Working Conditions and Workplace Barriers to Vocal Health in Primary School Teachers *Caitriona Munier and †Rory Farrell, *Geneva, Switzerland, and yDublin, Ireland Summary: Objectives. The purpose of this study was to identify the working conditions and workplace barriers to vocal health in primary school teachers. The relationship between working conditions and voice is analyzed. Study design. This is a survey study in 42 randomized schools from a restricted geographical area. Methods. An 85-item questionnaire was administered to 550 primary school teachers in 42 schools in Dublin. It was designed to obtain information on demographics, vocal use patterns, vocal health, work organization, working conditions, and teacher’s perceptions of the conditions in teaching that might cause a voice problem. The relationship between voice and overstretched work demands, and voice and class size, was examined. A chi-squared test was run to test the null hypothesis that the variables overstretched work demands and voice and class size and voice are independent. Subjects were given the opportunity to give their opinion on their working conditions and on the availability of advice and support within the workplace. A final question sought their opinion on what should be included in a voice care program. Results. A 55% response rate was obtained (n ¼ 304). It was found with 96.52% confidence that the variables overstretched work demands and voice are related. Likewise, it was found that the variables class size and voice are related with 99.97% confidence. Conclusions. There are workplace barriers to vocal health. The working conditions of primary school teachers need to be fully adapted to promote vocal health. Changes by education and health policy makers are needed to achieve this goal. There is a need for future research which focuses on the working conditions of teachers. Key Words: Working conditions–Vocal health–Voice problems–Overstretched work demands–Primary school curriculum–Workplace barriers–Class size–Support and advice–Early vocal symptoms–Voice training–Voice care programs– Teachers. INTRODUCTION One-third of the labor force works in professions in which voice is the primary tool of work.1 They include broadcasters, call center operators, court lawyers, teachers, business executives, singers, actors, clergy, and tour guides. To these professionals, the maintenance of vocal health is essential as voice is the critical component of their work. Excessive use or abuse of the voice at work can lead to the development of vocal symptoms of weak voice, sore throat, and to the development of a voice disorder.2 In the past, working conditions were not taken into account in the etiology of voice problems. The behavioral nature of voice was overemphasized as a factor in the development of a voice problem, and the responsibility was attributed to the individual. The impact of the working conditions was not considered nor was the relationship between working conditions and voice. There was no enough knowledge of the ergonomic and environmental aspects of voice disorders as an occupational health problem.3 The World Health Organization recognizes that work and health interact with one another. When work is fully adapted to human goals, capacities, and limitations and occupational health hazards are under control, work plays a role in promoting both physical and mental health. The work environment and its
Accepted for publication March 9, 2015. From the *Department of Banking and Finance, University College Dublin, Smurfit School of Business, Geneva, Switzerland; and the yMaxim Integrated International, Dublin, Ireland. Address correspondence and reprint requests to Caitriona Munier, University College Dublin, Smurfit School of Business, 5 Route du Bout du Monde, 1206 Geneva, Switzerland. E-mail: [email protected] Journal of Voice, Vol. -, No. -, pp. 1-11 0892-1997/$36.00 Ó 2015 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2015.03.004
characteristics can play a role, together with other risk factors in the development of diseases, having a complex multiple etiology. Some diseases can be called work related.4 Therefore, in the case of those who rely on their voice as their principal tool of work, their working conditions should be adapted to promote and maintain vocal health, and efforts should be taken to prevent the development of voice problems. Teachers Teachers represent the largest group of professionals who use their voice as their primary tool of trade.5 Voice is a worldwide problem in the teaching profession.6 Teaching puts heavy demands on the voice, teachers are heavy voice users, and they suffer from voice problems more frequently than other occupational voice users.7–14 They use their voice with high intensity, in noisy classrooms, for long periods without suitable breaks.15 Teachers sing more frequently and speak more loudly at work than nurses, and vocal loading factors are responsible for the appearance of voice problems in teachers.16 Voice problems in teachers are well documented in the literature. Studies have reported on their prevalence, nature, risk factors, number of years in teaching, vocal and physical symptoms, their impact on quality of life, performance at work, their economic impact due to absenteeism from work, and change of profession.7,11–14,17–25 Vocal symptoms The early identification of vocal symptoms in the workplace is critical in the prevention of a voice problem. Vocal symptoms were reported as being more common in teachers than in nonteachers (69% vs 36%).26 Munier and Kinsella20 reported that voice fatigue, dry throat, and inability to sing high notes were
2 statistically significant vocal symptoms in primary school teachers and may be the early signs of a developing voice problem. These findings on vocal symptoms are similar to those reported by Yiu.7 Vocal strain was reported to be the most prominent physical symptom in teachers.14 Ohlsson et al27 in a study of voice symptoms and risk factors in student teachers report that those with vocal symptoms are at risk of developing voice disorders during their career. One problem with voice is the inadequate or neglected examination and treatment of early symptoms.3 Impact of a voice problem Voice problems can lead to a diminished ability to teach and ‘‘extensive periods of sick leave and vocal rehabilitation which involves great financial loss.’’24 The author concluded that voice disorders impact on the teachers professional and social life and imply a major financial burden for society. In a Brazilian study, 29% of teachers reported that their voice limited their ability to perform certain tasks at work. They reported more adverse effects on job performance because of a voice problem.25 Many teachers need to stay at home because of a voice problem. Teachers also suffer from functional and psychological adverse effects because of a voice problem. They experience upset and excessive stress at work.28 In addition to impacting negatively on performance at work, quality of life, ability to socialize, and emotional state are also affected negatively.7 Lack of support from school colleagues and management compounds the problem.29 Primary school teachers versus other teacher groups Most literature reports on voice problems in primary school teachers, secondary school teachers, and sometimes even university lecturers as one group despite the fact that their working conditions are different. Primary school teaching puts much greater vocal demands on teachers than secondary school teaching. The main difference is in the duration of continuous voice use and opportunity for vocal rest. Primary school teachers teach for 5–6 hours continuously with little or no opportunity for vocal rest. Added to this are 37 hours of playground duty per year. This contrasts with the working day of secondary school teachers who teach for 45 minute periods, sometimes 90 minutes as a double period. These periods of teaching are interspersed with periods of vocal rest of 45 minutes or longer. This difference has been recognized by Sala et al,30 who suggested that vocal load for primary and preschool teachers is higher than for secondary teachers. Many studies have not taken this important difference into account and have reported on primary and secondary school teachers and sometimes university lecturers as one group in the same study.20 The first study to report on voice problems in primary school teachers as a single group was published in 2008.20 Since then, many studies on voice problems in primary school teachers as a single group have appeared in the literature.17,23,28,31 Given the above differences in working conditions, it is the opinion of this author, that studies should separate primary and secondary school teachers into two distinct groups.
