QUALITATIVE

Beardwood et al.HEALTH
/ VICTIMS
RESEARCH
TWICE OVER
/ January 2005 10.1177/1049732304268716

Victims Twice Over: Perceptions

and Experiences of Injured Workers

Barbara A. Beardwood
Bonnie Kirsh
Nancy J. Clark

The authors discuss the qualitative component of a participatory research project conducted
in Toronto, Ontario, between 1999 and 2001. Injured workers, who were trained as peer
researchers, conducted one-time, semistructured interviews with other injured workers
(N = 17) and helped with inductive coding and analyzing the interview transcripts. The
qualitative research group consisted of seven peer researchers, four academic researchers,
and a community legal worker. The group recruited interviewees by advertising on bulletin
boards and in newsletters and newspapers, and selected a diverse group of interviewees who
had encountered problems with the return-to-work process. Interviewees believed that the
process victimizes them and renders them powerless and dependent on others. Furthermore,
they considered that health professionals and bureaucrats impede their rehabilitation. The
authors suggest that injured workers should be included in the decision-making process of
rehabilitation and rebuilding their lives.

Keywords: injured workers; compensation process; return-to-work; participatory

research

I njured workers vary in the trajectory they follow after sustaining their illness or
injury. Some are injured for a brief time, return to work, and encounter few, if any,
further problems. Others are clearly permanently disabled and receive a pension to
compensate for this disability. Still others perceive themselves to be injured but
encounter problems both in returning to work and in obtaining recognition from the
compensation system that they have a legitimate workplace injury. This latter
group of injured workers is similar to the “undeserving poor” of the 19th century, in
that attitudes toward them are characterized by blame and marginalization
(Frankcom, 1992; Jolly, 2000; Lippel, 1999). The difference in the case of injured
workers is that this attitude is hidden beneath the rhetoric of return to work and
rehabilitation.
In this article, we focus on the perceptions and experiences of injured workers
who have encountered problems with the compensation, medical, and rehabilita-
tion systems, and difficulties in returning to work. We discuss a participatory

AUTHORS’ NOTE: This study was supported by the Research Advisory Council of the Ontario Work-
place Safety and Insurance Board. We thank the many injured workers and representatives of injured
worker organizations who participated in this project.
QUALITATIVE HEALTH RESEARCH, Vol. 15 No. 1, January 2005 30-48
DOI: 10.1177/1049732304268716
© 2005 Sage Publications
30

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 Beardwood et al. / VICTIMS TWICE OVER 31

research study in which injured workers were involved in setting the research
agenda, and analyzing and reporting the results. The study was funded by the
Ontario Workplace Safety and Insurance Board (WSIB) and was limited to the
Toronto area because of the funding source and the difficulties in organizing and
training injured worker–peer researchers from a wider area. It had three main com-
ponents: a survey of injured workers; analysis of documents relevant to the context
and treatment of injured workers; and qualitative, in-depth interviews with injured
workers. In this article, we discuss the qualitative research, in which injured work-
ers were involved in translating concerns into questions, interviewing other injured
workers, developing codes, analyzing the data, and producing a final written
report.
We argue that some injured workers are viewed as the undeserving injured.
They are treated with suspicion, because their injuries from the late modern work-
place have no specific etiology, might be multicausal, are frequently invisible, and
do not fit any template of recovery. Furthermore, they never completely
reassimilate into the workplace and are accommodated either with difficulty or not
at all. In addition, they find it difficult to regain some semblance of their former
lives. They become powerless and dependent. They lose control over their bodies
and become dependent on health professionals and bureaucrats, and sometimes
their employers, to be able to function physically and financially. They perceive
themselves to be victims twice over. First, they are victims of the workplace. Second,
they are victims of a system that implies they are fraudulent and that, in their eyes,
refuses them support and impedes their rehabilitation.

LITERATURE REVIEW

As the duration of work absence increases, the likelihood of return to work

decreases (Krause, Dasinger, & Neuhauser, 1998). Gamborg, Elliott, and Curtis
(1992) noted that 50% of those who do not return to work within 6 months never
work again; after a year, only 10% to 15% ever work again; and after 2 years, the
chances of working again are poor. Furthermore, injured workers who return to
unsuitable jobs might eventually give up this work. Although the rate of successful
returns to employment in Ontario, measured by first return to work, is 85%, the rate
of success over a longer period is only 50% (Butler, Johnson, & Baldwin, 1995).
Workers who are unable to return to work can become caught in a vicious cycle
of diminished self-worth, marital and family stress, financial strain, depression,
anger, and substance abuse (Gamborg et al., 1992). These problems can become
more incapacitating than the injury or illness and impede a satisfactory return to
work (RTW). Furthermore, workers who do not follow predictable patterns of RTW
are caught within a culture that “blames” them for their lengthy recovery and per-
ceives their attempts at negotiation and control as resistance (Headley, 1989).
A growing literature addresses factors that both promote RTW and contribute
to delayed recovery (Baril et al., 2003; El-Bassel, 1996; Greenwood, 1984; King &
Collins-Nakai, 1998; Shainblum, Sullivan, & Frank, 2000). This literature suggests
that although such factors as severity of illness, type of disability, and treatment
location (home vs. medical facility) affect RTW, other factors of a structural and
social nature also play a significant role. The findings indicate that powerful deter-
minants of RTW include personal resources, such as family status, family support,

