Abstract
Introduction
Compensable injury and disease has a substantial impact on economic and health systems (Murray & Lopez, 1996). In 2010-11, Australian workers’ compensation systems provided compensation for 127,330 injury claims at a direct financial cost of approximately $7.4 billion (AUD). Not only does compensable injury economic and health system impact at a societal level, it also has very real consequences for the injured individual and those around them. Despite providing access to health care and financial support (Lippel, 2007), compensation systems have been found to have a negative impact on outcomes for the injured person (Kirsh & McKee, 2003; Lippel, 2007; MacEachen, Kosny, & Ferrier, 2007), thus, there is a critical need to understand the factors influencing recovery from injury.
Research indicates that involvement with a compensation system can contribute to considerable stress (Roberts-Yates, 2003) and poorer outcomes for injured individuals (Kilgour, Kosny, McKenzie, & Collie, 2014a, 2014b). It has been identified that psychological factors (Gheldof et al., 2007) and social determinants (Feuerstein et al., 2001; Stone, 2003), as well as the process of interaction with the compensation system itself (Beardwood, Kirsh, & Clark, 2005; Kilgour et al., 2014b; Lippel, 2007) impact long-term outcomes following compensable injury. It has been suggested that the compensation system providers and processes can make the injured person feel misunderstood (MacEachen et al., 2007) and victimised (Beardwood et al., 2005).
Another factor that can have implications for the individual’s recovery from compensable injury is the presence or absence of ongoing pain (Alcock, 1986) and the response to such pain that is engendered within the worker (Phillips et al., 2012). Studies show that high baseline levels of pain significantly predict ongoing functional difficulties (Gheldof et al., 2007; Turner et al., 2006) and social disability (Gheldof et al., 2006). Not only is pain itself limiting but pain-related fear, such as a fear of re-injury (i.e., kinesiophobia), can further restrict an injured individual’s activities and behavioural performance, over and above the impact of pain severity alone (Crombez et al., 1999; Gheldof et al., 2006; Swinkels-Meewisse et al., 2006).
The complexity of the issue is exacerbated in cases where the injured individual loses financial independence through loss of earnings and dependence on others (Boden & Galizzi, 1999; Ebel et al., 2004). Depression is frequently reported following occupational injury, with injured workers being 44% more likely to be treated for depression within 3 months post- injury than non-injured workers (Asfaw & Souza, 2012). Individuals whose injury occurred at work are also more likely to become depressed than workers who incurred an injury outside of work (Kim, 2013). Worker-related psychosocial risk factors, including pain-related fear and depression contribute to poor return-to-work outcomes and prolonged work disability (Foreman, Murphy, & Swerissen, 2006; Gheldof et al., 2006; Sullivan et al., 2005). Moreover, if the injured individual is not able to return to work in their pre-injured capacity, their sense of well-being and identity as a worker suffers (Stone, 2003).
This experience can be interpreted within the fear-avoidance model of pain (Lethem et al., 1983). According to this theory, if pain is catastrophically (mis)interpreted by the individual as a threatening experience, they can enter an unhelpful cycle. Pain-related fear and associated safety-seeking behaviours (such as escape/avoidance and hypervigilance) leads to a withdrawal from their daily activities and their functional recovery stalls (Leeuw, Goossens, et al., 2007). In the early stages of acute pain following injury, pain-related fear can be adaptive as it directs attention towards the injury, increasing the care and facilitating healing. When the pain becomes chronic and is no longer explained by the injury itself, the pain-related fear and prolonged engagement in protective behaviours becomes dysfunctional and prevents the individual from disconfirming the perceived level of threat (Leeuw, Goossens, et al., 2007). Protective avoidant behaviours contribute to a self-perceived sense of disability, to depression and physical disuse of the injured body region (Vlaeyen et al., 1995; Vlaeyen & Linton, 2000, 2012).
