Robert J. Gatchel and Izabela Z. Schultz (eds.)Handbook of Musculoskeletal Pain and Disability Disorders in the WorkplaceHandbooks in Health, Work, and Disability10.1007/978-1-4939-0612-3_23

23. Work Accommodation in Musculoskeletal Disorders: Current Challenges and Future Directions in Research and Practice

Hanah C. Kwan¹ and Izabela Z. Schultz²

(1)

Department of Educational and Counselling Psychology, and Special Education, University of British Columbia, New Westminster, BC, Canada

(2)

Counselling Psychology Program, Department of Educational & Counselling Psychology and Special Education, University of British Columbia, 2125 Main Mall, Vancouver, BC, Canada, V6T 1Z4

Hanah C. Kwan (Corresponding author)

Email: hanahkwan@yahoo.ca

Izabela Z. Schultz

Email: ischultz@telus.net

Due to the economic, personal, and societal impact of workplace injuries, the return to work (RTW) process in occupational disability, especially in musculoskeletal disorders (MSD), has been extensively researched. It has been described as multifactorial and involving multiple stakeholders (Baril, Clarke, Friesen, Stock, & Cole, 2003; Carroll, Rick, Pilgrim, Cameron, & Hillage, 2010; Franche, Baril, Shaw, Nicholas, & Loisel, 2005; Friesen, Yassi, & Cooper, 2001; Krause, Frank, Dasinger, Sullivan, & Sinclair, 2001; Loisel, Durand, Baril, Gervais, & Falardeau, 2005; Loisel et al., 2001; Schultz, Stowell, Feuerstein, & Gatchel, 2007). This often means that, for many injured workers, the process is complicated and systems are difficult to navigate. Various systematic reviews and best evidence synthesis have been written about the existing RTW body of quantitative and qualitative studies. These reviews (Franche, Cullen, et al., 2005; Krause, Dasinger, & Neuhauser, 1998; MacEachen, Clarke, Franche, Irvin, & Workplace-based Return to Work Literature Review Group, 2006) and other studies (Arnetz, Sjögren, Rydéhn, & Meisel, 2003; Crook, Milner, Schultz, & Stringer, 2002; Loisel et al., 1997) have identified that work accommodations are critical components in enhancing RTW outcomes. However, on systematic review of best evidence-informed practices in the field of RTW, the effective implementation of workplace accommodations remains elusive (Schultz, Duplassie, Hanson, & Winter, 2012).

Work Accommodation in Current Literature: Conceptual, Research, and Practice Challenges

A wide range of RTW determinants have been identified in the research. Characteristics of the injured worker, components of particular medical and occupational rehabilitation interventions, physical and psychosocial job characteristics, workplace factors, the insurer or workers’ compensation scheme, and broader societal factors such as labor market conditions and the prevailing legal framework all have been shown to have some role to play in influencing RTW outcomes independent of the underlying medical condition (Krause et al., 2001; MacEachen et al., 2006; Pransky et al., 2002). One of the major challenges is that relevant research is not only cross-disciplinary but also partly unpublished and contained in reports from various statutory authorities and other stakeholders in the RTW process (Krause et al., 2001). This issue has resulted in an extremely large body of literature which, at the same time, is difficult to analyze, compare, and synthesize because of the variability in the population studied, sampling procedures, the study design issues, and the way the variables, including outcome variables, are defined and measured in the research (Krause et al., 2001). This chapter includes contributions from any research discipline that addresses the intersection of RTW and accommodations. This literature review concentrates on factors affecting RTW for workplace-injured workers with musculoskeletal injuries, including the role of various stakeholders.