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Purpose of this study The focus of this study is on the working conditions of primary school teachers and on the relationship between working conditions and voice. The purpose of this study carried out in Ireland was to contribute further to our understanding of voice problems in primary school teachers by examining their working conditions, teacher’s perceptions of these working conditions, and the relationship between working conditions and voice. The barriers teachers face in seeking advice, support, and treatment for a voice problem within the workplace are also examined. Understanding which working conditions may be barriers to vocal health is essential to our understanding of voice problems in teachers and to the appropriate timing of intervention, diagnosis, and treatment. There have been very few studies that looked at teacher’s perceptions of their working conditions and workplace barriers to vocal health. The first study to report on teacher’s perceptions of a voice problem examined the treatment-seeking behaviors of teachers in relation to their dysphonia.17 This study on barriers to care was informed by teachers perceptions, and this approach is very valuable in understanding voice problems in teachers. Work organization and working conditions of primary school teachers in Ireland According to the Central Statistics Office 2011 census, there are 32 600 primary school teachers in Ireland; this is of a total workforce of 1 836 000. Female teachers account for 85% of all primary school teachers with only 15% of these being male teachers.32 Their workday consists of a minimum of 5–6 hours of continuous teaching, with little opportunity for vocal rest outside of a 10-minute break midmorning and 30 minutes at midday. The class teacher teaches all subjects including physical education, art, music, and singing. A class includes a cohort of children of the same age-group, for example, in a ‘‘Junior Infant’’ class, the age range is 4–5 years. In addition to their normal teaching duties, their contract includes 37 hours of playground duty during the school year. Added to this, there is the extended working day which includes meetings with parents and fellow teachers, lesson preparation, and corrections. They work 183/187 days a year compared with 167/168 days for secondary school teachers. The extended working day can prolong the working day up to 10 hours. Teachers work 900 hours yearly as compared with the EU average of 700 hours. Many teachers teach classes of >30 pupils, and in some cases, class sizes can be as large as 40 or more. With these supersized classes, there is an increase in classroom noise level and consequently a need on the part of the teacher to increase vocal loudness to be heard. Yet, they are dependent on their voice to function throughout their entire working career, which can be as long as 35–40 years. Teaching also requires a wide variation in voice use in terms of pitch, volume, quality in reading, singing, teaching drama, and physical education. The Department of Education and Science in Ireland changed the primary school curriculum in 1999. The current
Caitriona Munier and Rory Farrell
Working Conditions and Workplace Barriers to Vocal Health
curriculum is commonly referred to as the ‘‘new curriculum.’’ The curriculum which preceded it was introduced in 1977 and was more traditional in its teaching orientation. Children were expected to work independently, and there was less emphasis on oral communication. An important component of the new curriculum is a greater emphasis on oral communication. Teachers are expected to encourage oral communication to enhance the child’s learning. In implementing this, a large amount of teacher-student verbal interaction is required. This focus is more vocally demanding for the teacher and gives less opportunity for vocal rest. It also creates more background noise as both children and teachers are expected to be more vocal. Another change has been an increase in the number of subjects taught from 9 to 11 subjects. Teachers teach the core subjects English, Mathematics, and Gaeilge (Irish). Other subjects include Science, Music, Drama, Art, History, and Geography. Religion, Physical Education, and Social Personal and Health education are also taught. By comparison, Scotland’s Curriculum for Excellence now has eight learning areas, and New Zealand also has eight learning areas.33 There are also recommendations on the number of hours per week that should spend teaching each subject. For example, the teaching of English and Irish should be allocated 4 and 3 hours per week, respectively.34 It is important to note that there is no voice training for student teachers or working teachers in Ireland, yet they are required to teach singing. The National Curriculum Council and Assessment (NCCA) has reviewed the 1999 curriculum in 2005 and 2008a. In both reviews, teachers and principals identified time as one of their greatest challenges in implementing the curriculum. Teachers reported that they had insufficient time to fully implement curriculum subjects or to address all the objectives within each of these subjects.35,36 Two separate dimensions of this time issue were identified: the scale and size of the curriculum; the challenge of meeting children’s individual needs particularly in multigrade and large classes. In 2010, the curriculum has been described as overloaded by the NCCA in their article review on curriculum overload in primary schools.33 HYPOTHESIS The aim of this study was to test the null hypothesis that there is no relationship between working conditions and vocal health. The relationship between the variables overstretched work demands and voice and class size and voice were examined. Overstretched work demands include long hours of teaching with little opportunity for vocal rest, curriculum teaching of 11 subjects, constraints of recommended number of teaching hours per subject, large class size, 37 hours of playground duty, and absence of advice and support for a voice problem in the workplace. METHODS An 85-item self-administered questionnaire was designed to investigate the working environment, professional vocal use, and voice problems of primary school teachers. Questions for this questionnaire were developed from the clinical experience
3
