‘Playing it smart’ with return to work: small workplace experience under Ontario’s policy of self-reliance and early return

Return-to-Work Experiences in Ontario Policing: Injured But Not Broken

PURPOSE

Police officers and others working in police services are exposed to challenging and traumatic situations that can result in physical and/or psychological injuries requiring time off work. Safely returning to work post-injury is critical, yet little is known about current return-to-work (RTW) practices in police services. This study examines RTW practices and experiences in police services from the perspective of RTW personnel and workers with physical and/or psychological health conditions.

METHODS

We used a purposive sampling approach to recruit sworn and civilian members from several police services in Ontario, Canada. The recruited members had experienced RTW either as a person in a RTW support role or as a worker with a work-related injury/illness. We conducted and transcribed interviews for analysis and used qualitative research methods to identify themes in the data.

RESULTS

Five overarching themes emerged. Two pointed to the context and culture of police services and included matters related to RTW processes, injury/illness complexity, the hierarchical nature of police organizations, and a culture of stoicism and stigma. The remaining three themes pointed to the RTW processes of accommodation, communication and trust-building. They included issues related to recovery from injury/illness, meaningful accommodation, timely and clear communication, malingering and trust.

CONCLUSIONS

Our findings point to potential areas for improving RTW practices in police services: greater flexibility, more clarity, stricter confidentiality and reduced stigma. More research is needed on RTW practices for managing psychological injuries to help inform policy and practice.

Return-to-Work Coordinators' Perceptions of Their Roles Relative to Workers: A Discourse Analysis

PURPOSE

This paper describes how Canadian Return to Work coordinators (RTWC) framed their job roles relative to workers in ways that went beyond the usual professional norms of helping worker recovery.

METHODS

In-depth interviews were conducted with 47 RTWCs across Canada in 2018-2019. We used critical discourse analysis to analyze the way coordinators viewed workers in the complex, multi-stakeholder system of RTW.

RESULTS

We identified four ways that RTWCs positioned themselves relative to workers: as trust builders, experts, detectives and motivators. These roles reflected RTWCs position within the system; however, their discourse also contributed to the construction of a moral hierarchy that valued worker motivation and framed some workers as attempting to exploit the RTW system.

CONCLUSIONS

RTWCs' positions of power in the coordination process warrant further investigation of how they exercise judgement and discretion, particularly when the process depends on their ability to weigh evidence and manage cases in what might be seen as an objective and fair manner.

American Society for Transplantation and Cellular Therapy Return to Work Guidance Committee Recommendations for Health Care Providers Who Take Care of Hematopoietic Cell Transplantation Patients

Hematopoietic cell transplantation (HCT) health care providers report a desire to improve long-term outcomes and quality of life for their patients. One of the items frequently cited by patients in terms of transitioning from being a patient back to pre-HCT life is return to work (RTW). However, these patients report little support from their health care providers in facilitating this process, and only 50% to 60% achieve RTW, at a median of 3 years post-HCT. Barriers are physical, psychological, and logistical, as well as poor communication between the patient and their employer. We convened a group of experts in survivorship, rehabilitation, social work, and psychology to draft an evidence-based document to assist health care providers in guiding their patients' RTW journey. Guidance is drawn from the existing literature for HCT and general cancer patients and is divided into pre-HCT, peri-HCT, and post-HCT categories. Collaboration among health care providers, patients, and their employers is key to this transition. Suggested referrals and evaluations also are provided. The goal is for this guidance to be continually updated as we advance the field with more HCT-specific literature.

The work disability trap: manifestations, causes and consequences of a policy paradox

PURPOSE

This article focuses on the risk that work disability policies lock people into work disability rather than promote durable health and return to work. We outline the concept of a work disability trap as a heuristic device to explore this policy paradox inherent in the design of most social insurance systems.

MATERIALS AND METHODS

This is a conceptual paper drawing on examples from existing research.

RESULTS

We identify three manifestations of the disability trap: not overcoming disability; underperforming; and returning to work prematurely. The causes of these manifestations are identified as structural rather than based on malingering clients, while negative consequences are identified both on client and system levels.

CONCLUSION

We emphasize the need for systems built on trust and reasonable expectations, and the need for providing rehabilitation support independently of economic compensation. Universal basic income is introduced as a potential tool to ameliorate some of the consequences of the disability trap.Implications for rehabilitationCompensation systems focusing too prominently on early return to work may have counter-productive effects on rehabilitation.Overly suspicious assessment systems nurture a view of people as malingerers.Rehabilitation professionals need to be attentive to system-generated effects which may prevent overcoming work disability.

Identifying predictors of return to work and the duration of time off work in first responders affected with musculoskeletal injuries or mental health issues

PURPOSE

To identify predictors of return to work, duration of time off work, and claim closure for first responders experiencing injuries or illnesses, and summarize the claim data.

METHODS

First responder claims collected between January 2012 and July 2017 were obtained from a disability management company. Known predictors of return to work were extracted from the data including age, sex, diagnosis, years of service, claim lag, medical report lag, and the return-to-work duties. Survival analyses were performed to identify predictors of return to work and claim closure using the Cox proportional regression analysis. Log-rank tests were performed to identify predictors that affected the rate of return to work and claim closure. Summary statistics were performed for the injury and return-to-work data.

RESULTS

60 of the 67 (89.6%) identified first responders returned to work within the data collection period. Musculoskeletal injuries predicted an increased likelihood of returning to work (hazard ratio = 2.0, 95%CI = 1.14-3.60) and a shorter duration of time off work (37 days on average) compared to mental health issues. Everyday of claim lag and medical report lag predicted a 2% decrease in likelihood of return to work. Returning to work was the only predictor of claim closure. 45 (67.2%) first responders returned to their pre-absence duties. 22 (32.8%) mental health claims and 45 (67.2%) injury claims were identified.

