabl

e 2.

Ove

rvie

w o

f ob

serv

atio

nal m

etho

ds f

or r

isk

asse

ssm

ent

of p

hysi

cal l

oad

at w

ork.

Mor

e co

mpr

ehen

sive

pre

sent

atio

ns a

nd li

nks

toth

e m

etho

ds a

re a

vaila

ble

in a

S

wed

ish

repo

rt (P

alm

, Elia

sson

, Lin

dber

g, &

Häg

g, 2

014)

Scr

eeni

ng to

ols

Mai

nly

for r

epet

itive

wor

kM

ainl

y fo

r aw

kwar

d po

stur

esM

ainl

y fo

r man

ual h

andl

ing

QEC

Was

hing

ton

stat

eer

gono

mic

ch

eckl

ist

HAR

MK

IM II

IO

CR

ASt

rain

In

dex

HAL

RU

LAR

EBA

KIM

IIK

IM I

NIO

SH

liftin

g eq

uatio

nR

AMP

Push

/pul

lY

esN

oN

oN

oN

oN

oN

oN

oN

oY

esN

oN

oY

esH

eavy

lifts

Yes

Yes

No

No

No

No

No

Par

tlyY

esN

oY

esY

esY

esFo

rce

Yes

Yes

Rep

etiti

onY

esY

esY

esY

esY

esY

esY

esP

artly

No

No

No

No

Yes

Awkw

ard

post

ures

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Com

bina

tion

of

expo

sure

sY

esN

oY

esY

esY

esY

esY

esY

esY

esY

esY

esY

esY

es

Nec

k/sh

ould

ers

Yes

Yes

Yes

Par

tlyP

artly

No

No

Yes

Yes

No

No

No

Yes

Elbo

w/w

rist

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

Yes

Low

er b

ack

Yes

Yes

No

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Legs

No

Yes

No

No

No

No

No

No

Yes

Yes

Par

tlyN

oY

es

Incl

udes

tim

e di

men

sion

/ dos

e Y

esY

esY

esY

esY

esN

oN

oN

oY

esY

esY

esY

es

AIM

10

2 Aim

The aim of this thesis was to explore prerequisites, processes and practices of Occupational Health Services consultants in Sweden within the domain of primary prevention of work-related musculoskeletal disorders.

It was the work of the professionals who are employed as ergonomists by OHS in Sweden that was in focus of the research in this thesis.

The thesis focuses on the following specific research questions;

When are OHS ergonomists involved in ergonomics assignments?

When and how are observation based risk assessment tools used by Swedish ergonomists?

How reliable are risk assessments performed by ergonomists without the use of any standardized observational method?

What organizational prerequisites within OHS companies facilitate involvement in work environment assignments?

METHOD

11

3 Method

The following section presents the various data collection methods and analysis used in the research. Furthermore, reflexions regarding the author’s preconceptions and ethical considerations related to respective papers are presented.

3.1 Research designThe goal with this research has been to reach a deeper knowledge about the practice in OHS companies within the domain of primary preventive services, and for this various research methods have been used. Several methods were used in this thesis: survey, interviews, and inter- and intra-observer reliability testing. Use of multiple methods (triangulation), can help to achieve a deeper understanding and therefore a combination of both qualitative and quantitative research methodologies were used.

The first study (resulting in Paper A and C) aimed to explore the prerequisites which affected the ergonomists work and also to deepen understanding about the ergonomists’ work processes for risk assessment, a descriptive research design with an exploratory approach was used. This means that the research aimed to answer to the questions what (descriptive) and why (explanatory). In Paper A, both quantitative and qualitative methodology was used. The mixed methodology was chosen to get both a broad description regarding the use of OBRATs among Swedish ergonomist in general – for this, the questionnaire was the obvious choice. Furthermore, to explore the risk assessment process, interviews were considered to be an appropriate method since they gave an opportunity to gather in-depth information.

The research in the second study (resulted in Paper B) was conducted to evaluate the reliability of ergonomists’ risk assessment without the support of any standardized risk assessment tool. Research aimed at test reliability (and also validity) in different tools is important when it comes to preventing WMSD; reliable tools are a precondition for selecting different measures.

Table 3 shows an overview of the research design of the included papers.

METHOD

12

Table 3. Description of the design of the papers.

Paper A Paper B Paper CTitle Ergonomic Risk Assessment:

Tool Use and ProcessesInter- and Intra-Observer Reliability of Risk Assessment of Repetitive Work without an Explicit Method

Facilitators for the Implementationof Ergonomic Interventions

Publicationtype

Journal article Journal article Conference paper

Researchmethodology

quantitative and qualitative quantitative qualitative

Methods Web-based questionnaireSemi-structured interviews

Inter- and intra-observerreliability testing

Semi-structured interviews

Research questions inrespective paper

What are Swedish ergonomists’ knowledge and use of OBRATs, as well as OBRATs’ important immanent features?Explore the processes of assignments that include ergonomic risk assessment.

How reliable areexpert basedrisk assessments?

What factors within the OHS-companies facilitate ergonomic interventions? (From a Swedish context)

Respondents Survey answered by 107ergonomistsResponse rate: 43%Interviews with 12 ergonomists

Inter-observer reliability: 21 ergonomistsintra-observerreliability: 9 ergonomists

Interviews with 12 ergonomists

3.2 Data collection methodsThe methods used for data collection in the three papers included in this thesis are described below. The data for Papers A and C were collected during 2012 and for Paper B during 2014–2015.

3.2.1 Survey (Paper A)

To explore the use of OBRATs among Swedish ergonomists, a web-based questionnaire was conducted (Appendix A). To reach as many ergonomists as possible, the survey was attached in a periodical e-newsletter sent to all members (598, year 2012) of the Ergonomic Section of the Swedish Association of Physiotherapists. The distribution of the questionnaire was handled entirely by the Swedish Association of Physiotherapists. In total, 251 ergonomists opened the newsletter, of which 107 completed the survey (43%).

The questions included the ergonomists’ knowledge about and use of different OBRATs, and what qualities they considered important in them. The questionnaire was inspired of a similar survey by Dempsey et al. (2005). It contained an introductory part with questions about gender, age and work experience, followed by questions about 17 different OBRATs. Ergonomics

METHOD

13

students, several of whom were employed at OHS, answered a pilot version of the study. After the feedback the questionnaire was slightly revised before distribution.

3.2.1 Interviews (Papers A and C)

To complement the questionnaire in Paper A with deeper understanding about the process regarding risk assessment and the practical use of risk assessment methods, interviews with 12 ergonomists were conducted. The samples of ergonomist were strategic, and they all worked in OHS and represented both in-house and privately owned OHS and had experience of ergonomic risk assessment. Five of the recruited ergonomists were part of a network group involved in a project developing a new OBRAT (Lind, Rose, Franzon, & Nord-Nilsson, 2014). Through these ergonomists, different OHS with units spread in several regions were identified and additional seven ergonomists were asked to participate in the study. All ergonomists were RPTs and worked as ergonomists in eight different OHS. Three ergonomists were employed by the same in-house OHS department in a global industrial manufacturing company, working in different production plants. The other nine ergonomists were employed in privately owned OHS situated in seven different regions in the southern and central parts of Sweden.