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32 QUALITATIVE HEALTH RESEARCH / January 2005

and educational level; economic resources, including such factors as job tenure,
local job markets, and employment policy; the work culture, that is, the beliefs of
corporate executives, corporate culture, and problems of legitimacy; gender issues
related to assumptions that women’s work is not dangerous and that women are
more prone to injury; and work characteristics, such as monotony, time pressures,
perceived high workload, and little control over one’s job (El-Bassel, 1996; Green-
wood, 1984; King & Collins-Nakai, 1998; Messing, 1998; Shainblum et al., 2000).
However, within these studies, the perspectives of injured workers are rarely
examined.
Most studies examining workers’ perceptions focus on the workplace and sug-
gest that willingness to claim an injury is related to structural factors. Although
workers are aware of the relationship between work and health in terms of physical
and mental stress, they lack knowledge of their rights and consider work to be less
detrimental to their health than unemployment (Mullen, 1992; Walters & Haines,
1988). Furthermore, definitions of unsafe work and compensation claims are
socially constructed. Thus, the legitimacy of injuries is related to the economy, the
labor market, medical knowledge, and gender (Chung, Cole, & Clarke, 2000;
Tarasuk & Eakin, 1995; Walters, Lewchuk, et al., 1995). This complex set of relation-
ships might help to explain Shannon and Lowe’s (2002) finding that 40% of injured
workers who met the eligibility criteria for workers’ compensation in Canada did
not submit claims.
One significant study examined the perceptions of the actors involved in RTW
programs in three Canadian provinces. Baril et al. (2003) found that participants
ascribed success to the individual characteristics of injured workers, such as per-
sonal and sociodemographic factors, beliefs and attitudes, and motivation. With
respect to motivation, there were striking variations in perceptions of influences
over, and origins of, motivation. Human resources managers and health care pro-
fessionals related it to individual characteristics, but injured workers, worker repre-
sentatives and health and safety managers attributed it to workplace culture and
consideration of workers’ well-being. The authors argue that “RTW program suc-
cess seems to be related to labor-management relations and top management com-
mitment to Health and Safety” (p. 2101) Although the authors do consider that the
various systems affect RTW, they do not focus on workers’ perceptions and
experiences of these systems.
Studies that do examine workers’ perceptions and experiences of the compen-
sation and/or rehabilitation system focus on the effects of external factors, such as
union membership, as well as interpersonal issues, such as caring and legitimacy,
and the marginalization of the injured worker within the family rather than work-
ers’ perceptions of the effects of the system (Gleason & Roberts, 1993; Stikeleather,
2000; Strunin & Bodin, 2004). However, there are exceptions. Reid, Ewan, and Lowy
(1991) examined workers’ problems with requirements for objective measurements
of invisible disabilities. They noted that the requirement for a single, identifiable
cause and the emphasis of a verifiable injury for compensation excluded social and
structural processes in the production of repetitive strain injury. Furthermore, they
observed that some specialists revealed prejudices against semiskilled workers,
women, and compensation patients. Thus, women sought “moral affirmation” of
their condition through further assessments and treatments that probably contrib-
uted to the “chronicity of the condition” (pp. 602, 611). Other authors have argued
that compensation systems assume that some workers are acting fraudulently, or

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 Beardwood et al. / VICTIMS TWICE OVER 33

they encourage passivity, and that this can have either antitherapeutic or therapeu-
tic consequences (Frankcom, 1992; Lippel, 1999). Lippel suggested that the compen-
sation process involves multiple medical examinations to prove the legitimacy of a
condition, stigmatization, surveillance, suspicion, disputes regarding compensa-
tion, and consequent delays in decisions, all of which affect the health of claimants
negatively. Thus, the process per se promotes increased disability.
In summary, the literature suggests that the return of injured workers to full-
time, meaningful work after prolonged absence from the workforce is poor.
Research in this area has pinpointed various factors that affect workers’ RTW, espe-
cially structural factors in the workplace and at the managerial level. However,
some research has suggested that the process of engaging in the compensation sys-
tem might contribute negatively to rehabilitation and RTW (Baril et al., 2003; Lippel,
1999). Yet, few studies examine workers’ perceptions and experiences of the process
of compensation and rehabilitation and whether these affect their RTW. Baril and
colleagues focused on a variety of stakeholders across Canada, and injured workers
were not at the forefront of their study.
The purpose of our research was to enhance our knowledge about what injured
workers perceive to be the impediments created by the medical, compensation, and
rehabilitation systems to a successful RTW. Also, our goal was to develop recom-
mendations for improvements in these systems. Our central research question was
“What are the experiences of workers who have sustained an injury that they per-
ceive to be attributable to the workplace, who consider that they are receiving inad-
equate compensation and who are unable to return to what they perceive to be satis-
factory employment?” Our subsidiary question was “What changes would injured
workers like to see occur in the medical compensation and RTW systems?” We
wanted injured workers to voice their perceptions and experiences rather than
other stakeholders, as has occurred in other studies. To ensure that injured workers
would not be prevented from speaking out by fears of negative repercussions from
other stakeholders, we chose to conduct a participatory research study, with injured
workers interviewing injured workers.

METHOD

This participatory research (PR) study was conducted in Ontario, Canada, and
funded by the WSIB. PR is consistent with the mutual engagement model of Petras
and Porpora (1993), in which the research participants engage actively in the
research process. This model contrasts with conventional research, in which distinct
boundaries and roles exist for “passive subjects” and “expert researchers,” with the
latter group designing the project, gathering the data, interpreting the findings, and
recommending action (Whyte, Greenwood, & Lazes, 1989). Instead, in PR,
researcher knowledge, which is drawn from multiple contexts, is combined with
insider knowledge that reflects experience and detailed understanding of the issues
(Stoecker, 1999). In this study, injured workers and academics together participated
in setting the agenda, determining the research questions and methods, gathering
the data, and interpreting the results. There were numerous challenges, such as
complex issues related to power relations, level of ambiguity within the project, and
time lines. (For a full discussion of the PR process issues, see Polanyi & Cockburn,
2003.) Nevertheless, the process was one that helped all researchers—academics

