27 - Common Themes, Different Perspectives.indd

Common themes, different perspectives: A systemic analysis of employer-employee experiences of occupational rehabilitation Dianna T Kenny Rehabilitation Counseling Bulletin, 1995, 39, 1, 54-77. Workers with injuries and their employers were interviewed using a semistructured protocol to elicit their perceptions about their own and each others behavior and that of other stakeholders in the process of occupational rehabilitation. Four common themes emerged from the interviews. Whereas workers with injuries focused on the perceived failure of the system to provide adequate care, employers were concerned with issues of cost containment and productivity. A process of triangulation of stakeholders occurs that results in polarization of the primary employer-employee dyad. Changes to the current system are recommended, including specific educational campaigns targeting employers and the training and accreditation of rehabilitation coordinators.

INTRODUCTION The 1980s was an era of deregulation in Australia in which socially desirable ends were thought to be best achieved through the operation of market forces rather than by government intervention (Hopkins, 1994). The market approach relies on economic incentives, and its proponents in the area of occupational health and safety argued that government regulation had not adequately ensured worker health and safety. It was proposed that employers be provided with an economic incentive to minimize occupational injury and disease. In the 1980s, several state workers’ compensation authorities introduced premium incentive schemes. In New South Wales, the Workers’ Compensation Act was passed in 1987. This act not only introduced a premium incentive scheme for employers, but also provided for the occupational rehabilitation of workers with injuries. This meant that employers were obliged to establish a workplace rehabilitation program to assist their workers with injuries to return to work. This involved the appointment, either fulltime or part-time, of a rehabilitation coordinator, whose function is to provide information to the worker, to establish liaison with key personnel such as the supervisor and the treating doctor, and to negotiate suitable duties. The rehabilitation coordinator may also be involved in referring to specialist occupational rehabilitation providers for assistance such as workplace modification, development of upgraded return-to-work programs, or vocational redirection. The Industrial Relations Act (1992) complemented the employer’s obligations by making it an offense to dismiss an employee who is injured within 26 weeks of the injury solely or primarily because of the injury. The Work- Cover Authority of New South Wales, a statutory self-funding body, was established in 1990 Rehabilitation Counseling Bulletin

to administer the 1987 legislation. It is funded by a 4% levy on each workers’ compensation policy from every employer in New South Wales. Although there were many reported benefits of the new legislation (Kenny, 1994a), difficulties with the administration of the legislation became apparent, particularly in rural areas and for workers with longterm injuries (WorkCover Authority, 1992). These difficulties were reflected in poor return-to-work rates following occupational rehabilitation (Industry Commission, 1994) and the formation, in 1991, of the Hunter Action Group Against WorkCover. This organization, based in the Newcastle-Hunter region (a large regional city with surrounding rural areas) of New South Wales, consists of about 350 workers with injuries who have experienced difficulties with their rehabilitation and reintegration back into the workforce. Its charter is to provide advocacy for these workers to ensure that appropriate services are made available to workers with injuries in a timely and systematic way and to work toward improving the rehabilitation process. Recent analyses of injury occurrence and outcomes of injury can be categorized along two broad dimensions. These are the “victim blaming” approaches adopted by adherents of the medical model orientation to occupational injury and its management (see Davis & George, 1988) and the “system blaming” approach of many industrial sociologists (James, 1989; Quinlan & Bohie, 1991; Wiffiams & Thorpe, 1992). Neither of these approaches have attended sufficiently to the interactions between workers and systems nor have they demonstrated sufficient explanatory power for either the successes or failures of occupational rehabilitation. A third approach, namely the systemic model (Cottone & Emener, 1990), provides a possible alternative paradigm for understanding outcomes of the occupational rehabffitation process and for 1 Experiences of occupational rehabilitation

developing an approach to intervention. It proposes that the foci of study are relationships in context, rather than individuals. The focus of assessment is the relationship dynamics occurring between the worker with injuries and the system rather than an exploration of the individual’s traits, skills, and capacities in isolation. The goal of service therefore, is to find the best social fit for workers rather than to strive for the individual’s adjustment or readjustment following the injury. This model was applied to the system of occupational rehabilitation as it currently operates in New South Wales, Australia. Figure 1 presents a schematic representation of the proposed model. From the figure, it is clear that the worker and the workplace coexist in a reciprocal relationship that is influenced by both the characteristics of the worker and the characteristics of the workplace. When a worker is injured, the preexisting conditions both in the worker and in the workplace will interact with postinjury experiences and reactions to define the response of both to the injury. Provided that the injury is not so severe that return to work is impossible, ideally both worker and workplace will cooperate successfully in the postinjury period to effect a successful return to work. The injured worker-employer dyad is central and therefore critical to the return to work outcome. These two stakeholders may call on the services of other stakeholders such as rehabilitation coordinators, rehabilitation providers, the insurer, unions, and members of the medical and legal professions to assist them at various stages of the postinjury period. The number of stakeholders enlisted depends on a range of factors induding the nature and severity of the injury, the rehabilitation needs of the worker who is injured, the nature of the work, and the quality of the relationship between the worker and employer, which may be cooperative or adversarial. Some stakeholders, for example the rehabilitation coordinator and the rehabilitation provider, may provide services and be accountable to more than one other stakeholder. The rehabilitation coordinator is simultaneously accountable both to the employer and to the worker who is injured, and the rehabffitation provider is accountable to workers with injuries, employers, and insurers. Although this system has advantages in that it provides built-in safeguards against overservicing and excessive and unsupervised expenditure, it has the disadvantage of creating disequilibrium in the system via conflicts of interest between the worker who is injured and other stakeholders and of risking breakdowns in communication or adversarial competitiveness Experiences of occupational rehabilitation 2