The interviews were semi-structured and followed an interview guide (Appendix B). In the first part of the interview, the ergonomists were asked to describe one or several ergonomic assignment projects in which they had been involved. The broad initial question was intended to “open up” the ergonomists to talk freely about important assignments. Furthermore, each ergonomist was asked about how the assignment was initiated, methods used for ergonomic risk assessment and about how feedback to the client was given and whether assignments were evaluated. A pilot interview was conducted with two ergonomists, which resulted in slightly modification with more questions emphasizing the assignment process. The majority of the interviews were performed by the author of this thesis. Because of the ergonomists’ geographical spread most interviews were conducted as telephone interviews, with a length from 45 to 60 minutes. The interviews were audio-recorded and transcribed verbatim.

3.2.1 Inter- and intra-observer reliability test (Paper B)

Paper B aimed to evaluate the inter- and intra-observer reliability of ergonomic risk assessment based on the ergonomists’ own experience and without the support of any standardized risk assessment tool. Twenty-one OHS-employed ergonomists were recruited to the study, all of whom had at least one year of experience as an OHS ergonomist.

The risk assessment procedure consisted of the ergonomists watching video recordings of ten different work tasks. They were given complementary information about each work task such as duration of work task during the work day, break schedules, weights of handled goods, other physical factors, and ratings of discomfort on Borg’s CR10-scale (Borg, 1998), work demands and control. The video-recorded work task covered different types of repetitive work from different job sectors: grocery store work, meat cutting, industrial assembly, cleaning, post sorting and hairdressing. To provide as natural an observational view of the worker as possible, each work task was recorded with two to four video cameras. The different views were synchronized into one video consisting of multiple frames with a close-up on hand and wrist movement.

METHOD

14

The collected data consisted of the risk assessment protocol from each work task (Appendix C). At the protocol, the ergonomist rated the risk for WMSD. Risk was rated using a three-stage scale: high risk (red), moderate risk (yellow) and low risk (green), and it was rated for eight specific body regions: neck, lower back, right and left shoulders, arms/elbows, and wrists/hands, as well as for the global risk. Nine ergonomist performed the risk assessment procedure a second time and the protocols from the first and second assessments were used for calculation of intra-observer reliability.

3.3 Data analysis

3.3.1 Paper A

The questionnaire in Paper A was analysed descriptively using SPPS Statistics 22. The data were presented in numbers and percentages. The qualitative analysis of the interviews was more comprehensive. The approach for the analysis was content analysis with an inductive approach, meaning that it was not based on a previous theory (Elo & Kyngaes, 2008). The focus was on the manifest content (Graneheim & Lundman, 2004), which means that the analysis focuses on the visible and obvious components of the text.

The content analysis was performed by the author of this thesis, and the process contained the following steps:

The author:

1. Listened to the interviews and transcribed the text. Three interviews were transcribed by another person. During the transcription, reflections and interpretations began.

2. Created an overall picture of the content of the interviews. The goal of this step was to delve into the different interviews and get to know the material. This step included both listening and reading the interviews several times.

3. Highlighted words and sentences related to the research questions, both on paper and in the computer.

4. Condensed the text. In this step, the sentences, called meaning units (Graneheim & Lundman, 2004) were condensed and reduced into a brief summary format (Thomas, 2006). The condensed texts were abstracted and labelled with a code. The abstraction emphasized that the meaning of the text was interpreted on a higher logical level (Graneheim & Lundman, 2004). This step was done by copying highlighted meaning units from the transcribed documents into a table created in Word. The meanings were condensed and given a code.

5. Clustered the codes into different subcategories and further, three main categories were formulated. The categories constituted the manifest content of the interviews.

6. Formulated an overall theme. Finally, based on the aim of Paper A, an overall theme (Graneheim & Lundman, 2004) was formulated – “Process of ergonomic assessment assignments” – of which the three main categories represent different stages in the process.

The analysis process is illustrated in Table 4.

M

ETH

OD

15

Tabl

e 4.

Exe

mpl

ifica

tion

of h

ow te

xts

durin

g th

e an

alys

is w

ere

trans

ferr

ed fr

om m

eani

ng u

nits

into

cat

egor

ies

(Gra

nehe

im &

Lun

dman

, 200

4).

Mea

ning

uni

tC

onde

nsed

m

eani

ng u

nit

Cod

eSu

bcat

egor

ies

Cat

egor

ies

“The

[clie

nt c

ompa

ny] h

as a

n id

ea a

bout

the

man

agem

ent o

f the

ov

eral

l ris

k as

sess

men

t; m

y pa

rt [e

rgon

omic

risk

ass

essm

ent]

is

incl

uded

in th

e ov

eral

l ris

k as

sess

men

t.” (E

rgon

omis

t 5, e

xter

nal)

The

clie

nt a

ssig

ns th

e er

gono

mis

t as

an e

xper

t to

cond

uct e

rgon

omic

risk

as

sess

men

ts.

Par

t in

OH

SM

Pro

activ

e –

clie

nt

wan

ts to

exp

lore

er

gono

mic

risk

s.

Rea

son

to

cons

ulta

tion

(pro

activ

e)

“She

cam

e to

me

for p

hysi

othe

rapy

trea

tmen

t and

late

r I v

isite

d he

r wor

kpla

ce a

nd I

perfo

rmed

an

ergo

nom

ic ri

sk a

sses

smen

t …

Then

it e

mer

ged

that

job

rota

tion

wou

ld b

e be

nefic

ial f

or a

ll pa

rties

, not

just

for h

er …

” (E

rgon

omis

t 4, e

xter

nal).

The

ergo

nom

ist c

ondu

cted

in

divi

dual

clin

ical

trea

tmen

t of

WM

SD

.

Alre

ady

exis

ting

WM

SD

lead

s to

er

gono

mic

as

sign

men

t.

Rea

ctiv

e –

reha

bilit

atio

n of

W

MS

D.

Rea

son

for

cons

ulta

tion

(rea

ctiv

e)

“I pr

imar

ily u

se th

e co

mpa

ny’s

ow

n de

velo

ped

risk

asse

ssm

ent

tool

, but

in th

e lo

gist

ics

(dep

artm

ent)

we

use

othe

r too

ls; K

IM, a

to

ol fo

r sm

all l

ot d

eliv

ery

syst

em a

nd th

e E

rgon

omic

s Th

erm

omet

er. T

hese

are

all

stan

dard

ized

erg

onom

ic to

ols

that

we

use

…” (

Erg

onom

ist 1

1, in

-hou

se).

Des

crip

tion

of d

iffer

ent t

ools

us

ed fo

r ris

k as

sess

men

t tha

t ar

e pr

omot

ed fr

om th

e er

gono

mis

t’s o

wn

orga

niza

tion.