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34 QUALITATIVE HEALTH RESEARCH / January 2005

and injured workers alike—to understand more deeply the complicated reality of
being an injured worker within the existing set of system and societal norms. The
results of the project were disseminated to the compensation system, the injured
worker community, and the academic community (see Kirsh & McKee, 2003;
Polanyi & Cockburn, 2003); a report was submitted to the WSIB, a popular report
was developed and distributed to workers’ organizations and other interested par-
ties (Injured Worker Participatory Research Group, 2001), and the results were
released at a public meeting.
In the first stage of the research, we sought to involve injured workers in setting
the research agenda. To this end, the core research team of academics and represen-
tatives of injured worker organizations organized a conference for injured workers
who had experienced difficulties with either compensation or RTW. To contact
potential participants, we used contacts in the injured worker community; mailed
out flyers to key locations; contacted key newsletters; conducted direct, targeted
phoning; and put advertisements in a local newspaper. At the conference, we orga-
nized participants into small groups and facilitated injured workers in identifying
their main concerns and developing themes from these concerns, formulating ques-
tions from these themes, and discussing how we should obtain answers to these
questions. Finally, we asked injured workers to state how they would like to be
involved in the project, and we arranged a follow-up meeting with interested par-
ticipants. Members at this meeting developed a coordinating committee and three
research subgroups: a survey group, a qualitative research group, and a document
analysis group. Injured workers who wished to participate in the project were
designated as peer researchers and chose to join one of these groups.
Our goal in the qualitative group was to explore the lived experiences and per-
ceptions of injured workers. Qualitative methods are particularly appropriate in
studies that aim to uncover the meaning of a phenomenon from the informants’ per-
spectives and to explore factors that have an impact on that phenomenon (Marshall
& Rossman, 1989; Strauss & Corbin, 1990). We assumed that narratives from some
injured workers with problems might help to explain the deep anger and frustration
expressed by many injured workers. Moreover, anecdotal evidence from advocates,
injured workers, and conference participants suggested that there existed a group
of injured workers whose experiences could not be captured by survey research.
The qualitative group consisted of 12 members: 7 peer researchers, 4 academic
researchers, and a community legal worker. Initially, we discussed the utility of
qualitative research in understanding people’s perceptions and experiences. Then,
peer researchers were informed of the challenges they might encounter and trained
in interviewing techniques.
We recruited and interviewed a diverse sample of 17 injured workers who had
experienced difficulties in securing adequate compensation or returning to what
they perceived to be adequate, suitable work. We submitted an ethics protocol to the
university that was administering the project and received approval prior to
recruitment, including approval to use a translator where necessary. We placed
notices on bulletin boards, in newsletters, and in the employment sector of two
major daily newspapers. The interview group coordinator contacted potential par-
ticipants who had expressed interest in the project to discuss the purpose of the pro-
ject, describe the nature of the interviews, and address any concerns. The interview
coordinator then scheduled an interview date and arranged for a peer researcher to
conduct an interview, making sure that the interviewer did not know the

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 Beardwood et al. / VICTIMS TWICE OVER 35

participant. As suggested within the qualitative literature, we adhered to the princi-

ple of theoretical sampling, that is, we involved individuals who could deepen our
understanding of the issue under investigation (Creswell, 1998). The risks and ben-
efits were explained to all interviewees, the interviewer obtained written prior
consent, and the interviewees received an honorarium of Cdn.$25.00 plus travel
costs.
The group decided that semistructured interviews would provide both the
breadth and depth desired. Seventeen semistructured interviews lasting between 1
and 2 hours were completed. Interviews were conducted in person: 13 at the project
office, 2 at the interviewees’ homes, and 2 over the telephone. Two interviews
required a translator. The interviews were audiotaped, and on completion, the
interviewer noted any additional observations. We transcribed the interview tapes
and imported them into the NUD*IST qualitative analysis program. All identifying
information, such as individual or organization names, was removed.
The profile of participants was not intended to represent all injured workers
but, rather, to help us gain perspectives from a range of injured worker experiences.
Eleven of the 17 participants were male, and almost all were over 40 years old. Most
had a spouse and mainly adult children. About one third were born outside Can-
ada. Their education ranged from elementary to university level, and they worked
in a range of sectors. Approximately one half were union members, and one third
had been involved in an injured workers’ group. More than 50% had a back injury,
and upper extremity injuries were also common. Although the sample was variable
along several dimensions, we would have liked to have interviewed more women
and younger workers.
We then proceeded with an open coding method (Neuman, 2000). Members of
the group were divided into pairs of experienced and inexperienced coders. Each
pair coded two transcripts individually and then identified possible themes as a
pair. These themes were discussed and integrated by the group to develop a com-
mon set of themes. New themes were added as required. In the next stage, we prac-
ticed axial coding, in which we adopted a three-level coding framework (Neuman,
2000). First, we divided the injury and postinjury experience into five parts, repre-
senting stages, or phases, in the path of becoming and being an injured worker. Sec-
ond, we developed themes in each stage based on the data, and ensured themes
were saturated (Creswell, 1998), that is, no new data were needed to conceptualize
the theme. Third, we identified details or instances of themes within the transcripts.
We encountered a number of challenges in the qualitative research. Some chal-
lenges were the result of being a part of a collaborative, multidisciplinary, commu-
nity research team, which resulted in a tension around the extent to which experi-
enced researchers could direct the process. Also, there were the contradictory
positions of peer researchers, who had specific interests, and core researchers, who
were responsible to the funding body, which the peer researchers mistrusted. Thus,
collaboration was difficult at times, especially in writing the final report.
Challenges specific to the interview group were related to conducting inter-
views and the coding process. In the interviews, a major challenge was trust. Some
interviewees were reluctant to participate because they feared repercussions from
the compensation system. Another challenge was the emotional nature of the expe-
rience, so that interviewers had to be sensitive to the mental and emotional state of
the participant. Interviewers responded with active listening, and participants were
assured that the tape recorder and the interview could be stopped at any time that

