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Workload, Work Organization and Health Outcomes: The Ontario Disability Support Program

Authors:
WORKLOAD, WORK ORGANIZATION AND HEALTH OUTCOMES:
THE ONTARIO DISABILITY SUPPORT PROGRAM
WAYNE LEWCHUK
DIRECTOR, LABOUR STUDIES PROGRAMME
McMASTER UNIVERSITY
January 31, 2002
INTRODUCTION
This assessment was prepared for the Ontario Public Service Employees Union. It
examines the conditions of work in the offices of the Ontario Disability Support
Program. I was asked by the Union to assess the extent to which the organization of
work by the Employer makes reasonable provision for the health and safety of staff
and to offer recommendations, if any, arising out of my assessment. The assessment
provides evidence in support of the union's claim that "The employer is failing to make
reasonable provisions for the health of its employees in the ODSP by failing to
maintain sufficient staff to handle the workload required of its staff."
On the surface, it is the lack of staff to do the assigned work that is the most visible
health risk at ODSP. In my assessment, I conclude that the real problem is much more
complex. Not only is workload excessive, but it is done in a context where staff have
limited control over how work is done, where support at work is inadequate, and where
there is an imbalance between effort and rewards.
The assessment is based on a review of the key literature on work organization and
health. It draws evidence from fifteen interviews and two focus groups conducted by
the author during January of 2002 at three different ODSP offices. The fifteen
interviews included five Client Service Representatives, nine Income Support
Specialists and one Income Support Clerk. All those participating in the interviews and
focus groups were asked to complete the 14 question Karasek Job Content
Questionnaire (JCQ).
The assessment employs qualitative and quantitative research techniques. The
interviews and focus groups provide a rich qualitative data base. Relying on the words
of those interviewed, the assessment reveals how staff are experiencing the new
working conditions and a deeper appreciation of the degree to which their health is at
risk. Quantitative analysis of the JCQ survey provides a benchmark of working
conditions at ODSP against other forms of employment and an indicator of how
working conditions have changed since ODSP was introduced.
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SUMMARY OF FINDINGS:
Under ODSP, the organization of work is exposing staff to increased health
risks.
Workloads are excessive.
Staff have minimal control over working conditions.
Levels of support at work are inadequate.
Staff lack the training to do their jobs or to deal with issues of workplace
harassment.
There is a serious imbalance between effort and rewards.
Within the Karasek Job Demand-Control model, work at ODSP would be
characterized as "High Strain" exposing workers to a range of health risks.
Stress levels are high
The firm contracted to reorganize ODSP workplaces ignored the growing
body of research linking work organization and health. As a result they
introduced work practices that are having negative short-run health effects
and will lead to serious long-term health problems for ODSP staff.
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The report is divided into five sections:
Section One reviews the literature linking work organization and health
outcomes. Its objective is to show that work organization matters in
determining health outcomes. It explores the characteristics of work
organization that are considered to be the most critical to a healthy
workplace.
Section Two describes the changes in work organization associated with
the shift to ODSP in 1998, the refinement of work practices in 2000 linked
with the Business Practices Review (BPR), and the introduction of a new
computer system referred to as the Service Delivery Model Technology
(SDMT) piloted in the spring of 2001 and incrementally implemented
across the ministry in phases. Using data from the interviews it provides a
detailed picture of workload, control, support and the balance between
effort and rewards at work.
Section Three reports findings from responses to the short version of the
Karasek Job Content Questionnaire. It compares workload and control of
ODSP job classifications against working conditions under the Family
Benefits Act and at Canadian manufacturing establishments. It places
ODSP job classifications on the four-quadrant Karasek Job-Demand
Control grid.
Section Four returns to the interview data to explore the level of stress
being experienced by ODSP workers and their concerns regarding
potential harassment from clients.
Section Five Summarizes the findings and suggests some changes that
would improve the health of workers at ODSP.
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SECTION ONE: RESEARCH LINKING WORK ORGANIZATION AND HEALTH
WHAT IS WORK ORGANIZATION?
A key argument of this assessment is that the health impact of heavy workloads needs
to be examined in the context of a broad set of work organization characteristics. Work
organization is the complex set of practices which shape the physical and social
organization of workplaces. Together, these practices define how people interact with
their physical environment and how they interact with each other. Research has
focussed on four main characteristics of work organization: workload, control or
decision latitude, support at work, and effort-reward imbalance. Health outcomes can
be affected by each of these characteristics on their own, or by interaction between
them. For instance the Job-Demand Control model, which will be discussed below,
predicts health outcomes will be affected by the interaction between workload and
control.
Some examples of work organization characteristics at ODSP include: What kinds of
skills are required by workers? How are the various tasks allocated to workers? How
much work is allocated to each worker? Do workers work on their own or in groups?
Do workers have any control over how or when work is done? Can they change the
sequence of tasks? What kind of physical and social resources support workers as
they work? What systems are in place to ensure that allocated work is completed?
THE WHITEHALL STUDIES AND THE LINK BETWEEN WORK ORGANIZATION
AND HEALTH OUTCOMES
The Whitehall studies advanced our understanding of how work organization affects
health outcomes. In a project begun in 1967, Michael Marmot and his colleagues
exposed an age-adjusted social gradient in death rates and in absenteeism in a study
involving tens of thousands of British civil servants working in offices in London. Civil
servants in the highest employment grade (administrative) had from one-third to one-
half the incidence of mortality of those in the lowest grade (clerical) (Marmot et.al.,
1984; Marmot et.al., 1991; Marmot, 1997). The sample was unique in that it included
only office workers. These workers were not heavily exposed to traditional health risks
such as dangerous substances or biomechanical hazards associated with
manufacturing. Equally important, the health impact of poverty was largely removed
from the equation as even the worst paid employment grade enjoyed a comfortable
material standard of living.
What explains the causes of this social health gradient? Subsequent research
indicated that life style explained only a small component of this difference. Under
Whitehall II, begun in 1985, Marmot and his colleagues began exploring the role of
work organization as an explanation of this gradient. In a key paper, researchers
argued that prolonged exposure to jobs with limited control over decisions at work
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nearly doubled the risk of coronary heart disease compared to those working at jobs
with high levels of control (Bosma et.al., 1997). Using data from the same study, North
and her colleagues showed civil servants in the lowest employment grades had 3 to 6
times the level of short and long absences from work compared with civil servants in
the highest grade (North et.la., 1993 & 1996). They went on to argue that work
demands, control at work and support at work were significant factors in explaining the
pattern of absences from work. A recent summary report from the study concludes,
"The work environment appears to be an important influence on health. . . .Our results
suggest that interventions at the level of work design, organisation and management
may reduce morbidity in working populations." (Stansfield, Head & Marmot, 2000; see
Cooper 1998 for a review of some of this literature).
The Whitehall studies paved the way for a number of other studies into the impact of
work organization on health. In a major Canadian study by Statistics Canada, Wilkins
and Beaudet (1998) examined how workload, control at work, job insecurity, physical
demands, and support from supervisors and co-workers affected a number of health
outcomes including, blood pressure, repetitive strain injuries, back problems and
migraines. They found that for men, the combination of high workload and low control
at work was associated with migraines and psychological distress, while for women it
was associated with work injuries. High physical demands led to work injury in both
sexes, while low co-worker support was related to migraines in men and work injury
and psychological distress amongst women. Dollard et.al. (2000), studying workers
from a public sector welfare agency, concluded, "If workers are consistently in a
situation of chronic heavy workload with a lack of either support or control, strain and
ill-health, not to mention a lack of productivity can result." (p. 507) The Canadian Heart
and Stroke Foundation, in its annual Report Card on Canadians, warned, "Workers
who have little control in their jobs but are under great pressure, are at an increased
heart risk brought about by stress." (Heart and Stroke Foundation of Canada, 2000).
MODELLING THE RELATIONSHIP BETWEEN WORK ORGANIZATION AND
HEALTH
The recognition that work organization appears to influence health outcomes has led to
extensive research trying to explain why this is so. Three complementary models of
the relationship have emerged. They are:
Job Demand-Control Model (JD-C)
Iso-strain model
Effort-Reward Imbalance (ERI)
To fully understand the health implications of work organization at ODSP, and the risks
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these workers face, it is necessary to have a basic understanding of these models.
THE JOB DEMAND-CONTROL MODEL
A major breakthrough in our understanding of the relationship between work
organization and health came with the work of Karasek and Theorell (Karasek 1979;
Karasek & Theorell, 1990). They developed what is known as the Job Demand-
Control (JD-C) model. They pointed to "job strain", defined as the combination of high
psychological workload demands and low decision latitude or control as a key health
risk. Psychological demands are measured by questions asking; Is work excessive?
Are there conflicting demands? Is there time for work? Is it too fast or too hard?
Decision latitude is measured by questions asking; Can employees make their own
decisions? Can they choose how to do their job? Do they have a say on the job? Do
they take part in decisions? Researchers using the JD-C model have shown that a
variety of health problems, including high blood pressure and cardiovascular disease,
are more common where employees are exposed to "job strain". For instance, heart
disease is more common amongst over-worked cashiers and line workers than
amongst over-worked executives. The core of the JD-C model is control over tasks at
work including control over how to meet a job's demands or control over how to use
one's skills.
