Preventing and managing
discomfort, pain and injury
Introduction
Many workers suffer discomfort, pain and injury in their muscles and bones at some point in their working
life. Dealing with the effects and impact of discomfort, pain and injury can significantly affect people’s
lives both in and out of work, limiting what they do, how they interact with others and how they respond
to situations.
Preventing and managing discomfort, pain and injury makes good business sense.
Health and safety at work isn’t just a compliance issue, it’s an investment in people and productivity of
the business.
Having workers on sick leave and hiring new employees can be expensive for the company and timeconsuming for managers and other staff. Responding early to reports of discomfort or pain can help keep
workers at work. It can also reduce the financial costs like medical expenses and temporary staff.
You’ll see the benefits through:
Reduced absenteeism
•
Lower costs of replacement staff
•
Less time training replacement staff
•
No ‘overload’ on the remaining staff to pick up any slack from absent workers
•
Less bad feelings from remaining staff around taking on
extra work
Smoother running of your business
•
Increased productivity
•
Fewer stops and starts at work
•
Keeping your experienced staff at work
Less traumatic injury
•
Less immediate lost time/productivity due to staff assisting injured staff member
•
Less costs (ambulance /taxi, emergency supplies)
•
No drop in staff morale that can follow an injury to a worker
Use the cost calculator on www.acc.co.nz to find out the cost of having staff off work.
As an employer you have a legal responsibility to protect your workers from harm, which means you need
to address the factors present in your workplace that can lead to discomfort, pain and injury. While this
is a responsibility, you’ll discover there are rewards for taking action. For example, discomfort, pain and
injury can lower productivity and staff morale. For their efforts, businesses addressing discomfort, pain
and injury have seen significant improvements in these areas.
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We have produced this guide to give you an overview of all the factors you need to consider when trying to
eliminate discomfort, pain and injury from your workplace. We also explain the terminology and examine
pain, myths and other ACC information.
Importantly, this guide emphasises the need for you to take a coordinated approach in dealing with
discomfort, pain and injury. Because discomfort, pain and injury arises over time – not suddenly – it’s easy
to fall into the trap of only attending to the most obvious ‘cause’, for example:
•
Adjusting the workstation setup for symptoms related to a gradual process injury (or GPI,
otherwise known as OOS) or by buying different equipment.
•
Teaching ‘lifting techniques’ for low back pain.
When applied alone, these approaches are frequently unsuccessful. This is because there are a number of
contributory factors, working in combination, which may lead to the onset of discomfort, pain and injury.
We have grouped these factors into seven categories:
Individual factors: Things a person can and can’t change about the way they are.
Psychosocial factors: The way a person interacts with their social environment and the influences on
their behaviour.
Workplace layout/awkward postures: The way the workplace is set up and the working positions
workers adopt.
Work organisation: How work is arranged, delegated and carried out.
Task invariability: How much a task changes over time.
Load/forceful movements: What objects a person handles and the forces they have to apply to use
them.
Environmental issues: Where the work takes place and the conditions a person
works in.
If, as an employer, you address only one or two of these contributory factors, you may be disappointed by
the results. Instead, as encouraged in this guide, you need to take a holistic approach to prevention and
management of discomfort, pain and injury. That is, you need to consider and address all the factors, in
their relative proportions.
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Previous injury prevention programmes at ACC
Until now we have operated three separate ACC injury-related programmes for the workplace:
1.
OOS prevention programme
2.
Acute low back pain (ALBP) programme
3.
Serious (specific) back injuries (SBI) prevention programme.
While these programmes are effective in their own right, we saw an opportunity to help make the
management of workplace wellbeing easier for you by combining the information and advice.
The new discomfort, pain and injury programme explained in this guide combines the essential parts of
these three programmes into one complete workplace programme.
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What is discomfort, pain and injury?
Discomfort, pain and injury covers many conditions of the muscles and bones:
•
Gradual process injuries (GPI)
•
Simple back pain
•
Strains and sprains.
Usually, these arise gradually over time, rather than from sudden events, i.e. there is no immediate force
that sets off the discomfort, pain and injury.
Sometimes discomfort, pain and injury may appear as one of these conditions after a sudden event. But
in reality the sudden event may have been merely ‘the straw that broke the camel’s back’. For example, a
person may experience low back pain when bending over to tie their shoe laces. Although they experience
the pain immediately on bending, it’s unlikely simply bending over is the actual cause of their pain. Rather
it is a culmination of many events that have gone on before.
Importantly discomfort, pain and injury is by no means a clearly defined group of conditions. Even
traumatic injuries, such as cutting a finger or suffering a fracture in a fall, may have elements of the factors
that contribute to discomfort, pain and injury (explained on page 15 in this section) e.g. when fatigued and
so not paying enough attention to the task at hand.
Please note
The issues we include in this document relate to discomfort and pain, as well as injury. As discomfort and
pain may be present without there being a specific injury (see page 6 of this section) not everything we
have included here may be claimable from ACC.
In seeking to provide you with as practical a guide as possible, we have made every attempt to discuss
discomfort, pain and injury in the widest sense rather than narrow the information to specifically those
issues that may be covered by ACC.
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The size of the issue
ACC receives a large number of claims for conditions that may come under the umbrella of discomfort,
pain and injury (see table 1 below). The cost of each claim1 is also large – on average $10,000 per claim.
Table 1: Number and costs of new and ongoing claims for discomfort, pain and injury.
90,000
$180,000,000
80,000
$160,000,000
70,000
$140,000,000
60,000
$120,000,000
50,000
$100,000,000
40,000
$80,000,000
30,000
$60,000,000
20,000
$40,000,000
10,000
$20,000,000
0
Cost of claims
Number of claims
DISCOMFORT, PAIN AND INJURY CLAIMS AND COSTS
0
2001-07/2002-06
New number of claims
2001-07/2002-06
2001-07/2002-06
Ongoing number of claims
2001-07/2002-06
New cost of claims
2001-07/2002-06
Ongoing cost of claims
2001-07/2002-06
Total cost of claims
In fact, these figures show only the tip of a much,
much larger iceberg. A lot of discomfort, pain and
injury is not immediately ‘visible’ through workplace
reporting. So, though you may not see it, discomfort,
pain and injury probably exists in your workplace.
Likely to be
reported symptoms
Therefore it has the potential to become a significant
issue and, even at lower levels, may be affecting your
workplace productivity.
Aside from the actual financial cost, discomfort, pain
Unreported symptoms
and injury can also have a much larger social cost.
