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Practical advice for GPs: treating patients with workplace injuries

At a glance:
Although most injured workers return to work with minimal intervention,
intervention
A treatment or management program. Interventions often combine several approaches. In this field approaches include training in problem solving, adaptation of work duties, graded activity, an exercise and stretching program and pain relief.
 about 20% continue to have distress
distress
Severe suffering, pain, anxiety or sorrow
 and disability. It seems that workers with high morale are more resilient following an injury, and more likely to recover well. General practitioners can help patients to recover more quickly when they work with employees, employers and insurers, make early identifications of psychosocial
psychosocial
Refers to psychological and social factors. Examples of psychosocial factors that affect return to work area include: a person's beliefs about how they will cope with their condition, the attitude of the inured worker's family to their condition and return to work, the employer's return to work policy and the influence of the WorkCover system on a person.
 barriers, promote positive expectations and focus on the immediate injury.

 
Perspectives:
Employee
This paper looks at the factors that influence return to work. Studies have shown that the longer a person is off work, the less likely they are to return. As time passes it will become harder for you to make the transition back to work. Within this knowledge base (under “consequences of being off work') there are a series of studies that describe the negative effects of remaining off work. It is not just the injured person who is affected, but also their relationships and their family. Because people don't always understand what is likely to happen months down the track, it's hard to appreciate the importance of getting back to work quickly.

Your recovery will be improved if you return to your normal activities (including work) as quickly as possible. Employees sometimes encounter problems at the workplace that make it harder to return: for example, they may be blamed for their injury. If this is the case at your workplace, it's important not to let these barriers postpone your return. If you don't feel capable of managing your normal duties, think about returning to work with reduced hours or modified duties.

Try to keep in contact with the workplace while you are on sick leave, and involve your employer or supervisor when planning your return to work. Discuss your condition with your doctor so you know what to expect during your recovery.
Employer
Good morale makes workers more resilient after injury. Individuals and teams with high morale are better able to manage work pressures and less likely to withdraw, miss work, or make a stress-related workers compensation claim.

Supportive leadership and a co-operative workplace culture improve morale. Support injured workers by contacting them during sick leave, providing modified duties to help them get back to work sooner and helping them plan their return to work. Communicating well with the employee, the doctor and the insurer is important.

Employees usually know what motivates the workplace to communicate with them. Focus on the workers wellbeing and your return to work results will improve. If the worker feels that the workplace is only worried about statistics or costs, they will not feel supported.

Put in place a clear policy governing the treatment of injured workers and lead by example.
Treater
This article provides practical advice for treating patients with work-related injuries. The key messages are:

Incorporate return to work goals and timelines into treatment from the outset.

Be cautious about forming views of the workplace solely on the basis of information from a distressed patient.

Make early identifications of psychosocial barriers to recovery (such as distress).

Promote positive expectations about recovery.

Give the workplace sensible feedback about the case, and tell them what you think can be done to improve return to work results.

Separate management of return to work and human resource/industrial issues. Encourage employees to use unfair treatment review mechanisms if they feel they have been treated badly.

Encourage a return to work as soon as possible, particularly for stress cases.
 
Insurer
This article provides practical advice on the treatment of patients with work-related injuries. The key messages are that health professionals should:

Make early identifications of psychosocial barriers to recovery (such as distress).

Promote positive expectations about recovery.

Set up systems for each of those involved in return to work collaboratively

Help workplaces to understand the impact of the workplace culture on return to work. Ask the employer how encouraging the work team has been.
Original Article, Authors & Publication Details:
P. Cotton1 (2006). Occupational wellbeing--management of injured workers with psychosocial barriers. Australian Family Physician; 35(12):958-961.

1Psychology Services, Health for Industry, Health Services Australia Group, Melbourne
 
Background, Study Objectives, How It Was Done:
Individuals with compensable injuries can be difficult to manage. While 80% of injured workers receive treatment and return to work without complications, 20% experience distress and disability
disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 that seems disproportionate to their initial injury. In 5% of cases, the levels of distress and disability observed cannot be explained in terms of the initial injury.

 Psychological
psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
 wellbeing and positive emotional states (termed “morale') influence return to work outcomes. Some studies have shown that declining morale can be a stronger driver of stress-related compensation claims than increasing levels of distress. When morale declines, people can begin to doubt their ability to cope, and their attention is more likely to be focussed on their distress and the negative factors in their environment. Workforces with good morale are more able to manage pressure and less likely to withdraw or miss work. There are a number of environmental influences on morale, the most important of which are supportive leadership and the quality of the workplace culture.

