Workplace injury Discussion Paper

Peter Cotton
BA(Hons), MA(ClinPsych), PhD,
FAPS, is Director of Psychology
Services, Health For Industry,
Health Services Australia
Group, Melbourne, Victoria.
peter.cotton@hsagroup.com.au
Occupational wellbeing
Management of injured workers with
psychosocial barriers


BACKGROUND
Although most injured workers return to work with minimal
intervention, approximately 20% show levels of distress and
disability beyond that expected for the injury. The level of
morale in a workplace seems to play a major role in this.
Workers who experience positive emotions leading to
increased morale are more likely to be resilient following injury.

OBJECTIVE
It is important for general practitioners to recognise the non -
clinical factors that exert a significant influence over employee
wellbeing and return to work outcomes. Some management
strategies are presented.

DISCUSSION
General practitioners who work collaboratively with all major
stakeholders, who identify and manage psychosocial barriers
early, who take an active role in promoting positive expectations,
and who focus on the immediate problem rather than its industrial

associations will achieve better outcomes for their injured patients.

Individuals with compensable injuries frequently exhibit
worse health outcomes than nonclaimants with similar
clinical profiles(1) and can be very challenging to manage
clinically. Nevertheless, most injured workers progress
through treatment and return to work with minimal
intervention and angst. Indeed, across all workers’
compensation jurisdictions, approximately 80% of
injured workers progress straightforwardly, while the
other 20% exhibit levels of distress and disability that
appear to be excessive when considered in relation
to their initial injury. A further 5% go on to exhibit
‘apparently disproportionate outcomes’ where levels of
long term disability and distress cannot be explained by
the initial injury.(2)

Occupational wellbeing
The psychosocial flags model(3) has become an influential
framework for identifying potentially complicating
psychosocial factors that are predictive of poor return
to work outcomes and long term disability, particularly
in relation to pain related injuries. Our own research in
this field has focused more specifically on work related
psychological wellbeing using the organisational health
framework.(4) This approach overlaps with the flags model
in terms of highlighting a number of nonclinical factors that
exert a significant influence over employee wellbeing and
return to work outcomes.(5)

In contrast to the traditional focus on negative
emotional indicators in the occupational stress literature,
organisational health research finds that indices of positive
emotional states (which we term morale) are important
determinants of a range of workplace people related
outcomes. For example, we have shown that a decline
in level of morale is typically a stronger driver of stress
related workers’ compensation claims among cohorts of
teachers and serving police officers than a substantive
increase in levels of distress.(5,6)

When morale declines, individuals begin to doubt their
capacity to cope and focus more on distress related
symptoms and negative aspects of their environment.
Conversely, we have found that individuals and work teams
with higher levels of morale are more resilient in managing
their operational demands and pressures and exhibit less
withdrawal behaviours including absenteeism and stress
related workers’ compensation claims.(5)

Levels of morale are strongly influenced by
environmental factors, and in the workplace, the most
potent factors are supportive leadership styles and the
overall quality of work team climate.(7)

This approach to occupational wellbeing also
intersects with recent clinical research on the construct of
‘resilience’.(8) Across a range of populations, Fredrickson et
Al(9) have demonstrated that it is the experience of positive
emotions that enables individuals to bounce back from
adverse experiences. More specifically, positive emotions
increase personal coping resources, reduce lingering
negative emotions and return a range of physiological
functions (including cardiovascular reactivity) to baseline
levels more rapidly.

Organisational health research suggests that when
individual morale declines beyond a certain level, individuals
start to disengage and begin to actively seek evidence
of lack of organisational support and unfair treatment in
the workplace.(7)

These findings also have relevance to physical injuries where
levels of supervisory support have been shown to influence
the submission of workers compensation claims for
musculoskeletal injuries and significantly mitigate the effects
of chronic pain on work performance.(10) Hence, poor
supervisory and organisational support is now increasingly
recognised as a significant psychosocial barrier contributing to
both psychological and physical injury outcomes.

The following are some practical approaches to treating
injured workers, irrespective of whether they are presenting
with psychological or physical injuries.

Work collaboratively with key stakeholders
Poor alignment and communication between key
stakeholders (eg. other treating practitioners, employer
representatives and workers compensation authorities)
increases the likelihood of poorer return to work
outcomes.(11) Some general practitioners and other
health practitioners cite confidentiality concerns as a
key barrier to communicating with other stakeholders.(12)

However, good practice in this field involves clarifying
up front with the patient that while personal information
will remain strictly confidential, communication with
other stakeholders about the functional impact of their
health condition, return to work management issues and
alternative duties are critical to achieving positive return to
work outcomes.(1)

Where a worker is highly resistant to proceeding in
this manner, this response should be considered to be
indicative of a likely psychosocial flag (i.e. significant work
problems) that should be actively addressed.(13) In this
situation, standard clinical interventions are likely to be less
effective and the best option is to liaise with case managers
and psychology service providers to address work issues or
consider developing alternative return to work goals.
Additionally, most workers’ compensation authorities
now have in house clinical advisors who can be readily
accessed by treating practitioners for assistance in
managing workers and advice regarding return to work
issues. It is also important not to unwittingly foster an
adversarial approach toward the employer or WorkCover
authority as this increases the risk of poorer outcomes.

