Humanising injury support – In search of Plan B

No one likes workers compensation. Keep your employees safe by humanising injury support.

The cumbersome systems that have evolved cause frustration and suffering for employers and workers. Employers get saddled with unpredictably volatile costs and workers get labelled as problems to be fixed. We therefore need humanising injury support. 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.

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.

Monica Worline and Jane Dutton, in their book[1] awakening compassion at work: the quiet power that elevates people and organizations, make the claim that a compassionate workplace is not only ethically desirable but is also good for the bottom line. They focus on the inevitability of suffering at work and its antidote, compassion.

They say that[1];

• Compassion is a felt and enacted desire to alleviate suffering.
• Compassion is defined as a four-part process involving attention, interpretation of suffering, felt empathic concern, and action to alleviate suffering.
• Suffering is pervasive in workplaces.
• Common sources of suffering flow from outside work boundaries, when people suffer from illness, injury, loss, divorce, financial pressures, addiction, or other hardships.

Research[2] shows that compassion for this kind of pain leads to more adaptability and more effective change processes, which are part of the strategic significance of compassion at work.

Without compassion, workplaces can become powerful amplifiers of human suffering[3].

It’s time to challenge this tendency to disregard the value of compassion[4]. While a growing body of research continues to highlight new benefits, significant questions about the fundamental value of compassion for organizations have been answered. Compassion is an irreplaceable dimension of excellence for any organization that wants to make the most of its human capabilities.

In health care[5], where compassion is at the heart of the professional value system, we see that the practice of compassion at work is often driven out by overload, time pressure, technological changes, financial worries, regulatory mandates, and other organizational pressures that make humanistic concerns seem marginal.

The workers compensation environment provides overload, time pressure, technological changes, financial worries, regulatory mandates, and other organizational pressures that make humanistic concerns seem marginal.

Amy Edmondson, researcher and author of The Fearless Organisation[6] observes that a compassionate approach to errors results in the psychological safety to admit to and discuss errors. Worline and Dutton discuss her findings and conclude that this approach creates an environment more conducive to learning.

“psychological safety[7]a willingness to discuss and learn from errors, failures, mistakes, or near misses. Compassion helps people to greet errors and failures with the open-mindedness and open-heartedness that foster learning.”

Edmondson says that;

“unless a leader expressly and actively makes it psychologically safe to do so, people will automatically seek to avoid failure.”

I’ve heard it said that open markets are good at creating efficiency but regulation is needed to ensure an ethical frame. I think all can agree that workers compensation is inefficient.

Jacques Ellul was concerned with the emergence of technological tyranny over humanity.[8] He observed that technology catalyses the questioning of anything that doesn’t advance our financial and technical state. He argued that humankind becomes subservient to technology rather than the other way around and he was concerned about how this bled into our education system. Ellul died in 1994 but his perspective was prescient. In his words.

[W]hat is at issue here is evaluating the danger of what might happen to our humanity in the present half-century, and distinguishing between what we want to keep and what we are ready to lose, between what we can welcome as legitimate human development and what we should reject with our last ounce of strength as dehumanization. I cannot think that choices of this kind are unimportant.[9]

Modern technology has become a total phenomenon for civilization, the defining force of a new social order in which efficiency is no longer an option but a necessity imposed on all human activity.[10]

In the end, technique has only one principle, efficient ordering.

If ever there was a good example of how technique and regulation combine to dehumanise people, then workers compensation is it. For many years I have been chipping away at humanising the workers comp experience. I can’t redesign the current system so I’m just trying to parasitize it with small interventions.

According to evolutionary biologist, Brett Weinstein, we shouldn’t leave evolution to fate. He says[11],

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.

I’m wary of plans (see here), they get in the way of learning and feed the hungry hubris monster. I’m not opposed, I’m wary. Plan B is a metaphor for an alternative approach. 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 have long been frustrated by the oversimplified approach to measuring in injury support (see more in this here). Last year (2019) I attended a two-day seminar at Monash university on Return to Work: Evidence and Innovation.   Professor Alex Collie and his team presented their findings and this sparked my imagination. I subsequently presented a summary of my thinking on a humanised approach to injury support to Alex and proposed that we form an informal partnership to examine my humanising theories.  I’m delighted that he has agreed to this.

Injury prevention and support is most often nestled within a centralised effort at control. This approach assumes that the safety manager, the regulator, the RTW coordinator, the insurer and the HR team can provide and decree systems of work that will satisfy the competing priorities of efficient productivity, safety and injury prevention with scarce resources and competing values. These gives rise to algorithms, heuristics, rules, plans and compliance – a perfect storm for dehumanising.