It’s difficult to measure the ‘cost’ of not being able
to pick up your children, of not being able to perform
well at sports or even sit comfortably to watch
television or talk to friends. Experiencing discomfort,
pain and injury can make you more irritable and
upset at work or home life.
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These figures are for ‘entitlement’ claims only, i.e. claims that have been accepted by ACC, and incorporate lost wages,
equipment costs, etc. as well as treatment costs. These figures do not include those claims where just medical costs are
covered (medfee claims). Medfee claims do not cost as much, but there are many more of them.
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Does pain equal injury?
Often the words ‘pain’ and ‘injury’ are used interchangeably. But on taking a closer look it’s clear there
can be quite a gap between feeling pain and incurring injury.
What is an injury?
In common terms, injury is damage or harm caused to the structure or function of the body, usually
caused by some outside agent or force, which may be physical or chemical2.
What is pain?
Pain is more difficult to define, especially as it includes an emotional element.
According to the International Association for the Study of Pain, pain is: “an unpleasant sensory and
emotional experience associated with actual or potential tissue damage, or described in terms of such
damage”.
Often, but not always, pain involves tissue damage. Often, but not always, it includes suffering. And the
only way to know someone is in pain is if they communicate it. In other words, pain is very individual to
the person experiencing it, which makes it highly complex.
What we think affects our experience of pain
Most of us believe that if we experience pain we’ve done damage to ourselves. If we believe the
sensations we experience are causing damage we’ll feel them more intensely than if we believe them to
be harmless. This changes how we respond to pain.
For example, it’s a popular belief that the back is easily injured and that where there’s back pain there’s
damage. But scientific evidence shows that a huge percentage of back pain (figures of around 80 – 90%
have been suggested3) has no specific structural cause. Around three percent is caused by a nerve
problem and two percent is caused by events such as cancer and fractures. Treating these more serious
events requires specific action. However, in the majority of cases of back pain, treatment involves good
pain relief, looking after yourself for a while and making a gradual return back to normal activity.
Prevent discomfort, pain and injury by promoting comfort
That’s not to say discomfort should be ignored. Ignoring discomfort can lead to fatigue, lowered
productivity and mistakes. Discomfort is the body’s way of telling you that you need to change something
before you do cause injury or damage. It doesn’t necessarily rule out an activity but discomfort indicates
that maybe you need to rest or change how you’re performing that activity. As humans we work most
productively when we can readily change position or posture, change tasks and have an interest in what
we’re doing.
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2
http://en.wikipedia.org/wiki/Injury
3
Deyo R. A. and Weinstein D. O. (Feb. 1, 2001) ‘Low Back Pain’ N Engl J Med, Vol 344, No. 5
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At one end of the scale, treating all pain as injury can mean some people avoid dealing with pain until it’s
embedded in their lives. At the other, medical treatment is sought unnecessarily. By promoting comfort
at work you can offer a balanced approach between the two extremes and go beyond just preventing
discomfort, pain and injury at work to achieving workplace wellbeing.
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What causes discomfort, pain and injury to occur?
If we use our bodies in the way they are designed to be used, we are unlikely to experience significant
problems. A small irregularity or ‘blip’ in the normal functioning of your body for a short time may have
little effect on you in the long run. However, if you let that small ‘blip’ persist over time, then its effect can
become magnified and problems will emerge.
How our bodies are designed to be used
We are designed for movement
The tissues of our bodies are designed for movement. Think of the body as an elastic band. If the band
moves regularly it keeps its ability to stretch out and return to a relaxed position. If the band does not
move it starts to break down; it becomes brittle and when next stretched it runs the risk of breaking. It’s
the same with our tissues.
We are not designed to repeat the same movement
While we are designed to move, repeating the same movement time and time again, without variation,
can fatigue tissues and cause excessive wear. This is due to a mismatch happening between the body’s
demands for nutrients and waste disposal to keep tissues in working order, and the body’s ability to
deliver these services.
Circulation
Our bodies are designed to move…
•
Blood brings nutrients and oxygen to the tissues and removes waste products.
•
To assist the heart in moving blood around the body, the muscles need to contract and relax,
thereby ‘pumping’ it along.
•
If the muscles stay static – unmoving – then the ‘muscle pump’ action does not happen.
•
If the muscles are static and tense – and thereby maintain a steady compression effect on the
muscles – even less blood is likely to work through the tissues.
•
Where no or limited amounts of blood reach the tissues, there are no nutrients or oxygen being
brought in and no wastes being removed. Fatigue will then set in, followed by discomfort, pain
and eventually injury or damage.
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Joints
Our bodies also need to move to keep our joints healthy…
•
Joint movement keeps the joint lubricated and nutrients moving around, and this is what allows
the joint to operate properly.
•
If there’s no movement in the joint, the fluids and gases within the joint gather in one place,
increasing the pressure in part of the joint and causing discomfort.
•
The less a joint moves, the less it can move. That is, little used joints become ‘stiff’ in the short
term and in the long term may lose part of their range of movement. Making sure you regularly
stretch and move joints through their full range of movement will ensure you keep their full
range of movement.
Think of your joints as operating much like a door hinge. Kept lubricated and regularly moved through
their full range, our joints keep their proper function. If not used in part of the range, a joint will become
stiff and may break down when forced.
Our tendons and connective tissues
Lack of movement also affects our tendons and connective tissues, by:
•
Decreasing their strength
•
Decreasing their supporting function
•
Decreasing the range through which they can move.
Nerves
Apart from the brain and spinal cord, nerves are either ‘motor’ – providing action – or ‘sensory’ –
providing feeling. Damage to motor nerves causes weakness or paralysis; they may easily fatigue or give
way. Damage to sensory nerves causes numbness, tingling or altered sensations, and pain.
A person may experience nerve injury from:
•
direct injury such as trauma and wounds
•
external harm from surrounding structures such as carpal tunnel syndrome where swelling
compresses the ulnar nerve at the wrist
•
neurogenic pain, where a structural abnormality or injury means the nerve can’t function
normally, such as with simple acute low back pain
•
neuropathic pain where a nerve stops functioning normally following injury or pain, causing
conditions such as chronic pain syndromes or ‘reflex sympathetic dystrophy4’.
4
A complex regional pain syndrome characterised by discrete sensory, motor and autonomic signs and symptoms.
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The aging process
As we age, our bodies quite naturally lose the ability to repair themselves or withstand excessive
demands placed on them.
