Shedding light on work-related and non-work-related hand injuries from the social work perspective

1 Introduction

As a term, “accident” is defined as an involuntary or unexpected event causing loss or injury [1]. “Work accident” is defined as an incident resulting in physical or mental disability in the insurance holder either immediately or afterwards, which occurs when the insurance holder is at the workplace or out of the workplace when he/she is not carrying out his/her main work provided that the insurance holder is sent on duty to that place by the employer, during transportation to and from the workplace using the vehicle provided by the employer [2]. As can be seen, not every accident is a work accident.

According to data of the Turkish National Social Security Institution, there were a total of 422,837 work accidents with 3,630,629 days of temporary incapacity recorded in Turkey during 2019. 2019 saw a decrease in the number of work accidents (2% less than during 2018) compared to previous years since 2012, when Act Number 6331 on Occupational Health and Safety entered into force (2018 data; total number of work accidents: 431,276, total days of temporary incapacity: 2,488,401) [3]. Work accidents may lead to substantial problems in functioning and result in work disability which is a threat not only to human life but also to activities and participation in major life areas including productivity. Upper extremity injuries may have a devastating impact on health-related quality of life including physical and social performance as well as emotional and general health of the injured workers [4].

Combining their physical effort with brain power, workers try to make their living, provide goods for their families, and try to keep up their standard of living. Reported as “unplanned occurrence causing personal injury, disease or death”, work accidents result in substantial disability along with significant psychosocial issues [5]. Hand injuries, work-related or not, cause loss of physical integrity and may affect a patient’s body, family, labour force and future. Patients’ future employment and career can be jeopardized. Kingston et al. found that almost 45% of patients (86.8% with more than 1 year since injury) with traumatic hand injury experience a moderate to extreme impact on their day-to-day activities, work activities and leisure activities [6]. In a survey study focusing on long-term functional impacts, over 90% of the respondents reported ongoing residual difficulties [7].

The medical, psychosocial and legal problems, and the problems with the employer may restrict the patients’ and their families’ functionality. Decrease of labour force affects production and, therefore, it affects family and society indirectly. The patient stands in the middle of these elements but usually does not get enough help other than medical treatment, therefore hand therapy becomes even more challenging [8, 9].

We see patients with hand injuries with a multiprofessional team including a social worker at the hand diseases outpatient clinic of the Department of Physical Medicine and Rehabilitation (PMR), Istanbul Faculty of Medicine, Istanbul University. As a result of patient interviews performed by the social worker in addition to medical examinations by PMR physicians, the considerably large numbers of psychosocial problems of the patients which needed closer attention were realized, which led us to thoroughly investigate psychosocial aspects of hand injuries.

The aim of this study was to compare demographic and work-related features of persons with hand injuries who sustained a work-related or a non-work-related injury to gain insights into possible predisposing factors for work-related injuries as well as psychosocial consequences of hand injuries.

2 Materials and methods

Between March and November 2018, among the hand injured adults who have been followed up after surgical repair in the hand outpatient clinic of the Department of PMR in Istanbul Faculty of Medicine, 30 hand injury patients in conformity with the definition of “work accident” (2) were included in the “work-related hand injury group (WRHIG)” and another sample of 30 patients with hand injuries having occurred outside of work and not related to work in the “non-work-related hand injury group (NWRHIG)” for this case-control study. The exclusion criteria for both groups were the presence of a psychiatric disorder, those self-harming themselves such as hitting a harmful surface with anger, those involved in a fight which led to the hand injury, those with gun injuries affecting the upper extremity, those with a hand injury which did not require any leave certificate, and those who did not attend regular follow-up visits. We included all cases with hand injuries due to work accidents within this time period according to inclusion/exclusion criteria, and 4 patients refused to participate in the study because of time constraints and 3 patients refused to participate because they did not want to share personal information. We included a control group of similar age and gender to 30 patients who had undergone surgical repair for a non-work-related hand injury and agreed to participate in the study. Preprepared documentation forms were used to register demographic and work-related features of the participants.