The aim of this study is to explore the experiences of injured people in compensation systems, focusing on factors that impact on their health and mental well-being. To achieve this aim, we will be guided by the WHO International Classification for Functioning, Disability and Health (ICF) (World Health Organization, 2001). Based on the bio-psychosocial model of disability (Engel, 1980), the ICF framework identifies three levels of human functioning: functioning at the level of body or body part, the whole person, and the whole person in a social context. Disability therefore involves dysfunction at one or more of these same levels: impairment, activity limitation and participation restriction. This study will adopt the bio-psychosocial model of disability to explore the experiences of those who have sustained a compensable injury.
Methods
Procedure and participants
Individuals who had sustained a compensable physical injury were recruited from three Australian injury compensation authorities, including two workers’ compensation systems and one motor vehicle accident compensation system. A purposive sampling technique was used for recruitment. A representative within each compensation authority assisted with generating a random selection of individuals based on their type of injury and time since injury. After receiving the consent of the injured persons to being contacted, the final list of injured persons’ names and contact details were provided to the research team. A member of the research team (AA) was then responsible for contacting individuals and gaining consent for participation. Participation was entirely voluntary and the compensation authority representatives had no control over the participation of injured persons or knowledge of which individuals participated. In other words, the representative was not involved with the research process to ensure the conduct of the interviews was independent of stakeholder influence.
Sixteen individuals were approached by the member of the research team and were asked if they were willing to participate in an interview. Fifteen consented to participate. The sample comprised of 10 males and 5 females, with a mean age of 49 years (SD = 14.65, Range = 21–66). All had been engaged in employment at the time of the injury and had taken at least one day off work following their injury. The majority of participants were recruited from the workers’ compensation systems (n = 14), while only one participant was recruited from the motor vehicle accident compensation system. At the time of the interview, two participants had been able to return to work on full duties, seven had a capacity for modified duties and six were classified (by the relevant compensation body) as having no current capacity for work. Information regarding the sample is shown in Table 1.
Each interview was conducted over a half hour period. The interviewer did not have a prior relationship with the participants and no other individuals were present during the interview. Each interview was conducted via telephone from a private room facility of our university.
The dialogue was audiotaped and transcribed following each interview. Any identifying information, including names of individuals or workplaces, was removed prior to data analysis to ensure anonymity and confidentiality. Ethics approval for the project was gained from Monash University’s human research ethics committee.
Measures
The authors designed four open-ended questions to reflect the components of the ICF framework. We sought to gain an understanding of the impacts of compensable injury on the injured person. Specifically, the participants were asked to comment on how the injury influenced the following ‘aspects’ of their lives: the impact of the injury on the injured person’s (1) physical functioning (ICF body function domain); (2) psychological functioning (ICF body function domain); (3) level of involvement in daily activities (ICF activity domain); (4) level of involvement in social activities (ICF participation domain). The questions were pilot tested prior to the interviews to ensure consistency of meaning and terminology of the questions. Throughout the interviews, the facilitator used prompts to encourage further discussion about the impacts of the injury both in the short-term (immediately post-injury), and the longer-term (ongoing).
Data and data analysis
We analysed the data using thematic analysis (Miles & Huberman, 1994). First, we used open coding, involving a close reading of the interview transcripts and the use of descriptors. In this study, we identified descriptors as fragments of dialogue within the transcripts, which were coded based on relevance to a personal impact on the injured person. For example, quotes in which participants elicited a response that indicated an impact on their physical and psychological functioning, and level of involvement in daily or social activities were coded. Following this process, the identification of themes commenced with a broad search for possible concepts whereby each new idea (or meaningful unit) was coded. In subsequent reviews of the data, through a process of constant comparison, concepts were more closely scrutinised for similarities and differences with other coded concepts. This approach enabled new and emerging themes to be identified. To address interrater reliability (Kirk & Miller, 1986), the final list of descriptors was verified by a second analyst with repeated review of the data until consensus was reached. The two coders (AA and SN) met regularly to discuss emergent findings.