between parties. The impact of a range of variables has been reported in rehabilitation literature, including the nature and severity of the injury and characteristics of workers (Kenny, 1994b), financial commitment from management to occupational health and safety projects (Ferguson & Talbot, 1992), education of all staff within organizations to ensure that rehabilitation programs are viewed as integral to the treatment plan of injured workers (Bruyere & Shrey, 1991; Ferguson & Talbot, 1992), consultation between all key parties (Remenyi, 1992; Shrey, 1993), and early referral to appropriate rehabilitation services (Gardner, 1987; Pati, 1985; Shrey, 1993; Strautins & Hall, 1989). Nevertheless, little specific attention has been paid to the impact of employer-injured worker relationships in return-to-work outcomes. The aim of this study was to examine in depth, via semistructured interview, the relationship between injured workers and their employers, and to elicit their perceptions of each other and of the roles and effectiveness of other stakeholders in the occupational rehabilitation process to clarify some of the factors that each perceived to make an impact on the process and outcomes of occupational injury. METHOD Interview Design An in-depth semistructured interview protocol was developed for injured workers and employers based on a review of the rehabilitation literature pertaining to the identification of relevant variables that affect return to work, the Workers’ Compensation Act (1987), policy documents and brochures for stakeholders developed by the WorkCover Authority of New South Wales, and the use of data obtained from an interview study of workers with long-term injuries (Kenny, 1995). For injured workers, the two-part format consisted of 28 questions obtaining demographic details (sex, age, first language, education, marital status, dependent children, current and past employment history, and injury data), followed by a series of 34 open-ended questions (with probes). The open-ended questions were supplemented with more specific questions (in the form of probes) about certain aspects of their experience, if these did not emerge in their free accounts. In addition, participants were asked to rate their satisfaction on a 5-point Likert-type scale (1 = very dissatisfied, 3 = neither satisfied nor dissatisfied, 5= very satisfied) with the various Kenny D. T., 1995

Rehabilitation Counselling Bulletin

3 Experiences of Occupational Rehabilitation

professionals with whom they had come into contact over the course of their injury, and to give reasons for the ratings assigned. Participants were also asked to describe in detail their experience of occupational rehabilitation in their workplaces, with particular emphasis on the communication between key stakeholders (e.g., “After you were injured, who was responsible for your case management?”); their attribution of blame and responsibility (e.g., “Please describe the general attitude and behavior of your employer [your coworkers, the insurerl toward you since you were injured?” “For you personally, what could have been done differently to help you to return to work?”); and the provision of suitable duties (e.g., “After you were injured, did your employer provide you with suitable duties? How were suitable duties determined?”). The format for the employer questionnaire was similar to that for the workers who were injured. The first part contained 13 demographic questions, including personal details (sex, age, country of birth, educational qualifications) and company details (ownership of company, number of employees, financial status, and insurance arrangements). The second part contained 20 open-ended questions (with probes), exploring the issues of “workplace culture,” (e.g., “How possible is it for your organization to provide suitable duties for injured workers?” “How would you describe Systemic Analysis of Occupational Rehabilitation the level of understanding and commitment to rehabilitation by your managerial staff?”); and attitudes toward injured workers (e.g., “What is your understanding of how this injury occurred? What are your perceptions of why this worker failed to return to work? What could have been done to facilitate this worker’s return to work?”). Some of the questions were common with the injured workers’ questions (e.g., “What do you think are the main barriers to the successful return to work of injured workers in your workplace?”). Participants Participants in the study were 49 workers with injuries and 23 employers from the NewcastleHunter region in the state of New South Wales, Australia. Because of the labor-intensive and therefore costly methodology of in- depth interviewing, a stratified purposeful sampling technique was used in sample selection. Participants were not selected to meet the criteria of representative sampling. Experiences of occupational rehabilitation 4

Cases were selected from those workers who were successful and unsuccessful in returning to work after their injuries or illnesses ensuring that each of the dimensions of sex, industry, injury type, amount of time lost, and employer size were represented in the selection procedures. The sample size was sufficient to ensure that the variations that existed in the experiences of workers belonging to the different dimensions were adequately covered. Participants were drawn from a study population provided by the Work- Cover Authority of New South Wales. This group of 3,041 workers had all made claims for workers compensation between July 1, 1991 and December 31,1992, had more than 1 week time lost from work, and had worked in the manufacturing, retail, or health industries operating in the Newcastle- Hunter regions of New South Wales (defined by postcode). Workers were grouped according to the specified dimensions and then divided into a primary list of 50 workers and secondary and tertiary lists of 50 workers each. An attempt was made to contact each worker on the primary list. If the worker was not able to be contacted (e.g., had relocated with no current address) or refused to be interviewed, the equivalent worker on the secondary or tertiary list was contacted until the sampling frame was completed. A total of 49 workers were interviewed. Table 1 summarizes the outcome of all worker contacts. There were 27 men and 22 women, of whom 82% were between the ages of 25 and 54, 90% spoke English as their first language, and 47% had not completed high school. Of those interviewed, 67.5% were working at the time of interview (16.5% were part-time). The remainder were receiving workers’ compensation (16.5%), or some other benefit (16%). Workers with back injuries (34%) constituted the largest group, followed by sprain and strain injuries (21%); occupational overuse (17%); fractures (7%); dislocations, not including back (7%); cuts (7%); and hernias (7%). In comparison with the WorkCover Authority’s statistics (1992), the final sample of workers represented the range of major demographic and injury characteristics of the population of workers with injuries who had made claims for workers’ compensation during the study period. Consistent with the aims of the study, however, time lost due to injury and return to work status were weighted toward longer time lost and inability to return to work. Table 2 summarizes the sampling frame. Employers were selected from the final sample of 49 workers with injuries, so that both perspectives Kenny D. T., 1995

of the workplace, that of the worker and that of the employer, could be obtained and compared. Procedure Workers with injuries were interviewed in their homes and employers were interviewed in the workplace by the chief investigator and two trained research assistants experienced in the conduct of in-depth interviews. Informed consent and permission to tape-record the interview was sought and obtained before the interview. Each interview took between 1.5 and 2.5 hours. The interview tapes were transcribed verbatim and these transcriptions, and subsequent coding of the transcriptions, formed the basis for a discussion of the findings presented as follows. Analysis The initial stage of coding involved a content analysis of individual transcripts. Key words and ideas were identified and a data index was constructed that permitted the grouping together of answers from different people to common questions. The unit of analysis was the theme, as it emerged in single words, phrases, sentences, paragraphs and within the transcript as a whole (Minichiello, Aroni, Timewell, & Alexander, 1992). These units were analyzed in terms, of the semantics indicated in the informants’ usage of them. The focus in explicating themes was on the latent content of the material (Berg, 1989). This method of analysis was selected because there were significant differences in the informants’ capacities to articulate their ideas and perceptions. This included the degree of elaboration of an idea, the grammatical complexity of verbal expression, and the richness of associations to emerging ideas. If the theme of nonelabora ted material was not clearly apparent, the interviewer asked the informant for clarification in the form of questions such as, “Can you tell me a little more

