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The “Toxic Dose” of System Problems: Why Some Injured Workers Don’t Return to Work as Expected

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Abstract

Introduction Most workers who incur an injury on the job follow a relatively straightforward path through a workers’ compensation claim, recovery and return to work. However, a minority of compensation claims is prolonged and can be disproportionately costly. We conducted this qualitative study in order to gain an understanding of systemic, process-related problems affecting injured workers who had failed to return to work as expected. Method A total of 69 in-depth interviews were conducted with injured workers with complex and extended workers’ compensation claims and with return-to-work (RTW) providers such as health care providers, insurers, legal advisors, and workplaces. The study was based in Ontario, Canada. A modified grounded theory analysis led to the identification of common mechanisms in RTW problems. Results We identify problems with return to work and extended workers’ compensation claims in dysfunctions in organizational dynamics across RTW systems including the workplace, healthcare, vocational rehabilitation and workers’ compensation. These system problems are difficult to identify because they appear as relatively mundane and bureaucratic. These appeared to have damaging effects on workers in the form of a ‘toxic dose’ affecting the worker beyond the initial injury. Conclusions Worker’s problems with extended claims were linked to RTW policies that did not easily accommodate conflict or power imbalances among RTW parties and by social relations and processes that impeded communication about RTW situations and problems. Avenues for intervention are located in a shift to a critical lens to RTW process that addresses differences of knowledge, resources, and interests among different parties.

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References

  1. Wickizer TM, Franklin G, Plaeger-Brockway R, Mootz RD. Improving the quality of workers’ compensation health care delivery: the Washington state occupational health services project. Milbank Q. 2001;79(1):5–33.

    Article  PubMed  CAS  Google Scholar 

  2. Geary J. Return to work: what we need to know. Institute for Work & Health Plenary Session, Toronto; November 21. Toronto: IWH; 2006.

    Google Scholar 

  3. MacEachen E, Ferrier S, Kosny A, Chambers L. A deliberation on “hurt versus harm” logic in early return to work policy. Policy Pract Health Saf. 2007;5(2):41–62.

    Google Scholar 

  4. Eakin JM, MacEachen E, Clarke J. ‘Playing it smart’ with return to work: small workplace experience under Ontario’s policy of self-reliance and early return. Policy Pract Health Saf. 2003;1(2):19–42.

    Google Scholar 

  5. Lippel K. Therapeutic and anti-therapeutic consequences of workers’ compensation. Int J Law Psychiatry. 1999;22(5–6):521–46.

    Article  PubMed  CAS  Google Scholar 

  6. Roberts-Yates C. The concerns and issues of injured workers in relation to claims/injury management and rehabilitation: the need for new operational frameworks. Disabil Rehabil. 2003;25(16):898–907.

    Article  PubMed  Google Scholar 

  7. Mills CW. The sociological imagination. Baltimore: Penguin Books; 1959.

    Google Scholar 

  8. Holmqvist M. Medicalization of unemployment: individualizing social issues as personal problems in the Swedish welfare state. Work Employ Soc. 2009;23(3):405–21.

    Article  Google Scholar 

  9. Seff MA, Gecas V, Ray MP. Injury and depression: the mediating effects of self-concept. Sociol Perspect. 1992;35(4):573–91.

    Google Scholar 

  10. Ash P, Goldstein IS. Predictors of returning to work. Bull Am Acad Psychiatry Law. 1995;23(2):205–10.

    PubMed  CAS  Google Scholar 

  11. Bryngelsoon A. Long-term sickness absence and social exclusion Scand J Public Health. 2009. doi:10.1177/1403494809346871.

  12. Himmelstein JS, Feuerstein M, Stanek EJ, Koyamatsu K, Pransky GS, Morgan W, et al. Work-related upper extremity disorders and work disability: clinical and psychosocial presentation. J Occup Environ Med. 1995;37((11EM113)):1278–86.

    PubMed  CAS  Google Scholar 

  13. Loisel P, Durand M-J, Betrthelette D, Vezina N, Baril R, Gagnon D, et al. Disability prevention: new paradigm for the management of occupational back pain. Disabil Manag Health Outcomes. 2001;9(7):351–60.

    Article  Google Scholar 

  14. Kennedy MQ, Badger E, Pompeii L, Lipscomb HJ. The North Country on the job network: a unique role for occupational health nurses in a community coalition. AAOHN J. 2003;51(5):204–9.

    PubMed  Google Scholar 

  15. Lipscomb HJ, Moon SD, Li L, Pompeii L, Kennedy MQ. Evaluation of North Country on the job network: a model of facilitated care for injured workers in rural upstate New York. J Occup Environ Med. 2002;44(3):246–57.

