Stuck in the middle: The emotional labours of case managers in the personal injury compensation system

Abstract

BACKGROUND: Case managers within injury compensation systems are confronted with various emotional demands.

OBJECTIVE: Employing the concept of emotional labour, this paper explores distinctive aspects of these demands.

METHODS: The findings are drawn from focus groups with 21 Australian case managers.

RESULTS: Case managers work was characterised by extra-role commitments, emotional control, stress and balancing tensions arising from differing stakeholder expectations about outcomes related to compensation and return to work.

CONCLUSIONS: By examining the experiences of case managers, the findings add to the literature on the emotional labour of front line service workers, especially with respect to the demands involved in managing the conflicting demands of work.

Keywords

Emotional labour case managers compensation industry

1 Background

Workers’ compensation and motor accident compensation schemes have operated in Australia for decades. Indeed, personal injury compensation is a feature of social welfare systems in most industrialised nations. Australia has a complex and fragmented network of legal arrangements for the provision of financial support and health and rehabilitation services for those affected by transport accident and work-related injury (collectively, personal injury compensation). There are currently 20 personal injury compensation systems in Australia (12 Workers’ Compensation and 8 Motor Vehicle Accident Compensation). Although these systems share a common goal of facilitating the recovery and return to work of those injured, there is a diversity of legislation, policies and practices across the nation. Regulatory authorities that manage the public insurance schemes that are responsible for compensation costs of the treatment and rehabilitation of workplace or transport-related injury generally control these systems. Each authority is comprised of multiple workplace units that interact internally and externally with stakeholders who are critical to the compensation processes.

Despite this diversity, case management (also known as injury management or claims management) is a critical component in all injury compensation systems. Case managers are the primary interface between the compensation system, the person with an injury and others involved in the rehabilitation process (healthcare providers, employers, etc.). Case managers have a critical decision making role regarding payments for treatment, income replacement and provision of healthcare and other services to the person with an injury. There is now substantial evidence that certain approaches to case management can either have positive impacts on recovery [1] or substantially impede recovery and even exacerbate mental health concerns in some people with an injury [2, 3]. Effective and efficient case management is also considered to be critical to maintaining the financial viability of the injury compensation systems and ensuring a positive experience for a person with an injury and employers engaging with the system.

Case managers are effectively front-line service workers in units that manage compensation and return to work processes. They are customer-oriented service workers in large bureaucracies as well as intermediaries between the person with an injury and other critical stakeholders (e.g., health providers, lawyers and employers) in the compensation process. They are also involved with parties closely interacting with the person with an injury such as family members and carers. Their relationship with the client can extend from weeks or months to years, unlike the brief, transient interactions of most customer service workers such as hotel service staff [4].

As Lu and Xu [5] explain, ‘In the field of work injury rehabilitation, case management is a collaborative process which includes evaluating, planning, implementing, coordinating and monitoring the options and services required to meet injured workers’ health and work-related service needs (p50)’. Case managers are required to develop and maintain effective interpersonal relationships at multiple levels, and constantly manage multiple stakeholder expectations. The role of the case manager inherently demands emotional labour and requires interpersonal skills of a kind required to successfully navigate between a variety of stakeholders who have different and sometimes conflicting stakes in the processes of compensation and rehabilitation. Consequently, their interactions may lead to unpredictable dynamics, and a context of uncertainty. Case managers both adapt to and initiate change [6]; however, in the context of unpredictable dynamics they adapt to changing demands and relationship dynamics rather than strictly complying with the requirements of the work role. While emotional labour is intrinsic to this occupational role, it is rarely acknowledged or examined in studies of workers’ health and wellbeing. This article asks, what is the character of the emotional labour performed by case managers in workers compensation organisations? Specifically, we examine how emotional labour is manifest in the management of the multiple and potentially conflicting demands of their role as they endeavour to ensure compliance with the formal requirements of the injury compensation system, while negotiating with other actors in the injury compensation system and exercising a duty of care in regard to claimants.