Cla

rity

abou

t whi

ch

tool

s th

at s

houl

d be

us

ed.

Use

of r

isk

asse

ssm

ent t

ools

.

How

erg

onom

ic

risks

can

be

dete

cted

“To

use

stan

dard

ized

tool

s m

eans

that

you

get

mor

e lo

cked

. I fe

el

the

need

for f

lexi

bilit

y; to

dis

cuss

, to

film

… If

I us

e [s

tand

ardi

zed]

to

ols,

I te

nd to

lose

som

e of

the

dyna

mic

s in

wor

k be

caus

e th

e to

ols

are

not f

lexi

ble

enou

gh.”

(Erg

onom

ist 1

, ext

erna

l)

Thin

ks th

at s

tand

ardi

zed

risk

asse

ssm

ent t

ools

are

infle

xibl

e.

Ass

ess

risk

base

d on

exp

erie

nce

and

do n

ot u

se to

ols.

Do

not u

se

stan

dard

ized

tool

s.

METHOD

16

3.3.1 Paper B

Inter-observer reliability is the degree to which different observers are consistent in their observation. Intra-observer reliability is the degree to which the same observer is consistent within him- or herself between two separate occasions (test–retest). Several statistics for reliability were calculated to present as credible a result as possible and to enable comparisons with other studies. Calculations were performed in MATLAB 8.5 (MathWorks Inc., Natick, MA, USA).

Inter-observer reliability

The inter-observer reliability was based on the assessments of the 21 observers’ first assessments. Proportional agreement (%) was calculated as the number of rating pairs in agreement divided by the total number of rating pairs. This gave an overall view about consistency between and within the ergonomists. However, to ensure the agreements were not a result of chance, the proportional agreement shall always be presented together with other statistical parameters such as kappa statistics (Cohen, 1960).

Cohen’s kappa is only applicable between two raters or if test–retest reliability is evaluated. A pairwise kappa average for all pairs was therefore calculated in a way described by Davies and Flesiss (1982). The expected agreement, Pe, in Cohen’s kappa formula for each pairwise comparison, k = (Po-Pe) / (1-Pe), is replaced by the average Pe of all pairs. However, the risk ratings represent ordinal data (low, moderate and high risk) and Cohen’s unweighted kappa does not distinguish minor from major discrepancies in ratings, which resulted in a linearly weighted kappa (Cohen, 1968) also being computed and averaged; this was done in the same way as the unweighted kappa (Davies & Fleiss, 1982; Hallgren, 2012; Sawa & Morikawa, 2007).

Intraclass correlation (ICC) was also calculated because other similar reliability studies (Comper, Costa, & Padula, 2012; Paulsen et al., 2015; Stephens, Vos, Stevens, & Moore, 2006) have used ICC (2.1), two-way according to (Shrout & Fleiss, 1979). Another calculated statistical parameter was the Kendall’s coefficient of concordance (KCC). KCC is a non-parametric relative to ICC that is applicable to ordinal data (McDowell, 2006). KCC was also used to facilitate a comparison with other studies (David, Woods, Li, & Buckle, 2008b).

Intra-observer reliability

The nine observers who repeated their assessments composed the intra-observer group. The calculated statistics for intra-observer reliability were as described above: proportional agreement. Furthermore, Cohen’s kappa was calculated for each of the nine observers, and then the mean value of these kappa values was used (Cohen, 1960). Additionally, weighted kappa, ICC and KCC were calculated.

3.3.1 Paper C

During the work with the interviews for Paper A, it was revealed that the organization and management of the OHS had an impact on the ergonomists’ work. The analysis of the interviews had also resulted in categories related to organizational issues which were not included in Paper A. Therefore, a separate paper (Paper C) was dedicated to present these results. The data analysis in Paper C followed the same steps described for the qualitative analysis in Paper A.

METHOD

17

3.4 Preconceptions of the authorMainly when it comes to qualitative research in which the researcher interprets information such as interviews, it is important to consider the preconceptions of the researcher. Malterud (2001) describes, “A researcher’s background and position will affect what they choose to investigate, the angle of investigation, the methods judged most adequate for this purpose, the findings considered most appropriate, and the framing and communication of conclusions” (p. 483–484). My own background has greatly influenced my research area. After my one-year master’s studies in ergonomics, I was excited to start working to prevent WMSD. It turned out that my theoretical conception about working as an OHS consultant was something else in reality. After some years as an occupational ergonomist/RPT, my employer gave me the opportunity to be a part-time PhD student in the research programme “Future occupational health services – research for continuous evaluation, learning and improvement”. My position was that OHS companies ought to take a proactive role in the relationship with the client and to focus on primary preventive measures. However, my practical background indicated that OHS practitioners often were contacted for individual rehabilitation (secondary or tertiary prevention) and that the primary preventive services were not the main focus. But was this my perception or was this the fact? In my first research project, I had the opportunity to explore this.

My preconception of the ergonomists work may have influenced the interviews I conducted since I was familiar with the topic and could quite easily understand the situations the ergonomists described. However, during the projects I have constantly tried to be aware of my own values and experiences, and my ambition was to create a position outside my professional knowledge and experience as ergonomist practitioner.

3.5 Ethical considerationsEthical approval was not needed for the study which resulted in Papers A and C (SFS 2003:460). However, four main principles regarding ethics in research described by the Swedish “Council of science” were taken into consideration (Vetenskapsrådet, 2002). First, the principle of information was fulfilled given that all interviewed participants and respondents of the survey were provided information about the aim of the study and that participation was voluntary so if they wanted they could withdraw from any part of or the entire interview/survey at any time. This was given as written information before the interviews and at the time of the interview they were also informed orally. Second, the principle of consent was taken into account. The interviewees gave their consent to participation either orally or written. Third, the principle of confidentially was taken into account as the result from the survey and the recorded and transcribed interviews were password protected, digitally stored and handled with care. Names in the interviews were coded during transcription. Only participants from the project team had access to the files. The fourth principle deals with information about individuals only being allowed to be used for research and such individual information was not in question for the studies included in Papers A and C.

The study presented in Paper B was part of a comprehensive research project. For this project, ethical approval was given by the regional ethical vetting board in Stockholm (Dnr 2013/308-31/3).

SUMMARY OF RESULTS

18

4 Summary of results

The following section presents a short summary of the papers included in this thesis. The summary includes the research questions, a short description of the result and discussions from the papers.

Table 5 provides an overview of the results from the papers.

Table 5. Short description of the results from included papers related to the research questions of this thesis.Research questions of the thesis

Paper A Paper B Paper C Results in brief

When are OHS ergonomists involved in ergonomic assignments?

XEssentially reactively, after identification of WSMD.

When and how are OBRATs used by Swedish ergonomists?

X

Generally low use of OBRATs except from AFS-98/AFS-12 (SWEA 1998, 2012). OBRATs can be supportive as communication tool for feedback.

Are generally not used as evaluation tools.