Results
This study explored the various impacts of compensable physical injury from a Bio-psychosocial framework. A number of key themes emerged, including fear, physical disuse, depression, disability and readjustment.
Fear
Seven participants reported avoiding physical activities they once enjoyed, such as tennis, jogging and going to the gym. For nine participants there were psychological barriers to physical activity (over and above any physical limitations). The language used in their responses was quite dramatic, with words like “scared”, “terrified” and “anxious”. For these participants, activities that were normal pre-injury were now perceived as “risky”. Several participants lived with a fear of falling over and re-aggravating their injury.
I’m very hesitant out by myself walking, I won’t go on public transport because I’m so scared of falling and damaging the arm that’s already been damaged let alone anything else, I might have another fall. (Mild injury; shoulder).
If I go out and if I fall over and I hurt my arm again, you know, I think what impact is that going to have on me for the rest of ... I just don’t do it, I don’t go out. (Moderate injury; epicondylitis).
This fear of re-injury impacted on re-engagement with the workplace. One young woman with a back injury spoke of sitting at home and mentally preparing herself to go back to work on light duties for an hour or two, but finding that this task was associated with an overwhelming fear of worsening the pain. Another participant voiced a degree of anxiety surrounding his scheduled return-to-work. Although he was no longer having the physical issues experienced in the early days of his back injury, this was replaced with a sense of apprehension. This participant said he was looking forward to getting back to work, but this was overshadowed by nervousness that he might suffer a further injury.
Physical disuse
Participants often talked of a general lowering of physical activity. Six of the individuals had an injury isolated to a specific limb (such as the knee, shoulder or elbow), and there was resultant disuse of that specific body region. One participant with epicondylitis (tennis elbow) had ceased going to the gym since her injury and consequently had to stop playing netball, as she no longer had the strength in her arm to shoot the ball towards the goal.
Nine of the participants had sustained injuries that affected the body more broadly; for example, neck injury or back injury. These injuries affected engagement in physical activity and had the potential to become a vicious cycle of disuse/pain.
It’s a little bit hard for you to go for a run, go for a bike ride or go swimming when your neck’s sore all the time ... it’s a little bit of a catch-22; my neck hurts because I’m unfit and I’m unfit because my neck hurts. (Moderate injury; musculoskeletal neck injury).
Depression
While post-injury depression or depressive symptoms were not objectively measured, more than half of the participants reflected on dealing with feelings of depression. These responses were often associated with other changes experienced, such as having previously been an active person but now being immobile, or having previously been independent but now relying on others. The sense of depression or despair expressed by participants often related to feelings of being out of control.
I’d be depressed because I’d just need to look at my arm and it was sore. (Mild injury; shoulder).
Physically, mentally, it’s affected ... I don’t know. I don’t like to talk to anyone. I feel like I’m going down, like I’m really going down. (Mild injury; musculoskeletal back injury).
The process of interacting with the compensation system emerged as a point of frustration for seven participants. Issues were raised around claim acceptance, poor communication from compensable bodies or insurers and delayed or rejected applications for access to health care services or aids. These difficulties had the potential to make individuals feel that “no one was listening” and there was a suggestion that these issues may have contributed to declines in mental health.
[I] didn’t receive any notification as to how my claim was progressing. So I had no idea what was going on. Extreme frustration. And a little bit of, a little bit of “woe is me” and also a bit of “me against the world”. (Moderate injury;musculoskeletal neck injury).
Thing is, you know, you’re already going through hell ... you’re off work for whatever reason, you’re already feeling down in the dumps because of that and other things and plus you got the pain. The last thing you really want to have to worry about having to fight for your right to decent medical treatment in a timely fashion. (Mild injury; knee).
Disability
When asked what impact their injury had on their physical ability, responses ranged from driving to sporting pursuits to the most ‘basic’ day to day chores like showering, getting dressed and brushing one’s hair. In the early stages post-injury, many of the participants had relied on parents, partners or children to assist with their self-maintenance duties.
