Lean Transformation of Industrial Work Understanding What Supports Socially Sustainable Working Conditions During Lean Manufacturing

MALIN HÅKANSSON

Doctoral thesis No. 31, 2019 KTH, Royal Institute of Technology School of Engineering in Chemistry, Biotechnology and Health SE-141 57 Huddinge, Sweden

TRITA CBH-FOU-2019:31 ISBN 978-91-7873-202-9

The included papers are reprinted with permission from each publisher.

© Malin Håkansson, Nacka 2019 Printed by US-AB, Stockholm

Akademisk avhandling som med tillstånd av KTH i Stockholm framlägges till offentlig granskning för avläggande av

medicinsk doktorsexamen, onsdagen den 29 maj kl. 13:00 i sal T1 - Emmy Rappe-salen, KTH Hälsovägen 11,

Huddinge, Sverige.

To Per & Leo

There is more to life than simply increasing its speed. ―Mahatma Gandhi

Abstract The overall aim of this thesis is to contribute to the understanding of to what extent lean manufacturing transforms industrial work, including psychosocial and physical working conditions, and, to understand how socially sustainable working conditions can be supported in a lean organization.

Four studies with different methodological approaches are included. The first study is a literature overview of the associations between lean and risk factors for musculoskeletal disorders. The second study documented physical workload and pain among operators, through direct measurements and pain ratings, in a process industry with extensive usage of lean practices. In addition, two 3-year case studies were carried out in a medium-sized, Swedish manufacturing family company. The studies focused on the influence of lean on work charcteristics, psychosocial working conditions, and what leadership practices contributed to supporting the socially sustainable working conditions respectively.

The literature overview on lean and physical workload showed that the literature in the area was limited, of varying quality, and that none of the included studies had directly measured the physical workload. Further, it suggested that lean tended to have better outcomes for employees in the Nordic countries and in those cases where the lean initiative was combined with an ergonomic or work environment intervention. The measurements of physical workload in the process industry showed that the exposures were low across the study period. Ratings of neck and upper extremity pain were relatively high across the years, but did not increase significantly. The results from the manufacturing company showed that employees could sustain important work resources including favorable psychosocial working conditions: Good social support, low stress levels, and a good self-rated health were sustained while role conflicts decreased, and justice and respect increased significantly. There was a trend toward gradually increased work content through job enlargment with increased elements of more qualified tasks, and more employees were cross-trained. The work standardization, however, meant that some work processes were simplified and that employees’ influence over the daily work seemed to have decreased, while there were still opportunities for them to influence what would be included in the work assignment, and employee influence through improvement practices increased. Both case studies indicated that the participatory leadership approach in combination with a value-creating leadership that focus on health and employee development, contributed to making the lean initiative socially sustainable.

In conclusion, lean can affect work characteristics and employees’ working conditions in different ways depending on how, and in what type of work, it is implemented. Previous studies on lean in industry have mostly shown that lean tends to increase workload and reduce control over daily work. This thesis, however, provides examples showing that it is possible to have low levels of physical exposures in a lean process industry and that it is possible to sustain important psychosocial work resources. The work practices seemed to be shaped in an interplay between organizational context, type of job, managerial practices, lean practices employed, and employees’ involvement. Knowledge about how work is shaped is important for those who want to proactively contribute to a work design that supports the development of resourceful jobs. Findings in this thesis point to the need to actively monitor and care how lean affects working conditions in order to support resourceful jobs.

This thesis shows that it is possible to make lean initiatives in manufacturing companies more socially sustainable. Overall, findings from this thesis indicate that important and interdependent components that can contribute to socially sustainable lean initiatives involve having a conscious focus on work environment management and health, in combination with a value-creating leadership that actively support important work resources and involves employees in a conscious manner.

Keywords Organizational Ergonomics, Work Design, Physical Ergonomics, Lean Production, Manufacturing, Working conditions, Work Content Analysis, Musculoskeletal Pain.

TRITA CBH-FOU-2019:31 ISBN 978-91-7873-202-9

Sammanfattning Arbetssystem med krav höga krav på effektivitet är vanliga i dagens arbetsliv. I Sverige är konceptet lean produktion (lean) är ett vanligt sätt att organisera produktionen för ökad effektivitet. Det övergripande syftet med denna avhandling är att bidra till kunskapen om hur lean kan påverka arbetsinnehåll, fysiska och psykosociala arbetsförhållanden vid industriarbete, samt att bidra till förståelsen för hur socialt hållbara arbetsförhållanden kan stödjas i en lean organisation.

Fyra studier med olika metodologiska ansatser är inkluderade. Den första är en litteraturstudie kring sambanden mellan lean och risker för belastningsrelaterade besvär. I den andra studien genomfördes med två års mellanrum ergonomiska mätningar av den fysiska arbetsbelastningen och skattningar av smärta i en processindustri som vid baslinjemätningarna arbetat tio år enligt lean-principer. Därtill ingår två 3-åriga fallstudier som genomfördes i ett svenskt, medelstort familjeföretag inom verkstadsindustrin som framgångsrikt arbetat med lean. Studierna fokuserade på lean-konceptets påverkan på arbetsinnehåll och psykosociala arbetsförhållanden respektive vilka ledarskaps-praktiker som bidrog till att skapa de socialt hållbara arbetsförhållandena.

Litteraturöversikten om belastningsergonomi och lean visade att litteraturen på området var begränsad, av varierande kvalitet samt att ingen av de ingående studierna mätt fysisk belastning vid leanifierat arbete. Dock pekade flera av studierna på att lean tenderar att öka den upplevda arbetsbelastningen och att upplevd kontroll över det dagliga arbetet minskar. Vidare noterades att lean hade en tendens att ha bättre utfall för medarbetare i de nordiska länderna och i de fall lean-satsningen kombinerats med någon form av ergonomi- eller arbetsmiljöinsats. De ergonomiska mätningarna av fysisk belastning i en processindustri visade att belastningarna för övre extremiteterna kunde hållas på låga nivåer trots en hög grad av lean. Dock var skattningar av smärta i nacke och övre extremitet relativt höga, men ökade inte signifikant under perioden.

Resultaten från lean-arbetet på verkstadsindustrin visade att medarbetarna kunde behålla viktiga arbetsresurser inklusive en god psykosocial arbetsmiljö: Ett gott socialt stöd, låg stressnivå och en god självskattad hälsa, samtidigt som rollkonflikter minskade och rättvisa och respekt ökade signifikant. Vidare innebar lean för medarbetarna en trend mot ett gradvis utökat arbetsinnehåll. Detta genom arbetsutvidgning, ökade inslag av mer kvalificerade uppgifter och att fler medarbetare kunde rotera mellan olika arbetsuppgifter. Dock innebar standardisering av arbetet att några arbetsprocesser förenklats och att inflytandet över det dagliga arbetet verkade ha minskat, samtidigt som det fortsatt fanns möjligheter att påverka vad som skulle ingå i arbetsåtagandet i stort och möjligheter till utökat inflytande via ständigt förbättringsarbete. Påverkan på arbetets innehåll verkade formas i ett interaktivt samspel mellan ledare, medarbetarnas involvering, miljön och lean.

De fyra praktiker som stödde den socialt hållbara lean-satsningen bedömdes vara: (1) En sammanhängande satsning med en tydlig riktning, (2) Ett värdeskapande ledarskap innefattande främjande av delaktighet och ett omtänksamt ledarskap med samtidigt fokus på hälsa och produktion, (3) En medveten, stegvis involvering av medarbetarna och strategier för att koordinera initiativ från medarbetare och ledning samt (4) Fokus på att främja meningsfulla jobb och hälsa med stöd i ett aktivt arbetsmiljöarbete.

Slutsatserna från denna avhandling är att lean kan påverka arbetsinnehåll och medarbetarnas arbetsförhållanden på olika sätt beroende på företagets förutsättningar, typen av arbete och hur lean implementeras. Denna avhandling visar att det går att göra lean-satsningar inom industrin mer socialt hållbara. Viktiga komponenter som kan bidra till en socialt hållbar lean-satsning är ett medvetet fokus på arbetsmiljö och hälsa i kombination med ett värdeskapande ledarskap som aktivt stödjer viktiga arbetsresurser och involverar medarbetare på ett medvetet sätt.

Preface Health, and what promotes health, has been a long interest of mine. One of the first books I encountered during my first university course in Health Promotion, over 25 years ago, was the book Unravelling the Mystery of Health: How people manage stress and stay well by Aaron Antonovsky (1987). That course and following courses in, for example, Health Psychology, Work and Health, introduced me to the salutogenic perspective—i.e. understanding what promotes health rather than what factors contribute to pathologies. A perspective that has followed me ever since.

Even as a physical therapist, I tried to maintain a ‘healthy’ perspective. Later, my magister studies in Ergonomics provided a platform for understanding work in a systems perspective, including human interactions and health in the workplace.

The aims and direction of the research project, which formed the basis for this thesis, was to a large extent outlined in the research plan before I was engaged in the project. The opportunity to study how a management concept affects the work content, physical workload, and health attracted my interest. Our research group set out to explore lean production’s effects on working conditions in industrial settings. During my studies I have had the opportunity to learn more about Organizational Ergonomics, a subject which is partly influenced by Work and Organizational Psychology. My mentor, Måns Waldenström, the work psychologist who trained me in conducting the work content analysis (ARIA), made this possible and put me on track to understand the underlying psychological theories. Along the road my interest in work itself, and how it is shaped, grew, which encouraged me to deepen my knowledge in the area of work design. One of my co-authors, Richard Holden, has also been an invaluable source of knowledge regarding work design from a system perspective.

As I noticed that one of the studied companies had managed to sustain favorable social working conditions, my salutogenic perspective spurred me to try to understand what factors may have contributed to them achieving that. Then, my supervisor Lotta Dellve and co-writer Andrea Eriksson’s extensive knowledge about health-promoting leadership made it possible for us to focus on managerial practices promoting the sustainable working conditions in study IV.

Prior to starting my PhD-journey, I worked as a physical therapist for eleven years in different Healthcare organizations, but I had no prior work experiences in industrial settings. At the start of the project, my experiences of lean were only brief; I had played the Lean Game, attended a lecture about lean in hospitals, and witnessed some initial lean projects in the hospital I was working at prior to the project. Thus, the discussions with my late colleague Mikael Brännmark, where we compared lean in health care and in industry, were most valuable for me to gain an understanding of industrial organizations and terms used there. This made it easier for me to interpret the information gained during the interviews and I started to develop the skill of translating between the different worlds. Participating in the research network on lean and Japanese production systems, as well as the course ‘Lean and the work environment’, has also been very valuable for my understanding of the lean concept. The evolvement of my preconceptions during the research process are further elaborated in the methods section.

Nacka, April 2019 Malin Håkansson

List of Scientific Papers

I. Brännmark, M. & Håkansson, M. 2012. Lean production and work-related musculoskeletal disorders: overviews of international and Swedish studies. Work: A Journal of Prevention, Assessment and Rehabilitation, 41, 2321–2328.

II. Håkansson, M., Forsman, M. & Nyman, T. Continuous lean development in industrial process work: Implications for physical workload and pain in the neck and upper extremities. Submitted manuscript.

III. Håkansson, M., Dellve, L., Waldenström, M. & Holden, J. R. 2017. Sustained lean transformation of working conditions: A Swedish longitudinal case study. Human Factors and Ergonomics in Manufacturing & Service Industries, 27, 268–279.

IV. Håkansson, M., Holden, J. R., Eriksson, A. & Dellve, L. 2017. Managerial practices that support lean and socially sustainable working conditions. Nordic Journal of Working Life Studies, 7, 63–84.

Contents

1. Introduction ....................................................................................................................................... 12

1.1 Lean Manufacturing .................................................................................................................... 14

1.1.1 The Lean Concept ............................................................................................................... 14

1.1.2 The Lean Concept and its Potential to Transform Work ............................................. 15

2. Aim ...................................................................................................................................................... 17

2.1 Research Questions .................................................................................................................... 17

3. Background ......................................................................................................................................... 18

3.1 Focus of the Thesis ..................................................................................................................... 18

3.2 Human Factors/Ergonomics .................................................................................................... 18

3.3 Health of People at Work .......................................................................................................... 21

3.4 Managing and Organizing for Healthy Work ......................................................................... 22

3.4.1 Work Design ........................................................................................................................ 23

3.4.2 Leadership Supporting Engagement and Health ............................................................ 26

3.4.3 Organizational Change and Sustainable Improvements ................................................ 28

3.5 Working Conditions ................................................................................................................... 31

3.5.1 Sustainable Working Conditions ....................................................................................... 31

3.5.2 Work Characteristics and Work Design .......................................................................... 32

3.5.3 Psychosocial Factors at Work ........................................................................................... 34

3.5.4 Physical Workload ............................................................................................................... 36

3.5.5 Work-related Musculoskeletal Disorders ......................................................................... 37

3.6 Lean and the Work System ........................................................................................................ 40

3.6.1 Lean and Psychosocial Factors at Work .......................................................................... 41

3.6.2 Lean and Physical Working Conditions ........................................................................... 42

3.6.3 Lean Leadership and Management ................................................................................... 44

3.6.4 Lean in Combination with Ergonomics and Safety and Health ................................... 45

4. Research Methodology ..................................................................................................................... 48

4.1 Overview of Research Designs ................................................................................................. 48

4.2 Case Study Design ...................................................................................................................... 50

4.3 External perspective ................................................................................................................... 50

4.4 Methods ........................................................................................................................................ 51

4.4.1 Settings and subjects ........................................................................................................... 51

4.5 Data Collection and Measures .................................................................................................. 53

4.5.1 Literature Overview ............................................................................................................ 53

4.5.1 Direct Measurements of Physical Workload .................................................................. 54

4.5.2 Interviews with Management ............................................................................................ 55

4.5.3 ARIA – Assessment of Work Characteristics ................................................................. 56

4.5.4 Questionnaires ..................................................................................................................... 57

4.5.5 Tour of the Production and Key Performance Indicators ........................................... 58

4.6 Analysis ........................................................................................................................................ 58

4.6.1 Qualitative Analysis ............................................................................................................ 58

4.6.2 Quantitative Analysis .......................................................................................................... 59

4.7 Preconceptions ............................................................................................................................ 60

4.8 Ethical Considerations ............................................................................................................... 61

5. Results ................................................................................................................................................. 62

5.1 Study I – Overview of Studies About Lean and WMSD ...................................................... 62

5.2. Study II – Physical Workload and Musculoskeletal Pain in a Process Plant .................... 63

5.3 Study III – Lean and Transformation of Work Characteristics........................................... 64

5.4 Study IV – Managerial Practices Supporting Socially Sustainable Lean ............................. 65

6. Discussion .......................................................................................................................................... 66

6.1 Lean and Transformation of Work Characteristics .......................................................... 66

6.2 Lean Manufacturing and Physical Workload and WMSD ............................................... 67

6.3 Supporting Socially Sustainable Jobs and Health .............................................................. 68

6.4 Methodological Considerations ........................................................................................... 70

6.5 Theoretical Implications and Future Research .................................................................. 71

6.6 Implications for Lean and Ergonomics Practioners ......................................................... 72

7. Conclusions ........................................................................................................................................ 75

Acknowledgments ................................................................................................................................. 76

References ............................................................................................................................................... 79

Appendix A .......................................................................................................................................... 110

Appendix B ........................................................................................................................................... 111

Appendix C........................................................................................................................................... 112

List of Abbreviations and Terms

ARIA A Swedish acronym for a form of work content analysis

CI Continuous Improvements

CTS Carpal Tunnel Syndrome

5S A tool for systematically structuring the workplace in five steps: Sort, Set in order, Shine, Standardize and Sustain.

HAL Hand Activity Scale

HFE Human Factors/Ergonomics

JCM Job Characteristics Model

JD-C Job Demand-Control model

JD-R Job Demands-Resources model

JiT Just-in-Time production—a system where the materials are acquired just when needed and in the right quantity.

Lean Lean Production—A multidimensional production and management concept aiming at reducing wasteful operations and increasing value-adding activities.

Kaizen A continuous improvement system.

Kanban A visual system tool applied to achieve Just-in-Time production (JiT).

KPIs Key Performance Indicators

Muda Wasteful activities that do not add value to the product.

Lean-ARIA A work content analysis, see ARIA above, in combination with questions about the organization’s lean practices.

Lean Game A game simulating a lean factory to learn about lean production.

OSH Occupational Safety &Health

SBU Statens Beredning för medicinsk Utvärdering [Swedish Council on Health Technology Assessment]

SMED Single-Minute Exchange of Dies—Setup time reduction.

SMEs Small and medium-sized enterprises

STS Socio-Technical Systems

SWEA Swedish Work Environment Authority

SSWC Socially Sustainable Working Conditions

Takted Production that is aligned with takt time, i.e. the frequency in which a product needs to be manufactured to meet customer demands.

TLV Threshold Limit Value

TPS Toyota Production System

TQM Total Quality Management

VAW Value-adding work

WMSDs

WHO

Work-related Musculoskeletal Disorders

World Health Organization

VPC The company in studies III and IV.

VSM Value Stream Mapping—mapping of material and processes to understand what activities that add value to the product.

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1. Introduction Working life is changing due to significant societal and technological changes which, in turn, affect work and how work is designed (Hollnagel, 2014, Parker, 2014, Brännmark et al., 2012b). Work systems with high demands for efficiency are increasingly common in contemporary working life (Westgaard and Winkel, 2011), even though rationalization of work has been advocated at least since the beginning of the last century (Björkman, 1996). This may affect organization of work and employee working conditions in different ways (Härenstam, 2006).

One way of increasing organizational efficiency, is by using the concept of lean production, henceforth lean. Lean is a Toyota-inspired multidimensional production and management concept for increasing operational performance and customer value (Shah and Ward, 2007). This concept has been implemented in many industrial companies and service organizations worldwide (Samuel et al., 2015, Stone, 2012), and in Sweden, lean is presently one of the dominating concepts in industrial settings (Johansson and Abrahamsson, 2009, Börnfelt, 2006). Previous studies have shown that lean is associated with improvements in profitability, quality and productivity (Liker, 2004, Shah and Ward, 2003). However, consequences of lean on the nature of work, including the physical and psychosocial working conditions, and, in turn, employee health, are not yet fully understood (Landsbergis et al., 1999, Hasle et al., 2012, Koukoulaki, 2014, Fagerlind Ståhl and Ekberg, 2016).

This raises questions about what the consequences are for the employees in this rather new work system. The first advocates for lean, Womack et al. (1990), predicted in their book The Machine That Changed the World that lean would have mainly positive effects on employee working conditions. However, since the lean concept does not explicitly focus on promoting sustainable working conditions or employee health (Pettersen, 2009a, Niepce and Molleman, 1998), one cannot assume that it supports a work design that is favorable for employees. On the contrary, for example, the streamlining and standardization of work could possibly mean more repetitive jobs and decreased autonomy. There is still an ongoing debate among researchers and practitioners on how lean affects employees. In general, research on lean and employee effects is of varied quality, shows mixed results, albeit pointing in the direction of worsened working conditions (Landsbergis et al., 1999, Westgaard and Winkel, 2011, Hasle et al., 2012, Koukoulaki, 2014). In addition, most previous studies on lean in industry are set in the car industry and studies from small and medium sized manufacturing companies are scarce.

However, more recent studies and more human-oriented lean approaches, especially from the Scandinavian countries, indicate strengthened psychosocial conditions (Dellve, et al. 2015). This points to a need for more detailed studies of lean practices, and in what ways lean and favorable working conditions can be supported (Hasle et al., 2012). Drawing on experiences from an implementation of Just-in-Time (JiT) production, it seems that how human and social practices are designed is of importance (Mullarkey et al., 1995). There are, however, surprisingly few studies about management and leadership practices that support sustainable working conditions in a lean work system (Torvatn et al., 2015).

Since lean work systems have been linked to work intensification (Westgaard and Winkel, 2011) this way of organizing work could potentially contribute to increased workload and prevalence of work-related musculoskeletal disorders (WMSDs). In addition, WMSDs are still common in industrial settings (NRC, 2001, NRC, 1999, SWEA, 2014b). Despite this, studies on lean and how it affects the physical workload are rare (Arezes et al., 2015, Hasle et al., 2012,

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Landsbergis et al., 1999, Koukoulaki, 2014, Westgaard and Winkel, 2011). Moreover, none of the studies have actually measured the physical workload, and only a few have evaluated lean’s effects on WMSDs and risk factors thereof (c.f. Saurin and Ferreira, 2009, Brenner et al., 2004). The methodologically most advanced study, used an ergonomic observation method to compare the physical workload in lean and less lean jobs (Womack et al., 2009).

In addition, studying working conditions for employees has crucial importance, since employees can be viewed as being one of the most important resources in the company (Wright et al., 2001), and especially so since they are often key stakeholders in lean (Womack and Jones, 2003) and are expected to participate in improving the company and its processes. Furthermore, knowledge about how the changes are brought about and what factors may influence the outcomes for the employees, are lacking. Thus, it is important to obtain well-controlled empirical knowledge about the consequences of the introduction of lean in today’s working life, and what factors that may contribute to socially sustainable lean implementations.

Similarly, Hasle (2014), pointed to the need for future lean studies to explore the role of contextual factors and lean implementation, and to explore how lean can be used and developed in such a way that it promotes good job characteristics and reduces the possible negative effects of lean. Similarly, de Treville and Antonakis, (2006, p.100) point to the need for lean studies that explore how the different lean practices interact. In a similar vein, Karsh et al. (2014) point to the importance of moving beyond the idea that ‘context is important’ to explore what conditions and what elements of context that are important for employee working conditions.

Previous research on lean, has paid little attention to work itself, as in how the conditions of work are actually changed, not just how the working conditions are perceived by the employees. To my knowledge, only one previous study assessed the nature of lean work from a more objective perspective (Schouteten and Benders, 2004). To understand changes in contemporary work life, it has been advocated by Barley and Kunda (2001) to bring studies about work back into organizational research. In a similar vein, Parker (2014) has also called for context-sensitive studies of contemporary jobs in order to understand what factors influence work design.

Since the previous literature on lean and working conditions shows conflicting findings—but point in the direction of increased workload and decreased autonomy—there is a need to understand what factors or conditions in a lean work system may promote or enhance the type of conditions that support SSCW. This knowledge could, in turn, be used to design lean work systems that counteract possible negative effects of lean and support socially sustainable working conditions, even in times of lean rationalizations.

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1.1 Lean Manufacturing

1.1.1 The Lean Concept

…if we are to understand what these organizations actually do as part of their Lean programs, we need to describe the Lean interventions in much more detail. Simply

relying on the label Lean tells us little about the contents of the interventions.

(Brännmark et al., 2012b, p. 44)

Lean is a multidimensional management and production concept with diverse content and meaning (Shah and Ward, 2007), which has disseminated into many sectors within the Swedish working life (Brännmark, 2012), and is increasingly common in contemporary industrial settings (Börnfelt, 2006, Johansson and Abrahamsson, 2009, Samuel et al., 2015). The book that popularized lean The machine that changed the world (Womack et al., 1990), was the starting point for the lean concept’s way into western companies. The book, which presented research from Massachusetts Institute of Technology’s (MIT) International Motor Vehicle Program, provided descriptions of how Japanese companies, with Toyota in the lead, worked highly efficient and used ‘less of everything compared with mass production—half the human effort in the factory, half the manufacturing space…’ (Womack et al. 1990, p. 13.)—what they, inspired by John Krafcik, referred to as a ‘lean’ way of manufacturing. In many ways, lean can therefore be thought of as a translation of Toyota’s production system (TPS), even though other Japanese companies were also included in the program (Pettersen, 2009b, Womack et al., 1990).

