Tool for the Meaningful Consideration of Language Barriers in Qualitative Health Research.

Individuals who experience language barriers are largely excluded as participants from health research, resulting in gaps in knowledge that have implications for the development of equitable policies, tools, and strategies. Drawing on the existing literature and on their collective experience conducting occupational health research in contexts of language barriers, the authors propose a tool to assist qualitative researchers and representatives from funding agencies and ethics review boards with the meaningful consideration of language barriers in research. There remain gaps and debates with respect to the relevant ethical and methodological guidance set forth by funding agencies and institutions and proposed in the scientific literature. This article adds to knowledge in this area by contributing our experiences, observations, and recommendations, including around the issue of conducting research in contexts of more or less linguistic diversity.

Perceived Role and Expectations of Health Care Providers in Return to Work.

Purpose Health care providers (HCPs) play an important role in return to work (RTW) and in the workers' compensation system. However, HCPs may feel unsure about their responsibilities in the RTW process and experience difficulty making recommendations about RTW readiness and limitations. This study examines the ways in which HCPs and case managers (CMs) perceive HCPs role in the RTW process, and how similarities and differences between these views, in turn, inform expectations of HCPs. Methods In-depth interviews were conducted with 69 HCPs and 34 CMs from 4 provinces. Data were double coded and a thematic, inductive analysis was carried out to develop key themes. Findings The main role of HCPs was to diagnose injury and provide patients with appropriate treatment. In addition, the majority of HCPs and CMs viewed providing medical information to workers' compensation board (WCB) and the general encouragement of RTW as important roles played by HCPs. There was less clarity, and at times disagreement, about the scope of HCPs' role in providing medical information to WCB and encouraging RTW, such as the type of information they should provide and the timelines for RTW. Conclusion Interviews suggest that different role expectations may stem from differing perspectives of HCPs and the CMs had regarding RTW. A comprehensive discussion between WCB decision-makers and HCPs is needed, with an end goal of reaching consensus regarding roles and responsibilities in the RTW process. The findings highlight the importance of establishing clearer role expectations.

Recovery Within Injury Compensation Schemes: A System Mapping Study.

Purpose Many industrialised nations have systems of injury compensation and rehabilitation that are designed to support injury recovery and return to work. Despite their intention, there is now substantial evidence that injured people, employers and healthcare providers can experience those systems as difficult to navigate, and that this can affect injury recovery. This study sought to characterise the relationships and interactions occurring between actors in three Australian injury compensation systems, to identify the range of factors that impact on injury recovery, and the interactions and inter-relationships between these factors. Methods This study uses data collected directly from injured workers and their family members via qualitative interviews, analysed for major themes and interactions between themes, and then mapped to a system level model. Results Multiple factors across multiple system levels were reported by participants as influencing injury recovery. Factors at the level of the injured person's immediate environment, the organisations and personnel involved in rehabilitation and compensation processes were more commonly cited than governmental or societal factors as influencing physical function, psychological function and work participation. Conclusions The study demonstrates that injury recovery is a complex process influenced by the decisions and actions of organisations and individuals operating across multiple levels of the compensation system. Changes occurring 'upstream', for instance at the level of governmental or organisational policy, can impact injury recovery through both direct and diffuse pathways.

Do Health Service Use and Return-to-Work Outcomes Differ with GPs' Injured-Worker Caseload?

