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The nature of work is changing at whirlwind
speed. Perhaps now more than ever before, job stress poses a threat to the
health of workers and, in turn, to the health organizations. Through its
research program in job stress and through educational materials such as
this booklet, NIOSH is committed to providing organizations with knowledge
to reduce this threat.
This publication highlights knowledge about
the causes of stress at work and outlines steps that can be taken to prevent
job stress.
Stress in Today's Workplace
 The longer he
waited, the more David worried. For weeks he had been plagued by aching
muscles, loss of appetite, restless sleep, and a complete sense of
exhaustion. At first he tried to ignore these problems, but eventually he
became so short-tempered and irritable that his wife insisted he get a
checkup. Now, sitting in the doctor's office and wondering what the verdict
would be, he didn't even notice when Theresa took the seat beside him. They
had been good friends when she worked in the front office at the plant, but
he hadn't seen her since she left three years ago to take a job as a
customer service representative. Her gentle poke in the ribs brought him
around, and within minutes they were talking and gossiping as if she had
never left.
"You got out just in time," he told her. "Since the
reorganization, nobody feels safe. It used to be that as long as you did
your work, you had a job. That's not for sure anymore. They expect the same
production rates even though two guys are now doing the work of three. We're
so backed up I'm working twelve-hour shifts six days a week. I swear I hear
those machines humming in my sleep. Guys are calling in sick just to get a
break. Morale is so bad they're talking about bringing in some consultants
to figure out a better way to get the job done."
"Well, I really miss you guys," she said. "I'm afraid I
jumped from the frying pan into the fire. In my new job, the computer routes
the calls and they never stop. I even have to schedule my bathroom breaks.
All I hear the whole day are complaints from unhappy customers. I try to be
helpful and sympathetic, but I can't promise anything without getting my
boss's approval. Most of the time I'm caught between what the customer wants
and company policy. I'm not sure who I'm supposed to keep happy. The other
reps are so uptight and tense they don't even talk to one another. We all go
to our own little cubicles and stay there until quitting time. To make
matters worse, my mother's health is deteriorating. If only I could use some
of my sick time to look after her. No wonder I'm in here with migraine
headaches and high blood pressure. A lot of the reps are seeing the employee
assistance counselor and taking stress management classes, which seems to
help. But sooner or later, someone will have to make some changes in the way
the place is run."
What Workers Say About Stress on the Job
Scope of Stress in the Workplace
David's and Theresa's stories are unfortunate but not unusual. Job stress
has become a common and costly problem in the American workplace, leaving
few workers untouched. For example, studies report the following:
- One-fourth of employees view their jobs as the
number one stressor in their lives. -Northwestern
National Life
- Three-fourths of employees believe the worker has
more on-the-job stress than a generation ago.
-Princeton Survey Research Associates
- Problems at work are more strongly associated with
health complaints than are any other life stressor-more so than even
financial problems or family problems. -St.
Paul Fire and Marine Innsuance Co.
Fortunately, research on job stress has greatly expanded
in recent years. But in spite of this attention, confusion remains about the
causes, effects, and prevention of job stress. This booklet summarizes what
is known about job stress and what can be done about it.
What Is Job Stress?
Job stress can be defined as the harmful physical and
emotional responses that occur when the requirements of the job do not match
the capabilities, resources, or needs of the worker. Job stress can lead to
poor health and even injury.
The concept of job stress is often confused with
challenge, but these concepts are not the same. Challenge energizes us
psychologically and physically, and it motivates us to learn new skills and
master our jobs. When a challenge is met, we feel relaxed and satisfied.
Thus, challenge is an important ingredient for healthy and productive work.
The importance of challenge in our work lives is probably what people are
referring to when they say "a little bit of stress is good for you.
But for David and Theresa, the situation is different-the
challenge has turned into job demands that cannot be met, relaxation has
turned to exhaustion, and a sense of satisfaction has turned into feelings
of stress. In short, the stage is set for illness, injury, and job failure.
What are the Causes of Job Stress?
Nearly everyone agrees that job stress results from the
interaction of the worker and the conditions of work. Views differ, however,
on the importance of worker characteristics versus
working conditions as the primary cause of job
stress. These differing viewpoints are important because they suggest
different ways to prevent stress at work.