Despite many efforts to capture what the lean concept comprises, there is no well-recognized definition of lean. Arlbjørn and Freytag (2013) concluded that the concept seemed vague, because of its low level of operationalization. Pettersen (2009a), on the other hand, concluded that there is quite good agreement on what characteristics lean have and that it at least can be distinguished from similar concepts like Total Quality Management (TQM). Moreover, the concept of lean and ways of implementing lean are continually evolving (Hines et al., 2004). In addition, different companies make, and are supposed to make, their own interpretations or local adaptations of the concept (Pettersen, 2009) in order to succeed with their implementation. Different companies could also be diversely successful in their implementation, depending on their specific context and how the implementation is undertaken. This implies that the adoption of the concept can vary greatly. Therefore, lean can be implemented in many shapes and versions. This makes it more difficult to study in practice and needs to be considered during the research process. Lean can be present at different levels of the organization, both as a philosophy (lean thinking) and a set of tools (Shah and Ward, 2007, Pettersen, 2009a). Lean thinking is, according to Womack and Jones (2003), based on five important principles:

(1) Specify value for the customer, (2) Identify the value stream—the set of activities that add value for the customers, (3) Create a smooth value flow, (4) Produce according to customer pull, and (5) Strive for perfection.

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Central lean themes are thereby to remove non-value adding activities or ‘waste’ (in Japanese: muda), to decrease unevenness (mura), and to avoid overburdening of people and machines (muri) (Ohno, 1988, Dennis, 2007). In the TPS, seven different types of waste can be distinguished: waiting, transportation, unnecessary movements, inventory, overwork, overproduction, and re-work (ibid). Thereto, Liker (2004) added an eighth form of waste: the untapped creativity of employees.

There are, in this context, various lean tools available for organizations to select from, which can either support improvements in production or in the organization (Pettersen, 2009). The application of lean tools can, for example, be related to formal management approaches for policy deployment and monitoring of results. Other common lean tools used are standardization of work, JiT production, continuous improvements (CI), and defect control (Pettersen, 2009a). In addition, some multi-skilling practices are associated with lean, for example, cross-training, problem solving, job rotation, and employee participation (Adler and Cole, 1995). According to some researchers, employee participation in CI is one of the key elements of lean (Womack and Jones, 2003, Liker, 2004), besides improved product flow. However, not all lean efforts include employee participation, and other scholars regard it as just one of many other dimensions of the lean system (Shah and Ward, 2007). In a review by Pettersen (2009a), based on the most cited contemporary lean books and journal articles, only 78% of them list activities related to human resources management, such as employee involvement, cross-training, and teamwork.

However, the lean models that have been influential in the Swedish industry—Liker’s (2004) interpretation of the Toyota system and Scania’s way of practicing lean (Bergman and Klefsjö, 2010)—both emphasize employee participation as a key component in continuous improvement efforts and highlight human values, such as: ‘Respect for the individual.’ This is not, however, the case in all lean implementations.

1.1.2 The Lean Concept and its Potential to Transform Work The lean concept has the potential and intention to transform the work system, work structures, and work processes, and thereby important characteristics of work, how work is done and appraised by the employees, and thus organizational performance and well-being (Holden, 2011). However, the lean most commonly described lean practices does not have an explicit focus on employee health or promoting sustainable working conditions (Pettersen, 2009a). Nevertheless, lean tools potentially affect job design and work characteristics that are important for employee health, such as control, work demands, social support, recognition, meaning of work, predictability, and how the work is performed (Cullinane et al., 2013).

There are several possible ways in which lean can alter work. Some of the principles of lean would be expected to contribute to better working conditions, such as equalizing flows and participation through continuous improvement initiatives. Hasle (2014), in his article about possibilities for an employee supportive lean, lists potential opportunities for better working conditions, for example: increased social support through teamwork and more feedback/ attention from managers, increased predictability of work due to standardization and thereby more knowledge about how to perform work tasks. In addition, he suggests that focus on customer value, and how your work contributes to that, possibly increases a sense of meaning of work. On the negative side, he points out that standardization may affect control over daily work and that less resources and work intensification may increase work demands. Other lean principles, such as creating short-cyclic, line-based work, where variation and buffers are minimized, could be expected to contribute to a deterioration of working conditions. On the

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other hand, if the lean improvement activities somehow address high physical loads, such as manual handling of heavy loads, the level of load could possibly be reduced.

To secure a positive development of the work system, it has been suggested that the lean initiative need to include a human perspective, and focus on the work environment and the organization of work (Abrahamsson and Sederblad, 2013).

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2. Aim The overall aim of this thesis is to contribute to the understanding of to what extent lean manufacturing transforms industrial work, including psychosocial and physical working conditions, and, to understand how socially sustainable working conditions can be supported in a lean organization.

2.1 Research Questions

The following research questions were specified:

RQ1 To what extent does a lean transformation influence process operators’ physical workload?

RQ2 To what extent does a lean transformation influence the prevalence of work-related musculoskeletal pain among process operators?

RQ 3 How are work characteristics and psychosocial working conditions affected and shaped during a lean transformation in a lean manufacturing company?

RQ4 What factors contribute to supporting socially sustainable working conditions in

a lean manufacturing company?

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3. Background This chapter includes a description of the theoretical framework for the thesis, including previous research on lean and working conditions.

3.1 Focus of the Thesis

The focus of this thesis is on the implications of lean on the nature of industrial work, with an emphasis on work characteristics, psychosocial working conditions, physical workload, and employee health. It is based on empirical longitudinal case studies in two industrial organizations that have implemented lean to various extents and one overview of the literature regarding lean and physical ergonomics. The research perspective is that of human factors and ergonomics. Knowledge from the two ergonomic domains: Organizational Ergonomics and Physical Ergonomics (IEA, 2019) are combined, with an emphasis on work tasks and employee effects.

3.2 Human Factors/Ergonomics

The overarching theoretical framework in the thesis, is derived from the field of Human Factors/Ergonomics. Fundamental characteristics of ergonomics, as described by Dul et al. (2012), are:

(1) A systems approach to understanding work and work systems, (2) Focus on design and, (3) Simultaneous focus on employee well-being and system performance.

Another central element of HFE is the focus on the interactions in the work system. For example, interactions between tasks, human, technology, the work environment and, organization of work, that are designed to work toward a joint purpose (Wilson, 2014). Human resource management (HRM) is closely related to HFE, but HRM differs from HFE in that it focuses more on the selection and development of people in order for them to fit the company’s needs, whereas HFE focuses on adapting and developing the system design in order to fit human needs (Human factors engineering) (Neumann and Dul, 2010). HFE have, by the International Ergonomics Association (IEA), been defined as:

Ergonomics (or human factors) is the scientific discipline concerned with the understanding of the interactions among humans and other elements of a system, and the profession that applies theoretical principles, data and methods to design

in order to optimize human well-being and overall system performance.

(IEA, 2010)

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The thesis focuses on the interactions between the production system, organization of work, the characteristics of work, and, in turn, the consequences for the working conditions. Wilson’s (2000) definition of ergonomics, is even closer to the approach in this thesis:

Ergonomics is the theoretical and fundamental understanding of human behavior and performance in purposeful interacting sociotechnical systems, and the

application of that understanding to design of interactions in the context of real settings.

(Wilson, 2000, p. 560)

Different HFE work systems models have been used to describe the system and the interactions between the elements in the system, including the socio-technical systems model (STS) (Pasmore, 1988), the human-technology-organization model (HTO) (Eklund, 2003, Karltun et al., 2017), the Balance Theory model (Carayon, 2009), and Porras and Robertson’s model of the organizational work setting (1992). Eklund’s HTO-model is centered around human work activities, and especially how the organizational setting, environment, and technology interact with the human work activities (Figure 1). On a general level, Eklund’s model fits well with this thesis’ focus on work itself and how it is transformed and is consistent with the thinking that work itself needs to be focused. This reasoning is also in line with Rice (1963), who points to the need to focus on the organization’s primary task and its potential for being the starting-point for change. Rice (1963, p.13) described that an organization, each part or whole, at any given time has a primary task: ‘the task that it [the organization] must perform to survive.’

Figure 1. Eklund’s (2003) Human-Technology-Organization model (HTO-model), where the human work activities required for performing central operations is at the center of the work system.

A literature review of manufacturing design changes has shown a high convergence between employee and system effects, with the majority the of the studies showing better improvements of both operations and the human aspects (Neumann and Dul, 2010). For example, poor physical ergonomics have been found to result in product quality defects

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(Erdinç and Yeow, 2011, Eklund and Yeow, 2015). Similarly, in a Swedish manufacturing company, Axelsson (2000) found that quality deficits were almost ten times more likely in jobs with poor ergonomic design. Today there is an awareness in the ergonomics field that context matters (Karsh et al., 2014). However, there is a lack of explanatory and tested models of interactions across levels and what contextual factors are important for producing what outcomes, and under what circumstances. Thus, as a first step, qualitative studies exploring these interactions have been called for (ibid.). To describe the consequences of the new production system on work characteristics and working conditions for the employee, a modified version of Smith and Carayon’s Balance Theory of Job Design model was used to guide the analysis in case studies III and IV (Figure 2). The balance theory of job design for stress reduction, first described by Smith and Carayon-Saintforth in (1989), was an attempt to integrate knowledge about job design and its effects on well-being and performance of individuals. The work system is in this model divided into five elements: person, tasks, tools and technologies, organizational conditions, and the physical and social environment (ibid.) The model was later developed and adapted by Holden (2011) to understand changes in work design (work structures and work processes) induced by lean in a health care setting. Holden’s model was modified for industrial settings to suit the purpose of the included case studies.

Figure 2. A lean work systems model, modified from Holden (2011), suggesting that different lean initiatives and company contexts may differently transform the work characteristics and the way work is performed, and in turn, the employee working conditions and organizational performance. The model further suggests that lean could affect the employee outcomes both directly and indirectly through changes in the designed work characteristics. The model is reprinted with permission from Wiley & Sons.

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Holden (2011) points to the importance of understanding how lean affects work structure and processes, as in previous studies of health care, he has seen how they, in turn, affect the working environment. The direct effects of lean, which could arise without changing the design of work, might be that employees are positively affected by being involved in change projects and making suggestions for improvement of the business. Direct negative effects can, for example, be the worries about losing one’s job—evoked potentially only through the initiation of a change project (Holden, 2011, Abildgaard et al., 2018). Similarly, a longitudinal study by Parker (2003) suggests that lean effects on employees’ health is mediated through the characteristics of work. This means that the effect of lean on employee health is partly mediated by its effects on the design of work.

3.3 Health of People at Work

Organizational factors at work are presumed to have an impact on working conditions and, in turn, employee health (Härenstam et al., 2006), and the workplace is an important setting for the promotion of health (ENWHP, 1997/2018). The optimizing of human well-being is also one of the goals of ergonomics interventions (IEA, 2010) and Westgaard (2000) has suggested that a health focus needs to be integrated into all tools and indicators used to control and manage the organization. In line with The Luxembourg declaration on workplace health in the European Union, the concept of workplace health in this thesis encompasses work-related health factors, i.e. practices to improve the work organization and the working environment, to support active participation, and to encourage personal development (ENWHP, 1997/2018). This view taken on health is further elaborated below.

Health is a multifaceted concept, and can be affected not just by what goes on in the workplace, but also by the individual’s physical, mental and social conditions in general (Morrison and Bennett, 2016). In this thesis, health is, in line with the World Health Organization’s (WHO) definition, viewed as positive concept:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

(WHO, 1946)

In line with the with the Ottawa charter of Health promotion (WHO, 1986), health is viewed as a resource for everyday living. Resources emphasized in the charter are physical capacities and personal resources, as well as social resources (ibid.). A theory of health that is compatible with health in the workplace, is the Holistic Theory of Health (Nordenfelt, 2007), put forward by a Swedish professor of philosophy of medicine and health care. The theory states that an individual is healthy when the person ‘has the ability, given standard circumstances, to reach all his or her vital goals’ (Nordenfelt, 2007, p.7). Vingård et al. (2001) have adapted Nordenfelt’s definition to suit work life health even more. Because of its focus on actions and compatibility with Kira and van Eijnatten’s (2009) definition of sustainable work, their definition has been adopted in this thesis:

Good health can be said to include both a sense of well-being and an ability to act. A good employee health can then, in harmony with the health concept, mean possessing opportunities to act that make it possible to carry out work

with a sense of well-being.

(Vingård et al., 2001, p. 2, my translation)

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The notion of health promotion also has a focus on activity, which can be useful when discussing ability to perform at work. More particularly, it has been defined by Nutbeam (1998; 1996) as a process that strengthens employees’ abilities to act. Similarly, according to WHO (1986), health promotion is seen as the process in which people are enabled to improve and increase control over their health.

The approach to health in this thesis has both a preventive component—finding risk factors for ill health (study II) and a promoting component—finding factors at the organizational and management level that support health (study IV). Unfortunately, however, an inverted risk factor is not always a health factor (Lindberg, 2006). In study IV, managerial practices that may have contributed to employee engagement and health are analyzed in order to decode whether some practices are more health-promoting than others. Taking a critical view on the well-being goal of ergonomics, Hollnagel (2014) argues that the goal could be more closely related to the actual work situation:

the goal could be to improve the ability to manage expected as well as unexpected work situations. If it becomes easier for people to make sense of their work, not in the sense of avoiding verfremdung [alienation] but in the sense of being better able to understand what happens (as well as understanding what has happened and what will happen) and thereby

cope more efficiently, then this will reduce the uncertainty of the work and increase people’s ability to manage what they are doing.

(Hollnagel, 2014, p. 44)

3.4 Managing and Organizing for Healthy Work

Theories and knowledge about organizations and how to manage, design, and organize work may contribute to an increased understanding of how these processes can be facilitated and what might the consequences be of certain ways of organizing. The organizing of work refers to how work is designed and how work is performed (NIOSH, 2002). Three levels in the organization can affect the way work is designed: (1) Public and economic policy and other forces (i.e. economic, political, legal, technological factors, etc.), (2) Organizational context (i.e. human resource policies and management and production practices), and (3) Work context (working conditions like task design, social-relational aspects of work (social climate), employee development, and job security, etc.). The focus in this thesis is on how the organizational context affects working conditions in practice and characteristics of work, rather than terms of employment. The main focus is on the inner organizational context (i.e. management and production practices) and how it affects the work context (working conditions like task design, social-relational aspects of work (social climate), employee development, and job security etc.).

The term organizing is used to better illustrate the dynamic dimensions of the work system and is in this thesis conceptualized as the company’s ability to effectively work with, for example, CI, even though the concept can comprise more than that. The company context can, according to Pettigrew (1987), be divided into outer and inner context, with outer context referring to the economic, political, social, and competitive environment in which the company operates. Inner context refers to the structure and corporate culture within the company (ibid.) Ellström (1992) points to the importance of considering the potential impact of the work context, especially the task environment, on the work characteristics, since different task characteristics and company cultures may have different impacts on the employee. The

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changes implemented are also thought to be affected by the organizational culture. Schein (1984) describes organizational culture as existing at multiple levels in the organization, and as something that is shared among its employees. He further states that it exists as visible artifacts, symbols and creations (i.e. technology and observable behavior), explicit values, and underlying basic assumptions (i.e. unconscious assumptions about the organization and about employees). More particularly he defines organizational culture as:

… the pattern of basic assumptions that a given group has invented, discovered, or developed in learning to cope with its problems of external adaptation and internal

integration, and that have worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and

feel in relation to those problems.

(Schein, 1984, p. 3)

3.4.1 Work Design To promote human and socially sustainable working conditions, including employee health and organizational performance, the design of work needs to be focused (Shain and Kramer, 2004). According to Parker (2014, p. 662) work design concerns: ‘the content and organization of one’s work tasks, activities, relationships, and responsibilities.’ Research demonstrates that how work is designed and organized will affect job satisfaction, worker stress, absenteeism, and more; see, for example, a meta-analysis conducted by Humphrey et al. (2007). Despite this, an evidence-based and comprehensive understanding of the mechanisms or forces that impact work design in contemporary work life, is lacking (Parker et. al, 2017). Furthermore, little attention has been put on what constrains or enables the design of work. Traditionally, models of work design start with the designed work characteristics and go on to describe the intermediary factors that affect employee outcomes (ibid.). Holman et al. (2002) suggest that we need to study the process in which jobs are shaped and under what circumstances a certain job design works:

We also need to study how jobs get to be the way they are, how they work, under what circumstances, and why they have the impacts they do.

Holman et al. (2002, p. 203)

Detailed studies of work follow the tradition of early organizational researchers (c.f. Trist and Bamforth, 1951, Argyris, 1971, Taylor, 1911/1947). To understand changes in contemporary working life, it has been advocated by Barley and Kunda (2001) to bring work back into organizational research. Traditionally, early organizational research anchored their theories and principles on first-hand studies about work in practice (ibid.). For example, Taylor (1911/1947) formulated his Principles of Scientific Management based on systematic studies of work practices.

Succeeding job design theories were developed based on employees’ practices and work motivating factors (Herzberg et al., 1959/1993, Hackman and Lawler, 1971). However, in the 1960s and 1970s organizational studies drifted away from work itself toward more abstract descriptions of organizations, due to trends in organization theory (Barley and Kunda 2001). The focus was then shifted toward systems theory and how organizations are affected by their environment (ibid). In a historical perspective, some job design theories have been more influential than others, and some continues to influence the organization of work even today.

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Taylor’s principles of work, one of the first theories about work organization, continues to influence work even today (Börnfelt, 2017). His methods aimed at increasing the efficiency of work by defining the ‘best’ or most efficient ways of working (Taylor, 1911/1947). One of the main characteristics of his methods, referred to by others as Taylorism, was the vertical and high division of work—a work system where employees only performed the manual work, while the planning and control of work was allocated to white-collar workers. This way of designing work also led to job simplification. Taylor’s ideas gained popularity in Sweden in the 1920s and were institutionalized in larger companies and technical universities during the 1930s, and later disseminated to other work sectors as well (Börnfelt, 2017).

Another invention introduced in the beginning of the 20th century was Henry Ford’s moving assembly line (Parker and Wall, 1998). As a result, the work was paced by the machinery and consisted of short-cycled work tasks (Dankbaar, 1997). The Fordistic organization was oriented toward mass production, highly specialized, and required buffers between the different production steps to function, as opposed to lean production where buffers are kept to a minimum. Similar to Tayloristic organization, the division of labor was high in the Fordist system, and so-called indirect tasks, for example, maintenance, machine setup, and quality control, were performed by separate departments and assembly workers had no responsibility for the quality of the product. Repair work was instead performed by special repair workers (ibid.).

The next contribution to work design research was the Human Relations movement, which was also inspired by close studies of work and highlighted the importance of social relationships and designing work around groups or teams (Johansson and Abrahamsson, 2008).

Another classical work design theory, the socio-technical systems theory (STS) was largely a criticism of the rationalization movement (Björkman and Lundqvist, 1981). STS was initially associated with shop floor democracy through its concerns about decision-making and employee control and humanization of work through a set of design principles (Thorsrud, 1968, Mumford, 2006). The theory is focused on the interdependence between the social and technical elements of the work system (Trist, 1981). One key feature of STS is the proposal that there should be a joint optimization of the social and technical subsystems, and that they should be designed in parallel (Mumford, 2006). Creating opportunities to learn, enriching and enlarging work tasks have been emphasized in the socio-technical work design perspective in order to strive for richer and healthier jobs (Trist, 1981). This was based on the assumption that meaningful and complete tasks with more employee control over how to perform the job in terms of procedures and methods used, provide opportunities for personal development and to control and balance the workload (Trist, 1981). Furthermore, the STS states that work content should be varied and that employees should be able to comprehend how their own job contributes to the organization’s goals (Thorsrud, 1968). Another important STS-principle is multifunctionality (Cherns, 1987), meaning that employees should be cross-trained to be able to work in other jobs, if necessary. STS have, however, gained some critique for not containing specific enough guidance for work system design (Hackman and Oldham, 1980), and Clegg (2000) has suggested a set of socio-technical principles that extend Cherns’ principles and attempt to integrate them in a better way. Historically, the Scandinavian countries have been highly influenced by STS (Trist, 1981). Implementing lean in combination with STS, has, in a study of Swedish companies, been shown to lead to better organizational performance than if the concepts were implemented one-by-one in isolation (Dabhilkar and Åhlström, 2013).

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Another influential job design model, the Job Characteristics Model (JCM: Hackman and Oldham, 1980, Hackman and Oldham, 1976), focuses on five job characteristics; task identity, task significance, feedback, and autonomy. This, in order to promote good work design and thereby employee motivation, sense of meaningfulness, sense of responsibility, and knowledge of results. Autonomy referring to: ‘The degree to which the job provides substantial freedom, independence, and discretion to the individual in scheduling the work and in determining the procedures to be used in carrying it out.’ (Hackman and Oldham, 1980, p. 79).

Three examples of making jobs more varied and satisfying, are the application of job rotation, job enrichment, and job enlargement (Luczak et al., 2012). Job enrichment, originating from Herzberg’s theory about employee motivation, involves incorporating higher level skills through adding more challenging or specialized tasks—a vertical widening of a job by giving an employee increased responsibility for decisions or tasks previously traditionally performed by managers or administrators (Parker and Wall, 1998). The job can, for example, be enriched in such a way that discretion, performance feedback, and opportunities to grow and learn, are enhanced. Job enlargement refers to a horizontal widening of a job scope so as to include a greater number and variety of work tasks (Luczak et al., 2012). The work content analysis, in studies III and IV are partly based on this thinking. This kind of research, highlighting the importance of good work design to promote employee motivation, starting in the mid-1970s (Parker and Wall, 1998), was a reaction to Taylor’s (1911/1947) ideas about highly specified and narrow tasks.

Work design theories have traditionally focused on enhancing employee motivation and performance. However, employee performance at work might mean different things, and several approaches are currently being used (Griffin et al., 2007). In addition, theories of work design all try to optimize work performance, but attempts to link work design to performance have been difficult and inconsistent (Humphrey et al., 2007). In addition, German action regulation theory points to the importance of understanding work and work actions, rather than only motivational factors at work (Frese and Zapf, 1994), as reflected in the following quote:

…. people demonstrating the highest job performance in a job are not always the most motivated workers, but rather those who have the best cognitive

understanding of the job and the better work strategies.

(Hacker 1992 cited in Frese and Zapf, 1994, p. 272)

Moreover, Parker (2014) posits that focusing on work motivation is necessary— but not sufficient, and suggests that work design theories in contemporary jobs also need to focus on how health, opportunities for learning and development may be supported. Humphrey et al. (2007) further points out that work context and the social environment at work need to be focused. More recent theories of work design focus more on relational and social aspects of work, as well as in what ways employees have opportunities to influence and craft their own work designs (Grant and Parker, 2009).

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3.4.2 Leadership Supporting Engagement and Health

... the task of the supervisor who attempts to enhance subordinate motivation should be to create and develop the organizational conditions in which his

subordinates perform such that they become more potent motivating factors. (Oldham, 1976, p. 67)

Growing evidence shows associations between how employees are managed and their well-being (Skakon et al., 2010, Kelloway and Barling, 2010, Kuoppala et al., 2008). There are several possible pathways, in which the leadership can affect the working conditions and health. Most of the research has looked into direct links between leadership and health, without considering what factors might mediate or moderate the outcomes, or without taking working conditions or context into consideration (Nyberg, 2009). One suggested conceptual model of how managerial practices can be linked to employee outcomes are Dellve and Eriksson’s model (2017), which describe the work system from individual level to factors outside of the organization, including conditions for health-promoting and sustainable managerial practices.