Work Accommodation Research: What We Know and What We Do Not Know

The terms workplace interventions, modified work, job modifications, and accommodations have been overlapping and entangled concepts in the literature (Durand et al., 2007). The accommodation research could be divided into two broad categories. The first category describes an inclusion strategy for employees with long-term disabilities from non-work-related injuries (Butterfield & Ramseur, 2004; Gates & Akabas, 2011; Habeck, Kregel, Head, & Yasuda, 2007; Moon & Baker, 2012; Schartz, Hendricks, & Blanck, 2006). The second category encompasses an intervention to facilitate RTW of injured workers temporarily or recurring and, henceforth, referenced as RTW accommodations and RTW accommodations process. This body of research is multidisciplinary, involving disability studies, human resource and management, occupational disability, and physical and occupational therapy. Accommodations as an inclusion strategy may be more extensive including transportation access, personal assistance, assistive technology such as voice recognition software and applications. This category often has a greater focus on macrosystem interventions aimed at changing societal attitudes such as duty to accommodate, reasonable accommodations, human rights legislation, and legislative policies for inclusion. Some researchers have postulated the need to distinguish between permanent and temporary modifications to the work situation in order to advance the accommodation research (Durand et al., 2007). The terms “recurring” versus “one-time requests” for accommodations have also been used (Baldridge & Veiga, 2006). In addition, much of the research to date does not distinguish accommodations for work- or non-work-related injuries. There are indications of possible differences in the processes for these two types of accommodation requests. Interest-ingly, Schartz and associates found that current employees who become disabled are more likely to receive workplace accommodations as compared to job applicants with disabilities entering the workforce and requesting accommodations (Burkhauser, Schmeiser, Weathers & Robert, 2011; Schartz et al., 2006).

Injury and Disability Type

The injury-related conditions studied have varied in the RTW literature (Burton, Kendall, Pearce, Birrell & Bainbridge, 2009; Waddell & Burton, 2001). Much of the conceptual models of RTW have been derived from research on MSD and have been applied to RTW processes for all types of work disability (van Oostrom et al., 2009). As such, there is a large body of research on MSD (e.g., Arnetz et al., 2003; Bültmann et al., 2009; Franche et al., 2007; McCluskey, Burton, & Main, 2006) and a specific focus on back pain (e.g., Karjalainen et al., 2003; Loisel et al., 1997; Soeker, Wegner, & Pretorius, 2008; Steenstra, Verbeek, Heymans, & Bongers, 2005; Yassi et al., 1995) and upper extremity disorders (e.g., Williams, Westmorland, Schmuck, & MacDermid, 2004). However, in a review of workplace accommodations, Butterfield and Ramseur (2004) noted that 19 of the 30 articles were single-subject case studies describing specific accommodations made for specific individuals. The other 11 multi-subject studies mostly looked at accommodations for people with musculoskeletal limitations and visual impairments. The question of the cross-validity, generalizability, and application of these studies for differing conditions is an unanswered question in the research literature. Few published studies have described and compared the types of accommodations used by people within and across user groups (Sanford & Milchus, 2006). Furthermore, van Oostrom and associates’ review of workplace interventions found that there were insufficient numbers of studies to determine whether workplace intervention outcomes differ by condition type for MSD, mental health problems, and other health conditions (van Oostrom et al., 2009).

Key Accommodations by Type

Descriptive studies of the prevalence of various types of accommodations and outcome studies of the efficacy and effectiveness of accommodations for specific populations are generally lacking (Sanford & Milchus, 2006). Although the importance of work accommodation in RTW is recognized, little is known about the impact of specific ergonomic, work organization, and schedule components on outcomes (Franche, Baril, et al., 2005). Research in modified work has identified the need for tools to (1) provide a link between measures of physical function and specific work tasks, (2) improve concordance between ergonomic exposure categories and usual methods of accommodation, and (3) provide a structured process for including employee and employer preferences (Lincoln, Feuerstein, Shaw & Miller, 2002; Franche, Baril, et al., 2005). However, valid and reliable assessment methods and studies that identify information needs for making decisions, including evidence of functional limitations, about appropriate accommodations are also lacking (Sanford & Milchus, 2006). Sanford and Milchus (2006) put forth that:

The absence of empirical evidence base in workplace accommodations has often resulted in unnecessary reinventing of wheels and perhaps over reliance on unproven or ineffective ones in the practice of workplace accommodations (p. 329).

