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EFFECT OF WORK ABILITY/DISABILITY ON HUMANS "Go to the ant, thou sluggard; consider her ways, and be wise" (Proverbs 6:6).

Unique Medical Research in Biblical Times from the Viewpoint of Contemporary Perspective Examination of Passages from the Bible, Exactly as Written

Liubov Ben-Nun, M.D., M.S. Professor Emeritus at Ben Gurion University of the Negev, Faculty of Health Sciences, Beer-Sheva, Israel.

NOT FOR SALE

Work and health are two concepts whose formulation varies from one society to another depending on unique and temporal appreciation. A person's entire activity pattern, including work ability, is important, and strategies for promoting health should take into account the person's situation as a whole. Are there any descriptions about work ability in the Bible? Who worked hardly? What are the consequences of an intensive work? Is it necessary for humans to work during their span of life? Is work associated with humans' health? Does the work is related to the QOL? What is the relationship between the various professions and work? Is productivity associated with any diseases? What happens when people lose their ability to work? What are dimensions of return to work? Is the workplace associate with recovery? What are the modalities of workplace interventions and health promotion? The Biblical texts are examined and verses relating to work of the tiny ant are studied examining this issue from a contemporary viewpoint.

Author: Dr. Liubov Ben-Nun, Specialist of Family Medicine, Professor Emeritus at Ben Gurion University of the Negev, Faculty of Health Sciences, Beer-Sheva, Israel.

96th Book Published by : B.N. Publication House. Israel. 2017. E-Mail: [email protected] Technical Assistance: Carmela Moshe All rights reserved

NOT FOR SALE

CONTENTS FOREWORD INTRODUCTION BIBLICAL DESCRIPTION OF THE TINY ANT WORK WORK ABILITY/DISABILITY HEALTH EFFECTS HEALTH RELATED QUALITY OF LIFE WORK STRESS INFLUENCE OF VARIOUS PROFESSIONS ON ABILITY/DISABILITY

TRANSPORT DRIVERS CONSTRUCTION WORKERS EXPOSION TO VIBRATION OTHER JOBS HEALTH CARE PROVIDERS WORKING WHEN ILL TEAM WORK WORK PRODUCTIVITY RELATE TO VARIOUS DISEASES WORKPLACE INJURIES RETURN TO WORK AFTER INJURY OR ILLNESS RECOVERY AT/AFTER WORK WORKPLACE HEALTH PROMOTION SUMMARY

6 9 11 12 19 26 30 WORK 34 34 37 39 41 44 57 59 62 116 124 128 132 144

ABBREVIATIONS ACR ACS ADL AIBDs AIC AIDS AIS AOR AP ASES BASDAI BASFI BMI CHD CHF CIDI CI CML COMWEL C-V CVD DM EQ-5D EWTD FACIT FBA GERD GHQ-12 G-I HA HAQ HAVS HCP HR HRQOL HTN HZ IACIA IADL IBS IBS-D IBS-C ICD ICU IHD IR IRR ISS LBP LICC LT MCS MI MWH NHS NSTE NSTEMI

American College of Rheumatology Acute coronary syndromes Activities of daily living Autoimmune bullous dermatoses Abbreviated injury scale Acquired immunodeficiency syndrome Active Isolating Stretching Adjusted odds ratio Angina pectoris Arthritis Self-efficacy Scale Bath Ankylosing Spondylitis Disease Activity Index Bath Ankylosing Spondylitis Functional Index Body mass index Coronary heart disease Congestive heart failure Composite International Diagnostic Interview Confidence intervals Chronic myeloid leukemia Compensation and Welfare Service Cardiovascular Cerebrovascular disease Diabetes mellitus Euro Quality of Life five dimensions questionnaire European Working Time Directive Functional Assessment of Chronic Illness Therapy Functional Behavior Analysis GastroEsophageal reflux disease 12-item General Health Questionnaire Gastrointestinal Heart attack Health Assessment Questionnaire Hand-arm vibration syndrome Health care provider/worker/professional Hazard ratio Health-related quality of life Hypertension Herpes zoster Industrial Accident Compensation Insurance Act Instrumental activities of daily living Irritable bowel syndrome Irritable bowel syndrome diarrhea subtype Irritable bowel syndrome constipation predominant International Classification of Diseases Intensive care unit Ischemic heart disease Incidence Rate Incidence rate ratio Injury severity score Low back pain Systemic Lupus International Collaborating Clinics Liver transplantation Mental component summary Myocardial infarction Multimodal work hardening National Health Service Non-ST elevation Non-ST elevation myocardial infarction