Couldn’t bath myself, couldn’t dress myself, couldn’t do anything for about five weeks, my daughter had to do it all for me. Extreme stuff you know. (Moderate injury; shoulder).
Across interviews and even within interviews, the effects of reliance on other people manifested itself in one of two different ways. Some comments were reflective of a positive external context, while others were reflective of a sense of guilt or of being a burden on others. It also appeared evident that the individual’s experience was mediated by the input received and relationships with those aroundthem.
Interviewee’s comments highlighted the importance of feeling supported by others, with a number of participants expressing their gratitude for the love and assistance of family and friends. For two of them, it helped to have a friend or relative who had been through or was presently going through a similar situation with their own experience of injury, as this gave the injured participant a peer to relate to. It also made them feel like they were not alone and that there was someone else who could understand the pain and frustration they were suffering.
I have a very, very wonderful wife and she’s been nothing but sympathetic and helpful. Yeah she’s been spectacular. I have a very, very good close knit group of friends. One particularly so who lives in the same street as me and he understands continual pain as he had a hip replacement done recently and he understands, because of his hip replacement, he was in a fair bit of pain too so he understood what I was going through and the emotional effect it was having on me. (Moderate injury; musculoskeletal neck injury).
Home duties often proved a challenge post-injury. Four participants reported that the compensable body had arranged or paid for home help such as cleaning or gardening. Nine participants reported that family members had to take over household chores or work longer hours to maintain financial security. Five of these participants reflected on feelings of guilt related to the feeling that they had become a burden on those around them. There was a loss of a sense of autonomy and independence. It tended to be the females who spoke about the emotional and domestic impact on others, while the male participant’s comments were more directed to the financial impact that their inability to work had on their partner, parents or other family members.
I feel like a bastard because she’s working her guts out. (Moderate injury; musculoskeletal back injury radiating into legs).
I’ve been living at my mum’s place which has helped out tremendously. Because otherwise I’d be out in the street, I just wouldn’t be able to afford rent ... So my mum and stepdad have been really good ... they seem to be putting themselves into a bit of debt just to help me ... I kind of feel bad about that ... yeah, it’s messed up. (Mild injury; knee).
Although the injured person remained grateful for the help of others, it appeared that the willing assistance of family members, friends or others (including services supplied via the compensation system) had the potential to reinforce the interviewee’s self-perceived sense of disability and/or dependency. Comments reflected the fact that the injured individual tended not to have a chance to carefully “test” their abilities as their recovery progressed.
My wife jumps in and pushes me out of the road and helps, or does it before me. (Severe injury; spinal injury).
Readjustment
Beyond the initial post-injury limitations, ten of the participants had ongoing restrictions either from their physical impairments or manifested through fear of re-aggravating their injury or re-experiencing the pain associated with their injury. Those participants who previously could do physical tasks, found themselves readjusting to the fact that certain day-to-day activities were no longer an option, post-injury.
And then of course, you’ve got to be realistic and realise that you can’t do what you used to be able to do. (Severe injury; spinal neck injury).
Participants who were used to lifting heavy objects, going to work each day and doing the house work unassisted had accepted that they could no longer do the tasks they had taken for granted; leading to a state in which they felt “useless” or “hopeless”. In the course of the interviews, it became clear that this re-adjustment was a source of frustration and depression.
I was never like that before. I find that I want to do things and when I try to do it and I find out I can’t I get frustrated, I get upset, I cry. I just want to be able to do what I could before, and I know I can’t, I’m never going to be able to have that. I’ve already been told that, but it doesn’t sink in because I just want to be who I was prior to this, I’m sick of crying every time I get frustrated about it. And the pain is just always there. (Moderate injury; epicondylitis).
My life’s changed in a direction that I didn’t want to. Just not being able to do the things that I want to do is depressing. (Mild injury; musculoskeletal back injury radiating into legs).
