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Description

Call centre work – characteristics,

and health related outcomes Kerstin Norman

Doctoral Thesis No

2005-975

Graduate School for Human-Machine Interaction Division of Industrial Ergonomics Department of Mechanical Engineering Linköping University National Institute for Working Life Department of Work and Health

arbete och hälsa | vetenskaplig skriftserie isbn 91-7045-764-6 issn 0346-7821

National Institute for Working life

Arbete och Hälsa Arbete och Hälsa (Work and Health) is a scientific report series published by the National Institute for Working Life

The series presents research by the Institute’s own researchers as well as by others,

both within and outside of Sweden

The series publishes scientific original works,

criteria documents and literature surveys

Arbete och Hälsa has a broad targetgroup and welcomes articles in different areas

The language is most often English,

but also Swedish manuscripts are wel­ come

Summaries in Swedish and English as well as the complete original text are available at www

Arbete och Hälsa Editor-in-chief: Staffan Marklund Co-editors: Marita Christmansson,

Birgitta Meding,

Bo Melin and Ewa Wigaeus Tornqvist © National Institut for Working Life & authors 2005 National Institute for Working Life S-113 91 Stockholm Sweden ISBN 91–7045–764–6 ISSN 0346–7821 http://www

se/ Printed at Elanders Gotab,

Stockholm

Original papers This thesis is based on the following five publications,

which are referred to in the text by their Roman numerals: I

Norman K,

Nilsson T,

Hagberg M,

Wigaeus Tornqvist E,

Toomingas A

Working conditions and health among female and male employees at a call center in Sweden

American Journal of Industrial Medicine 46 (1):55-62

Norman K,

Toomingas A,

Wigaeus Tornqvist E

Reliability of a questionnaire and an ergonomic checklist for assessing working conditions and health at call centres (Submitted to International Journal of Occupational Safety and Ergonomics)

Norman K,

Toomingas A,

Wigaeus Tornqvist E

Working conditions in a selected sample of call centre companies in Sweden (Submitted to American Journal of Industrial Medicine)

Norman K,

Kjellberg A,

Herlin RM,

Hagman M,

Toomingas A,

Wigaeus Tornqvist E

Psychosocial conditions,

stress and energy in a selected sample of call centre companies in Sweden (Submitted to Work & Stress)

Norman K,

Floderus B,

Hagman M,

Toomingas A,

Wigaeus Tornqvist E

Musculoskeletal symptoms in relation to work exposures at call centre companies in Sweden (Submitted to Work)

Co-author statements Norman has written all articles appended to this thesis,

under the supervision of the co-authors

Norman has participated in the planning,

data-collection and the statistical analyses in study II-V

In paper I,

the co-authors have planned and performed the data-collection

In paper II,

the co-authors have assisted in the interpretation of the analyses

In paper III,

the co-authors have assisted in discussing analyses,

In papers IV and V,

have given advice about the statistical analyses,

and have assisted in discussing the results

List of abbreviations ACD

Automatic call distributor

Call centre

Call centres

Confidence interval (95%)

Computer Telephone Integration

Musculoskeletal disorder

Odds ratio

Short message service

Upper extremity musculoskeletal symptoms

Contents Original papers List of abbreviations Introduction What is a call centre

? The history and development of the call centre business What’s new

? Health related outcomes among call centre operators An exposure-effect model focusing on work at call centres Characteristics of work at call centres Physical exposures Psychosocial exposures Individual characteristics Life outside work,

social exposures Why study call centre work

Study groups and methods Companies Subjects Methods Ethical considerations Data treatment and statistical methods Results/Summary of papers Characteristics of work Physical exposure Psychosocial exposure Individual characteristics Health related outcomes Associations between work exposures and health related outcomes Reliability Discussion Main findings Methodological issues Conclusions

Further research

Summary

Sammanfattning (Summary in Swedish)

Acknowledgements

References

Introduction The development of computer and information technology is perhaps one of the most dominating factors in the ever-changing working life of today

The 1990s saw a rapid computerisation of Swedish working life (Aronsson et al

Lennerlöf,

Thirty-seven per cent of the female working population and 35 per cent of the male workforce use computers,

at least half of their working time (The Swedish Work Environment Authority,

Computer technology has affected the work environment and the users in different ways,

resulting for example in more constrained sedentary work

Technological developments in general have had a great impact on working life

With the help of technology,

activities are no longer confined to a particular place or time,

a phenomenon that is clearly illustrated by call centres (CCs)

The basis of this thesis is to describe characteristics of work,

physical and psychosocial exposures and health related outcomes,

What is a call centre

? There is no universally accepted definition of “call centre” or “operator”,

although the following ones have been suggested: Call centre – a work environment in which the main business is conducted via the telephone whilst simultaneously using display screen equipment (www

This includes both parts of companies dedicated to this activity,

such as internal helplines as well as whole companies

CC operator (also known as customer service advisor/agent/handler) – is an individual whose job requires them to spend a significant proportion of their working time responding to calls on the telephone whilst simultaneously using display screen equipment (www