Purpose To determine whether healthcare use and return-to-work (RTW) outcomes differ with GPs' injured-worker caseload. Methods Retrospective analyses of the Compensation Research Database, which captures approximately 85% of all injured worker claims in Victoria, Australia was conducted. Four injured-worker caseload groups were examined that represented the 25th, 50th, 75th, and 100th percentiles of claimants seen per GP over the 8-year study period (2003-2010): (i) 1-13 claimants; (ii) 14-26 claimants; (iii) 27-48 claimants; and (iv) 49+ claimants (total claims, n = 124,342; total GPs, n = 9748).The characteristics of claimants in each caseload group, as well as the influence of caseload on three outcomes relevant to RTW (weekly compensation paid, work incapacity days, medical-and-like costs), were examined. Results Distinct profiles for high versus low caseload groups emerged. High caseload GPs treated significantly more men in blue collar occupations and issued significantly more 'alternate duties' certificates. Conversely, low caseload GPs treated significantly more women in white collar occupations, predominantly for mental health injuries, and issued significantly more 'unfit-for-work' certificates. Few significant differences were found between the two intermediate GP caseload groups. High caseload was associated with significantly greater medical-and-like costs, however, no caseload group differences were detected for weekly compensation paid or duration of time-off-work. Conclusions Training GPs who have a low injured-worker caseload in workers' compensation processes, utilising high caseload GPs in initiatives involving peer-to-peer support, or system changes where employers are encouraged to provide preventive or rehabilitative support in the workplace may improve RTW outcomes for injured workers.

Fear of (re)injury and return to work following compensable injury: qualitative insights from key stakeholders in Victoria, Australia.

BACKGROUND: Return to work (RTW) is important for recovery post-injury. Fear of (re)injury is a strong predictor of delayed RTW, and therefore much attention has been given to addressing injured workers' fear beliefs. However, RTW is a socially-negotiated process and it may be important to consider the wider social context of the injured worker, including the beliefs of the key people involved in their RTW journey. METHODS: This paper involves data collected as part of a wider study in which semi-structured interviews explored RTW from the perspectives of 93 key stakeholders: injured workers, GPs, employers and insurance case managers in Victoria, Australia. Inductive analysis of interview transcripts identified fear of (re)injury as a salient theme across all stakeholder groups. This presented an opportunity to analyse how the wider social context of the injured worker may influence fear and avoidance behaviour. Two co-authors performed inductive analysis of the theme 'fear of (re)injury'. Codes identified in the data were grouped into five categories. Between and within category analysis revealed three themes describing the contextual factors that may influence fear avoidance and RTW behaviour. RESULTS: Theme one described how injured workers engaged in a process of weighing up the risk of (re)injury in the workplace against the perceived benefits of RTW. Theme two described how workplace factors could influence an injured workers' perception of the risk of (re)injury in the workplace, including confidence that the source of the injury had been addressed, the availability and suitability of alternative duties. Theme three described other stakeholders' reluctance to accept injured workers back at work because of the fear that they might reinjure themselves. CONCLUSIONS: Our findings illustrate the need for a contextualised perspective of fear avoidance and RTW behaviour that includes the beliefs of other important people surrounding the injured worker (e.g. employers, family members, GPs). Existing models of health behaviour such as The Health Beliefs Model may provide useful frameworks for interventions targeting the affective, cognitive, social, organisational and policy factors that can influence fear avoidance or facilitate RTW following injury.

Factors associated with sickness certification of injured workers by General Practitioners in Victoria, Australia.

BACKGROUND: Work-related injuries resulting in long-term sickness certification can have serious consequences for injured workers, their families, society, compensation schemes, employers and healthcare service providers. The aim of this study was to establish what factors potentially are associated with the type of sickness certification that General Practitioners (GPs) provide to injured workers following work-related injury in Victoria, Australia. METHODS: This was a retrospective population-based cohort study was conducted for compensation claims lodged by adults from 2003 to 2010. A logistic regression analysis was performed to assess the impact of various factors on the likelihood that an injured worker would receive an alternate/modified duties (ALT, n = 28,174) vs. Unfit for work (UFW, n = 91,726) certificate from their GP. RESULTS: A total of 119,900 claims were analysed. The majority of the injured workers were males, mostly age of 45-54 years. Nearly half of the workers (49.9%) with UFW and 36.9% with ALT certificates had musculoskeletal injuries. The multivariate regression analysis revealed that for most occupations older men (55-64 years) were less likely to receive an ALT certificate, (OR = 0.86, (95%CI, 0.81 - 0.91)). Workers suffering musculoskeletal injuries or occupational diseases were nearly twice or three times at higher odds of receiving an ALT certificate when compared to fractures. Being seen by a GP experienced with workers' compensation increased the odds of receiving ALT certificate (OR = 1.16, (95%CI, 1.11 - 1.20)). Occupation and industry types were also important factors determining the type of certificate issued to the injured worker. CONCLUSIONS: This study suggests that specific groups of injured workers (i.e. older age, workers with mental health issues, in rural areas) are less likely to receive ALT certificates.