Participants generally reported having enjoyed their previous work; one participant describing himself as a “workaholic”. For this man in particular, it was a “psychological battle” to accept the reality that his injury left him unable to work for several weeks. There was a psychological discord for participants between the physically and mentally strong, capable and independent individuals they had previously imagined themselves to be, and the disabled role that had emerged, post-injury.
I’ve always been a very independent person and I don’t like asking favours of anyone, in fact I loathe it. In fact that taught me that I have to sit back and ask; and that, gee that was hard. (Moderate injury; shoulder).
The nature of an injury as being compensable has the potential to impact an individual’s current and future employment. One participant voiced their concern that she would be rejected when applying for a new job, given she must declare having had a previous compensation claim. One woman had been through an appeals process when the compensable body’s insurer tried to push her back to work on full duties when she was still awaiting an operation. Another described a protracted ‘battle’ with their employer who did not want to accept responsibility for the compensation claim and subsequently fired him while he was unable to work. He said the worst aspect of his experience had been trying to prove his rights to access compensation.
Several participants discussed how their injury had impacted on their ability to interact with their children or grandchildren. One father of a young family lamented that for almost the first whole year of his son’s life, he was unable to pick the boy up at night-time. Three of the older participants indicated their sadness over the fact that they couldn’t hold, hug or help feed their grandkids in the ways they would have liked. Essentially, their role as a parent or grandparent had changed. Those who spoke about their injury affecting their ability to interact with young children tended to be the same participants for whom a fear of re-injury was prevalent. In the case of one female participant, the recognition that she was unable to pick up babies had become a source of significant distress as it left her feeling ‘abnormal’ in relation to her peers.
Oh my god, I can’t do just normal things. ... I can’t take babies on my hands ... I can’t hold babies. So sometimes it’s really depressing that I’m not normal, I’m feeling like that. (Mild injury; musculoskeletal back injury).
One participant who had suffered a spinal cord injury three years prior spoke of how hard it had been for him to “readjust” his life and way of thinking. It had been difficult for him to come to grips with the reality that certain activities he could do pre-injury were no longer possible. He had since come to accept his physical limitations and incorporate his injury into a new self-image. While his condition had generally stabilised, other participants had not yet reached a point of knowing the long-term impact of their injury. One described feeling ‘stuck’; although the compensation system was funding physiotherapy, he had been told that he needed surgery and the claim to access this had been repeatedly rejected. For a few of participants, there was a sense of pre-occupation with their injury and an overtaking of their self-image as being an injured person.
You live with it day in and day out. You sleep with it, you wake up with it and it’s there. It’s constantly there, constantly on your mind. (Moderate injury; epicondylitis).
Discussion
The aim of this study was to examine the impacts of compensable injury from a bio-psychosocial perspective. It is known that an injured worker’s involvement with compensation systems affects outcomes for the claimant, with various elements of the process having the potential to negatively impact on recovery (Kilgour et al., 2014a, 2014b; Lippel, 2007). In line with previous research in this area, the current study found that rather than having made progress in their recovery, the vast majority of participants were in fact still struggling to move beyond their injury and the impacts it has on their life. Research has shown that key influences in recovery from compensable injury are pain (Alcock, 1986) and the individual’s response to pain (Phillips et al., 2012). These emerged as relevant factors in this study as road blocks to progression of the injured individual’s recovery.
The key themes that emerged from the interviews were fear, physical disuse, depression, disability and readjustment. These themes of the study are consistent with the components identified within the fear-avoidance model of pain and re-evaluation of sense of self. It was suggested that interaction with compensation systems impacted on depression, perceived disability and capacity for readjustment. This study provides a unique contribution to the literature exploring the influence of compensable injury on recovery, as these elements have not previously been explored together in a compensable population.
Consistent with the fear-avoidance behaviour model (Gheldof et al., 2006), the majority of the participants exhibited elements of pain catastrophizing and their subjective reflections on their experience fit well into the fear-avoidant cycle. These participants reached a point in their recovery where their pain levels were manageable, but for each there was significant apprehension associated with the prospect of pain returning. These results are consistent with past research which has shown pain-related fear to be a contributor to functional and social disability (Crombez et al., 1999; Gheldof et al., 2006; Leeuw, Houben, et al., 2007).
