Capturing complexity in work disability research: application of system dynamics modeling methodology

Development of the Systems Thinking for Health Actions framework: a literature review and a case study

BACKGROUND

Systems thinking is an approach that views systems with a holistic lens, focusing on how components of systems are interconnected. Specifically, the application of systems thinking has proven to be beneficial when applied to health systems. Although there is plenty of theory surrounding systems thinking, there is a gap between the theoretical use of systems thinking and its actual application to tackle health challenges. This study aimed to create a framework to expose systems thinking characteristics in the design and implementation of actions to improve health.

METHODS

A systematised literature review was conducted and a Taxonomy of Systems Thinking Objectives was adapted to develop the new 'Systems Thinking for Health Actions' (STHA) framework. The applicability of the framework was tested using the COVID-19 response in Pakistan as a case study.

RESULTS

The framework identifies six key characteristics of systems thinking: (1) recognising and understanding interconnections and system structure, (2) identifying and understanding feedback, (3) identifying leverage points, (4) understanding dynamic behaviour, (5) using mental models to suggest possible solutions to a problem and (6) creating simulation models to test policies. The STHA framework proved beneficial in identifying systems thinking characteristics in the COVID-19 national health response in Pakistan.

CONCLUSION

The proposed framework can provide support for those aiming to applying systems thinking while developing and implementing health actions. We also envision this framework as a retrospective tool that can help assess if systems thinking was applied in health actions.

Linking job duties, functioning, and employment status using the Work-Disability Functional Assessment Battery (WD-FAB): An expert coding and quantitative analysis

BACKGROUND

An understanding of the link between specific occupational demands and individual worker functioning is limited, although such information could permit an assessment of the fit between the two in a manner that would inform national and state disability programs such as vocational rehabilitation and Social Security disability programs.

OBJECTIVE

Our goal was to examine the utility of assessing physical and mental functioning relative to self-reported job duties to identify the domains of worker functioning most likely to create barriers to fulfilling an occupation's specific requirements.

METHODS

Through primary survey data collection, 1770 participants completed the Work-Disability Functional Assessment Battery (WD-FAB) instrument after reporting details on their occupations (or most recent occupation if not working). Expert coders evaluated the level of function expected to successfully carry out each self-reported job duty with respect to six scales of physical and mental function. Quantitative analysis is used to examine the relationship between functioning and job duties.

RESULTS

Those not working due to disability were more likely to fall short of the threshold of the physical and mental functioning requirements of their last job's three main job duties compared to those currently employed. Mental function scales were most likely to be the area experiencing a shortfall.

CONCLUSIONS

Functional difficulties impede the ability to continue working in particular jobs that require that ability. This points to a need for specific accommodations to be implemented to bridge the gap between job requirements and functional capacity so that workers may remain engaged in their current work.

A general framework for selecting work participation outcomes in intervention studies among persons with health problems: a concept paper

Background

Work participation is important for health and can be considered as engagement in a major area of life which is of significance for most people, but it can also be thought of as fulfilling or discharging a role. Currently, academic research lacks a comprehensive classification of work participation outcomes. The International Classification of Functioning is the foremost model in defining work functioning and its counterpart work disability, but it does not provide a critical (core) set of outcomes. Standardizing the definitions and nomenclature used in the research of work participation would ensure that the outcomes of studies are comparable, and practitioners and guideline developers can better decide what works best. As work participation is a broad umbrella term including outcome categories which need unambiguous differentiation, a framework needs to be developed first.

Aim

To propose a framework which can be used to develop a generic core outcome set for work participation.

Methods

First, we performed a systematic literature search on the concept of (work) participation, views on how to measure it, and on existing classifications for outcome measurements. Next, we derived criteria for the framework and proposed a framework based on the criteria. Last, we applied the framework to six case studies as a proof of concept.

Results

Our literature search provided 2106 hits and we selected 59 studies for full-text analysis. Based on the literature and the developed criteria we propose four overarching outcome categories: (1) initiating employment, (2) having employment, (3) increasing or maintaining productivity at work, and (4) return to employment. These categories appeared feasible in our proof-of-concept assessment with six different case studies.

Conclusion

We propose to use the framework for work participation outcomes to develop a core outcome set for intervention studies to improve work participation.

Exploring the return-to-work process in working people with serious mental illness

BACKGROUND

Few studies examined the return-to-work (RTW) process in working people after recovery from serious mental illness (SMI).

PURPOSE

The RTW process was explored in working people with SMI.

