Prepared for the inaugural COMCARE National Rehabilitation Conference; Canberra, November 2003.
In this paper, I argue that the standard definition of “rehabilitation” is fundamentally flawed, and in need of a major overhaul.
In this brief note, I wish to raise a few points for discussion at the inaugural Comcare National Rehabilitation Conference. Specifically, I wish to discuss whether there might be new opportunities to revisit what ‘Occupational Health’ can look like in the 21st century and what the implications for prevention and rehabilitation of common workplace problems might be if these suggestions are facilitated.
This paper will concentrate on broadening the definition of occupational health by considering aspects that are given low, or no, priority presently. The paper will argue that a widening of the traditional OHS focus – moving from focussing on treatment or rehabilitation to an explicit preventative perspective (which includes treatment and prevention) will better serve employers and employees alike, with benefits to both. I note here that the Australian Government operating environment continues to change and that risk management strategies are being built into its activities explicitly. This trend may provide the motivation to update the OHS legislation, or, perhaps, simply the focus of its implementation. In addition, I will consider a few examples of what appear to be contradictions between ‘duty of care’ and the rights of individuals. Finally, the paper will identify a number of potential ‘pressure points’ in the present system, via which change, if desired, might be effected
I speak for a small organisation which has been active in pursuing ‘organisational health’ in a few different ways: by working with individuals in group situations, by providing lunchtime seminars on a wide variety of health-related topics, and by working one-on-one with individuals with identified problems in a clinic environment. From many conversations with the participants of these classes, and with patients in the clinic, I wish to discuss how both ‘rehabilitation’, the OHS (CE) and SRC Acts are implemented presently from our perspective. This note is not intended to be a rigorous examination of either the legislation or its implementation – it is more of an ‘impression piece’, to facilitate ideas generation and exchange at a forum that is likely to provide ideas and, possibly, visions of how the future might unfold.
What does OHS look like?
Reduction of potential risks to health in the workplace is the main focus of OHS today, and to some extent this probably reflects the history of successful workplace claims on the insurance industry by injured employees, and ex-employees. In the ‘standard’ office environment, this means that an OHS officer’s time will be spent in determining the extent to which provisions of the Act are being met, and in actively improving the workplace with respect to the same provisions. Depending on the nature of the workplace, this may mean intervention strategies such as ensuring optimal desk-to-wrist-support height, optimum screen height, assessment of the suitability of the office furniture (with a view to reducing the likelihood of OOS or neck pain), and so on.
In a workplace where manual labour predominates, the focus will be on determining the extent of conformity to accepted safe handling practises, reduction of gross risks in the environment, the teaching of safe lifting techniques, and the implementation of increased use of mechanical devices (with a view to reducing the likelihood of lower back injuries), and similar.
An unfortunate consequence of pursuing this approach is that OHS officers are sometimes seen as training people to think like victims; encouraging staff to see the workplace as inherently ‘dangerous’; and even seen to be driving a wedge between management and staff. A ‘victim’ mentality sees change as management’s role, even where needed changes can only be achieved by the individual. Examples include giving up smoking, eating properly, doing indicated physical and relaxation exercises, and so on. OHS may be thought of as ‘old’ legislation – now there is an opportunity to revisit and reinterpret with respect to current and emerging needs.
Fitting workplace to employee
One deep assumption of the relevant legislation seems to be that the workplace should be optimised to fit the employee, and in respect of workplace hazards, this is a very respectable goal. Nothing in the Acts, however, constrains wider interpretations of what ‘occupational health and safety’ and ‘rehabilitation’ could mean in the future. What I am speaking about is how the legislation is enacted in workplaces everywhere, and is probably a reflection of the speed of natural evolution in these matters. The very natural human trait of risk aversion has led, on occasions, to OHS being viewed as a ‘spoiling’ operation, telling employees what they can and cannot do. This can give rise to the impression that there is a strong emphasis on physical aspects of the workplace (like height of electrical outlets, for example) and perhaps insufficient focus on the larger picture (whether particular officers are simply being required to work too many hours – no matter how ‘safe’ the environment, for example).
Fitting employee to workplace?