The perspective on leadership in this thesis is about how the managerial practices are shaped and practiced in daily interactions between individuals and groups in the organization, and in daily activities (Alvesson and Sveningsson, 2003). In line with Hosking (1988, p. 147), managers’ acts of organizing that contribute to the structure of relationships and interactions, and activities, are focused. The view taken on leadership in this thesis is also in agreement with Rost’s (1993) definition of leadership as ‘an influence relationship among leaders and their collaborators who intend real changes that reflect their mutual purposes’ (p. 99), thus also focusing on managerial work bringing about structural change. In addition, Rost highlights three important elements of genuine leadership: Bi-directional influence, both top-down and bottom-up and both within and from outside the organization, and with employees as active participants, although he added that the relationship is always uneven. Finally, he emphasized collaboration between leaders and employees to achieve common purposes.

Traditionally, leadership research has focused on identifying what factors may contribute to effective leadership by focusing on the leader traits and leadership behaviors, as well as situational factors that may moderate the effect, for example, type of task, and employee and organizational characteristics (Alimo-Metcalfe, 2013). In recent years, the interactions between leaders and employees have gained increasing attention (Yukl, 2013) as has engaging leadership (Alimo-Metcalfe, 2013). One of the most influential leadership theories is the transformational leadership theory (Bass, 1990). The notion of transformational and transactional leadership styles was first introduced by Burns (1978), and later further developed by Bass (1996). A transformational leader motivates the employee by appealing to the common good for the organization, this through: idealized influence—i.e. conveying a desirable future vision and through leading by example; intellectual stimulation—supporting employees to look at things from new perspectives and use their creativity; individualized consideration, where the leaders support, coach and encourage employee development through paying attention to employee needs and delegating assignments; and inspirational motivation, where the leader communicates an inspiring vision and high values in order to promote involvement and extra efforts (ibid.). On the other hand, a transactional leadership, involving an exchange process between the leader and the employee, motivates employees through appealing to self-interest. This involves, for example, using contingent rewards—incentives and clear descriptions of what is necessary to get rewarded (Yukl, 2013). According to Bass (1985), transactional and transformational

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leadership are not necessarily different processes, but are still distinct concepts. Transformational leadership is assumed to motivate engagement among employees by raising consciousness concerning values, providing meaningful visions, and creating a considerate and intellectually stimulating learning climate for the individual employee (Bass, 1990). This kind of considerate leadership style has been suggested to be particularly suitable for leading change (Eisenbach et al., 1999).

In their review on leadership styles and effects on employee health, Nyberg et al. (2005) concluded that research in the area was limited, but from the existing literature the following leader behaviors were associated with employee health: consideration toward employees, providing structures—especially during times of stress, allowing employees to influence their work environment by providing empowering structures and opportunities for control and participation, promoting a meaningful work, and providing intellectual stimulation. A study by Nielsen et al. (2008) suggests that work characteristics as perceived by the employee; (i.e. opportunities for development, role clarity, and meaningful work) partially mediate the relationship between a transformational leadership style and mental well-being. Their study only showed limited evidence for a direct path between leadership behaviors and employee well-being.

Danish studies of companies implementing lean (Hasle & Paarup Nielsen, 2013), point to several important leadership strategies and activities for supporting engagement in change and developing favorable employee working conditions: Managers who provide employees with a transparent and coherent long-term plan, are able to combine short-term lean projects with their long-term strategy, create room for integrating learning into daily practice, hand over responsibility to employees gradually as their skills increase, are able to build trust, and can come up with reasonable explanations for what obtained results should be used for. They also stress the importance of a management style that is aware of how lean affects the social capital in the organization (ibid). The central elements of organizational social capital are justice, trust, and collaboration (Gylling Olesen et al., 2008). If the employees’ trust in management is low during lean implementation, then their willingness to engage and participate in work improvement may be lower (Sørensen et al., 2011).

Social capital has been suggested as an important factor to consider in lean organizations in order to ensure positive employee outcomes, alongside the psychosocial factors and change management processes (Hasle, 2014). Hasle further suggest that work sites with higher social capital might have a stronger focus on employee opportunities for control through, for example, continuous improvement practices and teamwork. The concept of social capital was first studied as a societal phenomenon (Adler and Kwon, 2002), but in recent years the importance of studying social capital in the workplace has been highlighted. Social capital ‘exists in the relations among persons’ (Coleman, 1988 p.100), and it can be seen as a resource in the organization that facilitates employee actions. Research suggests that an important factor for developing social capital is the quality of the leadership (Kristensen, 2010). In addition, one dimension of organizational justice—justice of decision-making and interpersonal treatment, has been associated with employee health (Kivimäki et al., 2003). Perceived organizational social support has been shown to mediate the association between organizational loyalty, operationalized as high affective commitment and a low degree of turnover intentions, and interactional justice (informational and interpersonal justice) (Otto and Mamatoglu, 2015). Similarly, to be able to be both efficient and innovative, Adler et al. (2001) point to the need for creating a collaborative enterprise where the following set of skills needs to be mastered: building a shared purpose, cultivating an ethic of willingness to contribute, developing

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processes and abilities for coordination of employees’ efforts, and creating an infrastructure and social climate in which collaboration is rewarded and valued.

To facilitate collective work, Yukl (2013) proposed the following ten leadership practices: Help interpret the meaning of events, create alignment on objectives and strategies, build commitment and optimism, build mutual trust and cooperation, strengthen collective identity, organize and coordinate activities, encourage and facilitate collective learning, obtain necessary resources and support, develop and empower people, and promote social justice and morality.

Other characteristics of positive management practices, in relation to how favorable working conditions are shaped, are participatory and dialogue-based practices and non-hierarchical relations (Torvatn et al., 2015). The creation of opportunities for learning and goals for organizational activities were also emphasized in the Swedish studies included (ibid.). The context sensitive leadership in Swedish organizations can, in general, be characterized by dialogue and supportive management practices (Eriksson, 2011, Torvatn et al., 2015). Saksvik et al. (2007) identified the following criteria for healthy organizational change: awareness of how to deal with employees’ diverse reactions to change, role clarification at an early stage, available managers, as well as making use of constructive conflicts as a way of dealing with the inevitable resistance that changes may evoke. Leader availability seemed to be a key factor for this, and their results indicate that ‘management by being there for me’ was an important factor—a factor they suggest can be seen as a further specification of the similar activity ‘management by walking around.’ One difference between the two could be activities/behaviors enacted by the leaders and how these practices are perceived by the employees. Employees’ perceptions concerning how the organization care for their well-being and value their contributions have been associated with employee commitment and lower levels of absenteeism (Eisenberger et al., 1986).

One common characteristic of family-owned firms, as the company in studies III–IV, can be a heightened responsibility to their employees, a long-term business focus, visible and active ownership, and a high degree of continuity in ownership and power (Brundin and Melin, 2012).

3.4.3 Organizational Change and Sustainable Improvements Many contemporary industrial organizations are under constant pressure to implement changes due to the dynamic nature of their environment. Bringing about organizational changes, however, can be challenging and many change initiatives fail (Bhasin and Burcher, 2006). The term organizational change is a broad term incorporating a range of different methods and strategies for company-wide changes (Saksvik et al., 2007). Several theories about change management have been suggested while only a small selection of them will be represented in this thesis, with a focus on sustainable change.

Several of the theories and approaches can be traced back to the early work of Kurt Lewin and his phase-model: (1) Unfreeze, (2) Change, and (3) Refreeze (Weick and Quinn, 1999). Another popular model of planned change is Kotter’s (1996) eight-step model for successful change, including factors such as clearly communicating the vision, building trust, short-term wins, and anchoring the change in their culture. Pettigrew (1987), on the other hand, has argued that a systems-oriented model is needed to understand change; where the interactions between the content of the change, inner context (i.e. company culture and organizational structures), outer context, and processes of change, are considered when determining the

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results of the change initiative. Thus, to get a deeper understanding of inner contextual factors during change, Pettigrew’s approach was applied in studies III and IV.

While many change theories identify various important systemic components as the levers for change, few of them include employee behavior as a prerequisite for systems to change, as Porras and Robertson (1992) do in their comprehensive framework for organizational development:

…change in the individual organizational member’s behavior is at the core of organizational change and, therefore, any successful change will persist over the

long term only if, in response to changes in organizational characteristics, members alter their on-the-job behavior in appropriate ways.

(Porras and Robertson, 1992, p. 724)

To support change, active employee participation is emphasized by several scholars (c.f. Armenakis and Harris, 2009, Nielsen and Randall, 2012, Nielsen et al., 2010). Organizational change may, however, evoke feelings of uncertainty among employees, challenge trust in management (Sørensen et al., 2011, de Jong et al., 2016), and have been shown to mainly negatively impact the well-being of employees (de Jong et al., 2016). Employees’ reactions to change can be affected by several factors. Drawing on experiences from an implementation of JiT, it seems that how the human and social practices are designed is of importance (Mullarkey et al., 1995). Similarly, a review of studies about restructuring of organizations (de Jong et al., 2016) indicate that employees’ satisfaction with the way the change was managed and organized, communication about change, sharing of information, and fair procedures, can have an impact on how employees react to the change process. Managerial activities aiming at repairing trust during change may also aid in the change process (Sørensen et al., 2011). Creating readiness for organizational change throughout the organization has also been highlighted as an important factor for involving employees (Armenakis and Harris, 2002, Nielsen et al., 2010). Employees’ commitment to change might, however, be negatively impacted if they perceive the work changes as unfavorable (Jaros, 2010), whereas when employees experience the change as being valuable to them and when support from leaders is available, employees may be more motivated to commit to change (Armenakis and Harris, 2009).

Moreover, research by Nielsen and Randall (2012) shows that employees need to notice actual changes of daily work procedures if increases in important psychosocial factors such as job satisfaction and autonomy are to occur. Their study also highlights the necessity of evaluating psychosocial factors including the degree of employee participation to monitor the change process and to ensure that employees’ experiences are used. Similarly, a study by Rapp and Eklund (2002) also indicate that employees need to appraise that spending time on change practices benefits their own work. This could be done through ongoing monitoring of the change process and by measures of employees’ appraisal of the changes made or of changes underway (Nielsen, 2018). The results from the monitoring can then be used to find opportunites for improvement of the change process, as well as to design activites and employee support that may counteract the negative effects of change (Abildgaard et al., 2018).

Continuous improvements, one of the core characteristics of lean (Liker, 2004), can be seen as a special form of organizational change, with high levels of participation, use of specific methods, and ongoing continuous changes (Ellström and Kock, 1999).

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For CI programs to be successful over time, Bessant et al. (1994) propose that they include these key principles:

(1) A clear strategic framework, (2) A supportive culture – i.e. recognition of the value of CI, believing that everyone in the organization can contribute, and encouraging experimentation, (3) An enabling infrastructure – efficient communication and decentralized decision-making, (4) Strategic management – i.e. goals accompanied with displayed performance feedback, (5) Managing as a process – using iterative cycles of problem solving, and (6) A supporting tool kit– i.e. problem-solving tools, including training in how to apply them.

Other factors that are closer to the work practice, found by Rapp and Eklund (2007) to influence employees’ involvement in raising suggestions, and thus the sustainability of the system, were, for example, targeted campaigns on different themes that encouraged employees to submit suggestions, employees’ willingness to submit suggestions regarding their own work environment, and focus on supporting group-based suggestions. Other critical practical aspects, which are important for encouraging employees and, thus, the overall sustainability of the improvement system, as stressed by Lawler and Mohrman (1985), are to provide quick and knowledgeable feedback about the submitted suggestions and to convert them into action:

Official approval of their ideas may please participants but isn’t enough to motivate them to come up with new ideas. People need to see their ideas in action

and to receive feedback on how they are working out.

(Lawler and Mohrman, 1985, para. 24)

Moreover, Lawler and Mohrman (1985) also noted that employees often want to solve problems beyond their direct work area—particularly issues that can affect the company’s performance, but get frustrated when they themselves cannot initiate the changes needed. On a positive note, Swartling and Poksinska (2018) have identified several mechanisms that can contribute to sustaining a lean system in a process industry, for example; an organization that is open to change, including supporting new social interactions (operating at the edge of chaos); ‘a constant flow of novelty and change’ followed by a new relative stability (p. 1008); managers who support and coach employees; self-managed work teams that, to a greater extent, are self-managed and who have greater control over daily operations and improvements thereof; and managers who enable employee learning and collaboration, and who set up a reward system that reinforces teamwork. Brännmark and Benn (2012), on the other hand, suggest that in order to call the continuous change program sustainable, it also needs to have other qualities, in addition to being durable, such as stake-holder-balance and a project design that support long-term effects. Enablers identified for a sustainable organizational implementation with long-term effects include active ownership of the change by managers who take responsibility for the implementation, professional change management, opportunities for developmental learning, necessary resources allocated, and an integration of operations and human management (Svensson et al., 2007).

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3.5 Working Conditions

According to the European Industrial Relations Dictionary (Eurofound, 2011), the term working conditions refers to the work environment and employees’ terms and conditions of employment. This encompasses aspects such as: organization of work, skills, training, wages, employability, safety & health, working time, and work–life balance. The work environment can further be divided into physical work environment, the organizational work environment, and social work environment (Carayon, 2006, Wilson, 2000). In Sweden, about every fourth employee reported having work-related health concerns, either physical or psychosocial problems, or both (SWEA, 2014a).

3.5.1 Sustainable Working Conditions Sustainability is a broad concept that can be defined in many ways and which comprises several different interdependent dimensions: ecological, economic, and social (Docherty et al., 2009). One of the global goals for sustainable development in the Agenda 2030 (United Nations, 2015) concerns work: ‘Goal 8. Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all.’ Sub-goals related to this thesis, concern, for example, ‘decent job creation’ and the promotion of secure and safe work environments. Building on the World Commission on Environment and Development’s report about our common future (Brundtland et al., 1987), sustainability is, in general, often referred to as:

…a general worldview according to which people should strive to fulfil their needs in a manner such that the ability of future generations to fulfil their needs is not

endangered. (Docherty et al., 2009, p. 3)

In working life, social sustainability refers not only to preservation of the human resources, but also to support human growth and development (Kira and Van Eijnatten, 2009). According to Kira and Van Eijnatten (2009), sustainable work systems are aiming at simultaneous development of different stakeholders, and can be defined as:

…the ability of employees, groups, and organizations to keep on functioning in any situation faced.

(Kira and Van Eijnatten, 2009, p. 234)

The functioning here is a functional capacity—a capacity for groups and employees to adapt to new situations faced, being able to proactively create new opportunities at work and having a capacity for change (ibid.) A sustainable work system is therefore by nature dynamic and aims for development. The definition is similar to other stakeholder models, where simultaneous development of different stakeholders are emphasized (Eklund, 1998), and the dual goal of HFE to jointly promote performance and well-being (Dul et al., 2012). Furthermore, sustainable work can, by analogy with the perspective of environmental resources, be defined as a resource-regenerative—work that supports the growth of employees’ resources and strengthens their capacity to deal with future challenges at work rather than consuming employee resources (Kira and Forslin, 2008). Drawing on Antonovsky’s (1987) sense of coherence-concept, Kira and Forslin (2008) define regenerative work as work that promotes employees’ sense of coherence by providing psychosocial resources aiming to promote a

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meaningful, comprehensible, and manageable work situation. Thus, they argue that to be able to keep on functioning, the employee needs to find the work meaningful. In terms of working conditions, Docherty points to some characteristics and values of the working conditions in a sustainable work system:

In a sustainable work system, employees’ capacity to deal with the world’s demands grows through work-based learning, development and well-being. The

growth of the social resources is secured through equal and open interaction among the various stakeholders, leading to better mutual understanding and

greater capacity for collaboration.

(Docherty, 2009, p. 3)

Building on this reasoning, SSWCs are, in this thesis, broadly defined as a work system that is able to develop its human resources and has a work environment with sufficient job resources to support employee growth, meaningful work, and health (Schaufeli and Bakker, 2004, Kira and Forslin, 2008).

3.5.2 Work Characteristics and Work Design The work tasks are the interface between the employee and the organization (Frese and Zapf, 1994). By studying the nature of the employee’s work tasks and the conditions they are given to complete them (the so-called work content), you get an understanding of the individual’s possibilities to perform in the job, but also an understanding of how the organization or managers have succeeded in communicating the tasks and goals to the employee. One condition that has been extensively studied and described is worker control. It is a central aspect in both job design and in stress theories. Although many different terms and models are in use for this phenomenon, for example, room for action (Semmer 1984 in Frese and Zapf, 1994), degrees of freedom (Hacker, 1986 in Frese and Zapf, 1994), decision latitude (Karasek, 1979), and autonomy (Hackman and Oldham, 1980), they can all be subsumed under the term control, according to Frese and Zapf (1994). Frese (1977) refers to control as having impact on the conditions and one’s activities in relation to a goal. Things to control in working life, are for example: in what order and when to do a task, and to decide upon goals and take part in planning of the job. In action theory, control is viewed as an instrument to better choose between adequate strategies to handle the situation, i.e. when something goes wrong (Frese and Zapf, 1994).

In addition, lack of control is one factor in stress theory that has been identified as important for explaining people’s stress reactions and ill health (Karasek and Theorell, 1990). For example, a large, prospective Swedish study by Oxenstierna et al. (2005) found that lower self-reported decision authority was associated with higher prevalence of bodily pain after work and a higher incidence of long-lasting sick leave (> 60 days), as compared to employees with higher decision authority. Worker control is also a central aspect in the external work content analysis (ARIA) used in this thesis. In ARIA, the work content refers to the work tasks in combination with what resources you are given to fulfill the work goals and what hindrances there might be for doing so (Waldenström, 2007). The resources focused in ARIA are at the interpersonal level (supervisor and co-worker support) and at the task level (work tasks, control over one’s work tasks, participation through continuous improvements and time pressure). The focus is, however, not so much on the organizational level (i.e. salary, career opportunities, terms of employment, and job security). In particular, the balance between

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demands and resources are of interest, if the employee has the resources needed to complete the task and reach a clearly defined goal. If there is a balance, then the job is considered ‘good’ (Waldenström, 2007).

Striving for ‘the good work’, inspired by socio-technical principles, was introduced already in the 1980s in the Swedish manufacturing industry (Johansson and Abrahamsson, 2009). More recently, Lundqvist and Henriksson (2007) have described criteria for ‘good’ work, in what they call a humane workplace. In that kind of workplace, job satisfaction through personal development, balance between your resources and abilities and work demands, and social support, combined with quality and efficiency, are thought to contribute to genuinely responsibility-taking, participative, and development-oriented employees. The described criteria are similar to the ones emphasized in the STS (Trist, 1981) and can be exemplified in the following statement:

Employees who have convincing evidence that their organization has committed itself – long term – to joint optimization are more likely to commit themselves

than those who do not. (Trist, 1981, p. 32)

The criteria and meaning of ‘good work’ have, however, changed over time depending on the prevailing theories about work, for example, from Taylor’s narrow view on good work, through theories about learning organizations emphasizing collective learning, and to Antonovsky’s (1987) theories about how work should be perceived (manageable, meaningful, and comprehensible) to have positive outcomes (Kira, 2003). The following action strategies by Waldenström and Härenstam (2008) have been found to contribute to create ‘good work’: having both financial and quality goals, feedback based on performance measurements, a formal management structure, managers who aid in creating feasible and structural solutions to concrete work problems, a clear allocation of work tasks, and teams taking common responsibility to reach targets.

Employees’ job expertise has been identified as an important component in the design of work interventions (Kompier et al., 1998, Nielsen et al., 2010). Furthermore, Rosskam (2009) argues that when employees are invited to participate in analyzing work practices, the likelihood of changes being useful, appropriate, will increase. Participatory approaches have a long tradition in ergonomic interventions (Wilson, 1991, van Eerd et al., 2010, Haines et al., 2002). The multifactorial concept covers a broad range of practices and ideas, and has been defined by Wilson (1995) as:

The involvement of people in planning and controlling a significant amount of their own work activities, with sufficient knowledge and power to influence both

processes and outcomes to achieve desirable goals.

(Wilson, 1995, p. 1071)

Traditionally, in the literature, a distinction is made between direct participation, where the employees have the opportunity to take part in decisions directly, and representative (indirect) participation, where influence is via elected employee representatives (Busck et al., 2010). In addition, Haines et al. (2002) refers to the concept of partial direct participation—where an employee represents a larger work group, but does not necessarily represents the views from others in the group. Regarding decision-making power, Haines and colleagues (2002) also make a distinction between delegative participation, where employees are given increased responsibility and discretion to solve problems autonomously, versus consultative participation, where the

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employees are encouraged to contribute with their views, but the management retain the authority to make decisions.

Opportunities for development and learning are an important factor for sustainable jobs and working conditions (Kira and Van Eijnatten, 2009). Learning at the workplace can be seen as an individual, group, and organizational activity (Dilschmann et al., 2000). This thesis focuses both on individual learning and on conditions promoting organizational learning. The latter can, according to Ellström (2001), be defined as:

…changes in organizational practices (including routines and procedures,

structures, technologies, systems, and so on) that are mediated through individual learning or problem-solving processes.

(Ellström, 2001, p. 422)

3.5.3 Psychosocial Factors at Work Psychosocial working conditions are shaped by an interaction of psychological and social factors, and refers to the employee’ s appraisal of these conditions (Aronsson et al., 2012). The term psychosocial was first used by the psychologist Erik H. Eriksson, (Eriksson, 1959 in Westlander, 1978). By using the term psychosocial, Eriksson wanted to point to the fact that humans develop in interaction with their environment, and he especially emphasized the importance of the social environment (ibid.). When discussing the psychosocial working conditions or the working climate it is important to distinguish between the ‘actual working conditions’ and how these conditions are perceived by the employees (Kompier, 2006). This since employees can have different appraisals of objectively the same working conditions. Thus, in this thesis, psychosocial factors are, in line with Hagberg et al. (1995, p. 11), defined as ‘the subjective aspects of work organisation and how they are perceived by workers and managers.’

There are several models related to describing the psychosocial work factors and their relationships with employee health (Kompier, 2006). One of the most used models of job stress, is Karasek’s (1979) Job Demand-Control model (JD-C), where job demands and decision latitude (control) constitute the key dimensions (Karasek and Theorell, 1990). The term decision latitude includes both the employee’s ability to influence their own work activities (task authority) and their use of skills (skill discretion or task variety). One of the underlying assumptions in the model is that employees who can influence their work tasks and breadth of skills used, and thereby job demands, will not experience high job strain. Another assumption is that learning, motivation, and opportunities for learning will be present in jobs with both high job demands and decision latitude, the so-called ‘active-learning jobs’ (Karasek, 1979). A meta-analysis of studies concerning psychosocial work factors have shown that high demands in combination with low decision latitude (high job strain), are risk factors for mental health problems (Stansfeld and Candy, 2006). High job strain is a risk factor for cardiovascular disease as well (Schnall et al., 1994, SBU, 2015).

Later, workplace social support, from both managers and co-workers, was added as another dimension in the model (Johnson and Hall, 1988, Karasek and Theorell, 1990). This since it, for example, had been found to be a buffering factor between mental stressors and health outcomes. Karasek and Theorell (1990, p. 70) also hypothesized that social support could support ‘active behavior patterns’ through the ‘positive sense of identity’, based on recognition of the employees’ contribution to the organization’s collective goals.

