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People Factors
Factors that can affect a person's ability to return to work

At a glance:
One of the key steps in returning to work is the assessment of a person's ability to function, also called their “capacity'.
This article reviews the many factors that can negatively influence the assessment of function.
Having ongoing pain is difficult, and affects people in different ways. Some of the issues that can accompany pain after injury are described in this paper and may be relevant to your situation, others may not.
Pain can have many complex effects on a person's life. Studies have indicated that people generally cope well with pain for about three weeks, but then it begins to have a range of negative impacts. Ongoing pain can be worrying, debilitating, and leave the person uncertain about their future.

Finding a person who understands your situation, and who can assist you to move forward is important. If you think some of the issues resolved in this study are affecting you, discuss them with your treating practitioner.
Return to work is more successful when employees feel supported. This becomes even more important when their condition is long term or complex.

When patients are fearful, distressed, or blame their employer they are less likely to return to work. Try to understand the issues affecting the employee and help to resolve them.

This proactive involvement can be an effective strategy for improving return to work outcomes.
Managing patients with long-term pain can be difficult. Treating practitioners may feel disempowered by the complexity of the issues that affect the management of the patient's pain and disability, for example workplace issues, and financial gain or loss. The author of this study suggests that many of these issues can be addressed, but they require working with other parties toward a shared understanding.

Establishing a relationship with the patient in which there is trust and respect will help you to tackle the more complex issues. This may be achieved simply by ensuring the patient understands how much financial compensation they are likely to receive, taking into account the impact of the person's financial situation on their current predicament and understanding that issues such as these are the cause of distress
Severe suffering, pain, anxiety or sorrow
 and fear about the future.

Ensure there is adequate time in the consultation to discuss these areas. Alternatively, refer the individual to a trusted health colleague, who you feel is better able to deal with the issues in a positive fashion. This may assist the patient to come to terms with their condition and work out a plan for the path forward.
Dealing with people with complex problems that stem from their pain can be a challenge.

Developing a trusting relationship with an injured worker will help you communicate with them about complex issues affecting their recovery. Sorting out these difficult areas can greatly improve return to work outcomes. Recognising when complex issues are relevant, and being able to address them in an open and positive way, can assist the patient and the employer and hasten return to work.
Original Article, Authors & Publication Details:
R. J. Gatchel1 (2004).

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.
 factors that can influence the self-assessment of function. Journal of Occupational Rehabilitation; 14(3):197-206.

1 Department of Psychiatry, The University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
Background, Study Objectives, How It Was Done:
This paper's author suggests that many factors can influence the assessment of a person's level of pain and their ability to function. Therefore, it is best to approach assessment by taking into account this broad range of factors, rather than using one simple measure.

The aim of this paper is to better understand the factors that can influence assessment of function and recovery. The paper reviews some evidence from previous studies, and then recommends an approach for assessing a person's ability to function after sustaining injury.
Study Findings:
The following factors can influence a persons beliefs and approach to recovery and in turn can affect their return to work. Each factor needs to be understood in order to be addressed. While this can be difficult it can make a significant difference.

Secondary loss issues

Secondary loss can be a barrier to recovery. Some types of loss that can be caused as a secondary result of injury are:
  • Economic loss
  • Loss of relationships at work
  • Loss of social support networks
  • Social stigma of being disabled, or on workers compensation
  • Guilt about disability
  • Loss of recreational activities
  • Loss of respect from family and friends
The papers author indicates that these losses can have a cascade effect, leading to significant emotional distress. This then complicates the physical problem. Effective management of return to function acknowledges secondary loss, and assists the patient to address these problems positively.

Secondary gain

Secondary gain has been defined as "the interpersonal or social advantage obtained by the patient as a consequence of illness". Secondary gain is a normal facet of life. For example, a person with a headache may not have to do the dishes, and someone with a cold may spend a day at home rather than at work. It is a normal for people to experience secondary gain
secondary gain
Any indirect gain that occurs as the result of an injury or illness. For example, financial gain (in the form of compensation), not having to work, sympathy or attention.
 in a modest way.

However in some circumstances the secondary gain becomes a significant issue, and can interfere with return to function. Secondary gain can range from fulfilment of token needs and wishes (such as to be taken care of, to change family dynamics or to get even when blame is involved) to more material issues (such as financial gain, or avoiding work while maintaining income).