OA OECD OHC OLT OR OSHRI OSHT OSI PCI PCS PM&R PR PsA pSS QOL RA RCT RR RTW SD SEP SES SF-36 SF-6D SLAM SLE SLEDAI SLICC SMD SpA STEMI TNF UAP UK UNOS USD VR VTE VWF WAI WHO WHODAS II WHP WHWPs WLBCS WLQ WMSDs WPAI WPAI-GERD WPAI:GH WPQ WTL

Osteoarthritis Economic Co-operation and Development Occupational health clinic Rehabilitation process after liver transplantation Odds ratio Occupational Safety and Health Research Institute Occupational safety and health technologists Occupational Stress Index Percutaneous Coronary Intervention Physical component summary Physical medicine and rehabilitation Prevalence ratio Psoriatic arthritis Primary Sjögren syndrome Quality of life Rheumatoid arthritis Randomized controlled trial Relative risk Return/returning to work Standard deviation Socioeconomic position Socioeconomic status Short-Form 36 Short Form-6 dimension Systemic lupus activity measure Systemic lupus erythematosus SLE Disease Activity Index Systemic Lupus International Collaborative Clinics Standardized mean difference Spondyloarthritis ST elevation myocardial infarction Tumour necrosis factor Unstable angina pectoris United Kingdom United Network for Organ Sharing U.S. Dollar Vocational rehabilitation Venous thromboembolism White finger Work Ability Index World Health Organization World Health Organization Disability Assessment Schedule Workplace health promotion Worksite health and wellness programs Work-Life Balance Culture Scale Work Limitations Questionnaire Work-related musculoskeletal disorders Work productivity and activity impairment Work Productivity and Activity Impairment questionnaire for GERD WPAI Questionnaire: General Health version Work and Productivity Questionnaire Without work time loss

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FOREWORD Work and health are two concepts whose formulation varies from one society to another depending on temporal appreciation. Updating them to our time involves the challenge to understand their construction as part of consuming organized societies. Political and social processes during the last decades must be analyzed, and so must be the worker subject as a psychophysics unit. Health, as well, ought to be considered a universal right, from where to focus and understand pathological social behaviors impacting the workplace. The subject's social dimension and the health-work relationship are dynamic. Keeping this dynamic involves to continuously review principles, norms and regulations which need to fit reality, and specific communication and language modes, as well as working conditions and environmental aspects. These processes must be considered as taking part in social imaginary worth highlighting: a shift in how the State's role is considered, the public policy's sense, the importance of working in a complementary and interdisciplinary way, redesigning the concept of health through the broadening of those under the State's care and considering and building the workplace as a healthy space (1). The value of creative employees to an organization's growth and innovative development, productivity, quality and sustainability is well established. The perceived relationship between creativity and work environment factors of 361 practicing HCPs was examined, and whether these factors were present (realized) in their work environment were explored. Job design (challenges, team work, task rotation, and autonomy) and leadership (coaching supervisor, time for thinking, creative goals, recognition and incentives for creative ideas and results) were perceived as the most important factors for stimulating creativity. There was room for improvement of these in the work environment. Many aspects of the physical work environment were less important. Public health sector employers and organizations should adopt sustainable strategies which target the important work environment factors to support employee creativity and so enhance service quality, productivity, performance and growth. Implications of the results for ergonomists and workplace managers with a participatory ergonomics approach were essential. Creative employees were important to an organization's

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innovation, productivity and sustainability. HCPs perceived a need to improve job design and leadership factors at work to enhance and support employee creativity. There were implications for organizations and ergonomists to investigate the creative potential of work environments (2). The World Health Report launches the Health Workforce Decade (2006-2015), with high priority given for countries to develop effective workforce strategies including healthy workplaces for HCPs. Healthy workplaces improved recruitment and retention, workers' health and well-being, quality of care and patient safety, organizational performance and societal outcomes. Over the past few years, healthy workplace issues in Canada have been on the agenda of many governments and employers. A progress update was provided, using different data-collection approaches, on knowledge transfer and uptake of research evidence in policy and practice, including the next steps for the healthy workplace agenda. The current healthy workplace initiatives that were currently under way in Canada were summarized, what has been done in reality was synthesized to determine how far the healthy workplace agenda has progressed from the perspectives of research, policy and practice, and the next steps for moving forward with the healthy workplace agenda were outlined to achieve its ultimate objectives. Some of the key questions were as follows: has the existing evidence on the benefits of healthy workplaces resulted in policy change? If so, how and to what extent? Have the existing policy initiatives resulted in healthier workplaces for HCPs? Were there indications that HCPs, particularly at the front line, experienced better working conditions? While there has been significant progress in bringing policy changes as a result of research evidence, the synthesis suggests that more work is needed to ensure that existing policy initiatives bring effective changes to the workplace. The steps for research, policy and practice are required to help the healthy workplace agenda to achieve its ultimate objectives (3). Aspects of everyday life in addition to established risk factors and their relationship to subjective health and well-being among public sector employees in Sweden were explored. Gainful employment impacted on employees' health and well-being, but work was only one part of everyday life and a broader perspective was essential in order to identify health-related factors. Data were obtained from

