work-injury management and return-to-work in the

Work-injury Management and Return-to-work in the Manufacturing Industry in Selangor, Malaysia

Dr Siew Wei Fern 15 October 2018

In fulfilment of the requirements for the degree of Doctor of Philosophy in Medical and Health Sciences. Supervisors: Prof. Dr. Stephen Periathamby Ambu Associate Dean, IMU Research Lab, B. Med Sc Programme, International Medical University

Prof. Dr. Mak Joon Wah Vice President, Research, International Medical University

Dato’ Sri Dr Mohammed Azman bin Dato’ Aziz Mohammed Chief Executive Officer, Social Security Organisation (SOCSO), Malaysia

This study was funded by the internal research grant of IMU.

This research was aimed to answer the following questions:

Research question (1):

What approaches had SOCSO incorporated to engage the key

stakeholders (nurses, employers and workers with work related injuries) in

its national RTW programme relating to work injury management, return to

work practices and workplace adjustments or modification practice?

3


What organisational policy and practices were in placed to manage work

injury, return to work practices and workplace adjustments or modification

practices in the manufacturing industry in Selangor, Malaysia?


How do nurses, employers and workers with work related injuries

perceived their experiences in participating with work-injury

management, return to work practices and workplace adjustments or

modification practices?

Global perspective

Work-related injuries

occurrences have been a global

burden to the developed and

developing countries for many

decades. (Takala et al, 2014)

Employers, workers and the

society are burdened by the

economic cost of work injuries

due to accidents which come in

the form of direct and indirect

costs.

PROBLEM STATEMENT

Organisation’s burden:

staff turnover costs

training costs

loss of output

increased insurance premium

and legal cost

Injured workers’s burden:

net loss of future earnings

(minus compensation)

medical cost and rehabilitation

cost

Society’s burden:

social payout

investigation / inspection

costs

work, safety and health

promotion

loss of human capital and

medical subsidy 4

Figure 1.1 Number of industrial accidents 2004 – 2013

Note. From SOCSO Annual Report 2004 – 2013.

Figure 1.2 Compensation – employment injury 2004 – 2013

Note. From SOCSO Annual Report 2004 – 2013.

In Malaysia, numbers of work-

related injuries due to

industrial accidents have

reduced considerably over

the last ten years, but do not

correspond with SOCSO

compensation pay-out, which

has increased over the years.

5

3

Over last 10 years

Over last 10 years

RTW is a complex issue broad understanding of the

processes is vital. (Shaw, Feuerstein, Miller & Wood, 2002)

Workers have also reported a sense of powerlessness in the

process of recovery and RTW following a workplace injury (Friesen, 2004).

6

Statutory obligations may be in place for workplace rehabilitation

but most employers have adopted a minimalist approach,

introducing workplace rehabilitation solely because “it’s the law”

or rather than as a component of a risk management strategy (Hawkins, 2000)

committed participation by the various key stakeholders in

the management to ensure early return to work of workers

sustaining injuries

Acknowledges that:

workers form the major component of human resources

in the industries

workers are highly in demand for every sector of the

various industries

they are the assets to the organisation

In Malaysia, the Ministry of Human Resources is greatly

concern over the number of occurrences in work injuries

related to industrial accidents as well as the economic

costs resulting from these accidents.

When workers sustained injury while at work which

resulted in time loss at work, they are deemed as a liability

to their organisation. 7

workers were rushed through the recovery and rehabilitation

process by, e.g healthcare professionals and employers, who tend

to not believe that the workers have a legitimate problem

My professional perspective from observations

8

employers have no clues how to accommodate modified duties

when workers are prescribed with light duties by the physician

workers were inadequately counselled on early RTW, pressed

to RTW once they have exhausted their medical leave

entitlement or otherwise face the consequences of having their

wage deducted / terminated

nurses were not empowered to provide holistic counselling to

the injured workers as the role of counselling was done by the

in house or visiting doctors

9

Effective communication

Readiness in managing the process

Policies and practices in place

Present job guaranteed

Injured worker well facilitated through their

recovery and return to sustainable employment

Questions

‹#›

Conceptual Framework of this Study

Figure 1.6 Conceptual framework of the study

Workers

Compensation

SOCSO

Workplace

(manufacturing industry)

Work

Injured

Workers

Nurses servicing

in this industry

Employer

External

Acci

dent

Surg

ery

Acut

e

Inpa

tient

Trea

tmen

t

Pros

thes

is? Physical rehabilitation

Vocational rehabilitation Constant communication

Constant monitoring

GOAL?