When morale is high, people are more able to bounce back from negative experiences, a capacity we term ‘resilience'. Positive emotional states also increase coping resources, stop negative emotions from lingering and return people to normal physiological function more quickly.

A lack of organizational support (particularly from supervisors) is increasingly recognized as a significant psychosocial barrier to recovery from work-related injuries.

This study aimed to provide practical advice to general practitioners on the incorporation of non-medical factors into treatment of work-related injuries.
 
Study Findings:
This study suggests the following practical approaches to treating injured workers:

1) Work collaboratively with all parties

Poor communication between treating practitioners, employers, employees and workers compensation authorities reduces the likelihood of a return to work. General practitioners need to communicate with other stakeholders in order to define patients' functional limitations, manage the return to work and suggest appropriate alternative duties. It is good practice for general practitioners to clarify with patients which information is to be kept confidential and which can be discussed with others involved in the return to work process. This ensures that confidentiality requirements do not prevent communication.

Strong worker opposition to this approach is often an indicator of problems in the workplace, which, if not addressed, may constitute psychosocial barriers to recovery and return to work. In these cases general practitioners need to work with case managers and psychology professionals to address workplace problems, or consider alternative return to work goals. Most workers compensation authorities also employ clinical advisors who can help health care professionals to manage injured workers.

It is also important not to alienate the employer or WorkCover authorities.

2) Identify and manage potential psychosocial barriers early

Treatment of workplace injury should include early screening for psychosocial barriers. Psychologists sometimes complain that it takes a year or more for workers with significant psychosocial barriers to receive a referral to their service. Research suggests that these barriers can be identified by screening within 3 months of the injury, and that treatment at this early stage is much more effective.

If the worker is angry and thinks that they have been treated unfairly by their employer, general practitioners can explain that they are at higher risk of developing a disability if they do not try to return to normal activities such as work. Advise patients who feel wronged that it's reasonable to pursue redress, but this goal should not get in the way of return to work efforts. Alternative duties or a new work location can be an option for people with significant problems in the workplace. The goal is to maintain morale by minimizing time off work and keeping the injured worker connected to the workplace.

Sickness certification (except under exceptional circumstances) should be given for no more than 3 weeks for pain related injuries and no more than 2 weeks for stress related injuries, although workers could resume work with reduced hours. Return to work goals and timelines should be incorporated into treatment from the outset. The power of medical reassurance and encouragement to focus on specific goals cannot be underestimated.

3) Active expectation management

A patient's education and expectations of recovery affect the time it takes them to return to work. The patient develops these expectations in their initial treatment sessions. General practitioners can establish positive recovery expectations by informing patients about the course of recovery from injury. Medical reassurance can contribute greatly to patient morale.

4) Focus on the work injury

Some workers come to treatment with pre-existing problems that are not directly related to their injury. An example could be an injured worker who happens to have a history of childhood abuse. Addressing these underlying, peripheral problems during the return to work process can reduce the chances of getting back to work. These issues need to be recognized and acknowledged, but can be more effectively dealt with once the worker has returned to their normal work and home activities. When these issues become the focus of treatment, overall outcomes can be worse. Outcomes will also be improved if these issues are addressed from a stronger morale base.

5) Don't try to solve management and industrial issues through clinical treatment

Organisational health research suggests that where human resource/industrial issues are blurred with health issues the overall outcome for the patient is likely to be worse. Issues of unfair treatment are usually best pursued through the appropriate workplace review mechanisms. It's important to consider the likely effect of additional time off work: will it help the patient to deal with workplace problems, or will it reinforce avoidant behaviour? If the worker has been subjected to significant harassment, then returning to an alternative worksite is a more appropriate goal.

Be cautious about forming views of the workplace solely on the basis of a distressed worker's information. Some workers selectively describe workplace issues to treating practitioners
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
 and over-report negative experiences, often due to high trait emotionality (present in 17% of the general population) and higher levels of distress.

 
Conclusions:
A patients recovery after workplace injury can be improved by:

A focus on maintaining morale

Establishing positive recovery expectations

Working cooperatively with others involved in the return to work process

Maintaining a focus on the injury, rather than any underlying/peripheral distress or problems. These should be acknowledged, but should not become the focus of treatment.

Encouraging at least a partial return to work as early as possible.
 
References:
PubMed Abstract

 
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