sierz017 Occupational Stress Index (OS!) | Unhealthy Work ga THE CENTER FOR SOCIAL EPIDEMIOLOGY ‘Causes of Il Health » Occupational Stress Index (OSI) Posted by Erin Wigger on Jul 19th, 2011 in Other Job Stress Modsls | Comments Off on Occupational Stress Index (OS) ‘THE OCCUPATIONAL STRESS INDEX: AN INTRODUCTION 8 Dr. Karen Beikic August, 2000 ABRIEF BACKROUND ‘The Occupational Stress Index (OSI) isan additive burden model, which focuses on work stressors relevant tothe cardiovascular system (Belkic 1998(a). The OSI incorporates elements ofthe Job Strain Model (Karasck 1979), as well as other formulations of how stress leads to cardiovascular disease, such as features of work in high-risk occupations. However, in contrast to constructs such as Job Strain Ibid.) and Ffort-Reward Imbalance (Siegrist 1991, 1996), which are based heavily upon sociological theory, the OSI derives more from cognitive ergonomics and brain research, allempting to describe, in quantitative terms, the burden of work procestes upon the human being. The underlying motivation for developing such ‘an approach isto help pinpoint areas for intervention, by striving to reflect actual work experiences. ‘There have been two major approaches in occupational psychosocial research using self-report methods. One has been to develop occupation- specific questions. This ean provide rich, detailed information useful in identifying key areas for intervention, However, these job-specfic {questionnaires generally eannot measure job stressors across various occupations. The other approach has been to measure generic job ‘characteristics using questions ofa general nature. However, “this approach is less useful for intervention studies, because questions are more “remote from actual work experiences" (Landsbergis 2000). The OSI represents a potential means of bridging these wo divergent approaches. As stated by Landsbergis and Theorel (Ibid) ” A recent innovative approach used occupation-speitic questions (useful for workplace interventions), that are based on general questions. The Occupational Stress Index (OSI) can be tailored to specifi occupations, thus allowing comparison among, ‘occupations ofthe stress burden faced by workers" (p. 164). We can make comparisons regarding the total burden, as well asin the nature ofthe ‘occupational stress burden, These questions ae of interest not only inthe research setting, but are also those articulated by working people themselves. Figure 1 The Occupational Stress Index [cacear ant dace ; Fetornaton nderioad igh Demand sricmess |i me Wncrour —fSymbene een ressure rosures) tversiveness) [Uncertainty Fiiogacoae [Smeal — ne ——|FNecomoroner | Fie vst of — Squat Ras reaming rigalsfatcrmntion —|fegitment foofpeeder pace rato Geos [nti Pw nearest fcoming signals seer of oSiga/ Sigal faccmcy [pny Frooctey pe pot ieait[folowed Fors alone iccepsncou iets Fat moastiy my |*High frequency fone ‘emir Fs cxory htp:tunteatthywork orglatherjob-stess-modelsloccupationa-stross-ndox-osi! a0gier2017 Occupational Stress Index (OS!) | Unhealthy Work dais Fecommuniction sential for ork i" Missing pin Limited information \cenirat bp. Fecompliates purer of wrong dcisison Pee for nie cisions lhecaons _[Peclommingpacson cmt an ave serious ESR, Becton. tote om Pievins ate ESS hopped poral fat oem Mating put [Decisions affect ied sequences formation FNeedforrapia|Pumber of [Unexpected onect decision ens change Hiecision-making rs [ietropeneous [Hoomogencous FAS |Confictng tasks FSimutancous |bWork must |+No contol over bn space and ime fou Task fasts" [texccton foecasmity:lfasksscomian [YS | hitaradoun tsk [era cor eewion Pimple tasks IeCompex tasks Hefned standard ate net mper take Nothing do {COMP tke met ask execution Fovene wok, px bo cold fEmoconaty K:lolds 2 jobs [position |SPeed-up eat [*Work accident charged work General Fixed pay [[Holds2-jobs postion peactine cat ass work frp reals onfined space [Pres pase/fumes/dusts interpersonal fies) Night work From: Belkic K, Savie C, TheotellT, etal. Mechanisms of eardiae risk among professional drivers. Scan J Work Environ Health. 20:73-86, 1994, ORGANIZATION OF THE Ost Levels of Information Transmission ‘As seen in Figure (1), the OSI is arranged into a two-dimensional matrix, with the vertical axis comprised of “Levels of Information Transmission” 1) Sensory input 2) Central desision-making 5) Effector output (task performance) ‘These ate the basic cognitive ergonomic processes, as described by Welford (1960), that can be mapped overtime using neurophysiologic methods (vanitsky 1980), These provide a useful format for categorizing a broad range of occupational endeavor, Luezak (1971), e.g, employed this formulation in work simulation analysis. We have added a “General”, level for elements that ar related o the overall work environment and not localized toa specific level of information transmission. Sivess Dimensions ‘The stress dimensions or aspects ofthe OST are placed along