Maintain patient-doctor-

employer relations

Safe recovery

RTW

Permeability between the

inner and outer circle for

cohesive work-injury and

RTW management

12

Figure 1.5 Comprehensive Disability Management Model.

Adapted from “A conceptual model for Comprehensive Disability Management," by

H.G. Harder and L.R. Scott, 2003, Journal of the Ontario Occupational Health

Nurses Association, p. 20.

Healthcare

Lawyer

Family

Workers

Compensation

Insurance

Third party

administrator

Safety

Agencies

Advocates

Social

Support

Expectations

Employee

Assistance

Programs

Community

Agencies

Workplace

Work

Worker Union

Co-workers Management

External

Conceptual Framework of this Study Based on CDMModel

Research design: Mixed methods approach

Methodology

Objective (2)

Self-reporting QA

Employers 13

Figure 3.4 Morgan (2014) multipart sequential mixed methods approach applied in this study

Preliminary phase

QUAL

data collection, analysis, results

Second phase

QUANT

data collection,

analysis, results

Follow-up extension

phase

QUAL

data collection,

analysis, results

Interpretation

Triangulate corroborate & converge data

25

Objective (1)

Document review,

Non-participant observation

Objective (3)

FGDs – employers

Semi-structured

interview: workers and

industrial nurses

26

Table 3.1

Tabulated sample size from stratified random sampling of study

Manufacturing industry enterprises Strata

population

Calculated

sample size

based on

formula

A Manufacture of food, beverage, tobacco

207 48

B Textile, wearing apparels and leather

industries

41 9

C Manufacture of wood and wood products

including furniture

44 10

D Manufacture of furniture (non-wood), paper

product, printing and publication

120 28

E Manufacture of chemicals (paint, rubber,

plastic)

404 93

F Non-metallic industry (eg: cement,

ceramic)

141 33

G Basic metal industry

136 32

H Electrical, electronic product, machinery

equipment, automobile)

487 112

I Other manufacturing enterprises

30 7

Total 1610 310

Add 20% 372

*3 attempts, 1 reminder (April 2012 to May 2013) 405 QAs returned, and

392 duly completed

15

Interviews – Industrial Nurses

Table 4.37

Industrial nurses’ details (Interview).

Nurses Sex Age Types of enterprise

Years of working

experience in industrial

nursing

Year graduated as

Registered Nurse

Clinical experience

prior current job

N 1 F 28 A 3 2011 Fresh graduate

N 2 F 35 E 4 2010 Fresh graduate

N 3 F 36 H 4 2010 Fresh graduate

N 4 F 44 H 8 2006 2 years hospital

experience

N 5 F 33 D 5 2009 3 years hospital

experience

N 6 F 52 E 15 1999 3 years hospital

experience

Note. F=Female; A=Manufacture of food, beverage, tobacco; D=Manufacture of paper product, printing and publication;

E=Manufacture of chemicals (paint, rubber, plastic); H= Metal and machinery equipment (electrical, automobile)

16

Interviews - Workers Table 4.36

Workers’ details (Interview).

Workers Sex Age

Types

of

enterprise

Job scope

before

injury

Years

of service

with

company

Type of

injury

sustained

Site of injury

Injury

occurred

after how

many

years of

service

Job scope

after

injury

W1 M 48 H Mechanic /

Technician

21 Crush Hand: right

index finger

(distal phalanx)