According to one school of thought, differences in
individual characteristics such as personality and coping style are most
important in predicting whether certain job conditions will result in
stress-in other words, what is stressful for one person may not be a problem
for someone else. This viewpoint leads to prevention strategies that focus
on workers and ways to help them cope with demanding job conditions.
Although the importance of individual differences cannot
be ignored, scientific evidence suggests that certain working conditions are
stressful to most people. The excessive workload demands and conflicting
expectations described in David's and Theresa's stories are good examples.
Such evidence argues for a greater emphasis on working conditions as the key
source of job stress, and for job redesign as a primary prevention strategy.
| In 1960, a Michigan court upheld a
compensation claim by an automotive assemblyline worker who had
difficulty keeping up with the pressures of the production line. To
avoid falling behind, he tried to work on several assemblies at the same
time and often got parts mixed up. As a result, he was subjected to
repeated criticism from the foreman. Eventually he suffered a
psychological breakdown. By 1995, nearly
one-half of the States allowed worker compensation claims for emotional
disorders and disability due to stress on the job [note, however, that
courts are reluctant to uphold claims for what can be considered
ordinary working conditions or just hard work].
-1995 Workers Compensation Yearbook
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NIOSH Approach to Job Stress
On the basis of experience and research, NIOSH favors the
view that working conditions play a primary role in causing job stress.
However, the role of individual factors is not ignored. According to the
NIOSH view, exposure to stressful working conditions (called job stressors)
can have a direct influence on worker safety and health. But as shown below,
individual and other situational factors can intervene to strengthen or
weaken this influence. Theresa's need to care for her ill mother is an
increasingly common example of an individual or situational factor that may
intensify the effects of stressful working conditions. Examples of
individual and situational factors that can help to reduce the effects of
stressful working conditions include the following:
- Balance between work and family or personal life
- A support network of friends and coworkers
- A relaxed and positive outlook
NIOSH Model of Job Stress
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Job Conditions That May
Lead to Stress
The Design of Tasks.
Heavy workload, infrequent rest breaks, long work hours and shift work;
hectic and routine tasks that have little inherent meaning, do not
utilize workers' skills, and provide little sense of control.
Example:
David works to the point of exhaustion. Theresa is tied to the
computer, allowing little room for flexibility, self-initiative, or
rest.
Management Style.
Lack of participation by workers in decision- making, poor communication
in the organization, lack of family-friendly policies.
Example:
Theresa needs to get the boss's approval for everything, and the
company is insensitive to her family needs.
Interpersonal Relationships.
Poor social environment and lack of support or help from coworkers and
supervisors.
Example:
Theresa's physical isolation reduces her opportunities to interact
with other workers or receive help from them.
Work Roles.
Conflicting or uncertain job expectations, too much responsibility, too
many "hats to wear."
Example:
Theresa is often caught in a difficult situation trying to satisfy
both the customer's needs and the company's expectations.
Career Concerns.
Job insecurity and lack of opportunity for growth, advancement, or
promotion; rapid changes for which workers are unprepared.
Example:
Since the reorganization at David's plant, everyone is worried about
their future with the company and what will happen next.
Environmental Conditions.
Unpleasant or dangerous physical conditions such as crowding, noise, air
pollution, or ergonomic problems.
Example:
David is exposed to constant noise at work.
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Job Stress and Health
Stress sets off an alarm in the brain, which responds by
preparing the body for defensive action. The nervous system is aroused and
hormones are released to sharpen the senses, quicken the pulse, deepen
respiration, and tense the muscles. This response (sometimes called the
fight or flight response) is important because it helps us defend against
threatening situations. The response is preprogrammed biologically. Everyone
responds in much the same way, regardless of whether the stressful situation
is at work or home.
Short-lived or infrequent episodes of stress pose little
risk. But when stressful situations go unresolved, the body is kept in a
constant state of activation, which increases the rate of wear and tear to
biological systems. Ultimately, fatigue or damage results, and the ability
of the body to repair and defend itself can become seriously compromised. As
a result, the risk of injury or disease escalates.
In the past 20 years, many studies have looked at the
relationship between job stress and a variety of ailments. Mood and sleep
disturbances, upset stomach and headache, and disturbed relationships with
family and friends are examples of stress-related problems that are quick to
develop and are commonly seen in these studies. These early signs of job
stress are usually easy to recognize. But the effects of job stress on
chronic diseases are more difficult to see because chronic diseases take a
long time to develop and can be influenced by many factors other than
stress. Nonetheless, evidence is rapidly accumulating to suggest that stress
plays an important role in several types of chronic health
problems-especially cardiovascular disease, musculoskeletal disorders, and
psychological disorders.
