Towards a National Research Agenda.
Report of the Symposium convened by the Foundation for Research into Injury and Illness in the Workplace Inc.
Melbourne 25 May, 2006.
NOTE
This report was prepared by The Foundation for Research into Injury and Illness in the Workplace Inc as a general record of discussion prior to and during the 2006 ResWorks Symposium – Towards A National Research Agenda. This report captures and assimilates the main points put forward in writing and discussion by participants. This report is not a verbatim transcript of the Symposium’s proceedings, nor does it embellish, interpret, or expand upon matters or topics that were unclear or not addressed. Statements are the assimilated views of participants. Except as specifically noted, no statement in this report represents the position of ResWorks.
This report is Copyright for commercial purposes. Requests for reproduction must be made in writing to the Executive Officer. Non profit use is free of Copyright provided acknowledgement of ResWorks is made, including provision of an active link.
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‘If health outcomes for conditions suffered during employment were the same as outcomes for like conditions suffered outside of employment it would mean that Australian workers compensation systems were operating at the cutting edge of knowledge. They are not. There is a problem. The problem is within the system. How do we know this? Because the problem does not reside outside of the system.
The texture of the problem is felt daily by everyone in the system who suffers the experience of forcing someone to do something, finds something within it to escape from, or sees the system as a means to escape from other circumstances.
We feel the problem, but our policy frameworks do not fully understand it. We get a grip on bits of it, interventions, programs, are put in place and we see improvement in our grasp, but in that very moment we also see some other aspect ballooning out between our fingers.
Why? Because we haven't got to the root of the problem. There are an endless number of answers, however, if we do not understand the exact nature and dimension of the problem how can we be sure which of them is right?
If health outcomes for non work related conditions are clearly better than for like conditions suffered within employment, then the inescapable conclusion must be that the system itself damages people, even kills them. This is a matter of profound gravity.
Smoking is bad, driving dangerously is unacceptable, fluoride in water is good. Community attitudes are clear on these matters. However, as a society we do not understand the true consequence of workplace injury and illness. As a result our attitudes to it are diverse, contradictory, self interested. And bad stuff happens. ‘
–Symposium participant
TABLE OF CONTENTS:
EXECUTIVE SUMMARY:
INTRODUCTION:
METHODOLOGY:
SYMPOSIUM RESULTS:
1. RETURN TO WORK MANAGEMENT
1a) Prediction of poor outcomes
1b) Early intervention
1c) Psychosocial issues - identification and management
1d) Communication
1e) Role of treaters
1f) Workplace and supervisor management
1g) Assessment of capacity
1h) Legislation / system
1i) General Return To Work (RTW) management
1j) Treatment strategies / efficacy of treatment
1k) Enhancing motivation
1l) Re-employment Issues
1m) The value of determining what the individual wants / needs
2. IDENTIFYING AND QUANTIFYING THE PROBLEM - understanding what we are dealing with
2a) Factors that contribute to the problem
2b) Health outcomes - morbidity / mortality, work / non work
2c) The Impact - individual, social, financial.
3. GETTING RESEARCH INTO PRACTICE TO IMPROVE OUTCOMES
3a) Research information to improve treatment practices
3b) Employer management practices
3c) Rehabilitation management practices
4. EFFECTIVE WORKPLACE OR COMMUNITY CULTURE, AND THE EFFECT OF CHANGING CULTURES
5. BELIEFS AND ATTITUDES OF THOSE INVOLVED
6. OH&S
6a) Prevention of injuries
6b) Prevention of stress cases
7. AGEING WORKFORCE
8. MANAGEMENT OF CHRONIC CASES
VISUAL REPRESENTATION OF PRIORITIES:
NETWORKING:
CONCLUSION:
SYMPOSIUM PARTICIPANTS
RESWORKS BOARD:
SYMPOSIUM AGENDA
EXECUTIVE SUMMARY:
One would expect that bringing together a broad group of stakeholders for a short period of time to consider research needs across the entire landscape of workers compensation would result in a wide-ranging list of issues and statements. That is exactly what happened. The group process the Symposium followed identified an extensive list of potential research topics. The same group process was used to determine the key priority areas for attention in this list. These were identified in Categories and Sub Categories.
As a result the Symposium Report provides a very clear image of the diversity and scope of the problems that confront stakeholders in the Australian workers compensation systems. And in the experience of the event itself participants gave an equally clear picture of the extensive goodwill that exists between players and of their hunger to communicate with one another, create partnerships and make progress together.
The ten highest priority Sub Categories identified by participants are:
- Identify and quantify the factors that contribute to the problem
- Research information to improve treatment practices
- Prediction of poor outcomes
- Effective workplace culture, and the effect of changing workplace cultures
- Understand and the influence of beliefs and attitudes of those involved
- Communication between the relevant parties
- Health outcomes - morbidity / mortality, work / non work
- Identify and quantify the financial Impact
- Early Intervention practices
- Employer Management Practices
This Report has been organized and illustrated according to the group Category and Sub Category priorities. As far as possible the issues have been presented as a narrative on which to base further discussion and go forward together to a new level of refinement of subject, objectives and partnerships in action.