Individual capacity
Each person has a maximum capacity to perform work. This capacity can vary from person to person.
Capacity to work also varies within an individual over time. An individual’s maximum capacity can
increase as a result of training and work hardening and decrease as a result of fatigue, reduced fitness,
illness or injury.
Capacity can decrease during the day as a result of tiredness/fatigue.
The way we use our bodies at work
In times past, work was not specialised as it is today and workers performed many tasks throughout the
course of the day.
For example, cart-makers used to design their carts, source their materials, construct the different parts
of the cart, market their product and deliver to buyers. That is: a person’s work day, week, month and year
included many different tasks.
Today, in the drive to improve productivity and efficiency, modern business practice seeks to specialise
tasks. So, using the example of the cart-makers, they have all now pooled resources – one does design,
one sources materials, one makes wheels and another forms frames, and yet another delivers. Because
orders and production are up, one worker now stays in the office to manage the business. Each worker
now enjoys much less variety in working positions and body use. As a result all the workers have an
increased risk of experiencing discomfort, pain and injury.
The lesson
If we don’t heed our body’s basic requirement of being used as designed, then it may repay us with
discomfort, pain and injury. The solution is to try, as much as possible, to use the body as it is designed to
be used – varying positions and tasks and allowing adequate time for recovery.
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Relationship between work and non-work
The factors that can lead to discomfort, pain and injury exist outside the workplace as well as inside.
As much as we would like our workplace issues to stay out of our ‘non-work’ life, and vice versa, this
simply does not happen that easily. For example:
•
‘Issues’ such as overbearing management, deadlines or workplace bullying may keep workers
awake at night; they may become irritable with partners or children
•
Financial issues, neighbourhood disputes or relationship concerns may often be carried over into
the work environment.
Whether a person is employed makes little difference to the body on whether or not they experience
discomfort, pain and injury. (However, it may make a difference as to whether or not a claim may be
accepted).
We often perform the same types of activities at work or when out of work, for example, taking part in:
•
Computer use
•
Gardening
•
Construction
•
Child-care
•
Cleaning
•
Car maintenance
•
Care of elderly / disabled
•
Playing musical instruments
•
Cooking
•
Shopping
•
Sports.
We have provided more detail on the ‘contributory factors’ on page 15 of this section. You’ll find this
detail refers as much to non-work activities as they do to work activities, especially if they occupy a large
percentage of time or are similar to activities forming part of your employment.
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Myth busting
There are many beliefs about the subject of discomfort, pain and injury. In this section we attempt to put
some of them into perspective.
Myth: ‘OOS is a diagnosis for an injury caused at work’.
Reality: OOS is not a diagnosis in itself. It is simply an umbrella term used to cover a number of medical
diagnoses5 that have met certain criteria6 so they can be addressed as a group (e.g. so we can develop and
action injury prevention programmes). Using the term OOS is much like answering ‘a car’ when asked
what you drive.
If a person presents with a condition that meets the criteria of the OOS umbrella, their condition should
still be referred to by its appropriate medical diagnosis and NOT as ‘OOS’. This is especially important
when making an ACC claim – a specific diagnosis is essential. Going back to the car example, we need to
know the make.
Myth: ‘If I have pain, I must therefore have an injury’.
Reality: Pain can exist without injury (see page 6). Think of when you get a headache. Although you can
have a headache following an injury, you can also have one without an injury. Generally, we think little of
them past taking some pain relief.
Myth: ‘I’ve managed when I’ve been tired/fatigued before, I can cope
and it won’t affect my performance’.
Reality: When you are fatigued, you tend to over-estimate your own alertness and your judgement isn’t
good. Fatigue causes lapses in attention, a reduction in performance and is related to an increased risk
of injury. If you are very fatigued, motivation can’t stop you falling asleep. If you are experiencing fatigue
symptoms – you must stop and manage fatigue. Quality sleep is the only way to reverse fatigue.
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5
Whether or not a diagnosis belongs under the umbrella of GPI depends on various criteria, not simply on what the diagnosis
is. For example, a tennis elbow, if caused by playing tennis socially, does not come under ‘GPI’. But if it’s caused by person’s
workplace and job, then it may be a GPI condition. At ACC, for a claim, we would refer to this condition as ‘GPI – tennis elbow’.
6
Criteria for cover for conditions that may come under the umbrella of OOS (abbreviated):
•
The employment task or employment environment must have a particular property or characteristic that caused or
contributed to the physical condition.
•
The property or characteristic is not found to any material extent in the person’s non-work activities or environment, and
•
There is a greater risk of sustaining this type of personal injury for people who do this particular employment task or work
in that environment than for people who do not.
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Myth: ‘I use drugs and/or alcohol at home (recreationally), this does
not have an influence on my work or risk of injury’.
Reality: Drugs and/or misuse of alcohol can affect the brain and the body in a number of ways. They
can alter the way a person thinks, perceives and feels, and this can lead to either impaired judgement or
concentration. Drug and alcohol misuse can also bring about the neglect of general health and wellbeing. This may adversely influence performance at work, even when the misuse takes place outside the
workplace.
Myth: ‘The workstation is to ‘blame’ for discomfort, pain and injury
arising’.
Reality: Although workstations should be designed or arranged to adequately perform the task they are
meant to do, it doesn’t mean that it is the sole problem. For example, even with a ‘good’ workstation, if
you remain stationary at it for a long time you may still start to experience discomfort, pain and injury.
Many factors combine for discomfort, pain and injury to arise. If you don’t address them all (in their
relative proportion) the discomfort, pain and injury you experience is unlikely to go away.
Myth: ‘Ergonomists are only interested in the design and layout of
workstations’.
Reality: Workstation design and layout can be part of an ergonomist’s job but that’s not all that
ergonomists do.
Ergonomists use knowledge of human abilities and limitations to design systems, organisations, jobs,
machines, tools, and consumer products for safe, efficient, and comfortable human use.
Myth: ‘Ergonomically’ designed furniture or equipment must be good
for me’.
Reality: Unfortunately there are no controls or limits on the use of the words ‘ergonomically designed’ and
frequently they are used simply as a selling point. They are often applied to equipment that is in some way
adjustable or alternately designed – this does not necessarily mean that the equipment is better for the
task. Often, it is not what you use, but the way you use it that will determine whether it is ‘good’ or not.