How reliable are risk assessments performed by ergonomists without the use of any standardized observational method?

X

Inter-observer reliability: not acceptable.Intra-observer reliability: only acceptable for theassessment of risk forlower back pain.

What organizational prerequisites within OHS companies facilitate involvement in work environmentassignments? X

Close relationships with clients.Clients’ awareness of the wide-ranging competence of the professionals within OHS.

Utilization of standardized methods.Specialization/industry knowledge.Internal knowledge sharing.

4.1 Paper A - Ergonomic Risk Assessment: Tool Use and ProcessIn recent years, the SWEA has clarified the importance of conducting regular ergonomic risk assessment to prevent WMSD, a paragraph (§4) in the Ergonomic provision (AFS 2012:02) has been added, emphasizing the employers’ responsibility to perform risk assessments (SWEA,

SUMMARY OF RESULTS

19

2012). Hence, the first paper of the thesis aimed to give an understanding about the practical work concerning ergonomic risk assessment performed by OHS-employed ergonomists. The paper explored the use and knowledge of standardized OBRATs, how and when ergonomists were involved in ergonomic risk assessment assignments, and how they approached assessment of ergonomic risk factors.

The result indicated that the process of ergonomic risk assessment assignments was often initiated reactively after identification of WMSD at a workplace. The entry to the reactive assignments was either direct contact from the client as a result of one or more employees reporting WMSD, or one or more employees were under clinical rehabilitation by the ergonomist/physiotherapist.

Identification and analyses of ergonomic risk factors were often made based on the ergonomists’ own expertise, and information about ergonomic risk factors were collected through interviews with individual employees and general observations, often combined with photos/video. The web questionnaire revealed that the most commonly used OBRAT was AFS-98, which was used by all respondents. Other commonly used OBRATs were, in descending order, KIM I (51%), KIM II (36%), QEC (19%) and VIDAR (19%). The use of and knowledge about several internationally widespread OBRATs – for instance NIOSH lifting equation, RULA, REBA and OCRA – was low. Lack of knowledge/training was reported as the main reason for not using a tool.

Furthermore, the interviews revealed that potential effects of assignments most often were not evaluated. A barrier for evaluation was the inability to bill the client for revisiting, and it was not included in the process. However, in-house or partially in-house ergonomists expressed that they had greater possibilities for evaluating the effect of assignments.

In summary, there was a lack of systematic methodology for the risk assessment process and Swedish ergonomists only used a limited number of OBRATs.

4.2 Paper B - Inter- and Intra-Observer Reliability of Risk Assessment of Repetitive Work without an Explicit Method

As a natural consequence of the results in Paper A, which indicated that ergonomists often use their own expertise for ergonomic risk assessments, Paper B was driven by the curiosity to evaluate the reliability of experience-based assessments. The aim of the paper was to investigate the inter-observer and intra-observer reliability of risk assessments performed by ergonomists without the use of a standardized risk assessment tool.

The results were quite disparate. For the inter-observer reliability were both high- and low-risk ratings of the global risk present in seven out of ten work tasks. The average inter-observer proportional agreement of the global risk was 53%. The weighted kappa value for inter-observer reliability was between 0.12 and 0.32 for the eight body regions and weighted kappa was 0.32 for the global risk, indicating a fair reliability. The average intra-observer proportional agreement of the global risk was 61%. The weighted kappa was between 0.23 and 0.62 for the body regions (0.62 for low back) and 0.41 for global risk. The results showed a moderate agreement for the global risk.

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The results indicate that without the use of a standardized risk assessment tool the results can vary greatly between different observers even though they are specialists in the area. Even comparisons with previous assessments of the same ergonomist are likely to be rather unreliable. One would assume that if risk assessments of repetitive work are performed with standardization, it will probably lead to a higher level of reliability. It is recommended that practitioners use standardized tools for risk assessment.

4.3 Paper C - Facilitators for the Implementation of ErgonomicInterventions

Paper C was a conference paper. It came into being as a result of the analyses of the interviews for the first paper, which indicated that the OHS organization affects the likelihood of working systematically, including the use of standardized tools. The interviews in Paper A were so comprehensive that they also could be analysed on the basis of the aim of Paper C, which was to explore and reach a deeper understanding of factors within the OHS which facilitate ergonomic interventions in a Swedish context. Little is known about underlying contextual factors within the OHS that may be of importance for a successful implementation of an ergonomic intervention.

Five main facilitators were identified as important for ergonomic interventions. The first factor was having “close relationships” with the client, meaning both geographical proximity and frequent contacts with stakeholders at the client company. The second factor was “clients’ awareness of the wide-ranging competence of the ergonomist”: if the clients were aware of the ergonomists’ competence, it was more likely that the ergonomists were contacted for different assignments. The third factor “utilization of standardized methods”: simplified communication of ergonomic risks, which meant an opening for interventions. The fourth factor was the ergonomist “specialization/industry knowledge”. Possession of in-depth knowledge about a specific industry or sector facilitated the learning about its different hazards and the ergonomist could more easily propose ergonomic interventions to prevent WMSD.

“Internal knowledge sharing” was the last factor, meaning that if the OHS had systematic exchange of knowledge, for example regarding various projects at clients, it was a possibility for ergonomists to disseminate knowledge and to learn from each other within the OHS. Such an exchange could result in shared practices or procedures which indirect could support ergonomic interventions.

The paper discusses areas where the OHS can be improved to facilitate ergonomic interventions. A possible improvement of the relationship with clients could be the development and refinement of the contracts regulating business relationships (Paulsson et al., 2014). Another area for improvement is to market the OHS consultants’ expertise. It can also be a strategy for OHS companies to ensure specialization of their consultants within different industry sectors or domains of occupational specialization (ergonomists specialization e.g. visual ergonomic, physical ergonomics, cognitive ergonomics and organizational ergonomics). That would enable OHS to distribute assignments to different consultants based on their specialization.

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5 Discussion

In this section, the findings from the papers related to the research questions of this thesis are discussed and in the end the results from the different papers are linked together to practical implications addressed to OHS companies. In the end of this section, reflections on the methodology and analysis used in the paper are presented.

5.1 Results discussionThe aim of this thesis was to explore prerequisites, processes and practices of OHS ergonomists in Sweden within the domain of primary prevention of WMSD. Results from a literature review pointed towards that when OHS-consultants used systematic work methodology it was perceived to be useful and effective both for the OHS and the client (Eliasson, 2016).

5.1.1 Prerequisites for ergonomic assignments

An opening to learn about the prerequisites and practice of ergonomists was to explore the research question When are OHS ergonomists involved in ergonomic assignments? Results from Paper A indicated that there were mainly four reasons for clients to request ergonomic assignments (Table 6).