CCs are organisations or departments that are specifically dedicated to contacting clients and customers

These can either be a helpdesk,

or client service department of an organisation,

but companies may also have outsourced this to a CC company,

which handles all client contacts for a variety of organisations

One important distinction is therefore between internal and external CCs

The term external CC is usually associated with an independent company that uses telecommunications technology to handle everything from advice,

computer and mobile telephone support,

to ticket booking and telemarketing

The number of independent CCs is rapidly increasing,

as many companies are outsourcing their telephone services

The main new features are that operations on a larger scale are outsourced and have assignments from other companies

Internal CCs are departments or separate companies within a larger company,

usually with another main core business

It may be easier to vary the nature of work tasks in an internal company than in an external company

Another difference that may be of importance is that work tasks and type of customers may change more often in an external company

This could be both positive and negative for the operator

On the positive side it could be stimulating to work with different products and to learn new things

On the negative side it may be difficult to feel affiliated to the client company that the operator is currently working for and to get an understanding of the product and the business concept

A CC is a business where the employees mainly handle incoming and/or outgoing telephone calls

Typical services with outgoing calls are advertising campaigns,

market research and selling by telephone

Examples of activities with incoming calls are customer services,

taking orders and providing helpdesk functions

In the last few years operators have also started to handle e-mail,

fax and SMS (short message service)

The CC business has been characterised by high turnover

Internal CCs have an annual turnover of approximately 12

At external CCs the picture is more varied

There are two categories of turnover

At companies where the operators work during the daytime,

the annual turnover is normally 10 per cent

At companies where the operators work evening- or night shift,

with short projects or with telemarketing projects,

the annual turnover is between 40 and 133 per cent

The differences could depend on how the employment is seen: as a permanent job with a regular income,

or as an extra job on the side (Bulloc,

The history and development of the call centre business CCs have their origin in the USA,

where they started in 1908 when it became possible to use the telephone to sell advertisements in a telephone book

In the beginning of the1960s Ford Motor Company started to search for possible buyers for their cars by making 20,000,000 phone calls to the consumers

One of the largest telemarketing campaigns in Sweden was carried out in1978 when the Swedish telephone company (now Telia) decided to introduce the American concept “Yellow pages”

Most of the advertisers had to buy their advertising space by telephone instead of being visited by a salesman

At the end of the 1980s the number of telemarketing companies started to grow,

and more and more were established

The concept of CC was born in the year 1991

in 1994 Telia introduced a campaign for CCs and the concept became firmly established in Sweden (Nutek R 2000:10)

During the last few years’ companies that are called contact centres have been established in Sweden

The contact centre handles more than just telephone calls,

CCs constitute one of the most rapidly growing businesses in Sweden

In 1987 there were 52 telemarketing companies with 438 employees (Cohen,

In 1997-99 there were 110 external CCs with 7051 employees

The number of employees is estimated to increase by 10 per cent per year during the period 2002 to

In 2002,

about 60,000 persons were working in the business,

at 700-800 CCs in the country,

according to Invest in Sweden Agency (ISA),

which is equivalent to approximately 1

Most of the CC companies are situated in the big cities,

but almost 200 are situated in smaller towns or in rural areas

Even internationally the CC business has grown very fast

In the USA,

CCs employ about 5 per cent of the workforce,

CCs are said to be the most rapidly growing form of employment in Europe today (Paul and Huws,

Approximately 37 per cent of all new jobs within Europe during recent years have been in CCs

The overall trend is that more and more CCs are located at a distance from their customer base – even in other countries

It is estimated that,

the annual growth of CCs is 50 per cent

What’s new

? Telephone operator work has become progressively more computerised over the last few decades for example automatic distribution of calls and technical performance control has been introduced

These changes have resulted in a reduction of the variety of tasks performed by the operator,

and increased repetitiveness and machine-regulation of the work

Computer-telephone interactive tasks,

as performed in CCs are probably very special tasks to be studied,

since in these jobs video display units are used interactively during telephone calls

This means that repetitive movements and prolonged static sitting postures occur in complex situations,

responsibility and efficiency are expected from operators under the influence of time pressure,

ambitious goals and sometimes direct monitoring of performance

CCs use a range of information and communication technologies in order to maximise efficiency,

and the technology that is the key to the CC is the ACDcomputer (ACD = automatic call distributor)

This computer directs the calls to the next available and logged-in operator

The computer also tracks how long it takes until the customer is connected,

how long the call lasts and the time that the operator not is working actively with calls or is disconnected because he or she has left the workstation

This eliminates the need for a central telephone operator by automatically processing the distribution of incoming telephone calls to the operators,

who receive them through their headsets and seldom have to dial telephone numbers themselves,

or physically pick up a telephone receiver

Increasingly,

ACD systems are connected to a range of databases using Computer Telephony Integration (CTI),

which allows customer records to be transmitted to an agent’s computer screen along with the call

In addition,

many ACD systems have “voice response” mechanisms that are used to obtain basic information from the caller before they speak to an agent