General practitioners and sickness certification for injury in Australia.

BACKGROUND: Strong evidence supports an early return to work after injury as a way to improve recovery. In Australia, General Practitioners (GPs) see about 96 % of injured workers, making them the main gatekeepers to workers' entitlements. Most people with compensable injuries in Australia are certified as "unfit to work" by their GP, with a minority of patients certified for modified work duties. The reasons for this apparent dissonance between evidence and practice remain unexplored. Little is known about the factors that influence GP sickness certification behaviour in Australia. The aim of this study is to describe the factors influencing Australian GPs certification practice through qualitative interviews with four key stakeholders. METHODS: From September to December 2012, 93 semi-structured interviews were undertaken in Melbourne, Australia. Participants included GPs, injured workers, employers and compensation agents. Data were thematically analysed. RESULTS: Five themes describing factors influencing GP certification were identified: 1. Divergent stakeholder views about the GP's role in facilitating return to work; 2. Communication between the four stakeholder groups; 3. Conflict between the stakeholder groups; 4. Allegations of GPs and injured workers misusing the compensation system and 5. The layout and content of the sickness certificate itself. CONCLUSION: By exploring GP certification practice from the perspectives of four key stakeholders, this study suggests that certification is an administrative and clinical task underpinned by a host of social and systemic factors. The findings highlight opportunities such as practice guideline development and improvements to the sickness certificate itself that may be targeted to improve GP sickness certification behaviour and return to work outcomes in an Australian context.

Interactions between injured workers and insurers in workers' compensation systems: a systematic review of qualitative research literature.

INTRODUCTION: Work-related injury is a major public health problem and a worker's recovery can be shaped by their interactions with employers, healthcare providers and the workers' compensation system. Most research on the effects of compensation has concentrated on examining outcomes rather than considering the compensation process itself. There has been little attention paid to the interactions between stakeholders and only recently has the client's view been considered as worthy of investigation. This systematic review aimed to identify and synthesize findings from peer reviewed qualitative studies that investigated injured workers interactions with insurers in workers' compensation systems. METHOD: A search of six electronic library databases revealed 1,006 articles. After screening for relevance, 18 articles were read in full and a search of those bibliographies revealed a further nine relevant articles. Quality assessment of the 27 studies resulted in a final 13 articles of medium and high quality being retained for data extraction. RESULTS: Included studies focused mainly on experiences of injured workers, many of whom had long term claims. Findings were synthesized using a meta-ethnographic approach. Six themes were identified which characterised the interactions between insurers and injured workers. The majority of interactions were negative and resulted in considerable psychosocial consequences for injured workers. Positive interactions were less frequently reported and included respectful, understanding and supportive communication and efficient service from insurers. CONCLUSION: Findings from this synthesis support the growing consensus that involvement in compensation systems contributes to poorer outcomes for claimants. Interactions between insurers and injured workers were interwoven in cyclical and pathogenic relationships, which influence the development of secondary injury in the form of psychosocial consequences instead of fostering recovery of injured workers. This review suggests that further research is required to investigate positive interactions and identify mechanisms to better support and prevent secondary psychosocial harm to injured workers.

Healing or harming? Healthcare provider interactions with injured workers and insurers in workers' compensation systems.