Research to date has explored case managers’ perceptions of training programs [7, 8] and their role in managing competing expectations within the compensation system [9], but there is no research that has explored the emotional labour arising from their interactions with persons with an injury and other central stakeholders in the compensation system.

2 Emotional labour in ‘front-line’ service work

Since Hochschild’s seminal work [10], writers Bolton, Brook, Lopez [11 –13] have explored both the personal demands and the commercial exploitation involved in the management of worker’s feelings while at work. While emotional labour has traditionally been associated with female caring tasks such as childcare, nursing, and domestic work, the rapid growth of the service sector since the 1980s has meant that a growing proportion of the workforce is employed in occupations that call for emotional labour. Studies have explored relationships between displays of emotional labour and customer satisfaction in hotel enterprises [14], worker satisfaction in the performance of emotional labour between librarians [15], and self-emotion appraisal and job satisfaction among health workers [16] and airline staff [17].

Hochschild’s [10] distinction between ‘surface acting’ and ‘deep acting’ and the notion that workers belong ‘more to the organization and less to the self’ has been robustly debated [11]. Hochschild [10] distinguishes between the presentational work involved in service occupations where the emotional style of offering the service is part of the service itself’ and the experience of alienation associated with the often-intensive management of one’s emotions and the codification of ‘feeling rules’ associated with emotional labourers. Hochschild [10] argues that individuals come ‘more to belong to the organization and less to the self’ based on unequal power relationships.

Front-line service work is highly variable in the emotional demands involved. In front line service work such as call centres, sales assistance, and hospitality, the degree of engagement with customers is limited and they tend to work in rationalized production systems, involving the de-personalisation of customers, and the routinisation of tasks. In contrast, personal care work, such as nursing and other healthcare, and case management typically involve a high engagement with customers/clients and low routinisation [18]. Of course, a high degree of impersonalisation may occur especially as a result of widespread processes of rationalization associated with the audit culture, as exists in many contemporary hospitals and other large bureaucracies [19]. Through her study of cabin crew, Bolton argues that rather than employing ‘deep acting’, cabin crew are very aware that they are dealing with demanding and often difficult customers to whom they offer an ‘empty performance’; in other words, they ‘act out their role obligations’ [17]. Whatever the stress involved on the job, workers keep it separate from their inner selves, thereby illustrating the contradictory, oppositional and dynamic nature of the processes involved in emotional labour [13]. In recent years, these various theoretical frameworks have been employed to help make sense of the changing nature of labour work and the specifics of various types of service work [20].

Enabling organisations to effectively tackle the stressors associated with emotional labour— not just the experience, but also the predisposing factors— is an important priority in the promotion of workers’ health and wellbeing. This issue is particularly important for the role of case managers, as personal communication with senior management within Australian compensation schemes suggests a 29 per cent turnover of these staff each year which is high for white-collar industry in Australia [21]. Deeper understanding of the case managers’ experiences will assist in developing processes that may lead to improved interactions with key stakeholders in the compensation process and better health outcomes for a person with an injury as well as retention ofcase managers.

3 Methods

3.1 Procedure and participants

Employees from three Australian injury compensation systems were recruited, including two workers’ compensation schemes (WCS1, WCS2) and one motor vehicle accident compensation scheme (MVCS). Two of these schemes employed in-house case management staff, while the third scheme outsourced their case management to third party private insurers.

A purposive sampling technique was used for recruitment. A representative within each compensation scheme assisted with recruiting participants. Participation was entirely voluntary and the management representatives had no control over the participation of case managers. In other words, the representative was not involved with the research process, thus ensuring that the conduct of the focus groups was independent of the influence ofstakeholders.

All twenty-one individuals (eight males and thirteen females) initially approached by the representative within each compensation scheme volunteered to participate in the focus groups, giving a 100 per cent response rate. Thirteen participants were directly responsible for managing compensation claims (that is, their day to day tasks involved direct interaction with injured and ill workers, and other participants in the rehabilitation process); eight participants were employed as ‘team managers’ and were responsible for the daily management of their respective units and the case managers within the unit. Participants had been employed with their respective compensation schemes for an average of 5 years (Range = 5 months to 20 years).