CONCLUSIONS

89.6% of first responders returned to work, although only 67.2% returned to their pre-absence duties. Predictors of return to work included injury type, as first responders with musculoskeletal injuries returned to work sooner, and claim and medical lag delayed the return to work.

Aligning stakeholders' understandings of the return-to-work process: a qualitative study on workplace meetings in inpatient multimodal occupational rehabilitation

Purpose: Although it is believed that involving the workplace and stakeholders in return-to-work interventions is beneficial, Norwegian occupational rehabilitation programmes rarely do. During 2015–2016, Hysnes Rehabilitation Centre provided inpatient multimodal occupational rehabilitation, including workplace meetings with employees, supervisors, and rehabilitation therapists. This study aims to explore the meetings´ content and stakeholders´ experiences.Methods: This was a multiple case study including non-participant observation of workplace meetings and interviews with participantsResults: Essential features of meetings included revealing and aligning the employee’s and supervisor’s understandings. Three components seemed instrumental in developing shared understandings leading to appropriate adjustments: 1) disclosing causes of absence, 2) validating difficulties, attitudes, and efforts, and 3) delimiting responsibility. Therapists played a vital role in addressing these components, supporting employees, and ensuring planning of appropriate solutions.Conclusion: Developing shared understandings by addressing and aligning illness- and return-to-work representations appears important for return-to-work interventions. Although pivotal to developing appropriate adjustments, disclosure depends upon supervisors’ display of understanding and should not be encouraged without knowledge of the employee´s work situation. How supervisors relate to employees and implement adjustments may be as important as the types of adjustments. The therapist’s support and validation of employees in vulnerable situations also seem valuable.Trial registration: The trial is registered at clinicaltrials.gov (NCT02541890), 4 September 2015. https://clinicaltrials.gov/ct2/show/NCT02541890.

Return to Work and Ripple Effects on Family of Precariously Employed Injured Workers

Purpose Work injury and return to work processes can have adverse effects on injured workers and their families. Family members may experience increased workloads, role reversals, dissolution of marriages or changes in relationships with children, as well as financial strain from loss of income. How these associations interact when the injured worker is precariously employed, however, is unknown. The aim of this study was to explore the impacts of work-related injury or illness as well as subsequent compensation and return to work processes on families and relationships of precariously employed workers. Methods Interviews were conducted with fifteen precariously employed injured workers recruited through on-line advertising, injured worker groups, and social media platforms in Ontario. Situational analysis was used to identify how family members were affected and their role throughout the injury process. Results Precariously employed injured workers felt caught between self-interested employers and disinterested workers' compensation. In some cases, this led to deteriorated mental health and well-being. The worker's difficulties with RTW challenged financial security of families and affected their day-to-day normal routines. While some workers received emotional and instrumental support from their family members, others had their families fall apart when chronic disability and unemployment proved to be too much. Conclusions This study addressed the complex ways that work injury and illness among precariously employed workers interact with family life and relationships. Findings illustrate how the income and employment insecurity associated with precarious employment has ripple effects on workers and their families when they become injured.

Breast Cancer Survivors Report Similar Concerns Related to Return to Work in Developed and Developing Nations

Aim To determine whether breast cancer survivors (BCS) at work following the diagnosis and/or treatment of breast cancer, in a rapidly developing country such as China experience similar to return to work challenges as reported in nations with established return to work (RTW) policy and procedures for employees with cancer. Methods Semi-structured interviews were conducted with 16 BCS who returned to work following diagnosis and/or primary cancer treatment. An Interpretative Phenomenological Analysis was used to investigate responses. Results Three recurring themes emerged: (1) challenges at work related to residual effects of diagnosis and/or primary treatment; (2) positive and negative responses from employers and/or supervisors; and (3) positive and negative responses from co-workers/colleagues. Although several participants experienced a high level of workplace support, there was a subgroup that did report challenges related to symptom burden, cognitive limitations, and both positive and negative responses by employers and co-workers were reported. Conclusions Findings indicate similar challenges in BCS who RTW during and/or following cancer treatment in both rapidly developing and developed nations. Results suggest that regardless of the existence of workplace policies and practices related to RTW for workers with a history of cancer, a subgroup of BCS experience similar challenges when returning to work. These findings highlight the international nature of RTW challenges and suggest the need for more global efforts to develop and evaluate workplace interventions to assist with these similarities.

Findings From the National Machine Guarding Program: Safety Climate, Hazard Assessment, and Safety Leadership in Small Metal Fabrication Businesses

This manuscript assesses safety climate data from the National Machine Guarding Program (NMGP)—a nationwide intervention to improve machine safety.

Application of the Theoretical Domains Framework and the Behaviour Change Wheel to Understand Physicians' Behaviors and Behavior Change in Using Temporary Work Modifications for Return to Work: A Qualitative Study

Purpose Applying the theoretical domains framework (TDF) and the Behaviour Change Wheel (BCW) to understand physicians' behaviors and behavior change in using temporary work modifications (TWMs) for return to work (RTW). Methods Interviews and focus group discussions were conducted with 15 occupational physicians (OPs). Responses were coded using the TDF and the BCW. Results Key behaviors related to applying TWMs were initiating the process with the employee, making recommendations to the workplace, and following up the process. OP behaviors were influenced by several factors related to personal capability and motivation, and opportunities provided by the physical and social environment. Capability comprised relevant knowledge and skills related to applying TWMs, remembering to initiate TWMS and monitor the process, and being accustomed to reflective practice. Opportunity comprised physical resources (e.g., time, predefined procedures, and availability of modified work at companies), and social pressure from stakeholders. Motivation comprised conceptions of a proper OP role, confidence to carry out TWMs, personal RTW-related goals, beliefs about the outcomes of one's actions, feedback received from earlier cases, and feelings related to applying TWMs. OPs' perceived means to target these identified factors were linked to the following BCW intervention functions: education, training, persuasion, environmental restructuring, and enablement. The results suggest that at least these functions should be considered when designing future interventions. Conclusions Our study illustrates how theoretical frameworks TDF and BCW can be utilized in a RTW context to understand which determinants of physicians' behavior need to be targeted, and how, to promote desired behaviors.