For example, an ‘ergonomically designed’ keyboard (with a space in the middle of the keys) may suit a
touch typist who uses many quick keys. But, due to its larger size, it may not suit the non-touch typist as it
requires an extended reach across the keyboard and, often requires a longer stretch to the mouse.
Myth: ‘If I remain in ‘the perfect’ working position then I won’t get
discomfort, pain and injury’.
Reality: Arranging the workstation to an anatomically ‘good’ working position simply provides a good
starting point. It’s important for the health and wellbeing of your body that you move it through a range
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of positions throughout the day (see page 8). If you change tasks while at the same workstation you may
also need to adjust the workstation so that you remain comfortable.
For example, when typing you usually need the keyboard to be lower (or further away from you) than for
reading or writing. The easiest way to cater for the differences is to raise your chair for typing tasks and
lower it for reading/writing tasks.
Myth: ‘Lifting correctly will prevent back problems’.
Reality: Unfortunately a ‘correct lifting technique’ is more a myth than a reality. Few people, having learnt
a technique, practice it on all occasions and at all times in their lives. Teaching correct lifting techniques
has little effect on its own and should be used in combination with other measures. Such measures
include identifying and controlling the hazards and addressing other contributory factors such as the
environment, task invariability and individual factors that contribute to back problems.
Myth: ‘Wearing a back belt will protect my back from harm’.
Reality: Studies from the early 1990s looked at the use of back belts. On weighing up all the evidence, the
widely respected National Institute for Occupational Safety and Health (NIOSH) in the United States
reported:
“…NIOSH stands behind its 1994 position of not recommending the use of back supports to prevent workrelated back injuries, the agency says voluntary use by employees is acceptable as long as that is within
the context of a comprehensive back injury prevention effort.”
We have no evidence to suggest ACC should not endorse this stance.
Myth: ‘It is possible to prevent acute low back pain’.
Reality: Acute low back pain is a common problem in everyday society. In a vast majority of people it
occurs without a diagnosable injury. The causes of this problem are not well known or established and
because of this it is almost impossible to prevent back pain from occurring.
Myth: ‘If I have acute low back pain, the best thing I can do is rest’.
Reality: One of the major changes in our approach to back pain is the way we now manage it. Instead
of the traditional view that bed rest was required, evidence shows us that keeping active and moving in
everyday activities is much more effective.
Myth: ‘Painkillers should be avoided if at all possible’.
Reality: Controlling pain with simple pain killers or analgesics is proven to help people remain active and
working. Regular doses, rather than ‘use as required’, have been shown to provide effective pain control.
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Myth: ‘I shouldn’t go back to work unless I am fully fit’.
Reality: Work (paid or unpaid) is important to both physical and psychological recovery. Maintaining work
or planning an early return to work will reduce the risk of long-term problems and chronic pain. Generally,
inactivity and unemployment negatively affect health and wellbeing and should be avoided wherever
possible.
Myth: ‘Employing someone with a past history of discomfort, pain
and injury is just asking for trouble’.
Reality: Discomfort, pain and injury is common – just think, for example, of simple back pain. There’s a
high chance that any potential employee has experienced some degree of discomfort, pain and injury in
the past.
A person may have experienced discomfort, pain and injury in the past due to a particular combination
of contributory factors at a particular time. It’s important to ask potential employees about their past
history and experiences to ensure that those factors are controlled if they are still in existence.
It’s also important to ensure that your workplace has addressed any contributory factors that may be
present so that existing problems don’t arise again.
Often, people who have a previous history of discomfort, pain and injury know best how to prevent further
episodes or manage any existing problems.
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The contributory factors
We describe each of the contributory factors in more detail in the following pages. These descriptions are
in no way definitive, but rather, are meant as an overall guide on the type of issues being dealt with.
Order of importance
The contributory factors are not listed in order of importance. That’s because there isn’t one. Within
each individual workplace and for each person, these factors will display in slightly different ways and in
different proportions.
However, we have deliberately introduced ‘individual factors’ first, as there are some factors here that
can’t be controlled, e.g. age, gender, genetic make-up. All the other groups have factors that you can
influence, to some degree.
Definitions
While we have explained the groups of contributory factors separately, both the groups and solutions
overlap. For example, physically repetitive tasks come under ‘task invariability’ but you may end up
managing them by improving ‘work organisation’ (getting workers to take breaks or rotating their tasks).
The contributory factors – combined effect
There are many factors that work together – in varying proportions depending on each person and task –
to cause discomfort, pain and injury. We call these the contributory factors.
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We have grouped the contributory factors into seven categories.
Individual factors: Things a person can and can’t change about the way they are.
Psychosocial factors: The way a person interacts with their social environment and the influences on
their behaviour.
Work organisation: How work is arranged, delegated and carried out.
Workplace layout/awkward postures: The way the workplace is set up and the working positions
workers adopt.
Load/forceful movements: What objects a person handles and the forces they have to apply.
Task invariability: How much a task changes over time.
Environmental issues: Where the work takes place and the conditions a person works in.
We discuss each of these factors in the following pages. However, it’s important you understand that it is
the combination of the factors at work that are significant in the occurrence of discomfort, pain and injury,
rather any one particular factor in isolation.
Combined effect
To explain the combined effect, imagine a container (shown here by the outline of a person). The white
‘empty’ area represents a person’s
capacity to tolerate discomfort, pain
and injury. To determine the risk of
discomfort, pain and injury occurring we
need to ‘pour in’ the contributory factors.
If the total of the contributory factors
overflows the container (i.e. it reaches the
person’s ‘critical mass’) then discomfort,
pain and injury may arise.
It’s important to understand that each
person’s container holds a different
amount or volume. This is because each of us has individual factors we can’t control, such as age, gender
and genetic make-up, which limit our capacity. To represent this, we need to put a block at the base of
the container (shown here in red), effectively changing the remaining volume for the remainder of the
contributory factors to go into. This block varies in size depending on the person, which explains why,
given identical working conditions, some people get discomfort, pain and injury and others don’t.
The remaining contributory factors – apart from some individual factors – can be represented as fluids in
pouring jugs. The amount of fluid in each jug will depend on how much that contributory factor impacts
the workplace.
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Imagine that the factors all get poured into the container (remember, that being fluid, they will combine
inside the container). If the container ‘overflows’ then the person’s critical mass has been reached and
they may experience discomfort, pain and injury.
As an employer your task is to try to reduce the amount of combined fluid so that it doesn’t overflow and
critical mass is avoided. As these illustrations show, to do this, you need to consider all the contributory
factors, giving them the appropriate attention depending on how much they impact the person.