The etiology linking "job strain" and health continues to be explored. In his early work,
Karasek argued that workers facing job strain would experience a state of arousal and
stress that inhibits learning which in turn further increases stress and arousal by
impairing confidence and self-esteem. More recent work has focussed on how
increasing control permits workers to minimize the effects of workload-related stressors
by allowing them to adjust their work pattern so they complete their job assignments
when they are best able to do so and in ways they find the least stressful. According to
Wall, et al., (1996) "Control provides the opportunity for individuals to adjust to
demands according to their needs and circumstances." (p. 155) In the short run, "job
strain" is hypothesized to lead to lower job satisfaction, exhaustion and depression,
and in the long run to stress-related illness, including cardiovascular disease. (See
Schnall, et al. 2002; de Jonge 2000a; Stansfield et.al. 2000).
One of the most compelling pieces of evidence in support of the "job strain" model
comes from a Swedish study. The results are summarized in Figure One. The
prevalence of heart disease symptoms is more than seven times higher for workers
with little control and high workload than for those with high control and high workload.
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FIGURE ONE: JOB DEMAND-CONTROL AND HEART DISEASE PREVALENCE
(Swedish males, 1974, N=1,621)
(Number on vertical bar is percentage in each category with symptoms)
Source: Karasek & Theorell 1990, p. 6.
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The Cornell Work Site study directed by Landsbergis & Schnall is investigating the link
between work organization and hypertension at eight workplaces in New York City.
Early results indicate that systolic and diastolic blood pressure are affected more by a
person=s workplace than by other demographic variables (Schlussel et.al. 1990).
Further research by this team combined data based on the Karasek 42 item Job
Content Questionnaire with ambulatory blood pressure readings. The results suggest
that the link between "job strain" and heart disease identified by Karasek is caused by
elevated blood pressure readings (Schnall et al., 1992; Landsbergis et al., 1994). The
initial study was repeated three years later with a total of 195 men and showed that
blood pressure was higher amongst workers facing "job strain" in both periods of time
("Chronic job strain") compared to those facing job strain in only one period or not at all
(Schnall et al.,1998). In addition, men leaving a situation of job strain over the 3 years
of the follow-up had a significant decline in their work blood pressure of 5.3 mm Hg
systolic and 3.2 mm Hg diastolic. The evidence in support of a link between work
organization and cardiovascular disease is summarized in Schnall et.al., 2000.
ISO-STRAIN MODEL
The Iso-strain model adds workplace support to the analysis of how work organization
affects health outcomes. Research during the last twenty years points to a link
between the degree to which individuals interact with others in their society and health
outcomes. Social cohesion, social capital and the decline in social capital are
important subjects for researchers trying to understand trends in overall public health
(Putnam 2000; Coburn 2000; Karasek & Theorell 2000). At work, this link is explored
within the framework of the Iso-strain model (Johnson & Hall 1988; Johnson 1991).
Recent research suggests that social support at work influences health through a
complex set of pathways, some related to buffering the negative effects of workload
and control, while others relate to increased collective control at work. Johnson (1991)
lists four routes through which social support influences health outcomes at work:
meeting basic human needs for companionship and group
affiliation;
providing resources to moderate the impact of job demands;
influencing adult socialization and promoting active patterns of
behaviour; and
through collective coping systems that protect groups of workers
against structural demands and pressures.
Stansfeld et al. (1998) provide some clues to the etiology between support and
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health. They hypothesize that the positive aspects of work (high levels of control, skill
discretion, work support, high rewards) combined with personal social support may
increase self-esteem and perceptions of control over the environment. These positive
psychological states may reduce chronic physiological arousal and boost immune
responsiveness leading to good health and greater resistance to the impact of life
events. The absence of a positive work and support environment may lead to a
chronic metabolic disturbance that may then lead to the development of impaired
functioning and disease.
Evidence confirming the role of support as a factor affecting health outcomes is
reported in Johnson (1991). From a sample of 13,779 Swedish male and female
workers, it was shown that low control and low support increased the risk of
cardiovascular disease. Johnson and his collegues found that the prevalence of
cardiovascular disease was higher for those reporting low control or those reporting low
support and was the highest for those reporting both low control and low support at
work (1.67 times that found in the high control/high support group).
EFFORT-REWARD IMBALANCE MODEL
A third approach to understanding how work organization affects health is the Effort-
Reward Imbalance Model (ERI) (Siegrist 1996; Siegrist & Peters 2000). Siegrist
argues that an imbalance between costs and gains at work (i.e. high effort/low reward
condition) results in a state of emotional distress with special propensity to autonomic
arousal and associated strain reactions. The ERI model does not abandon the earlier
focus on control at work or workload. Rather it places control and workload in the
context of a broader and deeper set of social forces and it introduces rewards as a key
factor determining levels of stress. In the ERI model, effort at work is viewed as part of
a socially organized exchange with workers receiving rewards from society. Those
rewards include money, esteem and status control. When effort and rewards are
imbalanced, the individual is stressed and in the long-run is more likely to experience
negative health outcomes.
The concept of status control is especially relevant in trying to understand the effect of
work organization at ODSP. Status control is a function of forced occupational change,
downward mobility, lack of promotion prospects, and occupying jobs inconsistent with
educational backgrounds. When workers experience low status control it can threaten
their sense of mastery, efficacy and esteem and evoke strong negative emotions of
fear, anger or irritation. It will be shown below that workers at ODSP are suffering a
decline in status control.
Evidence supporting the role of effort-reward imbalance in determining health
outcomes at work is becoming increasingly compelling. In the original study using this
model, Siegrist (1996) showed that the risk of acute myocardial infarction, sudden
cardiac death, and coronary heart disease was most elevated in those with at least one
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indicator of high effort and at least one indicator of low reward (p. 34). More recently,
the Whitehall II study has uncovered a significant relationship between effort-reward
imbalance and increased risk of alcohol dependence, psychiatric disorder, long spells
of sickness absence and poor health functioning (Stansfeld, Head & Marmot, 2000, p.
1).
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SECTION TWO: WORK REORGANIZATION AT ODSP
Section One reviewed the theoretical literature linking work organization and health
outcomes. Workload plays an important role in most of these studies. However, it is
now recognized that the impact of workload on health is influenced by other
characteristics of the workplace. In particular, levels of control at work, levels of
support, and the imbalance between effort and rewards are important. This section
uses data collected during 15 open-ended interviews and two focus groups at three
different ODSP offices. We begin with a description of work under the Family Benefits
Act, which preceded ODSP, to provide a point of reference. We then provide a
detailed description of the current organization of ODSP offices and end the section
with detailed discussions of workload, control, support and effort-reward imbalance at
ODSP.
WORK ORGANIZATION PRIOR TO ODSP
To provide a point of reference, we begin this section with a brief description of work
organization under the Family Benefits Act (FBA). Many of the staff of ODSP formerly
administered the FBA. Under the FBA, staff faced a heavy workload. However, they
enjoyed sufficient control and support at work to minimize negative health impacts.
There were significant intrinsic rewards from their work that kept effort and rewards in
balance.
Under FBA, much of the contact between Ministry employees and their clients was
through Income Maintenance Officers (IMOs). IMOs worked under a caseload system.
They were assigned a specific number of cases, from 400-500 individuals, for whom
they were the main contact. The IMO would process the initial application for benefits,
have access to local medical officials regarding the extent of disability, maintain the
files should there be a change in status and periodically review them for errors,
omissions or unreported changes in status. They were accessible to clients over the
phone, at the office, or during home visits. They became well versed in the special
needs of their clients, and could advise them not only of FBA programs but of other
forms of support for which they might be entitled. They got to know many of their
clients; their clients got to know them.
Workloads were heavy under FBA. Often, there were more demands than time to
satisfy these demands. However, staff had a high level of control over how work was
performed, reported adequate support and access to resources to do their jobs, and
enjoyed a balance between effort and rewards. Work organization was compatible
with workloads. The IMOs' sense of control was a function of the caseload system
which resulted in them having a personal and long-term relationship with their clients.
They got to know their clients and their needs making it easier to do their jobs. In
addition, medical assessments were done locally and IMOs had access to medical
information needed to perform their jobs efficiently. They had access to information
needed to assess potential risks that clients might pose for case workers. Staff
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reported they were consulted by management about how best to organize the
workplace and that there was sufficient flexibility in the system to allow local offices to
adapt to local conditions. Staff reported they were supported in doing their jobs and
that they worked as a team with management with the common goal of serving the
needs of their clients. They drew a sense of satisfaction in knowing they were doing a
good job and that clients recognized this. The work was intrinsically rewarding
contributing to the balance between workload and rewards. In short, they liked their
jobs.
The following quotes provide a sense of what it was like to work under FBA.
"We were happy, we had case loads, clients got tremendous service, there was
more integrity in the system" (Focus1).
"Everybody saw a finished product. We were getting through our work. At the
end of the day we were saying, I feel good because I was getting some work
done." (B11)
"When I got a job here many years ago I was quite happy and I liked doing it, I
liked visiting people in their homes YI found I was making a difference in their
lives. I could give them some type of counseling, I could give them information
or referrals, I could help them with the services that we provided. I felt good
about that and I felt good about being able to maintain my workload. I managed
it well. I didn't have things that were behind, people weren't waiting for service
from me." (B22)
"Oh yes, when we used to have our own caseload and our social support, oh yes
we used to have fun. You know, we enjoyed coming to work." (A23)
High levels of control and support under FBA played an important role in making the
work experience a positive and healthy one. The following are descriptions by different
people.