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employees at six Social Insurance Offices in Sweden, 250 women and 50 men. A questionnaire based on established instruments was used and questions specifically designed were asked. The final model revealed a limited importance of certain work-related factors. A general satisfaction with everyday activities, a stress-free environment and general control in addition to not having monotonous movements at work were factors explaining 46.3% of subjective good health and well-being. A person's entire activity pattern, including work, was important, and strategies for promoting health should take into account the person's situation as a whole. The interplay between risk and health factors is not clear and further research is warranted (4). The relative importance of central work functioning domains was determined and a method was proposed for composite weighted measurement of the concept "work functioning." Health-impaired workers, healthy workers, and employers (n=277) weighed work functioning domains by participating in a discrete choice experiment. The central domains were significant indicators of the work functioning of health-impaired workers. The domain with the highest relative importance was quality of work performance, followed by, respectively, recovery, quantity of work, and capacity to work. This pattern of results was observed in all subgroups. The central domains were relevant indicators of the work functioning of healthimpaired workers. Researchers should consider the relative importance of the domains and use the proposed weighting procedure, when measuring works functioning (5). References 1. García Blanco L. Work and health: two social rights. Vertex. 2015;26(124): 441-3. 2. Lukersmith S, Burgess-Limerick R. The perceived importance and the presence of creative potential in the health professional's work environment. Ergonomics. 2013;56(6):922-34. 3. Shamian J, El-Jardali F. Healthy workplaces for health workers in Canada: knowledge transfer and uptake in policy and practice. Healthc Pap. 2007;7 Spec No:6-25. 4. Erlandsson LK, Carlsson G, Horstmann V, et al. Health factors in the everyday life and work of public sector employees in Sweden. Work. 2012;42(3):321-30. 5. Boezeman EJ, Nieuwenhuijsen K, de Bekker-Grob EW, et al. The relative importance of the domains of work functioning: evaluations of health-impaired employees, healthy employees, and employers. J Occup Environ Med. 2015; 57(4): 361-6.

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INTRODUCTION Perceived work ability refers to a worker's assessment of his or her ability to continue working in his or her job, given characteristics of the job along with his or her resources. Perceived work ability is a critical variable to study in the U.S., given an aging workforce, trends to delay retirement, and U.S. policy considerations to delay the age at which full Social Security retirement benefits are perhaps obtained. Based on the job demands-resources model, cognitive appraisal theory of stress, and push/pull factors related to retirement, a conceptual model of antecedents and outcomes of perceived work ability was proposed and tested using 3 independent samples of U.S. working adults. Data regarding workers' job characteristics were from self-report and Occupational Information Network measures. Results from relative importance analysis indicated that health and sense of control were consistently and most strongly related to work ability perceptions relative to other job demands and job and personal resources when perceived work ability was measured concurrently or 2 weeks later in samples with varying occupations. Job demands (along with health and sense of control) were most strongly related to work ability perceptions when perceived work ability was measured in a manufacturing worker sample 1.6 years later. Perceived work ability predicted lag labor force outcomes (absence, retirement, and disability leave) while controlling for other known predictors of each. Consistent indirect effects were observed from health status and sense of control to all 3 of these outcomes via perceived work ability (1). The working population over 50 years of age will grow considerably during the next 15 years. After 2010, the number of retired people over 65 years of age will be almost double than that of 1995, with a strong impact on working conditions and the labour market. Work ability is a dynamic process that changes, through its components, throughout life and is the result of the interaction between individual resources (including health, functional capacity, education and skills), working conditions, and the surrounding society. Work ability creates the basis for the employability of an individual, which can be supported by a number of actions (e.g. legislation on work and retirement) and social attitudes (e.g. age discrimination). Consequently, the prevalence of limitations in work

