Working at sea and psychosocial health problems*

Report of an International Maritime HealthAssociation Workshop

Tim Carter*

(Rapportenr) Secretary, International Maritime Health Association, Transport safety, Local Governmentand the Regions, Room 2/09A,Great Minister House, 76 Marsham Street, SW1P 4DR, London UK

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KEYWORDSSeafaring;Maritime health;Psychosocial risk;Remote work

77-8939/$ - see front matter q 200i:10.1016/j.tmaid.2004.09.005

Presenters: F. Knudsen (Denmark) Pip. G. Ancane (Latvia) ‘Burnout Syndnds) Stress determined illness in seafJensen (Denmark) Work conditions

r equity. E Knudtzon Snincak (Norwoblems and reduced work capacity.solute and relative criteria for eafarer. H. Saarni (Finland) Risk SelLucero-Prisno (Philippines) The ro

dressing psychosocial health problem* Address: Chief Medical Adviser, Urt/Maritime and Coastguard Agenuse, 76 Marsham Street, London SW4 2030; fax: C207 944 2029.E-mail address: tim.carter@dft.gsi

Summary Many of the recognised risk factors for psychosocial health problemsimpact on seafarers because of the nature and organisation of their work. Theconsequences are serious because of the safety critical nature of many of the tasks atsea and because of the level of health required to continue working remote fromcare. There is relatively little relevant research on the scale of psychosocial healthproblems in seafarers and so the justification for taking preventative action is notsecure.

The workshop was convened to develop a consensus on how psychosocial risks atsea can best be characterised, their consequences in terms of health, well being andperformance and the steps which can be taken to provide better information on risksand on the validity of various forms of intervention. A number of interim measureshave been proposed in advance of more definitive research results.q 2005 Elsevier Ltd. All rights reserved.

5 Elsevier Ltd. All rights reserv

sychosocial load on boardrome’. B. Rikken (Nether-arers: whose problem is it?of seafarers: a challengeay) Seafarers with healthF-B. Schepers (Germany)valuating fitness of thef-evaluation in seafarers.le of health promotion in

s.K Department for Trans-cy. 2.09a Great Minster

IP 4DR, UK. Tel.: C209

.gov.uk.

Introduction

Seafaring has a number of features which suggestthat psychosocial issues are likely to be even moresignificant contributors to health and performancethan is the case on land. Work and non-workactivities are, for the duration of a spell of duty,spent in the same constrained environment withonly long term oscillation between home life andlife/work at sea. There is a range of constraints atsea which may influence the ability of people toadopt coping skills to reduce or remedy pressures.Also almost all jobs at sea are to a greater or lesserextent safety-critical and so decrements in per-formance from whatever cause, including psycho-logical ones, may put other seafarers, passengers orthe vessel at risk.

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T. Carter62

The psychosocial load on board ship

The assessment of psychosocial issues requires aholistic approach and one that will often rely onqualitative methods of investigation.

Seafarers feel different from other workersbecause of the pattern of their work and life,which has been equated with the regulated,restricted and secluded world of the prison orasylum by some investigators. While there is aseafaring identity there is rarely a common identitywithin a crew because of its divisions by rank,department, country and watch. This can result inconsiderable isolation.

Important stressors include the recurring need toincorporate and adapt to new crew-members. Alsothere is a pattern of constant or intermittent timepressure, usually dependent on the trade followedand the frequency of docking. Perhaps the mostsignificant disturbance is the need to adapt fromlife at sea to life on shore at the end of each periodof service. Thus there are two identities, one as aworking member of a crew and the other withunstructured time during leave with family andfriends. This will, where crewing is casual, also beassociated with concern about the next contractand future income. These pressures often beardown unequally on different members of a crew,where senior officers are permanently employedbut junior officers and ratings have no such security.

Perceived inequity can be contribute to distress.Common concerns are: hours worked, length oftour, the link of senior posts to nationality,different pay rates for the same job, age discrimi-nation in recruitment, access to health care duringemployment and between contracts. Inequity mayalso be seen as a form of neo-colonialism with richship owning countries exploiting those with lesseconomic strength. However even seafarers fromaffluent regions can feel under threat becauseattempts to reduce costs have progressivelymoved jobs to places where pay rates are lower.This can create attitudes that further fosterinequity and stress; for instance by disparagingthe competence of those from low wage countriesworking on the same vessel. Many of the inequitiescannot be isolated as solely occupational as theyare grounded in the social conditions of seafarers’home countries and in a person’s mix of economicand career motives. They come into particularlysharp focus at sea because of the proximity of livingand the organisational structure of the vessel.

While the master and senior officers may createthe psychosocial climate they are themselves alsoisolated and subjected to the direct pressure of

the owners, port operators and authorities. Increas-ingly systems of management and audit introducedfrom on-shore have to be followed by officers, andany incidents or damage are seen as their personalresponsibility, irrespective of whether the imposedworkload is a tolerable one. This may pose anidentity crisis such that a person, whose pride is intheir seamanship, sees themselves as a floatingclerk and scapegoat.