about. . .?“ If the informant was unable to clarify his or her intent, the interviewer would rephrase the idea and ask the informant whether that was a correct interpretation of his or her meaning. This process illuminated key issues for both workers and employers, and permitted the differing perspectives of each group on each central issue to be elucidated. The next stage of coding involved each question from the interview being coded dyadically (i.e., what each stakeholder said about every other stakeholder regarding the specific question). When every attribution about each stakeholder was indexed, a series of themes and subthemes were derived. Interrater reliability among the author (myself) and three research assistants on assignment of statements to thematic categories was assessed on five samples of transcript and ranged from .81 to .94. Any differences in assignment to thematic categories were resolved by consensus. On two occasions workers were recontacted to clarify meaning. Although a range of sensitizing concepts (e.g., such as communication pathways, information dissemination, competence, genuineness of injury, respect) were used in the construction of the questionnaire and in the coding process, indigenous concepts emerged during coding through attention to the presence of key phrases or terms or workers’ accounts of their experiences. The major indigenous theme to emerge was the formation of alliances and shifting coalitions among various stakeholders in response to dissatisfaction and power struggles among stakeholders at various stages of the process of occupational rehabilitation. This process, labeled triangulation (Bowen, 1966, 1978), became the pivotal concept around which relationships in the postinjury period were understood.

TABLE 1 Outcome of All Attempts to Contact Workers With Injuries Outcome of Contact Attempt Interviewed Contacted, but failed to attend interview Unable to locate contact number Unlisted number No reply Refused interview Insufficient English competency Total Rehabilitation Counseling Bulletin

N

%

49 16 48 6 15 11 2 147

33.3 10.9 32.7 4.0 10.2 7.5 1.4 100.0

5 Experiences of occupational rehabilitation

TABLE 2 Numbers and Proportions of Sample Classified by Time Lost and Return-toWork Outcome < 8 Weeks Time Lost N %

Item Return to work No return to work

20 3

40.8 6.2

RESULTS Common Themes Four common themes emerged in the accounts of workers who had been injured and their employers. These were (a) a generally insufficient knowledge of the legislated requirements and procedures among key stakeholders regarding occupational rehabilitation, (b) a breakdown in the communication and information pathways among key stakeholders in the occupational rehabilitation process, (c) a generally negative perception by the employers of the worker who is injured, and (d) structural and organizational difficulties in the implementation of the section of the Act that requires that all workers with injuries receive occupational rehabilitation. The main difficulty in this area was related to the provision of suitable duties. Each of these themes will be briefly elaborated on in the following sections from the perspectives of both the workers who are injured and their employers. Insufficient knowledge Compensation system.

of

the

Workers’

Both workers who are injured and employers perceived that they did not have sufficient knowledge to negotiate their way through the complexities of the workers’ compensation maze. One worker stated the following: The problem is, you may be given a book to read but when you’re injured and stressed out, you don’t really take it all in. You need someone to sit down with you and to go through it all and explain it. It’s just so complicated.

It would be tempting to attribute this difficulty in digesting information to the low educational or literacy levels of some employees. The problem seems to extend across all occupational groups, however. For example, a 26-year-old doctor also had difficulty acquiring the necessary information. I rang WorkCover to gain information and they did send me a package with some information in it. But I found some of it very confusing as to what the insurer was obliged to cover and what I could claim and how much. . .my rate of pay was the other Experiences of occupational rehabilitation 6

> 8 Weeks Time Lost N % 13 13

26.5 26.5

issue which was difficult to work out. They matched the flat rate but I had worked overtime every week for the past 18 months so all my projections and expenses were based on my overtime wage not a base wage.. .what would have been useful would have been someone to sit down and go through these things with me but I wasn’t able [to] find anyone. . .there was a coordinator but he wasn’t aware of a lot of information.

Employers expressed similar frustration in understanding the intricacies of the system. One employer commented as follows: [on the volume of] information they [WorkCover] throw at us, but it’s like fighting your way through a paper war. I just throw up my hands and say, “I give up.” There are so many rules and variations and exceptions. You don’t know what you are supposed to do half the time.

Another employer put it this way, “Everything is written for b----- academics. The language is not written in a style that can be absorbed or understood.” Additionally, workers who are injured and employers both reported that key personnel either did not have sufficient knowledge or did not pass it on to them. Nevertheless, workers with injuries designated the rehabilitation coordinator, and employers designated injured workers themselves and treating doctors as the most troublesome. The rehabilitation coordinator, who is employed on site at workplaces to case manage workers with injuries, was perceived by half of those interviewed to be inadequate to the task. The main criticisms related to workers’ perceptions that the rehabilitation coordinator did not understand his or her role or function, did not know how to deal with workers who are injured and their concerns, and did not have sufficient knowledge to inform these workers about necessary procedures related to their claim. In the absence of a strong case manager or advocate for the worker who is injured in the workplace, these workers found it difficult to access sufficient information to assist themselves with their workers’ compensation claim and with their occupational rehabilitation. Fifteen of the 23 employers opined that one Kenny D. T., 1995