OHS managers and staff have done significant work in the past 10-20 years in instituting thorough processes to minimise workplace accidents. No doubt there is more work of this sort to do, but the returns on this focus are likely to diminish. Now is the time to reassess what ‘risk management’ might look like in the 21st century. It will involve taking a fresh look at the notions of spreading risk and responsibility. It will involve a reinterpretation of the idea of ‘duty of care’, and will explicitly provide employees with access to preventive techniques which allow them to take care of themselves and, as a result, enhance their productivity and wellbeing. This form of risk management will avoid the familiar problems associated with identification of risk factors, by instead encouraging processes of education that help all employees (and managers!) to ‘self-identify’ and engage in processes that minimise the risk factors, expanded upon below.
Current best practice in risk management requires that risk be spread over all the ‘players’. Presently, risk management seems to be biased toward the employer. I suggest that risk management needs to be expanded to the employee equally, in a transparent, negotiated, and incremental fashion.
Redefining risk management will involve redefining ‘training’. Presently, employees are granted access to training in all areas that may affect their capacity on the job, but there are interesting contradictions. For example, it is commonplace for employees to take multiple days off from the workplace at considerable expense to attend training on how to operate their computer. Rare indeed, however, is teaching employees how to ensure their body and mind can function optimally so they can sit comfortably and safely at a desk for extended periods to operate that computer!
In this vein, it needs to be noted that human beings are expert at mobilising the ‘fight or flight’ response; this is well accepted and well documented in research. The fight or flight response served our ancestors well, but it may have outlived its usefulness in the modern workplace. Instead, the time has come for the complementary response, named the ‘relaxation response’ by Benson in the 70s, to be encouraged and developed. The capacity to relax in stressful environments (accompanied all the while by the mantra of ‘working smarter’, ‘doing more with less’, etc,) will confer its own evolutionary advantage, in terms of ‘managing upwards’ and effects on staff, and in terms of improved capacity to discharge excess tension (to reduce health risks).
Improved stress handling capacity is well correlated with improvements in general state of health, and so is easily able to be identified as being in the interests of both managers and employees alike. At the same time, managers need to realise that there are limits to what this approach can do: managers and employers alike need to take annual leave and work the accepted best practise number of work hours each week! Insistence on this basic principle helps ensure a healthy balance between work and non-work activities, and is an explicit endorsement of the principle that leisure activities and family life contribute very significantly – positively and negatively – to risk management in its broadest sense. As an aside, if this out-of-work-time dimension is to be factored in seriously, it needs to be out there ‘on the table’: for discussion and comment.
This discussion and comment, in addition to being a major part of culture shaping, is essential if any recommendations are to be implemented: nothing is more irritating to any of us than simply receiving instructions from above on where we are going to go – especially if this involves a major change of direction.
Indicators of risk
In addition to the stress aspect, advances in body work in the last ten years have recognised a number of indicators of likelihood of common workplace injuries like neck and back pain, and OOS. Identifying patterns of physical flexibility and the location of held tension can help the manager and the employee to avoid, or minimise, these problems. Reducing differences in range of movement (ROM) of the soft tissues and skeletal structures in a left-right sense in an individual’s body (with reference to their tighter side) is more effective in reducing risk than the conventional screening processes, and has the advantage of avoiding any stigma of how an individual ‘measures up’ in respect of some external idea of normal or desirable function.
Reaching all employees
On-going education programs in work time are suggested as one way of helping managers and employees become aware of risk factors associated with lifestyle choices. These programs will only be maximally effective in leading change if provided in work time, like other accepted education programs, through normative association processes. Too often, worthwhile seminars offered in lunch times only ‘preach to the converted’. Programs need to include wide perspectives on nutrition that help the employee make sense of the conflicting information from research and the popular media. In this context, managers will need to look carefully at the implications of the provision of standard fast food and drink vending machines in the workplace – what sort of signal do these send? Consistency of perspectives is essential, and there may be opportunities here to forestall future vexatious litigation.
Extending ‘duty of care’
The practise of smoking needs to be discussed briefly here. Fifteen years ago, smoking in the workplace was widespread and its banning was controversial. It is suggested here that within similar timeframes the widespread practise of employees being able to take regular breaks in work time to smoke outside buildings will stop. I believe that this change can be achieved non-legislatively. It will be achieved by a more consistent interpretation of ‘duty of care’ by management, and so doing may reduce the risk of future litigation.