INTRODUCTION: Healthcare providers (HCPs) are influential in the injured worker's recovery process and fulfil many roles in the delivery of health services. Interactions between HCPs and insurers can also affect injured workers' engagement in rehabilitation and subsequently their recovery and return to work. Consideration of the injured workers' perceptions and experiences as consumers of medical and compensation services can provide vital information about the quality, efficacy and impact of such systems. The aim of this systematic review was to identify and synthesize published qualitative research that focused on the interactions between injured workers, HCPs and insurers in workers' compensation systems in order to identify processes or interactions which impact injured worker recovery. METHOD: A search of six electronic databases for literature published between 1985 and 2012 revealed 1,006 articles. Screening for relevance identified 27 studies which were assessed for quality against set criteria. A final 13 articles of medium and high quality were retained for data extraction. RESULTS: Findings were synthesized using a meta-ethnographic approach. Injured workers reported that HCPs could play both healing and harming roles in their recovery. Supportive patient-centred interaction with HCPs is important for injured workers. Difficult interactions between HCPs and insurers were highlighted in themes of adversarial relations and organisational pressures. Insurer and compensation system processes exerted an influence on the therapeutic relationship. Recommendations to improve relationships included streamlining administrative demands and increasing education and communication between the parties. CONCLUSION: Injured workers with long term complex injuries experience difficulties with healthcare in the workers' compensation context. Changes in insurer administrative demands and compensation processes could increase HCP participation and job satisfaction. This in turn may improve injured worker recovery. Further research into experiences of distinct healthcare professions with workers' compensation systems is warranted.

Mental health claims management and return to work: qualitative insights from Melbourne, Australia.

PURPOSE: Mental health conditions (MHC) are an increasing reason for claiming injury compensation in Australia; however little is known about how these claims are managed by different gatekeepers to injury entitlements. This study, drawing on the views of four stakeholders-general practitioners (GPs), injured persons, employers and compensation agents, aims to describe current management of MHC claims and to identify the current barriers to return to work (RTW) for injured persons with a MHC claim and/or mental illness. METHODS: Ninety-three in-depth interviews were undertaken with GPs, compensation agents, employers and injured persons. Data were collected in Melbourne, Australia. Thematic techniques were used to analyse data. RESULTS: MHC claims were complex to manage because of initial assessment and diagnostic difficulties related to the invisibility of the injury, conflicting medical opinions and the stigma associated with making a MHC claim. Mental illness also developed as a secondary issue in the recovery process. These factors made MHC difficult to manage and impeded timely RTW. CONCLUSIONS: It is necessary to undertake further research (e.g. guideline development) to improve current practice in order to enable those with MHC claims to make a timely RTW. Further education and training interventions (e.g. on diagnosis and management of MHC) are also needed to enable GPs, employers and compensation agents to better assess and manage MHC claims.

Trends in sickness certification of injured workers by general practitioners in Victoria, Australia.

BACKGROUND: General practitioners (GPs) play a critical role in facilitating injured workers return to work via their ability to certify capacity to return to employment. However, little is known about the sickness certification patterns of GPs in the context of workers' compensation claims. AIM: To determine if GPs' sickness certification behaviour has changed between 2003 and 2010 in Victoria, Australia. METHOD: Retrospective population-based cohort study of all injured workers with an accepted compensation claim. Sickness certification rates per 1,000 working population per annum were calculated. General regression models adjusted for workers' age and annual claim number were fitted to summarize changes in count and duration (expressed as incidence rate ratios or IRRs) of unfit for work (UFW) versus alternate duties (ALT) certificates within six categories of work-related injury and disease. RESULTS: 92,134 UFW and 28,293 ALT certificates were identified. A significant decrease in the unadjusted annual certification rates per 1,000 working population was observed. However, after adjusting for the annual number of claims and age, the IRRs of certificates increased over time. The rate of injuries and IRRs of certificates varied across affliction categories, IRRs being higher in mental health conditions in women than in men (IRR: 0.40, 95 % CI 0.38-0.41 vs. IRR: 0.17, 95 % CI 0.16-0.18). The duration of certificates remained stable, with the ALT being longer than UFW certificates in all claimants. CONCLUSION: Our findings indicate that GPs in Victoria issue an increasing number of UFW sickness certificates each year. Further research is required to investigate the reasons for such practises.

Another Person in the Room: Using Interpreters During Interviews With Immigrant Workers.