Butterfield and Ramseur (2004) also reviewed the types of assistive technologies used in the workplace for work-related or non-work-related and broadly classified disabilities. They found that short-term accommodations were commonly implemented, such as adjusting work schedules, adopting flexible leave policies, and restructuring jobs, which they referred to as supported employment and adaptive strategies. The authors reported that computer technologies were the most prevalent workplace accommodation in the literature. Their review also looked at environment access accommodations (i.e., tool operation, seating, and positioning). Other modified work studies have found that the most common type of modified work or accommodations was light duty, followed by flexible schedule and reduced hours (Brooker, Cole, Hogg-Johnson, Smith, & Frank, 2001; Krause et al., 1998). Additionally, Yeager and associates found that employee requests for assistive technology were often granted, but many others had to pay for their own workplace assistive technology (Yeager, Kaye, Reed, & Doe, 2006). Williams, Sabata, and Zolna (2006) also found that among a sample largely of individuals with motor limitations, a significant number of participants indicated that they did not receive any workplace accommodations, despite functional limitations. As well, the researchers showed that older employees who have disabling conditions were less likely to receive workplace accommodations.

Workplace-Based Inventions and Modified Work

An increased focus on workplace programs for the timely and safe RTW of employees with the provision of modified work has resulted in two well-cited literature reviews examining workplace-based interventions. The reviews suggest that there is moderate quality evidence to support the use of workplace interventions to reduce sickness absence (van Oostrom et al., 2009) and strong evidence that work accommodation offers reduced work disability but insufficient evidence to support the sustainability of the effects of these workplace interventions (Franche, Cullen, et al., 2005). The results from these literature reviews summarize a wide range of different interventions, ranging from modified work as the only intervention to modified work as one of the elements in a multidisciplinary rehabilitation program, although studies reviewed by van Oostrom et al. (2009) did not all report whether the injury being accommodated was work-related or not. Furthermore, Krause et al., (1998) found that employees with temporarily modified work were twice as likely to RTW as employees without access to any form of modified work. It was estimated that, on average, a 50 % reduction in days lost from work could be expected for those employees with modified job activities (Krause et al., 1998). Overall, modified work programs facilitate RTW for temporarily and permanently disabled workers (Schultz, Crook, & Winter, 2005) and reduce work absence duration (Crook et al., 2002; Franche, Frank, & Krause, 2005; Krause et al., 1998; Turner et al., 2008).

In current conceptual models of RTW, timing is of particular importance; thus, interventions should be early but also appropriate (Pransky, Shaw, & McLellan, 2001; Franche, Frank, et al., 2005). Pransky and associates suggest that appropriate timing of RTW and properly structured accommodations or job modifications to decrease ergonomic risks constitute potential key determinants of a safe and sustained RTW (Pransky et al., 2002). In sum, the quantitative and qualitative literature suggests that employers and workplace interventions play a key role in the RTW process and that the most commonly used workplace interventions include work accommodations (Franche, Cullen, et al., 2005; Krause et al., 1998; MacEachen et al., 2006). However, the term “modified work” is often broadly defined to include all forms of modified work, including combination with other interventions (Krause et al., 1998). Moreover, the interventions carried out in workplace interventions are very heterogeneous and are often ill defined and idiosyncratic. Thus, they may not be replicable in research and practice. As such, Durand et al. (2007) recommended that better descriptions of workplace interventions are necessary in future research.

Economic Studies of Accommodations

Legislative frameworks also vary with respect to employer efforts to deal with disabling medical conditions and provide reasonable accommodations. Financial incentives for employers to reduce sickness absence also vary by country and by insurance system. Economic studies have examined the effects of economic incentives for employers, differences on compensation type during time off work, and cost–benefit analysis for insurance/compensation systems and employers. These studies have provided mixed evidence about the economic benefits of RTW interventions and programs (Anema et al., 2007; Arnetz et al., 2003; Loisel et al., 1997). Overall, there is moderate strength evidence to support the financial merits of interventions with work accommodation offers (Franche, Cullen, et al., 2005; Tompa, de Oliveira, Dolinschi, & Irvin, 2008; van Oostrom et al., 2009). It was noted that “The financial costs and gains of providing work accommodation are of particular concern to employers given their immediate and important role in the planning of work accommodations” (Franche, Baril, et al., 2005, p. 529). Costs of accommodations are often considered prohibitive despite the lack of empirical support for this notion in economic studies. Employers are most likely to respond positively where financial implications are favorable to productivity and profitability and where workplace roles are clear and not burdening (Franche, Baril, et al., 2005). Baldridge and Veiga (2006) found that monetary costs and impositions on others negatively influenced the likelihood of requesting recurring accommodations and the assessment of the social consequences of making such requests in employees with hearing impairments.