"We had some control . . . . We had control about how we dealt with cases,
when we did what, the ability to try to balance everything. Sometimes we did it,
sometimes we didn't. . . " (C22)
"We used to have staff meetings. We could go as a group and say we need
people here . . . .You would make suggestions under FBA, this is a suggestion
we have and this is why we are thinking this. Alright let=s give it a try and if it
doesn't work we will come back and look at it in six months." (F2)
"Under FBA, when we had caseloads, clients knew me and they knew that I was
a straight shooter and they knew exactly where they stood. They knew that they
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came and got an answer that was the answer. Where now in this mess I see
somebody and they don't know who I am and I don't know who they are and it
takes forever to explain things and then they're not sure because that's not really
the answer that they want and they don't know me and there's no trust." (B24)
WORK ORGANIZATION UNDER ODSP
For many of the staff formerly administering the FBA, their world of work was
fundamentally altered with the introduction of the Ontario Disability Support Program
(ODSP) in 1998. Single parents became the responsibility of Ontario Works and social
support for low income disabled Ontarians was left to ODSP. More important, the IMO
position was eliminated and replaced by Client Service Representatives (CSR) and
Income Support Specialists (ISS). Tasks were further fragmented by creating
specialist CSRs and specialists ISSs who performed one small component of the
overall CSR or ISS job. The IMO job, which had involved most of the tasks needed to
administer benefits to clients, was reassigned to five or ten specialists, each
responsible for one component of the task. A third type of worker, the Income Support
Clerk (ISC) provides office support under ODSP. At the same time the tasks of the
IMO were being divided, there was a shift from the caseload system to a pooled case
management system. Under the latter the personal link between case worker and
client is broken. Clients are now the collective responsibility of all ODSP staff. Each
person in the office is responsible for their specialized task, but no one spends enough
time with a client to really get to know them. Further changes in work organization
were introduced in 2000 with the adoption of the Business Review Process (BRP), and
in 2001 with the introduction of a new computer software system referred to as the
Service Delivery Model Technology (SDMT).
The following personal descriptions of the work under ODSP provide a stark contrast to
that reported above under FBA.
"They are making the jobs more and more factory like. . . .It is more and more
like an assembly line approach. . . .You don't even have to think." (Focus 1)
"I can speak from experience Y it's just not a satisfying job. You don't get any
gratification; you feel like you're never getting anywhere. Everything is done by
the book, there's no room for leeway or say or opinions or concerns. It's just
never-ending. . . we're always behind in our work. . . there's just never a hope.
There's never any kind of glimpse that maybe it will get better."(B11)
"When I got a job here many years ago I was quite happy and I liked doing it, I
liked visiting people in their homes. . . . I found I was making a difference in their
lives. . . . I felt good about that and I felt good about being able to maintain my
workload. I managed it well. I didn't have things that were behind, people
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weren't waiting for service from me. . . .Now I feel I'm not doing that because I
am way behind in what I'm doing. All the time - if you take a day off, if you're
sick, you come back in when you're not well because you feel guilty because you
know you're getting even farther behind." (B22)
To understand how work could be so dramatically changed and how these changes
are affecting the health of ODSP staff, it is necessary to examine in detail the new
model of work organization at ODSP. This will be followed by sections exploring
workload, control, support, and effort-reward imbalance.
In organizing the work of administering ODSP, the Ministry was clearly guided by a
number of core objectives.
Divide the tasks done by IMOs under FBA between a number of more
specialized staff.
Assign much of the work to a new class of lower paid Client Service
Representatives.
Introduce a self-pacing system of work where staff generate tasks for
each other, complete tasks presented to them, and follow carefully
scripted steps in performing their tasks.
Depersonalize the link between ODSP clients and ODSP staff.
One suspects, the expectation was that this would create a more efficient and cost
effective system of work. Clients would get better service at less cost to the
government and taxpayers. Staff would enjoy better working conditions. The plan
appears to be going terribly wrong. Anecdotal evidence suggests that clients are not
getting better service. Conditions for staff administering this program have
deteriorated to the point where the health of staff is being negatively affected. The
system may be less expensive to operate in the short-run, but there is a danger of
serious long-run costs as the effects on employee health add up.
The shift to a pooled case management system is central to the new model of work
organization. Pooled case management facilitates an increase in the division of
labour, makes possible the implementation of rules and standards to make the work
flow through the office, and is instrumental in breaking the personal link between
ODSP staff and their clients. Under the new system, a client either phones an ODSP
office or visits one. Their first point of contact is normally the receptionist, a task
normally performed by an Income Support Clerk. The ISC routes the inquiry to a Client
Service Representative (CSR). The CSR makes an initial assessment of whether the
client is eligible for the program. If it is decided the client's claim should proceed the
CSR completes some preliminary forms and hands the "file" to the Income Support
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Specialist (ISS) specializing on intake.
The intake ISS is a specialized staff person who completes the application forms,
assesses their eligibility, and has the final say on whether a grant is made. They may
or may not have to meet with the client. To be eligible, a single client must have
income less than $930.00 a month (earned income may be treated somewhat
differently due to a Supports to Employment exemption) and assets less than $5,000.
While this may seem straightforward, it is not. The ODSP act itself fills a volume three
to four inches thick, and a regular stream of re-interpretations fills another volume 4-5
inches thick. The reason for this complication is in part related to the government's
desire to expand eligibility by taking a more liberal attitude to defining income and
assets that might disqualify an individual. The difficulty is in determining when income
is income and an asset an asset. This has become a gray area. An example points to
the problems. Owning a second home in Florida might not be considered an asset if
the client was asthmatic. There are similar problems assessing income. ODSP
extended benefits to the self-employed. Understanding the real earnings of a self-
employed person is trying for an accountant. ISSs must make a determination on
whether the income of a self-employed individual actually falls below the prescribed
maximum. ISSs receive minimal training in reading the accounts of self-employed
individuals and there is no systematic procedure for insuring that all ISSs are aware of
the regular policy interpretations. One ISS had taken it upon herself to collect all of the
interpretation e-mails and organize them by subject, a volume that is 4-5 inches thick.
Having assessed economic eligibility for benefits, the client must also be declared
disabled. This was previously done in local offices by the Medical Advisory Board and
the IMO had the opportunity, where necessary, of consulting with Medical Staff. staff.
Under ODSP the client is provided with a form to be completed by their doctor. The
forms are mailed to Toronto where a specialized unit determines a client's disability.
The local ISS is informed of the decision, however they are no longer entitled to
information about the nature of the disability.
Once a decision is made to grant income support, any number of people can get
involved with the client. The intake ISS hands the file over to the case management
ISS who oversees continued benefits and makes final decisions on supplementary
benefits on the recommendation of the appropriate CSR. The CSRs are the first
contact for a range of supplementary benefits including; employment start-up benefit,
community start-up benefit, drug and dental cards, and vision care benefits. They
administer the Mandatory Special Necessities Benefit which covers the costs of
diabetic supplies, surgical supplies and dressings, and transportation for medical
treatment. CSRs play an ongoing role monitoring client income and assets to ensure
continued eligibility for benefits. The client will be in contact with more than one CSR
as normally each CSR will specialize in one of these benefits. A third ISS is involved
reviewing client files (Consolidated Verification Process) every couple of years to
ensure the client is receiving the appropriate benefits. The number of people clients
see, and the number of people staff serve is further increased by the practice of
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rotating CSRs and ISSs through these positions about every six months, depending on
local resources. Under FBA, IMOs had a caseload of between 400 and 500 clients.
Under ODSP, an ISS or CSR can be responsible for their particular task for as many
as 4,000 clients.
The fragmentation of work across a number of CSRs and ISSs and the increase in the
number of clients they come in contact with eliminates the personal contact found
under FBA between client and staff. Other changes implemented by the Ministry
further eroded this personal link. Under FBA, clients could phone their IMO or visit
their IMO in the office on a day the IMO had set aside for office visits. Under ODSP
clients are not supposed to directly contact individual CSRs or ISSs. All calls to the
ODSP office are routed through the attending ISC who directs calls to the CSR who is
on the phones that day or on rare occasions to an ISS. Should the client visit the office
wishing to see someone regarding their file, the ISC would again direct the client to the
CSR responsible for office visits that day. The CSR might direct an enquiry to the ISS,
but only on rare occasions would the ISS see a client without a scheduled
appointment. The ISSs no longer hold regular office hours for client visits nor are they
supposed to share their phone extensions with clients. The closure of satellite offices
makes it difficult for many clients to even think of visiting an office. When they do
phone the office, they are advised to use the Integrative Voice Response System
which is supposed to give them access to basic information about their claims without
ever speaking to staff.