of the researcher, from knowledge gained through an examination of relevant questionnaires in the literature, and from a Hong Kong questionnaire.7 Some 550 questionnaires were distributed to all teachers in 42 randomly selected schools in Ireland. The study was carried out in the autumn term, to minimize the effects of winter colds and upper respiratory track infections on the voice. The distribution of the questionnaires at this time was also to avail of voice evaluation after a period of relative vocal rest during the summer vacation. A pretest of the questionnaire was carried out in a pilot study by asking 12 primary school teachers to fill in the questionnaire. On receipt of these, a follow-up telephone call to the participants was made to verify the answers. The aim was to perfect the questions. The results of these questionnaires and telephone conversations were used to modify and improve the original questionnaire. The questionnaire used in the pilot study was not included in this study. Each questionnaire was accompanied by a covering letter to all respondents, in which the purpose of the study was explained, and basic information on how to complete the survey. It assured respondents about the maintenance of an individual’s confidentiality. An envelope was provided with each questionnaire to protect confidentiality. Questionnaires were personally delivered to the schools and collected by the researcher. Formal ethical approval was not sought, as the study met all criteria for exemption, as set down by University College Dublin’s Human Research Ethics Committee. The study was anonymized, subjects were self-participating, and there was no conflict of interest. There was no bias or prejudice on subject’s careers as a result of having participated. In addition, the study did not involve a vulnerable group and was noninvasive. The questionnaire was divided into five sections: Section 1 was designed to obtain demographic information gender, age, and marital status, in addition to information on the working environment including class size, age-group taught, and number of years teaching. A question to determine if respondents had received voice training for teaching was included. Section 2 was designed to obtain data on vocal characteristics, recent changes in the voice, and common symptoms, which would indicate limitations in normal voice functioning were also elicited. Other questions were designed to obtain information on normal voice use and habits, singing and acting practices, recreational voice use, and the effects of teaching on the voice. Information was also obtained on stress, working environment, general health, and vocal health, including information on any visits to health specialist for a voice problem. Section 3 gave respondents the opportunity to report a voice problem and to include information on how it started, its evolution, duration, symptoms associated with it, and factors which may have caused it. This section relied on the respondents self-perception of their own voice and vocal health and provided an opportunity for identification of possible associated risk factors. Section 4 dealt with the effects of voice on work and lifestyle. This title and the 10 questions included in this section were used with permission from a Hong Kong study.7 It was designed to obtain information on the impact of a voice problem on work, on emotions, on communication, and on social life. Section 5 covered
4
Journal of Voice, Vol. -, No. -, 2015
knowledge of voice care and was also used with permission from Yiu.7 The last three questions were open-ended and gave respondents an opportunity to give their opinion of the conditions in teaching that may cause a voice problem. It also sought respondent’s opinion on the adequacy of medical and health and safety assistance available to them and to their colleagues. In a final question, respondents were also asked for their opinion on what should be included in a voice care program. This article reports on a subset of the data, which includes working conditions and their effect on voice. It also reports on class size and the availability of support and advice in the workplace. In an earlier publication using the same questionnaire, data on the prevalence of a voice problem, its impact, the effect of a voice problem on work, lifestyle, vocal symptoms, and level of teaching were analyzed.20 Responses to the questionnaire were analyzed quantitatively and qualitatively. The chi-squared statistical test for the proportion of dependence between two groups was used for the analysis of data. We ran a chi-squared test, to test the null hypothesis that the variables overstretched work demands and voice are independent. Similarly, we ran the same test, to test the hypothesis that the variables class size and voice are independent. Qualitative responses were elicited to questions on overstretched work demands, voice training, and availability of advice and support. The purpose of the qualitative analysis was to look for underlying information that was not available in the quantitative data. RESULTS Quantitative data A response rate of 55% was obtained with 304 questionnaires returned for analysis. Of the responses, 80% (n ¼ 243) presented with a self-reported voice problem, and 20% (n ¼ 61) indicated that they had no voice problem and considered their voice to be normal.20 In interpretation of the results, it is important to note that 93.7% (n ¼ 284) of a total of 304 teachers reported that they never had any voice training.20 Voice and overstretched work demands. Table 1 presents the relationship between voice and overstretched work demands from the group of 304 participants. A total of 47.37% of
TABLE 1. The Relationship Between Overstretched Work Demands and Voice Overstretched Work Demands
Voice Problem
n
Overstretched work 47.37% 144 demands No overstretched work 32.57% 99 demands Chi-squared value (N0: overstretched work demands and a voice problem are independent)
No Voice Problem
n
8.88%
27
11.18%
34
4.46
respondents reported that they had a voice problem along with overstretched work demands. Only 8.88% of those who reported overstretched work demands had no voice problem. A chi-squared test was run to test the hypothesis that these variables are not related. c2 (2; n ¼ 304) was calculated to be 4.46 which allows us to reject the null hypothesis using an alpha level of 0.05. This indicates that voice problems were more likely to be related to overstretched work demands than not. This can be stated with 96.52% confidence. Voice and class size. Table 2 presents the relationship between class size and presence of a voice problem from the same group of 304 participants. A total of 49.67% of respondents reported that they had a voice problem and taught a class of >30 students. Only 7.24% of those teaching a class of >30 pupils had no voice problem. A chi-squared test was run to test the hypothesis that these variables are not related. c2 (2; n ¼ 304) was calculated to be 13.37, which allows us to reject this null hypothesis with an alpha level of 0.01. This indicates that voice problems were more likely to be related to a class size >30 students than not. This can be stated with 99.97% confidence and thus would indicate that a class size of >30 students is more