The assessment methods utilized to determine costs have been criticized for not including indirect costs and direct and indirect benefits and for not distinguishing disability-related accommodation costs from generic employee costs unrelated to disability (Schartz et al., 2006). Blanck (1994) reported that most accommodations had no direct costs. Indirect costs of supervision and co-worker time were reported in accommodations for individuals with mental health disabilities (MacDonald-Wilson, Rogers, Massaro, Lyass, & Crean, 2002). Utilizing a model of direct and indirect costs, Schartz et al. (2006) suggest that accommodation costs may be even less than previously reported when disability-related costs are differentiated from general employee costs.

There has been an increase over the last decade in workplace accommodation offers from employers (Brooker et al., 2001). The discernible benefits of work accommodation include decreased worker anxiety (Pransky et al., 2001) and reduced re-injury rates (Yassi et al., 1995). Employers may also directly benefit from retaining valued employees, increasing employee productivity, and eliminating costs associated with training new employees (Hernandez et al., 2009; Job Accommodation Network (JAN), 2012). Indirect benefits include improving colleague interaction, increasing overall company morale, and increasing overall company productivity (JAN, 2012). However, a discrepancy continues to exist between the benefits and effectiveness of accommodations on the one hand and perceptions of workplace costs on the other (Schartz et al., 2006).

Workplace Factors in Accommodations

There are limited research studies on the relationship between accommodations and workplace factors. Worker-level, job-level, and workplace-level factors have been associated with offer and acceptance of work accommodation for individuals with musculoskeletal injuries (Franche et al., 2007). Job-level factors, workplace factors, and policies about mandatory work accommodation were stronger determinants of offer and acceptance of work accommodation than individual health factors (Franche et al., 2007). A number of factors may hinder workplace accommodation efforts, including organizational constraints and industry-specific barriers related to unions or legislation and barriers in the methods of assessing functional capacities relative to physical job demands, physical function, and workplace exposure that are not suited to the job accommodation process (Shaw & Feuerstein, 2004). Furthermore, providing adequate and sufficient accommodations can be challenging, particularly in small workplaces where there are fewer work options and, hence, larger companies often have more established policies and procedures and may have more flexibility in implementing accommodations (Schultz, Milner, Hanson, & Winter, 2011). Even with a detailed needs assessment and implementation process, significant obstacles may still remain for employers to allow or provide some accommodations (Lincoln et al., 2002). As well, the rights of an injured worker to modified duty may conflict with the right of another worker to access the same position due to seniority within unions and conflicts with multiple unions. Johnson and associates found that the specific types of job accommodations provided had no separate significant effect on employment outcomes; rather, employment outcomes were improved in firms with more proactive RTW policies, involving job accommodations, than in firms with more restrictive policies (Johnson, Butler, Baldwin, & Côté, 2012).

Examining factors affecting employee satisfaction with accommodations with mobility-related disabilities, Balser and Harris (2008) found that those employees whose input was sought by the organization and who later received the requested accommodation were significantly more satisfied with their accommodation. Also, the authors reported that employee race/ethnicity was indirectly related to employee satisfaction as these individuals often had less input in the process and were less likely to be granted accommodations (Balser & Harris, 2008). As well, Burkhauser, Butler, and Kim (1995) examined a dynamic model of job exit and found that the risk of a worker leaving the employer after a work-limiting health condition is significantly reduced when an employer accommodates the worker.