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Bakker and Demerouti (2007), however, have pointed to a series of shortcomings of the JD-C model, for example, that it does not include enough variables to reflect the complexity of work life, and that it is static with a fixed set of variables, that does not take into account that the requirements can be different in different occupations. These shortcomings have led Bakker and Demerouti (2001, 2007) to develop the Job Demands-Resources model (JD-R model), where every job is assumed to have specific risk factors for ill health. These factors are then classified into job resources and job demands. Job resources are factors that stimulate learning, development, and personal growth, which help reduce job demands and aid in achieving goals at work—including social, psychological, physical, and organizational factors (ibid.). The resources can be present at different levels of the organization, i.e. as conditions of employment (career opportunities, job security, pay etc.), as social interactions (social support, communication, and team-climate etc.), as organization of work (level of participation, role clarity etc.) and at task level as, for example, skill variety, task significance, autonomy, and feedback on performance. The JD-R model suggest, in line with Hackman and Oldham (1980), that job resources are important as motivational factors and contribute to engagement and high performance (Bakker and Demerouti, 2007), and that they can both fulfill human needs and be instrumental in achieving work goals.

Both the JD-R model and the JD-C model proposes that job resources are able to buffer the negative impacts of job demands on health (Bakker and Demerouti, 2007, Bakker et al., 2003, Karasek and Theorell, 1990). However, whereas the JD-C model states that autonomy buffer the job strain, the JD-R model states that the specific job characteristics of the studied organization will determine what job demands and job resources are more important in contributing to job strain. The JD-R model (Bakker and Demerouti, 2007) suggests that job resources like opportunities for development, social support, feedback, and autonomy are important factors for employee well-being in the workplace. This is because of their correspondence to basic human needs for autonomy, competence, and relatedness (Ryan and Deci, 2000). Some studies have confirmed that job resources can buffer the negative impacts of job demands on symptoms of burnout (cf. Bakker et al., 2005, Schaufeli et al., 2009). However, a recent longitudinal study by Ståhl et al. (2018) did not provide support for this hypothesis. Instead, the authors, concluded that it is important to focus on lowering job demands in order to prevent burnout, rather than only focusing on enhancing job resources. Thus, more research with longitudinal design in different contexts is needed to confirm the buffering-hypothesis.

Other psychosocial work factors related to psychological health and stress are concepts related to of role conflicts and role ambiguity (Kahn, 1964). Role conflicts referring to the conflict which can arise when employees experience incompatible demands, for example, due to different expectations. A related concept, role ambiguity, arises when an employee does not have satisfactory information to adequately perform the job and the employee thus becomes uncertain about what their responsibilities are and how the work activities are to be performed (Kahn et al., 1964). Both role conflicts and role ambiguity have been associated with stress-related outcomes (Jackson and Schuler, 1985), and it has been argued that clarification of roles is crucial in crafting a healthy change (Saksvik et al., 2007).

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3.5.4 Physical Workload The physical workload (biomechanical exposures) can be divided into external and internal loads (Westgaard and Winkel, 1997). The external load arises from workplace factors independent of the individual employee, for example: task design, design of the workplace and equipment, patterns of job rotation, schedule, and the frequency of lifts. The internal exposure—the mechanical load that arises on the musculoskeletal system as a response to the external exposure, may differ between individuals. This based on individual characteristics like strength, endurance, anthropometrics, work postures, and work technique. To assess the risk for WMSDs, three different dimensions of workload need to be considered: Duration, amplitude, and frequency (Winkel and Mathiassen, 1994).

There are different types of methods to assess risk factors for WMSDs, for example, self-reported data from employees about both psychosocial and physical factors, observational methods (Takala et al., 2010), including video analysis and direct measurements of postures and movements, using monitoring sensors attached to the employee during the work day, as in this thesis (David, 2005). Objective measures evaluating physical workload is a way to overcome problems linked to the human ability to recall and assess time in different postures, and the low precision of these estimates (Wiktorin et al., 1993, Hansson et al., 2001a) Direct measurements of physical workload during a whole working day, as in this thesis, are still, however, relatively rare (Mathiassen et al., 2003, Nordander et al., 2016).

Occupational epidemiological research supports multifactorial causes of WMSDs (c.f., Bongers et al., 2006). Risk factors include factors related to physical load, such as repetition, posture, workstyle, and workload, as well as psychosocial factors, and individual factors (c.f. Bernard, 1997, SBU, 2012, Mayer et al., 2012), as well as temporal aspects of work such as shift work (Labbafinejad et al., 2017, Mahesa et al., 2017). The associations between WMSDs and risk factors, however, have different strengths depening on, for example, body region, available studies, and inclusion criteria in systemtic reviews.

Regarding neck and/or shoulder complaints, a recent systematic review of 21 longitudinal studies, found strong associations between pain in the shoulders and some risk factors: e.g. manual materials handling, vibration, and working with hands lifted above shoulder level (Mayer et al., 2012).

Working postures associated with an increased risk of shoulder pain and disorders, are working with elevated arms (Svendsen et al., 2004, Punnett et al., 2000, van Rijn et al., 2010). The systematic review on physical load factors and shoulder disorders, by van Rijn et al. (2010), have shown associations between subacromial impingement syndrome and, for example, upper-arm elevation ≥45° ≥15% of the time, repetitive shoulder and hand/wrist movements exceeding two hours/day, hand–arm vibration, and high hand forces >1 hour/day.

The duration and extent of muscular ‘rest’ during work has also been suggested to be an important factor in predicting risks for WMSDs (Veiersted et al., 1993, Hägg and Åström, 1997, Rose et al., 2014). Lundberg et al. (2002) have even suggested that lack the lack of recovery from mental and physical load, on and off the job, might be an even more important health problem than the stress-level during work.

The epidemiologial workload data mentioned provide some, but limited, support and guidance regarding exposure levels and prevention of WMSDs. To date, however, there are no international standards for threshold limit values regarding physical workload in different body regions based on direct measurements (Hansson et al., 2016). A method that proposes threshold values, but which is based on assessments is the Hand Activity Scale (HAL: Latko et

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al., 1997). There are, however, proposals for threshold limit values, intended as indicators of increased risk for WMSD at group level (Hansson et al., 2016, Balogh et al., 2019). The Lund research group has, based on their extensive measurements of physical workload and the prevalence of musculoskeletal disorders in different occupations, suggested such action values to prevent WMSDs at a group-level (Hansson et al., 2016, Balogh et al., 2019). Their selected values corresponds to HAL (Latko et al., 1997). For example, based on the exposure-response relationship found in their studies between the physical workload and wrist/hand disorders, they suggest that the mean wrist velocity should not exceed 20 °/s over an 8-hour working day (Hansson et al., 2016, Balogh et al., 2019). This is grounded in their findings that the 7-day-prevalence of hand complaints increased by 6% for every increase of the hand velocity by 10 °/s and that the prevalence of one or more diagnosed hand disorders increased by 3% for every 10 °/s increase in hand velocity (Nordander et al., 2013). Balogh et al. (2019) further suggest that the threshold limit value for upper arm velocity should not exceed 60 °/s (median over an eight-hour working day).

3.5.5 Work-related Musculoskeletal Disorders Work-related musculoskeletal disorders (WMSDs)—disorders either resulting from or intensified by work (WHO, 2003, Hagberg et al., 1995), are still one of the most prevalent work-related complaints in Europe (Eurostat, 2010). According to the 2007 European Labour Force Survey, approximately 23 million people (8.2%) of the working population in EU had, during the past 12 months, experienced work-related health problems. Among the reported health problems, musculoskeletal disorders (MSDs) accounted for over 60% of the reported most serious health complaints (Eurostat, 2010). The problems most frequently reported were back-related musculoskeletal problems followed by complaints regarding upper-extremities (ibid). WMSDs are, additionally, associated with substantial direct and indirect costs for the company and individual suffering (Coyte et al., 1998, Bhattacharya, 2014). What also needs to be taken into account is that he prevalence of musculoskeletal pain/disorders have been shown to vary between occupations (Hagberg et al., 1995, Côté et al., 2008, Nordander et al., 2009). The following section will focus on the risk factors and WMSDs in the manufacturing industry, primarily for operators and assembly workers.

Regarding risk factors for WMSDs, according to EU Statistics from 2010, about 60% of the workforce report being exposed to ‘repetitive hand and arm movements’, at least a quarter of the work time (Eurofound, 2017). In addition, they perceive that they are working in ‘tiring or painful positions’, about half of the work time (ibid.). Similarly, the Swedish work environment survey (Swedish Work Environment Authority, 2016) showed that about 60% of machine and process operators, report that, for at least half of the work day, they need to repeat the same work operations several times an hour. In addition, 23% report working with elevated arms for at least a quarter of the workday (ibid.).

In 2016, according to statistics from Swedish Work Environment Authority (SWEA), 39% of reported occupational diseases were related to physical factors (SWEA, 2017). Another large part of the claims (37%) could be related to organizational or social factors, which have been on the rise in recent years. In Sweden, the sickness absence rate (sick leave > 60 days) related to MSDs, has decreased in recent years, from 38 % in 1999 to 27% in 2014 (Försäkringskassan, 2015). Instead, sick leave due to mental illnesses has increased, from 18% in 1999 to approximately 35% in 2014. In the Swedish manufacturing industry, however, more than half of the occupational diseases could be referred to physical factors (SWEA, 2017).

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Taken together, lifting, repetitive work tasks, and awkward posture are reported to account for about half of the underlying work exposures (SWEA, 2014b).

Regarding pain, about 40% of machine and process operators reported having pain in the neck/upper back, arms/shoulders, and lower back respectively, at least once a week, according to Swedish statistics (Swedish Work Environment Authority, 2016). This subgroup of the manufacturing industry reported pain to a greater extent than the manufacturing and process industry in general, where 30% report having pain in the same body regions, once a week

Comparisons across different epidemiological studies can, however, be difficult owing to different terminology, classification or type of criteria used to diagnose the disorders or symptoms (Hoy et al., 2014, Guzman et al., 2008). Difficulties comparing self-reported data can also be related to different type of questions; sometimes questions are related to the time frame of symptoms (commonly; now, past 7 days or past 12 months), and in other studies the questions can be related to the frequency of the symptoms (i.e. every day, once a week) (Sluiter et al., 2001). Furthermore, the different pain locations could be combined, and the pain rating could either be pain in general or work-related pain.

In a systematic review of neck pain in the working population, the 12-month prevalences ranged between 27.1% and 47.8% (Côté et al., 2008). The corresponding prevalence in the general adult population, has been documented to typically vary between 30% and 50% (Hogg-Johnson et al., 2008). As to shoulder complaints, previous studies similarly show that the 12-month prevalence vary from 5 to 51% (Luime et al., 2004, van der Heijden, 1999). In addition, previous studies have shown that women have a higher prevalence of musculoskeletal disorders, even with identical work tasks (Arvidsson et al., 2006, Nordander et al., 2008). For example, a study where neck/shoulder complaints have been combined, the 12-month prevalence was 61% for women in varied/mobile jobs versus 73% for women in constrained/repetitive jobs, whereas the corresponding prevalence was 56% and 62% for men (Nordander et al., 2009).

As to prevalence in process jobs, examples of studies from the pharmaceutical industry have documented 12-month neck prevalences of 35.9% and 41.7%, respectively, and concerning shoulder pain 26.1% and 40.5%, respectively (Yu et al., 2012, Pourmahabadian et al., 2008).

Studies of hand/wrist pain in the pharmaceutical industry have documented prevalence between around 9–50% (Yu et al., 2012, Pourmahabadian et al., 2008, Labbafinejad et al., 2017)

One study documenting 7-day prevalences among women in the pharmaceutical industry showed that 31% had experienced neck pain, 46% had experienced shoulder pain, and 20% had experienced hand/wrist pain (Chavalitsakulchai and Shahnavaz, 1993). None of the studies, however, rated the intensity of the pain which might, in line with a study by Andersen et al. (2012), predict the risk for sickness absence. In their study, an average pain intensity in the neck/shoulder region during the past 3 months of above 5 (on a scale between 0-9), was shown to increase the risk for being sick listed within the next year.

Physical and mental variation in work life is generally considered to be an effective way of preventing musculoskeletal disorders and fatigue in highly repetitive jobs with constrained postures (Mathiassen and Lewis, 2016, Mathiassen, 2006). However, recent reviews of the literature (Leider et al., 2015, Mathiassen and Lewis, 2016) show that research supporting this is scarce and provide little practical guidance on how to design work. Physical variation can be defined as: ‘the change in exposure across time’ (Mathiassen, 2006, p. 422). Three different aspects of variation can be described: How often and how much the load changes, and to what

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extent it changes (Mathiassen, 2006). Repetitive work is a special case of variation, where similar tasks are performed again and again (Kilbom, 1994). Physical variation can be achieved through changing the work design in mainly three ways: Different work content or work conditions, different time distribution of tasks and/or by adding new work tasks (Mathiassen and Lewis, 2016). To describe the extent to which work tasks differ from each other, the related concept diversity—‘the extent that exposure entities differ’ (Mathiassen, 2006, p. 422), is used.

The organizational factors in this thesis are, for example, the lean concept and the management style used, etc. The physical workload is related to the intensity, frequency, and duration of biomechanical and cardiovascular load (NRC, 2001). Important work design issues to consider here are about how repetitive the work tasks are and how much opportunities there are for variation in an individual’s movements (Mathiassen, 2006). The psychosocial load has to do with our work characteristics and how they are perceived. An important distinction is the difference between external loads and internal loads (Westgaard and Winkel, 1997). The external load is the objective load and could be e.g. the weight of the lifted object or regarding the cognitive work load the work tasks and the social support needed to fulfill them. The appraisal of the external load or an individual’s body composition and fitness level can then induce different bodily reactions in different workers. This thesis includes both internal and external loads for both physical and psychosocial working conditions.

Despite that several hypotheses have been put forward regarding possible causes and mechanisms for developing musculoskeletal pain, knowledge about definitive pathways is still lacking (Sluiter et al., 2001, Forde et al., 2002). The underlying causes of WMSDs are often dependent on several interacting factors (Karsh, 2006); social and cultural context, work organization, environmental factors, physical factors, and psychosocial factors. Several of the organizational and individual risk factors for WMSD may occur simultaneously and can interact in causing the symptoms (Bongers et al., 2006). Several potential pathways to how psychosocial working conditions can be linked to WMSDs have been suggested by Bongers (2002). For example, psychosocial work characteristics, like job demand and low control may have a direct impact on how fast employees need to work, applied forces, and postures. Stress could also be triggered, which may increase muscle tension and other physiological factors (ibid).

Previous studies have suggested that WMSDs are associated with, for example, management quality, control, low job satisfaction (Andersen et al., 2007, Hauke et al., 2011), and social support (Woods, 2005). Time-management or rationalization methods do not in themselves have any explicit focus on prevention of musculoskeletal disorders or promoting health, and there might be conflicting goals (Wells et al., 2007).

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3.6 Lean and the Work System

The lean concept can be viewed as a way of designing and organizing the production according to a set of principles, aided by associated tools and methods and can be accompanied by a set of work organizational practices (Olivella et al., 2008). Lean is therefore essentially a set of ideas that need to be translated, interpreted and made into concrete actions in the target organization (Langstrand, 2012). The consequence thereof, is that lean can be interpreted and implemented in several different ways and with different goals, and thereby have different impacts on the work system and the nature of work. Accordingly, lean has the potential to both affect how work is designed and how work is performed, as well as to affect the employees and their working conditions.

Recent studies indicate that how the human dimension of the lean system is considered will affect its success (Bortolotti et al., 2015, Martínez-Jurado et al., 2013, Longoni et al., 2013). For example, Longoni et al. (2013) concluded from their ten case studies, that companies that focus on human resources and prevention practices, and not only JiT practices, have better outcomes. They described the following necessary work system changes for a lean system: changes in how the employees are managed, how jobs are designed, adoption of a high-performance work system, including teamwork, job rotation, cross-training, employee involvement and incentives, and encouragement of employees to develop their expertise and to aid in improving the production system. Bortolotti et al. (2015) similarly describe that successful lean plants they looked at to a higher extent used soft lean practices (i.e. training to be able to perform multiple tasks and CI), had a high level of future orientation, and had a higher level of institutional collectivism (practices encouraging and rewarding collective actions and collective distribution of resources).

Early attempts to describe the interactions in the lean work system have used the JCM-model (Hackman and Oldham, 1976) or the JD-C model (Karasek, 1979, Karasek and Theorell, 1990). According to Cullinane (2013), those models are not really applicable to the lean work system since they lack important lean-specific job resources such as team-working and participation in CI. Lean-specific work characteristics are thus better captured in the model by Cullinane et al. (2013), where the JD-R model is combined with an updated and broader version of JCM (Campion et al., 2005, Morgeson and Humphrey, 2008).

Generally, research on lean and employee working conditions shows mixed results, although the trend points in the direction of increased efficiency and increased workload (Landsbergis et al., 1999, Westgaard and Winkel, 2011, Hasle et al., 2012, Koukoulaki, 2014). One thing to keep in mind is that the effects on the employees may vary between the implementation phase and when the practices are up and running as an operational phase. Conti et al. (2006) have argued that it is not necessarily more stressful with lean, but rather that it is dependent on the management’s way of running the business. Similarly, Westgaard and Winkel (2011), in their systematic review of rationalization strategies such as lean, concluded that interventions including employee participation, inclusive management approaches, and information and social support, were found to be associated with better employee outcomes. Other researchers claim that more recently implemented forms of lean (the second lean wave in Sweden) are more employee-oriented and that the lean concept is better able to handle health risks than many other production systems (Liker, 2004, Macky and Boxall, 2008). For example, the truck company Scania, whose lean implementation has been greatly inspired by Toyota’s production system has implemented a lean system where high priority is given to health and safety (Sederblad, 2013).

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In the TPS, the product value stream and people value stream are described as intertwined, forming the DNA of the Toyota system (Liker and Hoseus, 2008). According to Liker and Hoseus (2008), problem solving is at Toyota viewed as the connection between people and the product value stream, with mutual trust being at the center of the system, constituting a central component for supporting a work environment that encourages employees to identify problems and which motivates them to solve them. Improving work with respect for humanity in the TPS, can, according to Monden (2012), be achieved by giving the employees valuable jobs—that is increasing the number of value adding operations, and when eliminating wasteful actions instead use the time saved to perform other value-adding operations. Activities viewed as adding value to the Toyota people value stream are: attracting the right people and develop, engage, and inspire them so they can perform high-quality work, improve how work is done, stay committed to the organization, and continue to learn and grow (Liker and Hoseus, 2008).

The following five values are described by Toyota (2017) as key to their human resource management: Challenge, Kaizen (Continuous Improvements), Genchi Genbutsu (onsite hands-on experience), Respect, and Teamwork. Toyota’s focus on developing its employees is reflected in the following statement from Eiji Toyoda, one of the former presidents at Toyota:

Because people make our automobiles, nothing gets started until we train and educate our people.

(Toyota, 2004, p. 80)

3.6.1 Lean and Psychosocial Factors at Work Research about lean and worker control in industrial settings has shown mixed results; however, most studies show that lean restricts employee control (Landsbergis, 1999, Hasle, 2014). For example, Parker (2003) found that assembly workers’ influence on decision-making decreased. On the other hand, the workers appeared to have opportunities to solve problems because they had good social support. Schouteten and Benders (2004) concluded that the autonomy was limited in their studied assembly line. Lewchuk and Robertson (1997) and Lewchuk et al. (2001) found that indicators for control at work were decreased in the lean companies.

Two of the studies that have shown more favorable results in terms of worker control are from the Nordic countries (Seppälä and Klemola, 2004, Nielsen, 1996). Nielsen (1996) found no change in worker autonomy in five of six studied companies, but in one, the autonomy increased due to better planning. Similarly, a Finnish study of highly skilled metal workers found increases in both worker control and workload (Seppälä and Klemola, 2004). In a study of a Brazilian lean manufacturing company (Saurin and Ferreira, 2009), working conditions and worker autonomy improved, but workload and stress increased. A few studies have attempted to relate different work characteristics to health outcomes. Conti et al. (2006) found that participation, teamwork, and social support were moderating factors for decreased stress. Anderson-Connolly et al. (2002) found that manufacturing workers’ increased health was related to autonomy, while decreased health was related to work intensity, competence, and teamwork. Only one of the mentioned studies objectively measured changes in a broad array of work characteristics in a lean company (Schouteten and Benders, 2004), while other studies used subjective data obtained through methods such as questionnaires (Hasle et al., 2012).

In several case studies, Parry and Turner (2006) identified visual management as an important tool for the communication process and thus for facilitating employee engagement in continuous improvement practices. Regarding standardization, there are different opinions on how lean and standardized work may impact the working conditions (Fagerlind Ståhl et al.,

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2015, Poksinska, 2007). Standardized work may reduce opportunities to influence daily work and the potential for using work skills (Koukoulaki, 2014) and has, in several cases, resulted in a diminished work content that has a decreased need for special skills (Oudhuis and Olsson).

Similarly, a Swedish longitudinal union-survey of metal workers (IF Metall, 2011) showed that the general trend in Swedish industry was toward reduced multi-skilling. In 1998, just below 60% of metal workers stated that their work content was broadened or that they had gotten new work tasks. In 2010, however, only just above 30% stated that. Furthermore, in 2010, 68% of the employees reported having administrative (or white-collar work) between 1-10% of the working time, 4% stated that they did not have that at all, and 4% noted that they have that more than 50% of the time. Of the respondents, 40% reported that there is no development of their job, or that it has gotten worse over the past five years, and 33% report that there is a gradual development in all jobs, 23% stated that persons with qualified jobs experienced development in their jobs, and 4% state that only persons with less qualified jobs have had an increase in their work content.

Research on companies implementing the quality management standard ISO 9000 showed that the consequences for the perceived working conditions differed between organizations and seemed to depend on what was being implemented (content), the implementation process, and the degree to which the work tasks were standardized (Poksinska, 2007). Moreover, Poksinska’s research showed that if employees were invited to take part in the standardization process the outcome may be better, but if the standardization were done by a planning department and forced on employees, it may be the other way around (Poksinska, 2007). Another study by Conti et al. (2006), shows that standardization and resource removal have been associated with stress. 3.6.2 Lean and Physical Working Conditions It has been suggested that lean manufacturing contributes to work intensification. In support of that, most previous studies have shown that lean increases the perceived workload (Landsbergis et al., 1999, Westgaard and Winkel, 2011, Koukoulaki, 2014, Lewchuk and Robertson, 1996, Parker, 2003, Arezes et al., 2015), as well as creates an increased risk for heart diseases and WMSDs among employees (Landsbergis et al., 1999).

Early reports from Japanese plants in the United States (US), for example, by the Swedish researcher Berggren (1993), described growing health and safety problems due to increased pace, repetitiveness, and long working hours in Mazda’s car factory. Furthermore, Berggren reported extremely high levels of repetitive strain injuries (RSIs); about three times higher than other automotive plants in the US (ibid.). Similarly, professor Monden assessed the work in some of Toyota’s plants to be very hard for the workers:

When I first visited Toyota and also initially Daihatsu motor company, that’s a mini-car maker that belonged to Toyota but now they are a subsidiary company with Toyota owning more than 50% of their stock, I thought that this was a very severe way of manufacturing. Especially for their workers who had to work very hard, although they say this is efficient but not so hard. They said that they were trying to abolish the wasteful actions of workers, exchanging wasteful action with

other value-added action but to me this was very hard work. (Harrod, 2008, para. 2)

On the other hand, Womack et al. (1990) described that lean used less of resources compared to mass production, for example only half the human effort. However, increasing the

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proportion of value-adding work (VAW), could lead to an increase in controlled and restricted work operations, while variation in musculoskeletal load and the potential for natural breaks and recovery decreases. Previous studies on rationalizations have associated (VAW) with a higher physical task exposure as compared to non-value-adding work (Kazmierczak et al., 2005, Jonker et al., 2011, Østensvik et al., 2008, Palmerud et al., 2012, Neumann et al., 2018). Such a development could lead to an increased duration of repetitive movements and, thus, an increased risk of musculoskeletal complaints.

