Dr William Shaw, Research Scientist at the Center for Disability Research, Liberty Mutual Research Institute for Safety (US), gave RTW Matters a behind-the-scenes look at some of the groundbreaking research being conducted there.

The Institute, which aims to reduce occupational injuries and minimise work-related disabilities, conducts much of its return-to-work research with the question in mind, ‘How can things be done differently in the early stages of an injury?’
“In the US there’s a pretty good model for dealing with long-term cases of sickness absence and how best to bring people back to work, but we really falter when it comes to these early cases. Some of our research has focused on, ‘How can you identify somebody early on who is going to have more problems – of whatever sort – that will become an obstacle to return to work?’, said Dr Shaw.

Identifying who needs earlier intervention is one of the key focuses of Dr. Shaw’s research, and it’s an area in which he says the US has a lot of work to do.

“One of the things that we found from our cohort study is that most psychosocial factors can be identified the actual day that the injury is reported, at least in the case of lower back pain,” he said. “I think a lot of the concerns that workers have they have right off the bat, so there’s no reason to be waiting a month or two to find out about them.  So I would recommend that healthcare providers and employers routinely ask the worker, ‘Do you think this is going to work out and if not what are the things you’re worried about and lets go try to do something about that.’”

Dr Shaw outlined the types of survey questions that he and his colleagues are researching and refining, that can be asked on the day an injury occurs to help identify if an injured worker is likely to experience a difficult return to work or not:

• Is the worker’s employer likely to be cooperative?
• Does the worker have pain beliefs and attitudes that might stand in the way of early return to work?
• Does the worker have another co-morbid condition (for example, depression)?
• Does the worker feel discouraged about their pain?

“A parallel line of research at the Institute, that we continued to build upon, focuses on supervisors. What we’ve found is that workers have really extraordinary expectations of their supervisor in the event of a work injury. If you asked workers, ‘What would your supervisor probably do if you had work-related back pain?’, they have really very high expectations that the supervisor’s going to support them and help them along the way and communicate as primary conduit with the company; probably talk to their doctor, come up with a list of possible job modifications and just support them in all sorts of emotional ways,” Dr Shaw said. 

“When that doesn’t happen those workers obviously feel pretty let down and we think that’s a part of some long-term return to work cases,” he said.

To work towards a solution to this problem, Dr Shaw has been involved in working with supervisors to help them to improve their communication skills and teach them how to better facilitate the speedy return to work of their employees; often simply by “keeping in communication with workers, and just giving them positive reassuring messages throughout that, we want you back, and we going to try our best to do anything to get you back as soon as possible,” said Dr Shaw.

He found that many supervisors actually wanted to be more involved and proactive in the return to work of their employees than they felt they could be. “When we talked to supervisors initially a lot of them felt like they actually wanted to help with return to work and to deal with injured workers but they felt that the company was sending them messages saying don’t do this because you might get us in legal trouble, or you might say the wrong thing, or you might be encroaching on some medically confidential information about the employee,” Dr Shaw said.

Many supervisors, particularly in blue-collar work settings who’ve often done the work of their employees in the past and can understand that there is often a physical cost of the job, are sympathetic to their employees’ problems. “But they actually feel like the company has told them not to get involved,” he said. “I’ve seen training programs that have been offered to supervisors by companies where they’re sending all the wrong messages. They tend to be legalistic and administrative,” he said, and “very much about protecting the company’s legal and financial interest, which will be called the ‘proactive return to work program.’” Supervisors can emerge from such training with a firm resolution to avoid involvement in any work injury again because it sounds so frightening, and because it seems they could get their company into trouble.

Rather, said Dr Shaw, the focus of training should be more personal: “I think that the personal communication with the worker has to be emphasised first and make sure this person’s ok and make sure you understand what their concerns are and then fill out the injury report.”

Supervisors considering it best not to speak with an injured worker “are actually shooting themselves in the foot,” said Dr Shaw, creating the feeling among workers that “they’ve been cut off from the company and the person who they depend on for support,” said Dr Shaw. “I think when that happens, and it’s not really intentional on the part of the supervisor, but [workers] really feel that the company has tried to cut them out of the loop entirely.”

“What we try to do is encourage them that they can actually be a support to the worker. They don’t need to make a determination as to whether the injury’s work-related or not – which is a big issue in the US; they can let the doctor do their job and be reassuring and supportive to the worker and that will help move the case along. They don’t need to talk medical diagnosis with the worker, they don’t need to talk about treatments; all they need to do is say, ‘How are you feeling, what are the things you can and can’t do, and how can we begin to talk about modifying your work?’”      

In terms of what the future holds at the Institute, Dr Shaw discussed a new three-year study about to commence. “What we’re trying to get out of this study is to understand what different factors play into a supervisors’ support for job modification.” Supervisors will be asked to read case studies and scale how supportive they would be of various job modifications in their various work settings. The study will also look at:

• supervisory leadership style
• attitudes and beliefs about pain and disability
• beliefs such as when you have pain you should be inactive
• characteristics of the worker 
• information that they’ve been given by the health care provider and whether that influences their decision
• physical work demands

In an ideal world, with unlimited funds, Dr Shaw would like to see return to work being facilitated jointly by a doctor, the worker and their supervisor, and the return to work coordinator together in one room to discuss the worker’s case; “to have the worker say, ‘Here are the things I think I can and can’t do, here are the things that I’m sometimes asked to do that I think I won’t be able to’. Have the supervisor try to work with them to help them craft feasible ways the job could be modified temporarily; have the doctor say ‘Yes, that’s consistent with my recommendations’, and have the return to work coordinator there in the middle helping to arbitrate this discussion.”

In reality, of course, this is rarely the case. “What happens is that the doctor issues a letter, and sometimes those letters are not very helpful or not specific enough for employers to really untangle it, or it’s difficult for them to apply those medical restrictions in the context of the type of physical demands that the job has. They’re left with a lot of questions, but they’re rarely able to have an interchange with the doctors so they’re kind of stuck with whatever they’ve got.”

“An employer or somebody from the employer is left to translate those recommendations into reasonable job modifications – that’s more of an art than a science. I think that’s where a lot of the problems come up. The worker is pretty much cut out of this entirely; they get a phone call and the employer saying, ‘We read your medical restrictions and we can offer you this and this and you can take it or leave it’. If you don’t accept it then you risk losing benefits as a result, so it’s a pretty daunting prospect,” said Dr Shaw. He’d like there to be more opportunity for exchange between workers, supervisors and medical health providers.

He emphasised the importance of outreaches to employers and providers which facilitate information-sharing and better communication; and not just on the part of the employer. Another line of research Dr Shaw discussed looks at how employees can better speak-up about their health problems.

“This [research] came about as a reaction to the supervisor training idea. One employer said, ‘Well, if we’re going to help injured workers, the injured workers need to help themselves as well.’ Employers told us a lot about employees with recurring chronic health problems that were taking them in and out of the workplace, and they wanted those workers to really do their part as well in communicating effectively with them about their health condition,” said Dr Shaw.

Employers who strive to be flexible and accommodating of their ill or injured worker’s needs, who don’t feel that the care is reciprocated, will become easily frustrated.

This led to the idea of developing a training program to train employees on how to better communicate with their workplace about their health problems. “It will include, for example, ways to communicate pain problems to co-workers without annoying them, also being assertive when you do need help from people and being clear about that, and getting the right resources so that you can remain on the job and meet performance expectations.”

Dr Shaw has promised to keep RTW Matters up-to-date with new return to work research findings to come out of the Institute. We’ll be sure to share it with you!