©2004 Institute for Work & Health
www.iwh.on.ca
©2006 Institute for Work & Health
Ellen MacEachen
Agneiska Kosny, Sue Ferrier, Lori Chambers
Presentation for: RSI Awareness Day, February 29, 2008
Re-thinking “Hurt versus Harm” in Early & Safe Return to Work
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Why focus on “hurt versus harm”?
• It suggests: “It may hurt, but it won’t necessarily harm”
• It is the logic that creates the possibility of Early RTW--it makes Early RTW acceptable and even therapeutic
• It is accepted practice in many countries
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Most often, Early RTW is cast as rehabilitative for workers
Why early and safe return to work?
Returning to daily work and life activities can actually help an injured worker's recoveryand reduce the chance of long- term disability. In fact, worldwide research shows that the longer you are off work due to injury or illness, the less likely it is that you will return to work.
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What is this scientific research?
• What we know about Early RTW:
– Helps more people return to work, and faster
– Costs less
– Does not necessarily make people sicker
• What we don’t know about Early RTW:
– Long-term outcomes and RTW sustainability
– How Early RTW works in different types of work and businesses
– How employers apply Early RTW
– Worker quality of life during Early RTW
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Today I’ll describe:
I. What scientific evidence says about “hurt vsharm” and Early RTW
II. How our research has found that Early RTW can involve harms that do lead to hurts.
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We searched these documents for statements that might explain Early RTW
Ontario Medical Association Position In Support Of
Timely Return To Work Programs And The Role Of The Primary Care
Physician, March 23,1994
Injury/Illness and return to Work/Function: A Practical Guide for Physicians
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I. What science is behind “hurt vs harm” and Early RTW?
1. Back pain literature
2. Psychosocial literature
3. Psychological theories
4. Fiscal arguments
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Back pain literature
• Back pain research: activity helps recovery
• This idea provides Early RTW with a therapeutic logic: “work is an activity and so it is good for you.”
• BUT:
– Are findings about back pain true for all other health problems?
– Researchers don’t advise activity within work as optimal:
– “The scientific evidence leads the Task Force to authorize rather than to recommend return to work…..The significant effect of nonphysical factors such as the nature of insurance regimens, worker’s compensation legislation and labour relations on return to work should not be ignored.”
– Report of the International Paris Task Force on Back Pain (2000)Report of the International Paris Task Force on Back Pain (2000)Report of the International Paris Task Force on Back Pain (2000)Report of the International Paris Task Force on Back Pain (2000)
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Psychosocial literature
• Many studies show that the longer a worker is off work, the less likely he/she will return and the more likely he/she will experience mental health problems.
• This suggests that shorter work absence means fewer social, emotional complications.
• BUT:
– This assumes two-way logic: If a long time away is unhealthy, then a short time away is health promoting?
A B
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Psychological theories
• Donald Shrey, 1995 on “occupational bonding”: Workplace bonds can become ‘unglued’ by work absence.
• BUT:
– Occupational bonding is only theory, is not based on research about early RTW.
– It assumes that workplaces are always pleasant, cohesive
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Psychological theories (2)
• Fear avoidance model of chronic pain:
– exaggerated pain perception leads to unnecessary curtailment of physical activity
• BUT:
– Are all negative beliefs unwarranted? Can’t some be real?
– Fear avoidance appears to be based, again, on back research. And newer research says it’s relatively rare:
– “Evidence is accumulating that pain severity plays a more important role in disability than previously assumed….it is also important to note that the fear-avoidance model only accounts for … problems in a sub-group of chronic low back pain patients.”
– (Swinkels-Meewisse et al. 2003)
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The money argument
Modified work approach can “offset moral hazard problems with back pain cases”
• A study found workers with back pain are less likely to RTW than workers with other accidental injuries
– Johnson et al (1998) suggest that workers’ comp disability payments for back pain have “disincentive effects”
• BUT:
– Again, this ‘moral hazard’ model is based on back pain.
– It is a population theory being applied to individual behaviour. It assumes that individual workers are driven mostly by financial cost-benefit calculations
– It ignores physical, emotional, social hardship, and that
that being on comp is not ‘worth’ it.
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Also, the documents mentioned by WSIB advise RTW only under OPTIMAL workplace conditions:
E.g. Ontario Medical Association Position In Support Of Timely Return To Work Programs And The Role Of The Primary Care Physician (March 23,1994)
• “Proactive use of the workplace to promote employee health and timely return to work requires the availability in the workplace of a level playing field and neutral ground for dialogue between the employer and disabled employee in the context of a healthy employer-employee relationship.”
E.g. Injury/Illness and return to Work/Function Guide: Practical guide for physicians
• Statements are tempered by……good relationships with employers, good workplace support, satisfying job, control over job, family social support, belonging to a union, etc…
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So… we find that scientific support for hurt versus harm & Early RTW is not
strong
• It is based mostly on back pain literature—what makes it relevant for ALL injuries?
• It is based on odd logic (about 2-way effects, about a general problems of workers choosing to be on comp because of $$) and psychology theory (occupational bonding) and research (fear avoidance) that is now getting to be out of date.
• The back pain research advises that recovery at work is ‘authorized’ but not ‘recommended’, and all documents turn to qualifications that Early RTW is advisable only under certain quite ideal conditions
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Our study of injured workers with long-term claims
• Study examines understandings and experience related to why some workers fail to RTW as expected
• In-depth interviews with:
– 48 injured workers
– 21 service providers
– Across Ontario (north, south, urban, industrial)
– Participants recruited from diverse sources; data gathered 2004 & 2006
• The study focused only on workers with long, drawn out claims—the minority of workers.