11 Foreman

W2 M 51 G Skilled

Worker

22 Amputation Hand:

Amputated left

last finger, left

index and left

fourth finger

14 Store

Keeper

W3 M 31 H Machinery

repair

6 Amputation Hand: above left

elbow

amputation

1 Office IT

work

W4 F 49 A Machine

Operator

15 Amputation Hand:

Amputated right

thumb & index

finger

9 Quality

Departme

nt

W5 M 38 G Line Leader 7 Crush Hand: left index

finger

2 Production

line –reject

product

W6 M 36 A Production

Operator

8 Crush Hand: right

fourth finger

1 Same job

W7 F 53 A Machine

Operator

18 Amputation Hand:

Amputated right

index and

middle fingers

10 Quality

control

unit -

clerical

Note. A=Manufacture of food, beverage, tobacco; G=Basic metal industry; H= Metal and machinery equipment (electrical, automobile)

Method of analysis to qualitative components Table 3.10 Stages involved with developing the template.

Identify priori themes

Coded 1st FGD

Cluster codes from

1st FGD

Identify themes and developed the

initial template

Analyse 2nd and 3rd FGDs.

Review and revised the template

Analyse individual worker’s

interviews.


Analyse individual industrial

nurse’s interviews.


Analyse all the data from all the

FGDs and individual interview.

Develop final template

• not an expert in

counselling for injured

workers

• unable to modify

workplace

• unsure of the options for

light duty

• injured workers unable to

multitask

• lack of awareness and

training on compensation

scheme and return to

work programme

• communication gap

among employers

doctor(s) treating the

injured workers

• unable to cater to injured

worker(s) due to fast

production needs

17

18

Results & Discussion

19

Quantitative analysis

Non- parametric test was used as the dependent variables

failed the assumption of normality distribution:

Table 4.29

Tests of Normality

Shapiro-Wilk

Statistics df p

Work-injury case management subscale 0.921 392 <.001

RTW practices subscale 0.971 392 <.001

Work adjustments or modification practices subscale 0.883 392 <.001

OPP summated scores 0.933 392 <.001

*p < 0.05

20

Qualitative analysis

Themes:

Figure 4.1 Initial Template: priori themes to second template: modified

theme

The initial template

Coded and clustered into priori themes

following 1st FGD

The second template

Coded and clustered following the remaining

2nd, 3rd FGDs and interviews with nurses

Theme 1:

Not an expert to counsel injured

workers

Modified theme 1:

Uncertainties in decision making

Theme 2:

Unable to modify workplace for

injured workers

Theme 3:

Unsure of the options for light

Duty

Modified theme 2:

Commitment to extended roles

Theme 4:

Injured workers are unable to

multitask

Theme 5:

Lack of awareness in

compensation scheme

Modified theme 3:

Deficient knowledge related to process

management of RTW

Theme 6:

Communication gap among

employers and doctor(s) treating the

injured workers

Theme 7:

Unable to cater to injured worker(s)

job relocation need

Modified to Integrative theme:

Effective communication

21

Results

Document analysis findings

Treating doctor’s prescription in RTW to workers following

work-injury:

light duty, no prolonged lifting of weight more than two kilograms,

avoid heavy load of 5 kilograms, avoid operating heavy

machineries for two months and also avoid prolonged standing,

walking and sitting.

Reporting to SOCSO following injury by the Employer: (days)

Median length: 60

Minimum days: 2

Maximum 150

22

Results

N = 142

Types of injuries Frequency (n) Percentage (%)

Fractures 81 57.0

Crushes 31 21.8

Amputations 21 14.8

Sprains 9 6.4

Types of injuries


23

Results

N = 142

Site of injuries Frequency (n) Percentage (%)

Upper limbs 83 58.5

Multiple locations 32 22.5

Lower limbs 15 10.6

Back 9 6.4

Site of injuries


24

Results

N = 69

Medical leave taken (months) Frequency (n) Percentage (%)

> 1 month to 3 months

29 42.0

> 3 months to 9 months

37 53.6

> 9 months 3 4.4

Medical leave taken

Note. MDN = 67.5


25

Results

N = 142

Duration of intervention Frequency (n) Percentage (%)

1 to 3 months 47 33.1

> 3 to 6 months 18 12.7

> 6 to 9 months 20 14.1

> 9 to 12 months 17 12.0

> one year 40 28.1

Intervention duration for RTW programme.