At sea the concept of sick leave is not valid andthere is no scope for immediate replacement ofanyone who is unwell. The need for fitnessstandards and the limited scope for job adaptationalso mean that proportionately more seafarers haveto terminate their careers for health reasons than isthe case in on shore occupations. The pressure tostay on duty and to ignore any health relatedimpairment can create psychological problems forthe seafarer, as well as creating potential risk forthe vessel and for other crew members. A particularproblem arises where payment is by results andthere is job insecurity, as in fishermen who work ona catch share basis, where payment depends on theprice obtained for the fish. A different but notdissimilar pressure arises in customer service staffon cruise liners whose very low wages are made upby tips but where only the basic wage is paid ifunwell and where providing attentive service maydifficult in the presence of illness.

The normal medical assessment procedures forseafarers concentrate on the application of criteriafor fitness in relation to specific diagnosticcategories of illness. They were not developed toevaluate ‘level of health’. The limitation of dutiesfor medical reasons can of itself result in stressesbeing placed on the casually engaged individual,whose employment may be at risk, as well as onother crew members who have to do additionalduties. As a consequence the decisions of anexamining doctor or uncertainties while they areawaited can be potent stressors, especially as theyoften carry financial implications in terms ofcurrent pay and future pension.

Consequences of psychosocial healthproblems

Tension and stress are neither new problems norones specific to seafarers. Prevention at work hasbeen shown to require a managerial and organis-ational rather than a clinical approach. The highdemand and low control features of work at seawere seen to be classic predisposing factors tostress and its consequences.

Working at sea and psychosocial health problems 63

‘Burn out’ has been extensively investigated inhealth care workers but not in seafarers. Predis-posing factors have been found to include lone-liness, homesickness and disturbed circadianrhythms. ‘Strong professions’ with a tradition ofservice, stoicism and little sympathy for the personwho cannot make the grade seem particularlyprone. All these are features of seafaring as wellas of health care.

Two groups were seen to be particularly at risk:masters and senior officers, and the customerservice staff on cruise ships. Burn out was not acondition specifically associated with decisions toconsider seafarers unfit at their medical assess-ments. However a number of harmful forms ofcoping behaviour, such as alcohol and drug misuse,reactive mental health problems, for instanceimpairing depression or anxiety states, as well asa range of conditions which could reflect somatisa-tion were common findings.

The consequences of psychosocial problems interms of long term health, safety and performancehave been studied in onshore populations but not inseafarers. The two main concerns for the maritimeindustry are:

†

Do the effects of psychosocial risk factors inseafarers, whether arising at sea or elsewhere,have an adverse effect on safety, performance,crewing costs, or retention of experiencedseafarers and if so how large are the effectsand how can they be ameliorated?

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Do the demands of work as a seafarer create arisk to the health of seafarers, either in the shortor long term, how large are these effects andhow can any adverse consequences be reduced?

Action to reduce problems

Prevention and response to distress are sharedresponsibilities. However it was noted that severalstudies had identified that those working asseafarers were a population that had specificattributes and that the extrapolation of normsfrom onshore working populations was not necess-arily valid. Provision of facilities for mental, socialand physical stimulation on board in order toameliorate the passivating effects of institutionalliving has been found to be effective. All will only beeffective if there are adequate crewing levels, welldesigned cycles of work and rest and perceivedequity. However the right paradigm for preventionand intervention is also needed. In this respectseafaring is lagging behind other related activities,such as aviation where organisational factors in

safety and performance are taken into account intraining, rostering and investigation of incidents.The ‘medical model’ used for assessing seafarerfitness, based on diagnosed illness and an assump-tion of fitness in the absence of such a diagnosis, isnot a sound basis for considering psychosocial loadand its adverse effects. Investigation needs to beconcerned with both the organisation of work andwith the motivations, resilience and coping strat-egies of the crew, while intervention will seek tomodify these, with additional support and counsel-ling if the early stages of distress and impairmentare identified.

There has been no validation of psychologicaltest methods as predictors of risk at sea, althoughthey had been widely used in some countries for anumber of years. Studies on defence force navalrecruits were not considered to be relevant tomerchant seafarers, as there were major differ-ences in organisational structure, oversight, finan-cial pressures and crewing levels.

The results of a recent Finnish study on seafarersself-evaluation of risk were presented. Participantswere asked to evaluate both their current state ofhealth and their current working ability. A higherpercentage reported limited working ability thanpoor health. The contributions of health to overallworking ability was found to be small, with age,motivation, the condition of the ship, food onboard, work, skills, leadership, future stability ofemployment, home and lifestyle as other determi-nants. Hence improvements in working ability needto be addressed across many areas and thecontribution of health improvement alone may notbe large. Personal well-being itself contributes tohealth: being part of a prospering trade orenterprise, with support which can be mobilisedto assist the individual and good working conditionswill all be indirect contributors to health as well asdirectly improving working ability.