This new system of work has had a number of unintended consequences that raise
workloads. One problem is that the breaking of the personal bond between IMO and
client has created a situation where clients lack confidence in the decision of any one
CSR or ISS. Under FBA, clients would contact their IMO with whom they had a long
standing relationship. The IMO would either approve or deny a benefit and the client
could appeal if they disagreed. In most cases this did not happen as the IMO and the
client had established a sense of trust based on repeated contact. Under the new
system a client who phones at 10:00 and is dissatisfied with the outcome can phone in
the afternoon and speak with a different CSR and perhaps get a different outcome. It
was reported during the interviews that clients may phone as many as four times on
the same issue where before they would phone once. Repeat calls are increased by
the decision to turn CSRs into specialists in a specific benefit. When on the phones, or
doing office interviews, requests for all types of benefits may come their way. If the
CSR does not feel capable of dealing with the request, a situation which is itself
embarrassing to the CSR, they have to pass it on to the appropriate CSR, or in some
cases and ISS, where upon the client has to repeat their story. The depersonalization
of relations between ODSP staff and the clients they serve increases workloads by
creating more frustration with clients who are then more hostile in their dealings with
staff.
The organization of work under ODSP has fundamentally changed employee
experience of work. A detailed examination of the interview data allows us to
18
construct a fairly detailed picture of what it is like to work at ODSP.
WORKLOAD
One of the most obvious changes is a major increase in overall workload. For some
the load has simply become intolerable.
Client Service Representatives reported:
"We're never going to get caught up . . . I mean realistically most of the time
we're always behind by at least a month. . . .The system, it doesn't allow you to
get caught up, at least with the staff we have. . . . It creates a lot of stress." (B11)
"The majority of the time, depending on how many people we have on the
phones at one given time, as soon as you hang up the phone you've got another
call." (B11)
"(As a CSR) you never see the light of day, the mail just keeps churning in and
as a result it causes more phone calls (clients looking for answers) . . . in the
summer time, I know we were like at least seven weeks behind." (B13)
". . . you're supposed to yell out after three calls (in the queue). Nobody yells out
before double digits. Then on double digits you yell out and people look at you
and they're already too busy doing so many other things. . . . Last week I got
mad and I repeated myself and I said 'I don't think anybody heard me!' And then
everybody jumped on and that was it, everybody took one call and there was no
more calls in the queue and that was great. But it means that I have to look like
the big bee because I decided to get mad at my co-workers. Like I'm not their
mother. I was just frustrated and I acted out on a moment of frustration but does
that mean that I have to do that all the time?" (A11)
"The workload itself, I mean it goes up and down but it can be just staggering
sometimes I mean you don't know where to start. We always have people (off)Y
we have two people off on stress-leave right now. . . . There are people who are
off on sick leave for months at a time who aren't replaced. So the workload and
the stress, it's just a big issue."(A12)
Income Support Specialists report:
"But you're always behind and that's what bother me because I've never been
behind. When I had my own caseload, I was always totally up-to-date. I'm good
at managing my work. But there's a point beyond which with 1700 clients, and
you're dealing with all the difficult stuff, that I simply can't keep up-to-date, I can't
keep on top of it. And it bothers me because I know I'm not dealing with rich
people who want an income tax return, I am dealing with poor people." (B22)
19
". . . it's getting me from both sides and it makes you sick because you're not
doing your job, you=re not serving your clients, you=re not serving the taxpayer,
and you come in everyday and the stuff is falling out of your cabinet because it's
too much to do." (B22)
"Hopeless in the fact that we're never going to get our heads above water as far
as workload issues. . . . I feel hopeless on my end because I'm never going to
get through these mounds of paperwork so I can help these people. On the
other end they're sitting there, they're waiting, 'well when is she going to get it
done?' And it's just a vicious cycle. . . . We are granting files where the people
have already died because a decision hasn't been made. . . . but because of the
backlogs everywhere, you know, these things aren't getting done on time." (A24)
"It=s a very fast paced, forever changing environment. There are many tasks
that are expected to be done. . . . There are so many different things happening
all the time that it becomes very frustrating." (C22)
There are a number of reasons why staff feel they face excessive workloads. One is
the lack of staff to do the job and the failure of the employer to replace vacancies.
Equally important is the extra work generated by the system itself. Two themes
repeated again and again in the interviews were the increase in errors and mistakes
created by people rushing, and the extra burden of repeat calls or dissatisfied clients
as a result of the depersonalization of the relationship between staff and clients. For
example:
"Today . . . the same client phoned every one of us to get a different answer. He
wanted to get the answer he wanted to hear and every time he got the same
answer - he got an answer he didn't like - he yelled at us and hung up. So that's
what life on the phones is like." (B13)
"We're supposed to put a note in the computer every time we speak to someone.
So you'll open up a file and they've called five times and talked to five different
people hoping to get a yes from someone. . . . They'll just keep calling until they
get someone who says 'oh okay I'll do that up for you.' "(A12)
"As a CVP worker I'm going into files where I find situations that never would
have happened if it was in one person's hands that affect the client with major
over-payments, there are clients who shouldn't even be on the system who are
on the system."(F1)
"We're finding that people don't access the . . . interactive voice response,
because either they don't know how to use it or they want to talk to us directly.
They don't want to push all these buttons to get the information." (B11)
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"I use to deal with people that have psychiatric disabilities. . . . If they phoned in,
which this one client does day after day after day, the clerk could say would you
take that call . . . . I could say don't call back again today, you have gotten your
answer today, please don't call back, you can call me tomorrow. Where now, it
bounces to twelve different people, she is calling every half hour talking to those
same people and nobody has the authority or knows her well enough to say don't
do that." (F2)
Another source of extra work is the disorganization created as a result of the
fragmentation of work and the decision to introduce standards to control the work pace.
Mail is distributed through the office according to the person specializing on each task.
As well, mail is supposed to be answered in three days. Each day's mail is sorted
according to the day it arrives. After three days the mail goes to the manager's office
who then tries to find someone to deal with it. The following are descriptions of what
happens when a client calls seeking a report on the status of his mail request.
"In the past . . . as an IMO, mail came in for your client. The person would look
on the screen and say 203 goes to her box and it would all go there. So if
someone called in and said did you get my wheelchair repair request, it was all in
one spot. It is not in day one, two, three, four it is not back in the manager's
office. . . it is not with (a staffer) because she has a half hour to work on some
mail. . . . All that does when you are looking for one piece of paper in that mess,
all that does is backlog everything else because you are spending time looking
for this critical piece of paper to process something and you are wasting 25
minutes looking for it, in the meantime the phone is just ringing again. . . . But in
the manual it says that is the way the mail has to be processed." (F2)
"When a client calls to say 'well, you know, I mailed in my earnings a week ago
did you get them.' I'd flip through stacks and stacks of earnings to see if we got
those client's earnings meanwhile the queue is building. I'd prefer to do my own
client's earnings so that I have them on my desk, they're organized the way I
want to have them organized. I know that we have them, rather than spending
ten minutes going through a pile of paper. Oh every day we have to go through
several people's desks. There's too many hands on the files." (A12)
CONTROL
In all three models discussed in Section One, control at work is viewed as a key
moderator of the link between workload and health outcomes. Interviews with ODSP
staff suggest they have very little control over how work is done and much less than
was the case under FBA. There are a number of reason for this. One is that under
ODSP, and increasingly with the introduction of BPR in 2000 and SDMT in 2001, very
tight scripts were introduced on how to do each task. Province-wide procedures were
21
introduced for how calls are sequenced through the office, how mail is organized, how
quickly appointments must be scheduled, and what colour folder is to be used for
different types of claims. For example, the ODSP Procedures Manual dated October
25, 2000 provides a nine page task list for the CSRs, ISSs and ISCs dealing with a
self-referral application. Staff are directed to use the intake telephone script, advance
list, intake tracking tool, intake referral worksheet, intake log, intake checklist and
Canada Customs & Revenue Agency report. The four pages of instructions inform the
CSR when to use these tools, and stipulate that appointments with the ISS must be
made within 21 days, that confirmation of the applicant's status must be done the next
day as well as handing the file over to an ISC. The ISS is told how to prepare for
interviews, the detailed steps in completing an interview, where to file forms, and
sample narratives to use to describe decisions. The introduction of these province-
wide procedures has reduced control in a number of ways. First, staff report there was
minimal consultation with staff on how to organize the offices. For example:
"We had no objection to them reforming and changing but we expected that we
would be a very essential part of how those changes were formulated. We were
left completely out of it. It's like 'here is what is going to happen.' It's just
imposed on you from the top down. These are the changes, this is what is
happening. You have no rights, nothing." (B22)
There is frustration that it is difficult to change existing procedures as the goal was to
standardize offices across the province. Interviewees reported:
"We don't have the ability to change anything. Things are dictated to us and so
with that comes a sense of helplessness and powerlessness to do anything
about changing anything. I mean right down to something as basic as you know
when we're able to take our lunch and when we're not." (B13)
"We have no input. We have no power to change things. . . Our management is
quite ineffective and not supportive of us. They're supportive of the structure but
not of us particularly. They do nothing to help us, they don't even sympathize.
So you begin to feel powerless, helpless, hopeless. You muddle along and all
you think is 'nobody gives a damn.' Unless you goof up, then they're at your
door." (B22)
"Everything is so rigid. When you bring issues to the table to the regional office
to say this is a suggestion as to how we can fix things and how we can manage:
Absolutely not. We can't deviate from the book. We have to go by the process.