In external companies,

Predictive Dialling technology is used in order to telephone large pre-programmed lists of customers

In this case,

when the customer answers a call,

transfers it to a waiting agent together with an on-screen computerised record of the customer’s details

Health related outcomes among call centre operators High rates of upper extremity musculoskeletal symptoms have been reported among telecommunication workers or CC operators (Ferguson,

LeGrand,

Hadler,

Smith et al

Hales et al

Hocking,

Karlqvist et al

including a group of CC operators

In that group 57 per cent of the men and 72 per cent of the women reported symptoms in the neck/shoulder during the previous month,

which was higher compared with other groups of professional computer users (35 per cent of the men and 54 per cent of the women)

Knowledge about the causes of musculoskeletal symptoms has increased during the last years

we have extensive knowledge about the consequences of computerisation in a work environment

Intensive and sedentary work with a computer is often associated with symptoms in the neck/shoulder and arm/hand region,

but also to stress- related problems (Haavisto,

Hagberg,

Karlqvist,

Several studies have shown that long periods of constrained sitting or computer work are associated with musculoskeletal symptoms (Buckle,

Hagberg,

Karlqvist,

Punnett and Bergqvist,

Tittirononda et al

In other studies a combination of non-optimal physical and psychosocial working conditions,

has been shown to increase the prevalence of musculoskeletal symptoms (Punnett and Bergqvist,

Bongers,

Fausett and Rempel,

Fernström,

Several other risk factors can be identified in the CC environment,

high demands and low control (Ferreira et al

Hocking,

Sprigg,

These factors may be involved in the development of musculoskeletal symptoms in the neck/shoulder and arm/hand region

Multifactor models suggest that work-related risk factors can result from the work tasks and their performance,

as well as from the organisation of work,

and the physical and psychosocial work environment

Additionally,

individual and lifestyle factors could be risk factors for musculoskeletal symptoms (Hagberg et al

Plausible models,

supported by recent laboratory experimentation,

have provided support for an interactive relationship between physical and psychosocial risk factors in the workplace (Davis and Heaney,

Lundberg and Melin,

Most studies show that pain in the neck-shoulder region is more common among women than among men

According to the 2001 Work Environment Survey,

The differences seem only partly explainable by the gender-segregated labour market,

with a higher proportion of women in jobs where exposure to repetitive work is common,

hairdressers and cleaners (Work Environment Authority and Statistics Sweden 2002)

An exposure-effect model focusing on work at call centres The following model,

modified from Winkel and Mathiassen (1994),

tries to describe work at CCs according to an ergonomic multifactor perspective

The work-related exposures are categorised as organisation/characteristics of work,

salary and additional remuneration,

comfort related to work environment,

time spent seated during a working day,

duration of continuous computer work and work postures

psychological demands (emotional and cognitive demands and time pressure),

possibility of influencing the work,

support from colleagues and supervisor

the non-work-related exposures,

here called life outside work/social exposure,

family and financial situation

In addition,

may act as modifying factors for different exposures

The internal exposure,

comprises the stain in the body on e

The exposure causes an acute response,

a consequence of internal exposures,

If nothing is done to reduce the exposure,

this could lead to health related outcomes,

both short-term and long-term effects

Short-term effects could be divided into symptoms e

upper back and lower back and other health related e

stress-related somatic or mental symptoms,

In the longer perspective this could lead to long-term effects,

Job task

Type of company (Study IV)

Location (Study IV)

- Big town

Exposures Organisation/Characteristics of work (Study I,

Physical exposure (Study I,

Psychosocial exposure (Study I,

Internal exposure

Individual characteristics (Study I,

- Gender

Acute response

Life outside work / social exposure

Health related outcomes (Study I,

V) Short-term effects Symptoms Eyes,

upper back and lower back Other health related effects stress-related somatic or mental symptoms stress and energy Long-term effects Disability,

Sick-leave

Figure 1

Exposure-effect model,

modified by Winkel and Mathiassen (1994),

focusing on work at call centres

Different factors that may influence the health effects in the human body

This thesis is based on five studies (study II not included in this model),

which are referred to by their Roman numerals

Bold frames show the areas that have been studied

Characteristics of work at call centres The content and quantity of calls at CCs varies with the complexity of the phone calls

Work tasks of low complexity might give less variation in work content and a higher quantity of calls

The operators may sit in front of the computer most of the day,

with both physical and mentally monotonous,

Ferreira and co-workers showed that CC workers often spend 90 per cent of their working time on the telephone and in front of the computer (Ferreira,

In the extreme case a phone call could be as short as 15-20 seconds,

which means that one operator,

could handle 1,000 calls or more during a working day (Westin,

The service degree,

answering 80 per cent of the calls within a given time,

in the same way as high work intensity

Other negative factors that have been reported: working on a varying roster,

working in the evening and at night-time,

rapid changes in work content and insufficient information

The salary among CC operators has been described as low (Fernie and Metcalf,

Taylor and Bain,

Additional remuneration seems to be common in this business

Performance monitoring seems to be fairly widely accepted,

although that acceptance has depended upon the style of supervision

DiTecco et al

Aiello,

Schleifer et al

Westin,

Both call logging and monitoring could be a good way of showing the operator’s performance