In addition to the emergence of themes involving the fear-avoidance model of pain, the injured individual’s responses suggested that they felt a need to adjust their self-image in respect of the limitations that their injury imposed on them. For some, this was experienced for a short period of time while the acute injury healed; however, for others it was a need to accept the lasting impact of their injury. This change is reflected in the concept of “sense of self”; the collection of perceptions, belief and feelings held by an individual that relate to who they are (Maehr, 1984). The notion of self-hood includes subjective judgements made about one’s own competence or ability to succeed in performing tasks; these tasks may be in a specific area or across a broad range of performance domains (Maehr, 1984).
Participants’ experiences of re-evaluating their sense of self emerged within several themes. For many it included physical limitations and brought in new worrying thoughts about the potential for re-injury, while for others there was a realisation that the way one interacts with children or grandchildren has been changed against their will. This finding is consistent with research that has explored the “biographical disruption” brought on by chronic illness (Bury, 1982; Charmaz, 1983, 1995). This literature identifies that a significant physical injury can create a change in circumstance that often requires a re-ordering of life to account for new physical, mental and psychological limitations (Soklaridis, Cartmill, & Cassidy, 2011; Stewart et al., 2012).
The results identified that adjusting to life post-injury involved a significant learning process; identifying and accepting that certain movements or activities are no longer appropriate or possible, and adapting to learn and incorporate new behaviours and to cope with the impact that the injury has had. In particular, this study found that workers who had previously been strong and independent in their occupations had adjusted their self-image to account for the lasting ramifications of their injury. For example, heavy building materials that could previously be hauled around without issue now required the worker to stop and ask for assistance. Six participants had no current capacity for employment, while another six who had been able to return to work were working shorter days or performing modified duties. Each new challenge served to highlight to the worker and those around them that they are in some way “altered” by their injury experience. These results are aligned with past research which demonstrated that an individual reconstructs their self-identity to incorporate the new physical, mental or psychological limitations that life post-injury imposes on them and their functioning (Soklaridis et al., 2011; Stewart et al., 2012; Stone, 2003).
Results showed that the re-evaluated sense of self also involved acceptance of ongoing disability through one’s need to rely on others, as well as acknowledgement of a sense of guilt for how their injury impacts those around them. Participant’s experiences reflected the context in which their post-injury identity of functional disability included a reliance on those around them for help in their everyday lives. This is in line with previous research that shows how an injured person’s role within their family can be altered, with disruptions to home life a common outcome following injury (Keogh et al., 2000; Strunin & Boden, 2004). Changes to self-identity can subsequently feed back into the cycle and further disrupt relationships in an individual’s life (Soklaridis et al., 2011). There may be limitations on friendships, or interactions and playing with children, as well as impacts on intimacy and sexual relationships (Soklaridis et al., 2011). Situations that involve ongoing disability raise a further threat to the individual’s self-identity as an independent and autonomous person. As demonstrated by participants who spoke of worry for their future, this can incorporate not just the current sense of self, but also the person’s imagined future self; of who or what they might be in the future (Morley & Eccleston, 2004).
Theoretical and practical applications
Using qualitative methods, this study provides insight into the impacts of compensable injury. A unique aspect of this study was that the participant’s experiences aligned with the process of re-evaluation of sense of self and the lived experience of the fear-avoidance model of pain. The themes of physical disuse, depression and disability were linked to pain-related fear and fear-avoidant behaviour (Crombez et al., 1999; Vlaeyen et al., 1995; Vlaeyen & Linton, 2012). These components of the fear-avoidance model of pain are also aspects of self-identity that can contribute to and become incorporated in the changed sense of self that develops in the injured individual. While past research has explored the impact of fear-avoidant beliefs and behaviour (Burton et al., 2004; Crombez et al., 1999; Wideman, Adams, & Sullivan, 2009), as well as the process of re-evaluating one’s sense of self (Soklaridis et al., 2011; Stone, 2003), this study was unique in that it identified both of these constructs within the lived experiences of those who have sustained a compensable injury. It also showed that interaction with compensation systems has the potential to contribute to components of the fear-avoidance model, with frustration over dealings with the system contributing to depression and the provision of services factored into self-perceptions of disability. The compensable nature of an injury also impacted on capacity for readjustment to a post-injury sense of self, due to delays in access to treatment and effects on current and futureemployment.