Health care expenditures are nearly
50% greater for workers who report high levels of stress.
-Journal of
Occupational and Environmental Medicine |
Early Warning Signs of Job Stress
Job
Stress and Health:
What the Research Tells Us
Cardiovascular Disease
Many studies suggest that psychologically demanding jobs that allow
employees little control over the work process increase the risk of
cardiovascular disease.
Musculoskeletal Disorders
On the basis of research by NIOSH and many other organizations, it is
widely believed that job stress increases the risk for development of
back and upper- extremity musculoskeletal disorders.
Psychological Disorders
Several studies suggest that differences in rates of mental health
problems (such as depression and burnout) for various occupations are
due partly to differences in job stress levels. (Economic and lifestyle
differences between occupations may also contribute to some of these
problems.)
Workplace Injury
Although more study is needed, there is a growing concern that stressful
working conditions interfere with safe work practices and set the stage
for injuries at work.
Suicide, Cancer, Ulcers, and Impaired Immune
Function
Some studies suggest a relationship between stressful working conditions
and these health problems. However, more research is needed before firm
conclusions can be drawn.
-Encyclopedia of
Occupational Safety and Health |
Stress, Health, and Productivity
Some employers assume that stressful working conditions
are a necessary evil-that companies must turn up the pressure on workers and
set aside health concerns to remain productive and profitable in today's
economy. But research findings challenge this belief. Studies show that
stressful working conditions are actually associated with increased
absenteeism, tardiness, and intentions by workers to quit their jobs-all of
which have a negative effect on the bottom line.
Recent studies of so-called healthy organizations suggest
that policies benefiting worker health also benefit the bottom line. A
healthy organization is defined as one that has low rates of illness,
injury, and disability in its workforce and is also competitive in the
marketplace. NIOSH research has identified organizational characteristics
associated with both healthy, low-stress work and high levels of
productivity. Examples of these characteristics include the following:
- Recognition of employees for good work performance
- Opportunities for career development
- An organizational culture that values the individual
worker
- Management actions that are consistent with
organizational values
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Stress Prevention and Job
Performance
St. Paul Fire and Marine Insurance Company conducted
several studies on the effects of stress prevention programs in hospital
settings. Program activities included (1) employee and management
education on job stress, (2) changes in hospital policies and procedures
to reduce organizational sources of stress, and (3) establishment of
employee assistance programs.
In one study, the frequency of medication errors
declined by 50% after prevention activities were implemented in a
700-bed hospital. In a second study, there was a 70% reduction in
malpractice claims in 22 hospitals that implemented stress prevention
activities. In contrast, there was no reduction in claims in a matched
group of 22 hospitals that did not implement stress prevention
activities.
-Journal of Applied Psychology |
According to data from the Bureau
of Labor Statistics, workers who must take time off work because of
stress, anxiety, or a related disorder will be off the job for about 20
days.
-Bureau of Labor
Statistics |
What Can Be Done About Job Stress?
The examples of Theresa and David illustrate two different
approaches for dealing with stress at work.
Stress Management.
Theresa's company is providing stress management training and an employee
assistance program (EAP) to improve the ability of workers to cope with
difficult work situations. Nearly one-half of large companies in the United
States provide some type of stress management training for their workforces.
Stress management programs teach workers about the nature and sources of
stress, the effects of stress on health, and personal skills to reduce
stress-for example, time management or relaxation exercises. (EAPs provide
individual counseling for employees with both work and personal problems.)
Stress management training may rapidly reduce stress symptoms such as
anxiety and sleep disturbances; it also has the advantage of being
inexpensive and easy to implement. However, stress management programs have
two major disadvantages:
- The beneficial effects on stress symptoms are often
short-lived.
- They often ignore important root causes of stress
because they focus on the worker and not the environment.
Organizational Change.