So it's just such a feeling of why bother. We have some very creative, very
intelligent caring people in our ministry with ideas, 'okay, this isn't working, come
on let's get something let's fix it so it can work.' And we don't have the capability
of doing that."(B24)
"Try as hard as we do, we don't feel that we will ever make any changes. As
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many suggestions as we make they are overlooked and overruled. We don't
know why and that is part of the frustration. . . . We really feel we are the
doormat and it doesn't matter what we do or what we say or what we think. It is
not going to make a big difference to anything that goes on. You just have to
make the choice in your own mind 'am I going to continue doing this for the
paycheque every two weeks'. You don't look for a lot of satisfaction." (C13)
"It can't be so rigid. We're dealing with people's lives, we're not dealing with
insurance claims, or widgets or spickets or whatever. We're dealing with
people's lives in crisis and our clients, when they come to see us, a lot of times
they're in crisis. So you can't have a real rigid square box. . . you can't be so
rigid. There has to be some input into how things can work within your region . . .
. You have to have some input into how to make some changes into how things
can work." (B24)
The scripts themselves reduce staff decision latitude and make it difficult to adjust
practices to local conditions. For others, the inability to come even close to reaching
the prescribed goals set out in the procedures is frustrating.
"We have very little say in how it's done, although you try to bend behind
people's back. But there this step-by-step procedure by which you're supposed
to be doing your work - which is really stupid because it was designed for one
particular situation like maybe if you're in Toronto and you've got a couple
hundred people and you=re on ten floors, you=re not just in a small office, where
most of our offices in Ontario are small, and it's a very ridiculous procedure that
you're supposed to follow. "(B22)
"Turnaround times are just so unrealistic. Wheelchair repairs, they are supposed
to be handled with one day turnaround time. Well good luck if they even get
picked up within five days. It just impossible to meet those targets." (F2)
"When a transportation (request) is turned into the office, it's supposed to be
processed by the CSR within two days and then I'm supposed to have it off my
desk within 24 hours or something like that. The client is supposed to have the
cheque within three days. It probably sits in the office for two or three weeks
before it's ever processed by the CSR and then if this is the two or three days
where I can do it, then I do it. But otherwise I'll throw it into my filing cabinet
because I have to do this other stuff. Even things that are totally nothing
eventually get to be a problem if you don't do them." (B22)
The shift to the pooled case management system reduces staff control over client
support. Under the case load system the IMO had control of the majority of the
support package offered to a client. Under ODSP, a number of CSRs and ISSs are
23
involved in each client's file, some granting the initial benefits, others responsible for
one or more supplementary benefits, others for case management and others for case
review. Staff have lost control over the overall support a client receives, while at the
same time becoming more dependent on each other to accomplish the objectives set
out for them in the procedures manuals. For example:
"(Under FBA) I had more control over my work . . . you managed a specific case
load so you were responsible for specific clients so you could actually follow a
piece of work till the completion of that piece of work. . . . Now nobody is
responsible for any specific file so I may make an initial decision and someone
else may be responsible for following up or modifying my decision, or overturning
by decision. . . . So there is no actual sense that you have any control over what
you are doing." (Focus 1)
"But the ownership isn't there. If we know that some piece of information is
passed to someone, it's their responsibility to complete it. There's no ownership
now so you don't know who didn't do their job and who did their job."(B11)
"The part that I really find quite frustrating is that . . . there are expectations. . .
within five days that should be done, within ten days this should be done. But
when you have no control over that when there are so many other things that
impact on whether or not you can do that. But you are the one that has to
answer to it if it does not get done. If you were responsible for it then you could
adjust things and make sure that your targets and stuff are met."(F2)
While staff have become specialists in specific tasks, they are often asked to advise
clients outside of their specialty, particularly when CSRs are handling phone enquiries
or conducting intake interviews. Many staff feel ill prepared to advise outside of their
specialty and report a sense of lack of control when this takes place.
"The payments were a huge frightening thing for me because I didn't know how
to read the sheets and that was a large part of our job. The clients want to know
how they got this overpayment. It's all a question of your own self-worth, you just
felt like you were a big dummy, Y. Because they had plunked you in this job and
gave you no training. And it's different when you've got a client on the phone
you can say, you know, 'oh I'll have to ask, just wait.' versus a client sitting
across the table from you and you're trying to look at this file and look like you
know what you're doing and you don't." (B13)
Many ISSs report a significant loss of control now that their interviews must be
scheduled by an ISC. One described the loss as follows.
"Number one I cannot book or schedule my own appointments. I can't do that
and that's very important to me, If I'm phoning someone to clarify a point. . . I
24
give it to someone else to set up an appointment. . . . It's like a production line. .
. . I can't sit there and say to that person 'this is when you can come in and see
me.' I have to go to a clerk and say 'when can you book this person in, can you
book this person in because I can't do that. To me it's like a feeling of mistrust -
that I don't work. . . . It's because they feel that the ISSs wouldn't book
appointments on Mondays and Fridays. So my point is, what does it matter
when you have your interviews, you work five days, seven and a quarter hours a
day. Whether you schedule an appointment on Monday, or you schedule
interviews on Tuesday, as long as you get your quota - and that's what it is, its a
quota - as long as you get that done what does it matter when you do it? . . . I
feel insulted the fact that I cannot schedule an appointment after all these years
with the Ministry and all of a sudden I can't schedule . . . an ISC on a rate five
can schedule me an appointment but I cannot schedule an appointment." (B24)
SUPPORT
The stress created by the increase in workload described above and the loss of control
is further compounded by a lack of support at the workplace. Staff feel management
has abandoned them and that they are poorly trained for the tasks they are asked to
do. Particularly irksome to many staff is the willingness of local management to bend
to local political pressure to change decisions based on ODSP policy or move clients
ahead of others who have been waiting longer for a decision. Staff reported:
"Somebody calls the MPP, somebody calls the ombudsman, somebody calls the
minister's office. It's crisis management: somebody comes to the office and
makes a fuss, that one gets pulled and you deal with that - which isn't a good
way of doing your work." (B22)
"It gets to you after a while, dealing with hard people and unfortunately it's been
my experience that we do nothing but teach the recipients that if he is verbally
abusive or physically threatening he'll get what he wants. Because management
will turn right around and say 'we just don't want to go to the media, or we don't
want him to make more of an outburst of this so just give him what he wants and
shut him up.' And then here I've been telling him that he can't get this benefit
because he's gotten it twice already and he's only entitled to it once a year. . . .
That makes me look like an idiot and someone who doesn't know my job, and
I'm doing exactly my job following according to legislation and then just like that
it's overturned." (A11)
"We are constantly being overturned because it is just the squeaky wheel
syndrome that if clients phone up and complain they get the supervisor and the
supervisor overrides our decisions. Call the MPs office, call a minister's office
you are guaranteed that this will be overturned just like that. That is very
frustrating. . . . We do not like to see unequal treatment of people. . . . It takes
25
away our credibility"(C21)
"The pressure is on to appease the client. . . Give them what they want, shut
them up, get them out the door."(C21)
There is a general feeling that training has been reduced under ODSP, that training is
insufficient and that overall management is not providing staff with the tools to do their
jobs.
"Years ago there used to be three to four weeks intensive IMO training where all
you did was classroom training . . . . That stopped ages ago. . . . They changed
over to ODSP. . . . You are going to be in the applications unit. . . . There were 4
of us and we had never done applications, we had never granted Ontario Works
files, and it was just do it. It was a lot of talk amongst ourselves: how do you do
this, how do you do that. . . . Calling over to some of the older staff that were part
of this, or that were now on another floor and can you show me how to do this?
There was no formal training."(A24)
"I know the program. They refuse to give me the tools to work with it. . . . The tool
is proper training and less pressure to perform. What happens is if you go
through that office and notice any desk in there there is paper all over that desk
and there are mistakes being made all over the place because we are trying to
deal with so many issues. People have boxes of paper around their feet that
they cannot get to because there is a more pressing issue . . . on the other side
of the glass." (C13)
"(Under FBA) I think that there was training at every level and a much more
comprehensive training than there is now. Our programs have become more
complex and we get a new program about every year which makes it difficult,
policy changes, legislation changes, computer programs change." (C21)
"We got a new CSR a couple of months ago and it was up to myself and another
CSR to set up her team links on email, to set her up with a phone, to set her up
because no one else was doing it. So she came to us with tears in her eyes,
saying 'what do I do? I haven't been told what to do.' She wasn't told her work
hours, nothing, nothing." (A12)
"When I was trained [under FBA] . . . I had someone from Toronto come down
and train me for a week. And that was training and then I job shadowed behind
another intake clerk. Now we are lucky even if we get outside training, it is
usually within our own office, and it's usually your peer." (B11)
"I think it's up to the ministry to make sure that it does work and to make sure
that I have equipment that I can use to do my job correctly without any extra-
26
added stress or frustration in my day-to-day life. I've have a life after ODSP and
I can't function in that life because of the stress in my job for my seven and a
quarter hours a day." (B24)
"You know I think that most of our CSRs are pretty good, but it's a lack of
training, it's a lack of direction. We don't have time - we don't have time to sit
down and do our job properly. And we don't have enough tools or, you know,
direction."(B11)
"(I trained) on my own, trial and error, ask questions. Put the client on hold and
run to the back. . . . (The day I started) nobody said to me 'okay, we'll get you set
up, here's going to be your desk, we'll get your extension set up for you.' All
that's your responsibility. I mean it was like a question of, you know, run around
the desk and whatever chair's empty you sit in. And so I basically walked around
the office: oh, there's a desk. Is anybody sitting there? Okay, I'll sit there. And
that was my desk. And I had no idea what I was doing." (B13)
"The job just sucks. I just have such high expectations and (management) don't
give me the tools to do the job. It makes it impossible for me to do what they
want me to do." (B24)
"We essentially don't get training when we start here, you're put in front of the
computer and said 'here is your place, go for it!' Which puts a strain on the staff
that have been here before because we're responsible for training our new staff.