I’m seeking employers who are up for some humble enquiry[12].  I’d like to create a learning environment where we can apply what is known (evidence based) and also use our 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).

It’s not that the goal of RTW is wrong, there is no shortage of evidence that remaining at work or returning early is coincident with good outcomes (although I do worry that we are confusing correlation with causation). A single-minded focus on the achievement of fitness for pre-injury status creates an end justifies the means approach which sends us down the path of compulsion and coercion. We get independent opinions from doctors who have little time to form an opinion, we get conversational pressure from claims managers who imply that you should be better by now and we get very organised RTW coordinators writing plans that must be signed in order to lock workers into a ready-or-not outcome. There is an underlying assumption that we can predict outcomes and timeframes. We see workers having to prove they’re unwell to demonstrate their integrity.

RTW coordinators busy themselves writing and sharing plans and chasing signatures. This process often absorbs the current stage of RTW and by the time everyone has signed and submitted the RTW Plan a new certification is due and the cycle begins anew. It’s easy to be buried in paperwork. 

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

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 sense making. The missing link to recovery is the acknowledgement and facilitation of the workers sense making. 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.  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. Premature articulation should be avoided.

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. The question how long will they take to recover? Is as about as useful as “how long is a piece of string?”. In fact, trying to predict such 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.

Rosa Antonia Carrillo, a student of Edgar Schein (who has published prolifically on organizational culture), 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 Schein himself, in his book Humble Enquiry[12], notes that;

“Not only do we value telling more than asking, but we also value doing more than relating and thereby reduce our capacity and desire to form relationships.”

The act of humble enquiry, he says, goes beyond just asking overt questions. It’s about creating a genuine attitude of interest and curiosity, which are the foundations of a relationship.

Professor of psychology, Edward Deci, argues that an autonomy-supportive environment is preferred if we want to maximize individual and group motivation. Deci and Carrillo advocate for healthy relationships and authentic listening. Deci suggests we reframe the familiar question how can I motivate someone? As how can we create a more autonomy-supportive environment?

Dutton and Worline 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 humanized 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 inquiry. 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[13] 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. In such a case the work as planned is represented by the typical RTW plan and the variation from the predicted path of recovery provides fertile ground for learning.  The anxiety this causes the worker can be tackled and the RSG can help them to understand the guilt and blaming that arises when their treaters predictions are inevitably revealed as educated guesswork.

Such an approach sets right some typical misunderstandings that arise. These misunderstandings include assumptions that;

•       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

Rosa Carrillo explains the concept of sensemaking as follows;

“Sensemaking[14], a model developed by Karl Weick, is the process by which people make sense of the unknown so that they can take action. When sensemaking is done as a group, it is also serving the function of creating a common understanding of an event, a challenge or potential solution. Weick says that sensemaking is both an individual and group process.“

“The action taken when sensemaking is described by Weick as enactment.”

“Karl Weick[15] defines Enactment as people taking action to make sense of how things work and to solve problems (1988; 2009; Weick and Sutcliffe, 2007). It is also a way of approaching uncertainty. So enactment is a part of the learning process. Taking action sometimes leads to mistakes. Thus mistakes are also part of the learning process.”

“We often say that a mistake is an opportunity to learn but we are conditioned to believe that mistakes are wrong and making them makes us a failure[16].“

“Enactment[17] is acting out ideas or vision it brings them into physical reality. I like this explanation of how to create change, which means changing the reality around us. It seems contrary to the simplistic idea that developing an action plan with a list of corrective actions will solve a complex situation. The reality is that every action we take changes the situation we are facing. When it comes to enactment, the feedback must be continuous so that we can course-correct. It is action that creates reality. It is action that changes the course of intended outcomes. As discussed earlier, conversation is the primary enactment force in organizations.”

Carrillo articulates three key concepts;

1. Mistakes are inevitable and catalyse learning

2. Predictable outcomes via plans are fraught but acceptance of inevitable variability creates opportunity for learning

3. Conversation is crucial to make sense of the enactment

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 humanized 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 (empower their sensemaking)

•        Encourage involvement with and engagement of significant others

•        Encourage and provide autonomy support (see Professor Ed Decis work) around treatment options and suitable duties

Medical model

•        Put effort and time into truly collaborative partnerships with doctors & treatment providers (if the worker trusts me then their doctor usually does too)

•        facilitate the workers 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

•        no (or minimal) side bar conversations, the worker must trust the interactions between the RSG and the treating professionals