of the main barriers to successful occupational rehabilitation was the misperception by workers who are injured that they would receive a large lump sum payment as a result of their injuries and that the amount would increase commensurate with the amount of time that they were away from work. According to employers, this belief made some workers with injuries reluctant to return to work or to accept suitable duties. They felt that this misperception was reinforced by some treating doctors, many of whom had inadequate knowledge about the principles of occupational rehabilitation, particularly the concept of early return to work, using suitable duties as a transition to normal duties. Employers felt that “doctors put people off on compensation and say it is work-related far too easily,” or assert “that the person is unfit for work too readily,” that doctors do not “positively reinforce to the worker that he needs to return to work as soon as possible in whatever capacity he can manage,” and that “doctors like to play it safe. They are frightened of sending someone back to work early especially if it is to their normal duties. They worry about their liability if they get re-injured.” Employers thought that doctors were largely unaware of what suitable duties were available and that “doctors are a hindrance to the whole process because they will often opt for time off work.” This lack of awareness was attributed to their general ignorance of the nature of the various workplaces and their tendency to take at face value what the worker who is injured says. One employer gave the following account, “This bloke turns up with a certificate for 4 weeks off work. So I ring the GP (doctor) and say how about suitable duties and the GP said that F.M. (injured worker) told him there were no suitable duties available.” Employers implied that treating doctors were often aligned with the worker against them and, when this situation arose, would contact their insurers to seek alternative medical advice about the workers’ capacities to return to work or to perform suitable duties until fit to resume normal duties. Inadequate communication pathways. Because the workers’ compensation system is so complicated and because it involves so many stakeholders, efficient channels of information dissemination are essential for the system to function. Workers with injuries were asked how they had found out about workers’ compensation. There was no systematic avenue of information provision. Only 10% of workers had been fully informed by their employers. A variety of other Rehabilitation Counseling Bulletin

methods of information gathering were cited. Some of these included union representatives (16.5%), coworkers and relatives (10%), rehabilitation coordinators (8%), occupational health nurses (6%), solicitors (i.e., lawyers) (6%), the Hunter Action Group (4%), general medical practitioners (4%), and rehabilitation providers (4%). Of the workers interviewed, 85.5% reported some difficulties in the communication among different stakeholders, occasionally with serious consequences. The following experiences were reported by workers who were injured that highlight the difficulties arising from, and the consequences of, the failure of information dissemination. The three examples provided indicate breakdowns in communication between the worker who is injured and his employer, between the worker and health professionals, and between the worker and the legal profession. Greg was a motor mechanic who suffered a serious soft tissue injury to his right ankle. After 3 weeks off work and following intensive physiotherapy, Greg returned to work. He said that his coworkers reported rumors that he was going to be dismissed. Two weeks after his return to work, he was dismissed. The boss did it all behind my back. He told everybody but me until the last moment. After I was injured, he just wrote me off and didn’t want to know me. We were only a small company. Profits were small. The boss had to cut corners to stay afloat. I was a corner.

Jill was a 26-year-old doctor who had suffered a disc herniation. After having seen a number of health professionals, she was referred to a rehabilitation physician 6 weeks postinjury. She described her experience as follows: [The rehabilitation physician] was the only person to tell me the natural history of what I had done. I had a very big problem dealing with the fact that after 6 weeks I wasn’t better. I didn’t realize it

would take 6 to 12 months for a disc herniation to resolve. This wasn’t his main function but it was his main impression on me. That was very important to me because had he not told me that I don’t know what I would have done. I’m not sure whether I would have done the rehabilitation or gone and jumped off a cliff. Allen was a boiler maker who also suffered a disc herniation. After 6 months out of work, his worker’s compensation payments were terminated and he was advised to consult a solicitor. He said that he had received no information from either the insurer or the solicitor about why his claim was in dispute, and was simply advised of the date for his court 7 Experiences of occupational rehabilitation

appearance. Allen said: I was angry with the way it happened in court. I went there with the idea that I was going to fight to get my compensation back and I had 2 minutes to decide whether I wanted to settle for a lump sum or to go back on regular compensation payments. No one told me that this would be the choice. I had 2 minutes to think about the rest of my life.

Employers once again designated doctors as the stakeholders with whom they had the most difficulty communicating, particularly about when and under what circumstances workers with injuries could return to work. Eight employers cited doctors’ failure to communicate with the workplace about the availability of suitable duties as a major cause of unnecessary time lost among workers who had been injured. Seven of these employers had invited doctors to visit the work site so that they would better understand the nature of the work, but no doctor had visited. Another frequent complaint among employers was that doctors often failed to specify the nature of the work restrictions, providing only “vague medical certificates that were no use to anyone.” The issue of maintaining adequate communication was clearly a more significant issue for workers with injuries than for employers. Because other stakeholders must have the permission of employers to act or to incur costs associated with rehabilitation, it is the responsibility of stakeholders to keep the employer informed. Workers were more vulnerable in this regard and often felt that they were “the last to know what is happening.” Negative attitude toward workers with injuries. Thirty of the 49 workers reported that they had experienced some degree of discrimination from one or more stakeholders. This took a number of forms, including being treated with disrespect, being told that their injuries “were all in their heads,” being threatened directly or indirectly with loss of their jobs if they did not return to their full duties, being shunned by coworkers, being required to consult multiple insurance doctors, and being placed under insurance surveillance. Workers who had been injured felt very strongly about the perceived attitudes of their employers toward them as reflected in the language used to describe how they were treated. The comments from these eight workers reflect the main themes. He (employer) treated me like I had the plague. My boss treated me like a leper. I was just a nuisance to them, they didn’t want to know me. Experiences of occupational rehabilitation 8

They virtually ignored me since it happened. You are just a second rate nurse then. After I got hurt, they didn’t want to know me. I was just rubbish to them. They just dropped me from then on. It was like I didn’t exist any more. As soon as I was injured, they wanted to get rid of me straight away. They just wrote me off. End of story.

Although 81% of workers reported that their employers supported their claim for workers’ compensation in that they did not actively challenge it, most (85.5%) had not been directly contacted by their employers, were not offered acceptable suitable duties if needed (50%), were told directly or indirectly that their employment would be terminated if they did not return to full duties (25%), and that their injury either was not genuine (26.5%) or that they were exaggerating the extent of the injury (12%). One worker who had been injured summed up for the others. I have worked hard and long all my life, supported my family, paid my way, owing nobody. I am an honest, hard worker and it sickens me to be interviewed by doctors for 10 minutes at $250, literally called a “bludger” [i.e., a malingerer] and thrown onto the federal scrap heap. These doctors turn your employers against you, people you have given your all to for 30 years. They believe those nohoper insurance doctors and then they can’t get rid of you fast enough.