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ability varies significantly according to how it is evaluated and the frequency of work disability can vary considerably in different times, locations and populations. The WAI, created and used in a Finnish 11-year longitudinal study, has been proved a useful practical tool for the assessment of workers' fitness and a good predictor of work disability. Measures able to restore, maintain or promote work ability depend on the current work status and the needs of the target groups, and must concentrate on work content, physical work environment and the work community. The actions targeted towards the individual, on the other hand, concentrate on strengthening the health status and functional resources of the workers and developing professional expertise and skills. Correctly targeted and integrated measures improve work ability of ageing workers and therefore lead to improved work quality, increased productivity and improved QOL and well-being. They have positive long-term effects on the "third age", when the worker retires (2). Maintaining good work ability depends on satisfactory health and employment status, which is supported by suitable working conditions and correct life styles. From the biological perspective, ageing means a foreseeable progressive and overall deterioration of the various physiological systems, but not of such a kind and severity to consider most people over 50 years as too old or unfit for work, as has been shown by several papers that assessed work ability not only in terms of biological age, but of functional age and actual work output. From the physio-pathological perspective, either illness associated with the passage of time or age-related changes that might precipitate diseases, as well as environmental changes that modulate ageing and developmental changes that accelerate or retard ageing can be observed. From the practical point of view, it should taken into account that job demands often do not follow the natural biological and functional changes of the individual, consequently the relative work load can be higher in older workers. On the other hand, ageing means a professional growth in terms of strategic ability, shrewdness, wisdom and experience. The high interindividual variability of physical, mental and social conditions that is observed with the increase in age makes it necessary to adopt flexible and personally tailored measures, as shown by recent surveys in some European countries aimed at reducing age discrimination and work disability, and at promoting work ability by means of

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actions directed towards both improvement of work organization and support of psycho-physical conditions of older workers (3). Is the work ability described in the Bible? Who worked hardly? What are the consequences of an intensive work? The Biblical texts were examined and verses relating to work of the tiny ant were studied examining this issue from a contemporary viewpoint References 1. McGonagle AK, Fisher GG, Barnes-Farrell JL, Grosch JW. Individual and work factors related to perceived work ability and labor force outcomes. J Appl Psychol. 2015;100(2):376-98. 2. Ilmarinen J, Costa G. Aging of the working population in the European Union. Med Lav. 2000;91(4):279-95. 3. Costa G. Work capacity and aging. Med Lav. 2000;91(4):302-12.

BIBLICAL DESCRIPTION OF THE TINY ANT WORK These Biblical verses use the tiny ant as an illustration: "Go to the ant, thou sluggard; consider her ways, and be wise" (Proverbs 6:6). Here "With no guide, overseer, or ruler she provides her meat in the summer, and gathers her food in the harvest" (6:7-8).

What can we learn from this small creature? We see that the ant works all its life, with no policeman, manager or supervisor. Its life is dedicated to work. It gathers food in the summer, so that it has a sufficient supply for the rest of the year. There is a great wisdom in these verses.

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The ant's ability to work intensively can be extrapolated to human beings. Is it necessary for humans to work during their span of life? Is work associated with human health? Is work related to the QOL? What is the relationship between the various professions and work? Is productivity associated with any diseases? What happens when people lose their ability to work? What are dimensions of RTW? Is the workplace associate with recovery? What are the modalities of workplace interventions and health promotion?

WORK ABILITY/DISABILITY The concept of "work ability" is central for many sciences, especially for those related to working life and to rehabilitation. It is one of the important concepts in legislation regulating sickness insurance. How the concept is defined therefore has important normative implications. Through conceptual analysis, what the concept can and should mean is clarified, and a useful definition is proposed for scientific and practical work. Several of the defining characteristics found in the literature are critically scrutinized and discussed, namely health, basic standard competence, occupational competence, occupational virtues, and motivation. These characteristics are related to the work tasks and the work environment. Two definitions of work ability are needed, one for specific jobs that requires special training or education, and one for jobs that most people can manage given a short period of practice. Having work ability, in the first sense, means having the occupational competence, the health required for the competence, and the occupational virtues that are required for managing the work tasks, assuming that the tasks are reasonable and the work environment is acceptable. In the second sense, having work ability is having the health, the basic standard competence and the relevant occupational virtues required for managing some kind of job, assuming that the work tasks are reasonable and that the work environment is acceptable. These definitions give us tools for understanding and discussing the complex, holistic and dynamic aspects of work ability, and they can lay the foundations for the creation of instruments for evaluating work ability, as well as help to formulate strategies for rehabilitation (1).