influential on a teachers voice than overstretched work demands. Qualitative data Teacher’s perceptions. The aim of the qualitative research was to obtain responses from individual teachers to questions on working conditions and availability of advice and support. Their responses are divided into three themes; overstretched work demands, advice and support, and voice training. They are summarized in Table 3. These comments provide valuable insights into possible causes and the impact of a voice problem, and into the vocal behaviours of teachers. Therefore, they enrich the results of the quantitative analysis and give an insight into the real nature of the problem. Overstretched work demands. Table 3 presents teachers perceptions on overstretched work demands. Teachers reported that their work demands were overstretched with little time to fit their teaching demands into the working day. Their responses give the reader an insight into the thoughts of teachers, the difficulties they face in carrying out their work demands, and the impact the work demands have on their vocal health. One of the main difficulties at work reported by teachers was the implementation of an overloaded curriculum. Their responses give the reader an idea of the factors which make its TABLE 2. Table Presenting the Relationship Between Class Size and Voice Class Size
Voice Problem
n
Class size > 30 49.67% 151 Class size < 30 30.26% 92 Chi-squared value (N0: class size and a voice problem are independent)
No Voice Problem 7.24% 12.83% 13.37
n 22 39
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Working Conditions and Workplace Barriers to Vocal Health
5
TABLE 3. Teachers Perceptions of Working Conditions Overstretched Work Demands
Voice Training
Support and Advice
‘‘Greater demands on teachers. More emphasis on oral language from new curriculum.’’
‘‘No training available. Many teachers suffer from voice problems. It is an occupational hazard.’’
‘‘Totally nonexistent and inadequate assistance or care for teaching voices.’’
‘‘Overloaded curriculum, new subject areas but the same amount of time allocated.’’
‘‘Nonexistent, no training whatsoever in this area provided in college or schools.’’
‘‘No real duty of care for teachers from the Department of Education and Science. Children are number one in their eyes.’’
‘‘Time pressures, too many new subjects areas being brought into primary education. Have to fit more teaching into the day, less time to rest voice.’’
‘‘Teachers have very little knowledge of, or access to voice training.’’
‘‘No assistance available medically, just antibiotics and rest.’’
‘‘There is a complete lack of information available and no awareness of potential problems.’’
‘‘No advice given on protecting your voice or how to treat sore throats and hoarseness.’’
‘‘Voice training should be included in teacher training course.’’
‘‘Teachers only look for assistance when there is a major problem. Otherwise they put up with common less serious problems. problems. No advice on how to avert future voice problems.’’
‘‘There are too many demands on the teacher with extra subjects, behavioral problems, and parental demands.’’ ‘‘Very packed curriculum to implement while simultaneously trying to maintain high standards in the traditional focus areas ie, Literacy and numeracy.’’ ‘‘More demands on teachers with new curriculum, more preparation, correction, teaching. Find I have to fit more teaching into the day, less time to rest my voice.’’ ‘‘Implementation of the new curriculum. Introduction of new aspects too varied and content too great to fit into present timetable.’’ ‘‘Curriculum changes, more parental involvement, greater expectations of teachers.’’ ‘‘Huge changes in the curriculum. More assertive vocal pupils. Overloaded curriculum.’’
‘‘No voice training available, but would love to participate in it. I believe I could use my voice better and fear I will develop a problem soon. I notice a decline in my voice in the last year or so.’’ ‘‘Failure to inform teachers of the proper procedures to be used to mitigate damage to voice is a scandal.’’ ‘‘No support or training received whatsoever. Our voice is our profession and it should be trained.’’ ‘‘No voice training is given. Because of shortage of teachers, teachers still come to work when they are sick.’’ ‘‘In my many years teaching I have never come across advice on protecting your voice. I would very much to learn more about this very important area.’’
implementation difficult. They vary from remarks on the scale and size of the curriculum, the maintenance of high standards in focus areas, to the impact of its implementation on their voice. In a sample of responses, they report: ‘‘Very packed curriculum to implement while simultaneously trying to maintain high standards in focus areas of literacy and numeracy.’’ ‘‘Implementation of the new curriculum includes the introduction of new aspects too varied and content too great to fit into the present timetable.’’ Finally, ‘‘More demands on teachers with the new curriculum. I find I have to fit more teaching into the day, maximize teaching time, consequence; less time to rest my voice or no time at all to rest voice.’’ See Table 3 for teacher responses in this area. Advice and support. Table 3 presents teachers perceptions on availability of advice and support. They reported that there was a lack of advice and support available to them when they
‘‘No advice given within the job. No one deals with this!! No recommendation to get your voice seen to, it is up to yourself. Voice care should be a basic health and safety issue in schools. It is not. Even when you are hoarse it is nor referred to.’’ ‘‘There are no guidelines or assistance available. System is totally inadequate.’’ ‘‘Medical profession have little understanding of the demands put on teacher’s voices in the workplace.’’
experienced voice difficulties at work. A sample of three responses gives an insight into their perception on advice and support: ‘‘I feel teachers only look for assistance when there is a major problem and otherwise put up with common less serious problems.’’ ‘‘There is no training assistance or advice. Many teachers suffer voice problems. It is an occupational hazard,’’ and finally, ‘‘Failure to inform teachers of the proper procedures to be used to mitigate damage to voice is a scandal.’’ These and more responses are represented in Table 3. Voice training. In this article, we report that there is no formal voice training provided for teachers either in the college or in the workplace. This is confirmed by the fact that 285 teachers, 93.7% of 304 respondents had never had any voice training either in the college or in the schools where they work. Of the 19 teachers who had voice training, this was normally provided by private individuals as part of an in-service training in schools.