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36 QUALITATIVE HEALTH RESEARCH / January 2005

the material became too sensitive. A third challenge was language. Although we
used a translator who had experience in translating for injured workers, peer
researchers felt that it was sometimes unclear whether the person had finished com-
menting and whether the response was fully translated. Furthermore, when Eng-
lish was a second language, peer researchers had to be patient and careful not to
lead the interviewee. A fourth challenge was that although peer researchers helped
to break down barriers in an essentially wary population, sometimes they found
difficulty in refraining from sharing their own experiences, interrupting, or leading
the respondent. A fifth challenge was that the peer researchers were sometimes in
pain and were encountering problems with the medical, compensation, and reha-
bilitation systems, so that they were not always able to attend meetings, and the
group had to be flexible to meet their needs. Finally, reaching a consensus on a cod-
ing scheme took a great deal of time and attention to group process. Consistency in
coding was difficult to achieve because of the variation in the skill level and experi-
ence of the participants and the number of people involved in the process. Regular
group discussions of coding and the meaning of data were required to agree on a
coding scheme. The effects of these discussions mirror those listed by Strauss
(1987). They ensured a shared analytic framework, researchers were forced to
confront common team issues, and, on a more complex note, each researcher was
affected differently by the group sessions.

FINDINGS

From the data, we identified five major stages/phases reflecting workers’ involve-
ment with the compensation system: (a) pathways to becoming injured; (b) seeking
treatment; (c) seeking fair and adequate recognition and compensation; (d) seeking
return to adequate work; and (e) living as an injured worker. We developed a set of
themes within each of these phases, which we have used as an organizing frame-
work for the discussion that follows.

Pathways to Becoming Injured

Participants spoke at length about the manner in which their injury occurred,
reflecting on the workplace as well as their and their employer’s role. We identified
three themes: workplace conditions, employer insensitivity, and employees’ lack of
knowledge.
Many participants spoke about their work, their workplaces, and the degree to
which unsafe practices led to injury. Workers revealed a concern about the lack of
health and safety policies and procedures, as well as a compelling sense of obliga-
tion to complete the job despite the risks involved. One participant described the
dangers faced in dealing with chemicals on the job:

We’re talking about cyanide solutions, nitric acid, fluoboric acid, you name it.
There’s all kinds of dangers within this product that we were making for suppliers
out there . . . and there was nothing in health and safety there. Nothing whatsoever.
There were no masks. There was nothing there. And many a time one chemical
would get mixed with the other and a brown smoke would occur, like a fire taking
place . . . so we’d have to turn the water on and get the heck out the building as fast as

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 Beardwood et al. / VICTIMS TWICE OVER 37

we could. Now the fumes from all this stuff were visible. It existed. It was there. And
we breathed this stuff every day of our lives there.

Another participant, who also worked with chemicals, reported that a lack of infor-
mation regarding the dangers of the job was responsible for his work injury:

Well, we had absolutely no education that there was a problem with the wet chemi-
cal getting on your hands . . . I mean we had service people come in and they cleaned
the tanks and they’d do the whole bit. And they never wore gloves. They never wore
a respirator. So the Ministry of Labour told me that dangers of chemical exposure
existed for the workers. I had explained to them previously about my health prob-
lems. And they told me, “You have to file for compensation.”

Another concern was fear of unemployment. Workers were motivated by fear

of job loss so they continued to do work that had potentially harmful effects. Con-
flicting feelings about performing an unsafe task are rationalized by one worker’s
reflections on his pressing financial needs:

Well, you know, a hundred times you lift this crap and you dump it. I should have
had a pulley. I didn’t have a pulley. Afterwards, I don’t even know why I was doing
that. I wasn’t showing off. I knew the consequences of the job. I needed the money. I
needed the job.

This fear of becoming unemployed appeared to be accentuated for people who felt
marginalized or disempowered for other reasons, such as their minority status. A
worker who had recently arrived in Canada stated,

I’m a new immigrant. It’s very hard for me to find a new job. I like to work faster
because I’m afraid I’ll get laid off. They told me that the person that was here previ-
ously [was] slow and she got laid off. Even though I had all that pain I didn’t say
anything. I kept on doing the overtime.

We identified themes of insensitivity and callousness in employer responses.

Employers ignored the injury, expected workers to continue in their work, and
sometimes harassed workers into leaving if they were unable to perform at their
previous capacity. One such story reflects the lack of understanding from employ-
ers that workers encountered when they sustained an injury:

So I went to the manager . . . I said “I’ve fallen at the front and I’ve injured
myself . . . my knees are swelling, can I go home?” First of all, he said “No.” ’Cause I
was supposed to close that night. Close the restaurant. He said, “You have to find
somebody to fill in the spot.” And I’m thinking I’m an injured person. I’m in agony. I
want to go home. And he’s telling me no.

A recurrent theme was workers’ lack of knowledge about reporting injuries.

Many had not known that severe pain and discomfort could be reported as an
injury, and others had limited knowledge of the reporting procedures. As an exam-
ple, one worker revealed,

I didn’t do anything about it for about 2 years. And then when it proceeded to get
worse, it was diagnosed as tennis elbow. And that went on for probably another two
years. Through all this time I never reported my injury to anybody that could

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38 QUALITATIVE HEALTH RESEARCH / January 2005

document that I was having a problem. For example, a company nurse. I didn’t do
that. I didn’t do that.

Some workers accepted personal responsibility for not documenting and

reporting their injuries in an organized way. A worker who did not report his injury
reflected on his inaction with remorse:

But the fact that I didn’t document anything I have to just take part of the blame . . . I
mean—I sort of blame myself. That I did not go through the proper procedures. The
minute I had a problem here, I should have had it written down.

Seeking Treatment
Workers’ encounters with the medical system can be subdivided into diagnosis and
treatment. Within these areas, we discerned themes of difficulties in obtaining a
diagnosis, difficulties in accessing appropriate treatment, timely access to treat-
ment, and lack of control by workers over their treatment.
Most workers were “desperate for a diagnosis” and appropriate treatment to
enable them to return to work. One worker complained, “All I would like to do is to
get to one doctor that could tell me what the hell is wrong with me.” Another said,
“It got to the point when I just begged for an appointment with anybody.” However,
they described several impediments to attaining this goal. A major obstacle was
medical uncertainty, resulting in doctors giving different diagnoses. One woman
was obviously frustrated with the different diagnoses when she stated,

I’ve had people say it’s pulled muscles, spinal alignment . . . my hips are supposed to
be out of alignment, and then the third specialist . . . says it’s a slipped disc and that I
have to get a CT scan, then I have to go for an MRI scan, and they are also saying it’s
arthritis. I just want an answer so that I can deal with it.