    Article  PubMed  Google Scholar 

  16. Pergola T, Salazar MK, Graham KY, Brines J. Case management services for injured workers. AAOHN J. 1999;47(9):397–404.

    PubMed  CAS  Google Scholar 

  17. Kirsh B. Making the system better: injured workers speak out on compensation and work issues in Ontario. Toronto: University of Toronto; 2001.

    Google Scholar 

  18. Kirsh B, McKee P. The needs and experiences of injured workers: a participatory research study. Work. 2003;21:221–31.

    PubMed  Google Scholar 

  19. MacEachen E, Kosny A, Ferrier S. Unexpected barriers in return to work: lessons learned from Ontario injured worker peer support groups. Work. 2007;29(2):155–64.

    PubMed  CAS  Google Scholar 

  20. Eakin JM, MacEachen E. Health and social relations of work: a study of health-related experiences of employees in small workplaces. Sociol Health Illn. 1998;20(6):896–914.

    Article  Google Scholar 

  21. Habeck RV, Scully SM, VanTol B, Hunt HA. Successful employer strategies for preventing and managing disability. Rehabilit Couns Bull. 1998;42(2):144–61.

    Google Scholar 

  22. Disler P, Pallant J. Vocational rehabilitation. Br Med J. 2001;323:121–3.

    Article  CAS  Google Scholar 

  23. Lippel K. Compensation for musculoskeletal disorders in Quebec: systemic discrimination against women workers? Int J Health Serv. 2003;33(2):253–81.

    Article  PubMed  Google Scholar 

  24. Beardwood BA, Kirsh B, Clark NJ. Victims twice over: perceptions and experiences of injured workers. Qual Health Res. 2005;15(1):30–48.

    Article  PubMed  Google Scholar 

  25. Cromie JE, Robertson VJ, Best MO. Physical therapists who claimed workers’ compensation: a qualitative study. Phys Ther. 2003;83(12):1080–9.

    PubMed  Google Scholar 

  26. Reed DB, Claunch DT. Behind the scenes: spousal coping following permanently disabling injury of farmers. Issues Ment Health Nurs. 2002;23:231–48.

    Article  PubMed  Google Scholar 

  27. Dembe AE. The social consequences of occupational injuries and illnesses. Am J Ind Med. 2001;40:403–17.

    Article  PubMed  CAS  Google Scholar 

  28. Strunin L, Boden LI. Family consequences of chronic back pain. Soc Sci Med. 2004;58:1385–93.

    Article  PubMed  Google Scholar 

  29. Keogh JP, Nuwayhid I, Gordon JL, Gucer P. The impact of occupational injury on injured worker and family: outcomes of upper extremity cumulative trauma disorders in Maryland workers. Am J Ind Med. 2000;38:498–506.

    Article  PubMed  CAS  Google Scholar 

  30. Sachs PR, Ellenberg DB. The family system and adaption to an injured worker. Am J Fam Ther. 1994;22(3):263–72.

    Article  Google Scholar 

  31. Pransky G, Benjamin K, Hill-Fotouchi C, Himmelstein J, Fletcher KE, Katz JN, et al. Outcomes in work-related upper extremity and low back injuries: results of a retrospective study. Am J Ind Med. 2000;37:400–9.

    Article  PubMed  CAS  Google Scholar 

  32. Carette S. Chronic pain syndromes. Ann Rheum Dis. 1996;55(8EM56):487–501.

    Google Scholar 

  33. Corey D, Koephler LE, Ellin D, Day HI. A limited functional restoration program for injured workers: a randomised trial. J Occup Rehabil. 1996;6(4):239–49.

    Article  Google Scholar 

  34. Feuerstein M. Does the workers’ compensation system think multidimentionally? J Occup Rehabil. 1996;6(1):1–3. [Editorial Comment].

    Article  Google Scholar 

  35. Feuerstein M. Workers’ compensation reform in New York State: A proposal to address medical, ergonomic, and psychological factors associated with work disability. J Occup Rehabil. 1993;3(3):125–34.

    Article  Google Scholar 

  36. James P, Cunningham I, Dibben P. Job retention and return to work of ill and injured workers: Towards an understanding of organisational dynamics. Empl Relat. 2006;28(3):290–303.

    Article  Google Scholar 

  37. Patel S, Greasley K, Watson PJ. Barriers to rehabilitation and return to work for unemployed chronic pain patients: a qualitative study. Eur J Pain. 2007;8(11):831–40.

    Article  Google Scholar 

  38. Korzycki M, Korzycki M, Shaw L. Left behind on the return-to-work journey: consumer insights for policy change and practice strategies. Work. 2008;30:277–87.