On top of our workload" (A12)
Given the client base, many of whom suffer from serious mental disabilities while
others are simply frustrated by the low level of support and the difficulty and delays
associated with getting support form ODSP, it is shocking how little training staff have
in how to deal with potential harassment.
"The only training we have is ODSP legislation, how to work the computers. . . .
Basically how to do the work that's coming in, that's what the training is. I've
never had training in how to deal with an irate client . . . that's all up to me."(A11)
"In terms of the program, you really aren't told a whole lot, it's here's your desk,
here's the blue binder with the legislation, here are your fellow CSRs and ask
them if you have anything that you need to know about. . . . In the two and a half
years that I've been here I think I've had one half-day session on how to bring
people down if they're escalating their behaviour. . . . Most our clients are
mentally disabled. We don't know what we're going into when we go down into
an interview room to speak to someone. Are they on their meds? Have they
been taking their (meds). . . . I mean you don't know what you're up
against."(A12)
27
"Dealing with difficult clients, the last time that I had any training on that must
have been way back. . . . We're talking years ago." (A24)
"I think I once went to a (harassment) seminar for a day. You basically learn it by
experience and by reading notes that other workers have made as to how clients
behave when they were in the office. Very little in the way of formal training as to
how to observe body language or how to watch for escalation. You have to
basically pick this up yourself." (C21)
[Interviewer: If there is a problem in an interview room is there a warning
system?] "The button beside the desk. . . . You know what? There hasn't been
training in that in so long that if that alarm goes off that I bet we don't even know
what it stands for. . . . I'd forgotten all about that button." (B11)
EFFORT-REWARD IMBALANCE
The imbalance between effort and reward was one of the stronger themes in the
interviews. A lot is being asked of staff, many feel poorly paid, and most report low
levels of intrinsic rewards associated with doing a job well. One ISS described the
imbalance as follows:
"Hopeless that you're never going to get the satisfaction of doing your work the
way you want your work to be done. That there's no sensitivity on
management's part . . . And the helplessness is that things aren't going to
change, they're not going to get any better. You don't have enough time and
there's just too much of it. There's just too much." (A23)
A number of staff felt abandoned by management and reported management rarely
acknowledged a job well done. They seemed more concerned with the inability of
most offices to come even close to attaining the standards specified in procedures
manuals.
"I get more rewards from my peers . . . than from management. If you're
expecting a pat on the back from management, you're not going to get it. I only
hear about when things are wrong, or when my work=s behind, or how are you
with your MSNs. You know they're constantly asking for our stats. How are you
doing? - they really don't want to know how you're doing, it's, How far behind are
you? . . . It's a job and it pays the bills and that's about it. . . . I don't get a lot of a
sense of accomplishment from management. It just isn't there. . . I feel really
trapped." (B13)
Intrinsic rewards have fallen as a result of the division of labour in the office and the
28
sense that staff no longer interact with people but simply process files.
"(ODSP) has increased the workload plus you are not seeing anything through.
You are getting a bit in the middle. You are not getting it from the beginning and
seeing it through to the end and any job satisfaction. . . you get a chunk out of
the middle you do that and you give it to somebody else. The jobs not
intrinsically satisfying. . . . All you know is that you did your piece. You have no
idea what happens to the client after that. Before you use to be able to see
progression or not." (F1)
"Before there were lots of intrinsic rewards with the caseload because you would
get someone from OW who was in bad way financially, was often in a bad way
emotionally, the whole aspect of single mom on disability, they had lots of issues.
You could watch them progress through first income stabilization then through
referrals to other places. You could connect them with appropriate agencies and
then they would let you know what was happening. Eventually you would have
the aspect of someone remaining on but stable and working well because they
had all the supports they needed or going off to better things as in the case of
sole support moms. I found both of those things very gratifying. I also like the
continuity of having somewhat of a professional relationship with the people I
dealt with as clients and knowing them so that when they called I didn't have to
read ten minutes of narrative to get a picture of that person in order to deal with
the issue they had in hand. All of those intrinsic kinds of things are gone. For
me it is a big loss." (C25)
Increasingly, staff at ODSP no longer see themselves as social assistance workers.
They think of themselves as factory workers receiving few intrinsic rewards.
"[It is a] production line, it's true! You're just processing stuff YI think in FBA you
had time to get to know some of the clients and you really knew your own clients
but now you don't. You just process stuff, process it and move it on, do it, pass
it on, keep it going. That's exactly how you work, you just go, go, go." (B11)
"We do the same thing over and over and over. There is no variety, you don't
see anything through, you're in the middle, you do a function and that is the end
of it." (F2)
"I feel like . . . a milk factory or a cigarette factory where everybody has their own
task. Basically a task, not a job, a task. I can see it coming that there will be
specialized people for moving expenses and working visas and changes of
address. . . . So everybody's going to have this itty-bitty task and it's going to be
a giant machine. You know everybody's going to have to do their itty-bitty task
and if there's some place where something goes wrong the whole thing's going
29
to screw up." (A11)
"It is really bad the way that we are treated. We are just like robots. One day
the boss came in and said you are factory workers . . . " (C34)
The older staff I interviewed felt trapped in their current jobs due to lack of alternative
prospects, while younger staff did not see any career prospects and were looking for
other jobs.
"I'm not thrilled about my job. I'm looking for other jobs. One of the big issues
for me is pay" (A12)
SECTION THREE: JOB STRAIN AND ODSP WORKPLACES
The Karasek Job Demand-Control model is used extensively to predict the health
impact of different forms of work organization. The model was discussed in Section
One above. The core prediction is that as control falls and workload increases, health
risks increase. The highest health risks are found in the AHigh Strain@ quadrant where
control is low and workload is high. There is some debate about which quadrant has
the least health risks. Those in the AActive@ quadrant benefit from a positive work
experience and active learning, while those in the ALow Strain@ quadrant enjoy a
relaxed work environment. Both enjoy below average health risks. Those in the
APassive@ quadrant suffer from a gradual atrophying of learned skills and abilities and
a lack of motivation. Health risks are likely to be average.
Everyone who participated in the interviews or focus groups was asked to complete the
14 question Karasek Job Content Questionnaire (See appendix one). This is a
standard instrument used by researchers. Everyone was asked to complete one
survey to reflect their current job. Those who worked under FBA were asked to fill in a
second survey describing their last job under FBA. Surveys were received from 12
ISSs, 7 CSRs and 3 ISCs. Of these, 16 had worked under FBA including 12 as IMOs
and 4 in the OAG7 job classification performing mainly clerical work. This allowed a
comparison between IMOs and OG7s under FBA with ISSs, CSRs and ISCs under
ODSP. The author also drew on his personal data base of a large Canadian
manufacturing sector to provide comparisons with trades, technical/office/professional
classifications, and assemblers. To construct the quadrants, the average index scores
from the Cornell Work Site study were used.
There is strong evidence in support of the hypothesis that the average employee under
ODSP has less control and a higher workload than under FBA. Compared with the
average IMO, the average ISS reported a 37% reduction in decision latitude and a
22% increase in workload. Compared to the IMOs, the average CSR reported a 47%
reduction in decision latitude and a 35% increase in workload.
30
Relative to other job classifications, the IMO was the only classification located in the
Active quadrant in Figure Two. The three job classifications from the manufacturing
sector were on the border of the Passive and Low Strain quadrants. Their health risks
would be average to low. The old clerical classification under FBA, OG7 was just
within the High Strain quadrant. Perhaps the most striking was the result that all three
of the ODSP classification, ISS, CSR and ISC were well within the High Strain
quadrant where we would predict health risks to be above average.
31
SECTION FOUR: STRESS AND HARASSMENT AT WORK
Section Two described the system of work organization at ODSP. Section Three
reported results from the 14 question Karasek Job Content Questionnaire and showed
that relative to IMOs, CSRs and ISSs reported higher workloads and lower levels of
control. While the IMO under FBA fell into the "Active" quadrant, the new tasks
associated with the CSR, ISS and ISC were all in the "High Strain" quadrant, a
quadrant associated with higher health risks. All of the evidence reported to date
suggest that the health of workers at ODSP is at risk. The extent of this risk can be
documented using data collected during the interviews.
A number of interviewees described situations where stress led to people breaking
down at work.