Table 6. Reasons for ergonomic assignments.Reactive Proactive

Already existing symptoms of WMSD- Rehabilitation

Injunctions from SWEA

Part of the client’s systematic OHSM- Regular ergonomic screening of existing

workplace- Before a new workplace was introduced

The interviews revealed that assignments often start with rehabilitation, and this can result in further assignments in which assessments of the work environment can be included. This reactive approach of clients contacting ergonomists after identification of WMSD or after an inspection from the authority is in line with other studies (Laring et al., 2007; Whysall et al., 2004). Paper A implied that it was a connection between the development of client’s systematic OHSM and its use of ergonomists for primary preventive services. In their study about successful collaboration between OHS and their clients, Schmidt, Sjöström, & Antonsson (2012) point out that a good OHSM at the clients is a key factor in using the OHS company effectively. Clients with a developed OHSM know their needs, and the relation with the OHS has a more proactive aim (Schmidt et al., 2012). The interviews with the ergonomists imply, however, that a reactive approach from clients was the most common reason clients contacted OHS. Consequently, this indicates that the OHS have a passive (or reactive) approach waiting for the clients to “open the door” for different assignments. Obviously, it is the client that must order an assignment, but this does not mean that the OHS should be a passive recipient. Clients with an insufficient OHSM might also need the support from OHS to develop the OHSM. Through a close relationship, the OHS could operate actively and take a proactive initiative in supporting their clients by analysing the clients’ needs based at the clients OSHM and propose relevant assignments. A work method that possibly could lead to changes regarding the prerequisites for OHS is the “Prevention Pathway Method” described by Godderis et al. (2004). The method supports OHS to work

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preventively for their clients to identify and plan assignments together with them. Paulsson et al. (2014) and Schmidt, Sjöström, & Antonsson (2011) also highlight that thorough needs analysis might be an important work tool for OHS, which in collaboration with the client identify areas in which they can provide services and through that hopefully focus on primary preventive services.

Furthermore, through the research question: What organizational prerequisites within OHS companies facilitate involvement in work environment assignments? other prerequisites for the ergonomists´ work were shown. The factors “close relationships” and “clients’ awareness of the wide-ranging competence of the ergonomist” both involve the client and the OHS and point towards the importance for OHS to support good relationships. Whysall et al. (2004) also describe the importance of long-term relationships and the necessity of long-term contracts. However, a Swedish report showed that contacts between OHS and their clients seldom facilitated the cooperation between OHS and its clients, to create healthy workplaces (Paulsson et al., 2014). Development and refining of contracts regulating the business relationship between the OHS and their clients may provide conditions to create a close relationship and enable marketing of ergonomics and other OHS services. Long-term relationships may also entail better knowledge about the organization and its key stakeholders. This may ease the establishment of credibility, which is a factor that facilitates the implementation of ergonomic changes (Shtivelband & Rosecrance, 2011).

The prerequisites for ergonomic assignments may benefit from a shift of reactive character as it often is today, towards more proactive/primary prevention. As described above close relationships and use of work methods such as needs analysis may create better prerequisites for primary preventive assignments. However, it is also essential to evaluate the impact of the assignments and for that systematic methodologies such as standardized tools are a key factor.

5.1.1 Ergonomists use of risk assessment tools

As described in Paper C, the use of standardized tools such as OBRATs seems to support the possibility for interventions because the tools facilitated the assessment procedure. Therefore it was interesting to explore if ergonomists used existing OBRATs as a support during risk assessment and/or as a basis for feedback and evaluation. This was explored through the research question “When and how are OBRAT used by Swedish ergonomists? The question is interesting for several reasons. The use of OBRATs gives a standardized calculation of an estimation of risk for WMSD, which ought to assist the ergonomist in making risk assessments (which are often quite complex). Further, the standardization would support the ergonomist in communicating the risk to clients (providing a possibility for visualized feedback), and the use of OBRATs would also be helpful for evaluation of different measures, as well as assignments overall, something which should be of interest to the ergonomist, OHS and, of course, the client.

However, the findings from the interviews revealed that use of a systematic methodology for the risk assessment process was often lacking. In line with other studies, it appeared that the ergonomists largely relied on his or her own expertise and experience to make an assessment and information regarding different ergonomic risk factors was often gathered through interviews with individual employees and observations (without the support of OBRATs), combined with photos/video (Laring et al., 2007; Wells et al., 2013; Whysall et al., 2004). The use of specific OBRATs was quite limited; the majority of the respondents (both in the survey and the

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interviews) used mainly one ORBAT: AFS-98. Further, the KIM I and KIM II were the second most used OBRATs among the questionnaire responders (See Paper A). The usage of OBRATs which are commonly used internationally such as NIOSH lifting equation, RULA, REBA, OCRA and OWAS (Dempsey et al., 2005; Diego-Mas et al., 2015; Pascual & Naqvi, 2008) was substantially lower.

When OBRATs were used, it emerged that they also were a support for the ergonomist to explain and clarify hazardous ergonomic risk factors to different representatives within the client company. However, proposed measures were seldom evaluated, except among ergonomists who worked in-house and who had the opportunity to make re-assessments. Lack of opportunities for evaluations is also described among British ergonomists (Whysall et al., 2004).

The findings indicate that the use of OBRATs is influenced by multiple factors, as described in Table 7. Table 7. Factors related to use of OBRATs

OBRAT-related Ergonomist-related OHS organization/management-related Client-related

•Promoted by an authority•Different qualities

• Knowledge/interestabout OBRATs

• Possibility for client specialization•Education/training

• (Lack of) standardization/systematic approach for assignments

• Development of OHSM• Knowledge about OHS services

The result indicated that management has an important role to be supportive and create conditions to work with evidence-based and generally accepted methods and tools. Since a Swedish report showed that only 46% of Swedish OHS professionals feel supported by their management to work with evidence-based methods (Björk Brämberg et al., 2015), this may be a possible area of developments and improvements for Swedish OHS. In some OHS there is a “competence manager” who provides the OHS professionals with strategic intelligence and support when it comes to the utilization of different tools and methods as well as for the evaluation of the work. This may be an organizational opportunity for OHS to build up an internal knowledge base and, for example, educate (e.g. in risk assessment tools) internally. In coherence with Arezes, Miguel & Colim (2011), the result in Paper A indicated that education is an important factor for the use of OBRATs. It would be of interest to evaluate the role of the “competence manager” and how this person could strengthen the OHS organizations’ preventive work.

The results from Paper B, which addressed the issue if is it sufficient for ergonomic experts to rely on their knowledge and base risk assessment on their expertise of ergonomic hazards, also points towards the need to use generally accepted tools. The result showed that the intra- and inter-reliability of risk assessment without any standardized tool was not acceptable, except for intra-observer reliability of assessment of the lower back. When comparing risk assessment performed without the use of any standardized tool with assessments in which the OBRAT QEC (David, Woods, Li, & Buckle, 2008a) was used, the inter-observer reliability increased (Nyman, Palm, Eliasson, & Forsman, 2016). Furthermore, reliability without any standardized tool was generally lower compared with reliability studies in which specific OBRATs were used (Comper et al., 2012; David et al., 2008a; Paulsen et al., 2015; Spielholz et al., 2008).