Monitoring could be a good way of showing the quality of the operator’s services

Physical exposures Workstations located in open offices might give problems with disturbing noise

Sudden sounds,

human voices and movements in the field of vision attract the focus of attention

This is involuntary and interferes with the work activity (Jones and Morris,

Loewen and Suedfeld,

Sundstrom et al

Other negative sides of noise are the speech comprehension that could be disturbed and that it could lead to tiredness and stress (Evans and Johnson,

Kjellberg et al

In open offices there are no possibilities for the operators to adjust the indoor climate (temperature,

draught) or quality (humidity and dust) and lighting to an individual level,

which could lead to negative effects e

tiredness and eye discomfort (Tham et al

The increasing amount of computer work is a concrete example of modern change in working life that has affected the physical work environment

Considerable work has been done to improve the physical design of workplaces (Bernard,

Cherniak,

Dimberg,

Elivell,

Fernström,

Grandjean,

Sauter,

Computer workstation design improvements can prevent awkward postures and increase worker health and performance (Grandjean et al

Verbeek 1991

Smith and Cohen 1997

Bayeh and Smith 1999

Smith et al

It is common that operators at CC companies do not have their own workplace

instead they have to take any available workstation that is free

This means that there are higher demands for the furniture and equipment to be adjustable

CC operators need to be comfortable during the long,

unbroken periods they spend at their workstations,

so optimal environmental conditions are required

CC operators often work with constrained awkward postures and with repetitive arm/hand movement

Therefore,

work task variation is important

Regular breaks are known to have a beneficial effect on preventing upper extremity musculoskeletal symptoms (UEMSS) (Dul et al

Henning et al

McLean et al

Balci and Aghazadeh,

Ten-minute breaks every hour reduced the development of disorders among CC operators (Ferreira et al

Another study showed increased productivity following ergonomic improvements (Smith and Bayehi,

Psychosocial exposures Critical psychosocial risk factors are high psychological demands (emotional and cognitive demands and time pressure),

little opportunity to influence the work and limited social support (Cooper et al

Cox et al

Karasek and Theorell,

Theorell,

For many CC employees,

the daily experience is repetitive,

intensive and frequently stressful work,

based upon Taylor’s principles,

which can result in employee exhaustion

Taylor’s principles are closely associated with mass production methods in manufacturing factories

It relied upon time and motion studies,

to achieve optimisation of the work task

Some operators are forced to take calls one after another: calls that are of short duration and must be completed in a specific time

Service sector organisations have increased the pressure on CC workers by raising the expectations of customers about the service they can expect to receive (Ashforth and Humphrey,

The psychosocial work environment at a CC implies several simultaneous demands,

He/she should be stress-resistant,

he/she should also have fast reactions,

be able to handle a huge amount of information,

be able to handle different types of customer,

be able to handle emotional demands etc (Wiencke and Koke,

There could be a risk of conflict between these demands and it is the operator who has to choose between serving a customer well and keeping the call-time down

At the same time the working activities of the operators are characterised by an extreme division of labour,

by automatic distribution of calls and by technical performance control

Decision latitude for the operators may be rather restricted

Karasek (1979) proposed that we should study the extent to which the individual is able to influence work,

and introduced the concept “job strain”

“Job strain” occurs when high psychological demands are combined with too little decision latitude

This could lead to negative stress and mental or physical problems

The dimension of demand consists of parts such as work pace,

time pressure and conflicting demands

The dimension of control

emphasises the individual decision latitude in the working situation,

control over the work pace and the planning of the work,

as well as the individual’s opportunities to develop new skills in the occupation

Subsequent research expanded the Demand-Control model to the Demand-Control-Social support model of job stress (Johnson et al

Johnson and Hall,

Karasek and Theorell,

This model suggests that high level of social support can help protect against job strain,

while low levels can exacerbate it

In a Canadian study (DiTecco,

A large majority of operators,

and this contributed to their feeling of stress to a great or very great extent

Computer technology has become a critical component of workplace management in call centres (Batt,

It can be used to monitor the speed of work,

regulate the level of downtime when the operator is not available to take calls,

and assess the quality of the interaction between the service provider and the customer

Furthermore,

employees could be required to follow a tightly scripted dialogue with customers and conform to highly detailed instructions

This has left them with little flexibility in their interactions with customers (Wharton,

The operators have little opportunity to influence their work task when it comes to length of calls,

the time between calls and the amount of time they are logged-in and logged-off the system

Usually the call centre company in the contract with the client company decides this

ACD (Automatic call distributor) technology may lead to the operator having less control and more limited possibilities of influencing her/his own work

The operator cannot direct his or her own work

instead it is the ACD system that directs the work

The CC business is known as a branch with rapid changes

The assignment may change from one week to next,

and sometimes they change even more often

The constant changes and amount of information concerning products and services could be a source of stress