Identify and manage potential psychosocial
barriers early.
Early screening for potential psychosocial barriers should be
a standard element of clinical practice with injured workers.
Pursuing a stepped care approach where usual clinical
practice is monitored against normally expected recovery
timeframes can be used to trigger a clinical review and
additional intervention.(14)

A legitimate complaint psychologists sometimes make
is that workers with significant psychosocial barriers are
often not referred until 12+ months post injury. The evidence
suggests that psychosocial barriers can be accurately
identified within 3 months post injury and much more
effectively addressed at that time.(3,15)

Good practice also suggests that return to work goals
and timelines should be incorporated into treatment from
the outset. Again, where a worker is highly resistant to
engaging in return to work discussion, this should be
viewed as a psychosocial barrier to be actively addressed.

One option to consider here is case conferencing with
Other stakeholders in order to develop appropriate
strategies and formulate additional interventions.

Where the worker is angry and harbours perceptions
of unfair treatment by the employer, one approach that
can be helpful is to undertake a cost-benefit analysis of
the increased risk of long term disability if the worker does
not concurrently positively engage with return to work
processes. They can be advised that they are entitled to
pursue redress for perceived injustice, but that this should
not postpone efforts to resume normal functioning and
vocational involvements. The power of medical reassurance
and encouragement to focus on specific goals cannot be
underestimated here. Referral to a clinical psychologist
at this point can also be a useful adjunctive intervention.

Where there may be significant work problems, the case
conferencing process or liaison with a case manager
can be used to consider alternative duties or a different
work location. This may be a more realistic interim goal to
encourage the worker to maintain or redevelop a level of
positive vocational engagement and inhibit the progression
of the declining morale trajectory. The operative principles
here are attempting to ‘maintain morale’ by minimising
time off work and ‘keeping the injured worker connected
to the workplace’.

Occupational wellbeing – management of injured
workers with psychosocial barriers
There should be a very clear and strong clinical
rationale for providing any ongoing total incapacity
certification. For pain related injuries, 3 weeks
is frequently recommended as the limit after which
increased intervention and rehabilitation management
should be considered.(15) Less attention has been devoted
to psychological injuries in this respect, although earlier
guidelines have recommended a resumption of partial
employment by 14 days for stress related problems.(12)

Active expectation management
Evidence suggests that the time taken to return to
work can vary by up to one-third as a direct function of
education and recovery expectation setting in the initial
treatment sessions. This occurs irrespective of the type
of treatment being provided and the nature of the injury.(14)
Accordingly, explicitly establishing positive recovery
expectations and providing information about expected
recovery trajectories are crucial. Moreover, as noted above
in relation to psychosocial barriers, the power of medical
reassurance and encouragement in contributing to the
maintenance of morale should not be underestimated.
Maintain a focus on the work injury

Some injured workers present with pre-existing or
concurrent problems that are not directly related to
their compensable injury. Addressing these issues in the
context of a workers’ compensation claim can contribute
to poorer return to work outcomes. For example, a
worker who happens to have a history of childhood
abuse may exhibit a worse overall outcome if the abuse
related issues become the focus of treatment. This is
also an issue to consider when referring to psychologists
because some use holistic counselling models that
encourage a focus on underlying issues, and which are
actually not suitable for use with this population.

The recommended approach here is to ‘recognise
– acknowledge – quarantine’. That is, it is appropriate
to recognise these problems and to acknowledge them
with the worker. However, rather than then directly
addressing these issues, the worker should be advised
that they will be more effectively dealt with if resumption
of optimal functioning and vocational involvements are
first achieved. Thus, they should be ‘quarantined’ and
psychologically accepted without engaging or indulging in
internal thoughts and feelings related to these unresolved
problems. Such issues are more effectively addressed
from a stronger morale base. There is emerging evidence
that psychological acceptance strategies as opposed
to active engagement with negative internal thoughts,
feelings and memories, promotes better functioning.16
Don’t try to solve management and industrial
issues through clinical management

Be cautious about forming views about the workplace
based solely on information provided by the distressed
worker. While some workers are poorly treated
by harsh employers, some distressed workers also
very selectively describe workplace issues to treating
practitioners and significantly over report negative
experiences in the workplace. This is mostly not an
issue of ‘malingering’ but is more likely to reflect the
personality characteristic of high level trait emotionality.(17)

In the general population, approximately 17% of people
have high trait emotionality and are disposed toward
reporting higher than average levels of distress and
negative workplace experiences.(18)

Issues of unfair treatment are usually best pursued
through workplace fair treatment review mechanisms,
with the assistance of a support person. The question
that often needs to be considered in these situations is
whether additional time off work will actually help deal
with outstanding work matters, or is it simply delaying
the inevitable and reinforcing avoidance behaviours?
Of course, if the worker has been subjected to any
substantive harassment or related problems, then an
alternative worksite will be a more appropriate goal to
pursue. Organisational health research suggests that
where human resource/industrial issues are blurred
with health issues, there is an increased risk of a worse
overall outcome.(7)

In this respect, excessive advocacy can be a risky
strategy that often unwittingly further entrenches
problems, increases dependency, and reduces the
prospect of a positive longer term outcome.

Conclusion
Health outcomes for injured workers with significant
psychosocial barriers can be enhanced through a
focus on morale maintenance, establishing positive
recovery expectations, working collaboratively with other
stakeholders, containing underlying distress problems,
and ensuring at least partial vocational re-engagement as
early as possible.

Conflict of interest: none declared.

Reprinted from Australian Family Physician Vol. 35, No. 12,
December 2006

Peter Cotton
BA(Hons), MA(ClinPsych), PhD,
FAPS, is Director of Psychology
Services, Health For Industry,
Health Services Australia
Group, Melbourne, Victoria.
peter.cotton@hsagroup.com.au
Occupational wellbeing
Management of injured workers with
psychosocial barriers

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CORRESPONDENCE email: afp@racgp.org.au