In good voice

Employers may be open to damage claims from employees with voice disorders
if the hazards at work are not identified and properly managed, by Kieran

A mixture of astonishment, glee and indignation greeted the media
announcement a few years ago that officers and sergeants in Her Majesty’s Armed
Forces were required – on medical grounds – to moderate the volume of their
voices. Was the centuries-old tradition of addressing ranks loudly, celebrated
in caricature and comedy alike, becoming another victim of silly political

Such reactions were perhaps understandable, but occupational health
professionals may recognise the rationale behind the decision. What actually
led to the ban on shouting was the appointment of an experienced specialist in
occupational medicine to the Surgeon General’s department in Whitehall.

In an earlier role as chief medical officer with a large borough council,
this doctor had been responsible for advising his employer on legal claims for
damages from staff with voice disorders attributed to uncontrolled hazards at
work. The doctor had learned from this experience to advise his new employer,
the Ministry of Defence, to pro-actively control hazards to voices.

In this instance, professional action to prevent injury to those in the
habit of barking orders explained the public story, not political correctness
on etiquette nor concern for damage to the ears of those exposed to loud

The image of square-bashers being deprived of their bark may well raise a
smile for many of us, but – as experienced voice therapists will tell you –
voice injury can be painfully traumatic.

This article looks at the hazards to staff health associated with the use of
the voice at work, and the responsibilities of employers to control them.

The employer’s responsibility

Arising from the employer’s common law duty of care to employees, the
Management of Health and Safety at Work Regulations 1999 (Health and Safety
Commission, 1999)1 obliges an employer to assess risks of injury and manage the
risk competently. The standard of care required is not a recommendation of
perfection, but a pragmatic matter of ‘reasonable practicability’.

In practice, this involves two things: determining the risks of foreseeable
injury or illness, and taking measures to protect staff against these risks,
with a sufficient effort of scale to ensure proportionality between the level
of risks to individuals and the costs involved.

What is the scale of voice problems at work?

There will normally be sufficient evidence, both audible and documented, about
any voice disorder of an employee or job applicant. A reasonable employer will
take this into consideration in relation to tasks and the social demands of a
job, health and safety laws and regulations, and the person’s rights in
accordance with the disability discrimination legislation.

However, evidence of voice problems is more difficult to gather and evaluate
reliably. Speaking at a conference on teleworking and other forms of flexible
working on 28 November 2002, Moira Jevons, head of policy, division III, Health
& Safety Executive, acknowledged there is a lack of relevant
epidemiological data on voice injuries at work in the UK.

We are left to rely on indicators of occupational risk from the US and
Sweden for fairly reliable evidence on voice problems.

Presented in Table 1 (p26), ‘risk factor’ is jargon for the probability of
injury, multiplied by the average likelihood.

The data in this table suggests that in professional voice user roles –
where the voice is a primary instrument of work – voice hazards represent an
above-average risk to the staff involved and should be carefully monitored.

The growth in call centres may well mean the occupational risk factors –
reported in the telemarketer and ticket sales categories – may have increased
significantly since this data was collected between 1991 and 1993.

However, it is worth noting that the data indicates that the jobs with the
highest occupational risk factors after singers, are counsellors and teachers,
whose work involves a high degree of sustained, direct interpersonal behaviour,
often with a wide cross-section of people with diverse needs and expectations.

Managing voice hazards

Pinpointing hazards to voice users at work marks the beginning of the cycle
of managing the health of the occupational voice.

‘Voice loss’ is a general expression that refers not simply to little or no
vocal power, but also to smarting, burning, swelling pains, croakiness,
squawking, crackling and tension.

Table 2 profiles some typical hazards to people using their voice at work.
However, this generic model does not attempt to represent all the hazards that
may affect the voice user.

Identifying hazards to the voice show an important feature of the dual
character of the human voice, being both physiological and psychological.

The human voice is not simply a cluster of physical sounds uttered by a
person, but the mechanism that translates concepts in the mind of the speaker
into patterns of sound that others can decode in ways that make sense to them.

Hazards to professional voice users are both physical and psychological (or

There are two classes of behaviour. ‘Task-centred behaviour’ is an inherent
part of carrying out the activities required to achieve the goal of a task at
any time; it usually displays a relatively constant pattern once an employee is
skilled at it; and interpersonal behaviour is much less predictable in terms of
the degree of challenge it may make on the individual, and the intensity of the
emotional and mental concentration and energy it may call for.

The challenge of interpersonal behaviour can be greatly increased when money
is involved, or where communication is by telephone – which limits feedback by
body language – or where the hearing or language skills of either person is
impaired, and one or both participants are fatigued.

Managing possible pitfalls

While many of the physical hazards highlighted in Table 1 are often
comparatively straightforward to recognise, controlling both the ‘task-centred’
and ‘interpersonal’ forms of behavioural hazards shown in Table 2, can be much
more challenging.

Some managers may be inclined to overlook the significance of the
‘behavioural hazards’ as either too bothersome or too difficult to get to grips
with effectively. This is particularly the case in environments such as offices
and retailing, where attention to health and safety has traditionally been
relatively low key.

They are well advised to take note of evidence from leading researchers
(Butcher et al, 20012; Mathieson, 20013), which emphasises the part played by
behavioural hazards in mental and emotional strains expressed as voice
problems. In the light of their evidence, it is reasonable to conclude that for
some, hoarseness and loss of voice become the symptoms of occupational stress.