On the other hand,

these changes could be a possibility of variation for the operators

CC operators are faced with quick changes,

not only regarding work tasks,

but also as regards changes among the managers

Furthermore,

it has been shown in several studies (Aronsson et al

Punnett and Bergqvist,

Ferreira et al

especially when it comes to work content and distribution of work tasks

Work with computers may lead to higher demands on cognitive resources,

compared with more traditional work methods (Hockey,

Norman,

Salvendy,

Receptiveness,

working periods with short cycles,

is often considered to be both physically and mentally demanding (Cox,

The mental demands and several other demands that occur in CC work present the biological system with a challenge called Allostatic load

This concept,

meaning literally “maintaining stability through change” was introduced by Sterling and Eyer (1988) to describe how the cardiovascular system

adjusts to resting and active states of the body

If this system is activated during long periods of time with little opportunity to recover,

stress-related symptoms may be the result

Only a few senses may be used during the information process in CC work,

and it is in principle the short-term memory that is needed to perform the work task

Monotonous repetition information that only bounces in and out of the short-term memory before it is time for the next telephone call could produce a considerable amount of tiredness

Individual characteristics The mean ages among international CC operators are generally low and the proportion of women is in some companies higher compared with men

They usually have an elementary and/or upper secondary school education (Austin Knight and Calcom Group,

Individual characteristics like age and gender could modify the response and long-term health outcomes of different exposures

Most of the computer equipment is still designed for men’s dimensions

Small anthropometrics dimensions may cause women to work in more awkward postures or at higher relative muscle forces,

which may cause greater mechanical stresses than for men

Inter-individual differences in working technique may also modify the effect of exposure

The worker may choose to use a specific method,

or a specific work method may be inflicted upon her/him,

for example by a policy at the workplace

Within the frames of the method the individual will perform the work task in her/his way and with her/his individual movements patterns

The choice of work technique is presumably also influenced by the worker’s experience,

training and knowledge’s in the occupation and of the work task,

motivation and problem-solving skills (Lindegård,

Life outside work,

social exposures Non-occupational factors,

such as physical load outside work and poor social support from friends and family

This is likely to affect the body in a way similar to the occupational factors (Theorell,

Demanding conditions from life outside work include physical and psychosocial demands on the individual from husband/wife,

elderly relatives and household tasks

The family chores are,

more burdensome for females than for males (Josephson,

Lundberg et al

Other factors included in life outside work are poor social support,

conflicts with family members or friends,

lack of time for own interests and lack of time for physical and psychological recuperation after work

Why study call centre work

? Despite the relatively extensive scientific literature of CC specific exposures and symptoms,

increased knowledge is called for,

concerning the specific features of

the CC work environment that may contribute to health related symptoms e

upper extremity musculoskeletal symptoms (UEMSS)

The question is important,

considering the high prevalence of symptoms observed among CC operators,

and the rapid growth of the CC business

As the CC business employs more and more people,

as well as physical and psychosocial exposures may affect the operators health in a negative way and therefore need attention

It is therefore important to shed more light on them and at an early stage investigate potential risks that can occur,

in order to create sustainable work conditions for the CC operators

Aims of this thesis The overall aim of this thesis was to describe characteristics of work,

physical and psychosocial exposures and health related outcomes,

The specific purposes were: • to investigate the working conditions and musculoskeletal symptoms among female and male employees at one CC compared with a reference group of professional computer users in Sweden

(Study I) • to assess the test-retest reliability and internal consistency of questions in a questionnaire covering symptoms,

physical and psychosocial working conditions at CCs,

and also the inter-rater reliability of observations and measurements according to an ergonomic checklist (Study II) • to describe working conditions at CCs and compare work tasks of different complexity among operators at internal and external CC companies in Sweden (Study III) • to describe psychosocial conditions,

stress and mental energy for operators in different types of CC companies in Sweden

To identify risk indicators for stress and lack of energy

Further,

to compare differences between female and male,

differences between companies with different owners and between companies located in small villages and larger towns

(Study IV) • to assess associations between exposures during CC work and symptoms in the neck/shoulders and in the upper extremities,

among operators at internal and external CCs (Study V)

Study groups and methods This thesis is based on two main projects,

where study I is part of a project called “Epi-mouse study” and studies II-V are parts of a project called “Call centre study”

The “Epi-mouse study” was a cohort study aiming to identify risk – and preventive factors for musculoskeletal disorders among professional computer users

The “Call centre study” was a cross-sectional survey,

with the overall aim to get a scientific basis for development of sustainable CC jobs

Companies Study I Totally 46 different worksites in Sweden participated in the study

The worksites differed in size,

the smallest including only seven persons and the largest 260

The study population represented both private and public sectors and included a variety of occupations

Together with the employers and Occupational Health Care Centres of the different worksites,

departments or work groups were invited to participate

The worksites entered the study at different times between 1997 and 1999

the selection of computer users was not based on a random sample of the Swedish labour market,

but was selected to cover a wide range of different computer work tasks and computer work intensity