Of the 16 workers who made positive statements about their employers, half were positive in the negative. That is, they made statements that the employer did “not hassle me,” “they left me alone,” “no real problems, the same as usual.” Six experienced genuine concern from their employers. “They were good, they showed concern for me. They tried to make it easy for me.” Coworkers’ attitudes were perceived to be positive and supportive for 56% of workers interviewed; 30% were neutral and 15% were negative. The main thrust of the negative attitudes related to coworkers’ resentment of the worker with an injury being on suitable duties or shortened working hours, because they perceived these to be “special privileges,” (“There is a lot of resentment toward compo cases. It is very isolating.”); and disbelief about the injury (e.g., “Some of my workmates [coworkersi disbelieved me. They said she can do her housework and drive a car, why can’t she work?”). Twenty-five of the 49 workers (51%) expressed strong or very strong dissatisfaction with the insurance doctors they were required to consult Kenny D. T., 1995

by the insurance company. The main source of dissatisfaction identified was the attitude of the doctor toward the worker with an injury. Workers reported that insurance doctors were often rude, arrogant and sarcastic, openly disbelieved that the worker’s injury was genuine and were rough in their handling to the point of causing physical pain to the worker during examination. One worker’s account represents the view of most of the dissatisfied workers interviewed. I was sent to orthopaedic spedalists 15 times by the insurance company, and to this day, even having been to court, do not know the details of any report. I suspect they become insurance doctors because of their arrogant and demeaning manner, not being able to survive in private practice. I, like others I speak to, come away from their examinations feeling sore, humiliated and inferior. They read the words, bad back, and you are a “shonk” [i.e., a fraud] and that is the way you are treated.

The accuracy of the perceptions of workers with injuries, that employers tended to view them negatively, was confirmed in the interviews with their employers. Eighteen of the employers interviewed expressed frankly negative perceptions of workers who had been injured. Employers felt that the Workers’ Compensation system was open to abuse by workers, that some workers “get their lump sum payment and the next thing you know they are out playing golf. No problems at all as far as disability. And you’ve got no redress.” Employers were concerned that some workers see compensation as a “paid holiday,” or “a game in which every player wins a prize”; that some workers used their injuries to manipulate their employers, “so that they can get put where they want, or get out of a roster that they didn’t want to be in,” and that workers with injuries were often not prepared to take responsibility for their recovery. One employer complained that “you get those who are quite content to sit at home doing nothing and they won’t cooperate with us,” and that others “don’t want to get off suitable duties because they get paid normal wages • . .they think why should I bother getting back to normal work when I am sitting in a cushy position getting the same money?”

Six of the employers recognized that workers often struggled on in the face of difficulties caused by their injuries, that “a surprising number of people don’t want to let the side down [i.e., want to share the work load equitably] and will aggravate an injury further by carrying on working,” or “come back to work too early and hurt themselves again.” Rehabilitation Counseling Bulletin

Three employers commented on the hostility of other employees toward injured workers on suitable duties. One employer epitomized the sentiment. “It is not always said but you can tell they are thinking, ‘Here I am busting a gut and they are wandering around with a piece of paper’.” Structural and organizational difficulties. The WorkCover Authority specifies a series of steps that must be adhered to when a worker is injured. These include registering the injury in the Register of In juries book (54%), notifying the worker who is injured in writing about his or her rights and responsibilities (14.5%), assisting the worker in making a claim for workers’ compensation (81%), providing appropriate information (35.5%), and providing suitable duties if required (46%). The numbers in parentheses indicate the percentages of workers for whom these procedures were correctly applied. The attitude of the various stakeholders to the provision of suitable duties was pivotal to the return to work outcome for many of the workers interviewed. Half of the workers interviewed reported difficulties with the provision, the nature, and the support and supervision of their suitable duties. The difficulties are highlighted in the verbatim comments that follow. For example, one worker in a chemical plant reported his experience with suitable duties as follows: I had to fight to be offered alternative duties [i.e., suitable duties]. When they finally agreed, they gave me demeaning jobs. They use alternative duties to get rid of you. They give you nothing to do, they force you out.

Another worker in the timber industry commented thus: I worked for 38 long years timber cutting, and when my back finally gave out on me, the insurer said that any type of rehab or retraining was beyond me. My boss did his best in a cutthroat situation but in the end he said to me, “You can either do it or you can’t.”

A related key issue in the provision of suitable duties is the apparent inflexibility of some employers in accommodating the worker with an injury. For example, one worker who had suffered a serious knee injury (involving a patellectomy) felt that she could have returned to her preinjury position had she been permitted to rest her knee by sitting on a stool for regular, but brief intervals, throughout her shift. Because she was in a supervisory role in a large retail store, her employer informed her that it would be a bad example to other workers to see her sitting while on duty and did not allow her to do 9 Experiences of occupational rehabilitation

so, even though they had all been present at the time of her accident and were aware of the seriousness of her injury. Another worker with a back injury requested permission to drive his car closer to the work site (where there was parking for senior personnel) to avoid the 20-minute walk to the work site. Permission was refused. Consequently, the worker was in so much pain from the walk that he was not able to perform his duties, which he felt otherwise capable of performing, and his position was terminated because no alternative suitable duties could be found. A third worker, together with her rehabilitation provider, had worked out a return-towork plan that was rejected by the employer and the insurer. She reported that no adequate explanation for the rejection was given and no other suitable alternative was presented in its place. The role of the rehabilitation coordinator extends beyond simply providing information to workers who have been injured. Ideally, the rehabilitation coordinator liaises with employers, treating doctors, and rehabilitation providers to find appropriate suitable duties for these workers and negotiates with management to avoid the difficulties described by these workers. The apparent failure of rehabilitation coordinators to assume a strong case management role left some workers with injuries stranded in a complex system and in a vulnerable position with no advocate. This problem was exacerbated by the perceived conflict of interest inherent in the role of the rehabilitation coordinator, who is simultaneously an employee of the company and an advocate of the workers who have been injured within the company, whose “best interests” may conflict with those of the company. Workers who were injured commented frequently on this. They spoke with anger and bitterness about the way that they were treated by their rehabilitation coordinators. The following three workers describe the rehabilitation coordinators in their organizations, which highlight the major issues: The rehabilitation coordinator is not effective at all. He just waves a big stick at the staff. He threatens the staff, makes them feel very insecure and that they have to come back to work, regardless of how debilitated they are. Quite a few people have gone back because of his intimidation, and aggravated injuries to tbe point whei they have been asked to leave. The rehabilitation coordinator is anything but helpful. He became very company-minded overnight. . .he wasn’t going to give any help or guidance. . .he was all out to save the rehabilitation dollar. Speaking to her [the rehabilitation coordinator], Experiences of occupational rehabilitation 10

you always felt you were answering to the big boss all the time. With her, it was a real “us and them thing.” She was working for the company. She was only interested in getting me to return to work. She was not concerned about my injury or anything else.