"The girl that does the earnings, she has worked there for seventeen years and
was sitting there sobbing uncontrollably the other day because she didn't feel
she knew what she was doing anymore. They've taken away all of her
confidence." (C13)
"People are overworked so when you're overworked at one point your body or
your mind says enough is enough. . . . I've seen people cry in the office because
they're just overwhelmed. I've never worked in a place where I've seen people
cry because of just frustration of just being exhausted or just having too much
and not seeing the light at the end of the tunnel. I've never experienced that
before. And I say that's crazy. . . . $18 an hour definitely does not compare to
the stress or the being overworked and even dealing with a population like that."
(A11)
"They don't seem to care. . . I see the other staff leave the office crying. That's
just unheard of, I mean that should never happen. And when people get so
stressed out they start yelling at each other and things like that, that should also
not happen. That there is not someone there to pull things together, you know,
to assist people. They're sort of left on their own when they go home."(A23)
"I really like helping people. . . (but) in about the last 6 or 8 weeks, I don't want
to come in to work. . . . I was at work (last week) and I was just shaking . . . . I
thought enough is enough. I'm going to the doctor's. . . . I went down to this
clinic and I explained 'I don't like my job!' You know I used to like my job, I used
to keep up with things and all they can do is here's some anti-anxiety medicine."
(A24)
Others report problems sleeping and other stress-related illnesses.
"The person that comes back from vacation regrets going on vacation. . . . A
couple of days before you are due to come back from vacation you cannot sleep,
32
all you do is worry about what you are going to have to come back to face. . . . I
skip lunches, I work through my breaks, I even used to stay late, I used to stay
an hour every night . . . unpaid, I had this thing that it had to get done. . . .
Everyone I speak to cannot sleep on Sunday nights." (Focus 1)
"But you don't do that (miss work) too often unless you feel . . . like you're going
throw up or something because you know that people are relying on you being
there. . . . You think oh my God, why am I doing this to myself? I hate this. . . .
Nobody sleeps Sunday night because you're going back in to work Monday
morning and it's just what you think about. By Sunday supper it's what you're
thinking about: Monday at work." (B22)
"There are many people who when we are talking, talk about not being able to
sleep at night. Taking your feelings home, high frustration level. Because we
have been telling them for years that this isn't working, and they don't change it,
they don't get it. . . . They either don't listen or they don't care. The end result is
the same: nothing changes, nothing gets better, it only gets worse."(C21)
"I spoke to some of my colleagues to get how it is they are feeling, what kind of
emotions are they feeling. Sleepless nights, fatigue, frustration, big time
frustration, doubting of oneself, feeling of inadequacy, anxiety, mental and
physical exhaustion, people are experiencing headaches, neck and eye
problems. . .and anger, people are really angry." (C22)
"People are waking up at four o'clock in the morning and not being able to go
back to sleep. People are dreaming all night long about a place of employment.
People are just not healthy, they are not happy. It makes for a really sad work
environment." (C22)
"(The conditions) have caused sickness with me. Another lady was out on sick
leave with shingles . . . another lady suffers from migraines, two to three a month
. . . for myself I'm up half the night. I keep waking up, my sleep patterns are
broken. . . . I resent waking up worrying about somebody's community start-up
benefit at four o'clock in the morning wondering if I put the paper work in the right
place because a lot of people are depending on us. . . . We are all paying the
price for a lack of management, a lack of training." (C13)
Others report the workload and conditions interfere with life at home.
"They (management) don't really care about how realistic what they're asking you
to do is. I mean the standards that they're creating for you, they've set the
amount of people that we need based on our caseload for our office and that's
lovely on paper, but we don't have that and haven't had for quite some time. So
we've basically worked without our full complement of staff. But you know they
33
still crack the whip. . . . The standards are still there and you're still asked to
meet them. It's very stressful. I carry it home to my family and I shouldn't. I
should leave it at work and that should be it." (B13)
"I was off on stress-leave a year ago . . . because I was to a point where I was
overloaded. Like my brain was shutting down. Like I could feel myself - I would
stand in my kitchen at night and not even be able to think where the pots were to
make dinner." (B13)
"Hopeless that you know nothing=s going to change. You know if you're
swamped in work there's no hope that it's going to change. The system, the
BPR, is not going to change. They're not going to spend that money to change
the system and then change it back. If you have a really horrible client, nobody
else is going to want to deal with them so you're stuck dealing with him.
Helplessness, it's the same thing. Everyone is swamped, no one can help out
with other people for most of the part. So you sit there and, you know, 4:30 hope
it comes soon because there's nothing else to do. There's no way out of it at all.
I dread coming to work. I get used to it, but I do not like my job at all. You take
it home with you for sure. I get home and I'm exhausted." (A12)
" I think what you really have to take into consideration is the nature of the work,
the fact that we administer social services. We are probably dealing with the
most marginalized segment of the society and the decisions you do make impact
directly on the quality of life of these people. So that essentially is what you take
home, I didn't manage to finish doing this and now they don't have that . . . not
only that because you didn't manage to finish this so they don't that they are
standing in front of you and screaming how am I going to feed my kids." (Focus
1)
Stress at work is further compounded by a constant concern about harassment by
clients. As detailed above, staff get no training in how to handle harassment while at
the same time the organization of ODSP has increased the frustration level of clients.
Staff reported:
"I'm concerned (about harassment) . . . . I had a woman in the other day. She
was fine and it wasn't until afterwards that I realized that she had a flag on her
file. . . . I'm working at my desk because between walk-ins I'm processing my
MSN . . . so I can't go in to check (on my computer). I probably should - on
somebody else's computer" (B13)
"CSR will take a client into the office, shut the door and hope for the best." (F2)
"I had some letters that were sent over the holidays . . . threatening to do me in
34
and so and so on. The potential=s there." (F2)
"My biggest stress issue is the safety issue because if I don't feel safe then I'm
stressed. I mean I had an incident last summer where I was told that he was
going to kill me. That stressed me for a long, long time and now every time I'm
on intake that means that I have to deal with someone face-to-face in a room
that's not bigger than this little area here and there's nothing to protect me from
this person. I get really stressed out. . . I definitely don't feel safe. . . . If I'm
meeting someone that's potential 911 but hasn't acted out yet, it takes one
incident so we can code him as dangerous. [Once designated 911] you meet
them with the plexi-glass so that leaves you physically protected. But in order for
them to be in that 911 room or to have that code, you have to have an incident.
And it could be me, it could be someone else and it happens a lot."(A11)
"We deal with clientele, they're constantly screaming at us, harassing us, we've
been threatened, we've been stalked. Stuff like that, we have violent people, you
know getting yelled at for 8 hours a day is very stressful." (A12)
"I've had death threats left on my answering machine. I had to have the police
involved with one person. I had to have my boyfriend pick me up and drop me
off at work because this guy would be sitting there waiting for me. I mean, I had
to go be a witness so I could get a restraining order on him. I mean it's really
stressful."(A12)
"I had a client . . . he is on the phone ripping my face off, probably the worst I
have experienced in 15 years. Very intimidating, bullying, threatening, name
calling. I tried to reason with him. . . He came in . . . . When I went into that
interview I was shaking so bad . . . . I could barely hit the keyboard to strike a
key. I was afraid of him physically and I was intimidated by his bullying and stuff.
. . . In addition I had felt all the way along that I was totally unsupported." (C25)
35
SECTION FIVE: CONCLUSIONS
This assessment examined the organization of work and health outcomes at ODSP
offices. This assessment was informed by a body of literature linking health outcomes
with workload, control at work, support at work and the balance between effort and
rewards.
The assessment relied heavily on data drawn from interviews with ODSP employees. It
is rare for a group of employees to go to the length of challenging their employers over
work organization. In completing this assessment, I now have a sense why this has
happened. Their words paint a compelling picture of a troubled workplace, where the
organization of work has increased stress and is affecting health outcomes. The
interviews describe working conditions, levels of stress and risks of harassment that no
employee should have to accept in exchange for a job.
If management are serious about living up to their contractual obligation "to make
reasonable provisions for the health of its employees", they would want to heed the
recommendations found in a recent review of work organization in Canadian health
care workplaces. This review captures the spirit of our new understanding of how work
organization affects health outcomes. They recommend designing work to provide:
Tasks that are varied and require the use of a broad spectrum of skills;
Worker involvement in the whole job, not just part of it;
Jobs and organizational systems that enable workers to exercise discretion
and autonomy in how work is done;
Feedback from supervisors and coworkers into an individual's job
performance; and
Opportunities for workers to have an input on decisions that affect their jobs
and work environment. (Koehoorn, 2002)
At present, the system of work organization at ODSP has none of these characteristics
Having examined the interviews, analyzed the survey data and again reviewed the
literature, including my own studies in the field, I have concluded the following:
The employer has failed to consider the health of its employees in the
reorganization of work under ODSP. The consulting firm hired by the
employer to design this workplace revealed a shocking ignorance of the
growing literature linking work organization and health outcomes.
36
The changes in work organization first introduced in 1998 have increased
workloads, a situation compounded by the failure of the employer to fill staff
vacancies promptly.
The changes in work organization have reduced staff control over how work is
done and reduced the support given to staff to complete their tasks.
The changes in work organization have created an imbalance between effort
and rewards at work.
The increased stress reported by ODSP staff is directly related to the way
work has been organized.
Unless rectified this stress will result in serious short-term and long-term
health costs for ODSP staff.