6 On voice training teachers reported: ‘‘No training available, many teachers suffer from voice problems. It is an occupational hazard.’’ and ‘‘No training is given on how to protect your voice, because of shortage of teachers, teachers still come to work when they are sick.’’ Finally, ‘‘Teachers have little knowledge of or access to voice training.’’ See Table 3 for more teacher’s perceptions of voice training. Teachers insights and responses on overstretched work demands, on the availability of advice and support, and on voice training give us a greater understanding of teacher’s perceptions of their working conditions in primary schools and support the results of our quantitative analysis. In answer to question 85 ‘‘In your opinion what should be included in an educational voice care program?’’ Teacher’s responses highlight the need for a voice care program in the workplace. It would provide support and advice on one hand and voice training on the other to teachers. Their opinions and ideas are reported in Table 4.
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DISCUSSION Class size and voice problems In this study, large class size was related to voice. Teachers teaching the larger class size of >30 pupils reported more voice problems than those teaching the smaller class sizes of
Accepted for publication March 9, 2015. From the *Department of Banking and Finance, University College Dublin, Smurfit School of Business, Geneva, Switzerland; and the yMaxim Integrated International, Dublin, Ireland. Address correspondence and reprint requests to Caitriona Munier, University College Dublin, Smurfit School of Business, 5 Route du Bout du Monde, 1206 Geneva, Switzerland. E-mail: [email protected] Journal of Voice, Vol. -, No. -, pp. 1-11 0892-1997/$36.00 Ó 2015 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2015.03.004
characteristics can play a role, together with other risk factors in the development of diseases, having a complex multiple etiology. Some diseases can be called work related.4 Therefore, in the case of those who rely on their voice as their principal tool of work, their working conditions should be adapted to promote and maintain vocal health, and efforts should be taken to prevent the development of voice problems. Teachers Teachers represent the largest group of professionals who use their voice as their primary tool of trade.5 Voice is a worldwide problem in the teaching profession.6 Teaching puts heavy demands on the voice, teachers are heavy voice users, and they suffer from voice problems more frequently than other occupational voice users.7–14 They use their voice with high intensity, in noisy classrooms, for long periods without suitable breaks.15 Teachers sing more frequently and speak more loudly at work than nurses, and vocal loading factors are responsible for the appearance of voice problems in teachers.16 Voice problems in teachers are well documented in the literature. Studies have reported on their prevalence, nature, risk factors, number of years in teaching, vocal and physical symptoms, their impact on quality of life, performance at work, their economic impact due to absenteeism from work, and change of profession.7,11–14,17–25 Vocal symptoms The early identification of vocal symptoms in the workplace is critical in the prevention of a voice problem. Vocal symptoms were reported as being more common in teachers than in nonteachers (69% vs 36%).26 Munier and Kinsella20 reported that voice fatigue, dry throat, and inability to sing high notes were
2 statistically significant vocal symptoms in primary school teachers and may be the early signs of a developing voice problem. These findings on vocal symptoms are similar to those reported by Yiu.7 Vocal strain was reported to be the most prominent physical symptom in teachers.14 Ohlsson et al27 in a study of voice symptoms and risk factors in student teachers report that those with vocal symptoms are at risk of developing voice disorders during their career. One problem with voice is the inadequate or neglected examination and treatment of early symptoms.3 Impact of a voice problem Voice problems can lead to a diminished ability to teach and ‘‘extensive periods of sick leave and vocal rehabilitation which involves great financial loss.’’24 The author concluded that voice disorders impact on the teachers professional and social life and imply a major financial burden for society. In a Brazilian study, 29% of teachers reported that their voice limited their ability to perform certain tasks at work. They reported more adverse effects on job performance because of a voice problem.25 Many teachers need to stay at home because of a voice problem. Teachers also suffer from functional and psychological adverse effects because of a voice problem. They experience upset and excessive stress at work.28 In addition to impacting negatively on performance at work, quality of life, ability to socialize, and emotional state are also affected negatively.7 Lack of support from school colleagues and management compounds the problem.29 Primary school teachers versus other teacher groups Most literature reports on voice problems in primary school teachers, secondary school teachers, and sometimes even university lecturers as one group despite the fact that their working conditions are different. Primary school teaching puts much greater vocal demands on teachers than secondary school teaching. The main difference is in the duration of continuous voice use and opportunity for vocal rest. Primary school teachers teach for 5–6 hours continuously with little or no opportunity for vocal rest. Added to this are 37 hours of playground duty per year. This contrasts with the working day of secondary school teachers who teach for 45 minute periods, sometimes 90 minutes as a double period. These periods of teaching are interspersed with periods of vocal rest of 45 minutes or longer. This difference has been recognized by Sala et al,30 who suggested that vocal load for primary and preschool teachers is higher than for secondary teachers. Many studies have not taken this important difference into account and have reported on primary and secondary school teachers and sometimes university lecturers as one group in the same study.20 The first study to report on voice problems in primary school teachers as a single group was published in 2008.20 Since then, many studies on voice problems in primary school teachers as a single group have appeared in the literature.17,23,28,31 Given the above differences in working conditions, it is the opinion of this author, that studies should separate primary and secondary school teachers into two distinct groups.