One more recent study, comparing the physical workload at the job level in, a Japanese-owned factory, that was assessed to have ideal lean, with an American factory only in the beginning of implementing lean methodologies (Womack et al., 2009), using the Hand activity level scale to observe jobs (HAL; Latko et al., 1997), concluded that lean practices did not necessarily increased the risk for WMSDs. The productivity was higher in the ideal lean factory with less non-value-added time in the form of walking and waiting. The repetitive work rated by HAL was higher (5.5 compared to 5.0), but there were no significant differences in work postures. Hand postures were not assessed due to the difficulty in observing such small movements (Lowe, 2004). Ratings of peak hand forces were lower in the lean plant, which the authors related to the worksite’s focus on process quality. For example, a better fit between parts had made assembly easier. In addition, the lean factory had fewer jobs that exceeded the American Conference for Governmental Industrial Hygienists’ (ACGIH) recommended Threshold Limit Value (TLV). The study therefore indicated that the risk for WMSDs was not necessarily higher in the lean factory as compared to the traditional plant. However, what needs mentioning is the fact that about 60% of the jobs in both factories exceeded the TLV for ‘acceptable work’, which, according to the TLV- instructions, means that they would have to be redesigned (Womack et al., 2009).

A study by Lewchuk et al. (2001), compared employee self-reports of physical workload, pain, and physical fatigue between different automobile companies, building on the same data as in their previous articles by (Lewchuk and Robertson, 1997, Lewchuk and Robertson, 1996, Stewart and Garrahan, 1995) alongside a questionnaire conducted at General Motors (GM) in Great Britain in 1997, and concluded that a higher proportion of employees working in companies that were assessed to have progressed further in their lean practices, exemplified by teamwork, job rotation, standardized work, JiT, and CI, reported that the physical workload and work pace was too high.

In addition, the proportion of employees reporting that they had to work in uncomfortable working postures for more than half a day, were higher in the factories that had progressed further in their lean work. However, it is not clear as to whether the result was caused by the lean practices, other differences between the factories, or their way of implementing lean. At the time, GM was described to ‘drive a hard line’ against the employees and the union, and it had problems with productivity (Hasle et al., 2012). A cross-sectional study by Leclerc et al. (1998), which included 53 companies from different sectors (assembly lines, food industry, as well as footwear and clothing industry), identified a correlation between carpal tunnel syndrome (CTS) and JiT practices (OR 2.24), i.e. a clear connection between the prevalence of CTS and companies practicing JiT. Unfortunately, there was no further description of what the JiT practices encompassed; the companies are only classified into JiT or not JiT, making it difficult to know the production system impact, especially when many companies are included in the study.

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3.6.3 Lean Leadership and Management Leadership and management have, among other factors, been identified as critical factors for successful lean implementations within small and medium-sized enterprises (SMEs) (Achanga et al., 2006). An overview of studies from the Nordic countries (Torvatn et al., 2015) about ‘good’ management behaviors in relation to working conditions concluded that only a few of them had studied lean work systems.

Commonly used lean leadership practices are, for example, policy deployment, monitoring of results through visual management, and lean tools aimed at engaging employees in systematic continuous improvements (Liker, 2004; Womack & Jones, 2003). Thus far, only a few studies have investigated lean leadership practices (c.f.Liker and Convis, 2012, Poksinska et al., 2013, Vänje and Brännmark, 2015, Benders et al., 2016, Alpenberg and Scarbrough, 2016, van Dun et al., 2017). In some Swedish cases, lean seem to have increased managers’ time spent on the shop floor (Berglund, 2010, Vänje and Brännmark, 2015). Common leadership activities in lean companies, as described by Vänje and Brännmark (2015), were: managers who were listening, showed respect, and who were knowledgeable about the production. These managers also spent more time in the production area, discussed the lean practices with the employees, provided new perspectives, and helped with interpretation of how lean could be related to the employee’s work. The employees participated in the lean practices through change projects and temporary activities. A servant leadership approach (Spears, 2004, Greenleaf and Spears, 2002) emphasizing the role of the leader to first serve and support others—including employees, community, and customers, is described as an important feature of the Toyota leadership culture:

Team members doing the production work are building the sellable product; hence, they are the ones that matter most, and everybody and everything else is

here to support them and give them what they need to do their job.

(Liker and Hoseus, 2008, p. 320)

Emiliani and Stec (2005) have identified eleven common errors, that senior managers do when implementing lean: (1) Senior managers do not see lean as a comprehensive management system, but rather as a ‘manufacturing thing’ and limits the practices to some of the company’s operations; (2) Leadership behaviors are not yet aligned with lean principles; (3) Lack of leadership participation—senior managers not participating in improvement activities; (4) High management turnover; (5) Business metrics not adjusted to lean principles; (6) Layoffs — improvements resulting in layoffs will undermine future engagement in improvement activities; (7) Lack of strategy integration—lean is not linked to the general strategies and goals of the company; (8) Purchasing tools and practices are not consistent with lean principles; (9) Short time horizon; (10) Too narrow of a focus on shareholders at the expense of end-use customers and employees, and (11) Insufficient support and knowledge of lean principles in the supply chain.

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3.6.4 Lean in Combination with Ergonomics and Safety and Health Several authors have highlighted the value and possible synergy effects with integrating Occupational Safety and Health (OSH) into the processes and management procedures of an organization, and preferably integrating them into one integrated management system (IMS) (European Agency for Safety and Health at Work, 2010, Zwetsloot, 2000, Jørgensen et al., 2006). The integration can be implemented in different ways and to varying degrees. Zwetsloot (2000) have identified four maturity levels in OSH management:

(1) Ad hoc—a reactive stage with minimum of knowledge; (2) Systematization—setting up a risk management system and developing internal

competence; (3) A systems approach—OSH is structured and maintained, and supported by management; (4) Integrative —a proactive stage where OSH management is seen as a resource, CI are

focused, and its integration into other management systems (e.g. quality management), business processes, and/or other activities, is supported.

Jørgensen et al. (2006) also distinguishes between partial integration, where some procedures or activities are integrated, and total integration, which involves an integration-based continuous improvement with a process approach.

As concluded by Saurin and Ferreira (2009), there are a great deal of opportunities for synergy between lean and ergonomics practices as well. Ergonomics practices may, for example, contribute to improved quality and performance (Eklund and Yeow, 2015) and provide additional tools for creating value in the organization (Kester, 2013). In addition, Conti et al. (2006) found that job stress in the lean companies was significantly related to experiencing ergonomic difficulties in performing the work tasks. Thus, to counteract a one-sided focus on the traditional lean goals, such as reducing waste, the ergonomist Kester (2013) suggests that the traditional lean goals should be accompanied by human and ergonomic goals.

Hence, there are several domains where the goals of ergonomics and lean may coincide. For example, one of the seven lean wastes, unnecessary motion (Ohno, 1988), is related to human movements. Excess movements may cause worker fatigue, which in turn may affect product quality and increase expenditure of time, thereby causing waste (Eswaramoorthi et al., 2010). Thus, activities to reduce unnecessary motions can be considered as joint goal. Removing hard-to-do work (muri) as well as ways of leveling the production to decrease unevenness (mura), might also lead to better ergonomics (Dennis, 2007). In the traditional lean literature, however, descriptions of how lean companies have worked with ergonomics or health and safety management, in combination with their lean implementations, are rare (Tortorella et al., 2017). It is also not commonly described as one of the core components of lean production systems (Pettersen, 2009).

Descriptions of the TPS, on the other hand, include descriptions of safety practices (c.f. Liker and Hoseus, 2008, Japan Management Association, 1989). In the TPS, a clean and safe workplace, accomplished by applying 5S, is seen as a foundation for creating a safe work environment (Liker and Hoseus, 2008). A lean program at the Shingo Institute at Utah State University, inspired by Shigeo Shingo’s contributions to the development of the production system at Toyota, also points out that ensuring a leadership is in place that promotes health and safety, is an important part in showing respect for the employees (Shingo Institute, 2018). Moreover, in a description about Japanese manufacturing systems, modern factories designed with ergonomics taken into account are considered a strategic factor for attaining manufacturing excellence (Seng Chan et al., 1990). Ergonomics practices have also been a part

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of operations management at Toyota since the beginning of the 1990s, according to an interview with the Japanese researcher Yasuhiro Monden:

Ergonomics, the field of human engineering, was introduced in to the operations management of Toyota’s plants so that even women or elderly people could easily work in the plants without becoming fatigued. The main reason for why Toyota changed their production system to incorporate ergonomics was because of the

difficulty of getting employees.

(Harrod, 2008, para. 2)

A more recent description of ergonomics practices at Toyota is provided in the book by Yasuhiro Monden (2012) about the production practices at Toyota. There he provides descriptions of Toyota’s own ergonomic assessment method, Toyota Verification of Assembly Line (TVAL), for measuring the workload for each operation. Toyota’s ergonomic measurements and its machines that are adapted to humans are all described by Yasuhiro Monden as being part of the TPS-principle: respect for humanity:

Avoiding work strain and preventing work overload are part of respect for humanity in the working environment, and can also lead to productivity

improvements.

(Monden, 2012, p. 437-438)

In addition, Monden (2012), describes that ergonomic positioning of tools should be considered when arranging the workplace during 5S. Other traces of ergonomic thinking in the lean literature include ergonomic principles applied when standardizing work, as described by Pascal Dennis (2007) in his book Lean simplified – a plain language guide to the world’s most powerful production. Dennis worked at a Toyota plant in Canada and described the design guidelines they used, for example:

Work should be done in the ‘strong’ circle a yard in diameter ad directly in front of the worker. Maintain appropriate body posture.

Develop jigs to eliminate manual holding of materials. Use ergonomic tools (i.e. tools that are easy to grip, encourage good hand/wrist posture, and minimize

forces and vibration).

(Dennis, 2007 p. 62)

Dennis (2007) further described that they used pictures and illustrations to show how work should be done. Where possible they showed: proper postures, how the hands and feet should move, how to hold the tools, accumulated know-how or the nicks and knacks of the job, and critical quality of safety items.

The benefit of including ergonomics into the lean program is also supported by case studies, whose results suggest that lean has better outcomes if combined with ergonomic programs or health and safety initiatives (Womack et al., 2009, Adler et al., 1997, Saurin and Ferreira, 2009). In the study by Womack et al. (2009), the lean factories applied ergonomic guidelines during product development and simulation programs, in order to predict risks and develop job descriptions, using a skilled pilot team. The pilot team also tried to detect and prevent risks early on, such as awkward postures, repetitive jobs, and high loads. All jobs were classified into high-, medium- or low-risk, and they tried to eliminate high-risk tasks aided by

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feedback from the employees. By applying the Plan-Do-Check-Act (PDCA) they worked to continually improve the workplaces. Furthermore, ergonomic training was a requirement for all employees in production, and the team leader was responsible for ensuring that everyone on the team followed best practice through coaching and follow-ups. The practices were in line with guidelines from the National Institute for Occupational and Safety and Health (NIOSH), and resulted in a 19% decrease in reported disorders between the years 2000–2006 (Womack et al., 2009).

The lean literature does offer some examples of where work environment and health issues have been integrated into the lean practices. One example of how a lean tool can be combined with an ergonomic assessment is a method called ErgoVSM (Jarebrant et al., 2016, Edwards, 2014). This method combines a traditional value-flow analysis with ergonomic assessments of tasks in a participatory way. Another example from Swedish healthcare (von Thiele Schwarz et al., 2015) is an integration of work environment and health perspectives into existing continuous improvement practices. An example of integrating safety into an existing lean tool is by adding safety as sixth step to 5S (EPA, 2008). Taken together, this indicates that there are descriptions of ergonomics and health and safety practices at Toyota. It is not, however, as nearly as thoroughly described as their other practices. For some reason, early descriptions of lean production did not include descriptions of these practices, even though other human resources practices have been described (Liker, 2004, Shah and Ward, 2003, Magnani et al., 2019).

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4. Research Methodology This chapter describes the methodology—the approaches, methods, and underlying assumptions (Silverman, 2015) used to collect and analyze the data for this thesis. The methodological approach is derived from Human Factors and Ergonomics (HFE). When conducting HFE-research, a systems approach and concern for context are foundational principles for understanding the studied phenomena (Wilson, 2014). The approach in this thesis is closely related to organizational ergonomics or studies of organizational design and management. This has been a subdiscipline of HFE since around 1980 (Kleiner, 2008), and is often referred to as macroergonomics. The discipline focuses on the work system, by integrating perspectives from work and organizational psychology (Hendrick and Kleiner, 2002).

Conceptually, macro-ergonomics can be viewed as a top-down socio-technical systems approach to work systems design (Hendrick, 1991). Traditionally, this research approach is concerned with multiple factors and multiple levels of the organization (Karsh et al., 2014). As early as 1980, Hendrick (1991) argued for the need to integrate organizational design and management factors into ergonomics research and practice. The approach to work and health in this thesis, might also be referred to as organization-oriented work and health research (Härenstam et al., 2006).

4.1 Overview of Research Designs

This thesis focuses on the organizational impact on work itself, the physical and psychosocial working conditions, and, in turn, employee health. In general, this thesis was guided by Holden’s (2011) work systems model of lean, which point to the need to consider both how the management system affects the designed characteristics of work and the context shaping the employee and performance-related outcomes (Figure 1). An overview of the research design in each study is presented in Table 1.

The first study was based on a literature review initiated by SWEA (Brännmark et al., 2012a). Data for the three case studies (Study II–IV) were collected within a research project about lean production and employee effects in industry, financially supported by FORTE—The Swedish Research Council for Health, Working Life, and Welfare. The second study, which documented direct measurements of physical workload and musculoskeletal pain in a lean process plant, was performed and analyzed in collaboration with Institute for Environmental Medicine at Karolinska Institutet. Each year, the working conditions in study III–IV were captured using an external assessment of work characteristics in combination with employee questionnaires concerning the psychosocial working conditions, and interviews with managers.

The included companies’ lean practices were captured through interviews with the management, questionnaires to employees, tours of the production site, Key Performance Indicators (KPIs), and document studies. An overview of constructs and methods used, is presented in Table 2. This triangulation was done in order to get different perspectives on the work content for the employee, as well as to get both an employee and management perspective on what they had done in their lean work and what the employee’s participation had been in CI. Since there is no control group that is not doing lean, validated questionnaires were mainly used to allow for comparisons with national data and data from other studies.

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Table 1. Overview of aim, setting, research design, data, and type of analysis in each study

Study Aim Setting Design; Data Analysis

I

RQ 1+2

To summarize empirical studies regarding the relationship between lean and work-related musculoskeletal disorders (WMSDs) and risk factors for WMSDs.

Internationally: Manufacturing companies.

Sweden: All types of organizations.

Literature overview

Summary of studies and methodological considerations

II

RQ 1+2

To document physical workload and musculoskeletal pain in the neck and upper extremities in a lean process plant, and to determine the extent to which workload and pain changed over a period of two years of continuous lean development.

Process industry located in Sweden.

Longitudinal case study; Direct measurements of physical workload Employee questionnaires

Interviews with managers and employees

Quantitative Descriptive statistics—including cumulative distribution of postures and movements Qualitative Descriptive content analysis

III

RQ 3

To assess how lean contributed to transforming work characteristics in a medium-sized industrial company that had developed and maintained lean at all organizational levels.

Medium-sized Swedish manufacturing company.

3-year case study;

Employee questionnaires

Assessment of work characteristics: Lean-ARIA

Interviews with managers.

Qualitative: Content analysis

Quantitative: T-tests

IV

RQ 4

To understand what managerial approaches and actions promote sustainable working conditions, during a lean transformation.

Medium-sized Swedish manufacturing company.

3-year case study;

Employee questionnaires

Assessment of work characteristics: Lean-ARIA

Interviews with managers.

Qualitative Content analysis Quantitative T-test

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4.2 Case Study Design

The case study methodology was chosen for its suitability for studying a contemporary phenomenon in a real-world context (Yin, 2003), especially if the boundaries between the phenomenon studied and the context are vague. To get as a complete picture as possible of the phenomena and context a mixed-methods approach was used (Stake, 1995), where data from different levels in the organization were collected. Thus, the employee work characteristics are captured from both a managerial and employee perspective, and methods are triangulated to understand the interplay between lean and the work tasks, and factors supporting sustainable working conditions during lean. This multi-level and multi-method approach was used to achieve a more valid understanding of the cases (Stake, 1995), thereby, attempting to vivify the dynamics of the organizational development and so to say get a ‘picture’ of the work environment and the socio-cultural processes taking place there. The underlying assumption of the social reality in the case studies is based on a constructionist perspective (Hosking, 2006) where the organization is assumed to be shaped and co-constructed in interactions, and the goal is to get a deeper understanding of a phenomenon in relation to its context.

4.3 External perspective

Self-reported data through employee questionnaires have traditionally been the most common method used to collect data on psychosocial work factors (Kristensen et al., 2005). However, several authors have suggested including more objective data of the work situation or stressors, in order to overcome methodological problems with self-reported data, i.e. the risk for common method variance, supposedly introduced when employees report both the exposure to organizational factors and outcomes (Kristensen, 1996, Hurrell et al., 1998). Furthermore, since questionnaire data is based on how the employee perceives and appraises the working conditions and thus, may be biased by individual preferences, it may not reflect the objective task accurately (Karasek, 1979).

Frese and Zapf (1988) have described different ways of conceptualizing the terms subjective and objective in stress research. The definition of objective can be considered as a viewpoint that is independent of individual emotional and cognitive processing. Examples of more objective ways to obtain knowledge about work characteristics are: work observation and expert assessments (Frese and Zapf, 1988). Thus, to obtain rich descriptions of work characteristics and to be able to triangulate data from multiple levels in the organization, studies III and IV combined expert assessments with self-reported data on psychosocial work factors. The assessment is not objective in a true sense, since it based on employee descriptions and is interpreted and filtered through an individual’s cognitive and emotional processing, but it is an attempt to capture work characteristics that are less dependent on an individual’s cognitive and emotional processing and values. Rather, the goal with the assessment is to describe the work ‘from an external point of view’ (Waldenström, 2007, p. 2) and to reach intersubjective agreement between expert ratings. This kind of theory-guided, non-emotional and less dependent on a specific employee’s cultural or social frame of reference, and thus, more objective methodology, is referred to as having ‘an external perspective’ (ibid.).

When the work characteristics are assessed by a trained expert using a theory-guided interview technique Waldenström (2007), the goal is to get as concrete descriptions of the work as possible—a description free from the employee’s emotions and opinions about work.

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The aspiration during the work content analysis to get a description of the external work situation, so to speak ‘get the facts’ about their work. Since more objective measures are only able to identify potentially stressful work characteristics, but not how the employees appraise their work experiences and cope— factors known to play a role in eliciting either stress reactions or contribute to the well-being (Lazarus, 1995, Lazarus and Folkman, 1984), the external description is combined with self-reported data from questionnaires. Hence, in this thesis, the external perspective and perceived employee working conditions are viewed as complimentary.

4.4 Methods

This section presents the different methods used to collect and analyze the data, including subjects and settings.

4.4.1 Settings and subjects An overview of the included case settings and subjects for each study is presented in Table 2. The thesis is based on multi-year data from three different industrial worksites in two different companies: A midsize mechanical workshop and two units in a global process industry. Brief descriptions of the case companies are provided here, and deeper descriptions are given in each study’s section Mechanical workshop – studies III and IV. Metal workers from three departments in a medium-sized family business, referred to as VPC, were studied. The whole company had implemented and maintained their lean practices for some years. The selection of departments was done in collaboration with the production manager. They were chosen since they were able to take time away from production and because they had well-functioning lean practices right down to the shop floor level.

Process industry – study II. Two different work units in one department of a global process industry were studied. They had worked with different lean tools for some years, and lately especially standardized work. Data collection was made at baseline, in 2011, and two years later in 2013. Employees from six different assembly lines and all process workers were invited to answer the questionnaire. The company is described more in detail in study II.

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Table 2. Overview of included cases and number of subjects

Company Mechanical workshop

Process industry: process unit

Process industry: line unit

Type or work Metal workers Process operators Process operators

Study II and III IV IV

Size of the company Medium-sized Big Big

Studied units 3 units A process unit (3–4 working groups)

6 production lines

Start of lean 2007 2001 2001

Lean change during the observation period

Maintaining and improving lean in

general

Increasing standardization

of work

Increasing standardization

of work

Questionnaire, Year, (n)

2010, (18) 2011, (23) 2012, (26)

2011, (27) 2013, (33)

2011, (54) 2013, (66)

ARIA, work content analysis Year, (n)

2010, (3) 2011, (3) 2012, (3)

2011, (6) 2013, (5)

2011, (6) 2013, (5)

Interviews management (n)

2010, (3) 2011, (3) 2012, (3)

2011, (6) 2013, (6)

2011, (6) 2013, (6)

Interview ergonomist (n)

_ 2011, (1) 2013, (-)

_

Observations 2010, 2011, 2012 2011, 2013 2011, 2013

Direct ergonomic measurements (n)

_ Subjects representing each production process:

2011, (12) 2013, (12)

One production line: 2011, (8) 2013, (8)

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4.5 Data Collection and Measures

Data for this thesis were collected between the years 2010–2013. Data from several different sources were included: A literature review, questionnaires concerning the psychosocial working conditions, interviews with managers, expert assessment of work characteristics (ARIA), direct measurements of physical workload, document studies, and KPIs, Table 2. The procedures for the data collection and analysis of the data for each method are presented in the coming chapter. Company outcomes are not studied per se, but are used as descriptions of the company.

4.5.1 Literature Overview A literature search was conducted in the autumn of 2010 and first half of 2011 to find relevant articles about physical workload and health in lean manufacturing companies, as well as about Swedish lean organizations. The search was performed as part of mission by the Swedish Work Environment Authority (SWEA) (Brännmark et al., 2012a).

The included search terms on WMSDs were inspired by the search strategies in the systematic literature review: The importance of the work for the occurrence of disorders and diseases– Neck and Upper Extremities (SBU, 2012). The searches were performed in the following databases: Pubmed, Ergonomics Abstracts, and Business Source Elite. The search terms used were: lean production and its synonyms and characteristic tools, in combination with terms related to the physical working conditions and health outcomes. For examples: workload*, work characteristics, occupational exposure*, posture, exposure, biomechanic, force, recovery, repetitive motion. WMSD, MSD, disorder, musculo*, cumulative trauma disorder, repetitive strain, injur*, myalgi*, symptom*, syndrom*, entrapment, illness rate, job satisfaction, lost time injury, and similar terms. A detailed list of search terms is provided in Appendix A. The search was slightly modified to fit the criteria of Ergonomics Abstracts; see modified search string in Appendix B.

The search was limited to empirical studies published after 1980 and studies written in English or Swedish. Only studies with empirical data on physical workload, work-related musculoskeletal complaints, and risk factors thereof, were included. In addition, the search included psychosocial work factors, since previous studies have shown associations between psychosocial work factors and WMSDs (cf. Bongers et al., 2006). The selection of risk factors related to mechanical exposure was based on the same criteria as Westgaard and Winkel (2011). Note, however, that other consequences of the risk factors, such as cardiovascular diseases, are not included in the overview.

Articles that only study one part of the lean concept and aspects that can be considered as generic concepts, like teamwork, standardization, CI, were not included. On the other hand, articles only evaluating JiT were included, since this practice can be viewed as a central component of lean manufacturing. Furthermore, studies about TQM were excluded since the concepts have significant differences (Pettersen, 2009a). The reference lists of the full articles found were reviewed to find additional references meeting the inclusion criteria.

A systematic quality evaluation of the included studies was not performed. However, when comparing the studies, methodological considerations and limitations were discussed. Due to lack of Swedish studies on lean, a decision to include reports and conference papers, was made, in order to collect the best available knowledge (Slavin, 1995). The databases: Google Scholar and Arbline, were used to find Swedish reports and conference papers.