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A reason to use a standardized approach like OBRATs is the assumption that a standardized approach will give equivalent and reliable assessments. However, when evaluating reliability, the variability must be taken into consideration. Several factors of variability exist which may affect the assessment. Even if a standardized tool is used, some sources to variability are not affected, such as variability related to the worker performing the work task, the time of the observation, difficulties in visually assessing movements and postures, and the experience of the person who performs the assessment. Mentioned factors of variability are present when one single observer assesses one single sample of a work operation. To minimize the variability in assessments, an alternative could be repeated assessment of the same videos showing the work operation or having a team-based approach for the risk assessments in which several observers are engaged (Mathiassen, Liv, & Wahlström, 2013). Such an approach could also mean collaboration between workers and the ergonomist, which has been shown to be effective (Karsh et al., 2001; Rivilis et al., 2008).

A team-based approach has also been demonstrated to be more cost effective compared to the most commonly used method by practitioners when one single observer views one or more videos of work sequences (Mathiassen et al., 2013; Trask, Mathiassen, Wahlström, & Forsman, 2014). A team-based work methodology might be a successful way to improve OHS and it could lead to higher quality and efficiency in assignments. Another possibility for ensuring reliability in risk assessments can be the use of direct measurements of movements and postures instead of observation. Direct measurements are more precise compared with OBRATs and they have a high reliability. They may be a better alternative for evaluating exposure between workplaces or assessment of differences in exposure before and after an intervention.

Development of cheap and feasible direct technical measurements tools such as accelerometers enables this approach for practitioners (Dahlqvist, Hansson, & Forsman, 2016). Research regarding reference values for how to interpret data from direct measurements into risk for WMSD is ongoing (Dahlqvist, Enquist, Nordander, & Forsman, 2016; Hansson, Arvidsson, & Nordander, 2016).

5.2 Methodological discussionIn Paper A, the mixed qualitative and quantitative data was also a way to validate the results since use of more than one data source establishes a higher validity of results (Hignett, 2005; Kvale & Brinkmann, 2009). The gender distribution of the respondents, in both the questionnaire (81% women) and the interviews (75% women), can be described as representative for Swedish ergonomists. In 2013, 79% of the members of the Ergonomics Section of the Swedish Association of Physiotherapists were women (e-mail conversation in March 2013). The response rate of the online survey was 43%. In a study by Nulty, (2008), a comparison between the response rate for paper-based and online surveys was presented, showing an overall response rate of 56% for paper-based surveys and 33% for online surveys. In this context, the response rate in the present questionnaire can be considered acceptable. However, Draugalis, Coons, & Plaza, (2008) noted that there is general consensus that at least 50% of a sample should complete a survey. The present questionnaire was attached as a link in a periodical newsletter to all members in the Ergonomics Section. Through this process, the questionnaire reached a majority of Swedish ergonomists; however, the disadvantage was that the web survey was not mentioned in

DISCUSSION

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the subject line so only those ergonomists that opened the e-mail received information about the survey (n = 251). This might have contributed to a lower response rate.

The questionnaire focused on the use of OBRATs and did not cover other tools such as observation without any specific tool, interviews or video camera, which in agreement with Wells et al. (2013) emerged as the most commonly used methods according to the interviews. The questionnaire included seventeen OBRATs and the respondents were given the possibility of adding other OBRATs they used; two OBRATs not publically available were reported. Hence, it seemed that the included OBRATs to a large extent covered the most commonly used tools among this population.

The interviews in Papers A and C were conducted with ergonomists. The author´s background as ergonomist and preconceptions for the topic could have influenced the interviews and the analysis. Hence, interviews were also conducted by another member of the research team, and followed an interview guide. Interviews with other professions in OHS might have led to other pictures of the process regarding assignments and work methods. However, pilot interviews were conducted with management in OHS, and they could not describe or exemplify how assignments were performed by their consultants.

Most of the transcriptions of the interviews were performed by the author of this thesis in order to reach a deeper understanding of the data. The analysis of the interviews was also made by the author and a way to validate the analysis was through presentation of the categories in different ergonomists’ network meetings, a form of communicative validity in which the results are discussed and tested in dialogue with others (Kvale, 1996). Generalizability is generally limited in qualitative research. However, the results in Papers A and C are based on the interviews with twelve ergonomists, both in-house and external, with a mean period of 15 years (range 4-25 years) as OHS-employed ergonomists. This strengthens the possibilities of drawing conclusions about the ergonomists’ practices.

In Paper B, risk assessments were only performed from videos. In real situations, the ergonomists interview employees while on-site at the workplace. This limitation in the present study was addressed by supplying the observers with written information on the different work tasks.

The possible sources of variability mentioned above could have affected the result, but they were taken into consideration. The factor of variability related to the worker performing the work task was resolved by all ergonomists observing the same videos of the same workers and the time factor was minimized because all observers assessed the same video sequence. However, the ergonomists may have focused on different sequences of the work task, and the workers movements and postures might have varied within this time.

To be able to compare our results with other studies a number of different statistical parameters were calculated. ICC (2.1), which is mostly applicable for continuous data, was included because it has been used in other reliability studies on ordinal data (Paulsen et al., 2015). Interpretations of Kappa and ICC (2.1) have been made based on commonly accepted models (Landis & Koch, 1977; Stephens et al., 2006). In Paper B, the criteria of a 0.7 agreement and a kappa value larger than 0.4 were interpreted as acceptable. In consensus in the research team these values were considered to be suitable for the assessment of ergonomic risk factors. Stricter criteria could have

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been applied to intra-observer reliability because the between-observer variance is not present in intra-observer reliability. However, for simplicity, the same criteria were used for both intra- and inter-observer reliability.

5.3 General reflectionsIn summary, the studies included in this thesis point to that there is a lack of systematic methodology in the process regarding primary preventive ergonomic services of OHS. The OHS are dependent on the knowledge and professionalism of their consultants, and the value of the company is affected by the individual consultants. Strict systemization and standardization is not the intention. Each client and each assignment is unique and the consultant needs to adapt his or her services based on the client/assignment. However, the professionalism of the consultant is having knowledge about and the skills to use a range of tools. Use of mainly one or two tools might not be sufficient for the range of assignments that OHS consultants face. However, the OHS organization and management need to support their consultants in working systematically and with standardized tools. Among other things, this needs to be supported with 1) education/training in different tools, 2) implementation of systematic methodologies and 3) evaluation of assignments. Through systematic and standardized work methods OHS can create conditions which improve the quality of their services. For example, standardized tools can contribute to evaluation of assignments, making it easier to demonstrate the benefit of services.

My research has been based on a Swedish context and the conditions for OHS companies and their services differ between countries. The prerequisites for OHS to develop and specialize within primary preventive work environmental services are affected not only by laws and regulations but also by other incentives (e.g. public subsidies) which may also affect the type of services that the clients request.

CONCLUSIONS AND FURTHER RESEARCH

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6 Conclusions and further research

In the following chapter, the conclusions of this thesis are drawn. Further, it also points to practical implications of the research. Finally, proposals of further research are given.