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Researchers are confronted with numerous definitions of work ability/disability, influenced by their context of emergence, discipline, purpose, underlying paradigm and relationship to time. An in-depth analysis is provided of the concept through a systematic scoping review and the development of an integrative concept map of work (dis)ability. The research questions are: How has work (dis)ability been conceptualized from the perspectives of research, practice, policy and industry in the published scientific literature? How has the conceptualization of work (dis)ability evolved over time? A search strategy was designed with a library scientist to retrieve scientific publications containing explicit definition(s) of work (dis)ability in leading-edge databases. The screening and the extraction of the definitions were achieved by duplicate assessment. The definitions were subjected to a comparative analysis based on the grounded theory approach. In total, 423 abstracts were retrieved from the bibliographic databases. After removing duplicates, 280 unique records were screened for inclusion. A final set of 115 publications containing unique original conceptual definitions served as basis for analysis. The scientific literature does not reflect a shared, integrated vision of the exact nature and dimensions of work (dis)ability. However, except for a few definitions, there seems to be a consensus that work (dis)ability is a relational concept resulting from the interaction of multiple dimensions that influence each other through different ecological levels. The conceptualization of work (dis)ability seems to become more dynamic over time. The way work (dis)ability defined has important implications for research, compensation and rehabilitation (2). Since work ability is manifested in working life and ``bought'' by employers, employers perceptions of the concept are important to understand. Papers have shown that people with health problems want to take part in the labour market, but experience difficulties in gaining access. Papers have also demonstrated the doubt felt by employers when they consider hiring a person with a disability. Therefore, employers' conceptions of work ability were identified and characterized. Six male and six female employers from various workplaces and geographical areas in Sweden were interviewed. Three domains were identified: employees' contributions to work ability, employers' contributions to work ability and circumstances with limited work ability. Work ability regarded as a tool in

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production and its output, production, was the main issue. The employees' commitment and interest can bridge other shortcomings. The employers highlighted their own contributions in shaping work ability in order to fit with work circumstances. Health problems were not the only limiting issues; other circumstances, such as individual characteristics and contextual factors, could limit work ability too. Knowing the importance of commitment and interest is valuable in work rehabilitation (3). As paid work is the occupation that people spend the most amount of their time doing, it is an important provider of personal meaning in their lives. This meaning has been shown to vary from person to person and to be important for health and wellbeing. When a person is unable to work due to a disabling condition, it is unclear whether this meaning remains or is replaced by other meanings. The purpose of this scoping review was to explore what is known in the existing literature on what work means to those with work disability. This review involved identifying and selecting relevant studies, charting the data and collating and summarizing the results. Fifty-two papers explored the meaning of work for those with cancer, mental illness, musculoskeletal disorders, brain injuries, paraplegia, and AIDS. Work continued to be meaningful and important. Common themes across all types of disability included work being a source of identity, feelings of normality, financial support, and socialization. These meanings were found to be both motivating for RTW and health promoting. Conversely, a small number of studies found that the meanings and values ascribed to work changed following disability. New meanings, found both at home or in modified work, replaced the old and contributed to new identities. The exploration of the meaning of work provided important understanding of the experience of work and disability. This understanding can guide rehabilitation professionals in their interventions with the work disabled (4). Work-related physical activity and work ability are of growing importance in modern working society. There is evidence for ageand job-related differences regarding physical activity and work ability. Work ability and work-related physical activity of employees in a medium-sized business regarding age and occupation were analyzed. The total sample consisted of 148 employees (116 men 78.38% of the sample and 32 women, accounting for 21.62%; mean

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age: 40.85 ± 10.07 years). One hundred subjects (67.57%) were white-collar workers, and 48 (32.43%) were blue-collar workers. Work ability was measured using the WAI, and physical activity was obtained via the Global Physical Activity Questionnaire. Work ability showed significant differences regarding occupation (p=0.001) but not regarding age. Significant differences were found for workrelated physical activity concerning occupation (p55 years of age report higher job satisfaction when compared to the other groups. In medical and nursing staff in a Cyprus public general hospital working in radiotherapy, workplace environments have a negative impact on stress levels and the satisfaction of radiotherapy staff. In China, for healthcare staff including physicians, nurses and public health staff in hospitals, health service centers and health clinics, work stress, work-family conflict and doctor-patient relationship have significant effect on job satisfaction.