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We suggest another way to understand “hurts & harms”
• We found many hurts and harms
• Hurts were hidden in problems that may, to a WSIB decision-maker, seem ‘mundane’
• These hurts led to harms that impeded RTW
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Complex hurts and harms
‘MUNDANE’ HARMS
• Pain (severity)
• Waiting for an acceptable
diagnosis
• Waiting for claims processing
• Incomplete communication with compensation decision-makers
• Improper employer action
HURTS
• Injury, addiction
• Illness chronicity
• Mental strain, poverty
• Flawed entitlement decisions
• Delayed or denied claims
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1. The ‘hurt’: Pain
• Pain acknowledged as annoying but generally not abarrier to early RTW.
• There are no objective measures of back pain, so it is difficult to measure the extent of pain.
• The harms: Workers with severe (but unacknowledged) pain:
– attempt compliance with RTW plans
– use excessive pain medication/risk addiction
– become re-injured
[His problem is] low back injury….He has gone back to work, at eight Percocets a day. (Edith, peer helper)
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2. The ‘hurt’: waiting for complex diagnoses
• A process that leaves workers waiting while complex diagnoses are worked out to satisfaction of decision-makers may appear simply annoying.
The harms:
• Continuing deterioration of condition being diagnosed
• Poverty
“If anything, they enhance the disease process by prolonging diagnosis investigations, …Especially with working with occupational diseases, there's such a delay for Compensation to accept the claim.” (Dana, Occupational health physician)
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3. The ‘hurt’: the wait for claims processing
• Waiting inm general for claims and decisions to be processed appears inconvenient (but not harmful)
The harms:
– mental strain
– Poverty, no income, owing $$ to friends
– Hurting, not being believed
“Any claims that have any kind of problems…get thrown into an appeal situation and then you're talking about monthsand sometimes years and people just fall apart. They have no economic support . . . they're generally sick in one way or another and things just get worse and worse…It's a…devastating process.” (John, injured worker peer helper)
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4: The ‘hurt’: a lack of full communication with compensation decision-makers
• Workers do not have direct face-to-face contact with adjudicators—the key person who controls their claim.
• Decisions about entitlement & compliance are made without full communication with the worker.
• The harms:
– potentially flawed decisions.
I think one challenge is communication… They [workers] can’t seem to actually link up to a real voice at the other end of the phone to talk to. …Occasionally workers come to us literally with the letter the Board has sent them and they don’t have a clue what it means. The language is totally inscrutable to them. (Lori, occupational physician)
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5: The ‘hurt’ of improper employer reporting
• Employer improper reporting
– employer not reporting the injury properly, at the right time, or fighting a claim for reasons not related to worker’s injury (e.g. financial reasons)
• The harms:
– delayed claim, financial strain, strained workplace relations
– related physical and mental health problems.
• “I reported it to my boss… There was never a report filled out by my boss, my shoulder continued getting worse…The doctor filled out a report…. That’s when it was reported to WSIB. … So here I am on pain killers and trying to deal with it-- the lady at WSIB…turned down my claim stating…why did I go to work if I was injured? ….My boss didn’t help me with my claim was because I went to the defence of another co-worker who was treated very badly… and I wrote a letter on her behalf.” (Teresa, injured worker)
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CONCLUSIONS
Conclusion 1: Early RTW isn’t always applicable
• “Hurt vs harm” is a concept formed from a particulargrouping of research findings, logic and theory
• ERTW has questionable scientific foundations, and is recommended only under IDEAL conditions
• A dogmatic approach to ERTW may result in policy & practice that is distracted from problems that don’t fit its logic
• The problem isn’t simply “absence from work” BUT:
– the process that creates the absence
– the recognition that at times absence is appropriate and necessary.
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Conclusion 2: Hurts and harms can arise from administrative processes
• Our data shows how seemingly benign ‘hurts’ can lead to harms
• Thinking about that nature of ‘hurts’ and ‘harms’ allows us to consider:
– strengths and weaknesses of the research behind Early RTW
– Begin to see ways that claim duration can be extended by complex, administratively-related hurts and harms.
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THANK YOU
• MacEachen, E., Ferrier, S., Kosny, A., Chambers, L. (2007). A deliberation on ‘hurt versus harm’ logic in early-return-to-work policy. Policy and Practice in Health and Safety 5(2): 75-96.
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Sample details
• Time since injury
– Mean 11 yrs, median 9 yrs, mode 2 yrs
• Gender
– Injured workers: 20 male, 14 female
– SPs and PHs: 18 male, 17 female
• Worker age at interview
– Range 29 to 68; average 51
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Characteristics of CC Sample
69211434
9135South
193511North
14149East
271629Central
Total
Service
Provider
Peer
Helper
Injured
Worker
Ontario
Region
28
9Soft Tissue
1Respiratory
2Head
5Fracture
4Crush
1Cancer
11Back
1Amputation
Initial Injury
6Service (e.g., housekeeping, kitchen workers, custodians)
3Clerical
4Health Care
11Trades, Transport and Equipment Operators
(e.g., construction, machine operators, drivers, general labour)
8Manufacturing
Pre-Injury Occupation