Each of these workers’ claims resulted in failures to return to work and to protracted court proceedings. Once the workplace relationships became adversarial, the “fight” for “justice” was formalized in the court and direct contact between the parties who could have resolved the problems ceased. Nine of the workers with injuries commented spontaneously on the structural limitations of the current system of occupational rehabilitation. They recognized how difficult it was for some employers, particularly in heavy industry, to provide suitable duties for workers with limited transferable skills. One worker put it this way. Rehabilitation is not a word that I can connect to. I have always lived in a physical world of strength. Other workers younger and better educated than me might be able to go through some form of retraining, but the bottom line is, they still carry an injury. From my observations, very few employers are willing to take on such people when there are more than 3 million unemployed ‘fit’ people to pick from. (Reader’s note. The preceding is a verbatim comment from the worker who was injured. The current unemployment rate in Australia is 9.5% of the workforce, which represents approximately 950,000 workers.)

The main thrust of the structural and organizational problems for employers also centered around the difficulties in the provision of suitable duties. Of the 23 employers interviewed, 15 reported that it was possible but very difficult to provide suitable duties to the majority of their workers with injuries, 6 reported it to be possible without too much difficulty, and 2 reported that it “was virtually impossible.” Those employers who found it possible to offer suitable duties identified the large size of the organization and the varied work duties available as enabling factors. Those employers who found it possible but very difficult identified the nature of the work in their organizations as the principal inhibiting factor. Employers from heavy manufacturing industries and hospitals found the task of providing suitable duties particularly onerous. Of the employers, 8 said that most of the suitable duties available were not “productive work” and that it cost the company money to have a worker performing suitable duties. Restricted finances were cited as a barrier to the provision of suitable duties of the “nonproductive” type. Four employers were of the opinion that some Kenny D. T., 1995

workers with injuries preferred to have time off than to return to work on suitable duties and that workers’ negative attitudes to suitable duties were also a barrier to their successful provision. Two employers pointed out that sometimes the nature of the injury is so severe that provision of any duties at all was not feasible. Two of the employers clearly stated that their organizations did not want workers with injuries on staff because there were no suitable duties available or because the suitable duties were “neither meaningful nor productive.” There was a prevailing lack of incentive among II of the employers to “go beyond the letter of the law” in the provision of occupational health and safety and occupational rehabilitation programs in the workplace because they perceived these legislative requirements as “just another cost” of running their businesses. One employer expressed the concerns of the majority in the following way: The legislation puts a lot of onus on businesses and they probably don’t realize the extent of the burden. It costs to have workers on suitable duties, it costs to retrain them for those suitable duties or for other positions in the organization, it costs to replace the worker while he is off injured, it costs to pay the worker for producing nothing, it puts a lot of pressure on supervisors and employers who have to take care of the worker and find suitable duties and on top of that we have got no redress against large pay outs awarded by the courts.

Other employers commented on the anomalies in the system of payments in workers’ compensation, for example, “people can get make-up pay while they are on rehab. They can get money above normal wages such as averaged overtime, so they get money without having to work for it.” A number of employers perceived the system to be excellent conceptually, in that “it is part of the welfare net where workers are protected and not put on the scrap heap.” Furthermore, the system provides “an incentive in the form of claims experience to improve our performance and if we don’t manage our claims properly, there is a penalty for us.” These same employees, however, perceived that the costs of workers’ compensation were gradually rising and that these increased costs were attributed to: the influence of the legal profession and legal costs. It makes problems where legal claims are made. More and more people are making claims and it’s costing. For example, we’ve examined the costs. Using investigators cost our insurer $35,000 last year, use of specialists at $175 a visit. . .but once they get into court, those specialist reports are not worth a crumpet. They are thrown in the bin because they are not the treating medical officer. You can have Rehabilitation Counseling Bulletin

one GP lined up against five super specialists who disagree on his view but the court takes no notice. That’s wrong and that costs everyone.

Regarding “stringent Occupational Health and Safety regulations,” a number of employers responded: There are probably very few hospitals in this state who would comply with the fire regulations laid down. We could bring our institutions up to standard but the government would be bankrupt. This is the dilemma you are faced with. You have to keep it in perspective.

An additional structural problem raised by 12 of the employers interviewed related to what they perceived to be the unrealistic demands or goals of some rehabilitation programs and the burden of extra costs associated with them. Employers described a number of situations in which burdensome economic disadvantage resulted from the implementation of rehabilitation procedures. These included meeting the cost of supernumeraries who cover workers with injuries on suitable duties (“Suddenly we are faced with two salaries when we have only got a budget for one”); the cost of retraining employees who are injured for other positions in the organization; and the cost to the worker, to the employer, and to the taxpayer of retraining workers for jobs that do not exist (“A lot of workers who retrain just end up on unemployment. And they have missed out both ways. No job and no lump sum payment.”). DISCUSSION The major focus of the study was the central role hypothesized for the employer-injured worker relationship in influencing the outcome of injury. The perspectives of both workers with injuries and employers on injury management and the role and functions of key stakeholders in the postinjury period were canvassed to identify barriers to the successful return to work of workers who have been injured. In examining the different perspectives of workers and employers interviewed on the common themes that emerged, two major thematic divergences were apparent. First, it is clear that the employees’ perspective of the difficulties faced by workers with injuries is primarily a “system blaming” perspective and that the employers’ perspective is primarily “victim blaming,” although some employees and employers were able to take multiple perspectives on some of the issues. The other major difference in perspective was that employees were largely focused on issues related to care, concern, respect, and 11 Experiences of occupational rehabilitation