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Individual factors
About individual factors
The fact that people are all different influences
whether or not, or to what degree, discomfort, pain
or injury is felt or is present. In other words, given the
same set of circumstances, some people may develop
discomfort, pain and injury, while others won’t.
There are some individual factors that you can’t do
anything about. These are just ‘nature’s gift’ to you,
for example, your:
•
Gender
•
Age
•
Genetic make-up (including your likelihood of experiencing discomfort, pain and injury).
Then there are the individual factors you can do something about. These factors all blend together to give
you an overall picture of ‘health’, and include (amongst others):
•
Amount of alcohol / smoking and drugs used
•
Amount of water consumed (overall hydration)
•
Amount and quality of food consumed (nutrition)
•
Amount and quality of sleep taken
•
Amount and type of exercise taken
•
Amount of ‘fitness’ for the specific tasks in your job,
or work hardening.
Some individual factors, while under your control, are very difficult to change or alter, such as:
•
How you tackle problems or cope with difficult situations
•
Your attitudes and beliefs
•
What you perceive as pain or injury and how you approach it.
Putting individual factors into perspective
Brent works in the meat works every season. This year he’s had eight weeks off between seasons and has
just returned to his usual job as a boner. Aged 42, Brent has worked at the meat works for 12 years. During
most off seasons he works cutting firewood, but this year he decided to take it easy, and didn’t get into
any sports or other fitness activities. Brent is a sociable person who enjoys drinking with his friends and
eating barbecued food. Frequently he finds that he has a hangover in the morning, hasn’t slept well and is
putting on weight.
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The first week after he returned to his usual boning jobs he experienced pain over the inside of his elbow.
The elbow swelled up and felt really hot, and he found it hard to bend his wrist down, especially when
cutting. At the time they were processing large animals. He ignored it for two days but at the end of the
third, found he couldn’t hold onto the knife. He went to see his GP who said he had medial epicondylitis
and recommended a steroid injection. Brent asked his doctor why he had damaged his elbow when he’d
worked at the works for so long without any serious problems. His doctor thought it might have been
because he had eight weeks off work and hadn’t kept fit, active or ‘healthy’, so that when he returned to
quite demanding work, his elbow just reacted.
Suggestions for the workplace
•
Consider the physical requirements for the task
•
Allow workers to re-gain their ‘work fitness’ after an extended time off – allow for reduced
targets at work or simply time to return to ‘full speed’ at work
•
Introduce ‘wellness’ or ‘healthy worker’ programmes, e.g. weight loss, stop smoking
programmes
•
Provide healthy snack machines or options in canteen, provide water fountains.
•
Promote gym membership or provide facilities at work
•
Offer flexible hours to allow staff to exercise before work or at lunchtime and to ensure people
are getting adequate and quality sleep
•
Provide showers and places to keep sporting equipment, e.g. lockers and bicycle parks
•
Promote self management and self responsibility for workers reporting discomfort, pain and
injury.
For further information
•
http://www.arphs.govt.nz Auckland Regional Public Heath Service, gives information on public
health and offers ‘challenges’ to improve health, for example go to: http://www.arphs.govt.nz/
Projects/HeartBeat_Challenge/Heartbeat_Challenge.asp
•
Creating a healthy workplace faculty of public health www.fph.org.nz
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Psychosocial factors
About psychosocial factors
The way you react to issues and stresses both in and
out of the workplace are referred to as Psychosocial
factors.
If you take 10 people and expose them to exactly
the same stress, each person will have a different
expetrience. How they manifest their reaction to
the stress will also be different for each person. For
example, they could react by getting a headache,
having impaired concentration or by getting tense,
sore muscles.
Sometimes you won’t be aware of how much an issue
is bothering you until it is fixed. For example only once a money problem is sorted out or a dispute is
resolved will you realise just how tense you’ve been.
Psychosocial factors are often noticeable by their absence.
Some of the common psychosocial factors that can affect us are listed below. Note that this list is by no
means definitive.
Non-work
•
Family relationships with partners or other family members
•
Financial issues such as mortgage problems or large debts
•
Health worries, either your own or others’
•
Your attitudes and beliefs about pain, for example the belief that pain is always harmful or that
all pain must stop before activity continues.
Work
•
Workloads, deadlines, or lack of control over your work
•
Unsociable hours or shift-work
•
Feeling unsupported by your managers
•
Your relationship with your work colleagues and managers
•
How satisfied you are with your job
•
Your promotion prospects (or lack of them)
•
The culture at your workplace – whether it is generally a happy place to be or not.
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Frequently people in workplaces realise that any of the above could be a problem, but don’t take action
because they don’t feel able or equipped to deal with the issue(s). Even more, they may feel they don’t
have permission to do so. However, problems that are having an impact on the worker will not just go
away if ignored.
How you deal with psychosocial factors will depend on many things. Issues to consider include the type
of business you are in, the size and structure of your workplace/team and the working relationships that
exist. These vary from workplace to workplace and there is no ‘one size fits all’ solution.
Whatever you do, to effectively address discomfort, pain and injury you need to deal with psychosocial
issues, along with all the other groups of contributory factors.
Communication
Often the root of psychosocial issues is poor communication and developing better communication
channels is a good way to address this. Anonymity is sometimes required if sensitive or potentially
difficult issues are to be tackled.
Putting psychosocial factors into perspective
Over a relatively short period of time, a number of band saw workers at a local meat works suffered fingerpart amputations. Before the incidents a full hazard assessment had been undertaken and the meat
works health and safety personnel believed that ‘all practicable steps’ had been taken to avoid injury.
When the incidents were investigated it was found that each worker had experienced a significant
psychosocial event a few days before their injury.
•
Injury one – a personal relationship problem had escalated and the worker’s partner had left,
taking their children
•
Injury two – a close relative of the worker had died
•
Injury three – issues had erupted with an immediate line manager and the worker was issued
with a warning notice.
It became clear that the psychosocial factors were a distraction, and a factor contributing to injury in
each case. If these significant issues had been identified when they first appeared then it may have been
possible to do something about them before they contributed to injury.
Suggestions for the workplace
•
Encourage your workers to report any significant issues or ‘pressure’ they may be under
•
Start an ‘Employee Assistance Programme’ or offer free counselling sessions. Consider linking
with a Citizens’ Advice Bureau. It may not be appropriate for the workplace to deal with some
issues, and a neutral external agency or person may be more acceptable to your workers
•
Develop a drug and alcohol policy that includes support networks and rehabilitation
•
Consider flexible options to help staff deal with financial issues, for example access to budgeting
service etc.