Journal of Voice, Vol. -, No. -, 2015
Purpose of this study The focus of this study is on the working conditions of primary school teachers and on the relationship between working conditions and voice. The purpose of this study carried out in Ireland was to contribute further to our understanding of voice problems in primary school teachers by examining their working conditions, teacher’s perceptions of these working conditions, and the relationship between working conditions and voice. The barriers teachers face in seeking advice, support, and treatment for a voice problem within the workplace are also examined. Understanding which working conditions may be barriers to vocal health is essential to our understanding of voice problems in teachers and to the appropriate timing of intervention, diagnosis, and treatment. There have been very few studies that looked at teacher’s perceptions of their working conditions and workplace barriers to vocal health. The first study to report on teacher’s perceptions of a voice problem examined the treatment-seeking behaviors of teachers in relation to their dysphonia.17 This study on barriers to care was informed by teachers perceptions, and this approach is very valuable in understanding voice problems in teachers. Work organization and working conditions of primary school teachers in Ireland According to the Central Statistics Office 2011 census, there are 32 600 primary school teachers in Ireland; this is of a total workforce of 1 836 000. Female teachers account for 85% of all primary school teachers with only 15% of these being male teachers.32 Their workday consists of a minimum of 5–6 hours of continuous teaching, with little opportunity for vocal rest outside of a 10-minute break midmorning and 30 minutes at midday. The class teacher teaches all subjects including physical education, art, music, and singing. A class includes a cohort of children of the same age-group, for example, in a ‘‘Junior Infant’’ class, the age range is 4–5 years. In addition to their normal teaching duties, their contract includes 37 hours of playground duty during the school year. Added to this, there is the extended working day which includes meetings with parents and fellow teachers, lesson preparation, and corrections. They work 183/187 days a year compared with 167/168 days for secondary school teachers. The extended working day can prolong the working day up to 10 hours. Teachers work 900 hours yearly as compared with the EU average of 700 hours. Many teachers teach classes of >30 pupils, and in some cases, class sizes can be as large as 40 or more. With these supersized classes, there is an increase in classroom noise level and consequently a need on the part of the teacher to increase vocal loudness to be heard. Yet, they are dependent on their voice to function throughout their entire working career, which can be as long as 35–40 years. Teaching also requires a wide variation in voice use in terms of pitch, volume, quality in reading, singing, teaching drama, and physical education. The Department of Education and Science in Ireland changed the primary school curriculum in 1999. The current
Caitriona Munier and Rory Farrell
Working Conditions and Workplace Barriers to Vocal Health
curriculum is commonly referred to as the ‘‘new curriculum.’’ The curriculum which preceded it was introduced in 1977 and was more traditional in its teaching orientation. Children were expected to work independently, and there was less emphasis on oral communication. An important component of the new curriculum is a greater emphasis on oral communication. Teachers are expected to encourage oral communication to enhance the child’s learning. In implementing this, a large amount of teacher-student verbal interaction is required. This focus is more vocally demanding for the teacher and gives less opportunity for vocal rest. It also creates more background noise as both children and teachers are expected to be more vocal. Another change has been an increase in the number of subjects taught from 9 to 11 subjects. Teachers teach the core subjects English, Mathematics, and Gaeilge (Irish). Other subjects include Science, Music, Drama, Art, History, and Geography. Religion, Physical Education, and Social Personal and Health education are also taught. By comparison, Scotland’s Curriculum for Excellence now has eight learning areas, and New Zealand also has eight learning areas.33 There are also recommendations on the number of hours per week that should spend teaching each subject. For example, the teaching of English and Irish should be allocated 4 and 3 hours per week, respectively.34 It is important to note that there is no voice training for student teachers or working teachers in Ireland, yet they are required to teach singing. The National Curriculum Council and Assessment (NCCA) has reviewed the 1999 curriculum in 2005 and 2008a. In both reviews, teachers and principals identified time as one of their greatest challenges in implementing the curriculum. Teachers reported that they had insufficient time to fully implement curriculum subjects or to address all the objectives within each of these subjects.35,36 Two separate dimensions of this time issue were identified: the scale and size of the curriculum; the challenge of meeting children’s individual needs particularly in multigrade and large classes. In 2010, the curriculum has been described as overloaded by the NCCA in their article review on curriculum overload in primary schools.33 HYPOTHESIS The aim of this study was to test the null hypothesis that there is no relationship between working conditions and vocal health. The relationship between the variables overstretched work demands and voice and class size and voice were examined. Overstretched work demands include long hours of teaching with little opportunity for vocal rest, curriculum teaching of 11 subjects, constraints of recommended number of teaching hours per subject, large class size, 37 hours of playground duty, and absence of advice and support for a voice problem in the workplace. METHODS An 85-item self-administered questionnaire was designed to investigate the working environment, professional vocal use, and voice problems of primary school teachers. Questions for this questionnaire were developed from the clinical experience
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of the researcher, from knowledge gained through an examination of relevant questionnaires in the literature, and from a Hong Kong questionnaire.7 Some 550 questionnaires were distributed to all teachers in 42 randomly selected schools in Ireland. The study was carried out in the autumn term, to minimize the effects of winter colds and upper respiratory track infections on the voice. The distribution of the questionnaires at this time was also to avail of voice evaluation after a period of relative vocal rest during the summer vacation. A pretest of the questionnaire was carried out in a pilot study by asking 12 primary school teachers to fill in the questionnaire. On receipt of these, a follow-up telephone call to the participants was made to verify the answers. The aim was to perfect the questions. The results of these questionnaires and telephone conversations were used to modify and improve the original questionnaire. The questionnaire used in the pilot study was not included in this study. Each questionnaire was accompanied by a covering letter to all respondents, in which the purpose of the study was explained, and basic information on how to complete the survey. It assured respondents about the maintenance of an individual’s confidentiality. An envelope was provided with each questionnaire to protect confidentiality. Questionnaires were personally delivered to the schools and collected by the