the horizontal axis, as follows: 1) Underioad 2) High demand 3) Striciness 4) Extrinsic Time Pressure 5) Aversive(Noxious Exposures 6) Threatavoidant vigilance/disaster potential 7) Confictncertainty The Tvo-dimensional Matis ‘Thus, each factor has @ set of coordinates, localizing it tothe typeof stress and the level at which i affects the human operator. Summations by levels and by stess aspects can be made, and a wide variety of combined effects can be assessed. The sum othe factor scores comprises the (tal ‘OSI score, which is an attempt to quantitate the overall burden upon the human operator of given set of working conditions. AS mentioned above, sing the OSI hetween-group comparisons regarding total burden ean be made. Insight into the nature ofthe occupational stress burden can be ‘gained, as well. For example, it may tur out that two very different jobs, such as work as a teacher and an assembly line worker, ave similar total (OSI scores. The OSI would help elucidate how these two jobs differ. As will be discussed subsequently, teachers have very high demand on the input and central decision-making levels, together with various degrees of extrinsic time presture and conflict. In contrast, factory workers face underload (short-cyele, monotonous work), together with very strict constraints on the speed and content ofthe work they perform. The OSI can provide an in-depth profile of the relatively fixed, a well a potentially modifiable workplace stressors of a given jab, identifying the level at which the burden primarily occur, and the major contributing dimensions. Ths information helps pinpoint where modifications in the work environments ‘would be most beneficial ‘Threat Avoidant Vigilance-An Often Hidden, but Important Stress Dimensi hup:tunteatthywork orglatherjob-stess-modelsloccupationa-stross-ndox-os! 210sierz017 Occupational Stress Index (OS!) | Unhealthy Work ‘An in-depth discussion ofeach ofthe dimensions of the OSI as they relate to other psychosocial work stress models, to cognitive ergonomics, as ‘well as to cardiac risk can be found in (Belkic 1995(a), Belkic 2000(a)). However, stress dimension #6 warrants comment right at ths juncture, Ibecaise iti often left out of psychosocial job stress models, and yet is, in our opinion, an extremely important, albeit often unrecognized, work ‘We emphasize the following: when the potential consequences of one's actions can include disaster, work can become a “threat-avoidant” vigilant activity. Insofar as one anticipates the possiblity of encountering harm of some sort, this is inevitably associated with negative emotions (Lazarus 1967) There i epidemiologic, himan laboratory and experimental animal data that directly and indireetly inks prolonged exposure o avoidant vigilant activity with adverse cardiovascular outcomes, including cardiae electrical instability and even sudden cardiac death (Corley 1977, ‘Lown 1990, Mezotti 1985, Murphy 1991, Suurnakki 1987, Theorell 1993), Professional drivers, sea pilos, air traffic controllers and some other lasses of control pane! workers, all of whom perform primarily threat-avoidant vigilant work ate found to be at high sis for hypertension and/or far ischemic hear disease (Winkleby 1988, Belkic 199%, Ragland 1997, Cobb 1973, Erikssen 1981, Tuchsen 2000) Cognitive ergonomics end brain research illustrate thatthe heaviest burden upon conscious attentional resources occurs when one continvously follows a barrage of signals to which he or she must be prepared to repidly respond, such that momentary apse, error or delay could have serious, ot oven fatal consequences (Belkic 1992(a), Kalsbeck 1974, Levi 1981, Parasuraman 984, Stroh 1971). Por survival reasons, our nervous systems are constructed to selectively allocate mental resources to threatening stimuli, even ifthe threat is only of a symbolic nature A salient illustration ofthe importance ofthis hidden burden upon conscious attentional resources is seen in a study of human electrocortieal brain activity during a simulated traffic situation. Therein, an unusually high level of selective atention was elicited when persons were confronted with an imminent traffic aceideot seene (Martin 1992). That study also demonstrated that compensatory allowance (especialy increased time allocation) is essential in such situations, This needs to be calculated into the work planning “equation”, Description of the OSI Questionnaires The Occupational Stress Index is questionnaire-based, and does not require on-the-job analysis, Insofar as such is available, direct worksite ‘measurements and data ean be effectively incorporated into the OSI, and wil improve its accuracy. Each element of the OSI is scored on a scale from 0 10 2, with zero being “not present” and 2 as "strongly present” ‘The General OSI Questionnaire ‘The General OST Questionnaire is applicable to workers of any occupational profile. Tis has been applied among 345 workers of various ‘occupations and