Top-down and bottom-up
At this workshop, it will be interesting to explore the ways governments may require the present legislation to be interpreted to achieve this end; my feeling is that any top-down approach will need to be balanced with a bottom-up push from employees and their representative groups, to ensure that any expansion of the OHS role is not perceived as ‘big-brother’ at work.
What can be done now?
While I acknowledge the advantages of the “no fault” provisions of the SRC Act in terms of providing all possible assistance in returning to work as quickly as possible, I suggest that everyone involved in rehabilitation will benefit by shifting attention explicitly to from rehabilitation to prevention. An expanded and operationalised understanding of ‘prevention’ will include treatment and rehabilitation as options if prevention fails. A matter to be addressed in this context is the present interpretation of ‘rehabilitation’ to mean “returning an employee to a pre-injury state of fitness”, as a number of speakers at this conference have claimed. In the case of the common overuse injuries, the problem must be obvious: the pre-injury state of fitness was exactly what allowed the injury to arise in the first place.
The ease with which the shift from rehabilitation to prevention may be achieved will depend partly on the extent to which employers are seen to be fulfilling their duty of care responsibilities in terms of insistence on reasonable work hours and strongly encouraging employees to use their recreation leave.
Prevention will require a sober assessment of risk factors. These will include obesity (so, consideration of overall nutrition), habits such as smoking and recreational drug use (including alcohol), lifestyle choices (in all ways – some recreational activities pose risks of far greater magnitude than any in the workplace; similarly, no exercise at all poses risk too), and so on. The emphasis will be on a broad, open approach – workplace risk factors will thus be able to be better balanced with non-workplace factors. Rehabilitation will continue to be available regardless of how an injury occurred.
Self-help as complement
Complementing this shift in focus will be a broad range of self-help approaches – offered in work hours for employees to feel that management is serious about helping to change the work culture in directions that are acceptable to all. These will form part of the demonstration of duty of care I spoke of above, and will highlight the shift in focus from treatment and rehabilitation to prevention. These approaches will include the teaching of relaxation techniques, the facilitation of stretching exercise classes in the workplace (locating suitable venues, issues of access from neighbouring departments, and so on), presentations on nutrition where aspects like effects of foods and drinks on state of mind are discussed, and other health-improving presentations.
The P&F approach
The Posture & Flexibility organisation has been running “Pro-Active Occupational Health” classes on-location for the APS for over five years now in APS departments, including Customs, DOTARS, Health, DAFF, DFAT, Attorney-General’s Department and many others. We have been presenting lunch-time seminars on nutrition and relaxation/meditation techniques over the same time frames. P&F produces a wide range of multi-media to support these activities and has full production capabilities in-house to produce material to order to the specific needs of any department. P&F has the capacity to train interested OHS officers who would like to teach this material in their own workplaces, following a suitable training period. Health optimisation is our goal.
The APS P&F classes are self funded in most instances. Some departments fund a percentage of the cost of the classes; we recommend no more than 50% of the cost if this is done. We believe that, presently, attendees benefit from the explicit commitment that paying implies: attendance at free classes – despite the same material being presented – diminishes over time compared to the paid, or subsidised, classes. This ‘spur’ will become unnecessary as the culture changes.
HR officers in the APS departments where our classes have been running have informally tracked the participants and compared with suitable cohorts, and report the following:
- Reduced days off work
- Reduced injuries (especially low back pain, OOS, and neck pain)
- Full recovery from existing similar problems
- Experience using our methods in non-APS workplaces (for example, ComSteel in Newcastle) have helped organisations maintain their self-insuring status.
- The use of P&F techniques in the workplace has reduced insurance payouts in local companies.
We believe that a wider-scale implementation of these methods will allow organisations to argue for reduced insurance premiums (in a similar fashion to the distinction made between smokers and non-smokers presently), in time. The argument will turn on demonstrations of duty of care.
Finally, no note on this subject would be complete without mentioning the incredible social and financial costs to government and industry of just three compensable injuries: low back pain, neck pain, and OOS. These are just symptoms of organisational ‘ill health’.
I suggest a strategic task force to help bring about these changes, drawn from the participants of this conference. Helping to move organisational cultures along the recommended lines can only bring real benefits to the workplace, and will be exciting and important work. Let us consider a strategy for the next 10–20 years, and achieve a future we help design rather than one we inherit.