Cross-language research poses many challenges. When researchers and participants do not speak the same language, meanings expressed by participants might not be understood in the same way by researchers, and the richness of participants' experiences might be lost. This can lead to the misrepresentation and silencing of issues faced by these participants, especially newcomers. In this article, we critically examine our experience conducting qualitative interviews with injured immigrant workers with the help of professional interpreters. Using examples from our field notes and transcripts, we outline some of the key difficulties we faced: varying styles of interpretation, breeches of interview conventions, and miscommunications with interpreters. We discuss how these issues affected our study design, rapport with participants and, ultimately, data quality. We end with a discussion of how to improve cross-language and cross-cultural research.

Sickness certification of workers compensation claimants by general practitioners in Victoria, 2003-2010.

OBJECTIVE: To examine patterns of the sickness certification of workers compensation claimants by general practitioners in Victoria, Australia, by nature of injury or illness. DESIGN, SETTING AND PATIENTS: Retrospective analysis of Victorian workers compensation data for all injured and ill workers with an accepted workers compensation claim between 2003 and 2010. MAIN OUTCOME MEASURES: Type (unfit for work, alternative duties, or fit for work) and duration of initial medical certificates relating to workers compensation claims that were issued by GPs, in six categories of injury and illness. RESULTS: Of 124,424 initial medical certificates issued by GPs, 74.1% recommended that workers were unfit for work and 22.8% recommended alternative duties. Unfit-for-work certificates were issued to 94.1% of workers with mental health conditions, 81.3% of those with fractures, 79.1% of those with other traumatic injuries, 77.6% of those with back pain and strains, 68.0% of those with musculoskeletal conditions and 53.0% of those with other diseases. Alternative-duties certificates were significantly longer in duration than unfit-for-work certificates in all injury and illness categories (P < 0.001) but certificates for workers with musculoskeletal injuries and diseases, back pain and strains and other traumatic injuries were of lesser duration than those for workers with fractures, mental health conditions and other diseases. CONCLUSION: The high proportion of medical certificates recommending complete absence from work presents major challenges in terms of return to work, labour force productivity, the viability of the compensation system, and long-term social and economic development. There is substantial variation in the type and duration of medical certificates issued by GPs. People with mental health conditions are unlikely to receive a certificate recommending alternative duties. Further research is required to understand GP certification behaviour.

Buddies in bad times? the role of co-workers after a work-related injury.

INTRODUCTION: Co-workers can play an important role after a work-related injury. They can provide details about the circumstances of an accident, offer emotional support to the injured worker and help with job tasks upon a co-worker's return to work (RTW). Working with an injured co-worker, however, can also strain work relationships and increase workload. The purpose of this study was to determine the role that co-workers play after a work-related injury and during the RTW process in the unionized, electrical construction sector. METHODS: We conducted two focus groups with injured electricians and union representatives. We also interviewed co-workers who had worked with someone who had been injured in the course of employment. We examined the role that co-workers can play after a work-related injury and some of the factors facilitating and hindering co-worker support. RESULTS: The structure of work in the electrical sector-a focus on cost-cutting and competition, job insecurity, perceptions of "different camps" among co-workers, little modified work and poor formal communication-can impede co-worker support and contribute to making injured workers' experiences difficult. Management can play an important role in setting an example for how injured workers are regarded and treated. CONCLUSIONS: Future research should explore how workers can better be supported after a work-related injury and during the RTW process.

Delicate dances: immigrant workers' experiences of injury reporting and claim filing.

INTRODUCTION: Immigrants often come to Canada for the purpose of employment and make up a large proportion of our labour force. Yet, these workers' labour market experience may not always be positive - new immigrant workers can have difficulties finding a job in their field and may end up working in 'survival jobs' that expose them to workplace hazards. Workers who are new to Canada may not be familiar with legislation designed to protect them at work or with social programs that can help after a work-related injury. METHODS: Through a series of in-depth interviews this study examined the experiences of new immigrants after they were injured on the job. RESULTS: The analysis revealed that many workers were in manual, 'survival jobs' and had not received job or occupational health and safety training. Many did not speak the English language well and knew little about their rights. While workers often felt trepidation about reporting their injury, most told a health care provider or employer that they were injured or in pain. This, however, rarely led to timely or appropriate claim filing. Workers were often discouraged from filing a claim, misinformed about their rights or offered 'time off work' in lieu of reporting the injury to worker's compensation. In instances where a claim was filed, communication problems were common and led to mistakes being made on forms and misunderstandings with the adjudicator and employer. Interpretation services were not always offered consistently or at the correct time. CONCLUSION: Efforts must be made to systematically inform new immigrants of their health and safety rights, responsibilities and entitlements as they are entering the labour market. Systems must be put in place to ensure that immigrants can access the compensation system in the event of a work-related injury and that employers and healthcare providers fulfil their reporting responsibilities.