of both genders, in several counties (Belkie 1995(a), 1996). Our experience is that the general OSI hus good face validity, that ‘working people consider the questions relevant tothe daily life on-the-job, and that they understand quite wel even the somewhat more abstract ‘questions. The intemal consistency ofthe total general OSI is within the desired range (Cronbach alpha = 0.81), as are most, but not all ofthe scales, (The two scales from the General OSI, in which intemal consisteney is low are: Extrinsic time pressure ané Strictness. For more deals, see Belkic 1995(b), as well as Landsbergis 2000) The General OSI Questionnaire can be used for between-occupation comparisons, especially when evaluating a heterogeneous working population swith a wide range of profiles. However, as mentioned above, general questionnaires have a common weakness in their remoteness from actual work experiences. The General OSI is no exception. On the other band, tie General OSI, having been designed to focus upon objective featutes of work, can serve a8 a bridge to the next step inthe application ofthe OST. Namely, General OST data from several workers in a single occupation can be used asthe first phase inthe development of an occupation-specitic questionnaire, which can then be pilottested. Qualitative data from workers willing to put inthe extra time ‘to comment and explain their answers to the General OSI in relation to theit actual work environment proves to be valuable, This process is facilitated by a number of open-ended questions included at the end of the questionnaire, Expert observers can also be of great help. Occupation- Specific OSI Ques ur aim with the OST has been to develop a series of occupation-specific questionnaires that are all pat of the OST “umbrella. Tn other words, these would all be compatible with the General OSI, and allow between-oceupation comparisons, but Would be far more operationalized and streamlined. "Namely, the latter are derived from a moze qualitative approach, based on detailed knowledge ofthe eeeupation in question. Once developed, these ‘ccupation-speeific OSI allow us to omit questions about the fixed aspects of a given line of work and to focus on the variable features ofa given ‘occupation, and often pinpoint key stressors that could be the focus of intervention, These specific OSI are heing designed fora very wide range of occupational endcavor-from industrial, transport, to clerical and professional sectors, Thus fa, the OSI for professional drivers has been validated and widely tested, the OSI for physicians is inthe final phase of piloting, and OSI for teachers, production workers, clerical workers, ar traffic controllers and for aitine pilots are being developed. OSL for Professional Drivers Our experience withthe OSI for professional drivers illustrates these points. As scen in Appendix 2, the OSI Questionnaite for professional drivers is about half the length of the General OSI, and the questions are very conerete and germane to tis occupational group, ‘We fist identified those features of professional driving, which ate relatively constant, such as the need to make and carry out rapid, non-defetrable, but somewhat automatic decisions (a combination of decision-making underload and high demand) 20 possibility af ignoring incoming signals (strictness on the input level) “fixed posture while behind the wheel (strictness on the general level) no chance to influence the rate at which new signals are received (extrinsic time pressure on the input level) ‘These and other features contribute to the high demand and low control of professional drivers, but because they ae relatively fixed features ofthe ‘occupation, queries in this regard would be superfluous, Furthermore, professional driving. epitomizes threat-avoidant vigilant activity, with requirements for high levels af vigilance and potentially fatal consequences trom a momentary lapse or even a slight decision-making error. Again, there is no need to ask about this, We then took the remaining, variable features of professional driving, and sought to operationalize these in relation tothe trafic environment: road and vehicle conditions, type of routes, passengers, accidents, as well as work schedules, time table stringency, rest breaks, ete. These queries are presented in a neutral way, to minimize reporting bias, especially denial or repressive coping. htpstuneatthywork oro joa ss-modelsioccupationa-strossindex-osi! anosierz017 Occupational Stress Index (OS!) | Unhealthy Work Some examples are given of how this was done with respect to elements of input high demand versus underioad. Frequency of incoming signals is scored by where driving predominantly takes place: within the city signifies high frequency of incoming signals (high deman), whereas driving ‘mainly on long, interity routes is scored as low incoming signal frequency (underload). Heterogencous signals (high demand) are encountered ‘when driving on