One focus group was conducted with case managers from a MVCS and two focus groups were conducted with the WCSs either at their workplace or the research institution. Each focus group was conducted over a two-hour period. The dialogue was audiotaped and transcribed, with care taken to ensure anonymity and confidentiality. Ethics approval was received for the project from Monash University’s Human Research Ethics Committee.

3.2 Measures

Questions explored in the focus group were guided by definitions in the WHO International Classification for Functioning, Disability and Health (ICF) [22]. Based on the bio-psychosocial model of disability [23], the ICF framework identifies three levels of human functioning: functioning at the level of body or body part, the whole person, and the whole person in a social context. Disability therefore involves dysfunction at one or more of these same levels:impairment, activity limitation and participationrestriction.

Five open-ended questions were designed to reflect the components of the ICF framework. The purpose of the questions was to gain an understanding of the emotional labour arising from case managers’ interactions with a person with an injury and other critical parties in the compensation system. The case managers were asked to comment on how the following aspects of a person with an injury affected the case managers’ interactions with that person: (1) the type or severity of the injury (ICF body function domain); (2) a person with an injury and their level of involvement in daily activities (ICF activity domain); (3) a person with an injury and their level of involvement in social activities (ICF participation domain); (4) a person with an injury and their access to other services or support (ICF external environmental factors), and (5) a person with an injury and their personality ‘type’ (ICF internal environmental factors). The questions were piloted with colleagues of the authors prior to the focus group to ensure consistency of meaning and terminology of the questions. Throughout the focus groups, the facilitator used prompts to encourage further discussion, particularly in relation to understanding the emotional labours arising from interaction with key stakeholders in the compensation process (e.g. health providers,employers).

3.3 Data analysis

The data was coded [24], beginning with open coding involving a close reading of the interview transcripts and the use of ‘concept’ descriptors. Through a process of constant comparison, codes were scrutinised for similarities, differences and linkages. By reading and rereading the transcripts, repeated patterns of meaning were discerned [25] and concepts and theoretical notions in relation to the literature emerged.

4 Results

Case managers articulated the tensions related to their work role, particularly those that arose from their interactions with multiple parties involved in the compensation process for each claimant. Our findings revealed a number of recurrent themes including extra-role expectations, emotional control, stress and conflict-induced emotions.

4.1 Extra-role expectations

Case managers explained how they are expected by claimants to engage in extra-role behaviours by displaying emotional commitment to them. The literature defines extra-role behaviours as those that extend beyond normal role requirements and reflect discretionary individual behaviour that is not formalised in job descriptions or reward systems but can give rise to complex emotions [26, 27]. Four emotional commitments arose from the data: managing learned helplessness, dealing with social isolation, lack of client motivation and dealing with the complexity of the client’s condition.

In the context of compensation and recovery, learned helplessness in clients occurred in those regarded by the case manager as not taking control of their own recovery. This was often due to the clients’ assumption that they could do nothing to facilitate their own recovery. Closely related was the concept of the unmotivated client.

The issues associated with impairment are important in the compensation claims industry as this manager explains:

When you talk about the type of severity of impairment that definition of impairment is really important because there are certain thresholds that allow people to get access to certain benefits. So there’s a lot of negotiation that goes on with the impairment process. So the final assessment, someone’s final impairment rating and their actual impairment could sometimes not match necessarily, because there’s been a negotiation that’s occurred. I think that’s what you’re talking about when people may be less, clients may be less motivated to engage in treatment if they are receiving advice from others that they’re close to a threshold that would give them access to other benefits (MVCS, female).

Case managers described scenarios in which the client became a passive observer in their own recovery process, rather than an active participant. The impact of these types of clients meant that the case manager needed to have a greater involvement in the case than would otherwise be required by committing more time and greater attention to details of the case. For example:

If they know that they could be entitled to a payout, [this] could possibly hinder their recovery for rehab, not wanting to access services. Makes our job quite difficult, trying to motivate them and get them moving. Particularly if they’ve got people around them telling them, don’t do anything because you might get a payout. (Female participant MVCS)

It definitely comes across in their motivation when you’re talking about what treatments they need and what services and supports TAC can offer. You can often get a sense that they’re not motivated to be engaged or if you do, if that service does start occurring, they don’t seem to participate or be as actively involved or getting the outcomes that you would expect that they are with the services that they are getting (Female participant MVCS).