justice for workers with injuries, or the lack of it, as demonstrated by employers, whereas the employers were primarily focused on cost containment and productivity. These thematic divergences, which, in practice, represent differing agendas, are stress producing for the employer-worker dyad and result in both parties’ seeking out “allies” in the form of other stakeholders, to restore the shifting balance of power that occurs in the dyadic relationship at different stages of the postinjury period. As a result of the observation of these communication patterns, which involved shifting dyadic and triadic coalitions among the various stakeholders, it is proposed that the functioning of the occupational rehabilitation process can be conceptualized in similar terms to those of systemic family therapy. Bowen (1966, 1978) was a systemic family therapist who postulated the importance of the role played by triangles in family interaction. This process, termed triangulation, occurs in all social groups, as twosomes form to the exclusion of, or against, a third party. Bowen proposed that a twoperson system will form a three-person system under stress. For instance, tension might arise between the two, and the one who feels most uncomfortable or vulnerable may “triangle in” a third party, to relieve tension and to restore the power balance. The third party, once drawn in, may form his or her own set of alliances, thus creating shifting power balances. The action may not remain localized within the original triangle, as more and more stakeholders become involved in the ongoing struggle. Bowen associated pathology with rigidity and suggested that, although all systems create triadic patterns, these patterns will become more rigid during periods of crisis or stress. The rigidity of the response patterns set up by the injury and the central players’ initial response to the injury follow a limited and predictable path and set up a highly restricted set of choices for the stakeholders involved. In the following discussion, Bowen’s systemic model will be applied to the results obtained and where possible, interventions suggested by the model will be proposed. When a worker is injured, the matter is initially dealt within the injured worker-employer dyad. If the worker and employer deal with the matter to their mutual satisfaction, no other parties need become involved, other than in a service provision capacity. That is, the employer will notify the insurer, who will organize payment, and the worker who is injured may contact his or her doctor for medical treatment. If the employer is dissatisfied with the injured worker’s response to his or her injury, however (e.g., by taking too much time off work, Experiences of occupational rehabilitation 12

or by remaining on shortened hours of work), he or she may call in the insurer, not as a service provider, but as an ally against the worker with the injury. The insurer will respond by ordering expert medical opinion and instruct the worker to consult a doctor who is appointed by the insurance company. The worker with an injury may respond by consulting his or her own doctor, no longer only as a service provider, but also as an ally who will assist the worker to restore the power balance by organizing medical specialist opinion that is frequently contrary to the insurance doctor’s opinion. The parties may then become polarized in an apparently unresolvable dilemma. One of the reasons for this is that the issue of how best to manage the injury is replaced with the issue of stakeholder integrity, particularly that of the worker who is injured. The genuineness of the injury becomes the focus of stakeholder involvement, rather than searching for the best “social fit” for the worker and his or her employer. The more parties who become involved, the poorer the communication among them and the greater the suspicion. Recourse to the legal profession with protracted legal proceedings is often the next step in this process of triangulation. The role of the rehabilitation coordinator is of central importance in the successful management of the postinjury period, and the most frequently cited source of perceived inadequacy by workers with injuries. In addition, the structural problem of the role conflict that arises when a paid employee functions in this role needs to be addressed at the policy level. The workers with injuries in this sample perceived the rehabilitation coordinator to be triangulated with the employer against them. This had the dual effect of leaving them without support or an advocate in the workplace and of isolating and disempowering them in their dealings with their employers. The stress arising from feeling vulnerable and unsupported will often result in the process of triangulating other stakeholders, such as doctors and solicitors, whose vested interests of making money and keeping the client happy result in partisan advice that contributes further to the erosion of employer- employee relationships. This deteriorating situation is further exacerbated by the perceptions of doctors by employers that imply the triangulation of the doctor in the injured workeremployer dyad on the side of the worker. This dynamic was understood if not directly articulated by employers and had the result of polarizing doctors and workers against employers. When workers with injuries felt reempowered by their treating doctors’ allegiance to them, employers sought to redress the Kenny D. T., 1995

perceived imbalance by calling on the services of insurance doctors, through the insurer. A number of changes to the current system would alleviate some of these difficulties. For example, under the current system, rehabilitation coordinators can be selected from existing staff and are not required to have any basic knowledge or skills relevant to the position. It is recommended that the WorkCover Authority develop an approved training course for rehabilitation coordinators based on minimum competencies prescribed by WorkCover. Attainment of these minimum standards would be a prerequisite to appointment. The Authority could also accredit rehabilitation coordinator practice to ensure an appropriate standard of service, in the same manner that rehabilitation providers and insurers are accredited. Once accomplished, the rehabilitation coordinator could then perform a case-management and advocacy function for the worker with an injury, provided that the conflict of interest issue is resolved. One way this could be achieved is through the appointment of independent rehabilitation coordinators using the employers’ levy to fund these positions within workplaces. Appointment would be fractional based on the number of employees. It is conceivable that rehabilitation coordinators would service one or more employers within defined geographical regions. This scheme would provide services to small employers (i.e., workplaces with fewer than 20 employees) who currently are not required to provide the services of a rehabilitation coordinator. Internalized organizational and personal values of the workplace are embodied in its response to the worker who is injured. A significant number of workers studied reported feelings of distress at the poor relationship they had with several of the stakeholders, but particularly with their employers. The language used by workers with injuries to express their feelings about their employers’ attitude toward them is worthy of further attention. Many of the workers used descriptors (“nuisance,” “leper,” “second rate,” “plague-stricken”) that implied that they had assumed a deviant role for their employers. One view of the meaning of deviance is that it promotes cohesion, that is, the deviant’s main function for the group is to enhance solidarity and to highlight rules and norms (Durkheim, 1964). The rules and norms important in workplaces are productivity and cost containment, rules that are clearly violated by workers with injuries, who represent a visible drain on both productivity and cost containment. Systems can tolerate threats to their goals in the short term, but beyond a certain Rehabilitation Counseling Bulletin