26

Results

Permanent disability percentage

n = 31

Median percentage awarded: 9.5%,

Minimum: 2%

Maximum: 80% (amputated arm above the elbow)


27

Results

N = 118

RTW hierarchy Frequency (n) Percentage (%)

Same employer same job 15

12.7

Same employer similar job 36 30.5

Same employer different job 48

40.7

Different employer same job 2 1.7

Different employer similar job 1 0.8

Different employer different job 10 8.5

Self-employed 6

5.1

RTW hierarchy


28

Results

Non participant observations findings

The SOCSO rehabilitation service providers for the RTW programme:

12 centres

Klang valley; Seremban; Ipoh; Melaka; Pulau Pinang

SOCSO engages the employers and workers in its RTW programme

through various strategies. Its strategies are comprehensive and

commendable with an upstream system approach.

29

Results


Emerging topics over the four conferences were:

• strategies of RTW / disability management at workplace;

• early interventions for RTW;

• addressing disability at work with policies and actions;

• challenges in rehabilitation;

• stakeholders influencing RTW and breaking the barriers

• interchangeable topics on light duties, modifications at work and the

importance of early transitional work options for the injured workers.

There were still barriers ahead in the disability management system

among the organisational practices.

30

Results


SOCSO assured its case managers will work closely with the employers

and workers in RTW aspects.

SOCSO officers coordinate to provide information on job vacancies for the

disabled insured persons and assist in preparations for job application.

SOCSO - authorised organisation which is licensed to handle training,

organising the examination and the certification process of Certified

Return to Work Coordinator (CRTWC) and Certified Disability

Management Professional (CDMP) by International Disability Management

Standards Council (IDMSC)

31

Results

Information on safety and health practices: (N = 392)

81.4% (n = 319) of the employers responded that they were

familiar with OSHA 1994.

Some 12% (n = 49) of the employers still do not have a safety and

health committee established.

An alarming 100 % of employers having their teams not trained in

managing RTW.

84.7% (n = 322) utilised the workers’ injury data to help them in

solving problems related to safety and health.

Employers Survey

32

Results

Worker’s compensation awareness

100% employers aware of the roles played by SOCSO.

More than 70% (n = 285) of the employers were still unsure that

SOCSO offers two types of compensation schemes.

51.8% (n = 203) aware the reporting of accident to SOCSO within

is 48 hours of occurrence and yet 48.2% (n = 189) did not answer

this aspect correctly.

Small percentage, 15.3% (n=60) of the employers were still

unaware that SOCSO offers RTW programme to its insured

workers.

Employers Survey

33

Results

Table 4.28

Organisations proactive or passive work-injury management and RTW

Practices

(n)

Passive

Practices

Scores

% (cut-off

score)

(n)

Proactive

Practices

Scores

% (cut-off

score)

Work-injury case management subscale 392 100.0 (23) 0 0.0 (24)

RTW practices subscale 392 100.0 (24) 0 0.0 (32)

Work adjustments or modification practices

subscale

385 98.2 (9) 7 1.8 (12)

Employers Survey

34

Results

A Mann-Whitney U test indicates that Organisational Policies and

Practices (OPP) scores is significantly higher for employers:

who employ more than 500 workers (U = 11046, p = 0.039, r =.10)

are familiar with the Occupational Safety and Health Act 1994

(U = 7478, p < .001, r =.24)

have a safety and health committee (U = 4744, p < .001, r =.25)

use workers’ injury data to problem solve RTW (U = 6509,

p < .001, r =.20)

aware that SOCSO offers RTW programme (U = 6079, p < .001, r

=.24).