Studies II,

V Totally 38 CC companies,

were invited to participate in the studies

The inclusion criteria for participation in the study were that the companies should represent different forms of ownership,

be located in different parts of the country,

in small villages or larger towns

Both internal and external companies should be included,

with different work task complexity,

and with incoming/outgoing calls

Sixteen companies representing 28 different CC sites agreed to participate

this included internal as well as external companies,

companies with different task complexity,

with different owners and with different location,

The goal was not to obtain a representative sample of CCs,

but rather to get a basis for comparisons between CCs of different types

The work tasks at the companies varied from tasks with low complexity (e

booking tickets) to high complexity (e

The most common reasons for not participating in the study were lack of time,

or that there was a reorganisation or change of management going on in the company

Table 1

Number of worksites and participants,

mean age and age range of the whole study group and subgroups,

Whole group

Number of worksites 28

Number of participants Total Women Men n n n 1183 848 335

Mean age,

Internal External

510 673

365 483

145 190

Low task complexity,

486 87 399

363 49 314

123 38 85

Medium complexity,

105 28 77

High complexity,

327 279 48

220 200 20

107 79 28

Swedish public owner Swedish private owner International owner

146 92 97

36 (19-66)

32 (17-61)

Large town (> 50 000 inhabitants) Small village ( 0

for any of the exposure levels

In table 13,

we present the final model for internal and external CCs

In all multivariable regression models,

internal non-response in the exposure variables was included as separate categories in order to maintain the statistical precision

An overview of measures and statistical analysis methods used in studies I-V is shown in table 7

Table 7

Overview of measures and analysis methods used in studies I-V

Measures and analytical methods

Measures Frequencies Mean values Prevalences Prevalence ratios and 95% confidence intervals Odds ratio and 95% confidence intervals Differences between proportions and 95% confidence intervals Minimum and maximum values P10,

P90 1) Pearson’s correlation coefficient Spearman’s correlation coefficient Cohen’s Kappa Percentage agreement Analysis methods Chi-square test Three-way analyses of covariance Univariable logistic analyses Multivariable logistic analyses 1)

IV I V I,

III II II II,

IV II II II IV IV IV,

P = percentile of a distribution of values

All statistical analyses,

in studies I and V were performed with SAS statistical software (SAS,

SAS/STAT User’s guide,

1999-2001

NC: SAS Institute Inc

All statistical analyses,

were performed with SPSS (version 11

SPSS Inc,

Chicago,

Illinois)

Results/Summary of papers Characteristics of work In the female CC group,

computer work constituted 73 per cent of the working hours,

compared with 50 per cent among women in the reference group

In the male CC group,

computer work constituted 66 per cent of the working time,

and in the reference group 43 per cent

The operators worked with customer calls on average 5 hours per day,

which correspond to 64 per cent of the working hours (68 per cent of the working hours at external CCs and 59 per cent at internal CCs) (study III)

At external companies the duration of customer calls was significantly longer,

Operators handled on average 106 calls/day

At external CCs they took on average significantly more calls/day compared with operators at internal CCs

The length of a call was on average 4 minutes and 23 seconds

There were significant shorter calls at external CCs

It was most common to deal with incoming calls (79%),

with no marked difference between internal and external companies (82% and 76%,

and this was most common of all among operators with work tasks of low complexity at internal companies (100%)

It was more common with work task of low complexity at external CCs compared with internal CCs

More than half of the operators had received additional remuneration during the previous 12 months

The most common type of remuneration was prizes (44%) e

This was significantly more common at external companies

A majority of operators reported that call logging occurred at their workplaces

This was significantly more common at external companies

The most common reaction to call logging was that the operators felt controlled (46%),

but also that it was a way of showing their performance (43%)

Nearly a quarter of the operators experienced feelings of stress because of call logging

This was significantly more common at external companies

More than half of the operators reported that monitoring of the calls occurred

Monitoring was significantly more common at external companies than at internal companies

The most common reaction to monitoring was that it was a way of showing the quality of their service (42%) and a way of developing their calls (41%),

but also feelings of being controlled (21%) and feelings of stress (23%)

Table 8

Mean duration of customer calls/day,

number of calls/day and length of the calls and prevalence (%) of any additional remuneration,

in the total sample and at internal and external CCs,

Total (n=1183)

Internal CCs (n=510)

External CCs (n=673)

Average time customer calls/day,

Mean number of calls/day

Mean length of the calls (sec)

Received additional remuneration,

Occurrence of call logging,

Occurrence of monitoring,

Physical exposure Nearly all of the workplaces were located in open office landscapes

Only 4,

of the workplaces were located in separated room (study III)

The comfort of the furniture and equipment was generally rated higher than the comfort of noise,

Forty-three per cent of the operators were dissatisfied with the sound level at the workstation,

while 27 per cent were satisfied

Fortyfour per cent of the operators were dissatisfied with the climate (dust and humidity) in the office during the past month,

while 27 per cent were satisfied

No major differences between internal and external CCs

Operators at external CCs reported significantly lower comfort related to furniture and equipment,

whereas operators at internal CCs reported lower comfort related to noise,

There were more often deficiencies in worktables and chairs,

as well as keyboard- and input device placement,

at the CC compared with the reference group,

The workstations were neither individually adjustable nor adjusted to the work task performed