The findings from the studies included in this thesis point to that ergonomists employed in OHS are often contacted at a late phase after the occurrence of WMSD. It is common that ergonomic assignments are occasioned by rehabilitation. This indicates that both OHS companies and clients must take a more proactive approach to prevent WMSD. Furthermore, the results show that among Swedish OHS a systematic methodology for ergonomic risk assessment process is often lacking. In turn, this affects the use of standardized tools, such as OBRATs. Swedish ergonomists used few of internationally widespread OBRATs. Furthermore, the findings show that the ergonomists’ expertise is not sufficient to use for assessment of ergonomic risk factors and it is therefore recommended to use standardized tools. A way to increase the use of different tools is through education, and the results point to that education is an important factor for the use of OBRATs. This underlines the importance of additional/special education and opportunities for occupational specialization. The results indicate that specialized ergonomists also facilitate the implementation of ergonomic interventions at clients.

6.1 Practical implicationsIt is important that OHS have a close relationship with clients, promote the competence of their consultants and focus more on primary preventive services regarding work environment. Below, a number of proposals are presented based on the findings of this thesis that are addressed to the management of Swedish OHS. These proposals may be a step towards improving the primary preventive services of OHS.

Promote the use of a systematic methodology for assessments. Support education in different risk assessment tools ( e.g. OBRATs and direct measurements). Support branch specialization or occupational specialization. Distribute assignments to consultants based on their specialization. Support a team-based work methodology to perform assessments and analysis.

6.2 Further researchOHS must to a higher degree analyze the effects of their assignments/interventions. Based on the results of this thesis further research should include implementation and evaluation of different work methodologies (e.g team-based) and the use of standardized tools, whether they are valid and reliable and their effects to improve work envionments. Such research should include both the OHS companies and the clients.

Another interesting area is the role of the “competence managers”, which are employed in some OHS organizations. Their role should be of interest to further evaluate, for example how they support OHS consultants and whether their function promotes primary preventive services.

ACKNOWLEDGEMENTS

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7 Acknowledgments

The journey as a part-time PhD-student has taken many years, but is now approaching the final destination. A number of people have supported me during the work and I would like to express my deepest gratitude to everyone who has contributed to the process. In particular I would like to thank:

My main supervisor, Prof. Jörgen Eklund: Without you, the journey that enabled my licentiate studies would not have started. Thank you, for trusted my abilities and your encouragement. I deeply appreciate all your support during the way.

Dr. Teresia Nyman, my co-supervisor and mainstay. You have kept the levers and steered the way for me. Your support, enthusiasm and your inexhaustible ideas have made my journey to a happy adventure. Thanks for all your support and your advices. It is simply great fun to work with you. I hope this won´t be the last time we worked together…

My co-supervisor, Prof. Mikael Forsman and all other members of the research team in the “OBS-project”; MSc Ida-Märta Rehn, Dr. Katarina Kjellberg, Dr. Per Lindberg, MSc Peter Palm, Dr. Teresia Nyman. It has been an honour to work together with you all and it has been rewarding to take part of your great knowledge.

My co-authors to various papers and reports; MSc Carl Lind, Associate professor Göran Hägg and the team members in the “OBS-project”. Thanks for your fruitful discussions, your patience and your enriching cooperation. It has been fun working together and I have learned a lot from you all.

Thanks to everyone in the Unit of Ergonomics at the Royal Institute of Technology (no one mentioned, none forgotten). As a part time student I have only visited the unit very sporadically but I have always felt welcomed. I really appreciate your supportive and warm atmosphere.

Cristina Rofors, Anders Pernes and Anna Petersson management at Sensia Occupational Health. Thanks for supporting me by giving me the opportunity to embark on my PhD program. You have also contributed to show that the Swedish occupational health services have to recognize the importance of evaluating their work methods and, in a scientific way, show effect of its services.

My former colleagues at Sensia, thanks for your support.

All participants in my studies, thank you for your time and your willingness to participate.

Dr. Katarina Mikaelsson, Dr. Peter Michaelson and Prof. Lars Nyberg, Department of Health Sciences at Luleå University of Technology, my former teacher and supervisors, thank you for showing the way to the world of research.

My beloved family; Mårten, thanks for all the support you give me. Julia and Amanda, thanks for enriching my life. You are the joy of life.

My beloved parents and sisters; thanks for always being there for me and for all your support.

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APPENDICES

36

APPENDICES

Appendix A – questionnaire (in Swedish)

Bakgrund

1. Kön: Man Kvinna

2. Födelseår:____

3. Har du en kandidatexamen i sjukgymnastik?

Ja Nej, har en äldre examen (120-140 hp) Har en utländsk examen

4. Har du någon vidareutbildning inom ämnet ergonomi? Ja Nej

Om ja: 5. Vad hette utbildningen? Ange i tillämpliga fall omfattningen i högskolepoäng. _________________________________________________________________________

_________________________________________________________________________

6. Har du specialistkompetens i ergonomi enligt LSR:s specialistordning?

Ja Nej

7. Är du certifierad Europaergonom? Ja Nej

8. Antal års arbetslivserfarenhet som sjukgymnast:__________

9. Antal års arbetslivserfarenhet inom ergonomiområdet:_________

10. Hur arbetar du just nu: Företagshälsovård, eller annat inom ergonomi och arbetsmiljö Rehabiliteringsklinik, eller motsvarande Primärvård Egen företagare Arbetar inte Student Annat, ange vad:___________ Om egen företagare: 11. Ingår Ergonomi och arbetsmiljö i din verksamhet i ditt företag? Ja Nej

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12. Vilka branscher arbetar du främst mot? Flera alternativ kan väljas Manuell/industriell Kontor/administration Service/handel Hälso- och sjukvård Annat, ange vad:____________

13. Har du använt riskbedömningsmetoder för fysisk belastning i din yrkesroll? Ja Nej

Om ja: 14. Hur ofta genomför du riskbedömningar i ditt arbete? Minst en gång i veckanMinst en gång i månadenMinst en gång i kvartaletMinst en gång i halvåretMinst en gång per årMindre än en gång per år

Metoder

15. Har du använt någon av följande riskbedömningsmetoder för fysisk belastning? Fyll i ja, nej eller om du inte känner till metoden.