Application of the Theoretical Domains Framework and the Behaviour Change Wheel to Understand Physicians' Behaviors and Behavior Change in Using Temporary Work Modifications for Return to Work: A Qualitative Study

Purpose Applying the theoretical domains framework (TDF) and the Behaviour Change Wheel (BCW) to understand physicians' behaviors and behavior change in using temporary work modifications (TWMs) for return to work (RTW). Methods Interviews and focus group discussions were conducted with 15 occupational physicians (OPs). Responses were coded using the TDF and the BCW. Results Key behaviors related to applying TWMs were initiating the process with the employee, making recommendations to the workplace, and following up the process. OP behaviors were influenced by several factors related to personal capability and motivation, and opportunities provided by the physical and social environment. Capability comprised relevant knowledge and skills related to applying TWMs, remembering to initiate TWMS and monitor the process, and being accustomed to reflective practice. Opportunity comprised physical resources (e.g., time, predefined procedures, and availability of modified work at companies), and social pressure from stakeholders. Motivation comprised conceptions of a proper OP role, confidence to carry out TWMs, personal RTW-related goals, beliefs about the outcomes of one's actions, feedback received from earlier cases, and feelings related to applying TWMs. OPs' perceived means to target these identified factors were linked to the following BCW intervention functions: education, training, persuasion, environmental restructuring, and enablement. The results suggest that at least these functions should be considered when designing future interventions. Conclusions Our study illustrates how theoretical frameworks TDF and BCW can be utilized in a RTW context to understand which determinants of physicians' behavior need to be targeted, and how, to promote desired behaviors.

Stratégies de retour au travail d’employés ayant fait l’expérience d’une dépression : perspectives des employeurs et des cadres des ressources humaines

La dépression majeure est l’une des premières causes d’incapacité au travail dans le monde et a de nombreuses conséquences tant sur l’employé concerné qu’auprès des acteurs du milieu de travail.

ObjectifNous visons à documenter, selon la perspective des employeurs et des cadres des ressources humaines, les stratégies que ces acteurs préconisent dans leur organisation pour faciliter le retour au travail (RaT) d’employés en absence maladie due à une dépression.

MéthodeDeux cent dix-neuf employeurs et cadres de ressources humaines (n = 219) ont accepté de répondre à une entrevue semi-structurée téléphonique. La question abordée dans cet article était : « Selon vous, quelles sont les stratégies les plus efficaces pour aider un employé ayant reçu un diagnostic de dépression à retourner au travail ? » La codification duverbatima été effectuée à partir d’études empiriques et de théories existantes.

RésultatsTrente-quatre (34) stratégies réparties sur six grands principes ont émergé : 1) Contact avec l’employé en absence maladie (10 stratégies) ; 2) Évaluation et planification du RaT sans précipitation (6) ; 3) Formation des gestionnaires et du collectif de travail à la problématique de la santé mentale au travail (4) ; 4) Concertation des acteurs clés du RaT (4) ; 5) RaT progressif avec aménagements (4) ; 6) Suivi de la santé de l’employé et de son travail (6).

ConclusionCes principes articulés autour de 34 stratégies du RaT vont au-delà d’un processus étapiste de nature chronologique. Articulés dans un programme de RaT, ils devront être testés afin d’évaluer leurs retombées dans les organisations, notamment sur la gestion de l’incapacité au travail.

The structure and process of workers' compensation systems and the role of doctors: A comparison of Ontario and Québec

BACKGROUND

This study sought to identify impacts of compensation system characteristics on doctors in Québec and Ontario.

METHODS

(i) Legal analysis; (ii) Qualitative methods applied to documentation and individual and group interviews with doctors (34) and other system participants (31); and (iii) Inter-jurisdictional transdisciplinary analysis involving cross-disciplinary comparative and integrative analysis of policy contexts, qualitative data, and the relationship between the two.

RESULTS

In both jurisdictions the compensation board controlled decisions on work-relatedness and doctors perceived the bureaucratic process negatively. Gatekeeping roles differed between jurisdictions both in initial adjudication and in dispute processes. Québec legislation gives greater weight to the opinion of the treating physician. These differences affected doctors' experiences.

CONCLUSIONS

Policy-makers should contextualize the sources of the "evidence" they rely on from intervention research because findings may reflect a system rather than an intervention effect. Researchers should consider policy contexts to both adequately design a study and interpret their results. Am. J. Ind. Med. 59:1070-1086, 2016. © 2016 Wiley Periodicals, Inc.

New Business Structures Creating Organizational Opportunities and Challenges for Work Disability Prevention

Purpose Flexible work arrangements are growing in order to develop resource-efficient production and because of advanced technologies, new societal values, changing demographics, and globalization. The article aims to illustrate the emerging challenges and opportunities for work disability prevention efforts among workers in alternate work arrangements. Methods The authors participated in a year-long collaboration that ultimately led to an invited 3-day conference, "Improving Research of Employer Practices to Prevent Disability," held October 14-16, 2015, in Hopkinton, Massachusetts, USA. The collaboration included a topical review of the literature, group conference calls to identify key areas and challenges, drafting of initial documents, review of industry publications, and a conference presentation that included feedback from peer researchers and a roundtable discussion with experts having direct employer experience. Results Both worker and employer perspectives were considered, and four common alternate work arrangements were identified: (a) temporary and contingent employment; (b) small workplaces; (c) virtual work/telework; and (d) lone workers. There was sparse available research of return-to-work (RTW) and workplace disability management strategies with regard to alternate work patterns. Limited research findings and a review of the grey literature suggested that regulations and guidelines concerning disabled workers are often ambiguous, leading to unsatisfactory protection. At the workplace level, there was a lack of research evidence on how flexible work arrangements could be handled or leveraged to support RTW and prevent disability. Potential negative consequences of this lack of organizational guidance and information are higher costs for employers and insurers and feelings of job insecurity, lack of social support and integration, or work intensification for disabled workers. Conclusions Future studies of RTW and workplace disability prevention strategies should be designed to reflect the multiple work patterns that currently exist across many working populations, and in particular, flexible work arrangements should be explored in more detail as a possible mechanism for preventing disability. Labor laws and policies need to be developed to fit flexible work arrangements.