Martin & Darnley (1996)4 also emphasise how postural problems can
contribute to voice problems, through their effects on the quality of

Safeguarding professional voice users against voice hazards calls for
expenditure on a scale that is more than incidental. Evident costs include
disadvantageous levels of sickness absence, underperformance and turnover.

Where an employer simply disregards voice hazards, or, as is perhaps more
likely, underestimates the significance of the risks to voice users, employees
are left to find their own ways of coping with the strains.

If you want to design preventative measures to care for the voices of people
at work, you must carefully analyse the physical, task-centred and
interpersonal hazards. Start with a competent assessment of the degree of
likelihood of injury or illness, and the possible severity of harm. Assessment
of risks is often a lot more subtle than you might think. For example, many
call centre operators can face severe emotional stress, as the case study on
page 26 illustrates.

Unless these sources of emotional strain are identified and appropriate
controls put in place, adaptation to the hazards may cause avoidable injury, which
can prove to be more costly for the employer than the employee.

While some excellent voice coaching is available, regrettably, some
providers promote it as a health and safety measure, without evidence of
necessarily understanding the hazards to be controlled.

Beware when you are faced with an employee suffering from damage to the
voice or tension to the musculature around the larynx in the throat area. In
such circumstances, voice coaching without clinical attention from a competent
voice therapist could aggravate the problem.


Managing voice hazards involves the same cardinal principle as managing
every other class of hazards: tailor the controls to the needs, tasks and
responsibilities of individual employees. Variants on the ‘one size fits all
theme’ – such as ‘It worked for me, so it should work for everyone else’ – can
all too easily result in trouble.

In professional voice user roles where the voice is a primary instrument of
work, voice hazards represent a significant proportion of hazards to the staff
involved, and injury prevention applies in this area as much as in other areas
of occupational health.

For specialist help in identifying the hazards, some members of the Division
of Occupational Psychology of the British Psychological Society (www.bps., the Ergonomics Society ( offer expertise in task
analysis, and organisational health and members of the British Voice
Association ( are experts in healthy vocal

Kieran Duignan is a chartered occupational psychologist, ergonomist and
counsellor. He works with Enabling Space. tel. 020 8654 0808. E-mail His management guide, Managing Behavioural Risks, is
due for publication by Oak Tree Press in June.


1. Health and Safety Commission, Management of Health and Safety at Work
Regulations, HSE Books (1999)

2. Butcher, P, Elias, A and Raven, R, Psychogenic Voice Disorders and
Cognitive-Behaviour Therapy, Whurr Publishers (1993)

3. Mathieson, L, Greene & Mathieson’s The Voice and its Disorders, Whurr
Publishers, 6th edition (2001)

4. Martin, S & Darnley, L, The Teaching Voice, Whurr Publishers (1996)

5. Occupational risks for a voice problem, Verdoli, K and Ramig, L O, in Logopedics
Phoniatrics Vocology, 26: 37 – 46, Taylor and Francis (2001)

Case study
Call centre staff learn about hazards to voices

When the library supporting the
Office for National Statistics (ONS) outside Newport in South Wales was being
converted into a call centre, project manager Sallie Mogford commissioned
workshops to familiarise the 28 employees with hazards to their voices, and the
options for controlling them.

"We receive calls on a great variety of subjects, not only
from people in every part of the UK, but from other countries," she
explained. "Our staff’s work involves responding readily to enquirers with
different levels of understanding of the English language, different styles of
diction and pronunciation and so on. As a result, telephone conversations are

The ONS took measures to actively control the hazards to the
operators’ voices before opening its call centre. Educating staff about the
nature of hazards arising in the use of the voice at work – explaining the
basic principles of physiology and psychology involved in phone conversations,
providing training in appropriate breathing, healthy posture at work and using
simple mental relaxation exercises afterwards – were all practical ways of
preventing voice injury.

"The mental and emotional demands of the job is not
obvious to everyone," Mogford says. "They often have to really
concentrate in order to understand the exact enquiry and direct a conversation
while retrieving information from one or more databases.

"The reality is that a small but significant proportion of
enquirers have difficulty in expressing themselves clearly and calmly, and this
calls for a mixture of patience and firmness on the part of the operator.
Unless it is explained to them, it is not necessarily obvious that the severe
strain they feel at times is due to the nature of the complex
information-processing their job involves."

Table 1: Who is most at risk from
a voice disorder?

                                                                        Risk factor
Occupation                                                      US                               Sweden                                    US
& Sweden

Singer                                                               575                              n/a                                            575
Counsellor/Social worker                                  8.42                             1.98                                         5.20
Teacher                                                            4.67                             2.76                                         3.71
Lawyer                                                             n/a                                3.50                                         3.50
Clergy                                                              n/a                                3.15                                         3.15
Telemarketer                                                    2.95                             n/a                                            2.95
Ticket sales                                                      1.90                             n/a                                            1.90
Healthcare                                                        n/a                                1.1                                           1.1

What you need to know


– Look out for symptoms of voice problems of professional voice

– Educate professional voice users to manage risks to their

– Use a simple rating scale to monitor the voice health of
professional voice users


– Underestimate the total costs of voice problems

– Overlook the emotional angles of voice impairment

– Forget to assess behavioural hazards carefully

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