researcher. Formal ethical approval was not sought, as the study met all criteria for exemption, as set down by University College Dublin’s Human Research Ethics Committee. The study was anonymized, subjects were self-participating, and there was no conflict of interest. There was no bias or prejudice on subject’s careers as a result of having participated. In addition, the study did not involve a vulnerable group and was noninvasive. The questionnaire was divided into five sections: Section 1 was designed to obtain demographic information gender, age, and marital status, in addition to information on the working environment including class size, age-group taught, and number of years teaching. A question to determine if respondents had received voice training for teaching was included. Section 2 was designed to obtain data on vocal characteristics, recent changes in the voice, and common symptoms, which would indicate limitations in normal voice functioning were also elicited. Other questions were designed to obtain information on normal voice use and habits, singing and acting practices, recreational voice use, and the effects of teaching on the voice. Information was also obtained on stress, working environment, general health, and vocal health, including information on any visits to health specialist for a voice problem. Section 3 gave respondents the opportunity to report a voice problem and to include information on how it started, its evolution, duration, symptoms associated with it, and factors which may have caused it. This section relied on the respondents self-perception of their own voice and vocal health and provided an opportunity for identification of possible associated risk factors. Section 4 dealt with the effects of voice on work and lifestyle. This title and the 10 questions included in this section were used with permission from a Hong Kong study.7 It was designed to obtain information on the impact of a voice problem on work, on emotions, on communication, and on social life. Section 5 covered
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Journal of Voice, Vol. -, No. -, 2015
knowledge of voice care and was also used with permission from Yiu.7 The last three questions were open-ended and gave respondents an opportunity to give their opinion of the conditions in teaching that may cause a voice problem. It also sought respondent’s opinion on the adequacy of medical and health and safety assistance available to them and to their colleagues. In a final question, respondents were also asked for their opinion on what should be included in a voice care program. This article reports on a subset of the data, which includes working conditions and their effect on voice. It also reports on class size and the availability of support and advice in the workplace. In an earlier publication using the same questionnaire, data on the prevalence of a voice problem, its impact, the effect of a voice problem on work, lifestyle, vocal symptoms, and level of teaching were analyzed.20 Responses to the questionnaire were analyzed quantitatively and qualitatively. The chi-squared statistical test for the proportion of dependence between two groups was used for the analysis of data. We ran a chi-squared test, to test the null hypothesis that the variables overstretched work demands and voice are independent. Similarly, we ran the same test, to test the hypothesis that the variables class size and voice are independent. Qualitative responses were elicited to questions on overstretched work demands, voice training, and availability of advice and support. The purpose of the qualitative analysis was to look for underlying information that was not available in the quantitative data. RESULTS Quantitative data A response rate of 55% was obtained with 304 questionnaires returned for analysis. Of the responses, 80% (n ¼ 243) presented with a self-reported voice problem, and 20% (n ¼ 61) indicated that they had no voice problem and considered their voice to be normal.20 In interpretation of the results, it is important to note that 93.7% (n ¼ 284) of a total of 304 teachers reported that they never had any voice training.20 Voice and overstretched work demands. Table 1 presents the relationship between voice and overstretched work demands from the group of 304 participants. A total of 47.37% of
TABLE 1. The Relationship Between Overstretched Work Demands and Voice Overstretched Work Demands
Voice Problem
n
Overstretched work 47.37% 144 demands No overstretched work 32.57% 99 demands Chi-squared value (N0: overstretched work demands and a voice problem are independent)
No Voice Problem
n
8.88%
27
11.18%
34
4.46
respondents reported that they had a voice problem along with overstretched work demands. Only 8.88% of those who reported overstretched work demands had no voice problem. A chi-squared test was run to test the hypothesis that these variables are not related. c2 (2; n ¼ 304) was calculated to be 4.46 which allows us to reject the null hypothesis using an alpha level of 0.05. This indicates that voice problems were more likely to be related to overstretched work demands than not. This can be stated with 96.52% confidence. Voice and class size. Table 2 presents the relationship between class size and presence of a voice problem from the same group of 304 participants. A total of 49.67% of respondents reported that they had a voice problem and taught a class of >30 students. Only 7.24% of those teaching a class of >30 pupils had no voice problem. A chi-squared test was run to test the hypothesis that these variables are not related. c2 (2; n ¼ 304) was calculated to be 13.37, which allows us to reject this null hypothesis with an alpha level of 0.01. This indicates that voice problems were more likely to be related to a class size >30 students than not. This can be stated with 99.97% confidence and thus would indicate that a class size of >30 students is more influential on a teachers voice than overstretched work demands. Qualitative data Teacher’s perceptions. The aim of the qualitative research was to obtain responses from individual teachers to questions on working conditions and availability of advice and support. Their responses are divided into three themes; overstretched work demands, advice and support, and voice training. They are summarized in Table 3. These comments provide valuable insights into possible causes and the impact of a voice problem, and into the vocal behaviours of teachers. Therefore, they enrich the results of the quantitative analysis and give an insight into the real nature of the problem. Overstretched work demands. Table 3 presents teachers perceptions on overstretched work demands. Teachers reported that their work demands were overstretched with little time to fit their teaching demands into the working day. Their responses give the reader an insight into the thoughts of teachers, the difficulties they face in carrying out their work demands, and the impact the work demands have on their vocal health. One of the main difficulties at work reported by teachers was the implementation of an overloaded curriculum. Their responses give the reader an idea of the factors which make its TABLE 2. Table Presenting the Relationship Between Class Size and Voice Class Size
Voice Problem
n
Class size > 30 49.67% 151 Class size < 30 30.26% 92 Chi-squared value (N0: class size and a voice problem are independent)
No Voice Problem 7.24% 12.83% 13.37
n 22 39
Caitriona Munier and Rory Farrell
Working Conditions and Workplace Barriers to Vocal Health
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TABLE 3. Teachers Perceptions of Working Conditions Overstretched Work Demands
Voice Training
Support and Advice
‘‘Greater demands on teachers. More emphasis on oral language from new curriculum.’’