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References 1. Yeager VA, Wisniewski JM, Amos K, Bialek R. Why do people work in public health? Exploring recruitment and retention among public health workers. J Public Health Manag Pract. 2016;22(6):559-66. 2. Bovier PA, Perneger TV. Predictors of work satisfaction among physicians. Eur J Public Health. 2003;13(4):299-305. 3. Richardsen AM, Burke RJ. Occupational stress and job satisfaction among physicians: sex differences. Soc Sci Med. 1991;33(10):1179-87. 4. Ruitenburg MM, Frings-Dresen MH, Sluiter JK. Physical job demands and related health complaints among surgeons. Int Arch Occup Environ Health. 2013; 86(3):271-9. 5. Lindfors PM, Meretoja OA, Töyry SM, et al. Job satisfaction, work ability and life satisfaction among Finnish anaesthesiologists. Acta Anaesthesiol Scand. 2007; 51(7):815-22. 6. Bovier PA, Perneger TV. Stress from uncertainty from graduation to retirement--a population-based study of Swiss physicians. J Gen Intern Med. 2007; 22(5):632-8. 7. Lambert TW, Smith F, Goldacre MJ. Views of senior UK doctors about working in medicine: questionnaire survey. JRSM Open. 2014;5(11):2054270414554049. 8. Lachish S, Goldacre MJ, Lambert T. Associations between perceived institutional support, job enjoyment, and intentions to work in the United Kingdom: national questionnaire survey of first year doctors. BMC Med Educ. 2016 May 23; 16:151. 9. Clarke RT, Pitcher A, Lambert TW, Goldacre MJ. UK doctors' views on the implementation of the European Working Time Directive as applied to medical practice: a qualitative analysis. BMJ Open. 2014;4(2):e004390. 10. Sehlen S, Vordermark D, Schäfer C, et al. Job stress and job satisfaction of physicians, radiographers, nurses and physicists working in radiotherapy: a multicenter analysis by the DEGRO Quality of Life Work Group. Radiat Oncol. 2009 Feb 6;4:6. 11. Lambrou P, Kontodimopoulos N, Niakas D. Motivation and job satisfaction among medical and nursing staff in a Cyprus public general hospital. Hum Resour Health. 2010 Nov 16;8:26. 12. Zarei E, Najafi M, Rajaee R, Shamseddini A. Determinants of job motivation among frontline employees at hospitals in Tehran. Electron Physician. 2016; 8(4):2249-54. 13. Lu Y, Hu XM, Huang XL, et al. Job satisfaction and associated factors among healthcare staff: a cross-sectional study in Guangdong Province, China. BMJ Open. 2016;6(7):e011388. 14. Li L, Hu H, Zhou H, et al. Work stress, work motivation and their effects on job satisfaction in community health workers: a cross-sectional survey in China. BMJ Open. 2014;4(6):e004897.

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WORKING WHEN ILL. Recurrent reports from national and international studies show a persistent high prevalence of sickness presence among hospital physicians. The perception and experience with sickness presenteeism were explored among hospital physicians, and possible positive and negative foundations and consequences associated with sickness presence were examined. Semi-structured interviews were conducted with 21 Norwegian university hospital physicians. Positive and negative dimensions were associated with 1] evaluation of illness, 2] organizational structure, 3] organizational culture, and 4] individual factors simultaneously contributed to presenteeism. The inherent complexity of the causal chain of events affected sickness presenteeism, something that inhibited intervention. It appears that sufficient staffing, predictability in employment, adequate communication of formal policies and senior physicians adopting the position of a positive role model are particularly important (1). Sickness presenteeism is common in the health sector, especially among physicians, leading to high costs in terms of medical errors and loss in productivity. Predictors of sickness presenteeism in university hospitals, which perhaps were especially exposed to competitive presenteeism were investigated. The investigation included comparisons of university hospitals in four European countries. A cross-sectional survey analysis of factors related to sickness behavior and work patterns in the field of academic medicine was performed among permanently employed physicians from the HOUPE (Health and Organization among University Physicians Europe) study: (Sweden n=1,031, Norway n=354, Iceland n=242, and Italy n=369). The outcome measure was sickness presenteeism. Sickness presence was more common among Italian physicians (86%) compared with physicians in other countries (70%‑76%). Country-stratified analyses showed that sickness presenteeism was associated with sickness behavior and role conflicts in all countries. Competition in the form of publishing articles was a predictor in Italy and Sweden. Organizational care for physician well-being reduced sickness presenteeism in all countries. The data show that sickness presenteeism in university hospitals is part of a larger behavioral pattern where physicians seem to neglect or hide their own illness. Factors associated with competitive climate and myths about a healthy doctor may contribute to these behaviors.

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It is suggested that managers and organizations should work actively to address these questions since organizational care may reduce the extent of these behaviors (2). Multi-purpose self-completed surveys of doctors who qualified in the UK between 1993 and 2012 were undertaken. Doctors were asked specific questions about their careers and were asked to comment about any aspect of their training or work. Doctors' comments about working whilst acutely ill were reported. Participants included nine cohorts of doctors, comprising all UK medical qualifiers of 1993, 1996, 1999, 2000, 2002, 2005, 2008, 2009 and 2012. Main outcome measures included comments made by doctors about working when ill, in surveys one, five and 10 years after graduation. The response rate, overall, was 57.4% (38,613/67,224 doctors). Free-text comments were provided by 30.7% (11,859/38,613). Three-hundred and twenty one doctors (2.7% of those who wrote comments) wrote about working when feeling acutely ill. Working with Exhaustion/fatigue was the most frequent topic raised (195 doctors), followed by problems with Taking time off for illness (112), and general comments on Physical/mental health problems (66). Other topics included Support from others, Leaving or adapting/coping with the situation, Bullying, the Doctor's ability to care for patients and Death/bereavement. Arrangements for cover due to illness were regarded as insufficient by some respondents; some wrote that doctors were expected to work harder and longer to cover for colleagues absent because of illness. It has been recommended that employers ensure that it is not unduly difficult for doctors to take time off work when ill, and that employers review their strategies for covering ill doctors who are off work (3). ASSESSMENT: there is a high prevalence of sickness presence among hospital physicians. Sickness presenteeism in university hospitals is part of a larger behavioral pattern where physicians neglect or hide their own illness. Arrangements for cover due to illness are regarded as insufficient; doctors are expected to work harder and longer to cover for colleagues absent because of illness.