Another obstacle that workers encountered was the negative attitudes of doc-
tors or other health practitioners, who did not believe their complaints, did not lis-
ten to them, and disregarded their concerns. Moreover, some injured workers expe-
rienced discrimination by health care workers because of their race, language, and
gender. One injured worker was concerned enough to complain, “I said I won’t go
back to him any more, but I want when these other immigrant people go, a special
color or something, or they don’t have good English, he has to show respect to these
people.”
Another theme was the pain workers endured to obtain a diagnosis. One
worker stated, “It’s bad enough to get injured but they put you through torture.”
However, others complained about a superficial medical investigation or that the
physician was fixated on a diagnosis despite their descriptions of symptoms that
were inconsistent with the chosen diagnosis. For example, one woman was exas-
perated that her specialist did not explore other avenues and said, “He put scoliosis
every time you turned around. I had to fight about it. It wasn’t my real problem. I
was trying to cure it or stop it, you know, trying to get it better, but he didn’t
understand.”
Workers noted that when they did receive a diagnosis, it was sometimes unwel-
come or discounted by the compensation board and employers. One worker

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 Beardwood et al. / VICTIMS TWICE OVER 39

complained that the doctor would say, “Well this is what it is and this is how you
treat it,” but everyone else said, “Ah you’re just making it up . . . go on get back to
work, never mind the bullshit, just do it.” Also, workers resented the lack of accep-
tance of some injuries or illnesses by the compensation system. One worker consid-
ered that this was related to patients’ rights and suggested,

In the first place the injured worker should be entitled to accept a doctor’s diagnosis
and treatment without having to be challenged by people who are not the treating
physicians . . . and if you have a problem with the doctor’s diagnosis don’t take it out
on the patient, he’s sick, take it out on the doctor, litigate against the doctor. If you
think that the doctor is incompetent, then go after the doctor.

Factors that hindered treatment were often related to the complexity and/or the
invisibility of the condition and the uncertainty of medical knowledge. Thus, work-
ers considered that they had been sent to the wrong specialist or to too many spe-
cialists. For example, one worker declared, “I saw about six or seven doctors in four
to six weeks.” They complained about being given the wrong treatment, which was
painful or made the condition worse. One worker stated, “I went through two years
of dealing with the pain and the agony because doctors believed that I was just out
of shape and overweight.” Furthermore, medical uncertainty resulted in different
diagnoses, multiple tests, different treatments, several operations, and different
assessments of their ability to return to work. One worker who had been exposed to
chemicals discovered that “when you’ve had a chemical exposure it changes your
whole body chemistry, so it’s not uncommon for a test to come back positive one
time and negative another time,” and noted that the “respirologists were
confused.”
This uncertainty sometimes resulted in shopping for a doctor or a physiothera-
pist to try to obtain a diagnosis and treatment that was effective. However, seeing
different practitioners resulted in workers receiving contradictory advice. For
example, one doctor told a worker to return to work, whereas another doctor sent
the same worker for surgery. One health practitioner would tell participants not to
perform certain actions, such as neck exercises, or not to have surgery, and another
would state that such treatments would improve their condition. Workers’ conse-
quent reluctance to follow treatment or to have surgery sometimes resulted in their
being regarded as uncooperative. Alternatively, the hope of a cure sometimes
resulted in their enduring treatments that were painful and appeared to make the
condition worse.
Accessing treatment was also problematic. Injured workers encountered prob-
lems of access to timely, appropriate treatment, which was related to an overloaded
health care system. They encountered lengthy delays in obtaining appointments
with specialists, for treatment, and for surgery. These delays increased their feelings
of stress, as bureaucrats pressured them to get appointment dates immediately,
when this was not possible and doctors’ secretaries regarded them as trying to jump
the waiting list. One woman told the doctor’s secretary, “I’m on compensation. I’m
in a lot of pain. They want me to get it fixed and get back to work.” However she
reported that the secretary replied, “I told you before, when I get to you, I’ll get to
you. You’re not getting out of line.”
The amount of paperwork required by the compensation board was also a
deterrent to fast, appropriate treatment. Doctors were reluctant to see injured

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40 QUALITATIVE HEALTH RESEARCH / January 2005

workers, and they did not fill in the forms punctually or accurately. One worker
stated, “When I mentioned it was an accident at work, he wouldn’t take me right.”
Another complained, “When I told him [the family doctor] all my complaints, he
was in a rush. He didn’t take down all the details.” This lack of information delayed
treatment or compensation, and resulted in bureaucrats’ pressuring the injured
worker to pressure the doctor. Such events increased the stress levels of injured
workers.
A recurring theme was injured workers’ feelings of lack of control over their
treatment. Workers pointed out that they required approval before they could
obtain medication or other intervention, resulting in treatment delays. One woman
expressed her frustration at the delays, stating, “Everything has to wait. I have to get
permission from them for physiotherapy.” Workers sometimes found that alterna-
tive practitioners were more helpful than allopathic doctors, but the opinions of
these practitioners were often ignored. Furthermore, workers complained that they
were allowed a limited amount of time for treatment by a chiropractor or a physio-
therapist, and if they wished to continue, the cost was not covered.