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4.5.1 Direct Measurements of Physical Workload In study II, direct measurements of physical workload, in terms of work postures and movements, during a whole typical workday were conducted in two different units in the same production site, at baseline (2011) and at follow-up two years later (Table 2). Methods used were inclinometry, observation of work, and video recordings. The chosen parameters operationalize the level, frequency, and duration of the exposure (Winkel and Mathiassen, 1994; Winkel and Westgaard, 1992).

The selected time-related exposure metrics were presented according to Kazmiercszak (2005), where time for recovery is represented as ‘time at rest’. Similar to the Lund research group, velocity was chosen as a ‘measure of repetitiveness’. This since it represents a combination of the repetition and amplitude of the movement (Nordander et al., 2016). In order to estimate posture variation, the differences between the 10th and the 90th percentile were selected (Mathiassen, 2006). To be able to compare our exposure values with available exposure data, the results were later compared with the threshold limit values for the prevention of WMSD suggested by the Lund research group (Hansson et al., 2016, Balogh et al., 2019).

Work postures and movements of upper arms and inclination of the head were measured using a triaxial inclinometer system consisting of a data logger, which sample data at 20Hz using an external data logger, and four small sensors. The sensors were taped on the forehead and upper arms in accordance with Hansson et al. (2001b). At baseline, triaxial accelerometers from Logger Teknologi HB, Åkarp, Sweden, were used. At follow-up, triaxial inclinometers with integrated data loggers (USB Accelerometer Model X8M-3 Mini, Gulf Coast Data Concepts, Waveland, MS, USA), that have been shown to be comparable with the system used at baseline (Dahlqvist et al., 2016) were used. The inclinometers were calibrated by following movement procedures according to (Hansson et al., 1996, Hansson et al., 2001b). To measure hand movements (flexion/deviation), biaxial electrogoniometers (XM65, Penny & Giles Biometrics Ltd, Blackwood, Gwent, UK) were placed proximal to the wrists and on the dorsal side of the hands, in accordance with Hansson et al. (1996). All the loggers were carried by the subjects in waist packs. Due to technical problems with the goniometers, only velocity metrics could be presented.

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4.5.2 Interviews with Management In studies II–IV, semi-structured interviews about the company’s lean practices and other concurrent technical and organizational changes, were conducted with about three managers at each work unit. To get rich information about the company, its production, and their lean practices, managers representing different managerial levels were chosen, together with individuals who had been more involved in the lean implementation. The interviews were conducted at the company’s work site and lasted about 1–2 hours. The interviewer adapted the questions in the interview guide to fit the company context and the role of the respondents (Malterud, 2001) and their level of lean implementation.

The interview guide was developed in consultation with psychologist Måns Waldenström, my late colleague, quality engineer Mikael Brännmark, and professor Jörgen Eklund. It encompasses questions about the company, its production, occupational safety and health practices, employee work characteristics, as well as details about their lean practices: i.e. their goals, what lean tools they had used, the extent to which they were applied, and the results attained (Appendix C). The lean themes included were the same as the 12 themes in the Lean-index developed within the project: Leadership and Organisation for Health and Production (LOHP) at Linköping University (Fagerlind Ståhl, 2015), Table 3. The themes were, according to J. Eklund (personal communication, 2010) derived from the most commonly described lean characteristics found in a review of the lean literature (Pettersen, 2009a). The index has also been used in other lean studies (Lindskog, 2016, Dellve et al., 2015).

Table 3. The lean themes included in the Lean-index (Fagerlind Ståhl, 2015)

1) Values at the workplace 7) Waste reduction

2) Customer orientation 8) Employee involvement and respect for the employee

3) Teamwork 9) Value Stream Mapping

4) Meeting structures 10) Standardized work

5) Continuous Improvements 11) Housekeeping through 5S

6) Just-in-Time practices 12) Visual Management

To get a management perspective on the employees’ work characteristics, managers were interviewed about the employees’ work characteristics, described in more detail in section 4.5.3.

Some of the included questions about employee work characteristics and OSH practices were selected from the interview guide in the Health and Future project (Ahlberg et al., 2008). At baseline, the items about the OSH practices addressed whether lean had affected their way of organizing those practices and if they had evaluated work environmental outcomes during the transformation. At follow-up, to get a richer description, some general questions about their OSH practices were added, including descriptions of the organization’s most common health and safety problems and measures to counteract them, such as training programs and other supporting factors (Appendix C). In study IV, the department’s ergonomist was interviewed, at baseline, in order to get a description of their practices for the prevention of WMSDs.

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4.5.3 ARIA – Assessment of Work Characteristics In order to capture the work characteristics from an external perspective, a work content analysis referred to as ARIA was conducted (ARIA;Waldenström, 2007). ARIA is a Swedish acronym for work content analysis and it consists of a theory-based semi-structured interview, which aims at getting as objective, neutral, and concrete descriptions of the work tasks, work demands, worker control, opportunities for development, social interactions, time pressure, work goals, and hindrances as possible.

The work characteristics are here seen from an external point of view, independent of the employee’s frame of reference. Thereby, factors acting ‘upon’ the employee are assessed—a perspective the developers of ARIA refer to as an ‘external perspective’ (Waldenström, 2007). ARIA is based on the earlier German observational instruments VERA (about regulation requirements) by Volpert et al. (1983) and RHIA (about regulation problems) by Leitner et al. (1991). It was developed in the MUSIC-Norrtälje study (Waldenström et al., 2002). The dimensions encompassed in the ARIA are all related to health and employee development (c.f. Landsbergis et al., 2000, Kompier, 2003), and resemble recent stress-models, including the JD-R model (Demerouti et al., 2001, Corin and Björk, 2016). The ARIA dimensions about the balance between demand and control in the job have been compared to the JD-C model, and at group level the results corresponded to each other (Waldenström et al., 2002).

The interviews were conducted by an interviewer trained in applying the theoretical framework. Prior to the interview, the aim of the interview was explained to the employee in the following way: The aim of the interview is to obtain an overview of your work including what work tasks you have, what resources and hindrances there are for reaching your working goals, or for performing your work as intended. In accordance with ARIA-guidelines, concrete descriptions of work practices and examples thereof were encouraged.

To consider employees’ involvement in the company’s continuous improvement efforts, the original ARIA was further developed, in collaboration with one of the originators of ARIA: Måns Waldenström, to contain questions about the companies’ lean practices. The lean-questions were inspired by the dimensions in the Lean-index, Table 3. This version of ARIA is referred to as Lean-ARIA.

The ARIA analysis is based on the previously described action regulation theory (Frese and Zapf, 1994). One aim of the analysis was to find out how the employee had understood the goals for their work, what opportunities they had to influence one’s own conditions at work, and what hindrances there might be to reach their work goals. In each workplace, employees representing the most typical occupations were selected. The employees should be experienced, and not be the most skilled worker, but rather an average worker. The interviews lasted about 1–1.5 hours. Questions and follow-up questions were asked until illustrative and concrete examples of the phenomenon or consequences thereof were given, and until the interviewer could categorize some of the factors, as being low, moderate, or high. Each year, the same questions were asked. In the follow-up interviews, the respondent was also asked to reflect on their previous year’s answers in relation to each dimension. At the end of the interview, the interviewer summarized the responses as a way to validate the findings. The employee then had the opportunity to complement the summary.

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4.5.4 Questionnaires At baseline and follow-ups, the same questionnaire, consisting of a selection of several validated questionnaires, was distributed to all concerned employees in the chosen workplaces. The selected dimensions and items used in each study are described here in further detail.

Psychosocial Working Conditions: To get a broad picture of the perceived psychosocial conditions at work and factors associated with employee health, selected scales from the long version of the validated and theory-based ‘Copenhagen Psychosocial questionnaire II’ (COPSOQ-II), developed by the Danish National Institute for Occupational Health (Kristensen et al., 2005, Pejtersen et al., 2010), were chosen.

The questionnaire included dimensions from seven, at the time, influential theories about psychosocial factors at work (Kristensen, 2010, Kompier, 2003); (1) The Job Characteristics model, (2) The Michigan Organizational Stress model, (3) The JD-C model, (4) The Socio-Technical approach, (5) The Action-theoretical approach, (6) The Effort-Reward-imbalance model, and (7) The Vitamin model. How the seven theories relate to well-designed or ‘healthy’ jobs, is described in greater detail by Kristensen (2010) and by Kompier (2003). The following COPSOQ-dimensions, and associated items, were selected for study III and IV, respectively. The items were assessed using different 4- or 5-point scales:

(1) Work demands: The items Quantitative demands and Cognitive demands were rated using a 5-point scale from ‘Always’ to ‘Never/hardly ever’. The item Work pace was rated using another 5-point scale ranging from ‘To a very large extent’ to ‘To a very small extent’.

(2) Work organization and work content: The items Influence at work and Variation of work were rated using the 5-point-scale extending from ‘Always’ to ‘Never/hardly ever’. The items Opportunities for development, Meaning of work, and Commitment to the workplace, were rated using the other 5-point-scale ranging from: ‘To a very large extent’ to ‘To a very small extent’.

(3) Social support and leadership: The items Predictability — if employees receive important information about work, Rewards (recognition and respect), Role clarity —if goals and expectations are well known by the employee, Role conflicts, Quality of leadership—ability to solve conflicts, plan work, give priority to employee well-being, and see to that the employees have opportunities for development, were rated using the 5-point scale ranging from ‘To a very large extent’ to ‘To a very small extent’. The items Social support from colleagues, Social support from supervisors, and Social community at work were rated on a 5-point scale from ‘Always’ to ‘Never/hardly ever’.

(4) Work individual-interface: Job insecurity was rated on a 5-point scale ranging from: To a very large extent’ to ‘To a very small extent’, and job satisfaction was rated on a 4-point scale ranging from: ‘Very satisfied’ to ‘Very unsatisfied’.

(5) Values at the workplace: Vertical trust—between employees and management, Horizontal trust—between employees, and justice and respect. All items in this category were rated using the following 5-point-scale from: ‘To a very large extent’ to ‘To a very small extent’.

(6) Individual factors: General health, cognitive and somatic stress symptoms and self-efficacy—trust in your own ability—were used in study III as indicators of employee outcomes. General health was rated using an item originally from the SF-36 (Short Form 36 questionnaire) (McHorney et al., 1993): ‘In general, would you say your health is?’, and assessed using a 5-point Likert scale ranging from ‘Excellent’ to ‘Poor’. Symptoms of stress, during the past four weeks, was rated using a 5-point response scale ranging from ‘All the time’ to ‘Not at all’. Self-efficacy was rated on a 4-point scale from ‘Fits perfectly’ to ‘Does not fit at all’.

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Musculoskeletal Pain: In study II, the occurrence of pain (yes/no), during the past 12 months, in the upper limbs for the body regions: wrists/hands, elbows, shoulders, and the neck, was scored using the Standardized Nordic Questionnaire (SNQ: Kuorinka et al., 1987). The 7-day-prevalence of the worst pain in five different body regions during the past week was rated in two dimensions; pain intensity and pain-related disability (activity-limiting pain). The items were adapted from the Chronic Pain Grade Questionnaire (CPG) (von Korff et al., 1992, Manraj and Saurabh, 2013). Their level of worst pain was rated on a 0-10 response scale where 0 is ‘no pain’/ ‘no interference’ and 10 is ‘unable to carry on any activities’ (during work and leisure time).

To exclude employees with minor pain, only employees with a pain intensity score ≥3 is presented. Similar cut-offs for pain have been suggested in the literature (Andersen et al., 2012, Werner et al., 2005). The CPG was developed prior to the new International Classification of Functioning and Disability and Health (ICF) (WHO, 2001), but have been shown to cover all three levels of ICF-outcomes: Impairment, activity limitation and participation restrictions (Dixon et al., 2007). In accordance with the ICF-classification the pain-related disability is, in this thesis, referred to as ‘activity-limiting pain’. The activity-limiting pain was calculated for employees with a pain intensity score ≥3.

Lean-Index: A selection of the most characteristic items from the Lean-index, see Table 3, was used in study II to capture to what extent the employees appraised that their work was characterized by the following lean tools: Standardized work, JiT, 5S, Visual Management, Waste reduction, CI, and VSM. The items were rated using a 5-point-scale extending from ‘To a very large extent’ to ‘Not at all’, also including the response category: Do not know. The highest two response categories were later combined to represent the employees’ view on characteristic lean tools used.

4.5.5 Tour of the Production and Key Performance Indicators Each year, a tour of the production sites was made at VPC (studies III and IV) to get an understanding of their production and to observe their visible lean practices. The focus was on visual management, 5S, and the physical work environment. Camera and notes were used for documentation. KPIs, including lean indicators, were collected in studies III and IV, not as outcomes, but rather to get an indication of whether the lean practices had affected organizational outcomes. During the direct measurements in study II, several days were spent at the production site, which provided insights into how the production was run and their visible lean practices. Unfortunately, in study II, the data on productivity during the days of the measurements were not comparable between baseline and follow-up, and data on productivity could only be retrieved from the years 2001–2008, three years prior to our study.

4.6 Analysis

4.6.1 Qualitative Analysis In studies III and IV, the interview data was coded and analyzed in several steps using a qualitative content analysis approach (Graneheim and Lundman, 2004). The interviews were audio-recorded, later transcribed, and iteratively read through. Thereafter, the content from both employees and managers, was sorted using the main themes in the ARIA (Waldenström, 2009) and lean categories. In each study, the coding was guided by the research question (Kvale and Brinkmann, 2009). Thus, in study III, descriptions of employee work

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characteristics, for example worker control and work tasks, were condensed and analyzed to identify how they had changed during the study period, with an emphasis on the process of ‘how jobs get to be the way they are’ (Holman et al., 2002, p. 203).

To understand what factors may have contributed to the sustainable social working conditions in study IV, statements about managerial practices that might have an impact on the working conditions were coded (latent coding) (Graneheim and Lundman, 2004) into subthemes using a systems approach (Pettigrew, 1987). Since continuous improvement practices are a core element of the lean concept, and in addition can be considered as an interface between employees and managers, the analysis particularly focused on these practices were in. In addition, contextual factors interpreted as important for the changes were identified. A software for sorting qualitative data NVivo 9.2. (QSR International, Melbourne, Australia) aided during the coding.

In study II, data about organization of work, work tasks, and lean practices in use, and differences between the years, were compiled from the interviews.

Trustworthiness—a concept used in discussions about the quality of qualitative studies (Tobin and Begley, 2004, Kvale and Brinkmann, 2009), was supported through descriptions about how the interviews were conducted and analyzed (dependability), through validation at the site via encouraging and probing for examples of their practices and rich descriptions of their work, and through respondent validation at the end of the interview. In addition, ‘thick’ descriptions provide a better basis for assessing whether it is possible to transfer the results to other cases (Firestone, 1993).

4.6.2 Quantitative Analysis Psychosocial Working Conditions: In studies III and IV, mean item scores were calculated for the COPSOQ-items, in accordance with the test score manual by Pejtersen et al. (2010). Each item was scored from 1–5, or the other way around, depending on the nature of the item. Thereafter, the items were rescored from 0 to 100, and the mean item score was calculated, if at least half of the items were filled out (ibid).

Depending on the nature of the scale, a higher score may indicate higher satisfaction with working conditions or worse psychosocial conditions. For example, ‘leadership quality’ and ‘general health’ are supposed to be high, however, ‘job insecurity’ and ‘role conflicts’, are supposed to be low. Descriptive statistics were presented as mean scores and confidence intervals (95% CI). COPSOQ-results from 360 Danish industrial workers, based on a survey from the Danish National Research Centre for the Working Environment in 2004 (NFA, 2005), were presented as reference values. However, no formal tests were computed between our study and the Danish results. The whole Danish survey consisted of a random sample of the Danish work force: 3,517 active workers aged 20–60 years (ibid.). Statistical differences, between baseline (2010) and the two-year-follow up (2012) were calculated using independent group t-tests. The significance level was set to 0.05. The software program SPSS Statistics 19 (IBM, Stockholm, Sweden) was used for the COPSOQ-analysis.

Physical Workload: Descriptive statistics of postures and movements in study II are, in general, presented as means (M) and standard deviations (SD). For the analysis, work time, excluding lunch breaks, was used.

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Musculoskeletal Pain: In study II, the differences in prevalence of pain and activity limiting pain (disability), in the upper extremities and the neck, were calculated using z-tests for differences in proportions, stratified on process work and line work. Differences were classified as statistically significant at p<.05. Questionnaire data was analyzed using SPSS Statistics 22.

4.7 Preconceptions

In qualitative research, it is essential for the researcher to be aware of their own preconceptions and continually reflect on how they, alongside the researcher’s position and background, might influence the research process (Malterud, 2001). Thus, I have briefly described my background in the preface and will describe here some reflections about the interviewing made along the way.

During the interviews, I also sought to really understand what they described about their work and their context. This meant that I sometimes had to ask many follow-up questions, just to clarify that I had understood, despite that some of the questions needing clarification were probably straightforward for those who are accustomed to industrial settings. Nevertheless, I interpreted it that my questions were received in a good way, and that the respondents saw them as a genuine interest in learning more about their reality. I even think that my novice questions might have contributed to decreasing the power distance typically present in research interviews where the researcher sets the agenda and leads the interview (Kvale and Brinkmann, 2009). Furthermore, they write that a prerequisite for conducting the interviews in a skillful way is to be familiar with the context and the subject. For me, however, the knowledge of the environment developed during the project so that during the follow-up interviews I did not have to ask as many environmental-related follow-up questions.

Something that I benefited from, but also needed to be aware of during the interviews, was my experience of motivational and coaching conversations. My habit of asking exploratory questions and summing up during the conversation came in handy. While I was aware that by just asking questions about their work and how it had evolved, I could potentially affect their behavior, I deliberately did not try to influence the respondent in any direction.

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4.8 Ethical Considerations

Ethical approval of the lean research project was provided by the local ethics board at Karolinska Institutet in Stockholm, dossier number 2009/767-31/5. All employees gave their written consent to participate in the study. In addition, it was pointed out that, at any time during the study, they could withdraw from the study without consequences for their work. In addition, they were informed that the data would be handled with confidentiality.

Before filling out the questionnaires, employees were informed about confidentiality in an oral presentation as well as in the cover letter. The confidentiality was achieved through a coding procedure. In addition, questionnaire data were only analyzed and presented at group level. This was to ensure confidentiality for individual employees. Regarding the interview data, citations were carefully chosen so as not to be able to identify the individual employee. Furthermore, in the case studies, acronyms and general descriptions of the companies were chosen so as not to reveal the name of the company or the managers.

Registration of work movements and postures with technical equipment could possibly be perceived as intrusion to privacy, but does not induce pain or major discomfort. The measures taken to prevent experiences of integrity infringement were to provide detailed oral and written information to all participants.

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5. Results The main results from each study are presented here. The table references in studies II–IV in this section refer to the table in each article.

5.1 Study I – Overview of Studies About Lean and WMSD

The literature search yielded 23 peer-reviewed international publications about lean and WMSD, or risk factors thereof (Table 4). The search for studies in Swedish settings yielded 12 publications (four were scientific studies and eight were gray literature). Table 4. Overview of the included international and Swedish studies with indications of results

23 International scientific studies 12 Swedish publications Studies with WMSD data (8 studies): - 3 mostly negative results - 2 mixed results - 1 positive results - 2 no difference between lean vs. non-lean

Studies with WMSD data (1 publication): - 1 negative results

Studies with measurements of risk factors for WMSD (18 studies): - 7 mainly negative results - 8 mixed results - 2 showed positive results - 1 inconclusive results

Studies with measurements of risk factors for WMSD (12 publications): - 9 showed mixed results - 2 mainly positive - 1 mainly negative

The included studies were of varying design and quality and many of the studies are methodologically limited. Furthermore, the company’s lean practices were seldom described in any greater detail. Moreover, none of the studies used direct measurements of physical workload to determine risk factors of WMSD. The methodologically most advanced study (Womack et al., 2009), used observational methods to capture exposures at the job level.

Taken together, the small number of studies show mixed results and are methodologically limited. Thus, it is not possible to draw any firm conclusions from this overview. Nevertheless, the perceived workload and indicators thereof increased in several of the studies and worker control decreased in most of the studies which focused on that. The included studies, however, explored different aspects of control. Furthermore, it was noted that the international studies more frequently showed negative results, as compared with the Swedish publications, which might be explained by the higher level of employee participation and socio-technical work design tradition in the Swedish studies. Furthermore, studies combining their lean practices with a safety and health focus or an ergonomics intervention had more favorable results. Thus, one tentative conclusion is that lean may increase the risk for WMSD if it is not combined by an ergonomic interventions program. Due to a lack of longitudinal and rigorous studies measuring physical workload in lean organizations, future research on lean’s impact on measured physical workload and musculoskeletal pain is warranted.

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5.2. Study II – Physical Workload and Musculoskeletal Pain in a Process Plant

At baseline, the studied production site had practiced lean manufacturing for more than ten years, including extensive use of several lean tools in combination with a lean value system (Table 5).

At follow-up, the level of standardization was increased at the site. In particular, the production lines (line work) had increased standardization of work procedures, and some new work tasks were added such as weekly cleaning and increased documentation. The line where direct measurements were conducted had, however, not yet achieved a fully takted production. Changes to the work procedures in process work were only minor, but one major change was the merging of two working groups, which meant an enlarged work assignment for some employees (Table 1).

Physical workload: The physical workload for the upper extremities and the neck, as shown through percentile range of postures and movements, was low at baseline as well as follow-up (Table 7). For example, in process work the 50th percentile for head inclination was just above 15° at baseline and just below 20° at follow-up. For line work, the same parameter was below 15°. In addition, the 10th percentile for head inclination was below 10°. Regarding time-related parameters for the neck and the shoulders, there was a small tendency in both units that ‘time at rest’ and decreased over time; in process work it was 19.4% for the neck in 2011 and 13.9% in 2013 and in line work it was 15.3% in 2011 and 13.6% in 2013 (Table 7). Similarly, in process work, ‘time at rest’ for shoulders was 13.4% at baseline and 8.5% at follow-up and was 11.4% for line work at baseline and 10.1% at follow-up.

Working time with arms elevated >60° was slightly increased in process work from 7.1% in 2011 to 8.6% in 2013, but stayed about the same in line work (6.6% in 2011 and 6.4% in 2013). Both years in both units, the shoulder angular velocity (50th percentile) was between 17° and 19°. The wrist angular velocity (50th percentile) was at low levels in both units; for process work it was around 10 °/s and in line work it was below 13 °/s. In process work, ‘time at rest’ for wrists was about 28% and it was 26% for line work (Table 8).

Musculoskeletal pain: The 12-month prevalence of neck pain was just below 60% in both units at follow-up (Table 9). Similarly, the annual prevalence of shoulder pain was 67% in process work and 71% in line work at follow-up. At follow-up, the 7-day prevalences of neck pain had increased among process workers from 20% to 31% (p =.34). Thus, reaching about the same levels as for line workers (35% in 2011 and 33% in 2013) (Table 10). There was a tendency for increased shoulder pain in both units; from 34% to 45% (p=.21) in line work and from 35% to 42% in process work (p=.57). However, none of the pain ratings increased significantly (p >.05). The level of activity-limiting pain (disability) among both operator groups with pain (≥3) were generally at a moderate level (Table 10).