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•
Consider allowing time off or flexible hours so that your worker can deal with personal issues
•
Provide means of communicating workplace concerns anonymously, for example a suggestions
or comments box
•
Make sure you have clear channels for communication from employer to employee and vice
versa
•
Communicate to your workers that they are important to the company and that their
contribution is valuable. A small amount of appreciation goes a very long way
•
Provide leaders with training in leadership, problem solving and people skills.
Identifying psychosocial factors is not a one-off exercise. Psychosocial factors emerge and evolve over
time. As changes appear, different actions may be required.
For further information
•
www.mentalhealth.org.nz – Select Working Well and you can order the Working Well toolkit - a
practical guide to building mentally healthy workplaces
•
http://www.osh.dol.govt.nz/order/catalogue/stress/index.shtml - Dept. of Labour
•
http://www.ers.govt.nz/publications/er_info.html – Employment relations information
•
http://www.eapservices.co.nz - EAP Services provide Employee Assistance Programmes
•
‘Beating stress at work’ by David Brown ISBN 0-86472-481-0 www.pocket-stress.com
•
Linton SJ. A review of psychological risk factors in back and neck pain. Spine 2000;25; 1148-56
•
A Systematic Review of Psychological Factors as Predictors of Chronicity/Disability in
Prospective Cohorts of Low Back Pain - Pincus, Tamar PhD; Burton, A. Kim PhD; Vogel, Steve
DO; Field, Andy P. PhD. Spine: 1 March 2002 - Volume 27 - Issue 5 - pp E109-E120
•
European Agency for Safety and Health at Work. (2007). Work-related musculoskeletal
disorders: Back to work report. http://ki.se/content/1/c6/03/57/04/report_back_to_work_en.pdf.
•
European Agency for Safety and Health at Work. (2008). Work-related musculoskeletal
disorders: Prevention report. http://ki.se/content/1/c6/03/57/04/report_workrelated_
musculoskeletal_disorders_prevention.pdf
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Work organisation
About work organisation
Work organisation covers the way that work is
structured, supervised and processed. These tend to
be the real elements that a person may then react to,
and which trigger psychosocial issues. These include
issues such as:
•
Hours of work – including issues of shift
work, overtime, unsociable hours, being oncall, etc
•
Chains of command – who has power and/or
authority, how many levels of hierarchy exist
•
How work flow is managed – are there definite peaks and troughs in the work that is being done?
•
How the work is organised – are appropriate breaks taken to manage fatigue and allow rest and
recovery of the body?
•
How much variation the work involves – is there sufficient variation in the tasks performed to
change the demands on body and mind throughout the day?
•
How the workplace is laid out – e.g. printers placed away from computers so the operator has to
get up and move to get printing
•
What the overall workload is – can hours of work, amount of work or the tasks themselves be
changed to cater for the needs of new employees, employees returning from holiday or injured
staff?
•
Training – are the workers trained in the work required of them?
Work organisation can have a significant influence on fatigue in the workplace. Fatigue results from an
imbalance between the mental and physical effort of everything we do and the recovery of the body and
brain. Fatigue is both a mind and body experience and can severely impair judgement and performance.
For example it can be caused by working long hours, not getting enough sleep, a high intensity of mental
or physical effort or requiring people to work during some or all of the time when they would normally be
asleep.
Putting work organisation factors into perspective
Staff at a rest home were experiencing back pain. This began causing noticeable problems with rostering
issues, poor handling practices and the quality of patient care. Inevitably this affected workplace
atmosphere and culture. Management held a series of staff workshops focusing on all the potential
factors contributing to the back pain. One of the most effective measures suggested by staff was to
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remove the practice and policy that all patients should be up, dressed, fed and showered by 9am.
Staff offered patients a choice of wake-up times and found many wanted to wake later in the morning.
Residents were given the opportunity to ‘book’ their wake-up times and when they needed help from
staff. The staff roster and workload was then organised around this. These changes to the morning
routine decreased the stress and pressure on both residents and staff, and improved the atmosphere and
culture of the rest home. The incidence of back pain reduced significantly as a consequence.
Suggestions for the workplace
•
Consider rotating workers to perform different tasks throughout the day
•
Look at the work flow and try to even out peaks and troughs, attend to bottlenecks in operations
•
Reorganise work so that easier tasks are performed when we are more risk of fatigue – i.e. mid
afternoon when many experience a ‘post-lunch dip’ and between 3am and 5am
•
Schedule tasks at the appropriate time of day: heavier work in the morning (10am to 1pm) and
lighter work after lunch (between 3pm and 5pm). Only lighter work should be done in the hottest
part of the day
•
Confine higher risk activities to times when two or more people are present
•
Allow adequate recovery time after shift work
•
Manage overtime processes based on previous work and future scheduled work
•
Make sure that workers with sedentary roles have adequate opportunity to stretch and change
position throughout the day
•
Consider the likely impact on health and safety of any changes in the way your organisation does
business. Put health and safety responsibilities into every manager’s job description and consult
with all levels of the organisation when making any changes
•
Employ sufficient staff to cover sickness, deadlines and holidays
•
Allow a gradual introduction to work for new workers or for workers returning from an extended
break
•
Use reminders to prompt workers to stretch and take small breaks, e.g. software on a computer,
or egg timers for line staff, etc
•
Gear any reward/incentive schemes, including ‘home when finished’ schemes, towards safe
practice and efficiency rather than speed
•
Capture incident, accident and near miss data and link this to work designs or time of day
factors.
For further information
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•
‘Healthy Work – Managing stress and fatigue in the workplace’ (OSH, 2003)
•
http://www.hse.gov.uk/msd/experience/02.htm for Case Study
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Workplace layout/awkward postures
About workplace layout/awkward
postures
Workplace layout and awkward posture factors
often arise from workplace design. However, where
discomfort, pain and injury is reported, all too
quickly workplace layout becomes the focus of
attention. Certainly it is important to get this right.
But you still need to consider all the other contributory
factors as well.
The design of a workplace directly affects the positions
workers adopt. Wherever possible, you need to make
sure your workplace is designed and laid out to best
suit the workers who are there and the task(s) they have to perform. This may mean building in a certain
amount of adjustment and flexibility so that workers can best suit themselves. However, even with
adjustable workplace layouts, it is important that you train your workers in the use of equipment and why
it is important to adjust it to their needs.