Seeking Fair and Adequate Recognition and Compensation

A prominent theme in workers’ narratives focused on the need to be accepted and
understood. Workers wanted their voices to be heard and not dismissed, and appro-
priate recognition and compensation to be provided. Many were angered and dis-
appointed by the negative assumptions and suspicions that pervaded their interac-
tions with employers, bureaucrats, and doctors. Themes include the need for
respect and difficulties with the compensation system.
A striking and repeated area of concern expressed by injured workers was the
lack of respect that they faced in the absence of any wrongdoing. Many felt com-
pelled to provide evidence of their commitment and motivation to work to counter-
act the negative assumptions and stereotypes that they faced. One worker
described his determination and persistence in working through his pain:

And every one of those injuries I never wanted to give up because of them. . . . All
these injuries that I sustained there, I still wanted to go back to work. I went back to
work with the pain. It never went away . . . but I still suffered and I put up with it in
the workplace. Even with what had happened to me I still functioned there. But as
years passed I could not continue to do the same amount of work until finally I had
no other choice but to get out of there.

Another worker expressed sadness that the system viewed all injured workers in
such a negative light:

But what I felt bad about is that the victims shouldn’t be seen with the same eye, or
who is legitimate shouldn’t be put in the same pot with other people who try to take
advantage. So there must be a way of screening who is being truthful.

Stories of difficulties with the compensation system were abundant. However,

the major areas of tension could best be categorized as concern regarding the
adversarial nature of the relationship with the compensation system; the lack of
information, control, and choice provided by the system; and the fear and paranoia
that were evoked through interaction within this system.

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 Beardwood et al. / VICTIMS TWICE OVER 41

Many workers found themselves entangled in an adversarial relationship,

which was characterized by a lack of trust, misinterpretation of information pro-
vided, and a perception of inappropriate responses of workers within the system.
One worker stated,

Compensation paid me, but they fought with me every step of the way. They treated
me as if I was trying to rip off the system or something. It didn’t faze them that per-
haps maybe I would rather go back to work and make three times what they were
paying me. So I fought with them all the way through 1996.

Workers reported that information that they provided to the system was fre-
quently taken out of context. This worker described how portions of stories were
extracted for documentation:

It’s a procedure of denial and the way it works is that, if you give them a sentence
with ten words in it, for example, they will take four or five of the words out of the
sentence, put it into their own sentence, and use it as reason to deny. So in the end
they are not lying, but they haven’t looked at the entire situation.

Not unrelated to workers’ expressed desire for increased respect is the sense of
exasperation felt by workers when they encountered responses that they perceived
to be demeaning and inappropriate from bureaucrats in the compensation system.
For example, one worker told her story, which included tolerating condescending
advice:

Well, it was a very, very long and tough hike with them, because one of the adjudica-
tors told me when I called her to find out what is going on with my case. Her words
to me were, if the man I have cannot afford to support me then I should go and look
for another man; and this is the honest to goodness truth.

Workers reported that adjudicators did not inform them about their rights,
thereby increasing their sense of exasperation. The anger and frustration at the
many occasions when decisions were made without explanation were reflected by
one worker’s rational request for information:

I mean, I can accept facts that are dealt with in a logical way. If you’re going to say,
you are not disabled because . . . or we don’t look at this information because . . . and
give me a reason for that, then I will either have something to argue with, or accept
that their argument is valid. But in either case it doesn’t happen.

These experiences, characterized by mistrust, suspicion, and dismissal of indi-

vidual needs and choice, led to reactions of fear on the part of the worker. Many
feared what lay ahead, as their future appeared to be controlled by the system. Oth-
ers became worried that they would be “spotted” engaging in a daily activity that
was within their capacity, and that it would be taken out of context, misinterpreted,
and used to their disadvantage. A worker provided an analysis of the power
structures in this way:

It’s fear. They instill fear in you. They’re experts at that. They know how to instil fear
in the person that’s injured. You’re already injured so your defenses are down.
You’re now sort of backed into a corner because they’re the ones that are supposed

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42 QUALITATIVE HEALTH RESEARCH / January 2005

to be paying the money. And yet they’re not paying you properly. Or they’re threat-
ening to take it away. So you feel like you’re alone and you have no recourse. You
know. And it’s a rotten position to be in.

Seeking Return to Adequate Work

Workers reported on the struggles they experienced in returning to the workplace,
be it with their previous employment situation or a new one that was deemed to be
more suitable. Themes included the myth of modified work and limited options for
work.
Many workers returned to the workplace with a plan for modified work yet
were disillusioned to find that these accommodations were short-lived or nonexis-
tent. For example, one worker recalled how he had no choice but to work in his
nonmodified job:

I went back to the work—to the job—and there was no such thing as light duties.
That never existed in the workplace where I worked. It was never there. It never did
exist. . . . So you went back to the same job you had for the simple reason either you
did or you had no job. You were out the door. So for me, married with a house and
young children growing up around me, I could not afford to be out of a job.

One worker suggested that employers will continue to base their actions on the
needs of the company rather than the needs of the workers.

No, my employer . . . fought me on everything. They didn’t wish to help me. They
did not offer any assistance. When I tried to return to work there was no modifica-
tion to my job. Granted the only thing that they really could have modified was get-
ting me an assistant, which would have cost me money, or letting me use mechani-
cal equipment to do my job. They wouldn’t let me do that. I had to do everything
manually, and there wouldn’t have been a problem had I been in the shape to do
it. . . . WSIB cannot be making assumptions that employers out in the real world are
going to make modifications to the workplace to suit disabled people or injured
people. It’s not going to happen.

Many workers who were struggling to return to work experienced a lack of

choice and control over their vocational futures. This worker described how impor-
tant directions were decided without his input:

I told her that I liked maybe printing. You know. Because in printing you don’t have
to do any lifting. All you have to know is the machine. You have to know how to set
up the machine and run the press. And I said this is a good job for me. She said, No,
no. That they have selected this job for me . . . and this is the training I would get.

Even when workers conducted a job search, some found their options to be lim-
ited by gaps in their work histories that had resulted from their injured worker sta-
tus. One man described the repeated rejections he experienced:

Everywhere I go the first thing a prospective employer asks when they look at my
resume, is why am I am not working with them? And told them I had an injury.
Nobody wants to hire me. You know. I mean they won’t tell you that I don’t want to
hire you because of your injury. Because that’s against the company standards I
think. But nobody calls me for an interview. And even if I go, I never get a job.