Employers Survey

35

Figure 4.2 The final template

The final template

Coded and clustered and emerged themes interviews with workers

Final Theme from management representatives

and nurses

Final Theme from workers

Theme 1:

Uncertainties in decision making

Lack of awareness in compensation

scheme

o knowledge sharing

o working in silo

Injured workers are unable to multitask

o negotiation

No RTW contingency, ad-hoc

arrangements

o policy / SOPs

o top management commitment

A voice to be heard

Theme 4:

Fear of uncertainties

Isolated / singled out

o afraid to ask

o lack of confidence

o view as a burden

Theme 2:

Commitment to extended roles

Not within job scope

o Human Resources

o roles and responsibilities

extra workload

reluctance - no monetary

benefit

Unable to cater to injured workers

o prioritising - fast production needs

o not feasible to cater to a small

number of affected workers / or not

at all

Theme 5:

Support and respect

Transparent

Accept injury as genuine

o trust

Theme 3:

Deficient knowledge related to process

management of RTW

Light duty – broad statement

o not able to modify workplace

o unsure of options to offer

Not knowledgeable in RTW

management

o possess only basic nursing skills

o out of practice in assessment skill

(functional / physical assessment)

Continual professional development

opportunity

o financial resources

o limited courses / workshop on

RTW

o train the trainer

Integrative theme: Theme 6

Effective and assuring communication

Treating doctors are busy

o pay-to-get report SOP

Correct communication channel

o Employers, workers, treating doctors

o accurate information

o consensus in decision making

Key:

= level one of the hierarchical code

= level two of the hierarchical code – sub divisional code

o = level three of the hierarchical code – further sub divisional code

Results – FGDs and Interviews

36

Discussion

It is evidenced by past research that RTW is effective when interventions

for the workers following an injury at work starts from the day of accident

itself.

Australia - average days taken for submitting a claim with the employer

from an initial injury was slightly more than a month (38 days)

[Mdn 3 months] (Australia Government Comcare, 2005).

Kucera, et.al (2009) study - highlighted that workers with back injuries

were more likely to take 90 days or longer to RTW following a delay of 30

days or longer in the work-injury management

Besen, Harrell and Pransky (2016) study concluded that the predicted

length of disability reduced closed to 40 days less if work disability lag

time was zero days as compared with having a lag time of 30 days or

longer.

37

Discussion

Besen, Harrell and Pransky (2016) reasoned that the findings suggest

possibility of differences types of injury sustained and their study focused

specifically on low back injury, while the other study included all work-

related injuries. [fractures and crushes]

The extend of injuries unable to present the report immediately

because of their injury alongside with prolonged medical leave of absence

and extended periods of treatment. [medical leave in median length of

medical leave taken by these was 67.5 days, with minimum of 34

days and maximum of 478 days].

Hoffmann, 2015; Johnson, 2015; Jafri Mohd Rohani et al, 2015;

Barnett et al., 2010; Worksafe, n.d.; Perry et al., 2005; Silverstein & Clark 2004; Fan, McLeod &

Koehoorn, 2010)

38

Discussion

Vocational rehabilitation yields positive outcome when intervention is

immediate as recovery time for body stressing injuries takes no more

than six weeks in many cases and no more than 12 weeks in severe soft

tissue injuries. (Vandenbroeck, Verjans, Lambreghts & Godderis, 2016; Australian Government Comcare,

2006).

[shortest duration between one to three months, to the longest

duration of more than a year. ]

SOCSO RTW programme – 2007 – limited case managers

SOCSO Ministerial KPI - 116.09 (improved from tremendously from

more than 700 days) *international benchmark of 59.4 days (Olivier et al., 2012).

39

Discussion

Lack of clear RTW policies:

Concur with results from past research - that lack of clear local policies

being the backbone to the proactive early management of RTW may

possibly result in employers directing to solutions based on expense

avoidance instead of aiming at rehabilitation for workers as the focus of

importance is on own business and production revenues rather than a

long term of return of investment.

[the organisations are likely to comply with the provision of self-

regulation of OSHA 1994, with a duty of due diligence to safety and

health in order to ensure so far as is practicable, to protect their

workers at work. ]

Australia Government Comcare, 2016; Snell & Hart, 2009; Foreman, Murphy & Swerissen,

2006; Mills, 2012; Berecki-Gisolf et al., 2012; Nielsen et al., 2012; He et al., 2010; Lee &

Kielhofner 2010; Blank et al., 2008; Foreman, et al., 2006; SOCSO, 2007.

40

Discussion

Past research conducted which showed that larger companies exercise

formal RTW programme and are able to offer extensive range of

assistance to workers (Adya, et.al, 2012; Ossman et al., 2005; Johnson & Fry, 2002; Australia Institute for

Primary Care, 2006; Kenny, 1998).

