In search of plan B in workers’ recovery

The cumbersome systems that have evolved around workers compensation cause frustration and suffering for employers and workers. Employers get saddled with volatile costs and workers get labelled as problems to be fixed. Health professionals reluctantly and cautiously engage in the same way that we tolerate our obnoxious uncle at Xmas and the insurers charged with administering the system are plagued by revolving door syndrome as they struggle to recruit and keep their people. Inevitably, the politicians weigh in cyclically with the latest quick fix that might seem plausible to a disengaged and flooded voting population.

In my small corner of the world I would like to create the future I wish to inhabit. Plan B isn’t well formulated, and that’s ok. It will have to be discovered. It will have to be emergent. Plan B is a place holder for an alternative approach to the status quo (plan A). Not an approach that has all the answers but rather, one that allows for humility, curiosity and learning and explicitly acknowledges how little we know.

I’m seeking employers who are up for some humble enquiry[1]. I’d like to create a learning environment where we can apply what is known (evidence based) and also institutionalise imagination (collectively) to expand on what is known. I’m keen to develop a coalition of curious stakeholders who want to work together, dialectically, to learn more about supporting injured workers.

The humanised model (plan B)

This model is scaffolded by a skilled return to work (RTW) coordinator. But not in traditional form. The form I propose is a supportive and facilitative role rather than a management role. I would prefer to reframe RTW Coordinators as Recovery Support Guides (RSG).

The humanised model seeks to unlearn the plan and control mindset and adopt a posture of authentic curiosity. Instead of telling people how to get better, a humanised plan B infuses humble enquiry in order to facilitate learning and sensemaking.

A Recovery Support Guide (RSG) would start by meeting the injured worker and listening. No questionnaires, no assessment, just active listening and open questions. Workers have a story to tell, and the telling is critical to their sensemaking. The missing link to recovery is the acknowledgement and facilitation of the workers’ sensemaking. If they aren’t encouraged to experiment, take risks, make mistakes and learn, then their recovery is impaired. The challenge for the RSG is to avoid being an expert, to resist the urge to impose a process. Premature articulation should be avoided. The best time to offer advice is after it has been asked for. When the worker asks for advice, they are taking a tentative step towards a relationship, and Relating is doing.

Rosa Antonia Carrillo[2] says that ‘inclusion precedes accountability’. Carrillo argues that a worldview that advocates for control, where people need to be told what to do and monitored for compliance, undermines self-efficacy and accountability.

Professor Ed Schein, in his book Humble Enquiry[12], notes that the act of humble enquiry goes beyond just asking overt questions. It’s about creating a genuine attitude of interest and curiosity, which are the foundations of a relationship.

If we want to enhance recovery from injury we need to find creative ways to help people make sense of their unique circumstances. Regardless of the incidence of a specific type of injury, the complexity of individual personalities nested within an even more complex social context does not lend itself to a prescriptive algorithm for recovery. In fact, trying to predict timeframes and results, establishes expectations which, if not met, often sparks an unfortunate eruption of attribution by ‘experts’ with questionable competency in the art of prediction.

Monica Worline and Jane Dutton, American academics, in their book[1] “Awakening Compassion at work: the quiet power that elevates people and organizations”, advocate noticing. They counsel against fixing. Noticing suffering and engaging with sufferers is their theme. The world of workers compensation and the traditional medical model is saturated with ‘fixes’ and ‘fixers’.

Within the humanised model, the Recovery Support Guide spends their time more effectively by liberating themselves from telling and fixing, by facilitating autonomy support and by enacting humble enquiry. By valuing relating more than doing, the RSG engages in conversations with workers and their line managers. Not in a formal, sign-here-approach, but rather in a spirit of genuine curiosity and collective discovery.

Provan[3] et al., recommend an attitude of guided adaptability over the centralised control model. They propose that ‘safety professionals’ reframe the inevitable gap between work that is planned and what actually happens in the real world, as a learning opportunity rather than a compliance issue. A compassionate and curious RSG might adopt this approach with injured workers.

Such an approach is antithetical to the typical misunderstandings that arise. These misunderstandings include some assumptions such as;

· there is an algorithmic cure that, if followed, will result in predictable outcomes

· we can educate workers by lecturing and telling

· that we can motivate workers to recover by punitive means

Acknowledging our collective ignorance and fallibility not only puts us more in touch with reality it also provides a pathway to relationship building. The errant and/or efficacious actions we take create reality. The conversations we have about the deviations from our predictions can provide a portal to stronger relationships. And the relationships provide a substrate for learning.

So, what does the humanised model look like? This will vary according to the existing culture, but the basic approach might be as follows;

Worker

· Replace assessments with meetings (the kind where you have a coffee or a meal and a more human connection – the key is to spend enough time with the worker to develop trust)

· Replace telling with active listening that empowers their sensemaking

· Encourage involvement with and engagement of significant others

· Encourage and provide autonomy support (see Professor Ed Deci’s work) around treatment options and suitable duties

Workplace

· Replace RTW plans with a collaborative learning experience (worker, supervisors, doctor & treatment providers = conversational learning team)

· Accept that medical certification is at best a guess and encourage doctors to specify a range of restrictions (e.g. lifting up to 10kg and/or working up to 30 hours per week) and encourage workers and supervisors to experiment and learn as they go

· emphasise psychological safety (value the workers’ and the supervisors’ opinions and encourage them to speak up)

· coaching of supervisors around using the recovery experience to enhance interpersonal relationships

· replace the exercise of reviewing RTW plans with ongoing conversations about the difference between what was expected and what actually occurred (see example below) and the resultant adaptations

Medical model

· truly collaborative partnerships with doctors & treatment providers (if the worker trusts me then their doctor usually does too)

· facilitate the worker’s empowered decision making in collaboration with treaters and doctors

· face2face (or zoom in the covid context) as much as possible but in a relational mode rather than the current scrutineer (why haven’t they upgraded?) mode

· minimise side bar conversations, the worker must trust the interactions between the RSG and the treating professionals

· encourage treating professionals to engage ‘between’ consults via email/whatsapp/text etc to facilitate a more collaborative learning experience as the worker navigates their suitable duties and treatment. That is, sensemaking that is dynamic and responsive to enactment.