various routes while wit driving onthe same route day after day, relatively homogeneous signals are seen (underload). The conflict between meeting a strict time schedule and fulfilling the ther tsk requirements, as described by Gardell etal. (1983) is reflected in an item ‘on conflict at the level of task performance, ‘The OSI for professional drivers has now been applied in 327 persons. Drivers tellus that itis easy for them to complete the questionnaire and it takes only afew minutes for them to do so. The Cronbach apta forthe total OSI for professional drivers is 0.84 (variable features only). Some ‘results obtained using the OSI for professional drivers are presented inthe next section OSI for Physicians ‘An OSI for Physicians is in the Final phases of pilot testing, and should be available on this Website shortly. Since the authors ofthis instrument are physicians themselves (Drs. Karen Belkic and Cedo Savic), the frst phase of development was based upon our own experience ina variety of clinical settings. As we began to pilot test the OSI for Physicians, we contextualized this a “by physicians for physicians” within the framework of “participatory action research” approach. This point is emphasized here because of the pivotal position of physicians with respect to the work enviroment and health outcomes. Namely, physicians are often called upon to make decisions about fitness for work, ané can potentially have a impact upon patients’ working conditions by making informed recoramendations. (See Belki, Schnall & Ugljesic 2000(b), Fisher & Belkic 2000), [tthe same time, paysiians increasingly face an infringement of decision-making latitude, ineeased demands, et. especially within the context of ‘managed care. The underiying burden of the work of physicians is a heavy one, Documenting and quantifying this burden is important for many reavons. As an empowerment tool for physicians, we hope ths will help in efforts to improve the working conditions of our awn profession, We also hhope that this process can be translated into better insight by physicians into the working conditions of patients, The response of our colleagues during pilot testing has been very positive and we are grateful forthe time they have taken to provide invaluable insights into their working life, and hhow it might be improved. There are several elements on the decision-making level, that ar fixed features of work asa physician need to make complex and complicated decisions (high demand on the decision-making level) serious, potentially fatal consequences of a wrong decision (threat avoidance on the decision-making level) —teceiving contradictory information (conflits/uncertainty onthe decision-making level) Specific aspects ofthe physician’s work envionment, that can vary to some extent, and that contribute to their stress burden, inlude: squency of incoming signals: related to patent load and seting (emergency room or ICU versus outpatient) possibilty to postpone decisions: related to setting (emergency room or ICU versus outpatient) heed for rapid task execution: related to performance of invasive procedures or urgent care ess onthe decision making level: related to degree of control over areas such as indications for hospitalization and procedures rol over number of patents, scheduling, other external time pressure on the output level / control aver pace of task performance: related to duties (On the general level, in addition to accidents, we have included other cognitively aversive ~ disastrous consequences such as patent suicide or being faced with malpractice litigation. These are major stressful events that can occur inthe physician's career. We also expand the conflict dimension ot the general level to include cooperation with staf, colleagues and support inthe display of knowledge and career advancement. Larger issues related tw contol over institutional policies, et. can be covered in an expansion ofthe strictness dimension on the general level (see perspectives). In the future, we also hope to develop an OSI for nurses, and for other health care workers. O81 for teachers Increasingly, adverse health outcomes, especially burnout (van der Berghe 1999) are being reported among teachers, in relation to an ever-greater stress burden, We are now developing an OSI for teachers aimed at describing and quantitating this burden and helping to identify key points for A numberof fixed features oftheir work contribute to high demand: “Attention to several sources of information simultaneously (input high demand) “Communication essential for work (input high demand) “The need to make complex and complicsted decisions (central high demand) ‘Variable features in the teacher's work environmet Rapidity of new information -rlated to class size “Speedup and deadline pressure (extrinsic time pressure on the general level) — related to class size and curriculum demands, as well a the need tw perform otter duties such as administration “Conflict and uncertainty as well as threet-avoidant vigilant burden-problematic pupils “Administrative task assignment ~ a source of high demand, extrinsie time pressure and conflict “Threat of violence-threat-avoidance onthe task performance level Interruptions as requiring change of plan of work and hampering task performance (conflict on the central decision-making end task performance ave cited as exacerbating stressors include: Control over work pave-related to control over class size, number of problem pupils, size of curriculum and pressure to complet (0S! clerical workers = the human-computer interface Clerical work relies ever more heavily upon computer technology. While potentially increasing productivity there are specific stressors tha fom the human-computer interaction, o which clerical workers are exposed (Smith 1999). We are altempting to describe and quantitate these and ‘other stressors relevant to clerical workers in this specific OSI Some examples ofthese stressors include: “interruptions (a source of conflict), jobs hp:tunteatthywork orga 1s-modelsioccupationa-strossindex-osi! 4n0sierz017 Occupational Stress Index (OS!) | Unhealthy Work high workload, lack of control related to electronic monitoring, slow down-wait ime creating underioad, “disaster potential-(materal or other type of damage)-sending wrong file, opening a virus-infected file, cumbersome ~ incompatible types of software — hamper tsk performance, etc ir Transport Professionals: lers and Pilots ‘These professions entail enormous responsiblity, with maximum threat-avoidant vigilance on the input and decision-making level They ae also ‘characterized by alterations between underload and extremely high demands, with requirements to generate peak attention levels at certain ‘moments. As discussed by Levi (1981), generating these very high levels of attention ereates a heavy burden upon the human nervous system, Requirements for judgment place an onerous load upon decision-making capacities, Variable features that affect burden upon Ai Traffic Controllers include: average traffic donsity peak traffic density (highest attentional demand) Jatitide to alter decision-making strategy -considered a key buffer by Bisseret (1971) and Sperendio (1971), and one that is compromised by time pressure and other constraints Descriptions of these stressors can be found in Costa (1993), Emdad (1997(a)) and Landsbergis (1986). Semi-structured interviews are planned with air-traffc controllers who have worked in a variety of settings, ‘Maximum attentional demands are made upon pilots ding take-off and landing, Particularly during long flights there are extended periods of relative underload with need to continuously maintain high levels of vigilance. Plots are under extremely strict control upon their performance, and ‘must continuously fulfil rigorous licensing standards, Pressures to keep on schedule and at the same time to perform their jobs safely represents @ key source of conflict. [We have performed initial semi-structured interviews from which an initial version of the OSI for plots can be developed for testing ‘Assembly line work ean be considered as the epitome of ob strain, as paced work with low control and high demands. However, there are variations that exacerbate or ameliorate the stress burden, Trends inthe former direction i.e, lean production, ate reviewed in (Landsbergis 1999), Some variable features of production line work include: “High frequeney of incoming signals «elated to ine speed Simple and lnomogeneous tasks -input and ourput undertoad related to short eycle time “Stritnesson the task performance evel, as well as some degree of threat avoidant vigilance can be related to quality control procedure “Physical exposures (noise, glare, vibration, lifting, chemicals, heat, cold) Extrinsic time pressure onthe task performance level - whether working directly on assembly line ‘An important element of control over task performance rate relates to wheter the work is directly on the assembly line as opposed to those tasks that can be performed off the line (ona separate desk or work station). Inthe latter case, the worker would usually have more moment-o-oment ‘contol over speed of performance, “The OSI for productions the automobile industy, 1e workers is being developed together with Drs, Paul Landsbergis and Peter Schnall and will be tested among workers in ‘Some Saliont Results Obtained using the Occupational Stress Index (Unless otherwise specified, 2-sample 1” tests were used, with 2talled significance levels cited) ‘We will now briefly present some of our results using the OSI for between-occupation ané within-occupation analyses, Details about study ‘methodology, including assembly ofthe samples are provided in the cited references, ‘Between Occupation Analysis Total Occupations Stress Burden of Professional Drivers compared to Working Referents ‘As shown in Table 1, the examined groups of professional drivers (heterogeneous profiles) had approximately twice the total OSI scores compared to those of a heterogeneous group of building trade workers (N=227) and of subway guard attendants (N23) (Relkic 1992(b), Belkic 1996, Fmdad 19970). ‘Table 1 Mean Total OSI scores for Professional Drivers versus Referent Groups rofessional drivers (Referents ee Tevel of Significance ROEM [67.2 37-43 (N=258) |p < 0.001 53.0 17.9 (N=227) [esse a0) Ip oma OLD | References: Belkic ot al. (1992b) & 1996), Eméad etal. 1997(b) High Demand, Low Control and Job Strain among Professional Drivers compared to Working Referents hup:tunteatthywork orgatherjob-stess-modelsloccupationa-stross-ndox-os! 510sierz017 Occupational Stress Index (OS!) | Unhealthy Work Here isan example (Table 2) of how a more detailed and operationalized approach tothe demand and control dimensions helps identify professional drivers as a high stain occupational group. We found a significant, postive correlation between the demand/control ratio assessed using the Swedish Psychosocial Job Strain Questionnaire (Theorell 1988), andthe total OSI score. (Belkic 1996, Emad 1997(b)). However, using the standard five questions for the demand dimension from the above-mentioned questionnaire (Theorell 1988), professional drivers scored non- Significantly lower than the subway attendant referents. For decision latitude, skill discretion and demandicontrol rato asa quotient term, there were also no significant differences. In contrast, the total scores fo the high demand, strictness and extrinsic time pressure dimensions of the OSI all were significantly higher among the drives. Furthermore, a breakdown of tae demand dimension using the OSI reveals tht the heaviest demand is atthe input level, whereby divers must follow several information primarily visual sources simultaneously, but using all tree sensory modalities (Hixed features). In addition, the urban mass transit operators have a high frequency of incoming signal, and must communicate with the public. ‘Tuble 2 The Demand and Control Dimensions using the Swedish Psychosocial Job Strain Questionnaire and the Occupational Stress Index: Comparisons between Professional Drivers and Subway Guard Attendants Proresional DHvers eve of Significance jubNas Attendants [fob Strain N=) [ | [Skil Discretion (a ffon-signiicant | [Decision Lasiude prsers on-sgniicant Bavioa | [Demand [nase Ron-significant 33 | [Pemandcontar jpoTano3 fRon-signiicant Toros | lost [ [ | [High Demand elseaL 00 Gave | [Sricmess ov00 peo.001 BRNeLN | [Exim Time Premure A601? peo.00r SeUeLd | (imparFigh Demand P= 1 peor Saw | [Ceoural High Demand 2.07702 peor Istria | [Output High Demand 3.9770 pe0.00r LOWE | References: Belkc etal. (1996), Fmdad etal. (1997(6) ‘Within-Occupation Analyses ‘The Occupational Stress Index has also shown validity in within-oceupation analyses. Total OSI as a predictor of Smoking Intensity ‘The overall burden of exacerbating ({.e. non-fxed) stressors in the professional drivers” work environment, as gauged by the total OST independently predieiscardio-deletrious behaviors such as smoking intensity within this group (Belkic 1996, Emdad 1998). The multiple linear regression analysis is shown in Table 3, ‘Tuble 3 Significant Independent Predictors of Smoking Intensity among Professional Drivers who are Curreat Smokers (N32) andardized [Multiple Linear Independent ndep gression SE gression ‘Variables eresson fadjusted R squared Sumber of smoking hsp as 00s [ “Toul OST pz Oe fom References: Belkc etal. (1996), Emdad etal. (1998) Comparisons between Truck and City Bus Drivers As we have said, professional drivers as a group are exposed to very high levels of occupational stressors and all have much in common. However, ‘each driver profile also faces a specific set of stressors. As shown in Table 4, we used the OSI to compare 130 city bus drivers and 69 truck drivers, “The mean total OSI scores were very high for both groups (65.2 */- 3.6 and 68.7 +/3.8, respectively \(Bolkic 1995), However, while these Two ‘groups share many Features oftheir working environment, using the OSI, we were able to identify a number of important differences. ‘One major difference is that city bus drivers face predominantly overload, while truck divers are exposed to & mixture of underload and overload, City bus drivers had a larger high demand score duc to receiving a rapid flow of new information and having to communicate with the public, as ‘well as performing more tasks simultancously and often lacking rest breaks and working at night. In contrast, when driving on long routes, truck drivers have relatively low flow of new information (monotony) and frequently drive alone, which is another source of underioad, as well as sacial isolation. AUthe same time, they sill must keep their sensory systems (especially visual) on full ler at all times ready to make rapid decisions and htp:tunteatthywork orglatherjob-stess-modelsloccupationa-sross-ndox-os! ono