Case managers described situations where clients were socially isolated or where psychosocial factors, particularly depression, played a strong role in the client’s level of passivity. This type of complexity impacted significantly on the emotional labour required to manage the case. Other clients required a higher level of attention than would otherwise be required as they either did not have a strong social support network to facilitate their recovery or the client required services beyond the usual level of services.

A relapse, or surgery, or a failure can often affect their motivation or their mental health ... they’re going well then all of a sudden something has happened or they lose their job or something ... Or where they feel it wasn’t even my fault. They’re getting forward and then bang, something happens and then they can be quite devastated sometimes ... So whatever you sort of relate to that (Female participant MVCS).

The consequence for a case manager is that they need to distance themselves in order to manage their emotions but this can also cause distress:

There are occasions where you need to remove yourself from some of these claims because they are too close to home. That can be quite distressing especially if they have any sort of significance to you... it’s hard to say not have that empathy for somebody. But it’s when you start feeling, actually having sympathy and stuff, feeling sorry for them that it can impact on how you manage that claim (Female participant, WCS).

Complexity in case management could also bethe direct result of multiple other parties in the compensation process and the interactions required with them during case management. These typically included employers who were un-cooperative and did not want to facilitate the recovery process of the person with an injury, family members who needed to be frequently informed about the case and requested independent discussions with the case manager and other parties (e.g. health providers, lawyers), and differing opinions on what was considered ‘best’ for the person with an injury. One manager explained the impact of these complex interactions:

One of the complications, you can get those that access to a range of different services or interactions with different people as a circle becomes wider and wider in terms of the number of services or people that are workers interacting with it, it becomes more difficult to have everyone on the same page in terms of the outcome that everyone’s hoping to achieve with the worker which should be return to work and return to independence. (Male participant, WCS1)

Such interactions created emotional demands for case managers, and the nature of the relationships between critical parties in the system led to unpredictable dynamics.

4.2 Emotional control

The literature on emotional labour of serviceworkers has established that workers are expected to control their emotions in their interactions with customers and this in turn, influences the customer’s responses. Similarly, case managers were expected to keep their emotions under control during the performance of their work. However, frustration was a significance emotion arising from interactions with the person with an injury. The emotion of frustration tends to be related to a situation of emotional dissonance [10], which can have deleterious consequences for the health of service workers, including aggression, withdrawal, burnout and depression, which affect their interaction with management and clients [28]. In her recent study of aged care workers, King [28] found that frustrations were associated with the amount of time associated with paperwork, the lack of time available to interact with patients, the absence of resources required to meet patient needs, the rigidity of management, and ultimately the inability to provide the type of care that workers thought was appropriate. Such expressions of frustrationhave long been noted to be part of the ‘vocabularies of complaint’ characterizing health-related occupations, such as nursing, that are subject to structural constraints on their work autonomy [29]. Feelings of frustration also characterize the day-to-day experiences of case managers.

Two factors associated with a person with an injury that led to frustration included unmotivated clients’ and their [case managers’] own feelings of injustice. The unmotivated client was described as frustrating when they were unwilling to actively engage in the recovery process, regardless of the greater level of attention and encouragement given by the case manager. However, the case managers are expected to control their emotions in interactions with frustrating clients. The case managers’ relayed a sense of injustice in this context, when clients were not willing to comply with the rules of the compensation scheme. One scenario described case managers being made to feel like the ‘bad guys’ when asking clients for necessary documentation, such as providing regular doctor’s certificates. While the case managers sought to act in the clients’ best interests, the latter were seen as sometimes adopting aconfrontational stance:

I mean we’re paying them money all the time but yet the things we ask for them are just unacceptable or every small mistake that gets made is unacceptable or we’re threatening to take away their livelihood or their support structures, when in actual fact we might just be calling up to say hi, just need to go and see your doctor, it’s been twelve months ... . it’s that assumption sometimes it starts right from the very beginning of the claim that [name of compensation scheme] are the bad guys who are, again we talked about entitlement, take away that entitlement, rather than being people who are part of that support network tied in with the rehab providers, the agencies. (Male participant, WCS1)

Case managers’ interactions with other parties in the compensation process revealed two drivers of conflict that gave rise to the need for emotional control: balancing the needs of all parties and dependence on health providers. Balancing the needs of all parties was described as frustrating as there was a continuous need to find a balance between the needs of the person with an injury and the rights of the employer. Frustration was accentuated when there was a poor relationship between the employer and the person with an injury. However, this frustration is a symptom of the conflicting demands of the case manager’s role, which involves ensuring that clients comply with the formal requirements of the injury compensationsystem, whilst also negotiating with other actors in the injury compensation system and exercising a duty of care in regard to claimants. Dependence on health providers for information was a regular source of frustration as case managers were reliant on health providers’ diagnoses and assessments in order to make recommendations about the management of the person with an injury. The lack of timely intervention was also discussed as disruptive of the duty of care that case managers felt towardstheir clients:

And in the end you sort of go, okay I’m at capacity with this, I don’t know where else to go. I’m not getting the information. So you may make the choice to deny [the claim] until I get further information... it’s quite frustrating because you think gee there’s a person there that may need something. (Female participant, MVCS)

Case managers felt a duty of care which was challenged when conflicts arose over protocols and the determining of the legitimacy of a client’s claim. Case managers felt the pressure when trying to help a client within the constraints of the system. For example, “ ... you’re always trying to help but then the system pushes you back so you know you can’t actually help them” (Female participant, MVCS). The unpredictability of outcomes and the intrusion of legal factors and medical diagnoses created additional emotional demands. External assessments could override the case manager’s assessments and require the case manager to take a direction that they felt was not consistent with what they saw as possible for the person they had come to knowvery well.

4.3 Stress

Stress is a complex, largely subjective phenomenon that is difficult to measure; however, it tends to be defined in terms of physiological, psychological and behavioural changes [30]. What is experienced as ‘stress’ in the workplace will rely upon organisational, cultural, and personal experiential factors— an experience that is likely to vary through time as social changes disrupt the content of work, making it more or less ‘stressful’. While stress is inherently subjective and often difficult to quantify, it is frequently invoked by workers to explain the anxieties that surround their work and can affect both views on work and interactions with colleagues and clients [31, 32]. Negative stress contributes to staff turnover in personal injury compensation schemes and has been found to have long term deleterious effects on aworkers’ mental health [33, 34].

Case managers frequently identified ‘stress’ as affecting their interactions with injured clients. Two factors associated with the person with an injury were seen to lead to stress: emotional attachment to the case/client and emotionally unstable clients. First, the nature of the injury or the characteristics of the person with an injury was a cause of high levels of stress. As mentioned previously, case managers found some cases to be very distressing to the extent that they had to remove themselves from the case. Second, clients perceived to be unstable were a driver of case manager’s stress. Clients who self-harmed or threatened suicide directly impacted on the case managers’ own state of mind as well as the procedures they undertook to ensure duty of care. The pressure associated with ensuring the safety of the client and adherence to correct procedure was considered a major source of stress.

In addition to those factors associated with the person with an injury, stress was associated with case managers’ interaction with other parties in the compensation process. At this level, two drivers of stress were identified including lack of informed decision making and poor client-employer relationships. First, lack of information in case managers’ decision making capacity was described as stressful as case managers did not have allied health backgrounds and did not understand certain information given by the health provider. Second, the client-employer relationship was a driver of stress. Being the intermediary between employers and clients was described as stressful, particularly when a good relationship did not exist pre-injury. Compensable medical conditions that were complicated by an industrial issue within the workplace were very difficult to manage and caused additional layers of stress forcase managers.