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)

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 opinion 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

Examples of control orientation vs humanised approach

Controlling approach	Humanised approach
Worker is “assessed” by process that reveals a delay in reporting of several days and is given a warning for not reporting immediately. RTW coordinator and supervisor have a side bar discussion about attributed reasons for slow report. Perhaps worker doesn’t have a genuine injury? RTW coordinator tells worker lots of details about workers comp process including penalties for non-compliance. This approach often assumes that people are ‘empty vessels’ that can be filled with information.	RSG meets worker and hears explanation that worker hoped that it would get better in a few days. Didn’t report because team is under pressure at busy time of year and didn’t want to be a burden. RSG takes as much time as needed to hear the worker’s story and ‘steel man’ same. That is, the RSG repeats story back to the worker to test their hearing.  ‘Steel man’ success occurs if the worker agrees they have articulated their story accurately. The RSG recognises that the worker is probably ‘flooded’ with information and understands the need to develop a trusting relationship before dispensing advice.
Worker sent to ‘company doctor’ who diagnoses simple low back pain, offers reassurance and recommends suitable duties. RTW Coordinator attends doctor with worker and assertively puts suitable duties on the table.	Worker attends doctor of their own choosing.  RSG attends with them and, if the worker trusts the RSG because they have developed a respectful relationship, the doctor will usually sense it and a triadic relationship is formed. The goal of the interaction is the formation of the relationship. Relating is doing.
RTW coordinator develops a RTW plan and seeks signatures from key stakeholders.	Enactment of treatment options and suitable duties commence after conversational agreement or consensus is reached on the understanding that receiving treatment and discussing/undertaking suitable duties will result in learning. The learning might be manifest as an aggravation of symptoms (at one end of the spectrum) or a pleasant surprise for the worker that they can cope with the proposed duties better than they expected.  Either way there is learning and the RSG’s role is to listen, validate and facilitate adaptation and relationship building between worker and employer.
RTW coordinator holds worker to account by ensuring compliance with the RTW plan. Deviations may be managed with ‘verbal warnings’ and often discussed in ‘side bar’ conversations with a blame orientation.   RTW coordinator facilitates a functional capacity evaluation which often occurs in a clinic and results in recommendations about current capacity. Such recommendations tend to be quite specific and fail to recognise the variation in capacity that often occurs between	RSG facilitates conversations about the gap between expected response and actual response as a learning experience. This approach acknowledges our limitations in predicting outcomes. What was learnt about functional capacity from the enactment of suitable duties? What was learnt about the preliminary diagnosis from the enacted treatment? How should treatment and duties be adapted in response to the learnings?
Worker gets discussed at quarterly claims review between employer and insurer. Workers and treaters aren’t present so side bar conversations are a feature.	Insurer visits workplace quarterly to meet employer and individual workers. Face to face relationships are encouraged and insurer sees worker performing work in context. Insurer adopts a service orientation to support recovery. Ideally the face to face relationship creates a compassionate and caring approach.
Strict adherence to the hierarchy of RTW goals is managed. If regular ‘upgrades’ towards pre-injury status are not occurring then goal is changed to seek work elsewhere.	Line managers are creative with suitable duties. If a worker can upskill beyond their prior status that is viewed as a net positive outcome. Innovation around creation of new roles is encouraged.

Implementation

The national RTW Strategy 2020-2030, published by SWA, has three broad strategic objectives;

1.     Increase in workers staying in or returning to good work following a work-related injury or illness

2.     Increase in positive return to work experiences for workers with a work-related injury or illness

3.     Increase in employers preparing for, effectively responding to and managing work-related injury and illness in the workplace

They identify five action areas informed by 10 guiding principles;

Action Area 1 Supporting workers	Action Area 2 Building positive workplace culture and leadership	Action Area 3 Supporting employers	Action Area 4 Supporting other stakeholders	Action Area 5 Building and translating evidence
Aims to help workers be actively involved in their recovery and return to work	Aims to support workplaces to reduce stigma and promote positive relationships and behaviours	Aims to help employers effectively support workers in their recovery and return to work	Aims to help other stakeholders support workers in their recovery and return to work	Aims to make better use of data and research to drive continual improvement across the system
Informed by Guiding Principles 3, 4, 5, 8, 9	Informed by Guiding Principles 1, 2, 5, 7	Informed by Guiding Principles 1, 2, 3, 4, 5, 6, 7, 8	Informed by Guiding Principles 4, 5, 6, 8, 9	Informed by Guiding Principles 5, 10

The humanised approach is compatible with these principles and provides a source of innovation to enhance discovery.