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 Beardwood et al. / VICTIMS TWICE OVER 43

Living as an Injured Worker

The final stage was the impact on workers’ lives and the nature of living as an
injured worker. Themes included financial and social impacts, mental and emo-
tional impacts, impacts on activities of daily living, and living with pain.
Not surprisingly, workers described the financial hardships they experienced
as a result of losing their regular wages. Some incurred medical expenses alongside
these losses, which further increased their debt. One worker described the devastat-
ing impact of imposed poverty:

Right now, I am going into debt beyond belief. I am only currently receiving my per-
manent partial disability, which is just over a thousand dollars a month. My injury
has caused the end of my marriage and I’m raising both my children on that thou-
sand dollars a month. I’m trying to get the appeal process hastened a little bit, to
have this all resolved, but they are not being very cooperative. I cannot get a job. I’ve
tried. It’s just not going well.

Many workers were embroiled in advocacy or legal action with the compensa-
tion system, and this process significantly drained their financial resources, adding
to their distress. A worker explained,

What an appeal process is all about is challenging that and trying to get to the point
of being rational. . . . I’ve been without a lawyer for these ten years because I’ve been
wiped out by this entire process. I lost my house, I lost my entire savings, I lost my
vocation. I lost my entire social group. I was making between, well around 60 grand
a year, and now I’m on subsistence. We’re called poor people because we have only
an income of 20 grand a year, whatever. So like this is a culture shock for our entire
family.

The effects on family life and social inclusion were severe, as exemplified by this
worker’s report:

It has caused the end of my marriage. I do still have the custody of my children, but
my injury affects them. If I have some sort of painful episode, my five-year-old starts
to cry. My twelve-year-old really helps me out a lot by dealing with some things that
I physically can’t do. I get a lot of help from my parents. I’ve been forced to move in
with them because of the injury, and I’ll probably be stuck there for a while until I’m
able to be completely independent.

Many workers revealed that their psychological state had deteriorated through
the process of becoming injured and dealing with the system. They discussed the
effects of poverty, role disruption, and stress on their mental and emotional health.
Depression was a common experience. One worker revealed,

Psychologically, I fell into a deep state of depression. I mean, I’m not ready to com-
mit suicide or anything, but I suffered for a very long period of time from a deep
state of depression that was diagnosed and attributed to my injury and the change
of life that it caused, and they’ve denied it all.

Another worker stated,

I am in treatment with the psychiatrist right now because of my low self-esteem, I’m
so depressed . . . if I don’t scream at them I never get anything. I don’t like it. They

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44 QUALITATIVE HEALTH RESEARCH / January 2005

have made me so depressed right now, very depressed. . . . I came here when I was
thirty-two years old. If I were in my country right now I would be retired already.

Despite the financial, social, and psychological burden they carried, workers
expressed a common theme of resilience and determination to rise above adversity
through engaging in healthy and productive outlets. One stated, “I’ll never regain
my health. But I’ve been able to educate many thousands of technologists about
this. And hopefully have helped them improve their workplace and be able to save
their health.”
Workers described the limitations they experienced in their everyday lives, in
terms of restrictions on everyday living, and so-called simple things that are the fab-
ric of quality of life.
One worker described how limitations in self-care activities resulted in feelings
of dependency and social isolation.

The problem is that I can’t reach properly. Like probably my hair is messy today.
That’s because I can’t comb my own hair properly anymore. I can only reach certain
areas. And my husband had to go out this morning. I can’t get my brassiere on. But I
have all these things I can’t do. I can’t wash my hair right. I can’t comb it right. I can’t
reach my back properly to wash it.

Workers found that living with pain was physically and emotionally draining.
The pain, in combination with the stresses of dealing with employers, the compen-
sation system, and changes in family and lifestyle, was almost too much to bear.
One worker’s story revealed the extent to which it had changed his life:

My life since these accidents is not the same as it was before. There are things that I
could do before that I cannot do anymore. I cannot climb stairs or sit down very
long. I just have to keep moving to see if my body can suppress the pain, then get rid
of some of the pain. I have to take medication daily. I am on three different types of
medication right now, just to see if they can relieve the pain. Sleep, I don’t know
what sleep means. Many times I have to spread something on the floor and lay
down, I can’t lay on the bed.

DISCUSSION AND CONCLUSIONS

Overall, these injured workers feel that the impact of their injury is devastating
across a number of domains: functional, financial, social, and emotional. We do not
know how many injured workers have similar experiences.
The issue of legitimacy permeated every phase of the workers’ lives. Lippel
(1995) suggested that issues of legitimacy revolve around the intersection of medi-
cine and law in determining the legitimacy of an injury and whether it is related to
the workplace. In addition, Walters, Lewchuk, et al. (1995) and Tarasuk and Eakin
(1995) found that issues of legitimacy were pervasive across systems. Tarasuk and
Eakin also observed that even when the medical and compensation systems
deemed back injuries legitimate, injured workers still encountered a lack of legiti-
macy in the workplace. Other findings by Reid and colleagues (1991) have under-
scored this issue: They found that women endured multiple consultations, treat-
ments, and assessments in their search for credibility. Furthermore, Lippel (1999)