Am I ready to return to work? Assisting cancer survivors to determine work readiness

PURPOSE

A critical initial step in work re-entry involves the determination of work readiness. Cancer survivors have requested increased health care provider involvement in their work readiness decisions. However, there has been no exploration of current practices in determining work readiness, and thus no specific recommendations regarding how to assist survivors in answering the question: Am I ready to return to work?

METHODS

To explore return to work following cancer and the workplace supports survivors require, we completed an exploratory qualitative study. We conducted semi-structured interviews with (i) cancer survivors (n = 16) and (ii) health care/vocational service providers (n = 16). Data were analyzed using thematic analysis. Themes specific to work readiness are discussed.

RESULTS

Three key processes were deemed relevant to determining work readiness by health care providers and survivors: (1) assessing functional abilities in relation to job demands; (2) identifying survivor strengths and barriers to return to work; and (3) identifying supports available in the workplace. Challenges to work readiness determinations, were described by survivors and providers, related to: (i) the complexity of cancer, (ii) the accuracy of work readiness determinations, and (iii) the lack of established processes for addressing work goals.

CONCLUSIONS

Health care providers need to work collaboratively with survivors to determine if they are physically, cognitively, and emotionally ready to return to work, and with workplaces to determine if they are prepared to provide the necessary supports. Further stakeholder collaboration is also warranted.

IMPLICATIONS FOR CANCER SURVIVORS

Supports from health care providers in determining work readiness can ensure survivors do not return to work either "too early" or "too late."

Work reintegration after long-term sick leave: domains of influence on co-workers' ability to be supportive

PURPOSE

The purpose of the study is to identify domains of influence on co-workers' ability to be supportive of returning worker during the work reintegration (WR) process.

METHODS

An ethnographic study design was chosen involving fieldwork at four different workplaces, at an emergency care service, a waste disposal company and at two nursing homes. Qualitative methods for inquiry were used including participant observation, individual- and group interviews of 30 participants. Data were coded and analysed according to a grounded theory approach.

RESULTS

Four themes were identified related to domains of influence on co-workers' ability to be supportive of returning worker during the WR process: (1) organisation of work and level of interaction; (2) disruption of work routines, (3) relationship with returning worker and (4) attitudes towards sick leave.

CONCLUSION

The WR process after long-term sick leave is not only influenced by the WR's arrangements made, but also by the co-workers' responses to the process. Work arrangements not only affect the returning worker's ability to return-to-work (RTW) successfully, but also the co-workers' ability to be supportive and their ability to take active part in the process. Implications for Rehabilitation The process of WR after long-term sick leave involves interaction with co-workers. Domains of influence is in the co-workers' perspective influencing their ability to be supportive during reintegration of a returning worker. Future WR management could benefit from integrating the conditions for co-worker support. We encourage co-workers to be involved in the RTW planning, monitoring and evaluation with particular focus on how the WR arrangements are influencing their work and their ability to be supportive.

Returning to work after electrical injuries: workers' perspectives and advice to others

The objective of this study was to gain an understanding of workers' experiences with returning to work, the challenges they experienced, and the supports they found most beneficial when returning to work after a workplace electrical injury. Thirteen semistructured qualitative telephone interviews were conducted with individuals who experienced an electrical injury at the workplace. Participants were recruited from specialized burns rehabilitation programs in Ontario, Canada. Interviews were transcribed verbatim and thematic analysis used to analyze the qualitative interviews. Data regarding workers' demographics, injury events, and occupational categories were also gathered to characterize the sample.Participants identified three distinct categories of challenges: 1) physical, cognitive, and psychosocial impairments and their effects on their work performance; 2) feelings of guilt, blame, and responsibility for the injury; and 3) having to return to the workplace or worksite where the injury took place. The most beneficial supports identified by the injured workers included: 1) support from family, friends, and coworkers; and 2) the receipt of rehabilitation services specialized in electrical injury. The most common advice to others after electrical injuries included: 1) avoiding electrical injury; 2) feeling ready to return to work; 3) filing a Workplace Safety and Insurance Board injury/claims report;4) proactive self-advocacy; and 5) garnering the assistance of individuals who understood electrical injuries to advocate on their behalf. Immediate and persistent physical, cognitive, psychosocial, and support factors can affect individuals' abilities to successfully return to work after an electrical injury. Specialized services and advocacy were viewed as beneficial to successful return to work.

Manager Experiences with the Return to Work Process in a Large, Publically Funded, Hospital Setting: Walking a Fine Line

PURPOSE

Previous research on the role of managers in the return to work (RTW) process has primarily been conducted in contexts where the workplace has declared organizational responsibility for the process. While this is a common scenario, in some countries, including Denmark, there is no explicit legal obligation on the workplace to accommodate RTW. The aim of this study was to gain knowledge about the potential roles and contributions of managers in supporting returning employees in a context where they have no legal obligation to actively support RTW.

METHODS

Nineteen Danish hospital managers participated in a one-on-one interview or focus group discussions aimed at identifying barriers and facilitators for supporting employees in their RTW. Five individual interviews and two focus group discussions were conducted. Transcripts were analysed using thematic content analysis.