In contrast to stress management training and EAP programs, David's company
is trying to reduce job stress by bringing in a consultant to recommend ways
to improve working conditions. This approach is the most direct way to
reduce stress at work. It involves the identification of stressful aspects
of work (e.g., excessive workload, conflicting expectations) and the design
of strategies to reduce or eliminate the identified stressors. The advantage
of this approach is that it deals directly with the root causes of stress at
work. However, managers are sometimes uncomfortable with this approach
because it can involve changes in work routines or production schedules, or
changes in the organizational structure.
As a general rule, actions to reduce job stress
should give top priority to organizational change to improve working
conditions. But even the most conscientious efforts to improve working
conditions are unlikely to eliminate stress completely for all workers. For
this reason, a combination of organizational change and stress management is
often the most useful approach for preventing stress at work.
Preventing Stress at Work: A Comprehensive Approach
How to
Change the Organization to Prevent Job Stress
- Ensure that the workload is in line with workers'
capabilities and resources.
- Design jobs to provide meaning, stimulation, and
opportunities for workers to use their skills.
- Clearly define workers' roles and responsibilities.
- Give workers opportunities to participate in
decisions and actions affecting their jobs.
- Improve communications-reduce uncertainty about
career development and future employment prospects.
- Provide opportunities for social interaction among
workers.
- Establish work schedules that are compatible with
demands and responsibilities outside the job.
-American Psychologist |
Preventing Job Stress - Getting Started
No standardized approaches or simple "how to" manuals
exist for developing a stress prevention program. Program design and
appropriate solutions will be influenced by several factors-the size and
complexity of the organization, available resources, and especially the
unique types of stress problems faced by the organization. In David's
company, for example, the main problem is work overload. Theresa, on the
other hand, is bothered by difficult interactions with the public and an
inflexible work schedule.
Although it is not possible to give a universal
prescription for preventing stress at work, it is possible to offer
guidelines on the process of stress prevention in organizations. In all
situations, the process for stress prevention programs involves three
distinct steps: problem identification, intervention, and evaluation. These
steps are outlined beginning on page 17. For this process to succeed,
organizations need to be adequately prepared. At a minimum, preparation for
a stress prevention program should include the following:
- Building general awareness about job stress (causes,
costs, and control)
- Securing top management commitment and support for the
program
- Incorporating employee input and involvement in all
phases of the program
- Establishing the technical capacity to conduct the
program (e.g., specialized training for in-house staff or use of job
stress consultants)
Bringing workers or workers and managers together in a
committee or problem-solving group may be an especially useful approach for
developing a stress prevention program. Research has shown these
participatory efforts to be effective in dealing with ergonomic problems in
the workplace, partly because they capitalize on workers' firsthand
knowledge of hazards encountered in their jobs. However, when forming such
working groups, care must be taken to be sure that they are in compliance
with current labor laws.*
*The National Labor Relations Act may
limit the form and structure of employee involvement in worker-management
teams or groups. Employers should seek legal assistance if they are unsure
of their responsibilities or obligations under the National Labor Relations
Act.
Steps Toward Prevention
Low morale, health and job complaints, and employee
turnover often provide the first signs of job stress. But sometimes there
are no clues, especially if employees are fearful of losing their jobs. Lack
of obvious or widespread signs is not a good reason to dismiss concerns
about job stress or minimize the importance of a prevention program.
Step 1 - Identify the Problem.
The best method to explore the scope and source of a suspected stress
problem in an organization depends partly on the size of the organization
and the available resources. Group discussions among managers, labor
representatives, and employees can provide rich sources of information. Such
discussions may be all that is needed to track down and remedy stress
problems in a small company. In a larger organization, such discussions can
be used to help design formal surveys for gathering input about stressful
job conditions from large numbers of employees.
Regardless of the method used to collect data, information
should be obtained
about employee perceptions of their job conditions and
perceived levels of
- Hold group discussions with employees.
- Design an employee survey.
- Measure employee perceptions of job conditions,
stress, health, and satisfaction.
- Collect objective data.
- Analyze data to identify problem locations and
stressful job conditions.
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stress, health, and satisfaction. The list of job
conditions that may lead to stress (page 9) and the warning signs and
effects of stress (page 11) provide good starting points for deciding what
information to collect.
Regardless of the method used to collect data, information
should be obtained about employee perceptions of their job conditions and
perceived levels of stress, health, and satisfaction. The list of job
conditions that may lead to stress (page 9) and the warning signs and
effects of stress (page 11) provide good starting points for deciding what
information to collect.