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5.3 Study III – Lean and Transformation of Work Characteristics

The present case study provides an example of a manufacturing company that managed to maintain socially sustainable psychosocial working conditions five years after the initial lean implementation. The company had implemented several lean tools, i.e. VSM, SMED (Setup time reduction), 5S, CI practices alongside a lean value system. During the study period there was gradual changes in work characteristics for the employees. The socially sustainable lean transformation was indicated by the preservation of important job resources, while others were developed. Throughout the study period, for example, perceived general health, scores for role clarity, influence at work, and job satisfaction remained high, with role conflicts significantly decreasing (Table 2). However, in line with previous studies, task control was assessed as decreasing due to standardized work and simplification of work processes (Table 1). But, the employees could still control, to some extent, when and how to perform a task, take breaks when needed and influence their work assignment.

The assessment of work characteristics indicated that the company’s lean practices had contributed to a trend toward job enlargement through higher-skilled tasks, multi-skilling and that employees had extensive opportunities to influence work design through CI practices. The study provides an illustration of how lean contributes to the changes in work characteristics in an interplay with other important contextual factors, for example, the parallel technological development, customer demands, the type of diverse and skilled jobs, focus on cross-training, and a participatory leadership approach.

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5.4 Study IV – Managerial Practices Supporting Socially Sustainable Lean

The findings from this case study, in a Swedish family-owned manufacturing company, indicate that the socially sustainable working conditions were a result of mutually dependent relationships between managerial practices, employee engagement, work context, and their lean practices.

SSWC seemed to be dependent on the joint existence of conscious managerial practices and a beneficial work context. Throughout the study period, the questionnaire data confirmed that job insecurity was kept at a low level (Table 3). In addition, the score for quality of leadership and high levels of trust and commitment were maintained in the organization, while the score for justice and respect significantly improved over the years (Table 3). Four managerial practices were from the interviews identified as instrumental to promote health and build commitment:

(1) A coherent lean approach: Locally adapted and structured implementation, aligned with organizational goals and visions, which was well communicated.

(2) A value-creating leadership style: Managers promoting values for the employees in terms of promoting participation, development and learning, and caring for employee working conditions and health. This with a joint focus on production and employee well-being.

(3) Conscious employee involvement: Managers engaged employees in the lean practices in a stepwise fashion and provided structured ways to be involved according to the groups’ skills and abilities. Conscious coordination and integration of initiatives from the employees, alongside practices to maintain the momentum for change.

(4) A focus on promoting meaningful jobs and health: Actively promoting a favorable work content through willingness to delegate tasks alongside structured ways to promote and encourage employee development, learning, and job rotation. Systematic focus on work environment and health, with some practices integrated into the lean system.

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6. Discussion The overall aim of this thesis was to contribute to a deeper understanding of how lean may contribute to transforming the characteristics of work in industry, and to understand what factors that may support socially sustainable working conditions. This thesis illustrates the interactive nature of the relationships between organizational context, adopted lean practices, managerial practices, and employee engagement in shaping socially sustainable working conditions, even in a lean work system.

6.1 Lean and Transformation of Work Characteristics Findings from the case study at VPC showed that they managed to sustain and even develop some important job resources, except for task control, according to the ARIA- assessment in study III. The shaping of the work characteristics in a lean organization where there is a strong participatory focus, seems to take place in a complex interaction between the company’s specific application of lean, the company’s work context in terms of type of work, organization and technology, and employee engagement. Because of lean’s strong focus on ‘value for the customer’ and fulfilling customer needs, even factors outside of the organization may affect employee work tasks. This is, however, not unique to lean.

Furthermore, the self-reported psychosocial working conditions and health-related outcomes were sustained at favorable levels, with role conflicts decreasing significantly, which could be interpreted as a good sign, since role conflicts have been shown to be negatively associated with job satisfaction and positively associated with tension/anxiety (Jackson and Schuler, 1985). The results in the meta-analysis also indicated that role conflicts may have physiological consequences (ibid.), and in a later study it was positively correlated with somatic health complaints (Fusilier et al., 1987).

In general, the working conditions in VPC seemed to provide employees with sufficient resources for the job and also with opportunities for personal growth and, consequently, in keeping with Kira and Forslin (2008), were assessed as sustainable. Their adoption of lean seemed to be a gradual process with steps toward a lean organization taken even before the official start of the lean program. The fact that VPC had succeeded in sustaining their lean practices over the years, had gotten financial performance results, and at the same time maintained or even improved some already fair working conditions for the employees, could be considered a good result, given and that there have been several reports of worsened working conditions for employees in lean companies (Landsbergis et al., 1999, Westgaard and Winkel, 2011) and since many change initiatives usually fail (Kotter, 1996, Bhasin and Burcher, 2006). Comparing their lean practices to the classification of Jørgensen et al. (2007), the company was assessed to have gained a proactive lean culture in which lean and CI are a part of everyday work, the understanding and practicing of lean are quite high, and employee development is focused in order to support long-term sustainability.

This thesis contributes to the understanding of how jobs are created in contemporary working life, where employees are assumed to be invited to take part to a higher extent. However, this raises questions as to whether employees and managers have the competence to design work in the most beneficial way, considering both performance outcomes and employee health. Future research needs to focus on the ways in which employees are invited to influence the work design, as to generate knowledge about how this process can be supported, and what potential skills and competencies employee needs to aid in promoting SSWC, or in what ways work design experts or ergonomists can be involved in the changes.

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6.2 Lean Manufacturing and Physical Workload and WMSD The results from the literature overview in study I, showed a tendency for increased workload and risk of WMSD in lean work systems, especially if not accompanied by an ergonomic program (Adler et al., 1997, Womack et al., 2009) or a strong health and safety focus (Saurin and Ferreira, 2009). However, most studies found in the literature overview shared common limitations: use of non-validated questionnaires, small sample sizes, no control group, cross-sectional design, and deficient descriptions of the companies’ lean practices. In addition, none of the included studies had actually measured the physical workload. Thus, the results must be interpreted with caution.

After the literature was completed, I was informed about and encountered rigorous rationalization studies that measure the impact of increased value-adding work on physical exposure, and which did not show up in our search. Some of the rationalizations could have been performed as part of a lean initiative, but lack detailed enough descriptions of the company’s collected rationalization practices to qualify for a review studying lean practices. Examples of rationalization studies that, however, could contribute to the understanding of lean jobs are studies of forest workers, dentists, and assembly workers, which have indicated that value-adding work can be associated with a higher physical exposure than non-value-adding work (Kazmierczak et al., 2005, Jonker et al., 2011, Østensvik et al., 2008, Palmerud et al., 2012, Neumann et al., 2018). This increase in VAW, one of the lean goals, may induce both larger mean exposure and less variation—two knowns risk factors for WMSDs (Mathiassen, 2006). Taken together, the results from the overview and the above-mentioned rationalization studies can be interpreted to be in line with Berggren’s (1993) conclusion that lean usually implies working smarter AND harder not ‘work smarter, not harder’ as proponents of lean have claimed (Womack et al., 1990).

Berggren’s statement could, however, not be confirmed in the process plant in study II where the levels of physical exposure were rather low, as compared to the threshold limit values, proposed by the Lund research group (Balogh et al., 2019, Hansson et al., 2016), even after twelve years of extensive lean practices. Since employees’ physical workload is highly influenced by the nature of work and tasks (Allread et al., 2000, Nordander et al., 2016), the rather low physical exposures in study II might partly be explained by the type of lighter industrial process jobs performed by the operators, along with the company’s OSH-focus as well as interventions to improve the physical ergonomics. Similarly, the rather skilled and diverse jobs in study III may have contributed to the more positive outcomes regarding the work characteristics there. Thus, the findings from both studies II and III, lends support to the suggestion by Benders et al. (2016) that different task environments could differently affect lean’s impact on work characteristics.

Regarding musculoskeletal pain among the process operators, at follow-up, both the 12-month prevalences of around 60% in the neck and around 70% in the shoulders and the 7-day prevalences of pain in the neck (about 30%) and the shoulders (about 40%), were rather high. But they had not significantly changed from baseline. Even though the 7-day results are similar to Swedish statistics of machine and process operators, where 40% reported having pain in the neck and shoulders at least once a week (Swedish Work Environment Authority, 2016), they are not completely comparable. In our study operators with pain <3 are not included and, thus, the prevalences would be even higher if all operators with all pain intensities were included, as was done in the statistics from SWEA (2016). This gives rise to concern since a high degree of pain is a known risk factor for sickness absence (Andersen et al., 2012) and needs to be

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explored further to understand more about the underlying mechanisms. For example, shift work—a factor that is not explored in our study, could contribute to a higher prevalence of pain (Labbafinejad et al., 2017, Mahesa et al., 2017).

In addition, the role of psychosocial factors associated with WMSD (Bongers et al., 2006) need to be explored further in order to understand more about the prevalence of pain. Future studies should include questions about important job resources, job demands, and employee attitudes, including reactions to continuous change. Advantageously, questionnaires could be supplemented with employee interviews to explore important job resources and demands related to their lean work system. For example, exploring how they perceive that the level of standardization and rationalization have affected their stress-level, autonomy, and opportunities for social support, and problem solving. Furthermore, the study does not take into account individual factors that may affect the occurrence of pain, such as other diseases and sports involving the upper arm (Malchaire et al., 1997).

6.3 Supporting Socially Sustainable Jobs and Health As one of only a few longitudinal in-depth case studies of a company’s favorable lean transformation, this thesis may contribute to practitioners’ and academics’ understanding of how to adopt lean in a sustainable way. VPC’s focus on joint development of the social and technical parts of the system, and emphasis on human values, in a similar vein to the socio-technical tradition (Klein, 2014), is thought to aid in supporting the SSWC. Several factors seemed to interact to shape the SSWCs: organizational maturity, managerial practices, change competence, type of job, and other contextual factors.

In terms of organizing and supporting socially sustainable or meaningful jobs, there clearly are no quick fixes or simple solutions. The analysis of factors supporting socially sustainable working conditions in study IV illuminate the interactive nature of organizational activities, especially in relation to the adoption of a new management concept. Interpreting the results in the light of Kira and Forslin’s (2008) definition of regenerative work, the company’s coherent lean approach is also believed to have contributed to comprehensibility among the employees. An organizational climate where employees understand the meaning of the changes, and where these are comprehensible and manageable, is important for employees to be able to cope with change (Antonovsky, 1987).

In addition, several of the success factors for sustainable continuous improvements that Rapp and Eklund (2002) found in a Swedish case study were also present in VPC, for example, champions or real enthusiasts, simplicity, adjustability to the interests of stakeholders, work that is not too time-consuming, commitment from managers and shop floor workers, and quick feedback to employees regarding submitted suggestions (Lawler and Mohrman, 1985), were present. They made sure that the right problems were dealt with at the right level, provided the resources needed to solve problems, and offered timely feedback. This seemed to provide forward movement in the change process and ensured that there was an adequate level of mandates and expertise to take care of, develop, and implement the suggested solutions. This, in turn, is thought to contribute to employee commitment by giving employees the feeling that it is worthwhile to make suggestions since they are taken care of in an effective way. The gradual increase in involvement and the ability to consciously adapt the lean practices to the skill and ability of the employees were also identified as one of the company’s strengths. A capability to assess employee competence and provide assignments that are adapted to

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employees’ ability is also described by Dennis (2007)to be a characteristic of a good leader at Toyota.

VPC’s value-creating leadership style seemed to support social capital in the organization, which has also been associated with employee health (Oksanen et al., 2008), job satisfaction, and work engagement (Strömgren et al., 2016). Since facilitating participation and commitment contributes to both health and job performance (Spector, 1986), and successful changes (Kotter, 1996), the value-creating leadership style is thought to contribute to SSWC. The findings are consistent with a study of four hospitals (Arnetz & Blomkvist, 2007) which also indicated that participatory management, performance feedback, and goal clarity are associated with improved employee mental health.

Although, this thesis did not focus on the overall sustainability of the lean transformation, one can notice that several factors that have been pointed out as important for sustainable organizational change programs: collaboration between stakeholders (Svensson et al., 2007, Eklund, 1998), managers with a clear ownership of the change, employee participation, professional steering, competent leadership, and opportunities for learning (Svensson et al., 2007), were in practice at VPC. Furthermore, the company’s ability to balance, and simultaneously consider, the technical and social systems is in line with Westgaard and Winkel’s (2011) suggested model of sustainable production systems, in which performance and employee well-being are constantly balanced. Some of the common traits of managerial practices in family-owned business, such as a long-term perspective and a heightened sense of responsibility for their employees (Brundin and Melin, 2012), may also have contributed to shaping the SSWC.

Furthermore, it seems that the organizational readiness and stage-appropriate activities, described by Prochaska et al. (2001) as instrumental in successful change were present in VPC. Similarly, Dabhilkar and Åhlström (2013) suggest that, from an organizational learning perspective, companies that have previously succeded in implementing other production models (VPC had implemented quality systems prior to lean), are more likely to have developed competencies to be able and ready to implement the next wave of rationalizations. In addition, it is unclear how much the initial support from the national lean program may have influenced the outcome, but it may have contributed the coherent lean approach. At the time, there was, however, no explicit focus on working conditions and health in the program.

Since previous research indicate that more human-oriented lean interventions may have more favorable employee outcomes (Bortolotti et al., 2015, Longoni et al., 2013), one contributing factor for sustaining the favorable psychosocial working conditions in VPC seemed to be their conscious focus on work environment, and that it was partly integrated into their lean system. Similarly, the process industry in study II had a well-established health and safety management system integrated into the daily planning meetings with safety/health given the highest priority, alongside ergonomic efforts, which may have contributed to the relatively low physical exposure. This is in line with several scholars’ proposals to integrate OSH practices into the management system or other work practices (c.f. Frick, 1994, Westgaard, 2000, Village et al., 2014, Abrahamsson and Sederblad, 2013).

Organizational lean tools both have the intention and power to impact how work is designed and organized and some of them are more closely related to work itself. One possible pathway in which lean might contribute to a favorable work design, is through value stream mapping, where the focus is on creating value for the customer by analyzing the value flow. This tool automatically directs focus to work procedures, organizing of work, and the business primary task. Work environmental issues raised in relation to the primary task are then perhaps

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more likely to be taken care of. This reasoning is in line with a study by Framke and Sørensen (2015), which suggests that health interventions focusing on the primary task may support the intervention and avoid ‘side-lining’ of the project. Thus, knowledge gained about how lean contributes to a focus on the primary task can aid in developing methods for integrated health interventions, which has been called for by Kristensen (2005).

Moreover, since employees’ behavior and commitment are important for organizational change to happen (Armenakis and Harris, 2009, Porras and Robertson, 1992), considering and monitoring employee working conditions and employee appraisal of the change process, as suggested by Nielsen et al. (2007), throughout the change program might increase the chances of sustaining the program.

6.4 Methodological Considerations

Some of the strengths and limitations with the scientific methods in the included studies will be discussed here. First, one must consider if it even is possible to study such a management concept as lean—a concept without a commonly agreed upon definition, a concept that is constantly evolving (Hines et al., 2004), and where different companies make, and are supposed to make, their own interpretations or local adaptations of the concept. Based on the assumption by Pettigrew (1987) that the outcome will be influenced by the context, process, and content of the change, the included case studies tried to cover all those aspects through providing rich descriptions of the context, how the company has implemented lean, and what results they might have gained. However, since the managerial and lean practices seem intertwined in the studied company, it is, as Hasle et al. (2012) stated, difficult to exactly discern the contribution that the managerial practices and the lean practices may have had in terms of shaping the SSWC.

Another comment concerns the fact that the companies were not randomly selected, rather they were selected because of their interest to participate in the studies. Furthermore, it was not possible to have control groups in non-lean companies. This is because most Swedish industrial companies at the time were undertaking lean practices to some degree. This was partly remedied by using validated questionnaires, which made comparisons with other populations possible. Moreover, the companies willing to participate in a study regarding working conditions are likely biased. This, in the sense, that they may be more interested and knowledgeable in this area. One also has to question the representativeness of the included workplaces, as, according to Frese and Zapf (1988), supervisors or companies may have a tendency to locate research in the more presentable work units. Therefore, the selected companies may not be representative of the industry in general.

On the other hand, the beneficial results provide opportunities to learn from these ‘good’ examples. It is, however, not possible to draw conclusions about lean’s effects on working conditions in general from these studies. To be able to transfer the results from the included case studies to other companies, contextual factors and characteristics of the organization must be considered (Fishman, 1999).

The internal validity of the studies was increased by using established and tested methods like the ARIA, the COPSOQ, and direct measurements of physical workload, and through validating the interview data during the interview (Kvale and Brinkmann, 2009). The triangulating with multiple complementing data source, with different qualities, and a longitudinal approach was a way of advancing the methods approach in this area and a way of strengthening the internal validity. The fact that information from all sources included in the

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study pointed in the same direction also contributed to the sense that an as accurate a picture as possible of the phenomenon was gained. Observational studies, or interviews during work may, however, have provided even richer descriptions, since work practices often are easier to articulate while or adjacent to performing the work (Schön 1983 cited in Barley & Kunda, 2001).

Furthermore, the questionnaire sample size in the studies is relatively small which limits the generalizability of the study findings to certain work settings. Furthermore, comparing the questionnaire data with the Danish industry is not optimal, but could be regarded as sufficient considering the similarities between industrial working environments in the two Nordic countries. Another problem with subjective data is that they, for example, can be influenced by the employees’ overall dissatisfaction with the workplace and current well-being (Frese and Zapf, 1988).

In addition, the literature overview does not claim to be comprehensive, especially not regarding psychosocial risk factors in the work environment, such as stress, demands, control, job satisfaction, etc. that can affect the physical exposure. As in all literature reviews, it is likely that not all studies that met the inclusion criteria were found during the search, especially studies that did not mention or describe the company’s lean or lean-related practices. To help reduce this problem, we contacted scholars in the field asking them to review the included articles and provide recommendations to potential studies to include.

The direct measurements of physical workload in study II attempted to measure the workload for one whole production process, similar to measuring the product cycle exposures (Bao et al., 1996). This was however, not possible to pursue in that study, owing to a lack of available production data, but the product cycle exposure would be interesting to study in future lean rationalization studies.

6.5 Theoretical Implications and Future Research This thesis provided insights into factors influencing work design in a medium-sized manufacturing company, with rather skilled work (not line work). The results illuminate the interactive nature of organizational activities (Stake, 1995), and especially in relation to the adoption of a new management concept. However, the relationships and the ways in which the practices reinforce each other, need to be studied further. Future research needs to focus on how employees contribute to influencing the work design, in order to generate knowledge about how this process can be supported, and what potential skills and competencies are needed to ensure that the new work design is in line with a favorable design of work.

Since lean manufacturing can be implemented in several different ways, and might have different effects in different settings, future research needs to focus on exploring the effects of lean interventions in a broader array of organizational settings to see how the design of work, and in turn, how employees are affected in different settings.

As changes in work design can be assumed to occur more frequently and with a higher degree of employee involvement in lean companies due to continuous improvements, future research should focus on the process by which jobs are designed in order to further understand the mechanisms for how meaningful jobs can be supported in a fast-moving environment. Furthermore, it would be interesting to study how work assignments are shaped in other types of industries pursuing lean, to see if the findings also are applicable in other organizational environments. Gaining knowledge about how work is shaped is important for understanding and being able to support the development of meaningful and resourceful jobs,

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and thereby for ergonomists and occupational health professionals to be able to offer support close to the processes in which work is designed or shaped.

Unfortunately, the company’s work environmental practices or ergonomics programs are commonly not described in most articles about lean and, thus, it can be difficult to know whether they affected the outcome. Future research should also take lean companies’ health and safety programs into consideration while evaluating the lean initiative. Future research about prevalence of pain in contemporary lean companies are needed in order to determine if employees are at higher risk for developing WMSDs in lean companies.

The psychosocial questionnaire used, COPSOQ-II, did not include items about effects of organizational change and opportunities for participation in organizational change initiatives. Separate items had to be added to cover those aspects. In keeping with the suggestion by Sorensen (2013), items about employee participation in change initiatives could be explored and added to present psychosocial questionnaires, to make it more easily accessible.

Since the work assignment and human actions necessary to perform the work are closely interlinked with the social and structural organization, integrating studies of work into organizational studies, as suggested by Barley and Kunda (2001), could provide better images of the organization. This would allow for expansion of theoretical insights into contemporary ways of organizing, closely related to data. Furthermore, an increased understanding of how work and task demands are shaped could provide knowledge, not only about work itself, but also provide insights on how resourceful jobs and health can be supported in the organization.

What also has become apparent during my work with this thesis, which spans across several areas of knowledge, is the continuing need to integrate and translate concepts from different disciplines.

Future studies of leadership practices might also include more descriptions of concrete work activities that managers do to support the health in the organization and what they know about organizing for resourceful jobs and health. Furthermore, to understand how work is shaped, it would be interesting to interview managers about what models or principles they use, in order to influence work in a healthier way; for example, about what guiding principles they use in the process of organizing work or implementing new ways of performing work, including new technology. In terms of lean and leadership, it would be valuable to interview leaders who have worked successfully with lean about what lean practices or methods that have aided them in their supervisory role.

To gain knowledge about how OHS-practices supports, or possibly can support, lean implementations, future research should, to a greater extent, include descriptions of this inner contextual factor.

6.6 Implications for Lean and Ergonomics Practioners To make a lean initiative more socially sustainable, and possibly also contribute to overall project sustainability, this thesis suggests that integrating aspects of work environment management into the intervention is advisable. Thus, the question of how occupational health and safety issues could be systematically integrated into the lean goals and practices, need to be considered. For example, the structured and increasingly participatory system VPC had for working with improvements could be usefully extended to include occupational health and safety issues, similar to the practices described in the study by von Thiele Schwarz et al. (2015). As a further extension, in line with the integrated ergonomics practices described by Village et

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al. (2014), the company’s work environmental incident reports could be handled in a similar integrated manner as their customer complaints.

Other possibilities are to include aspects of safety and ergonomics into the 5S practice (EPA, 2008) or while conducting the value stream mapping, in accordance with Jarebrant et al. (2016). With advantage, participatory ergonomic observational methods (Takala et al., 2010, Eswaramoorthi et al., 2010), could be used to proactively assess physical risks in the lean workstations and as a basis for continuous improvement practices.

The Lean-ARIA, developed within this project, can be used to analyze work characteristics both from a ‘healthy’ job perspective and as a base for job and organizational development. By identifying both employee task control and employees’ opportunities to influence the lean work, it is possible to get a broader view of influence at work and therefore health-promoting factors. Further, the identification of opportunities and obstacles in employee jobs can provide valuable ideas for how improvement of operations and processes can be implemented in a way that supports continually favorable working conditions. The assessment could also provide insights into how employees’ participation in organizational development can be further developed.

In addition, experience has shown that the neutral description of the work gained through the ARIA can provide a good basis for constructive discussions about the work and organization without the question of who is right (Waldenström and Härenstam, 2006). Furthermore, as work tasks are the interface between the employee and the organization (Frese and Zapf, 1994), by studying the nature of the employees’ work tasks and the conditions they are given to complete them, an understanding of the individual’s possibilities to perform in the job is gained, in addition to, an understanding of how the organization or managers have succeeded in communicating the tasks and goals to the employees. Thus, this knowledge could be used in further development of the work design. The distinction between expert assessments of work characteristics and perceived work characteristics is also important to keep in mind, since it may lead to different interventions in the workplace. If the perceived conditions are also linked to objective work characteristics, then the work might have to be redesigned; if the conditions are just due to the individual’s appraisal of the situation, the intervention could perhaps be directed toward individual or group activities.

In lean companies engaging in continuous improvements, it can be assumed that changes in work design commonly occur more frequently, and in some cases to be aided by employees with on the-job-experience. Thus, both managers and employees need to have knowledge about how high-quality jobs are supported, and systems and structures need to be in place that enable direct and integrated consideration and monitoring of work environment aspects. In addition, managers need to be actively engaged in preserving and supporting valuable jobs.