In regards to the practical applications, this study has shown that fear-avoidance and the re-evaluation of sense of self often exist simultaneously and it supports the notion of a feedback loop existing between the two. For example, an individual who adopts a sense of disability due to their pain-avoidant behaviours would incorporate this ongoing disability into their self-image. Carrying this forward, future avoidant behaviours are reinforced as the individual feels they cannot carry out physically demanding movements or tasks due to the fact that they now view themselves as a person who has a disability.
This finding could have practical applications for the way compensation systems interact with injured persons. If it is possible to identify and intervene with those individuals who are showing evidence of pain catastrophizing and pain-related fear and avoidance (early elements in the fear-avoidance model), the resulting consequences of physical disuse, depression and disability may also be prevented. Circumventing the development of these factors would help to maintain the individual’s pre-injury self-identity as a capable worker.
The results of this study also inform psychological and/or social support interventions to help people recover from injury. Understanding how and why self-identity can change following injury may lead to interventions that facilitate constructive cognitive restructuring of individuals’ sense of self. In compensable populations, this could include approaches around return to work and whether there is the possibility for the person to maintain an identity as a worker, even when immediate circumstances proscribe return to work at that particular point in time. In doing so, consideration must be given to whether there are other factors, such as fear-avoidant beliefs or behaviours which are being incorporated into sense of self and may also be directly impacting on functional and social abilities.
Future research
This study explored the experience of individuals whose injury was covered by either a workers compensation or transport accident compensation system and who had at least one day off work following their injury. The sample of participants interviewed in this study is broadly representative of the compensable workplace injury population, as musculoskeletal injury is a common cause of compensable workplace injury (Bureau of Labor Statistics, 2013; Safe Work Australia, 2013). In Australia, the back is the most common bodily location of compensated injury or disease (22% of all serious injury claims), with the shoulder and knee also being commonly injured body areas; each accounting for 9% of all serious claims (Safe Work Australia, 2013). Injury to the hand, fingers or thumb represents a combined 12% of serious workplace injury claims, however no such participants were involved in the current study.
The experience and outcomes for compensable injury can differ greatly from those who have sustained an injury and not been compensated. This can comprise both positive and negative impacts of the process, including differences in the level of support, access to services and the overall experience of interacting with a compensation system (Kirsh & McKee, 2003; Lippel, 2007). Given that perceived independence, ability and identity as a worker can be a major element of sense of self, it is possible that the findings may have differed in a sample of injured individuals who were not receiving compensation or were not working at the time of their injury. In light of the links between psychological factors and return-to-work outcomes in a compensable population (Foreman et al., 2006), it is clear that further exploration is needed as to the factors that influence functional recovery after an injury.
Conclusion
Overall, this study identified impacts of compensable injury and found evidence of the utility of the fear-avoidance model of pain, in helping to explain the re-evaluation of sense of self that occurs in individuals within the injury compensation system. The physical disuse, depression and disability that may develop as a result of protracted fear-avoidant beliefs and behaviours are part of an individual’s subjective experience of their life post-injury, and thus become incorporated into their self-identity. Understanding the processes and factors that contribute to these changes has the potential to improve not just return-to-work outcomes in compensable populations, but the overall physical and psychological wellbeing of injured individuals.
Conflict of interest
The authors declare that they have no conflict of interest.
Funding
This research was supported by an Australian Research Council Grant (LP110200119).