RESULTS

Four main themes were identified: (1) 'Coordinator and collaborator'; (2) 'Dilemmas of the RTW policy enforcer'; (3) 'The right to be sick and absent'; and (4) 'Keep the machinery running…'. Our findings indicated that supervisors' capacity to support returning workers was related to individual, communication, organizational, and policy factors. Instances were observed where supervisors faced the dilemma of balancing ethical and managerial principles with requirements of keeping staffing budgets.

CONCLUSION

Although it is not their legislative responsibility, Danish managers play a key role in the RTW process. As has been observed in other contexts, Danish supervisors struggle to balance considerations for the returning worker with those of their teams.

National Machine Guarding Program: Part 2. Safety management in small metal fabrication enterprises

Background

Small manufacturing businesses often lack important safety programs. Many reasons have been set forth on why this has remained a persistent problem.

Methods

The National Machine Guarding Program (NMGP) was a nationwide intervention conducted in partnership with two workers' compensation insurers. Insurance safety consultants collected baseline data in 221 business using a 33‐question safety management audit. Audits were completed during an interview with the business owner or manager.

Results

Most measures of safety management improved with an increasing number of employees. This trend was particularly strong for lockout/tagout. However, size was only significant for businesses without a safety committee. Establishments with a safety committee scored higher (55% vs. 36%) on the safety management audit compared with those lacking a committee (P < 0.0001).

Conclusions

Critical safety management programs were frequently absent. A safety committee appears to be a more important factor than business size in accounting for differences in outcome measures. Am. J. Ind. Med. 58:1184–1193, 2015. © 2015 The Authors. American Journal of Industrial Medicine Published by Wiley Periodicals, Inc.

Recommendations to facilitate the ideal fit note: are they achievable in practice?

Background

Although the UK fit note has been broadly welcomed as a tool to facilitate return to work, difficulties and uncertainties have resulted in wide variation in its use. Agreement on what constitutes the ‘ideal’ fit note from the perspective of all stakeholders is needed to inform best practice. A recent Delphi study conducted by the authors reached consensus on 67 recommendations for best practice in fit note use for employed patients. However, such recommendations are not necessarily followed in practice. The purpose of this study was therefore to investigate the perceived achievability of implementing these Delphi recommendations with a further reference panel of stakeholders.

Methods

Potential participants were identified by the research team and study steering group. These included representatives of employers, government departments, trades unions, patient organisations, general and medical practitioners and occupational health organisations who were believed to have the knowledge and experience to comment on the recommendations. The consensus Delphi statements were presented to the participants on-line. Participants were invited to comment on whether the recommendations were achievable, and what might hinder or facilitate their use in practice. Free text comments were combined with comments made in the Delphi study that referred to issues of feasibility or practicality. These were synthesised and analysed thematically.

Results

Twelve individuals representing a range of stakeholder groups participated. Many of the recommendations were considered achievable, such as improved format and use of the electronic fit note, completion of all fields, better application and revision of guidance and education in fit note use. However a number of obstacles to implementation were identified. These included: legislation governing the fit note and GP contracts; the costs and complexity of IT systems and software; the limitations of the GP consultation; unclear roles and responsibilities for the funding and delivery of education, guidance and training for all stakeholders, and the evaluation of practice.

Conclusions

This study demonstrated that although many recommendations for the ideal fit note are considered achievable, there are considerable financial, legal, organisational and professional obstacles to be overcome in order for the recommendations to be implemented successfully.

How to engage small retail businesses in workplace violence prevention: Perspectives from small businesses and influential organizations

BACKGROUND

Small retail businesses experience high robbery and violent crime rates leading to injury and death. Workplace violence prevention programs (WVPP) based on Crime Prevention Through Environmental Design reduce this risk, but low small business participation limits their effectiveness. Recent dissemination models of occupational safety and health information recommend collaborating with an intermediary organization to engage small businesses.

METHODS

Qualitative interviews with 70 small business operators and 32 representatives of organizations with small business influence were conducted to identify factors and recommendations for improving dissemination of a WVPP.

RESULTS

Both study groups recommended promoting WVPPs through personal contacts but differed on other promotion methods and the type of influential groups to target. Small business operators indicated few connections to formal business networks.

CONCLUSIONS

Dissemination of WVPPs to small businesses may require models inclusive of influential individuals (e.g., respected business owners) as intermediaries to reach small businesses with few formal connections.

Early-return-to-work in the context of an intensification of working life and changing employment relationships

PURPOSE

Many Western welfare states have introduced early-return-to-work policies, in which getting sick-listed people back to work before they have fully recovered is presented as a rather unproblematic approach. This reflects a belief in the ability of employers and the labour market to solve sickness absence. Against this background, the aim of this study was to analyse return-to-work practice in local workplace contexts, in relation to Swedish early-return-to-work policy.

METHODS

Semi-structured interviews were conducted with 18 matched pairs of workers and managers. The material, comprising a total of 36 interviews, was analysed using qualitative content analysis.

RESULTS

Three main themes were identified: (1) intensive workplaces and work conditions (2) employer support-a function of worker value and (3) work attachment and resistance to job transition. The results reflected the intensity of modern working life, which challenged return-to-work processes. Managers had different approaches to workers' return-to-work, depending on how they valued the worker. While managers used the discourse of 'new opportunities' and 'healthy change' to describe the transition process (e.g. relocation, unemployment and retirement), workers regularly experienced transitions as difficult and unjust.

CONCLUSIONS

In the context of early-return-to-work policy and the intensity of modern working life, a great deal of responsibility was placed on workers to be adaptable to workplace demands in order to be able to return and stay at work. Overall, this study illustrates an emerging social climate where sick-listed workers are positioned as active agents who must take responsibility for sick leave and return-to-work process.

The Collision Auto Repair Safety Study (CARSS): a health and safety intervention

BACKGROUND

Collision repair employs approximately 205,500 people in 33,400 shops. Workers are exposed to a diverse array of chemical, physical, and ergonomic hazards.