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 Beardwood et al. / VICTIMS TWICE OVER 45

observed that workers have been forced to submit to multiple medical exams, many
of which have no therapeutic value, to ascertain the legitimacy of their case.
Related to legitimacy was the interviewees’ perception that their claims were
regarded as fraudulent until proved otherwise. Frankcom (1992) also observed that
injured workers are assumed to be passive or frauds, and Baril et al. (2003) noted
that workers experience the systems as unfair, which results in frustration, anger,
and anxiety. Our findings suggest that this experience goes beyond unfairness, as
our interviewees considered themselves maligned, and treated without respect by
bureaucrats and health professionals. They described being ignored and excluded
from the process of obtaining compensation and arranging rehabilitation. More-
over, they felt that it was important that the power holders acknowledge their prob-
lems and accept that their claims were legitimate instead of treating them with sus-
picion and trying to prove that their claims were fraudulent.
Lack of acceptance of the injury and a lack of respect for the injured worker by
power holders was a common experience. Workers felt they needed to prove that
there was a relationship between the injury and the workplace. However, in the case
of invisible injuries, proof might be the result of subjective assessments. Further-
more, injuries in the late modern workplace are frequently multicausal and have no
clear etiology or definition (Shainblum et al., 2000). Workers with invisible injuries,
therefore, pursue the search for credibility described by Reid and colleagues (1991),
but this extends beyond medical practitioners. Injured workers want to find not
only doctors who understand their condition and listen to them but also bureau-
crats who believe and help them, and employers who support them and are willing
to assist them in returning to the workplace. Unfortunately, their experience is that
they are stereotyped and their stories are not accepted, so they feel compelled
throughout the process to attempt to prove that these negative assumptions are
incorrect.
Coercion has rarely been noted by other studies, possibly because they were
mainly top-down studies, yet it was an issue that permeated each stage of the pro-
cess. Workers experienced coercion in both subtle and not-so-subtle ways. Failure
to prove their illness or injury existed and was legitimate would result in a life of
poverty and stigma, so workers feel they are pressured to endure tests and procedures
that they might under other circumstances refuse. Coercion through the threat of loss of
benefits was also used to persuade injured workers to return to work before they consid-
ered themselves ready or to pursue vocational training in areas that they felt were unsuit-
able or would result in unmarketable skills. Baril et al. (2003) noted that workers fear
reprisals in the workplace, so they do not complain or refuse nonmodified work. Our
interviewees also complained of subtle coercion by management to perform
nonmodified work, but they commented that there was no response if they com-
plained to the WSIB. This finding suggests a need for greater oversight of the reha-
bilitation process.
Lack of control was a frequent complaint of the interviewees. Some studies
mention workers’ feelings of disempowerment but fail to examine the multiple
ways in which injured workers feel disempowered by the process (Baril et al., 2003;
Frankcom, 1992; Lippel, 1999). In our study, workers expressed dissatisfaction with
their lack of control over the time and processes required to access the health care
system. They required permission from WSIB to fill a prescription, or to begin or
continue physiotherapy. Case workers pressured them to advance appointments
and surgery, events over which they had no control. Unless they had the financial

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46 QUALITATIVE HEALTH RESEARCH / January 2005

means, they were sometimes excluded from alternative health care or continuing
physiotherapy. Their choice of when they would return to work, what modifica-
tions would be applied to their work, or what type of vocational rehabilitation they
would receive frequently received little input from them, and they were forced to
comply because of a fear of loss of benefits. Workers were excluded from planning
their RTW and vocational rehabilitation, and their desires were ignored, resulting in
premature RTW, returning to unsuitable jobs, or unsatisfactory training. Karasek
and Theorell (1989) have argued that high demands and low decision latitude with
little support affects the health of workers in the workplace, yet there seems to be lit-
tle recognition that a similar situation in RTW systems might create similar stress
and ill health among injured workers.
Consistent with the findings of Walters and Haines (1988) and Smith (2000),
workers were unaware of their rights in the workplace and the process of reporting
an injury, and even when they were aware, they were fearful of refusing unsafe
work. We also found that injured workers did not realize the implications of work-
ing with an injury. Furthermore, they lacked information about their rights within
the compensation system, and the bases for decisions were not explained to them.
This lack of knowledge lays the foundation for passivity and dependence, so that
injured workers find it difficult to advocate for themselves. Clearly, then, there is a
need for improved access to information and increased support for workers, both in
the workplace and within the compensation process.
Our findings indicate that RTW is a complex process involving participation
and cooperation from employers, workers, the medical system, the compensation
system, and the rehabilitation system. Brooker, Clarke, Sinclair, Pennick, and Hogg-
Johnson (2000) have argued that clinical interventions without a tie-in to the work-
place do not reduce absence from work-related back pain. They suggest that RTW
requires supportive workplace policies and cooperation and communication
between all parties, as well as modified work and ongoing evaluation of the pro-
gram. We would add that it is essential that the injured worker be given more con-
trol over the process with support from all parties rather than making workers feel
that they are in a continual adversarial process and that their bodies are controlled
by others (MacEachen, 2000).
We suggest that some injured workers are victimized by the compensation,
medical, and rehabilitation systems. These workers have the legitimacy of their
injuries questioned, and they are subjected to coercion to undergo tests and treat-
ments. They have little or no choice about when they will return to work, what type
of modified work they will do, or what type of retraining they will undergo. Their
experiences increase their financial, psychological, marital, social, and, sometimes,
physical problems. Thus, they are victimized twice. First, they are victims of the
late-modern workplace, and, second, they are victims of compensation, medical,
and rehabilitation systems that fail to grant them legitimacy and respect, and yet
affect every aspect of their lives.
We propose that injured workers be given more information about their rights
and more support through the process. Furthermore, we suggest that injured work-
ers be granted more respect and that their injuries be accepted as legitimate; and
bureaucrats, health professionals, and employers should acknowledge that the
compensation, medical, and rehabilitation systems can hinder and deter return to
work. Above all, injured workers should be included in the decision-making pro-
cess, which affects their lives, and thus not victimized once again by the process.

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 Beardwood et al. / VICTIMS TWICE OVER 47

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Barbara A. Beardwood, Ph.D., is an associate professor in the Health and Society Programme, Division
of Social Science, at York University, Toronto, Canada.

Bonnie Kirsh, Ph.D., is an assistant professor of occupational therapy in the Graduate Department of
Rehabilitation Sciences at the University of Toronto, Canada.

Nancy J. Clark, B.A., M.A., is a doctoral candidate in sociology at York University, Toronto, Canada.

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