Immediately below is a summary of the three highest Category priorities for research of concern to Symposium participants.
Understanding the overall problem – what is the personal, social and economic cost of increased mortality and morbidity resulting from being off work in Australia?, why are there different health outcomes for like injuries in work and non work contexts? Clarify the non mechanical factors that create different outcomes. Understand the barriers to employee compliance with rehabilitation programs, quantify the risk factors for employees and employers in an early return to work. Facilitate mutual respect between employers and treaters. Consider ways the workers compensation systems can be standardized. Establish the unit of analysis as insured worker / person rather than claim / incident.
Return to work management – understand the impact of legislation on outcomes in different Australian jurisdictions. Assess existing early intervention strategies and create new ones. Develop predictors of poor health outcomes. Improve tools to inform treating practitioners, workers, managers, insurers and foster better communication. Understand the efficacy of treatment strategies. Refine work capacity assessment and enhance motivation for return to work through a better understanding of the positive benefits.
Getting research into practice – determine standards and guidelines to achieve practical outcomes from research projects. Establish a central repository in which local research can be collected (in plain English) and international findings can be adapted, from which the implementation of both can be advocated. Undertake a recurrent conference focusing on practical applications and implementation. Foster ongoing communication and partnerships between researchers, employers and policy makers. Improve treatment practices by developing and advocating an evidence base to support best practice medical care at each stage of a case to minimize chronic disability. Understand GP knowledge of the evidence base regarding workplace disability and advocate training improvements. Re-educate treaters to give appropriate return to work messages to patients. Assemble existing research on collaborative approaches and positive workplace cultures and advocate positive models to managers of large and small workplaces.
INTRODUCTION:
The Foundation for Research into Injury and Illness in the Workplace Inc., is a non-profit organisation. The Foundation’s objectives are to further knowledge and improve health outcomes in workplace disability. The Association undertakes research, provides communication and networking services and advocates reform.
In part ResWorks was formed to take up a role signaled by the Australian Faculty of Occupational Medicine (AFOM) when participants at its 2000 Workshop in Sydney called for more research and the establishment of an organisation to facilitate communication and support researchers in the field.
The 2006 Symposium – Towards a National Research Agenda, was convened by ResWorks to canvas research needs from the diverse viewpoints of the many stakeholders in the field. This report was written to inform researchers, employers, policy makers and funders of the range and weight of problems that confront stakeholders. In these pages are the many issues that Symposium participants considered would benefit from the development of a deeper evidence base to facilitate better treatment interventions, management practices and further policy development.
This report simply identifies the range and scope of the problems. No attempt is made here to foster more research into workers compensation, or to encourage that work to be undertaken in a co-operative and transparent manner by researchers and institutions. We make no attempt to discuss the co-ordination of research efforts across the country to ensure the most efficient use of available funds and facilitate a broad adoption of results. These are pressing problems to which ResWorks offers this report as a point of discussion.
ResWorks was assisted in mounting the Symposium by a grant from the Victorian WorkCover Authority, which partly met the cash costs of producing the event and for which we are grateful. We are also grateful for the generous gifts of time and thought contributed by the Symposium participants who have made this document possible.
METHODOLOGY:
On May 25th 2006 ResWorks convened the Symposium – Towards a National Research Agenda. Participation was by invitation to senior people representative of the diverse stakeholders in the field. 54 participants from 5 states attended the event and represented groups ranging from claimants to insurers, employers to policy makers, treating practitioners to researchers. 4 Union representatives were invited, two accepted the invitation, but unfortunately did not attend.
Prior to the event participants were asked to complete an online survey. The survey posed 2 questions:
- What do you consider the three most important research priorities in the area of work disability generally?
- What do you consider the three most important research topics within your field of expertise, regarding work disability?
A total of 41 of the 54 Symposium participants completed the initial survey. Responses were compiled to a single anonymous document ordered by profession. The result was 8 pages of closely typed material. This document was emailed to all participants a week prior to the event.
The Symposium opened with a welcome from Dr Mary Wyatt who presented an overview of the value of research together with examples of benefit. Mr Alan Clayton then described the structure of peak research bodies in Canada and Germany and Scandinavian countries, he also posed the question of the appropriate best practice model for Australia. Other speakers followed illustrating different stakeholder perspectives (see Agenda pg24).
Following morning tea Dr Wyatt summarized the initial survey from a subject perspective, providing participants with a graphical overview of the diversity of suggestion and the weight of interest in subject matter. A single page Categories Summary was distributed to participants (see pg17).
Workshops: two workshop sessions were conducted on the day. Five workshop groups each contained from 10 to 12 participants and were organized broadly along professional lines (except for policy makers who were distributed evenly among the 5 groups). The same workshop population met in both sessions. Each workshop group considered the section of the initial survey document which included their individual contributions.