METHODS

CARSS was based on a random and purposeful sample. Baseline and one baseline and one-year evaluations consisted of 92 questions addressing issues, such as Right-to-Know, fire protection, painting-related hazards, ergonomics, electrical safety, and personal protective equipment. Owners received a report and selected at least 30% of items found deficient for remediation. In-person and web-based services were provided.

RESULTS

Forty-nine shops were evaluated at baseline and 45 at follow-up. At baseline, 54% of items were present. This improved to 71% at follow-up (P < 0.0001). Respiratory protection improved 37% (P < 0.0001) and Right-to-Know training increased 30% (P < 0.0001). Owners completed 61% of items they selected for remediation.

CONCLUSIONS

Small businesses' interventions should address the lack of personnel and administrative infrastructure. Tailored information regarding hazards and easy-to-use training and administrative programs overcome many barriers to improvement.

A theoretical model of co-worker responses to work reintegration processes

PURPOSE

Emerging research has shown that co-workers have a significant influence on the return-to-work outcomes of partially fit ill or injured employees. By drawing on theoretical findings from the human resource and wider behavioral sciences literatures, our goal was to formulate a theoretical model of the influences on and outcomes of co-worker responses within work reintegration.

METHODS

From a search of 15 data bases covering the social sciences, business and medicine, we identified articles containing models of the factors that influence co-workers' responses to disability accommodations; and, the nature and impact of co-workers' behaviors on employee outcomes. To meet our goal, we combined identified models to form a comprehensive model of the relevant factors and relationships. Internal consistency and externally validity were assessed.

RESULTS

The combined model illustrates four key findings: (1) co-workers' behaviors towards an accommodated employee are influenced by attributes of that employee, the illness or injury, the co-worker themselves, and the work environment; (2) the influences-behaviour relationship is mediated by perceptions of the fairness of the accommodation; (3) co-workers' behaviors affect all work reintegration outcomes; and (4) co-workers' behaviours can vary from support to antagonism and are moderated by type of support required, the social intensity of the job, and the level of antagonism.

CONCLUSIONS

Theoretical models from the wider literature are useful for understanding the impact of co-workers on the work reintegration process. To achieve optimal outcomes, co-workers need to perceive the arrangements as fair. Perceptions of fairness might be supported by co-workers' collaborative engagement in the planning, monitoring and review of work reintegration activities.

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

INTRODUCTION

Co-workers can play an important role after a work-related injury. They can provide details about the circumstances of an accident, offer emotional support to the injured worker and help with job tasks upon a co-worker's return to work (RTW). Working with an injured co-worker, however, can also strain work relationships and increase workload. The purpose of this study was to determine the role that co-workers play after a work-related injury and during the RTW process in the unionized, electrical construction sector.

METHODS

We conducted two focus groups with injured electricians and union representatives. We also interviewed co-workers who had worked with someone who had been injured in the course of employment. We examined the role that co-workers can play after a work-related injury and some of the factors facilitating and hindering co-worker support.

RESULTS

The structure of work in the electrical sector-a focus on cost-cutting and competition, job insecurity, perceptions of "different camps" among co-workers, little modified work and poor formal communication-can impede co-worker support and contribute to making injured workers' experiences difficult. Management can play an important role in setting an example for how injured workers are regarded and treated.

CONCLUSIONS

Future research should explore how workers can better be supported after a work-related injury and during the RTW process.

Bearing the brunt: co-workers' experiences of work reintegration processes

PURPOSE

Work disability research has found co-worker support to be a significant but under-recognised aspect of work reintegration (WR) processes. Although co-workers work alongside returning workers, their practical contribution to WR success or failure is often invisible to others. This study aimed to gain further insight into the role and contribution of co-workers in WR interventions.

METHOD

An exploratory qualitative pilot study was conducted in Toronto, Canada in 2011. Three focus groups were conducted with 13 co-workers, recruited for their direct experience of 'working alongside' a returning worker. An iterative data gathering and analysis process occurred. Themes were generated from categories in open-ended interview questions and new issues arising from the data.

FINDINGS

The findings detail co-workers' practical experiences of WR processes and their reflections on social and work conditions that impacted their participation. Co-workers' capacity to support returning workers was related to the quality of the WR arrangements, the relationship with the returning worker, work culture, and the duration of the required support. Workplace privacy and confidentiality requirements were identified as a key challenge for co-worker participation. The effects on co-workers of WR processes ranged from the opportunity to learn new skills to disillusionment and withdrawal from the workplace. In worst case scenarios, 'ripple effects' including emotional distress, physical injury and termination of co-workers' employment had occurred.

CONCLUSION

Co-workers are not a neutral party in WR procedures. Formalizing the co-worker role to include communication, consideration and recognition might improve co-workers' WR experiences.

Preserving workers' dignity in workers' compensation systems: an international perspective

BACKGROUND

Workers' compensation systems are among the most generous disability insurance systems in North America, although they are also known to be potentially adversarial and may have iatrogenic effects on claimants. This article examines issues to be considered to ensure fair compensation provided in a way that respects the dignity of workers.

METHODS

An overview of the literature on characteristics and effects of workers' compensation systems is followed by an analysis based on classic legal methods, including those of comparative law, complemented with interview data to examine three models of disability compensation.

RESULTS

The first part of the article identifies cross cutting issues to be considered in the examination of the equity of compensation systems and the protection of the dignity of claimants. These include three underpinnings of workers' compensation: the links between a "no-fault" system and the adversarial process, the appropriate use of medical and scientific evidence in the determination of compensability and the application of appropriate measures for promoting return to work. The second part looks at accident compensation in New Zealand, where compensation is available regardless of the cause of the accident, and disability insurance in the Netherlands, where compensation is available regardless of the cause of the disability. It then describes a composite of characteristics favorable to equity drawn from the thirteen workers' compensation systems in Canada.