Ja Nej Känner inte till den AFS 1998:01 - belastningsergonomi

KIM - lyfta, hålla, bära

KIM - dra, skjuta

WEST

MAC

Plibel

Reba

LUBA

QEC

OCRA

RULA

VIDAR

ALBA

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OWAS

NIOSH

HAL (ACGIH)

Strain index

Om ja:

16. Vid vilka exponeringar använder du metoden? Ensidigt upprepat arbete Manuell hantering Arbetsställningar (Sittande, stående och gående)

17. I vilka sammanhang använder du metoden? Riskbedömning av enskild individs arbete Vid arbetsanpassning för enskild individ Riskbedömning/kartläggning av befintliga arbetsplatser Planering/projektering av icke befintliga arbetsplatser

18. Varför använder du metoden? Enkel att använda Den metod jag känner bäst till Den metod som passar bäst Snabb att använda Kräver ingen utrustning Lättolkade resultat Lätt att anpassa för de kunder/arbetsplatser jag normalt besökerResultaten är enkla att kommunicera med uppdragsgivarenAnnat, ange vad:__________________________________

19. Hur anser du metoden är att lära sig? Enkel Ganska enkel Varken eller Ganska svår Svår 20. Hur känner du till metoden? Genom kollegor Genom utbildning Genom branschtidning Genom branschnätverk (tex ergonomisektionen) Genom egen sökning på internet Annat, ange vad:____________________________

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Om nej: 21. Varför? Saknar kunskap/utbildning för metoden Inte nödvändig för mitt arbete Tar för lång tid att tillämpa Svårtolkade resultat Komplicerad att tillämpa Annat, ange vad:__________________________________

Övrigt

22. . Använder du någon metod som vi inte frågat efter? Ja Nej

Om ja: 23. Vilken/Vilka?

_____________________________________

_____________________________________

_____________________________________

_____________________________________

______________________________________

24. Vad saknar du för typ av metod idag?

_______________________________________________

_______________________________________________

_______________________________________________

25. Vilket hjälpmedel/gränssnitt skulle du föredra när du använder en metod? Flera alternativ kan väljas. Papper och penna Applikation för smartphone Applikation för surfplatta Program för bärbar dator Annat, ange vad:________________________

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26. Vilken egenskap är viktig för att du ska använda en metod? Välj ett alternativ mellan 1-5 där 1 är Inte alls viktigt och 5 är Mycket viktigt.

Inte alls viktigt 1 2 3 4 5 Mycket viktigt Att den är enkel att använda Att den är snabb att tillämpa Att den ger lättolkade resultat av exponering/risknivå – för mig som användare

Att den ger lättolkade resultat av exponering/risknivå – för kunden Att den är enkel att lära sig

Att den är enkel att anpassa efter de kunder/arbetsplatser jag normalt besöker Att den bygger på vetenskaplig evidens Att bedömning görs tillsammans- med individen som bedöms

Att den ger ett bra underlag för åtgärdsförslag

Att den är specifik Att den är generell Att den efterfrågas av kund Att den har en tydlig kundnytta

Att den finns översatt på svenska

27. Vilka önskemål har du på en framtida metod?

_______________________________________________

_______________________________________________

_______________________________________________

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Appendix B- interview guide (in Swedish)

Intervjuguide ERGONOM

namn________________________________________ datum______________ Informera om syftet med intervjun. Informanten får läsa igenom info om samtycke och skriva under. Sätt på bandspelaren: Det ska vara tyst i 5 sek.

Ålder, Nuvarande yrkestitel, år i nuvarande yrkestitel, år på företaget, utbildning (grundutbildning samt särskilda kurser kopplat till arbetet)

Kort beskriv organisationen du arbetar inom: ( FHV intern/ extern). Tillhör en större kedja eller är en enskild FHV? Vilka typer av företag arbetar du mot. Vilka branscher.

Intervjun kommer att inledas med att du ska få berätta om ett specifikt förändringsprojekt inom belastningsergonomi. Vi är intresserade av ett projekt som föll väl ut, som ni tycker har varit lyckat.

1. Kan du berätta om en situation där du varit delaktigt i ett förändringsprojekt gällande en belastningsergonomisk arbetsmiljöåtgärd? Börja med att beskriva hur ni fick förfrågan och vad som sedan hände….

2. Varför uppstod behovet till förändringen?

3. Under vilken fas i utvecklingsstadiet kom du in? (planeringsstadiet, befintlig arbetsplats, annat)

4. OM EJ PLANERINGSSTADIE - Om du inte var delaktig/tillfrågad i planeringsstadie vad tror du det beror på? Brukar det finnas efterfrågan att ni (ergonomer) är delaktiga under planeringsstadiet? Vilka typer av företag brukar komma med denna förfrågan? (storlek, branscher).

5. Berätta om vad du gjorde i projektet? Hur såg förväntningarna ut på dig?

6. Vad hade man för mål med projektet?

7. Berätta hur organisation och möten kring projektet såg ut. (vilka aktörer var med och vilka nätverk)

8. Skedde det någon uppföljning efter avslutat projekt?

Metoder

1. Vilka metoder använde du dig utav? (i det givna exemplet)

2. Hur kom det sig att du använde dig av denna eller dessa metoder? 2.1 Fanns det några alternativa metoder? 2.2 Hur kommer det sig att du inte använde andra metoder?

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3. Hur såg du på nyttan med metoden inom detta projekt? (nytta med metod för egen del och hur den kan kommuniceras)

4. Med tanke på nyttan med metoden i detta projekt – hur skulle metoden kunna ha förbättrats för att vara ännu bättre i detta projekt?

5. Vilka faktorer anser du varit viktiga för framgång i projektet?

6. Vilka faktorer anser du ha försvårat framgång i projektet?

7. Berätta hur du/ni argumenterade du för att få igenom belastningsergonomiska åtgärder? 7.1 Skiljer det sig beroende på vem inom företaget du pratade med?

8. Vilken effekt tror du att det hade?

GENERELLA FRÅGOR: Nu har vi pratat om det här specifika exemplet och jag vill gå vidare med mer generella frågor gällande arbetet med arbetsmiljöåtgärder med fokus på belastningsergonomi.

1. Berätta hur du argumenterar generellt för att få igenom arbetsmiljöförbättringar? 1.1 Vilka effekter tror du att det har?

2. Berätta om vilka fördelar du ser med att arbeta i en intern/extern företagshälsovård vad gäller att kunna påverka arbetsmiljöförändringar?

3. Vilka nackdelar ser du….?

4. Är det vanligt att kunden efterfrågar att FHV finns med på ett tidigt stadie i ett

förändringsprojekt?

5. Hur ser du på kompetensen inom din FHV i dagsläget att bistå med ergonomi expertis i ombyggnad eller nybyggnad av ny arbetsplats, maskin, utrustning? (ev. följdfråga - hur ser du på det).

6. Är du delaktig i uppföljning efter en arbetsmiljöåtgärd hos kund? Berätta om ett sådant tillfälle.

7. Hur sker återkopplingen av ett förändringsprojekt till den egna organisationen. Berätta om ett exempel

8. Är det något mer som du vill tillägga innan vi avslutar intervjun?

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Appendix C – risk assessment protocol (in Swedish)

Arbete som bedöms:

Tid när bedömning startar: Tid när bedömning slutar:

Jag bedömer detta arbete i sin helhet som:

Jag kom fram till denna bedömning enl. följande:

Kroppsdel Bedömning Ev. kommentar

Nacke

Höger skuldra/axel

Vänster skuldra/axel

Höger arm/armbåge

Vänster arm/armbåge

Höger hand/handled

Vänster hand/handled

Ländrygg