Stress emerged as a direct impact of working within the compensation scheme driven by expectations by higher-level management that case managers should be able to meet targets for the return of clients to work. This case manager highlighted the relationship between stress and management expectations:

When they don’t go back to work that puts a lot of pressure on the case managers because there’s certain expectation that if you’ve just got a broken ankle you’ll be back at work within ten weeks and then the pressure that you potentially could be putting on that case manager going well, why aren’t they back at work? (Female participant, WSC2)

4.4 Conflict induced emotions

A person with an injury’s perceptions of conflict arising between themselves and personnel within the compensation scheme has been widely documented [3]. This study found that case managers perceived that conflict was common in their interactions with the person with an injury, and that this created feelings of unease in their work. In their view, conflict arose from differences in clients’ interpretation of the compensation ‘rules’ in the form of legislation or policy, and of the significance of comorbidity (i.e., having concurrent medical conditions). In the former case, this was ascribed to clients’ interpretation being inconsistent with case managers’ own understanding and training. Such conflict often arose when case managers were delivering decisions to the client on what was deemed to be reasonable in regards to financial issues and treatment options. Comorbidity was cited as a source of conflict in cases where there was a lack of clear evidence to support treatment or financial support for the original injury as opposed to an unrelated condition.For example:

... .we see a lot of workers with degenerative injuries which are probably as much due to the aging process that they are due to their influence of work. So I think those sort of things are, it makes it a more complicated environment because you’re not dealing with like, in compensation I guess, you’re not dealing with black and white issues, you’re dealing with grey and often grey issues are probably more likely to lead to potential conflicts. (Male participant, WSC1)

The personal involvement expected of a case manager by clients was challenged by decisions being made about compensation:

And I guess the impact on an individual within our branch is probably around understanding that and that line between empathy and sympathy and the lines around advocacy and what an organisation such as ours can pay for or not pay for and that kind of personal challenge sometimes. So that personal or ethical challenge that would sometimes arise around, I’d really like to pay for this, I’d really like to support you around this but there are barriers for me to be able to do that (Female participant, MVCS).

Personal involvement also works in other ways as this dialogue among focus group participants illustrates:

Participant1:
You get a lot of clients actually ringing up just wanting to chat.

Just giving you a bit of an update.

They’ve got no one else to talk to.

I spoke to you last week, I’m telling you the same info.

I think we all have regular clients like that who call up just to chat.

But sometimes that’s nice from our perspective as well just to have that social interaction and not be on the level of, how’s your injuries? Talking about the accident all the time.

Not making decisions.

Yeah. And not having to go, what’s happening and firing questions at them. Just having that baseline chat so that they... it builds the relationship as well.

However, conflict was often associated with case managers’ interactions with other parties in the compensation process. Solicitors/lawyers were identified as the main source of conflict due to differences in what both parties believed was ‘best’ for the client. For example:

But I think that the solicitors/lawyers, I think we all want the best for clients but their definition of that is different. Their definition is maximising entitlements and if they do that, they’ve done a great job. And they are taught that from day one at law school so it’s just getting the same definition I think. (Female participant, MVCS)

This comment highlights the complexities surrounding case management that are not easily predicable or controllable given the ambiguities around the classification of injury and the intrusion of legal processes. It is not surprising that such interactions cause conflict for case managers and that they provided a major source of unease for them. The presence of legal representatives was a particular source of emotional discomfort. Similar reactions towards legal involvement have been identified by persons with an injury [35].
5 Discussion and conclusion

This study advances our understanding of the emotional work involved in case management in the injury compensation industry. Case managers in the compensation industry occupy a somewhat unique place in labour processes – they are white collar professionals who are also front-line workers providing and managing the delivery of services to clients, often over long periods of time. This study has revealed the previously unrecognised emotional labour undertaken by this occupational group and the challenges involved and tensions arising from their juggle of front-line work for clients and industry expectations of client outcomes.

We found that this labour was associated with managing conflict and differing expectations related to their role, particularly the multiple conflicting expectations of other parties, such as legal personnel, healthcare providers, and families and clients who may be suffering from complex problems. While such work is demanding and has potential negative impacts on workers’ health and wellbeing, this is rarely acknowledged in formal position descriptions, although it is implicitly considered to be ‘part of the job’. This study extends the growing literature that has examined the adverse impacts of the compensation process on the person with an injury [3] and informal support services including family members, carers [36, 37], employers [38] and healthcare practitioners[39, 40].