[OPP scores were significantly higher for employers who employ

more than 500 workers, other than the possible practice of due

diligence in safety and health by the organisations, it is more likely

that large organisations have greater financial capital and thus

have more resources to be able to support their RTW programme

internally].

Effective work transition exercise is impracticable when information on

worker’s capabilities and physical demands of the required job are

vague and not clearly specified, as it will not yield effective outcomes

[operationalised challenges]

(Gonser & Archibald, 2010; Tugman et. al, 2010).

41

Discussion

Training and communication is vital because those assigned to

manage the cases of injured workers returning to work would not be

familiar with the processes as the programme itself must be

individualised, where it is tailored to meet the specific needs of the

workers. Johnson & Fry, 2002, p. 17; Vandenbroeck, et.al, 2016

[However, managers and nurses have very little contact time

with the injured workers and therefore this is a crucial aspect

which need to be improved – knowledge deficient play as

evidenced]

RECOMMENDATIONS

1. Timely need for the Ministry of Human Resources Malaysia to review the Occupational Safety and Health Act 1994 to supplement a regulation mandating a written RTW policy to ensure commitment from the top management of large companies with more than 500 employees in compliance with the Part IV - General Duties of Employers and Self-Employed Persons: Section 15. General duties of employers and self-employed persons to their employees.

2. As for the smaller companies, SOCSO consultation shall be sought for the RTW related matters, nevertheless best practices are recommended.

3. The employers are recommended to seek consultation from SOCSO to assist in the practical implementation and application of the RTW programme at organisation level. This is when the RTW strategies of assessment, planning, implementation, evaluation and follow-up can be maximised. Through these strategies effective and assuring two-way communication between management and workers can be achieved.

4. Meanwhile, the management should start monitoring if the RTW programme generates a return on investment for the company for cases managed.

42

RECOMMENDATIONS 5. Digital resources can be used by employers to link worker’s compensation and RTW information to all the staff via an internet portal, or through staff bulletin board where information should be constantly updated.

This link can be customised to allow uploads of SOCSO Accident Reporting form 21 from the managers / supervisors /safety and health officers directly to the Human Resources. This could assist the Human Resources personnel to report the accident to SOCSO within the stipulated time of 48 hours.

6. The management should consider its best practice to encourage staff career development programme relating to disability management in order to create best workers who are knowledgeable and competent in this field. This can drive job satisfaction and improve motivation towards work as well for these workers.

7. Make courses related to disability management / rehabilitation affordable to all. As this encourages the generation of a pool of competent RTW coordinators. A home-grown curriculum is recommended.

8. Managements should consider setting up a mini place of exercise within the organisation,

as this will enhance wellness not only for the healthy employers and employees, but also provide a space and basic equipment for workers with disability to exercise (range of motion, isometrics) during their transition to work duties. They can be supervised by the nurses and ensure continuity of physiotherapy when time and transport are not in favour to them to attend the physiotherapy at the designated SOCSO rehabilitation centre.

43

Nurses, employers, workers with work related injuries and

SOCSO’s real involvement are depicted in their participating

efforts and strategies in work-injury and RTW management in

the manufacturing industry in Selangor, Malaysia.

It presents actual needs for developing an effective work

injury management with RTW programme within

manufacturing industry.

Nurses, employers, workers must play an active role here

and possess knowledge, skills, abilities and aptitudes in

collaborative work injury management.

Summary

44

This study can provide perspective to the human resources on

formulating organisational policy and SOPs for workplace injury

and RTW management to support and facilitate injured workers

returning to their occupation in optimum health and work

functionality.

As an academic, provide me with the opportunity to initiate work

with the various healthcare professionals / health ministry in

relating to nursing practice for nurses servicing the manufacturing

industry in Malaysia to enable them to advance and upgrade

themselves in the field of work rehabilitation.

The findings from this study could serve as a source of information

and reference for future studies to other countries who are

interested in work injury management and RTW.

Summary

45

THANK YOU

46

work-injury management and return-to-work in the

Documents