During the first workshop 40 minutes of group discussion, was followed by 20 minutes of writing by individuals (again anonymous). All copies were collected by staff and the additions and changes were made to the workshop documents.
The second workshop considered the revised documents. Participants were free to further revise, or add content, however, the principal aim of the session was to prioritize the research topics using a weighted numerical system. Participants were also asked to prioritize the headings listed on the Categories Summary page.
Following the Symposium ResWorks staff added any new material, and assembled a single draft document ordering the research topics according to category and priority. The research agenda material was edited for repetition (where it could be removed without blunting the intent of the contributors). The prioritized Categories document was used to create the Contents Table of this report.
The draft report was distributed to all participants for comment. The resulting feedback was used to edit and further refine the published report.
SYMPOSIUM RESULTS:
1. RETURN TO WORK MANAGEMENT
1a) Prediction of poor outcomes
Identification of injured workers who will develop chronic disability. Validity of tools used?
Develop a multi-dimensional and sophisticated model for predicting poor outcomes in acute to sub-acute work related injury.
Researching concrete data how do we identify the 20% (who will have poor health outcomes i.e. 80/20 rule) at the outset to better enable all parties to focus activities, resources etc., to this group. The next research project is then to understand what interventions make a difference in the course of those 20% claims?
Development of a multi-dimensional and sophisticated model for predicting poor outcome in workers referred to the Sprains and Strains Care Model
Develop predictive factors for delayed or non return to work.
Effective treatment/rehabilitation for predictive factors for delayed or non return to work?
1b) Early intervention
Early intervention strategies have the best potential for minimising work disability.
1. Research and establish a model to enable the early identification and management of injured workers who are at risk of chronic disability.
2. Develop and trial a program integrating known best practice strategies at the 'front end' of potentially long term claims using appropriate scientific methodology. The program should first determine the factors for early intervention and the factors for delaying intervention.
The interventions should be 'low-tech', simple, and maintain the worker at work without aggravating injury, using both medical and non-medical models. They should include, but not be confined to: early identification and management of significant injuries / improvement of communication between employers / patients / practitioners / education strategies / regular appropriate expert review strategies / provision of suitable, meaningful alternative duties as a process to facilitate full return to work.
The program should also include an evaluation and review strategy.
1c) Psychosocial issues - identification and management
What is the influence of biopsychosocial factors in limiting disability?
What are the common psychosocial barriers to return to work, how can they be understood and how can they be managed?
What attitudes of family members assist in the recovery from work injury? How can the promotion of safe and timely return to work be introduced to the domestic environment?
Research work-related (di)stress versus psychological injury. Perception versus substantiated events. Develop an intervention to best promote safe and timely returns to work?
Research the individual capacities of claimants to manage their case and claim. What are the characteristics of those who are reliant on the treaters?
1d) Communication
Research should be undertaken to understand and improve:
1. Practical communication between treating practitioners and employers
2. Communication within return to work programs
3. Early management of injured workers' catasrophising diagnosis, understand what effect it has on long-term outcomes?
4. Communication protocols between all key stakeholders - workers, unions, employers, agents, treating practitioners - to prevent chronic disability and manage at risk workers.
5. Integration and communication of and between stakeholders to prevent chronic disability and manage at risk workers.
6. Commonality of diagnosis and treatment across treating practitioners.
Undertake research to:
7. Establish the most effective way to promote collaboration between employers, injured employees, treating health practitioners and claims agents to achieve an early RTW and reduce disability.
8. Challenge and overcome the social stereotypes (e.g. uncaring employer, un-motivated worker, recalcitrant doctor) to enable collaboration.
1e) Role of treaters
Foster and advocate effective medical advice for people with an injury - at present the focus of treatment is on doing something - giving medication, applying manipulation, an exercise program. However, if the individual with the problem does not have knowledge and understanding of their situation, their likely path forward and what they can do as an active participant to improve their lot, their health outcome will be worse. The challenge is to identify the content of such advice? And learn how to deliver it so that it reaches people in an accessible, meaningful and useful way? Treaters, payers, and people with the condition need to recognise the importance of time and focus spent on this issue.
How do we assist medical experts to understand the psychosocial factors and the demands and flexibilities of the patient's job?
How can health care providers be assisted to recognise and integrate workplace factors into their management e.g. what is their role re unsupportive employers?
What is the impact of the skills / capacities of treaters on RTW outcomes ie should there be specialist/tertiary training for treaters dealing with compensable clients?
How can general practitioner knowledge in the benefits of early RTW be improved?
How to influence GP attitudes to work-related injury and encourage their support for safe and timely RTW. Should Occupational Physicians have a greater role?
What is the role of allied health practitioners in promoting independence to achieve earlier RTW?
Questioning the role of doctors:
1. What are the systemic influences on outcomes, eg stakeholder accountability, especially medical professionals?
2. Should they be the gatekeepers to the compensation scheme? Can this role be shared across health practitioners? Given existing relationships, workers & 'family', GP's may have a conflict of interest.
3. Are medical practitioners the best people to determine work capacity?