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References 1. Giæver F, Lohmann-Lafrenz S, Løvseth LT. Why hospital physicians attend work while ill? The spiralling effect of positive and negative factors. BMC Health Serv Res. 2016;16(1):548. 2. Gustafsson Sendén M, Løvseth LT, Schenck-Gustafsson K, Fridner A. What makes physicians go to work while sick: a comparative study of sickness presenteeism in four European countries (HOUPE). Swiss Med Wkly. 2013 Aug 22; 143:w13840. 3. Smith F, Goldacre MJ, Lambert TW. Working as a doctor when acutely ill: comments made by doctors responding to United Kingdom surveys. JRSM Open. 2016;7(4):2054270416635035.

TEAM WORK As empirically shown, increased job satisfaction and motivations correlate with reduced job fluctuation and costs of absenteeism in an organization. To provide a motivating environment for employees becomes important in the health-care system and thus also in radiology. Job satisfaction of a team was evaluated and important influencing factors were defined. For data collection, as standardized questionnaire was designed. As a result of a discussion in a focus group, 9 indicators characterizing job satisfaction and motivation were determined (four-point ordinal scale), in addition there were open questions as well as space for comments. The questionnaires were distributed to all employees at the institute during the period 11/2005. For statistical analysis, all replies were coded (scale 1-4) and transferred to an excel sheet. Rate of return was 92% (46/50). In general, employees enjoyed work (mean 3.37 +/- 0.5); insignificant difference between physicians, technicians and other staff members were observed. Factors most important for personal motivation were: good working climate (3.85 +/- 0.4), good reputation of the institute (3.56 +/- 0.8), and personal recognition (3.54 +/- 0.6). Wage raise (3.01 +/- 0.9) and bonus payments (3.11 +/- 0.9) were rated less important. Communication between groups of employees could be improved (2.78 +/- 0.7). When asked, which factors would improve motivation, common answers included teamwork and communication (n=9), more participation in planning processes (n=8), more appreciation (n=7), and continuing education (n=5). Profound knowledge of factors influencing job satisfaction and motivation of

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employees allows for the implementation of targeted strategies for continuous improvement (1). A changing healthcare landscape requires nurses to care for more patients with higher acuity during their shift than ever before. These more austere working conditions are leading to increased burnout. In addition, patient safety is not the quality or level that is required. To build healthier workplaces where safe care is provided, formal teamwork training is recommended. Formal teamwork training programs, such as that provided by the MedTeams group, TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), or participatory action research programs such as the Healthy Workplace Intervention have decreased errors in the workplace, increased nurse satisfaction and retention rates, and decreased staff turnover. Necessary determinants of teamwork, brief overviews of team-building programs, and examples of research programs demonstrate how teamwork brings about healthier workplaces that are safer for patients. Teamwork programs can bring these positive results when implemented and supported by the hospital system (2). To evaluate the effect of a 1-2 week multiprofessional team assessment, without a real rehabilitation effort, 60 patients suffering from long-standing pain and on long-lasting time on sick leave were studied. A questionnaire concerning their daily activities, QOL, pain intensity, sick-leave level, and their work state was filled out by all patients before starting the assessment and at a 1-year follow-up. The results from the assessment period and the multiprofessional team decision of the patient's working ability were compared with the actual working rate after 1 year. The follow-up showed a significant reduction of sick leave and a higher level of activity (p20 years of clinical experience were about 4 times more likely to develop WMSDs (OR 3.81, CI 1.08-13.4) than those with 11-20 years of