Knowledge of what companies and trade unionswant, what is required for legal purposes and whatis the contribution of a range of services, includingthose providing occupational health advice, isneeded to define priorities and catalyse action.The needs may vary for different groups ofseafarers, with mental work pressures on officersand more physical demands on ratings. Self-identified needs are more likely to be met thanimposed ones as they will be seen to bring desiredbenefits, this also shifts the locus of control to theindividual and so will inherently reduce the passi-vating influence of work at sea and be a potentmotivator.

A recurrent theme was that medical skills wereonly one contributor to health improvement at sea.

T. Carter64

The implication being that a major task was themotivation of other groups such as employers,trade unions and welfare services. All need tosee improving seafarer health and in particularit is psychosocial determinants as part of theiractivities.

Discussion

There are a number of reasons why seafaring can beexpected be an occupation where there is a highrisk of psychosocial factors contributing to poorperformance and risk but there is little specific dataon seafarers. In the main the evidence of risk comesfrom studies in on shore populations which identifythe importance of specific risk factors. Many ofthese are present in seafarers because of the natureof the tasks they do and the living conditions at sea.More and better studies are needed to investigatewhether this extrapolation to seafarers is justified.

The casual nature of many jobs at sea means thatsuch studies would be methodologically difficult.Those on casual terms of employment may beparticularly at risk because of the pressures createdby the lack of a stable career.

Self-assessment of personal risk factors and theability to take action to address these have beenshown to be effective ways to shift control to theindividual and empower them to help themselves.Such approaches require an attitude by employersthat recognises the nature of health risks, seesseafarers as an asset not a cost and is prepared toinvest in this view. Better supporting material andvalidated methods of intervention using it areneeded to demonstrate that such approaches arefeasible and to assess their benefits.

It is acknowledged that current approaches toseafarers’ health can do only a limited amount tocreate the changed attitudes to employment andworking conditions needed to secure such improve-ments. To be more effective medical assessorswould need to be able to liaise closely withmaritime employers and trade unions. They wouldneed to have the ability to look at groups ofseafarers rather than just at individuals, with linesof communication which will enable potentialproblems to be identified and acted on at an earlierstage. This does not fit well with a medicalexamination system that is often seen by seafarersas primarily aimed at depriving those with healthproblems of their employment.

Reducing the risks and impact of psychosocialfactors on the health of seafarers requires acollaborative approach. Careful thought is needed

whenever efficiency increases are sought abouttheir consequences for those at sea and, given theworld wide competitive nature of the industry,co-operation and action is needed at internationallevel by the major UN bodies concerned withmaritime health and safety. Forward looking mar-itime employers and operators and the maritimetrade unions would need to actively support andpush for such action.

Recommendations

Given the strong evidence from studies in otherworking groups, but only limited indications specificto seafarers, that psychosocial factors are import-ant determinants of heath and performance thefollowing steps need to be considered by themaritime industry and its regulators.

Good quality investigations among current sea-farers and those who have left the industry arerequired to identify both the conditions of workas a seafarer which may lead to psychosocialhealth problems and the risks consequent onsuch problems in the maritime environment.

Practicable and evidence based means to ident-ify and remedy such risks need to be developedand made available within the industry. In the interim a precautionary policy isrecommended.

For the industry

Considering how to reduce overload by simplify-ing procedures and ensuring that crewing levelsare sufficient to handle those tasks that arerequired.

Giving particular attention to the scheduling andtask demands of work where these can put thevessel directly at risk Review of the periods of maximum continuousservice at sea, given evidence of increased riskwith length of tour of duty Seeking to improve security of employment, withemphasis on the requirement to secure a fullcareer at sea Ensuring that quality assured and cost-effectivetreatment for medical conditions arising at sea isavailable in foreign ports Considering the means by which seafarers,including masters, can be made aware of thecontribution of psychosocial factors to poorhealth and impaired performance and areenabled to discuss and resolve such problems asfar as is possible on board. This could include

Working at sea and psychosocial health problems 65

the approach of self-assessment pioneered inFinland.

For health and welfare services, with industrysupport

Provision of accessible health, rehabilitation andwelfare services

The development of health and well beingeducational programmes which address psycho-social aspects of health Advice to employers and owners on healthrelated aspects of working conditions and taskdemands on board ship

Advice and support for individuals who areidentified as having or at high risk of developingpsychosocial health problems. This needs to beassociated, where indicated, with recommen-dations to employers.

Acknowledgements

Supporting funding was provided by the ITFSeafarers’ Trust. Latvian and Estonian membersof the International Maritime Health Associationorganised and hosted the workshop.