A national scan of employment standards, occupational health and safety and workers' compensation resources for new immigrants to Canada.

OBJECTIVES: The burden of work injuries in Canada is a serious public health concern. Nearly one million Canadian workers experienced nonfatal injuries that led to time off work in 2005. New employees and recent immigrants are more likely to experience a work-related injury. The purpose of this study was to examine services, programs and resources available to newcomers to Canada that focus on employment standards (ES), occupational health & safety (OHS) and workers' compensation (WC). METHODS: We reviewed resources available through community organizations, employers, settlement groups and unions, as well as provincial and federal prevention agencies and workers' compensation boards. The materials were categorized according to geographical distribution, content, resource type, audience and language. RESULTS: We found a total of 224 resources that met our search criteria. The greatest numbers were found in the provinces of Ontario, British Columbia and Manitoba. Most resources consisted of short factsheets on the topic of ES; WC was the focus of the fewest resources. The most comprehensive resources were teaching materials for ESL/FSL classes and Job Search Workshops. Most resources were specifically produced for newcomers but only available in French/English. Our scan uncovered no information for health care providers, union representatives or safety professionals working with immigrants. Very few resources were aimed at young immigrant workers or employers working with newcomers. CONCLUSIONS: Our research identifies gaps in the provision of health and safety resources for newcomers. Additional research is needed to evaluate the depth and quality of materials and to determine how decisions are made around the inclusion or exclusion of ES, OHS and WC information in language and labour market preparation programs for new immigrants.

Workplace Violence Prevention: Flagging Practices and Challenges in Hospitals.

BACKGROUND: Flagging is a standardized way to communicate the risk of patient violence to workers. We add to the limited body of research on flagging by describing hospitals' approaches to and challenges with flagging patients with a history of violent behavior. METHODS: We used a qualitative case study approach of hospitals in Ontario, Canada and their patient flagging practices. Key informants and our advisory committee identified 11 hospitals to invite to participate. Hospitals assisted in recruiting frontline clinical and allied health workers and managers to an interview or focus group. A document analysis of hospitals' flagging policies and related documents was conducted. Thematic analysis was used to analyze interview and focus group data. FINDINGS: Five hospitals participated. Of the five hospitals, four had a flagging policy where frontline clinical workers (n = 58), frontline allied health workers (n = 31), and managers (n = 42) participated in an interview (n = 43) or focus group (n = 15). Participants described three challenges: patient stigmatization, patient privacy, and gaps in policy and procedures. CONCLUSION/APPLICATION TO PRACTICE: Flagging patients with a history of violent behavior is one intervention that hospitals use to keep workers safe. While violence prevention was important to study participants, a number of factors can affect implementation of a flagging policy. Study findings suggest that hospital leadership should mitigate patient stigmatization (real and perceived) and perception of patient rights infringement by educating all managers and frontline workers on the purpose of flagging and the relationship between occupational health and safety and privacy regulations. Leadership should also actively involve frontline workers who are the most knowledgeable about how policies work in practice.

The role of health care providers in long term and complicated workers' compensation claims.