The case managers involved in this study were aware that they occupied a position of authority within the compensation system, given their role as decision makers with regards to the provision of financial support and treatment to the person with an injury, and that this imposed certain demands on them. They were well aware of the extra-role emotional commitment expected of them. Yet, case managers felt ‘stuck in the middle’ of the system, with multiple and sometimes conflicting goals of trying to assist the person with an injury to recover or return to work, maintaining adequate financial control of the claim, and ensuring other stakeholders were engaged with, and supportive of the decisions being made in the case management process.

This finding has implications not only for the emotional wellbeing of workers, as the literature reveals, but also clients. The end-goal of the injury compensation system is about assisting injured individuals to re-establish an independent functioning role in society, or at least to be as independent and to function as well as they can be given the constraints posed by their health and circumstances. The case manager position in injury compensation system is characterised by role ambiguities and conflicts, and the kinds of emotional response highlighted by this research suggests that the system of case management may not always operate in an optimalmanner.

The negative impacts of stress, frustration and emotional commitment were also generated from other parties including family members, employers, and interaction with allied health professionals. Family members were frequently the source of emotional demands for case managers imposing implicit expectations of extra-role behaviours, as well as increasing case managers’ workload, because the involvement of family members can hamper the claims management process and thus produce unanticipated impacts.

Case managers reported that stress and frustration resulted from their interaction with allied health professionals (e.g., GPs, physiotherapists, occupational therapists). This stress and frustration was driven by case managers not having the necessary skills to make clinical judgments or the knowledge to translate information from allied health professionals. This finding is consistent with other research that identifies that the compensation system generates unrealistic expectations in regards to the type and extent of information health professionals need to provide to case managers [41]. Together, these findings suggest ambiguity in the role of health professionals in their interaction with case managers.

Case managers also reported that conflict was the result of their interaction with lawyers. It was reported that these impacts were driven by different end-goals for the client. Consistent with other research exploring client-lawyer interactions [35], case-mangers reported that lawyers were primarily motivated by financial gain rather than by what was considered best for the client. In contrast, the results of this study suggest that case managers’ motivation was driven by the need to return the client to their pre-injury state of health to enable them to work. Given these perceptions of opposing end-goals, it is not surprising that case managers report conflict in their interaction with lawyers.

Although this study advances our understanding of the emotional work involved in case management in the injury compensation industry, a limitation needs to be acknowledged. This study was conducted in a state in Australia that operates a no-fault compensation scheme. This means that injuries are compensable regardless of whether a party is found to be responsible for the accident. Research indicates that, within compensable road trauma populations, a person’s perceptions of responsibility for an accident is strongly associated with post-accident mental and physical health outcomes. Participants in our study who reported lower levels of responsibility for their accident showed significantly poorer mental and physical health outcomes [42]. However, responsibility for the accident was not accounted for in the design of the current study; thus, it is possible that the experiences of case managers and their associated emotional demands could possibly be different from that found depending on their client’s perceptions of responsibility. This factor needs to be addressed within future research designs with compensable road trauma populations.

In summary, the goal of this study was to qualitatively explore the impacts of case managers of their interactions with key stakeholders in the compensation process. This study unpacks the elements of case managers’ emotional labours, which differs from the much discussed ‘service triangle’ between workers, managers and customers [12]. This article considers the distinctive emotional demands of case management work and implications for the wellbeing of case managers and the routine management of injury compensation cases. The data revealed that their emotion management is not prescriptive – indeed, our analysis shows that they self-regulate. However, the contradictions for the industry are that they need case managers who are able to engage in complex emotional labour while not prescribing how they might undertake this task. Understanding the emotional labours undertaken by case managers in assessing injury compensation is an important foundation for developing compensation system case management models that both support injured people to return to health while providing healthy working conditions for case managers. Future research is needed to conceptualise and evaluate the effectiveness of alternative models that incorporate both objectives.

Conflict of interest

The authors have no conflict of interest to report.

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