    PubMed  Google Scholar 

  39. Thompson A. The consequences of underreporting workers’ compensation claims. Can Med Assoc J. 2007;176(3):343–4.

    Article  Google Scholar 

  40. Robson C. Real world research. Oxford: Blackwell Publishers Inc.; 2002.

    Google Scholar 

  41. Danermark B, Ekstroom M, Jakobsen L, Karlsson J. Explaining society: critical realism in the social sciences. New York: Routledge; 2002.

    Google Scholar 

  42. Williams SJ. Beyond meaning, discourse and the empirical world: critical realist reflections on health. Soc Theory Health. 2003;1:42–71.

    Article  Google Scholar 

  43. Logan L, Mustard C. Cross-jurisdictional survey of case management services for long-term and complex workers’ compensation claims. Toronto: Institute for Work & Health; 2009.

    Google Scholar 

  44. Patton MQ. Qualitative evaluation and research methods. 2nd ed. Newbury Park, CA: Sage Publications; 1990.

    Google Scholar 

  45. Strauss A, Corbin J. Basics of qualitative research: techniques and procedures for developing grounded theory. Thousand Oaks: Sage; 1998.

    Google Scholar 

  46. Workplace Safety and Insurance Act Sections 82 and 83, Sections 82 and 83 (2008).

  47. Morneau-Sobeco. Recommendations for experience-rating. Toronto: Morneau Sobeco; 2008.

    Google Scholar 

  48. OMA. OMA position on physician workforce policy and planning revisited: recommendations to address Ontario’s doctor shortage. Ontario Med Rev. 2007.

  49. Kaye HS. Stuck at the bottom rung: occupational characteristics of workers with disabilities. J Occup Rehabil. 2009;19:115–28.

    Article  PubMed  Google Scholar 

  50. WSIB. What are the WSIB’s responsibilities? 2009.

  51. WSIB. Statistical supplement to the 2007 annual report. Toronto: Workplace Safety and Insurance Board of Ontario; 2007.

    Google Scholar 

  52. MacEachen E, Clarke J, Franche RL, Irvin E. Systematic review of the qualitative literature on return to work after injury. Scan J Work Environ Health. 2006;32(4):257–69.

    Google Scholar 

  53. Parrish M, Schofield T. Injured workers’ experiences of workers’ compensation claims process: institutional disrespect and the neoliberal state. Health Sociol Rev. 2005;14(1):33.

    Google Scholar 

  54. Trief PM, Donelson RG. The potential impact of workers’ compensation system on quality of life outcomes: a clinical analysis. J Occup Rehabil. 1995;5(3):185–93.

    Article  Google Scholar 

  55. Lippel K, Lefebre MC, Schmidt C, Caron J. Managing claims or caring for claimants: effects of the compensation process on the health of injured workers. Montreal: University of Quebec at Montreal; 2007.

    Google Scholar 

  56. Feuerstein M. Does the workers’ compensation system think multidimensionally? J Occup Rehabil. 1996;6(1):1–3.

    Article  Google Scholar 

  57. Watson R. Ethnomethodology and textual analysis. In: Silverman D, editor. Qualitative research: theory, method and practice. Thousand Oaks: Sage; 1997. p. 80–98.

    Google Scholar 

  58. Pollner M. Mundane reason: reality in everyday and sociological discourse, vol. EM427. New York: Cambridge University Press; 1987.

    Google Scholar 

  59. Newell S, Robertson M, Scarbrough H, Swan J. Managing knowledge work. New York: Palgrave; 2002.

    Google Scholar 

  60. Ritzer G. Sociological theory. 3rd ed. New York: McGraw-Hill; 1992.

    Google Scholar 

  61. Wallace RA, Wolf A. Contemporary sociological theory. Fifthon shelf, editor. Upper Saddle River, New Jersey: Prentice Hall; 1999.

  62. Parsons TC. Structure of social action glencor. Illinois: Free Press; 1949.

    Google Scholar 

  63. Barnes B. The elements of social theory. Princeton: Princeton University Presson shelf; 1995.

    Google Scholar 

  64. Young AE, Wasiak R, Roessler RT, McPherson KM, Anema JR, Popper MNM. Return-to-work outcomes following work disability: stakeholder motivations, interests and concerns. J Occup Environ Hyg. 2005;15(4):543–56.

    Google Scholar 

  65. (Ontario) WSIB. Workers. 2010 [cited 2010 January 11]; Available from: http://www.wsib.on.ca/wsib/wsibsite.nsf/public/ReturnToWork.

  66. MacEachen E. The demise of repetition strain injury in sceptical governing rationalities of workplace managers. Sociol Health Illn. 2005;27(4):490–514.