Since employees’ appraisal of the change process might affect the outcomes of the intervention, it is important to assess how they perceive the change process (Nielsen et al., 2007). Advisably, the monitoring also includes questions about their opportunities to be involved or take part in the change initiative. This, since employees’ participation is an important component in creating a sustainable change initiative (Docherty et al., 2009, Svensson et al., 2007).

The conscious involvement of employees at VPC can be seen as an inspiration as to how to engage employees with different change management skills. The question they initially used to collect suggestions for improvements, ‘What do you need to make this 10% faster’, can with advantage be rephrased to mirror what resources employees need to be able to do their job and how the organization can support them in achieving that.

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When implementing lean practices, the company need to have ‘design thinking’ as opposed to ‘copy thinking’ and consider what practices best suit the organization, and aid in supporting a high-quality work design. Where, for example, opportunities for employee development need to be considered both through CI, and employees’ primary tasks.

Since lean interventions in manufacturing settings show mixed results, but may increase the risk of WMSDs and risk factors thereof. Especially, if they are not accompanied with ergonomic interventions or similar initiatives to promote health and safety, it has been suggested that it would be good to somehow monitor how employees are affected by the lean implementation (Hasle, 2014), in order to capture the positive effects as well as counteracting or reducing problems.

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7. Conclusions The extent to which lean manufacturing transforms industrial work has been extensively debated. The findings from this thesis show that lean can transform work and employee outcomes differently depending on the work context, lean tools used, and the change process employed. This thesis further illustrates the interconnected nature of factors affecting the work characteristics, which appear to be shaped through an interplay between organizational contexts, including type of job, managerial practices, lean practices employed, technological development, and employees’ involvement. This knowledge about how work is shaped in a lean organization can provide guidance for practitioners who proactively want to contribute to a work design that supports the development of resourceful jobs.

The included overview of studies on physical workload in lean industries has shown that only a few investigations assessed physical workload, and that studies using rigorous methods are lacking. Nevertheless, the results of these studies point to an increased perceived workload. Taken together with physical exposure studies that have associated value-adding work with a higher task exposure, these findings suggest that lean manufacturing can make work harder. This, however, was not confirmed by our measurements of physical workload among process operators, where exposure was low across the study period, despite a high level of lean adoption.

Even though early reports on work-related musculoskeletal complaints point to increased risks in lean factories, studies evaluating the prevalence of musculoskeletal pain are scarce, methodologically limited, and results mixed. There are, however, indications of lower prevalences of such musculoskeletal complaints if lean is combined with ergonomic interventions. The 7-day prevalence of neck and shoulder pain among the process operators studied in this thesis was rather high, about 30% and 40% respectively, but did not increase significantly across the study period.

Findings from lean transformation in a midsize family-business showed that lean, in line with what advocates of lean propose, had contributed to a trend toward job enlargement and multi-skilling of workers. While, similar to other studies, standardization of work procedures seemed to have decreased task control, opportunities to influence work through undertaking continuous improvement activities had increased. Furthermore, the company managed to sustain favorable psychosocial working conditions, with scores for role conflicts decreasing significantly and justice and respect increasing significantly.

Four interlocked management practices were identified as being instrumental in supporting the socially sustainable lean initiative: (1) A coherent approach with clear direction, (2) A value-creating leadership, including a participatory and caring leadership approach with a joint focus on health and production, (3) A conscious and stepwise involvement of employees, including capability and strategies to coordinate and integrate initiatives from employees and management, and (4) A focus on supporting meaningful jobs and health, aided by a partly integrated work environment management.

Findings in this thesis also point to the need to actively monitor and care how lean affects working conditions in order to support resourceful jobs. Employees’ opportunities and interest in participating in lean practices should also be monitored to be able to facilitate employees’ engagement in change and thus steer toward socially sustainable working conditions.

This thesis shows that it is possible to make lean initiatives in manufacturing companies more socially sustainable. Overall, findings from this thesis indicate that important and interdependent components that contributing to socially sustainable lean initiatives include a conscious focus on work environment management and health, in combination with a value-creating leadership that actively supports important work resources and involves employees in a conscious manner.

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Acknowledgments A long and rewarding journey has come to its end. It has been a great challenge for me, someone who is basically a sprinter by training, to persevere through this long course of thesis writing, all the way to the finish line. On the other hand, it has been a great learning experience and I have met so many nice people along the way. I am therefore grateful for this opportunity to thank the many people who have supported and guided me through this challenging learning process. It took some perseverance for both you and me to see it through.

First, I want to thank, FORTE—The Swedish Research Council for Health, Working Life, and Welfare, for funding the studies. Second, I want to express my gratitude to the participating companies, managers, and employees, without whose time and engagement this thesis would not have been written.

Ewa Wigaeus Tornqvist, my first main supervisor and project manager: Thank you for setting up such an interesting project, for believing in me, for creating such a welcoming and supportive atmosphere during my first years as a PhD student, and for sharing your positive energy with me and the department. Your knowledge, thrift, and friendliness have inspired me.

Jörgen Eklund, my second main supervisor and second project manager: Thank you for making this journey possible and for sharing your deep knowledge about ergonomics in a systems perspective. A special thanks for coaching me about lean manufacturing and how to communicate with industry. Your patience and persistence have inspired me.

Lotta Dellve, my third main supervisor. Thank you for all your support and for sharing your extensive knowledge about health-promoting leadership, as well as practical tips about the research world. Without you, it would not be possible to pursue the trip into trying to understand managerial practices.

Svend Erik Mathiassen, my co-supervisor: Thank you for your bright and forward feedback on the manuscript in study II, and for sharing your extensive knowledge about physical ergonomics and direct measurements.

Teresia Nyman, my second co-supervisor: I am most grateful to you for your positive attitude, your friendliness, and for your social and statistical skills. You have made the journey easier and brighter, and you have been of great help through difficult stages during the journey.

Måns Waldenström, my mentor and ARIA-trainer. Thank you for sharing your expertise in how to conduct the ARIA-interviews, for answering all my questions about the methodology, for conducting some of the ARIA-interviews in study II, and for cheering me on and being such a wise and caring person.

Malin Josephson, co-supervisor during the first year. Thank you for valuable discussions about how to conduct the Lean-ARIA follow-ups.

Richard Holden. Thank you for your invaluable support and discussions while co-authoring study III and IV. Thanks for understanding what I wanted to accomplish in those studies and for generously sharing your extensive knowledge about Work Systems Design and Ergonomics. Thanks also for helping me improve my English, for believing in me, and cheering me on. And not to forget—thanks for teaching me the Oxford comma.

Andrea Eriksson. Thank you for being such a generous collaborator, for your help in sorting out reviewer comments regarding study III, and for the pleasure of having you as a co-author in study IV. Thank you also for all our interesting discussions about leadership and sustainable workplaces.

Members of the ‘Lean and Ergonomics’ project-team at Karolinska Institutet and assisting colleagues in study II: Thank you for teaching me how to conduct the direct measurements.

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I am especially grateful to Mikael Forsman: Thank you for hanging in there from start to finish! First, as a project member, responsible for the direct measurements and co-writer, and later as manager at KTH. I am especially grateful for the joyful moments we had while collecting all our exposure data. A special thanks for your valuable support in analyzing and writing of the exposure data. Thank you to Eva Bernmark for your careful preparation, carrying through of exposure measurements and analysis at baseline. I also want to thank Vanda Barkstedt for doing the same good job at follow-up. It was great to work with you. Many thanks to Kjerstin Vogel, who, in the first year, assisted in the data collection while I was giving birth to my son. Many thanks to Jan-Anders Kipping for your fine assistance in collecting exposure data. Thank you to Xuelong Fan for computing the final version of the exposure data.

Mikael Brännmark, my late colleague. Thank you for being ‘my own’ lean-guru in the beginning of this journey. I am so grateful for everything you taught me about lean manufacturing, how industry works, quality control, and for all our valuable and respectful discussions with mutual learning. Writing a report and study I with you was a pleasure.

Carl Lind, my roommate during a major part of the journey: A special thanks to you for always being there with a smile, an interesting read, and kindness. Thank you for all your support and interesting discussions about ergonomics, children, and life in general.

I am also most grateful to Per Nylén, supervisor for my magister thesis, for encouraging me to embark on this journey. Thanks for the laser pointer that showed the way. Thank you for being so supportive and for providing valuable feedback on some of the manuscripts.

Former and present fellow PhD students, colleagues, and guest researchers at the Division of Ergonomics: Thank you for interesting discussions and valuable tips during PhD lunches, breaks, writing camps, and seminars. A special thanks to Karin Andersson for nice collaboration on the literature search, within the ‘Lean in Retail’ project, regarding the integration of lean, ergonomics and OSH. Hopefully we can write it down soon.

Svend-Göran Eriksson, statistician: Thank you for the opportunity to discuss statistical questions regarding study III–IV with you.

I am also very grateful for Kasper Edward’s questions and comments during my half-time seminar, Kristina Palm’s valuable comments at my final seminar, and for the anonymous reviewers’ contribution to shaping the manuscripts.

I would also like to thank my most frequently cited researchers in the thesis. It really is like standing on the shoulders of great researchers. You have been a great inspiration.

My colleagues at Elvnäs Applied Behavior Research: Thank you Simon Elvnäs for welcoming me to your exciting leadership research team and for your valuable support. Thank you to Ned Carter for sharing your wisdom and contributing to improving my English writing skills during our collaborative writing sessions. What you stated during one of our sessions: ‘In addition to perseverance, you need patience,’ really holds true for my PhD studies. Thanks to my former colleague Kalle Hedqvist for interesting discussions and your kind support.

Daniel Lundqvist and colleagues at NAV. I am most grateful to you for the welcoming atmosphere, interesting workshops, and the opportunities for co-working you have created. It has been a most inspiring place to write about sustainable working conditions in.

Ola Schenström, Beatrice Blidner, and colleagues at Mindfulnesscenter. Warm thanks for providing great Mindfulness- and Compassion programs, which have been important resources for my self-leadership, focus, and well-being during the second half of the PhD-journey.

I would also like to express my warmest thank you to my friends for your invaluable support, discussions, and presence. A special thanks to Annika Åhs, Anki Nyström, Mia Mellegård, Shole Alinagi, Malin Lundgren, and Karolina Lindström for your supportive

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listening skills and for cheering me on, and thanks again to Annika Åhs, for providing insightful tips about the PhD journey and on writing.

To my family, it would not have been possible to undertake this journey without your support. Thanks to my parents for believing in me, for all your support, and for cultivating my thirst for learning. Thank you to Per for your patience and consistent support throughout the process, for becoming our master chef, and for playing with Leo while I had to write. Leo, my beloved son, thank you for being part of this journey, and for your presence while collecting some of the data. Thank you for being who you are, and for understanding that the book needed to be written—you have enriched my life in so many ways. I am proud to be your mum and I was glad that you, about the time I was about to write up the first final draft of this thesis, asked me to teach you how to write. An honorary task, and I look forward to reading your papers. Den som kämpar klarar det.

You never fail until you stop trying. ― Albert Einstein

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Appendix A Table 5. Search terms used in the databases Pubmed and Business Source Elite. Lean terms were combined with exposure and outcomes according to the following search logic: ‘lean AND (exposure OR outcome)’. The search was conducted in the Abstract section

Lean terms Exposures (external/internal)

Outcomes

Lean Production Continuous Improvement Lean six sigma Lean management Lean manufacturing Kaizen JIT, Just in time Lean thinking Lean enterprise Toyota production system Toyota way Lean method

Work content Working condition/s 1 Work characteristics Workstation design Work station design Workplace, work-place Occupational exposure/s Workload/s, Work-load/s Static load, Dynamic load Physical exposure/s ((posture or postures or postural) and work) Exposure/s Bio-mechanic/al Biomechanic/al Force/s Recovery, Rest Repetitive motion/s Repetition/s Physical ergonomics Human factors Ergonomic/s, Ergonomy Lift/s/ing Job strain Work related, Work-related ((demand or demands) and job)

WRMSD, WMSD, MSD or ((Disorder or disorders) and musculo*) CTD, cumulative trauma RSI, repetitive strain injury/ies Repetitive strain Repetitive stress injury/ies Myalgia/s Symptom/s, Syndrome/s Problem Entrapment/s, Compression/s Pain Disease/s Overuse syndrome Sick leave Health, Well-being Lost time injury Illness rate Job satisfaction Physical strain Injury/ies Employee outcome, Worker outcome Employee effect, Employee health

1 The search was conducted using both ‘working condition’ and ‘working conditions’.

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Appendix B Search terms used for the literature overview in the database: Ergonomics Abstracts.

Table 6. Search strings for the database Ergonomics Abstracts, used in study I, are presented here. The search was slightly modified to fit Ergonomics Abstracts criteria. The search included essentially the same keywords as in Pubmed, but some keywords were excluded since they were considered too general, i.e. lean-method and problem. Others were excluded when they did not yield any hits. Due to limitations of the database, the search had to be performed in two steps: (1) Lean and exposures and (2) Lean and outcomes

Lean and Exposures Lean and Outcomes

"lean prodution" OR "lean manufacturing" OR "Just in time" OR "Just-in-time" OR jit OR "lean thinking" OR "lean enterprise" OR "lean six sigma" OR "toyota production" ) AND workload OR work-load OR physical OR exposure* OR repetition OR motion OR human OR factors OR ergonom* OR "work content" OR "work characteristics" OR "working conditions" OR "workstation design" OR workplace OR occupational OR load OR movement* OR postur* OR lift* OR stress* OR force OR recovery OR biomechanic* OR "bio-mechanical" OR demand

“lean prodution" OR "lean manufacturing" OR "Just in time" OR "Just-in-time" OR jit OR "lean thinking" OR "lean enterprise" OR "lean six sigma" OR "toyota production" ) AND health OR musculo* OR wrmsd OR msd OR wmsd OR ctd OR rsi OR "cumulative trauma disorder" OR repetitive OR disease* OR disorder* OR syndrom* OR satisfaction OR strain OR well-being OR injury OR injuries OR illness OR employee OR myalgi* OR worker OR physical OR overuse OR entrapment* OR compression* OR "sick leave" OR pain OR symptom*

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Appendix C The organizational interview about lean practices and work content [In Swedish] HOF= Items from the Health and Future interview guide (Ahlberg et al., 2008). HOF modified = Items modified from the Health and Future interview guide (Ahlberg et al., 2008).

Beskrivningar av företaget/verksamheten 1. Kan du kort beskriva hur er organisation/avdelning ser ut?

(Hur leds produktionen? Antal kunder?) 2. Vilken är din roll? 3. Hur har företaget förändrats de senaste åren (tekniskt och organisatoriskt)? 4. Vad har varit anledningen till de förändringarna? 5. Finns det strategiska system för ledning/styrning av verksamheten? HOF 6. Är arbetet med Lean integrerat med era ledningssystem? Hur i så fall?

Beskrivning av produktionen/verksamheten 7. Vad tillverkar ni för produkter här? Hur många olika typer? 8. Beskriv kort flödet av produkter, tjänster som går igenom verksamheten från det de

kommer in tills de går ut. 9. Har graden av automatisering ändrats sedan ni började med Lean?

Arbetsinnehåll för medarbetare (frågor till arbetsledare/första linjens chef)

10. Vad har produktionspersonalen för arbetsuppgifter? HOF 11. Vad finns det för möjligheter till raster eller pauser under arbetsdagen? 12. Roterar personalen mellan olika arbetsuppgifter? Hur ofta i så fall? 13. Hur är arbetstiden fördelad? Tvåskift, treskift? 14. Förekommer det övertid? 15. Finns det någon form av hinder för O att utföra sina arbetsuppgifter? Brist på resurser? (Tid, egen kunskap, personal, teknik, lokal). HOF 16. Hur är vanligen arbetsbelastningen för operatören? HOF modified 17. Vad påverkar/vem påverkar hur medarbetarnas arbetsinnehåll ser ut? HOF 18. Hur täcks extra arbetsbelastningar upp? HOF 19. Har arbetsuppgifterna för produktionspersonalen förändrats sedan ni började med

Lean? Hur i så fall? HOF modified 20. Vad finns det för chanser för produktionspersonalen att lära nytt? Exempel?

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Appendix C The organizational interview about lean practices and work content [In Swedish] Beskrivning av företagets Lean-arbete Uppstart och mål Lean

21. När startade ni arbetet med Lean? 22. Vem tog initiativet till att börja med Lean? 23. Vem har lett införandet av Lean? 24. Vem håller i Lean-arbetet nu? (Ägarskap) 25. Vilka personer på företaget har varit engagerade i Lean-arbetet? 26. Vad var anledningen till att man startade med Lean? (Syfte med Lean?) 27. Vad har ni för mål med Lean-arbetet? (Praktiska och visionära) 28. Hur är dessa mål kopplade till era andra mål på företaget/avdelningen? 29. Har verksamhetens mål förändrats sedan ni börja med Lean? 30. Hur mäter ni själva processerna och måluppfyllelsen i Lean? 31. Har ni nått några av era mål med Lean-arbetet? 32. Har ni förändrat ert sätt att mäta sedan ni började med Lean? På vad sätt i så fall?

Genomförande (HUR) 33. Kan du övergripande beskriva vad ni gjort/uppnått inom ert arbete med Lean? Exempel på följdfrågor om de inte kommer på vad de gjort: - Vilka Lean-verktyg/arbetsmetoder har ni infört eller håller på att införa? - Vilka delar av företaget har börjat arbeta med Lean? - Vilka processer har ni inriktat er på i Lean-arbetet?

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Appendix C The organizational interview about lean practices and work content [In Swedish]

Lean-index med intervjufrågor Frågor som kan ställas genomgående:

Hur långt har ni kommit med vart och ett av verktygen? Vad har ni uppnått hittills genom ert Lean-arbete? Exempel?

Värderingar (återkommande interna diskussioner om värderingar på arbetsplatsen)

34. Hur har ni jobbat fram värderingarna? 35. Hur levs och upprätthålls värderingarna i vardagen? Kan du ge exempel?

Kundorientering (kundorderstyrd verksamhet, fokus på kundnyttan) 36. Har arbetet med Lean påverkat ert sätt att jobba med kundfrågor? 37. Har ni några gemensamma system eller med kunden?

(prognoser tillsammans, produktutveckling tillsammans) 38. Hur kundorderstyrd är er verksamhet?

Arbetsgrupper eller team 39. Är produktionspersonalen organiserad i grupper eller team? 40. På vilket sätt i så fall? (Storlek grupper, vem teamledare?) 41. Följer de någon specifik arbetsmodell? 42. Har de fått någon utbildning i team-arbete? 43. Hur är teamen sammansatta?

Regelbundna möten (dagliga eller veckomöten i grupper) 44. Vad har ni för typ av regelbundna möten? 45. Vad är syftet och målen med dessa möten? 46. Hur leds mötena? 47. Vilka deltar på dessa möten?

Ständiga förbättringar 48. Hur ser ert arbete med att förbättra/utveckla verksamheten ut? 49. Har ni någon speciell arbetsmodell? 5 varför? 50. Vilken typ av förslag kommer från medarbetarna, i så fall? 51. Hur hanteras förbättringsförslagen? 52. Har ni någon statistik på hur många förslag som genomförts? 53. Kan du ge exempel på förslag som genomförts?

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Appendix C The organizational interview about lean practices and work content [In Swedish] Just-in-time (leverera i rätt tid med minimala lager)

54. Jobbar ni med just-in-time? På vad sätt i så fall? 55. Har ni använt några Lean-verktyg för att förbättra leveransprecision och

lageromsättningshastighet? 56. Har ni förändrat er lagerhantering sedan ni börjat införa Lean? 57. Har ni förändrat era leveranser till kund sedan ni börjat med Lean? 58. Kan ni beskriva hur det arbetet gått till i så fall? 59. Har ni ställt om till dragande produktion? 60. Hur ser samarbetet ut med era leverantörer? (konstruktion tillsammans, gemensamma system) Har ni jämnat ut era arbetsflöden på något sätt? Hur i så fall? Kan du ge exempel? 61. Har ni beaktat arbetsbelastningen för personalen när ni jämnat era

arbetsflöden? På vad sätt i så fall?

Minskad resursåtgång (eliminera slöseri, ställtidsreduktion, ledtidsreduktion, minska lager och buffertar)

62. Hur har ni jobbat med att minska slöseri? 63. Har ni tagit några Lean-verktyg till hjälp? (Spagetti, SMED, standardisera, värdeflödesanalys) 64. Kan du ge exempel på vad ni gjort för at minska ledtider? 65. Kan du ge exempel på vad ni gjort för att minska ställtider? 66. Hur jobbar ni med förebyggande underhåll? 67. Har ni förändrat er batch-storlek senaste året? Enstycksflöde? 68. Har ni förändrat era buffertar mellan stationer senaste året?

Delaktighet, respekt för individen 69. Vad har ni gjort för att få medarbetarna delaktiga i Lean-arbetet? 70. Hur har utbildningen/träningen av de anställda genomförts och vad har

utbildningen omfattat? 71. Hur har förankringen/förklaringen av Lean gått till på företaget?

(Informationsspridningen) 72. Hur upprätthålls delaktigheten hos medarbetarna? 73. Vad innebär respekt för individen för er? 74. Kan ni ge exempel på hur respekt för individen märks i det dagliga arbetet i

organisationen? 75. Hur har medarbetarnas engagemang/motivation påverkats av omställningen

till Lean? 76. Får de anställda erkännanden, stöd, uppskattning, ersättning och belöning för

goda insatser? I så fall hur? HOF

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Appendix C The organizational interview about lean practices and work content [In Swedish] Värdeflödesanalys (kartläggning av material och informationsflöden för att identifiera kundvärden)

77. Har ni analyserat era produktionsflöden och på vilket sätt i så fall? 78. Har ni analyserat era informationsflöden, och på vilket sätt i så fall? 79. Vad har den eller dessa analyser gett för resultat? 80. Har ergonomi/arbetsmiljö tagits med i analysen?

Standardiserat arbetssätt 81. Har ni dokumenterade arbetsbeskrivningar för varje arbetsuppgift? 82. Kan vi ta del av några exempel på arbetsbeskrivningar? 83. Vem har gjort dessa beskrivningar? 84. Hur förs de nya arbetssätten in i det dagliga arbetet? 85. Hur hanteras uppdateringar? 86. Vet du i hur stor utsträckning dessa beskrivningar följs? 87. Vad har varit målet med att standardisera arbetet?

Ordning och reda (t.ex. 5S, sortera, strukturera, städa, standardisera, skapa vana) 88. Har ni börjat med någon form av ordning och reda? 89. Vilken nivå av 5S har ni uppnått? 90. Kan du ge exempel på 5S-projekt? 91. Vad har ni för rutiner för att upprätthålla ordning och reda?

Visuell styrning, visualisering (resultat anslås på displayer och speciella anslagstavlor) 92. Använder ni någon form av visuell styrning? 93. Vad visar ni upp för information på displayer och tavlor?

Beskrivning av arbete med Arbetsmiljö och hälsa

94. Har Lean påverkat ert sätt att arbeta med arbetsmiljöfrågor? I så fall hur? 95. Utvärderar ni själva effekter på arbetsmiljön vid omställningen till Lean? 96. I så fall hur?

Beskrivning av arbete med Arbetsmiljö och hälsa – tilläggsfrågor uppföljning

1. Hur ser ert arbete med arbetsmiljöfrågor ut nu? 2. Har ni haft någon utbildning inom ergonomi/arbetsmiljö under de senaste 2 åren (för

chefer eller medarbetare)? 3. Vilka är de största arbetsmiljöproblemen och/eller ergonomiska problemen nu som du

ser det? 4. Vad fungerar bra i arbetsmiljöarbetet respektive mindre bra? Inre/yttre faktorer som

hjälper/hindrar? HOF modifierad