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experience. Working in the same positions for long periods (55.1%), lifting or transferring dependent patients (50.8%), and treating an excessive number of patients in one day (44.9%) were the most perceived job risk factors for WMSDs. Getting help in handling heavy patients (50.4%), modification of nursing procedures in order to avoid re-injury (45.4%), and modifying patient's/nurse position (40.3%) were the top three coping strategies. The data indicate that a high proportion of Nigerian nurses report WMSDs at some body site in their occupational lives with the low back being injured most often. Education programs on prevention and coping strategies for musculoskeletal disorders are recommended for nurses in order to reduce the rate of occupational hazards and also promote efficiency in patient care (7). ASSESSMENT: rheumatic diseases are chronic illnesses, cause of functional impairment, working disability and absence from work. In spite of this, affected patients maintain a significant functional ability. Work productivity loss is associated with poorer mental health, physical role limitations, a biological therapeutic medication, dissatisfaction with the work, work instability, poor HRQOL, and pain. The rate of work disability among persons employed with rheumatic disease onset is high, a fair amount of work disability occurs in the early years of disease. A high proportion of Nigerian nurses reports WMSDs at some body site in their occupational lives with the LBP being injured most often. Among automobile assembly workers, the worker height and smoking habits are factors which affect musculoskeletal disorders. References 1. Minisola G. Rheumatic diseases and work ability. G Ital Med Lav Ergon. 2014;36(4):276-81. 2. Allaire SH. Update on work disability in rheumatic diseases. Curr Opin Rheumatol. 2001;13(2):93-8. 3. Long MH, Johnston V, Bogossian F. Work-related upper quadrant musculoskeletal disorders in midwives, nurses and physicians: a systematic review of risk factors and functional consequences. Appl Ergon. 2012;43(3):455-67. 4. Wang ZX, Qin RL, Li YZ, et al. The epidemiological study of work-related musculoskeletal disorders and related factors among automobile assembly workers. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi. 2011;29(8):572-8.

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5. Kim KH, Kim KS, Kim DS, et al. Characteristics of work-related musculoskeletal disorders in Korea and their work-relatedness evaluation. J Korean Med Sci. 2010;25(Suppl):S77-86. 6. Jang TW, Koo JW, Kwon SC, Song J. Work-related musculoskeletal diseases and the workers' compensation. J Korean Med Sci. 2014;29 Suppl:S18-23. 4. Tinubu BM, Mbada CE, Oyeyemi AL, Fabunmi AA. Work-related musculoskeletal disorders among nurses in Ibadan, South-west Nigeria: a crosssectional survey. BMC Musculoskelet Disord. 2010 Jan 20;11:12.

ARTHRITIS Employment rates are significantly lower among individuals with arthritis compared to a general population. There is, however, limited research about how men with arthritis perceive their ability to maintain working. The aim of this investigation was to explore their perception of this issue. Participants included nine employed men with arthritis who were purposively sampled. Interviews were performed and informed by the central concepts of the Model of Human Occupation. The Empirical Phenomenological Psychological method was modified and used to analyze and interpret collected data. Men with arthritis perceived a desire to work, adjusted their activity pattern, were aware of their own capabilities, had good work conditions and environmental support and used effective medication to maintain their ability to work. The findings suggest that HCPs can help men with arthritis to find strategies and a balance between recreation and work. This knowledge can guide HCPs to target men needing interventions to prevent sick leave (1). ASSESSMENT: men with arthritis perceive a desire to work, adjust their activity pattern, are aware of their own capabilities, have good work conditions, environmental support and use effective medication to maintain their ability to work. Reference 1. Österholm JH, Björk M, Håkansson C. Factors of importance for maintaining work as perceived by men with arthritis. Work. 2013;45(4):439-48.

SPONDILIOARTHITIS. The effect of early SpA on worker's participation was explored and variables associated with work outcomes as well as the effect on resource use were investigated.

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Patients included in an early SpA cohort completed a questionnaire comprising items on employment status, sick leave, presenteeism, and resource use. Participants were 140 patients. Of the patients, 69% were male, the mean age was 41 years, and the disease duration was 4.8 years. Twenty-six patients (19%) were not employed because of SpA. Among 114 employed patients, sick leave was reported in 28% in the previous year. Of the patients, 41% reported reduced productivity at work. High Bath Ankylosing Spondylitis Metrology Index and Ankylosing Spondylitis QOL score were associated with not being employed and with reduced productivity at work. Annual costs of productivity loss attributable to sick leave and presenteeism amounted to €2000 per patient. Patients who reported sick leave showed a higher (health-related) resource use. After only 5 years of diagnosis, a considerable proportion of patients with SpA was not employed, and those working had substantial sick leave and productivity loss. Among patients reporting sick leave, resource use was higher. Alertness to work participation even in patients with short disease duration is urgently needed (1). Work productivity and associated factors in patients with SpA were assessed. This cross-sectional postal survey included 1,773 patients with SpA identified in a regional health care register. Items on presenteeism (reduced productivity at work, 0-100%, 0 = no reduction) were answered by 1,447 individuals. Absenteeism was defined as register-based sick leave using data from a national register. Disease duration, disease activity (BASDAI), physical function (BASFI), HRQOL (EQ-5D), anxiety (HAD-a), depression (HADd), self-efficacy (ASES pain and symptom), physical activity and education were also measured. Totally, 45% reported reduced productivity at work with a mean reduction of 20% (95% CI 18-21) while women reported a higher mean reduction than men (mean 23% vs. 17%, p