    Article  PubMed  Google Scholar 

  67. Alvesson M, Deetz S. Doing critical management research. Thousand Oaks: Sage; 2000.

    Google Scholar 

  68. Faubion JD, editor. Michel foucault: power. New York: The New Press; 1994.

    Google Scholar 

  69. Melles T, McIntosh G, Hall H. Provider, payor, and patient expectations in back pain rehabilitation. J Occup Rehabil. 1995;5(2):57–69.

    Article  Google Scholar 

  70. Stahl C, Svensson T, Petersson G, Ekberg K. The work ability divide” holistic and reductionistic approaches in Swedish interdisciplinary rehabilitation teams. J Occup Rehabil. 2009;19:264–73.

    Article  PubMed  Google Scholar 

  71. Scott HK. Reconceptualising the nature and health consequences of work-related insecurity for the new economy: the decline of workers’ power in the flexibility regime. Int J Health Serv. 2004;34(1):143–53.

    Article  PubMed  Google Scholar 

  72. Scott-Marshall H. Work-related insecurity in the new economy: evaluating the consequences for health. Politics Neolib Struc Process Outcome Res Polit Sociol. 2007;16:21–60.

    Google Scholar 

  73. Mayhew C, Quinlan M. The effects of changing patterns of employment on reporting occupational injuries and making workers’ compensation claims. Saf Sci Monit. 2001;5(1):1–12.

    Google Scholar 

  74. Zoller HM. Manufacturing health: employee perspectives on problematic outcomes in a workplace health promotion initiative. West J Commun. 2004;68(3):278–301.

    Google Scholar 

  75. Sullivan MJL, Adams H, Horan S, Maher D, Boland D, Gross R. The role of perceived injustice in the experience of chronic pain and disability: scale development and validation. J Occup Rehabil. 2008;18:249–61.

    Article  PubMed  Google Scholar 

  76. Franche RL, Lee H, Severin CN, Hyunmi L, Hogg-Johnson S, Hepburn CG, et al. Perceived justice of compensation process for return-to-work: development and validation of a scale. J Psychol Inj Law. Pending.

  77. Roberts K, Markel KS. Claiming in the name of fairness: organizational justice and the decision to file for workplace injury compensation. J Occup Health Psychol. 2001;6(4):332–47.

    Article  PubMed  CAS  Google Scholar 

  78. Russell G, Brown JB, Stewart M. Managing injured workers: family physicians’ experienmces. Can Fam Physician. 2005;51:71–9.

    Google Scholar 

  79. Friesen MN, Yassi A, Cooper J. Return-to-work: the importance of human interactions and organisational structures. Work. 2001;17:11–22.

    PubMed  Google Scholar 

  80. Clarke J, Cole D, Ferrier S. Return to work after a soft tissue injury: a qualitative exploration. Working Paper. Toronto: Institute for Work & Health; 2000. Report No.: 127.

  81. Niemeyer LO. Social labeling, stereotyping, and observer bias in workers’ compensation: the impact of provider-patient interaction on outcome. J Occup Rehabil. 1991;1(4):251–69.

    Article  Google Scholar 

  82. Abenhaim L, Rossignol M, Valat JP, Nordin M, Avouac B, Blotman F, et al. The role of activity in the therapeutic management of back pain. Spine. 2000;25(4):1S–31S.

    Article  PubMed  CAS  Google Scholar 

  83. Friedman PJ. Predictors of work disability in work-related upper-extremity disorders. J Occup Environ Med. 1997;39(4):339–43.

    Article  PubMed  CAS  Google Scholar 

  84. Franche R-L, Cullen K, Clarke J, Irvin E, Sinclair S, Frank J, et al. Workplace-based return-to-work interventions: a systematic review of the quantitative literature. J Occup Rehabil. 2005;15(4):607–31.

    Article  PubMed  Google Scholar 

  85. MacEachen E, Chambers L, Kosny A, Keown K. Red flags/green lights: a guide to identifying and solving return-to-work problems. Toronto: Institute for Work & Health; 2009.

    Google Scholar 

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Acknowledgments

Funding for this study was received from the Ontario Workplace Safety and Insurance Board Research Advisory Counsel. This funding does not imply endorsement of the research findings. We thank the injured worker representatives, occupational health physicians and workers’ compensation policy makers who comprised the study Advisory Committee and who provided thoughtful advice and reflections over the course of the study. Finally, we thank Diana Pugliese for her help with arranging and editing this paper.

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MacEachen, E., Kosny, A., Ferrier, S. et al. The “Toxic Dose” of System Problems: Why Some Injured Workers Don’t Return to Work as Expected. J Occup Rehabil 20, 349–366 (2010). https://doi.org/10.1007/s10926-010-9229-5

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