CONCLUSION

Systems that succeed in reducing opportunities for adversarial interactions and that provide substantive protection could better promote the dignity of claimants.

The 'ability' paradigm in vocational rehabilitation: challenges in an Ontario injured worker retraining program

INTRODUCTION

In recent years, a focus on workers' ability, rather than impairment, has guided disability management services. However, a challenge with the notion of 'ability' is identification of the border between ability and inability. This article considers this gray zone of disability management in the case of a workers' compensation vocational retraining program for injured workers in Ontario.

METHODS

In-depth interviews and focus groups were conducted with a purposive sample of 71 participants who were directly involved with the vocational retraining process. Workers in the program had on average incurred injury 3 years earlier. Procedural and legal documents were also analyzed. Principles of grounded theory and discourse analysis guided the data gathering and analysis.

RESULTS

A program focus on worker abilities did not allow for consideration of unresolved medical problems. Concepts such as maximum medical rehabilitation distracted attention from workers' ongoing chronic and unstable health situations, and incentive levers to employers directed some of the least capable workers into the program. As well, communication pathways for discussing health problems were limited by rules and provider reluctance to reveal problems. Therefore, workers completing the program were deemed 'employable', while ongoing and problematic health conditions preventing employment remained relatively uncharted and invisible.

CONCLUSIONS

This study reinforces how the shift in disability management paradigm to a focus on ability and return to work requires consideration of environmental conditions, including policies and programs and implementation. A focus on the environment in which worker ability can be enacted might be as important as a focus on improving individual worker characteristics.

The social interaction of return to work explored from co-workers experiences

PURPOSE

The objective was to explore the role and contribution of co-workers in the return-to-work process. The social interaction of co-workers in the return-to-work process are analysed within the framework of the Swedish national and local employer organisational return-to-work policies.

METHODS

An exploratory qualitative method was used, consisting of open-ended interviews with 33 workplace actors across seven work units. Organisational return-to-work policies were collected from the three public sector employers.

RESULTS

The key findings that emerged during analysis showed that some co-workers have a more work-task oriented approach towards the return-to-work process, whilst others had a more social relational approach. In both situations, the social relations worked hand in hand with job tasks (how task were allocated, and how returning workers were supported by others) and could make or break the return-to-work process.

CONCLUSION

A suggestion for improvement of return-to-work models and policies is the need to take into account the social relations amongst workplace actors, especially involving co-workers when planning for return-to-work interventions. Otherwise the proper attention to work arrangements, social communication and the role of co-workers in the return-to-work process might not be seen.

Exploring workplace actors experiences of the social organization of return-to-work

INTRODUCTION

There is a limited body of research on how the actual social exchange among workplace actors influences the practice of return-to-work. The objective of this study was to explore how workplace actors experience social relations at the workplace and how organizational dynamics in workplace-based return-to-work extends before and beyond the initial return of the sick listed worker to the workplace.

METHOD

An exploratory qualitative method approach was used, consisting of individual open-ended interviews with 33 workplace actors at seven worksites that had re-entering workers. The workplace actors represented in these interviews include: re-entering workers, supervisors, co-workers, and human resource managers.

RESULTS

The analysis identified three distinct phases in the return to work process: while the worker is off work, when the worker returns back to work, and once back at work during the phase of sustainability of work ability. The two prominent themes that emerged across these phases include the theme of invisibility in relation to return-to-work effort and uncertainty, particularly, about how and when to enact return-to-work.

CONCLUSION

The findings strengthen the notion that workplace-based return-to-work interventions need to take social relations amongst workplace actors into account. They also highlight the importance and relevance of the varied roles of different workplace actors during two relatively unseen or grey areas, of return-to-work: the pre-return and the post-return sustainability phase. Attention to the invisibility of return-to-work efforts of some actors and uncertainty about how and when to enact return-to-work between workplace actors can promote successful and sustainable work ability for the re-entering worker.

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

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

Health and safety in small workplaces: refocusing upstream

Small workplaces have particular injury risks and are enduringly difficult for the occupational health and safety (OHS) system to reach. This paper puts forward an "upstream" perspective on OHS in small workplaces that moves beyond the attributes of the workplace and those who work there. The paper draws on and synthesizes ideas and findings from emerging upstream OHS research, our own empirical investigations in Ontario and Quebec, and our collected research experience in small workplace health. Upstream structures and processes (regulations, policies, services, interventions, professional practices) are often misaligned with the conditions of work and social relations of small workplaces. Key upstream factors include regulatory exemption, subcontracting, unionization levels, the changing character of small enterprise, joint management, service and inspection constraints, competing institutional accountabilities, institutional orientation to large business, and inappropriate service and policy. Misalignment of the OHS system with the nature and practical realities of small workplaces can undermine prevention and the management of ill health and injury. To address such misalignments, the paper calls for: 1) restructuring of data collection and consultation processes to increase the visibility, voice and credibility of small workplaces; 2) "audits" of OHS-related legislation, policy and interventions to assess and address implications for small workplaces; 3) reflection on current terms and concepts that render workers invisible and capture poorly the essence and (increasing) diversity of these workplaces; and 4) extension of the upstream gaze to the global level.

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

INTRODUCTION

Small businesses (SBs) play an important role in global economies, employ half of all workers, and pose distinct workplace health problems. This systematic review of qualitative peer-reviewed literature was carried out to identify and synthesize research findings about how SB workplace parties understand and enact processes related to occupational health and safety (OHS).

METHODS

The review was conducted as part of a larger mixed-method review and in consultation with stakeholders. A comprehensive literature search identified 5067 studies. After screening for relevance, 20 qualitative articles were identified. Quality assessment led to 14 articles of sufficient quality to be included in the meta-ethnographic findings synthesis.