Especially women at the CC worked with “non-optimal” workstation design and equipment placement

A higher proportion of CC employees had rather long periods of continuous work in front of the computer compared to the reference group

Table 9

Prevalences (%) in the call center and reference groups of “non-optimal” ergonomic design of the workplace,

based on observations among subjects without symptoms

Differences in prevalences between the call center and reference groups with 95% confidence intervals (95% CI),

Women Call center Reference Diff % (n=12) %(n=471) [95% CI] “Non-optimal” input device placement

Men Call center % (n=20)

Reference Diff % (n=382) [95% CI]

44 [40,

53 [48,

14 [-13,

-10 [-26,

22 [19,

28 [23,

39 [23,

“Non-optimal” keyboard placement “Non-optimal” screen placement

On average,

the operators reported that they spent 80 per cent of the working day sitting

Almost all operators,

spent more than half of a typical working day sitting

On average,

the operators worked for 2 hours (119 minutes) at the workplace before they took a break for at least 10 minutes,

with no major differences between internal and external CCs

Psychosocial exposure The subjects reported a high level of work intensity in both call centre and reference group (study I)

The subjects in the CC group also experienced deficiencies in the psychosocial environment – poor support from immediate supervisor,

and limited opportunities to influence their work compared with the reference group

Emotional demands were experienced during almost the whole working hours (81%)

Cognitive demands were experienced during more than 60 per cent of the working hours,

Cognitive demands occurred during fewer per cent of the working hours at high complexity CCs (59%) compared with the lower complexity CCs (78%)

Operators at international companies reported more limited decision latitude than operators in Swedish CCs

Operators at international CCs reported the most,

and private Swedish CCs the least limited support from their supervisor

CCs located in smaller villages experienced higher levels of cognitive demands and time pressure than those from CCs in larger towns

On the other hand,

limited social support and limited support from a supervisor,

was judged to be less good in the large city CCs

Women experienced emotional demands and time pressure during a somewhat larger part of the working hours than men did

Men and

2 [-21,

women reported the same degree of limited social support from colleagues and limited support from their immediate supervisor

Individual characteristics The CC operators were in average young (mean age 28 years,

study III) compared with the reference group (mean age 44 years,

The CC operators had worked for a shorter time,

both with their present tasks (mean 20 months,

study III) and with a computer,

only operators in study I (mean 4

5 years,

compared to the reference group (mean 143 months and 11

5 years,

The level of education was lower in the CC group compared with the reference group

Ten per cent of the CC operators had college or higher education,

and 25 per cent of the operators in study III,

compared with the reference group were about half of them had college or higher education

Women constituted 72 per cent of the CC group,

The proportion of women was significantly higher at CCs with work tasks of low complexity (75%) than at CCs with work tasks of high complexity (67%)

Operators at external CCs were significantly younger (32 years) than operators at internal CCs (38 years)

Health related outcomes Compared with the reference group a higher proportion of the CC group reported symptoms from each of the body regions,

A majority,

of the women in the CC group reported musculoskeletal symptoms (at least 3 days during the preceding month) in one or more body regions

The corresponding figure for the women in the reference group was 72 per cent

More men in the CC group than in the reference group,

reported musculoskeletal symptoms,

Headache and neck-scapular symptoms were the most common symptoms for women in the CC group

Eye symptoms were more common in the reference group

With the exception of women younger than 25 years of age,

there was a higher prevalence of subjects reporting symptoms in all age groups in the CC group,

compared with the reference group,

The prevalence ratios,

2 (95% CI,

4 (95% CI,

Table 10

Prevalences (%) of subjects in the CC and the reference groups that reported symptoms from any of the body regions,

lasting 3 days or more during the previous month in different age groups

Differences in prevalences between CC and reference groups with 95% confidence intervals (95% CI),

Age group (years)

Women Call centre Reference % (n=29) % (n=756)

Younger than 25 25

- 34 35

- 44 45

Diff [ 95%CI]

-8 [-32,

2] 19[-2,

40] 30[24,

Men Call centre Reference % (n=28) % (n=470) 71 (n=7) 63 (n=19) 100 (n=1) 100 (n=1)

- (n=0)

Diff [95%CI] 29 [-14,

Three out of four operators reported symptoms in one or more of the requested body regions,

with no major differences between the internal and external CCs,

Sixty-five per cent of the operators were classified into the neck/ shoulder category and 49 per cent of the operators into the arm/hand category

The prevalences of the symptoms considered were more common among women than among men,

an association with increasing age was observed

Stress and energy The strongest risk indicators for stress were: limited social support from colleagues,

limited support from the supervisor,

limited decision latitude and time pressure

whereas the strongest risk indicators for lack of energy were: limited decision latitude,

limited social support from colleagues,

limited support from the supervisor (table 11) (study IV)