Objective measures such as absenteeism, illness and
turnover rates, or performance problems can also be examined to gauge the
presence and scope of job stress. However, these measures are only rough
indicators of job stress-at best.
Data from discussions, surveys, and other sources should
be summarized and analyzed to answer questions about the location of a
stress problem and job conditions that may be responsible-for example, are
problems present throughout the organization or confined to single
departments or specific jobs?
Survey design, data analysis, and other aspects of
a stress prevention program may require the help of experts from a local
university or consulting firm. However, overall authority for the prevention
program should remain in the organization.
Step 2 - Design and Implement Interventions.
Once the sources of stress at work have been identified and the scope of the
problem is understood, the stage is set for design and implementation of an
intervention strategy.
In small organizations, the informal discussions that
helped identify stress problems may also produce fruitful ideas for
prevention. In large organizations, a more formal process may be needed.
Frequently, a team is asked to develop recommendations based on analysis of
data from Step 1 and consultation with
- Target source of stress for change.
- Propose and prioritize intervention strategies.
- Communicate planned interventions to employees.
- Implement Interventions.
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outside experts.
Certain problems, such as a hostile work environment, may
be pervasive in the organization and require company-wide interventions.
Other problems such as excessive workload may exist only in some departments
and thus require more narrow solutions such as redesign of the way a job is
performed. Still other problems may be specific to certain employees and
resistant to any kind of organizational change, calling instead for stress
management or employee assistance interventions. Some interventions might be
implemented rapidly (e.g., improved communication, stress management
training), but others may require additional time to put into place (e.g.,
redesign of a manufacturing process).
Step 3 - Evaluate the Interventions.
Evaluation is an essential step in the intervention process. Evaluation is
necessary to determine whether the intervention is producing desired effects
and whether changes in direction are needed.
Time frames for evaluating interventions should be
established. Interventions
- Conduct both short- and long-term evaluations.
- Measure employee perceptions of job conditions,
stress, health, and satisfaction.
- Measure employee perceptions of job conditions,
stress, health, and satisfaction.
- Include objective measures.
- Refine the intervention strategy and return to Step
1.
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involving organizational change should receive both short-
and long-term scrutiny. Short-term evaluations might be done quarterly to
provide an early indication of program effectiveness or possible need for
redirection. Many interventions produce initial effects that do not persist.
Long-term evaluations are often conducted annually and are necessary to
determine whether interventions produce lasting effects.
Evaluations should focus on the same types of information
collected during the problem identification phase of the intervention,
including information from employees about working conditions, levels of
perceived stress, health problems, and satisfaction. Employee perceptions
are usually the most sensitive measure of stressful working conditions and
often provide the first indication of intervention effectiveness. Adding
objective measures such as absenteeism and health care costs may also be
useful. However, the effects of job stress interventions on such measures
tend to be less clear-cut and can take a long time to appear.
The job stress prevention process does not end
with evaluation. Rather, job stress prevention should be seen as a
continuous process that uses evaluation data to refine or redirect the
intervention strategy.
The following pages provide examples of actions some
organizations have taken to help prevent stress in their workplaces.
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Stress Prevention Programs:
What Some Organizations Have Done
Example 1
A Small Service Organization. A department head in a
small public service organization sensed an escalating level of tension
and deteriorating morale among her staff. Job dissatisfaction and health
symptoms such as headaches also seemed to be on the rise. Suspecting
that stress was a developing problem in the department, she decided to
hold a series of all-hands meetings with employees in the different work
units of the department to explore this concern further. These meetings
could be best described as brainstorming sessions where individual
employees freely expressed their views about the scope and sources of
stress in their units and the measures that might be implemented to
bring the problem under control.
Using the information collected in these meetings and
in meetings with middle managers, she concluded that a serious problem
probably existed and that quick action was needed. Because she was
relatively unfamiliar with the job stress field, she decided to seek
help from a faculty member at a local university who taught courses on
job stress and organizational behavior.
After reviewing the information collected at the
brainstorming sessions, they decided it would be useful for the faculty
member to conduct informal classes to raise awareness about job
stress-its causes, effects, and prevention-for all workers and managers
in the department. It was also decided that a survey would be useful to
obtain a more reliable picture of problematic job conditions and
stress-related health complaints in the department. The faculty member
used information from the meetings with workers and managers to design
the survey. The faculty member was also involved in the distribution and
collection of the anonymous survey to ensure that workers felt free to
respond honestly and openly about what was bothering them. He then
helped the department head analyze and interpret the data.