Compensation system (the insurer)

· Replace process with relationship (cultivate trust and autonomy)

· Replace paperwork with conversation (I’m not opposed to keeping case notes and careful records, but I try to minimise the paperwork the worker is exposed to)

· Minimise dehumanising language (e.g. claimant), legalistic jargon and claim numbers in correspondence to/from workers

· Minimising controlling behaviours by insurers, human resources and supervisors (this is quite challenging)

· Facilitate face to face meetings between insurers and workers

Relationships are the key. Common ground must be established between the competing values of the sub-cultures (employer, insurer, worker, medical). The employer is well placed to facilitate this with their insurer.

The Recovery Support Guide needs to be ‘pan-tribalist’. They need to speak the language of the worker, the insurer, the medical team and the employer and be skilled at finding the common ground between them. Each sub-culture has its own language and norms and they often engage in a manner that frustrates each other.

Barnes and Limberg[4] recommend ‘grey pilling’, a concept that was developed by Venkatesh Rao, which adds a third dimension to the dichotomous red/blue pill idea referenced in the movie, The Matrix…

A grey pill, according to Venkatesh, is the process of “relearning the value of questioning and doubt after you’ve been seduced by answers and certainties; it’s leaving comforting ‘secret’ societies for continued intellectual growth.” Grey pills can engender an existential crisis, but at the right dose they can provide a confident unknowing and a sexy uncertainty, what Stephen Fry calls “passionate and positive doubt.” In a world of tyrannical certainty, grey pilling may be an ethical act.

This speaks to the concept of dialectic engagement, where we assume we’re always talking to someone who has something to teach us, where we assume we could be wrong (intellectual humility), where we acknowledge our confirmation bias. It’s this type of engagement that I’m advocating for the Recovery Support Guide. ‘Sexy uncertainty’.

After an injury there is a lot of uncertainty. Traditionally we like to think we can minimise uncertainty and facilitate healing with diagnosis, treatment and RTW plans. In the humanised model we accept that there is much we don’t know about the diagnosis and prognosis and we encourage injured workers, and those pulled into their orbit, to engage in enacting and talking and learning (aka sensemaking). This approach satisfies the duality of supporting the individual’s recovery while simultaneously providing learning opportunities for the organisation.

I feel like we are missing an opportunity. My thesis is that by caring for people authentically, not only do we support their recovery, but we can strengthen their relationship with their work, with their colleagues and with their employer. And perhaps, more ambitiously, the enactment of a relating approach permeates the organisational discourse. Imagine a worker who feels so well supported in their recovery that their motivation and discretionary effort increases as a result of their injury experience.

[1] https://www.youtube.com/watch?v=BOw0IDrKvuw

[2] Carrillo, Rosa Antonia. The Relationship Factor in Safety Leadership (p. 90). Taylor and Francis. Kindle Edition.

[3] https://www.journals.elsevier.com/reliability-engineering-and-system-safety

[4] https://medium.com/s/world-wide-wtf/memetic-tribes-and-culture-war-2-0-14705c43f6bb

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James Ellis

Managing Director at The Framework Group

Latest posts by James Ellis (see all)

• In search of plan B in workers’ recovery - July 29, 2020
• What and how should we measure to support recovery from injury? - May 24, 2017
• Humanising Workers Compensation: the missed opportunity - April 24, 2017
• I work in workers compensation - September 22, 2015
• Talking Risk Video–Anti-Fragility - May 16, 2015

B.App.Sc (Physio)After finishing High School I experimented with a range of vocations including 12 months as a midshipman in the Royal Australian Navy, a false start studying Engineering at UNSW and a very enjoyable 5 years as a gym instructor at a variety of gyms in Sydney.I graduated as a Physiotherapist from the University of Sydney in 1991. After 12 months as an intern in the public hospital system in NSW I travelled to Michigan, USA, where I obtained experience in an outpatient facility servicing the local community and the adjacent private hospital. I then returned to Australia and obtained a full time position at the Hills Street Sports Medicine Centre in Gosford, NSW, treating sports injuries.In 1995 I founded Hills Street Occupational Rehabilitation Service which later became Hills Street Group and, more recently, Framework Group. Over the past 19 years we have grown to have several franchised teams throughout NSW.I really enjoy the daily challenge of problem solving in the complex arena of workplace injury management. At Framework, we focus on humanising injury management. We've developed a unique model of injury management that allows our employer clients to maintain and enhance their relationships with their workers which, in turn, has very positive commercial implications. We believe that injury management provides employers with a portal through which they can demonstrate how much they care about their team. We believe that mistakes and injuries are inevitable, because people are fallible, but this same fallibility provides opportunities for learning and enrichment of relationships.