Table 11,

also summarises the results of multivariable regression analyses of stress and energy with psychosocial indices as risk indicators in the first block of the regression model

The multivariable analyses showed that limited social support from colleagues and time pressure were the strongest association to stress,

but that limited support from the immediate supervisor and limited decision latitude also contributed significantly to the association

For energy,

indicators that contributed significantly to the association were limited decision latitude,

limited social support from colleagues and cognitive demands

In contrast to the other psychosocial indices,

cognitive demands showed a positive association,

Table 11

The psychosocial indices as risk indicators of stress and energy ratings

Pearson’s correlation coefficient and standardised regression coefficient (Beta) from multivariable logistic analyses with psychosocial indices as association,

Cognitive demands

Pearson r

Beta multivariate analyses

Emotional demands

Time pressure

Limited decision latitude

Limited social support

Limited support from the supervisor

** for p 0

comfort of furniture and equipment,

social support from colleagues,

anxiousness and psychosomatic symptoms

Four indices were classified as having low internal consistency (Cronbach’s alpha < 0

Indices with fair to good test-retest reliability were: comfort of furniture and equipment,

Indices with poor test-retest reliability were: comfort of sound,

Inter-rater reliability of assessments in the ergonomic checklist Among the variables on ratio and ordinal level,

measurements of actual desk height and seat height adjusted by the operator had high reliability

Viewing angle,

some of the luminance variables,

risk for glare in the field of vision and luminance in the peripheral working area had poor reliability

Among variables on the nominal level,

looking at the screen and the operator’s knowledge concerning how to adjust the armrest had high reliability

Variables such as visible reflections on the desk,

risk of reflections on the desk,

the keyboard positioned within forearm’s length and shoulder width,

were classified as having poor reliability

Discussion Main findings Characteristics of work This thesis has identified different CC-specific exposures that may be potential risk factors for the operator’s health and also identified differences between internal and external CCs

CC work requires a balance of qualitative skills,

assertiveness and persuasiveness,

together with the quantitative skills of keyboard,

computer systems and product knowledge (Fernie,

It is also a sedentary job with constrained postures,

restrictive and excessively monitored

Although the operators work in teams,

their job is solitary with little or no time to converse with team mates

Opportunities for varying work tasks and also to influence the quantity of work are probably important factors for CC operators

Other studies have shown that less variation in work content and a higher quantity of calls may lead to more sedentary work with less variation in both physical and mental respects (Holman,

Rabe and Rocha,

There are concerns about monotonous work with lack of stimulation

Supervision and control of the CC operators has often been discussed as a special stressor (Aiello,

DiTecco,

Schleifer,

Westin,

In this thesis,

Monitoring of calls was less common compared with call logging

Call logging and monitoring was most common at external CCs

Many reported a feeling of stress,

Call logging emphasises the quantity,

whereas monitoring focuses on quality,

which easily leads to conflict

It was common for the operators to receive additional remuneration

This could lead to the operators trying to increase their working speed in order to get more remuneration

Too much focus on remuneration may also affect the atmosphere among the operators and have a negative impact on solidarity at the company

A theoretical model is proposed to assess the adverse health effects of stressful experience at work: the effort-reward imbalance model (Siegrist,

The focus in this model is that there has to be a balance between the reward (wages,

promotion and benefits) and the effort that the work involves

Physical exposures Open-office design has been reported to create problems

vision ergonomics and air quality is parameters that could be affected in a negative way in this type of offices

The operators were dissatisfied with the air quality and noise environment in the premises

This maybe a consequence of that many operators dealing with customer calls and were working in the same room

When the operators sit close to each other there is a risk of disturbance,

arise if there is a lack of noise screening and noise reduction

Several studies have pointed out that people in open office landscapes feel disturbed by each other (Evans and Johnson,

O’Neill,

Design of the working environment and equipment is important for the productivity and quality of the computer-produced work (Tharr,

Tittiranonda et al

Jensen et al

In an occupational setting,

a lack of fit between anthropometrics features and furniture or other equipment may mean that it is more difficult for the worker to find neutral work postures

This is crucial for the prevention of musculoskeletal problems (Hagberg et al

It is important that furniture and equipment can be adjusted to each individual,

and also that the operator has the appropriate knowledge about how to adjust and use the equipment in an optimal way

On average the operators spent 80 per cent of the working day seated

This may lead to fewer opportunities to get physical variation

Other studies,

have shown that long periods of constrained sitting may lead to musculoskeletal disorders (Buckle,

Hagberg,

Karlqvist et al

Punnett and Bergqvist,

Tittirononda et al

Psychosocial exposures Emotional demands were one of the most prominent psychosocial workload among operators in this thesis

The operators experienced emotional demands almost the whole working time

Many operators also experienced cognitive demands during a large part of their working hours

The operator is faced with simultaneous emotional and cognitive demands

He/she is supposed to interact with the customer,

computer and the telephone system,

automatic distribution of calls,

as well as technical performance and control,

characterises the work at many of the CCs in this study

The consequences of emotional and cognit