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 and with their line managers.

How to best support recovery within our fragmented, attention grabbing, self-appointed expertise and telling focussed culture may not be a solvable problem but my hope is that the humanised approach provides more opportunity for development of personal sovereignty[18] and collective sensemaking than the existing system.

Peter Limberg[19], in his essay on memetic tribes and the culture war suggests;

A new role might be required in the Culture War, that of the Memetic Mediator. This mediator would be a pan-tribalist participant who has the ability to communicate across tribes in a way that seems fair and reasonable to each tribe. They would have the mental agility, empathy, and wisdom needed to shift between a multitude of perspectives.

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.

Rosa Carrillo calls her approach, Relationship Centred Leading (RCL), and suggests[4];

• The quality of leadership is equal to the quality of relationships in the organization.
• If you want engagement be inclusive. Inclusion builds relationships; exclusion destroys them because it diminishes a persons sense of identity and belonging.
• Relationship and communication are inseparable.
• Conversation is the trigger and vehicle for organizational change.
• Leaders are responsible for the level of psychological safety, and therefore for the level of learning in their organization.
• Rules and regulations do not control or direct peoples actions.

A neurological connection exists within all humans for the purpose of survival. It is a powerful connecting force that drives human motivation. Although we may only be conscious of it to the extent that individuals are important to our well-being and within the context of cultural expectations, it has a wide effect. Because everyone in the organization is connected, either optimism or fear (therefore engagement or disengagement) can spread to affect the entire organization through conversation and interaction. RCL is the art of leading others into a positive state of relationship. It starts with building a common awareness of what is and moving together towards a different way of seeing the world. Contrary to approaches that seek to attain higher levels of employee engagement and awareness through programs and policies, this approach mirrors the way work happens organically through a multitude of human interactions. It is a worldview where everything is a non-linear interconnected network of relations as expressed by Fritjof Capra and Pier Luigi Luisi (2015). This takes us away from planned change to the ambiguous process of trusting others to self-organize. If this thought raises a red flag of concern about risks, remember the reality is that the self-organizing is happening all of the time. The real question is whether or not we have prepared people to maintain relationship during uncertainty. If not, the communication breaks down, raising the risk of failure.

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 recovery while simultaneously providing learning opportunities for the organisation. It requires attention to the detail of how the worker does their job and surfaces the barriers to work as done.

Limberg recommends grey pilling, a concept, he observes, 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 were 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 (sovereignty) and attempt to meditate on it. It’s this type of engagement that I’m advocating for the Recovery Support Guide. Sexy uncertainty.

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[1] Worline, Monica. Awakening Compassion at Work: The Quiet Power That Elevates People and Organizations (p. 8). Berrett-Koehler Publishers. Kindle Edition.

[2] Worline, Monica. Awakening Compassion at Work: The Quiet Power That Elevates People and Organizations (p. 9). Berrett-Koehler Publishers. Kindle Edition.

[3] Worline, Monica. Awakening Compassion at Work: The Quiet Power That Elevates People and Organizations (p. 11). Berrett-Koehler Publishers. Kindle Edition.

[4] Carrillo, Rosa Antonia. The Relationship Factor in Safety Leadership (p. 96). Taylor and Francis. Kindle Edition.

[5] Worline, Monica. Awakening Compassion at Work: The Quiet Power That Elevates People and Organizations (p. 14). Berrett-Koehler Publishers. Kindle Edition.

[6] Edmondson, Amy. The Fearless Organisation: Creating psychological safety in the workplace for learning, innovation and growth. Harvard Business School, Wiley publishers 2019.

[7] Worline, Monica. Awakening Compassion at Work: The Quiet Power That Elevates People and Organizations (p. 20). Berrett-Koehler Publishers. Kindle Edition.

[8] https://en.wikipedia.org/wiki/Jacques_Ellul

[9] https://en.wikipedia.org/wiki/Jacques_Ellul#cite_note-FOOTNOTEEllul1989140-31

[10] Fasching, Darrell (1981), The Thought of Jacques Ellul: A Systematic Exposition Edwin Mellen Press, p. 17.

[11] https://bretweinstein.net/

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

[13] file:///Users/pothole/Downloads/1-s2.0-S0951832018309864-main%20(5).pdf

[14] Carrillo, Rosa Antonia. The Relationship Factor in Safety Leadership (p. 30). Taylor and Francis. Kindle Edition.

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

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

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

[18] https://medium.com/deep-code/on-jordan-peterson-and-the-future-51402a370d79

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