RESULTS

This review finds that SBs have distinctive social relations of work, apprehensions of workplace risk, and legislative requirements. Eight themes were identified that consolidate knowledge on how SB workplace parties understand OHS hazards, how they manage risk and health problems, and how broader structures, policies and systems shape the practice of workplace health in SBs. The themes contribute to 'layers of evidence' that address SB work and health phenomena at the micro (e.g. employer or worker behavior), meso (e.g. organizational dynamics) and macro (e.g. state policy) levels.

CONCLUSIONS

This synthesis details the unique qualities and conditions of SBs that merit particular attention from planners and occupational health policy makers. In particular, the informal workplace social relations can limit workers' and employers' apprehension of risk, and policy and complex contractual conditions in which SBs are often engaged (such as chains of subcontracting) can complicate occupational health responsibilities. This review questions the utility of SB exemptions from OHS regulations and suggests a legislative focus on the particular needs of SBs. It considers ways that workers might activate their own workplace health concerns, and suggests that more qualitative research on OHS solutions is needed. It suggests that answers to the SB OHS problems identified in this review might lie in third party interventions and improved worker representation.

Exploring the meaning of early contact in return-to-work from workplace actors' perspective

PURPOSE

The objective of this article was to explore the meaning of early contact in return-to-work, and how social relational actions and conditions can facilitate or impede early contact among actors in the workplace.

METHOD

An exploratory qualitative method was used, consisting of individual open-ended interviews with 33 workplace actors at seven worksites across three public employers in Sweden. The workplace actors represented in these interviews included re-entering workers, supervisors, co-workers and human resources managers. Organisational policies on return-to-work were collected from the three employers.

RESULTS

The analysis indicated that early contact is a complex return-to-work measure with shifting incentives among workplace actors for making contact. For instance, the findings indicated obligation and responsibilities as incentives, incentives through social relations, and the need to acknowledge and balance the individual needs in relation to early contact.

CONCLUSION

The findings strengthen the importance of early contact as a concept with a social relational context that comprises more than just an activity carried out (or not) by the employer, and suggest that early contact with a sick-listed worker is not always the best approach for a return-to-work situation. This study provides a starting point for a more articulated conceptualisation of early contact.

Workers describe the effect of the workers' compensation process on their health: a Québec study

This article reports on a Canadian qualitative study designed to examine the workers' experience of the workers' compensation process and to look at the effects of the process on the physical and mental health of claimants. Eighty five in depth individual interviews of injured workers in Québec and six group interviews with workers and worker advocates from Québec, Ontario and British Columbia were analysed to determine the positive and negative impact on claimant health of various steps of the workers' compensation process and of behaviours of significant actors in that process. While superior access to health care and access to economic support both contributed to claimant well-being, various facets of the process undermined the mental health of workers, and in some cases, also had a negative impact on physical health. Primary characteristics of the process that influenced outcomes included stigmatization of injured workers and the significant power imbalance between the claimants and the other actors in the system; the effect of both these mechanisms was tempered by social support. The article describes how caseworkers, physicians, appeal tribunals, employers and compensation boards contribute to the positive or negative impacts on worker health and concludes with recommendations designed to promote the therapeutic aspects of workers' compensation and to curtail those facets that are harmful to worker health. It also has implications for researchers who wish to consider the role of lawyers or compensation in the development or prevention of disability.

Owner attitudes and self reported behavior towards modified work after occupational injury absence in small enterprises: a qualitative study

INTRODUCTION

Opportunities for modified work after an occupational injury are thought to be limited in small enterprises. This paper explores owner attitudes and self reported behavior towards modified work after injury-absence in small enterprises.

METHODS

Twenty-two owners of small construction and metal-processing enterprises were interviewed.

RESULTS

Opportunities for modified work were possible in spite of some owners' general objections. Owners found their own solutions here-and-now without help from external stakeholders, and had little knowledge of possibilities for financial or practical support for early return-to-work initiatives.

CONCLUSIONS

Initiatives formalizing modified work must be arranged in a way that supports the close social relations in small enterprises. Information to support the return to work process must be given when it is needed, i.e. at the onset of the prospect of lengthy work absence. The actual form of modified work should mainly be left up to the employer and the injured worker.

Workplace-based return-to-work interventions: optimizing the role of stakeholders in implementation and research

INTRODUCTION

The challenges of engaging and involving stakeholders in return-to-work (RTW) intervention and research have not been well documented.

METHODS

This article contrasts the diverse paradigms of workers, employers, insurers, labor representatives, and healthcare providers when implementing and studying workplace-based RTW interventions.

RESULTS

Analysis of RTW stakeholder interests suggests that friction is inevitable; however, it is possible to encourage stakeholders to tolerate paradigm dissonance while engaging in collaborative problem solving to meet common goals. We review how specific aspects of RTW interventions can be instrumental in resolving conflicts arising from differing paradigms: calibration of stakeholders' involvement, the role of supervisors and of insurance case managers, and procedural aspects of RTW interventions. The role of the researcher in engaging stakeholders, and ethical aspects associated with that process are discussed.

CONCLUSIONS

Recommendations for future research include developing methods for engaging stakeholders, determining the optimal level and timing of stakeholder involvement, expanding RTW research to more diverse work settings, and developing RTW interventions reflecting all stakeholders' interests.

From the environment to the workplace and back again? Occupational health and safety activism in Ontario, 1970s-2000+

This article addresses the issue of alliances between social movements through an investigation into the possibility of a convergence and/or allliance between two of the most enduring social movements in Ontario over the past three decades: the occupational health and safety (OHS) and the environmental movements. Both movements have not only endured, but been successful movements. Presently, however, each movement is fragmented and becalmed. Recent political developments are leading many OHS/labour movement activists to argue for an alliance with environmental movements. I argue that while there is benefit to both movements in such undertakings, continuing class differences between these two movements militates against any enduring alliance.