Emergence of Conceptual Models

A number of conceptual models of the accommodation process have been postulated and well cited though they have yet to be empirically validated. Cleveland, Barnes-Farrell, and Ratz (1997) consider the workplace’s reaction to accommodation to be related to four major factors: (1) the rationale for the accommodation; (2) the nature of the accommodation; (3) whether the accommodation is organization, employee, or jointly initiated; and (4) the characteristics of the person being accommodated. The rationale for accommodation may be a legal mandate, social/moral obligation, or business consideration. Cleveland et al. (1997) describe business considerations, changing workforce demographic characteristics and enhancing productivity and reward for performance as reasons and incentives for employers to implement accommodations. The authors assert that accommodations are not limited to responses to disabled individuals and that organizations routinely use accommodations to compete for qualified individuals by adjusting work activities or the work environment. These accommodations are often labeled extra benefits or perks of the job.

Co-worker responses may be a factor supervisors consider when deciding whether to grant an accommodation (Cleveland et al., 1997). Baldridge and Veiga (2001) considered the decision process to request accommodations by workers and proposed that past responses to accommodation of group members would influence the likelihood of future requests being made. An employee would request an accommodation based on the perceived usefulness of an accommodation, the appropriateness of seeking help, and the workplace accommodation culture (Bainbridge & Veiga, 2001). Organizational justice models have also been utilized to explain that the conditions of “fairness” or justice may be relevant to understanding the employers’ and employees’ reactions to accommodations (Cleveland et al., 1997; Colella, 2001). Two of the components of organizational justice are distributive justice and procedural justice. Distributive fairness or justice refers to the perceived fairness of the outcome of a decision, which in this case means how fair co-workers believe the accommodation is in terms of its effect on the distribution of rewards and resources (Cleveland et al., 1997). Procedural fairness or justice is defined as the perceived fairness of the processes or procedures through which outcome decisions were made (Colella, Paetzold, & Belliveau, 2004). In this case, procedural justice judgments would refer to the degree to which the process of granting an accommodation was fair (Cleveland et al., 1997). Colella (2001) proposed a model that focuses on co-workers’ perceptions of distributive fairness and suggested that if the accommodation is salient and relevant to co-workers, those co-workers will engage in evaluating the distributive fairness of the accommodation based on rules of fairness and need. Colella et al. (2004) further proposed that individual and organizational factors are likely to influence co-workers’ procedural justice inferences.

RTW Accommodation Process: Lessons from Mental Health, Musculoskeletal and Social Interaction Research

The focus of accommodation research has recently shifted to individuals with mental health conditions. This literature is relevant for understanding of the work accommodation in MSD for two reasons: mental health conditions, such as depression and anxiety, often develop in chronic pain conditions, and both mental health and pain disabilities are non-visible and more stigmatized than other clinical conditions. Despite an extensive body of research on RTW, much of the literature has focused on strategies most successful in reducing the duration of work disability and returning injured workers to the workplace rather than on how these strategies are implemented (Hepburn, Franche, & Francis, 2010). The mental health research literature has made strides in this area. Schultz and her team found that employers are generally familiar with communication and interaction-oriented, management-based job accommodations such as open communication, positive reinforcement, and additional training (Schultz, Milner, et al., 2011). Employers were less familiar with structural, environmental, and organizational aspects of job accommodations that required multilevel support with the workplace and were more complicated to implement for individuals with mental disorders (Schultz, Milner, et al., 2011) and relationship accommodations (Gates, Akabas, & Oran-Sabian, 1998). Recent research evidence supports the following components and needs in the accommodation process, which apply well to MSD:

Assessment of the accommodation needs and the workplace environment’s readiness, such as mutual impact of accommodation on individual and work group, support for effective communication, and flexibility to accommodate the individual (Gates & Akabas, 2011).

Additional training, education, and increased awareness of accommodations may be needed for the workplace (Schultz, Milner, et al., 2011).

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Work Accommodation in Musculoskeletal Disorders: Current Challenges and Future Directions in Research and Practice

23. Work Accommodation in Musculoskeletal Disorders: Current Challenges and Future Directions in Research and Practice

Work Accommodation in Current Literature: Conceptual, Research, and Practice Challenges