Analysis of the survey data suggested that three types
of job conditions were linked to stress complaints among workers:
- Unrealistic deadlines
- Low levels of support from supervisors
- Lack of worker involvement in decision-making.
Having pinpointed these problems, the department head
developed and prioritized a list of corrective measures for
implementation. Examples of these actions included (1) greater
participation of employees in work scheduling to reduce unrealistic
deadlines and (2) more frequent meetings between workers and managers to
keep supervisors and workers updated on developing problems.
Example 2
 A
Large Manufacturing Company. Although no widespread signs of
stress were evident at work, the corporate medical director of a large
manufacturing company thought it would be useful to establish a stress
prevention program as a proactive measure. As a first step he discussed
this concept with senior management and with union leaders. Together,
they decided to organize a labor-management team to develop the program.
The team comprised representatives from labor, the medical/employee
assistance department, the human resources department, and an outside
human resources consulting firm. The consulting firm provided technical
advice about program design, implementation, and evaluation. Financial
resources for the team and program came from senior management, who made
it clear that they supported this activity. The team designed a two-part
program. One part focused on management practices and working conditions
that could lead to stress. The second part focused on individual health
and well-being.
To begin the part of the program dealing with
management practices and job conditions, the team worked with the
consulting firm to add new questions about job stress to the company's
existing employee opinion survey. The survey data were used by the team
to identify stressful working conditions and to suggest changes at the
work group and/or organizational level. The employee health and
well-being part of the program consisted of 12 weekly training sessions.
During these sessions, workers and managers learned about common sources
and effects of stress at work, and about self-protection strategies such
as relaxation methods and improved health behaviors. The training
sessions were offered during both work and nonwork hours.
The team followed up with quarterly surveys of working
conditions and stress symptoms to closely monitor the effectiveness of
this two-part program.
These examples are based on adaptations of actual situations. For other
examples of job stress interventions, see the Conditions of Work
Digest, Vol. 11/2, pp. 139-275. This publication may be obtained by
contacting the ILO Publications Center at P.O. Box 753, Waldorf, MD
20604 (Telephone: 301-638-3152). Or call NIOSH at 1-800-35-NIOSH.
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Need Additional Information?
• More about NIOSH
National Institute for Occupational Safety and Health (NIOSH)1-800-35-NIOSH
4676 Columbia Parkway) Outside the U.S.: 1-513-533-8328
Cincinnati, Ohio 45226-1998
http://www.cdc.gov/niosh
NIOSH provides information and publications about a wide
range of occupational hazards, including job stress. NIOSH information about
job stress can be found on the NIOSH job stress internet page
(http://www.cdc.gov/niosh/topics/stress/),
or call 1-800-35-NIOSH
(1-800-356-4674)
• More Information about Job Stress
The Encyclopaedia of Occupational Health and Safety, 4th Edition
(ISBN 92-2-109203-8) contains a comprehensive summary of the latest
scientific information about the causes and effects of job stress (see Vol.
1, Chapter 5, Mental Health; Vol. 2, Chapter 34, Psychosocial and
Organizational Factors).
International Labour Office (ILO) Publications Center)
301-638-3152
P.O. Box 753
Waldorf, MD 20604
• Other Publications about Job Stress
Go to the NIOSH job stress internet site
(http://www.cdc.gov/niosh/topics/stress/),
or call the NIOSH 800 number
(1-800-35-NIOSH).
• Location of a Psychologist or Consultant in Your Area
American Psychological Association (APA) 1-800-964-2000
750 First St., N.E. fax: 202-336-5723
Washington, DC 20002-4242
State psychological associations maintain a listing of
licensed psychologists who may be able to help with stress-related issues.
Call the APA or your State psychological association for more information,
or refer to the APA internet site with this information
http://locator.apahelpcenter.org.
External Link: http://locator.apahelpcenter.org
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Yale University
Barsade S, Wiesenfeld B, The Marlin Company [1997]. Attitudes in the
American workplace III. New Haven, CT: Yale University School of Management.
Disclaimer
Mention of any company name or product does not constitute
endorsement by the National Institute for Occupational Safety and Health.
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DHHS (NIOSH) Publication No. 99-101
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