The patients were evaluated using a questionnaire designed by one of the authors (KG) based on the principles of social work that focuses on the “individual within his/her environment”/“individual in interaction with the environment” including the following topics: thought-emotion-behaviour features, family and friend relationships, need for family support and professional psychosocial support [10]. Likert scales were used including the 4 options of agreement, satisfaction, being worried, and problem increase for specific questions. A number of questions required Yes/No answers. Ethics committee approval from Istanbul University Faculty of Medicine and informed consent from the participants were obtained.

Statistical analysis was performed using SPSS v21.0 (SPSS Inc., Chicago, IL, USA). Normality was assessed using the Shapiro-Wilk test. Continuous variables were presented as mean and standard deviation (SD), and categorical variables as frequency and percentage. The Chi-square test or Fisher Exact test, where appropriate, were used to analyze categorical variables. Comparison of continuous variables between two groups was performed using the Mann-Whitney U test. Spearman correlation was used to evaluate the association between the time to return to work and the level of education. A p value < 0.05 was accepted as statistically significant.

3 Results

The main implications based on the results of this study derived from statistically significant outcomes include the following: The low level of education may play an important role on the occurrence of work-related hand injuries; blue collar workers seem to be more exposed to work accidents than those in other positions in the work environment; most of the persons suffering from work accidents think that the fault is of the workplace and nobody warned them about possible accidents that might happen; and there may be a relationship between work-related hand injuries and working off-the-clock as well as delayed return-to-work (Table 2).

There was an inverse relationship between educational level and incidence of work accidents. The rate of work accident was lower in well educated workers than in those with a lower educational level in our study in line with the results of a study in Taiwan where it was also found a risk factor for work injuries [11]. The finding that the lower the educational level, the higher the incidence of work accidents points to the notion that less educational levels contributes to “occupational health threats” which are conceptualized as work accidents, work-related diseases and work stress in the social service literature [12].

The likelihood of sustaining a work injury of various types is higher in blue collar workers as found in a French national survey including 46,962 employees [13]. Regarding more frequent involvement of blue collar employees in work accidents, it can be speculated that working conditions are disadvantageous for blue collar workers and are not adequately well organized to reduce the risks. It should also not be forgotten that blue-collar workers work in more risky jobs. However, this requires more careful organization of working conditions.

Our results indicate that both working off-the-clock and being uninformed about work safety rules are risk factors for work accidents (Table 2). According to the Organisation for Economic Co-operation and Development (OECD), data about Turkey, almost 33% of employees work very long hours (>48 hours per week); on the other hand, this ratio is only 11% in OECD countries [14, 15]. It should also be noted that “the informational social influence” created by warning and informing the workers is also important in preventing accidents. A study on manual workers in Korea found that longer work hours and lack of sufficient safety information increased the risk of injury, which was in line with our results [16]. It is also important to note that holding others responsible but not themselves for the work accident as reflected by the answers to the question “Who is responsible for the accident?” may also pose a threat to work safety. This statement should not only be interpreted as the person doing the job not taking responsibility, but also as not being able to work in conditions that are safe enough to feel responsible. Blue collar workers may have less control over the equipment used, where the work is done and possibly how it is done. However, both situations pose a risk to occupational safety and answers may depend on cultural differences in approach to work and perception of events.

In our study, patients with work-related hand injuries returned to work after 123.5 days, which is significantly higher than in NWRHIG (69.7 days). Similar to our results, Opsteegh et al. reported that work-related injuries needed more time to return to work compared with non-work-related injuries [17]. The notion of holding others responsible for the work accident has also been found associated with delayed return to work in a prospective study involving 383 participants [18]. In our study, although returning to work took a shorter period for those who thought they were at fault, there was no significant difference between the two groups, probably due to the small number of people in this group (8 vs. 22). In a Canadian study conducted on 872 participants with work-related hand injuries to describe factors related to return to work, von Schroeder et al. reported that self-reported functional disability and presence of depression were associated with unsuccessful return to work [19]. In our study, we were not able to observe this relationship, which might be a result of our lower number of participants. Educational level also seems to be an important factor contributing to the time to return to work. Therefore, it can be concluded that our results are consistent with previous studies associating quicker return to work with higher educational levels [20, 21].

In addition to the above discussed issues regarding predisposing factors for work accidents, some interesting psychosocial issues surround hand injuries due to accidents, such as thought-emotion-behaviour features as well as family problems after accidents and the need for psychosocial support.