INTRODUCTION: Health care providers (HCPs) play a central role in workers' compensation systems. In most systems, they are involved in the legitimization of work-related injury, are required to provide information to workers' compensation boards about the nature and extent of the injury, give recommendations about return-to-work capability and provide treatment for injury or illness. This study identifies problems that occur at the interface between the health care system, injured workers, and workers' compensation boards (WCBs) that may complicate and extend workers' compensation claims and the mechanisms that underlie the development of these problems. METHODS: Interviews were sought with injured workers, peer helpers and service providers from a variety of geographic locations in order to get a broad picture of return to work problems and concerns. This analysis includes data from total of 34 interviews with injured workers who had long term and complicated claims. Interviews were also conducted with 14 peer helpers and 21 service providers. RESULTS: We identified four domains related to injured workers' interface with the health care system that played a key role in complicating and prolonging compensation claims. These problems, related to health care access, conflicting or imperfect medical knowledge, limited understanding of compensation system requirements and confusion about decision-making authority, resulted in frustration, financial difficulties and mental health problems for injured workers. CONCLUSION: Recommendations are made about how compensation system parties can find better ways to serve injured worker health care needs and facilitate a smooth relationship between the compensation board and HCPs.

The "toxic dose" of system problems: why some injured workers don't return to work as expected.

Introduction Most workers who incur an injury on the job follow a relatively straightforward path through a workers' compensation claim, recovery and return to work. However, a minority of compensation claims is prolonged and can be disproportionately costly. We conducted this qualitative study in order to gain an understanding of systemic, process-related problems affecting injured workers who had failed to return to work as expected. Method A total of 69 in-depth interviews were conducted with injured workers with complex and extended workers' compensation claims and with return-to-work (RTW) providers such as health care providers, insurers, legal advisors, and workplaces. The study was based in Ontario, Canada. A modified grounded theory analysis led to the identification of common mechanisms in RTW problems. Results We identify problems with return to work and extended workers' compensation claims in dysfunctions in organizational dynamics across RTW systems including the workplace, healthcare, vocational rehabilitation and workers' compensation. These system problems are difficult to identify because they appear as relatively mundane and bureaucratic. These appeared to have damaging effects on workers in the form of a 'toxic dose' affecting the worker beyond the initial injury. Conclusions Worker's problems with extended claims were linked to RTW policies that did not easily accommodate conflict or power imbalances among RTW parties and by social relations and processes that impeded communication about RTW situations and problems. Avenues for intervention are located in a shift to a critical lens to RTW process that addresses differences of knowledge, resources, and interests among different parties.

Workplace health understandings and processes in small businesses: a systematic review of the qualitative literature.

INTRODUCTION: Small businesses (SBs) play an important role in global economies, employ half of all workers, and pose distinct workplace health problems. This systematic review of qualitative peer-reviewed literature was carried out to identify and synthesize research findings about how SB workplace parties understand and enact processes related to occupational health and safety (OHS). METHODS: The review was conducted as part of a larger mixed-method review and in consultation with stakeholders. A comprehensive literature search identified 5067 studies. After screening for relevance, 20 qualitative articles were identified. Quality assessment led to 14 articles of sufficient quality to be included in the meta-ethnographic findings synthesis. RESULTS: This review finds that SBs have distinctive social relations of work, apprehensions of workplace risk, and legislative requirements. Eight themes were identified that consolidate knowledge on how SB workplace parties understand OHS hazards, how they manage risk and health problems, and how broader structures, policies and systems shape the practice of workplace health in SBs. The themes contribute to 'layers of evidence' that address SB work and health phenomena at the micro (e.g. employer or worker behavior), meso (e.g. organizational dynamics) and macro (e.g. state policy) levels. CONCLUSIONS: This synthesis details the unique qualities and conditions of SBs that merit particular attention from planners and occupational health policy makers. In particular, the informal workplace social relations can limit workers' and employers' apprehension of risk, and policy and complex contractual conditions in which SBs are often engaged (such as chains of subcontracting) can complicate occupational health responsibilities. This review questions the utility of SB exemptions from OHS regulations and suggests a legislative focus on the particular needs of SBs. It considers ways that workers might activate their own workplace health concerns, and suggests that more qualitative research on OHS solutions is needed. It suggests that answers to the SB OHS problems identified in this review might lie in third party interventions and improved worker representation.