Don’t be misled by the myth of the ‘perfect working position’ which, simply doesn’t exist. The human
body needs to change and move around. Holding one position (even a very ‘good’ one), or working in one
particular way for a long time, may still result in discomfort, pain and injury arising. It is often said, ‘the
best position to be in is the next one!’
•
As a ‘rule of thumb’ our joints and muscles work best around the mid-position of the joint or
range. That is, not fully stretched and not fully bent, e.g. the wrist should naturally sit around
the middle of its range of movement, not all the way back, forward or to either side
•
From there, regular changes from that mid-position are required
•
To maintain joint flexibility and muscle length (the conditions under which the body functions
best), joints and muscles should be moved regularly and be stretched occasionally through their
full range of movement
•
Having to apply force when in an awkward posture increases the stress on the muscles involved.
Putting working positions and workplace layout into perspective
Staff on a biscuit packing production line complained of discomfort, pain and injury in the upper limbs,
nausea and dizziness. Additionally there was a high accident rate and high staff turnover. Ergonomists
were called in to determine what workplace improvements could be made:
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Hazard / Risk
Solution
Upper conveyer too high, causing stretching
above shoulder height
Reduce conveyor height
Containers too far away, causing reaching
and stretching
Reduce width of conveyor and allow
containers to overlap it
Lower conveyer too low, leading to stooped
back posture
Raise conveyer
Standing for long periods, causing discomfort
and fatigue
Provide appropriate seating, foot-rail and
anti-fatigue matting
Waste put in box under lower conveyor,
leading to awkward bending and stooping
Provide waste chute within easy reach
After making the changes the company saw increased productivity (output up 33%, with 25% more
operatives), improved product quality, decreased labour turnover, a significant decrease in accidents,
reduced sickness absences and fewer health problems reported (upper limb disorders down 48%). The
payback period of the total investment required was well under three years.
Suggestions for the workplace
•
Provide scissor lifts under boxes to help maintain working heights
•
Consider tilting containers part-way to help with loading and unloading
•
Provide standing ‘prop’ chairs to bear part of the body weight when standing
•
Provide foot rails to allow one foot to be raised, e.g. like in pubs with a foot rail round the base of
the bar
•
Make sure the workspace is designed to suit the task being performed. Fine tasks, such as
jewellery making, need to be performed up close, while tasks requiring greater force (e.g.
hammering) need to be further away
•
Regularly rotate tasks that require awkward or sustained postures. Encourage workers to help
each other by regularly rotating task components (within a certain task)
•
Video tasks to use in educating your workers on using good working postures.
For further information:
•
Dul J and Weerdmeester B. (2001) ‘Ergonomics for Beginners – a quick reference guide’ 2nd
Edition
•
HSE (1994) ‘A pain in your workplace? – Ergonomic (sic) problems and solutions’
•
Correcting work postures in industry: Applied ergonomics 8:4 pp199-201
•
Manual Handling Code of Practice – http://www.osh.govt.nz/order/catalogue/68.shtml
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Task invariability
About task invariability
Task invariability is concerned with repetition and
its effects (see page 8), as well as the effects of
not moving at all (see page 8). It also includes the
impact of a lack of variety on the cognitive (mental/
concentration) load of a person: both too little and too
much can have negative effects on your workers.
Task invariability factors overlap considerably with
work organisation. That is, good work organisation
can address many aspects of task invariability. Task
invariability issues include:
•
Too much repetition of movement – this
can lead to the body being unable to keep up with demands for nutrients and waste removal.
Discomfort, pain or injury may then follow
•
No movement (i.e. static holding) – the muscle may not be able to pump nutrients and oxygen or
perform the waste removal required for tissue functioning. Discomfort, pain or injury may follow
•
Too much cognitive demand – the worker may feel unable to ‘keep up’, and discomfort, pain or
injury may occur
•
Too little cognitive demand – the worker may get bored, not be bothered with work, or even
become destructive. Therefore discomfort, pain or injury may occur
•
Duration of a task – this plays a large factor in whether task invariability becomes an issue or
not.
Putting task invariability into perspective
Operators at a helicopter manufacturing plant used a ratchet spanner to turn and screw a ‘rosean’ (a
steel peg threaded at both ends) into a transmission housing. An employee had to insert between 87 and
108 roseans into each transmission, and the whole housing unit took one employee over eight hours to
assemble.
Several operators reported elbow and upper arm pains thought to be from the task. This was due to the
repetitive motion combined with poor posture.
Pneumatic nut runners were introduced. This allowed the operator to turn the rosean to screw it into the
transmission housing simply by squeezing a trigger rather than repeatedly turning the ratchet spanner.
This resulted in:
•
A reduction in reports of upper limb pain
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•
The unit assembly time was cut from eight to five hours
•
The product quality improved with a lower rejection rate on inspection of the driven roseans.
Starter suggestions for the workplace
•
Look at engineering the task design to eliminate the problem task altogether
•
Ensure breaks are taken where there is high task invariability. Encourage workers to perform
stretches or exercises during the break
•
Rotate tasks so that different muscle groups or parts of the body are being used
•
Give workers the opportunity to stretch or do a micropause, e.g. 3-5 seconds every 3-7 minutes
•
Balance up workloads with periods of high cognitive demand with some ‘downtime’ and low
cognitive demand
•
Encourage workers to tell their supervisor if they have a fatigue or boredom problem while at
work and provide a mechanism to support the individual
•
Ensure only the amount of muscle power actually required is being used to perform the task. For
example try not to tense shoulders when holding arms up to cut hair, tap gently on keyboard
(hitting keys harder does not necessarily help the task).
For further information
•
Dul J and Weerdmeester B. (2001) ‘Ergonomics for Beginners – a quick reference guide’ 2nd
Edition
•
Kroemer K.H.E. and Grandjean E. (2001) ‘Fitting the task to the human – A textbook of
occupational ergonomics’ ISBN 0-7484-0665-4
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Load/forceful movements
About load /forceful movements
Load and forceful movements factors relate to the
attributes of objects and the amount of force your
workers need to apply to use or control those objects.
The sorts of load factor attributes you would look at
include:
•
Actual weight of object
•
Bulky or unwieldy
•
Unpredictable
•
Uneven in weight distribution
•
Difficult to grip, greasy, slippery
•
Blocks vision
•
Presence of handles
•
Sharp edges.