‘‘No training available. Many teachers suffer from voice problems. It is an occupational hazard.’’
‘‘Totally nonexistent and inadequate assistance or care for teaching voices.’’
‘‘Overloaded curriculum, new subject areas but the same amount of time allocated.’’
‘‘Nonexistent, no training whatsoever in this area provided in college or schools.’’
‘‘No real duty of care for teachers from the Department of Education and Science. Children are number one in their eyes.’’
‘‘Time pressures, too many new subjects areas being brought into primary education. Have to fit more teaching into the day, less time to rest voice.’’
‘‘Teachers have very little knowledge of, or access to voice training.’’
‘‘No assistance available medically, just antibiotics and rest.’’
‘‘There is a complete lack of information available and no awareness of potential problems.’’
‘‘No advice given on protecting your voice or how to treat sore throats and hoarseness.’’
‘‘Voice training should be included in teacher training course.’’
‘‘Teachers only look for assistance when there is a major problem. Otherwise they put up with common less serious problems. problems. No advice on how to avert future voice problems.’’
‘‘There are too many demands on the teacher with extra subjects, behavioral problems, and parental demands.’’ ‘‘Very packed curriculum to implement while simultaneously trying to maintain high standards in the traditional focus areas ie, Literacy and numeracy.’’ ‘‘More demands on teachers with new curriculum, more preparation, correction, teaching. Find I have to fit more teaching into the day, less time to rest my voice.’’ ‘‘Implementation of the new curriculum. Introduction of new aspects too varied and content too great to fit into present timetable.’’ ‘‘Curriculum changes, more parental involvement, greater expectations of teachers.’’ ‘‘Huge changes in the curriculum. More assertive vocal pupils. Overloaded curriculum.’’
‘‘No voice training available, but would love to participate in it. I believe I could use my voice better and fear I will develop a problem soon. I notice a decline in my voice in the last year or so.’’ ‘‘Failure to inform teachers of the proper procedures to be used to mitigate damage to voice is a scandal.’’ ‘‘No support or training received whatsoever. Our voice is our profession and it should be trained.’’ ‘‘No voice training is given. Because of shortage of teachers, teachers still come to work when they are sick.’’ ‘‘In my many years teaching I have never come across advice on protecting your voice. I would very much to learn more about this very important area.’’
implementation difficult. They vary from remarks on the scale and size of the curriculum, the maintenance of high standards in focus areas, to the impact of its implementation on their voice. In a sample of responses, they report: ‘‘Very packed curriculum to implement while simultaneously trying to maintain high standards in focus areas of literacy and numeracy.’’ ‘‘Implementation of the new curriculum includes the introduction of new aspects too varied and content too great to fit into the present timetable.’’ Finally, ‘‘More demands on teachers with the new curriculum. I find I have to fit more teaching into the day, maximize teaching time, consequence; less time to rest my voice or no time at all to rest voice.’’ See Table 3 for teacher responses in this area. Advice and support. Table 3 presents teachers perceptions on availability of advice and support. They reported that there was a lack of advice and support available to them when they
‘‘No advice given within the job. No one deals with this!! No recommendation to get your voice seen to, it is up to yourself. Voice care should be a basic health and safety issue in schools. It is not. Even when you are hoarse it is nor referred to.’’ ‘‘There are no guidelines or assistance available. System is totally inadequate.’’ ‘‘Medical profession have little understanding of the demands put on teacher’s voices in the workplace.’’
experienced voice difficulties at work. A sample of three responses gives an insight into their perception on advice and support: ‘‘I feel teachers only look for assistance when there is a major problem and otherwise put up with common less serious problems.’’ ‘‘There is no training assistance or advice. Many teachers suffer voice problems. It is an occupational hazard,’’ and finally, ‘‘Failure to inform teachers of the proper procedures to be used to mitigate damage to voice is a scandal.’’ These and more responses are represented in Table 3. Voice training. In this article, we report that there is no formal voice training provided for teachers either in the college or in the workplace. This is confirmed by the fact that 285 teachers, 93.7% of 304 respondents had never had any voice training either in the college or in the schools where they work. Of the 19 teachers who had voice training, this was normally provided by private individuals as part of an in-service training in schools.
6 On voice training teachers reported: ‘‘No training available, many teachers suffer from voice problems. It is an occupational hazard.’’ and ‘‘No training is given on how to protect your voice, because of shortage of teachers, teachers still come to work when they are sick.’’ Finally, ‘‘Teachers have little knowledge of or access to voice training.’’ See Table 3 for more teacher’s perceptions of voice training. Teachers insights and responses on overstretched work demands, on the availability of advice and support, and on voice training give us a greater understanding of teacher’s perceptions of their working conditions in primary schools and support the results of our quantitative analysis. In answer to question 85 ‘‘In your opinion what should be included in an educational voice care program?’’ Teacher’s responses highlight the need for a voice care program in the workplace. It would provide support and advice on one hand and voice training on the other to teachers. Their opinions and ideas are reported in Table 4.
Journal of Voice, Vol. -, No. -, 2015
DISCUSSION Class size and voice problems In this study, large class size was related to voice. Teachers teaching the larger class size of >30 pupils reported more voice problems than those teaching the smaller class sizes of