The ratio of the participants who believed in the idea of a divine retribution and faith in destiny were similar in both groups of hand injured with the latter having been reported almost by all. The take-home message from these results might be that these notions should not get in workers’ way of pursuing their rights and should not let us think that work accidents are natural outcomes. Pursuing rights and self-awareness are indispensable criteria for psychosocial functionality.

The hand-injured individuals showed similar characteristics regarding emotional and behavioural features, except for loss of joy since the incident and being worried about the future, which were significantly more frequent in individuals in the WRHIG than that in the NWRHIG. As told in the social service literature, there are 24 things that we need to have to live independently and one of those is employment or engaging in work activities [22]. Inability to work may cause loss of joy. In the study by von Schroeder et al., 30.3% of all participants were reported to be depressed after occupational injury, especially the group who were not able to work after discharge, with a depression percentage of 71% [19]. In our study, 60% of the participants in the study group and 40% of the control group expressed their need of psychosocial support to some extent. The rates are high and closely correspond to the percentage of patients with loss of joy, which has implications that a hand injury is devastating regardless of etiology and any accident resulting in an injury to the hand regardless of the setting (either at work or elsewhere) causes similar problems in terms of thought-emotion-behaviour features (Table 2) as well as psychosocial consequences.

Limitations of the study: One of the limitations of this study is its small sample size. Therefore, the study findings need to be interpreted with caution. Another one could be that we did not take into account the severity of disability due to hand injury which might provide more detailed assessment of the association of psychosocial consequences with the severity of disability. However, the aim of this study was to stress psychosocial consequences regardless of the level of disability and to direct attention to the psychosocial domain of hand injuries from a social work perspective and the need for a team approaching those with hand injuries in the context of a biopsychosocial model where a social worker can have a facilitating role [23, 24]. Nevertheless, we believe that the concept of severity has been reflected by recruiting individuals who required a leave certificate after the hand injury (which actually ranged from 10 days to 210 days) despite the fact that we did not use any indices such as “Modified Hand Injury Severity Score” to assess severity [25]. Rather than individually designed assessment forms, we would also recommend the use of an ICF-based outcome assessment, which is an international standard and a common language to make the study methods replicable [26]. Another limitation of the study is that the answers given to the questions may be affected by cultural differences.

With the progress of hand surgery in Turkey in 1970 s, hand rehabilitation started to become an organized, special topic of interest [27]. A review of the literature shows that the social work discipline does not seem to have contributed much to the topics of hand rehabilitation and work accidents. Most of the literature related to industrial social services is from developed countries [8, 29].

Despite its shortcomings, we believe that this study points to the need for an holistic approach to people who sustained a hand injury as defined in the International Classification of Functioning, Disability and Health (ICF), which is a biopsychosocial model [30]. Hand injuries are not only associated with impairments in body functions and structures, but also with activity limitations and participation restrictions, as well as environmental factors, which need to be managed with a multiprofessional team under the leadership of a PMR physician, where a social worker may have a significant role to address nonmedical needs.

It has been shown that the rehabilitation process was prolonged and return to work was delayed in the absence of social support following a work injury [31]. It is suggested that dealing with psychosocial factors early during the rehabilitation process may facilitate the recovery process for a more rapid return-to-work after musculoskeletal injuries [32].

The psychosocial consequences of hand injuries merit further investigation and appropriate rehabilitation interventions aiming not only to improve physical functions but also to reduce unfavourable psychosocial consequences.

5 Conclusion

As rehabilitation professionals, we are responsible for physical, mental and social well-being of patients. After work accidents, employees go through an important and difficult period where they recover from injury and adapt to their new situation. This study shows that workers have not only medical, but also psychosocial difficulties getting over these times. In situations like this, a multiprofessional rehabilitation team including a social worker is critical in addressing psychological, social, financial and legal needs and easing of the burden in addition. Patients need to be evaluated widely and carefully in their environment as defined in the ICF to target a variety of appropriate interventions.

Ethical approval

This case-control study was approved by the ethics committee of the Istanbul Faculty of Medicine, Istanbul University (file number: 2018/201, approval number: 247).

Informed consent

Informed consent was obtained from all participants included in the study.

Conflict of interest

No conflict of interest was declared by the authors.