Unless rectified this stress will reduce staff productivity and raise costs
associated with administering ODSP benefits.
Accordingly, I recommend that the employer:
Increase staffing levels;
Create a qualified and trained labour pool that can be drawn on to fill
vacancies until permanent replacements are found;
Provide adequate training in how to interpret ODSP policy, how to interpret the
stream of policy interpretations, how to detect situations that could lead to
harassment by clients, and how to manage such situations;
Provide adequate release time from normal duties while staff are being
trained;
Recognize that training takes time and that staff must be relieved of their
normal duties when being trained;
Make local management aware of their role in supporting local staff and
minimizing the health effects of stressful work; and
Re-examine the assumptions shaping the organization of work at ODSP
offices. Staff need to be viewed as assets, not simply as costs. This will
require a full evaluation of current work practices and a commitment to make
changes in line with our current understanding of how work organization
affects health.
37
To ensure that work is reorganized I recommend:
The employer and the union jointly initiate a consultation with local ODSP staff
to solicit suggestions regarding how to reorganize workplaces to improve
health outcomes. Staff have a wealth of knowledge regarding what works and
how to make things work better while at the same time reducing stress levels.
It is my opinion that this will also improve staff productivity.
Amongst other things, this consultation should examine changes that will
reduce workloads, increase staff control at work, increase support and create
a balance between effort and rewards.
These local suggestions need to be moulded into a province-wide plan for
reorganizing workplaces. This could be a task for the Management Employee
Relations Committee (MERC).
As evidence of the Employer=s sincerity in this process, they should
immediately write to all staff employed by ODSP expressing their regret
regarding the effect that recent changes in work organization are having on
staff and a commitment to rectify the situation.
An independent agent should be appointed to monitor this process and to
assist the parties in their quest for a truly healthy workplace.
38
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41
APPENDIX ONE:
A) CONTROL QUESTIONS
1. My job requires that I learn new things.
strongly agree agree disagree strongly disagree
2. My job involves a lot of repetitive work.
strongly agree agree disagree strongly disagree
3. My job requires me to be creative.
strongly agree agree disagree strongly disagree
4. My job allows me to make a lot of decisions on my own.
strongly agree agree disagree strongly disagree
5. My job requires a high level of skill.
strongly agree agree disagree strongly disagree
6. On my job, I have very little freedom to decide how I do my work.
strongly agree agree disagree strongly disagree
7. I get to do a variety of different things on my job.
strongly agree agree disagree strongly disagree
8. I have a lot to say about what happens on my job.
strongly agree agree disagree strongly disagree
9. I have an opportunity to develop my own special abilities.
OPSEU ODSP SURVEY
January 2002
42
strongly agree agree disagree strongly disagree
B) WORKLOAD QUESTIONS
10. My job requires working very fast.
strongly agree agree disagree strongly disagree
11. My job requires working very hard.
strongly agree agree disagree strongly disagree
12. I am not asked to do an excessive amount of work.
strongly agree agree disagree strongly disagree
13. I have enough time to get the job done.
strongly agree agree disagree strongly disagree
14. I am free from conflicting demands others make.
strongly agree agree disagree strongly disagree
43
FORMULAS FOR CALCULATING JCQ CONTROL & WORKLOAD
(0 = low control/low workload 100=high control/high workload)
(All responses coded 0=strongly agree to 3=strongly disagree)
Control= [((15-learn-creative-skill-variety-develop+repeat)*2) +
((6-decision-say+freedom)*4)] * (100/72)
Workload= [ ((6-fast-hard)*3) + ((excess+time+conflict)*2)) ] * (100/36)
TABLE A1: CONTROL/WORKLOAD VALUES BY JOB CLASSIFICATION
JOB CONTROL WORKLOAD JCQ QUADRANT
CLASS
A) FBA
IMO 76.2 67.4 Active
OAG7 52.8 65.3 High Strain
B) ODSP
CSR 42.6 91.3 High Strain
ISS 48.1 81.9 High Strain
ISC 38.0 78.7 High Strain
C) MANUFACTURING
ASSEMBLER 26.4 55.3 Passive
TECHNICAL/OFFICE 65.6 50.7 Passive
PROFESSIONAL
SKILLED TRADES 69.1 46.6 Low Strain
D) CORNELL STUDY 69.0 56.0
44
APPENDIX TWO: GLOSSARY
BRP Business Practice Review
CSR Client Services Representative
CVP Consolidation Verification Process
ERI Effort-Reward Imbalance
FBA Family Benefit Act
IMO Income Maintenance Officer
ISC Income Support Clerk
ISS Income Support Specialist
JCQ Job Content Questionnaire
JD-C Job Demand-Control
MSN Manditory Special Necessities
ODSP Ontario Disability Support Program
SDMT Service Delivery Model Technology
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Study objective: Despite an overall decline in mortality rates, the social gradient in mortality has increased over the past two decades. However, evidence on trends in morbidity and cardiovascular risk factors indicates that socioeconomic differences are static or narrowing. The objective of this study was to investigate morbidity and cardiovascular risk factor trends in white collar British civil servants. Design: Self rated health, longstanding illness, minor psychiatric morbidity (General Health Questionnaire (GHQ) 30 score, GHQ caseness and GHQ depression subscale), cholesterol, diastolic and systolic blood pressure, body mass index, alcohol over the recommended limits, and smoking were collected at baseline screening (1985-88) and twice during follow up (mean length of follow up 5.3 and 11.1 years). Employment grade gradients in these measures at each phase were compared. Setting: Whitehall II, prospective cohort study. Participants: White collar women and men aged 35-55, employed in 20 departments at baseline screening. Analyses included 6770 participants who responded to all three phases. Results: Steep employment grade gradients were observed for most measures at second follow up. In general, there was little evidence that employment grade gradients have increased over the 11.1 years of follow up, but marked increases in the gradient were observed for GHQ score (p<0.001) and depression (p=0.05) in both sexes and for cholesterol in men (p=0.01). Conclusions: There is little evidence of an increase in inequality for most measures of morbidity and cardiovascular risk factors in white collar civil servants over the 11.1 years to 1998. Inequalities have increased significantly for minor psychiatric morbidity in both sexes and for cholesterol in men.
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Objective-To describe and explain the socioeconomic gradient in sickness absence. Design-Analysis of questionnaire and sickness absence data collected from the first phase of the Whitehall II study. Grade of employment was used as a measure of socioeconomic status. Setting-20 civil service departments in London. Subjects-6900 male and 3414 female civil servants aged 35-55 years. Main outcome measures-Rates of short spells (less-than-or-equal-to 7 days) and long spells (>7 days) of sickness absence. Results-A strong inverse relation between grade of employment and sickness absence was evident. Men in the lowest grade had rates of short and long spells of absence 6.1 (95% confidence interval 5.3 to 6.9) and 6.1 (4.8 to 7.9) times higher than those in the highest grade. For women the corresponding rate ratios were 3.0 (2.3 to 3.9) and 4.2 (2.5 to 6.8) respectively. Several risk factors were identified, including health related behaviours (smoking and frequent alcohol consumption), work characteristics (low levels of control, variety and use of skills, work pace, and support at work), low levels of job satisfaction, and adverse social circumstances outside work (financial difficulties and negative support). These risk factors accounted for about one third of the grade differences in sickness absence. Conclusion-Large grade differences in sickness absence parallel socioeconomic differences in morbidity and mortality found in other studies. Identified risk factors accounted for a small proportion of the grade differences in sickness absence. More accurate measurement of the risk factors may explain some of the remaining differences in sickness absence but other factors, as yet unrecognised, are likely to be important.
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Improvements in health have become expected in wealthy countries. But both within and between countries there are substantial inequalities in health that have remained despite overall improvements. In some cases, these inequalities have become even more clearly visible. While universal access to high quality, affordable medical care is a social goal that should have high priority, it alone will not eliminate social inequalities in mortality rates. Inequalities in health are not limited to worse health among the poor. A gradient runs across society, in combination with the close link between income inequalities and health which indicates that relative deprivation is an important determinant of health inequalities. Providing more people with fulfilling jobs, adequate compensation, and social environments that foster good relationships may be of crucial importance in reducing inequalities in health. -from Author
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The Whitehall study of British civil servants begun in 1967, showed a steep inverse association between social class, as assessed by grade of employment, and mortality from a wide range of diseases. Between 1985 and 1988 we investigated the degree and causes of the social gradient in morbidity in a new cohort of 10 314 civil servants (6900 men, 3414 women) aged 35-55 (the Whitehall 11 study). Participants were asked to answer a self-administered questionnaire and attend a screening examination. In the 20 years separating the two studies there has been no diminution in social class difference in morbidity: we found an inverse association between employment grade and prevalence of angina, electrocardiogram evidence of ischaemia, and symptoms of chronic bronchitis. Self-perceived health status and symptoms were worse in subjects in lower status jobs. There were clear employment-grade differences in health-risk behaviours including smoking, diet, and exercise, in economic circumstances, in possible effects of early-life environment as reflected by height, in social circumstances at work (eg, monotonous work characterised by low control and low satisfaction), and in social supports. Healthy behaviours should be encouraged across the whole of society; more attention should be paid to the social environments, job design, and the consequences of income inequality.