point, employer and worker become polarized in the pursuit of conflicting goals. For the worker, the goal is to be treated with care, concern, and respect, and to receive what she or he perceives to be just entitlement, whereas for the employer, the goal is to restore the workplace to its former level of productivity and profit, a goal that is hindered by the continuing presence of the worker who has an injury. Bales (1969) described this process as it occurs in groups when the rate of disagreement reaches a threshold: “Apparently, when ill-feeling rises above some critical point, a ‘chain reaction’ or ‘vicious cycle’ tends to set in. Logic and practical demands of the task cease to be governing factors” (p. 150). This process may explain the apparently inexplicable inflexibility demonstrated by some employers to accommodate their workers with injuries, particularly with respect to the provision of suitable duties. In the examples cited, each of these workers was eventually terminated from his or her position, although each stated that he or she would have been able to return to work with the modifications requested. Nevertheless, all of these workers had been seriously injured and had cost their companies large sums in workers’ compensation. Their demands for additional support in the form of suitable duties or other job changes pushed their employers beyond the “critical point” where mutual cooperation and shared agendas break down. The issue often becomes transformed at this point to a question concerning the genuineness of the injury. When this point is reached, triangulation of other stakeholders occurs as the battle rages to determine who is “right.” The practical demands of the task, that is, to restore the worker with an injury to his or her optimal level of functioning, thereby reducing the cost of the injury to the employer, ceases to be the agenda for either the worker or the employer. Recent studies suggest that the employeeemployer relationship is more important than the medical care and rehabilitation services received by workers with injuries when returning to work (Johnson & Baldwin, 1993), notably the willingness of employers to assist with modifications to the workers’ jobs or conditions or hours of work. This implies that careful consideration be given to the “fit” between the worker’s limitations as a result of his or her injury and subsequent job requirements. Employers need to be educated about the mutual benefits to both employer and employee of occupational rehabilitation, particularly the provision of suitable duties, around which many of the battles in postinjury management are currently 13 Experiences of occupational rehabilitation

fought. These educational efforts would need to focus on the economic benefits to employers of the timely return of employees to work and the key role that suitable duties would play in the return-to-work process. The rehabilitation coordinator, correctly trained in conflict resolution, could provide a valuable resource in the workplace to prevent the polarization of workers with injuries and their employers. Furthermore, if the model of district rehabilitation coordinator were implemented, it would be possible for employers, through the rehabilitation coordinator, to network and assist each other with providing suitable duties. For a significant minority of workers and their employers, the process of occupational rehabilitation is fraught with emotional tension and unsatisfactory outcomes. A model, based on the principles of systemic theory, has been proposed to explain how these difficulties arise. Some solutions have been suggested as possible means of alleviating the stress caused to both employees and employers by occupational injury and of reducing the triangulation of stakeholders that creates insoluble symmetrical struggles for which the only recourse is in the courts. Detailed case study analysis would be the next step in further explicating this process. REFERENCES Bales, R. (1969). In Conference. In A. Etzioni (Ed.), Readings on modern organizations (pp. 145–154). Engeiwood Cliffs, NJ: Prentice-Hall. Berg, B. (1989). Qualitative research methods for the social sciences. Boston, MA: AlIyn & Bacon. l3owen, M. (1966). The use of family theory in clinical practice. Clinical Psychiatry, 7, 345–374. Bowen, M. (1978). Family therapy in clinical practice. New York: Aronson. Bruyere, S., & Shrey, D. (1991). Disability management in industry: A joint labor-management process. Rehabilitation Counseling Bulletin, 34, 227–242. Cottone, R. R., & Emener, W. G. (1990). The psychomedical paradigm of vocational rehabilitation and its alternatives. Rehabilitation Counseling Bulletin 34, 91–102. Davis, A., & George, J. (1988). States of health: Health and illness in Australia. Sydney, Australia: Harper & Row. Durkheim, E. (1964) The division of labour in society. London, England: Collier-Macmillan. Ferguson. S., & Talbot, K. (1992). Employee occupational rehabilitation programs: They work! Proceedings of the First National Australian Society of Rehabilitation Counsellors Conference (pp. 33–37). Sydney, Australia: Experiences of occupational rehabilitation 14

Australian Society of Rehabilitation Counsellors. Gardner, J. (1987). Vocational rehabilitation: Lessons for employers. Business and Health, 5(20), 20–24. Hopkins, A. (1994). The impact of workers’ compensation premium incentives on health and safety. The Journal of Occupational Health and Safety-Australia and New Zealand, 10, 129–136. Zealand Industrial Relations Act. (1992). New South Wales, Australia: Government Information Service. Industry Commission. (1994). Workers’ compensation in Australia (Rep. No. 36). Canberra, Australia: Australian Government Publishing Service. James, C. R. (1989). Social sequelae of occupational injury and illness. Unpublished doctoral dissertation, Griffith University, Queensland, Australia. Johnson, W. C., & Baldwin, M. (1993). Returns to work by Ontario workers with permanent partial disabilities. Ontario, Canada: Research and Evaluation Branch, Strategic Policy and Analysis Division, Ontario Workers’ Compensation Board. Kenny, D. T. (1994a). The relationship between workers’ compensation and occupational rehabilitation: An historical perspective. The Journal of Occupational Health and Safety-Australia and New Zealand Zealand, 10, 157–164. Kenny, D. T. (1994b). Determinants of time lost from workplace injury: The impact of the injury, the injured, the industry, the intervention and the insurer. International Journal of Rehabilitation Research, 17, 333–342. Kenny, D. T. (1995). Barriers to occupational rehabilitation: An exploratory study of long-term injured workers. Journal of Occupational Health and Safety-Australia and New Zealand Zealand. Minichiello, V., Aroni, R., Timewell, E. and Alexander, L. (1992). In-depth interviewing. Melbourne, Australia: Longman Chesire. Pati, C. (1985). Economics of rehabilitation in the workplace. Journal of Rehabilitation, 51(4), 22–30. Quinlan, M., & Bohie, P. (1991). Managing occupational health and safety in Australia. South Melbourne, Australia: Macmillan Australia. Remenyi, A. (1992). The workplace as a rehabilitating environment. Proceedings of the First National Australian Society of Rehabilitation Counsellors Conference (pp. 1–7). Sydney, Australia: Australian Society of Rehabilitation Counsellors. Shrey, D. (1993). Workplace-based disability management: challenges and opportunities for joint employer rehabilitation professional initiatives. Proceedings of the Second National Rehabilitation Conference (pp. 27–36). Sydney, Australia: Commonwealth Rehabilitation Service. Strautins, P., & Hall, W. (1989). Does an early referral to an on-site rehabilitation program predict an early return to work? Journal of Occupational Health and Kenny D. T., 1995

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