It is often said that financial compensation encourages disability.
A condition or function that leaves a person unable to do tasks that most other people can do.
 If patients are paid to be sick, they may learn to continue to seem to be sick, as using this behaviour brings them reward. It is often expected that people will return to normal functioning when they are no longer receiving compensation for their injury. However, when the financial reward stops, the authors of this paper suggest that the behaviours often do not change. People can continue to behave in a way that allows them to avoid activity.

The authors also go on to suggest that treating practitioners shouldn't assume that patients with financial secondary gain issues cannot be treated effectively. Studies have shown that even in the presence of unresolved financial gain claims, treatment outcomes can be positive. One of the risks of focusing on secondary gain is that it deters the treater from appropriate treatment, which may result in poorer outcomes.

It is recommended that the treating practitioner
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
 take into account the persons situation and any barriers to recovery, and focus on improving their level of function. The focus should not be on freeing the patient from pain, but rather on supporting active rehabilitation.

Management of this situation includes:
  • Defining a medical endpoint
  • Arranging a treatment plan in communication with all parties, with the aim to return to as normal a life as possible. This may involve family members, other health care providers, claims managers, and employers.
  • The team should:
    • Establish trust and rapport with one another
    • Plan the return to work
    • Address any financial issues, including secondary gain, and provide the person with an understanding of the financial implications
    • Set goals, including the injured person in this process
    • After trust has been established, educate the patient about their reasonable expectation for recovery
Emotional distress

Changes in a person's mood often accompany pain and in turn this affects function. Studies have indicated that 40 to 50% of all chronic
continuing a long time or recurring frequently
 pain patients experienced some form of depression.
Anxiety is also common. People who are fearful of pain avoid activity that they think may cause pain. They often experience more distress and secondary loss
secondary loss
Any indirect loss that occurs as the result of an injury or illness. For example, loss of social contact with work friends, loss of status, financial loss from reduced income.
 issues. The fear of pain prompts avoidance behaviour and retreat from normal daily activities. In turn this leads to increased social isolation, inability to return to function and prolonged disability.

Anger is also becoming recognised as an emotional state that can affect function. Anger may be directed at persisting symptoms, unsuccessful treatment, a person blamed for the injury, the workplace where the injury has occurred, the workers' compensation system, any delay in management, or family, or colleagues who may be unsympathetic. Anger that is not expressed is associated with increased intensity of pain and perceived interference with activities of daily living. People who are angry seem to be less motivated to respond to assessment or treatment.

Other factors the author notes influence a persons level of distress are:
  • Uncertainty about:
    • how they should manage the condition
    • the likely outcome (how long the condition will take to improve and whether the condition is likely to leave them with long-term problems)
    • the best treatment
  • Feelings of being misunderstood
  • Lack of understanding about their entitlement, such as delays in being paid, difficulties in sorting out the level of pay, etc.
Symptom magnification

It is rare that a patient is consciously faking functional disability. Symptoms may be exaggerated consciously, or unconsciously, as a way of expressing the person's illness.

Compliance and resistance issues

Fear and trust can be major issues for some people, and can interfere with their willingness, or motivation to participate in a rehabilitation
The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition.
 program. These issues need to be dealt with in a supportive and educational manner. It may take some time to develop a level of trust that supports a collaborative working relationship to overcome these barriers.

Patient comprehension

Treating practitioners tend to assume that patients understand discussions and any provided reading material. However, some information needs to be presented a number of times, or in different ways for patients to fully grasp its meaning. It is important that the treating practitioner recognise when a patient does not fully understand the information and advice given about their condition.

 Iatrogenic effects
iatrogenic effect
An unwanted negative health effect that occurs as a result of treatment. E.g. side effects of medication, the problems that can occur from a person being told to rest, a complication from surgery.

An iatrogenic effect it is an unwanted effect inadvertently introduced by a health care professional, or their treatment. For example, after being advised to rest to relieve pain a person may continue to rest for longer than necessary. In turn this can change the person's behaviour, or beliefs in response to their condition and alter their routine. It is important that treating practitioners understand this issue, so that appropriate advice is given.
This study notes that there are many factors that influence a patient's return to function and their assessment of their own ability and recovery. Acknowledging and dealing with secondary loss and secondary gain issues, emotional distress, and the potential for treatment to cause unwanted effects is needed to accurately assess function. These issues can be complex, but the authors indicate that they can be effectively addressed with adequate time, focus & communication and the development of trust.
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