Load may also be internal rather than external. For example, holding a limb in position to perform other
tasks, such as dental technician helping with dental procedures. Holding the limb in position is a load on
the body.
Forceful movements factors cover the amount of energy a person needs to use to move or control
an object. In some instances, the force needed to move an object can be greater than the load itself,
especially if the load is moved quickly or jerked.
It is not helpful for us to prescribe specific load limits because of the complexity of the way the different
risk factors combine. But clearly, the risk of harm increases with increasing load and/or force.
Putting load and forceful movements into perspective
Managers at a printing firm (that was printing ACC back pain guides!) realised they were putting
unrealistic loads on their staff. While they could fit 25 books into a box, after 17, the box was considered
too heavy for safe handling. They decided to limit the weight of the boxes to 12kg, even if it meant packing
the remaining space loosely with newspaper.
The couriers who were collecting the boxes offered a special deal for ‘one load’, so the printer taped
the boxes together to get the deal. But, the courier driver was unable to lift it! After negotiation with
the courier company, the printer set a 12kg maximum on all outgoing loads. After negotiating with its
suppliers (dyes, stationery, etc.) all incoming loads were also limited in size or increased in size so that
manual handling was not required (bulk ordering). The printer then purchased two hydraulic scissor
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paid off over the next 12 months with no time lost during that year due to back pain. The printing firm’s
policy had knock on effects with their customers changing their policies as well.
Starter suggestions for the workplace
•
Use ACC’s Risk Score tool to assess risk in tasks involving handling
•
Split loads into more manageable sized parts to reduce weight
•
Improve the stability of loads by repackaging or redesign. Improve or attach handles
•
Use slides, rails, roller tracks or castors to reduce friction and force required
•
Consider whether mechanical aids can be used to help with the manual handling tasks, e.g.
overhead pulleys or scissor lifts
•
Consider whether you can design manual handling out of the workplace, e.g. by ordering in bulk
so forklifts are used
•
Seek specialist advice if handling people or animals
•
Avoid focusing primarily on ‘safe lifting techniques’ as an intervention
•
Ensure only the amount of muscle power needed for the task is used. For example, hitting
computer keys hard rather than softly tapping them will have the same effect on the keyboard,
i.e. depressing the keys, but may have very different effects on the body; or, having tense,
elevated shoulders when cutting hair (maybe because of some unresolved psychosocial issue)
will not benefit the worker. Rather, encourage the worker to use less muscle power and to relax
the shoulders.
For further information
•
Manual Handling Code of Practice – http://www.osh.govt.nz/order/catalogue/68.shtml
•
ACC1342 The NZ Patient Handling Guidelines – The LITEN UP approach
http://www.acc.co.nz/wcm001/idcplg?IdcService=SS_GET_PAGE&ssDocName=WCM001675&ss
SourceNodeId=4141
•
Analysis Tools – http://hsc.usf.edu/~tbernard/ergotools/
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Environmental issues
About environmental issues
The environment in which a person works can have a
significant impact on them, especially if an aspect of
your workplace is very dramatic. For example:
•
Very cold – e.g. fisheries or meat works.
•
Very hot – e.g. working in a smelter, rest
home (kept warm for sedentary pensioners
rather than the staff), kitchens, etc.
•
Noisy – this could be very loud such as
working with or near heavy machinery, or
simply irritating noise, e.g. mobile phones in
workplace, or fans whirring.
•
Lighting issues – e.g. low lighting in factory, bright lights in office, glare off water (fishing) or on
computer screens, etc.
•
Vibration – e.g. driving trucks or other industrial machinery.
•
Windy – e.g. near large fans or working outside.
•
Slippery surfaces – e.g. round swimming pools, in bakeries, on farms.
•
Fumes / bad smells – e.g. chemical use in printing, painting, exhausts, etc.
Putting environmental issues into perspective
Andrea works in the chiller in a food processing plant. She has to move stock brought into the chiller
on pallets, pick the correct items for each order, stack them onto stock shelves and then take the pallet
outside. Andrea has to wear steel cap boots with double thickness socks, thermal underwear, a hat and
polypropylene gloves when working in the chiller because she finds it very cold. She has regular (enforced)
work breaks out of the chiller, but spends the majority of her day in a cold environment.
Andrea often finds that her fingers and toes are very white (she has Raynaud’s syndrome), and that she
has trouble holding onto stock, so she holds on tightly. She has been developing tingling and numbness
in her fingers, especially at night, and wakes sometimes to shake her hands and fingers so they ‘wake up’
again. Lately Andrea’s found that her grip isn’t so good, and she drops things at work, and even at home.
She is wondering whether she should do something about how long she spends in the chiller, or whether
she can find some warmer gloves.
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Starter suggestions for the workplace
•
Consider whether the task can be isolated from the contributory factor. For example, placing
screens between a worker and furnace, or instead of unloading vehicles outside in cold/hot/wet/
windy conditions, driving vehicles undercover for unloading.
•
Determine whether the contributory factor can be minimised. For example, providing personal
protective equipment, ensuring the worker has regular breaks away from contributory factor.
•
Promote good ‘housekeeping’ by cleaning, removing clutter and obstacles.
•
Improve/provide/clean lighting.
•
Ensure a system is in place to provide a sufficient and effective maintenance programme for
tools, plant and equipment and that your workers are informed and trained on their use.
•
Provide rest and kitchen facilities (if possible) to allow individuals to have breaks from
environmental stressors and manage fatigue.
For further information
•
Parsons K. (2003) ‘Human Thermal Environments’ ISBN 0 415 23793 9
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References
1.
ACC (1999) ‘New Zealand Acute Low Back Pain Guide’ ACC1038 ISBN 0-478-25193-9
2.
ACC/Dept of Labour (2001) ‘Code of Practice for Manual Handling’ ACC532
ISBN 0-477-03651-1
3.
Department of Labour (1995) ‘Approved Code of Practice for the use of Visual Display Units in the
Place of Work’ ISBN 0-477-03575-2
4.
HSE (2005) ‘Improved early pain management for musculoskeletal disorders’ Research Report 399
5.
HSE (1994) ‘A pain in your workplace? – Ergonomic problems and solutions’
ISBN 0-7176-0668-6
6.
Kroemer K.H.E. and Grandjean E ‘Fitting the task to the human – a textbook of Occupational
Ergonomics’ (2001) ISBN 0-7484-0665-4
7.
Parsons K. (2003) ‘Human Thermal Environments’ ISBN 0-415-23793-9
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