METHOD

A qualitative study was conducted using the grounded theory. Twenty seven interviews were analyzed using Corbin and Strauss's approach (2015).

RESULTS

The core category "syncing with an ordinary workstream" emerged with three categories: "proceeding RTW strategies," "staying at work strategies," and "relative adaptation with work."

CONCLUSION

"Syncing with an ordinary workstream" can help researchers develop a new practice model to facilitate the RTW process in working people with SMI.

Development of employment indicators to advance the quality of spinal cord injury rehabilitation care: SCI-High Project

CONTEXT

Employment and Return to Work (RTW) rates following spinal cord injury/disease (SCI/D) are low due to individual and impairments characteristics, secondary health conditions, social and environmental barriers, prior work experience, workplace supports and resources, and physical or psychosocial work demands. To improve RTW, the SCI-High Project team developed a set of Employment structure, process, and outcome indicators for adults with SCI/D in the first 18 months after rehabilitation admission.

METHODS

A pan-Canadian Working Group of diverse stakeholders: (1) defined the Employment construct; (2) conducted a systematic search of available outcomes measures; (3) constructed a Driver diagram summarizing factors associated with employment. Subsequent facilitated meetings allowed for the creation of structure and process indicators, and the selection of outcome indicators.

RESULTS

The structure indicator is the proportion of SCI/D rehabilitation programs with an employment resource center. The process indicator is the proportion of SCI/D rehabilitation inpatients who receive an employment assessment during inpatient rehabilitation. The intermediary and final outcome measures are the Readiness for Return-to-Work Scale (RRTW) and Work Productivity and Activity Impairment (WPAI). Scale A of the RRTW for those who are unemployed and Scale B of RRTW and WPAI will be used for those who are employed.

CONCLUSION

This framework of Employment indicators intends to support the RTW needs of persons with SCI/D by ensuring that rehabilitation professionals provide opportunities to explore RTW within the first 18 months after rehab admission. Increased employment rates have the potential to enhance the wellbeing, health, and longevity of individuals with SCI/D.

Getting the Message Right: Evidence-Based Insights to Improve Organizational Return-to-Work Communication Practices

Purpose There is an absence of evidence-based guidance to support workplace stakeholders in the effective delivery of return-to-work (RTW) messages. Our study examines the specific RTW communication practices and their impact on the management of work disability. Methods Within two large and complex healthcare organizations, semi-structured interviews were conducted with workplace stakeholders (e.g., supervisors, union representatives, disability management professionals and workers' compensation representatives) and workers who had previously experienced sickness absence related to an occupational injury or illness. For workplace stakeholders interview questions asked about their roles and responsibilities in the RTW process, and specific communication strategies and messages that were used at different phases of the RTW process. For worker participants, interview questions explored RTW experiences and the impact of communication on work re-integration. An interpretative descriptive approach was used to inductively examine themes from interviews to create ways of understanding phenomena that yielded applied findings. Results Forty participants were interviewed including workplace stakeholders and workers. Participants frequently described effective RTW communication as messages that were delivered by a workplace stakeholder that included the content required by an injured worker to navigate the organizational disability management process and utilized specific strategies to address the perceived attitudes and perceptions held by an injured worker regarding work re-integration. Workplace stakeholders described five specific communication strategies including relaying messages of support, optimizing the timing of communication, careful word choice, framing messages, and tailoring communication to the injured worker.  Conclusion RTW communication is an active process that requires a strategic approach. Effective communication practices represent an important strategy for workplace stakeholders to address the barriers held by injured workers and foster early and sustained RTW.

Work Disability Management Communication Bottlenecks Within Large and Complex Public Service Organizations: A Sociotechnical Systems Study

Purpose Within large and complex organizations work disability (WD) communication bottlenecks emerge and contribute to avoidable disability days. Our study utilized soft systems methods to better understand communication problems in WD management. Methods Semi-structured interviews were conducted with disability case managers (n = 10), frontline supervisors (n = 15) and human resource/labor relations specialists (n = 5) within three public service organizations. Interview questions asked about organizational WD system structure and communication practices. Thematic analysis was conducted to examine system structure and emergent communication bottlenecks. Results WD communication took place across a number of internal and external stakeholders. Communication bottlenecks tended to concentrate within WD case manager and frontline supervisor activities. Inconsistent communication across organizations, challenges interacting with external stakeholders, mental health disability information exchange, lack of WD communication experience and previous worker performance represented communication bottlenecks that contributed to avoidable disability days. Conclusions To strengthen communication practices, systems-focused responses towards organizational WD management are required.

Recovery Within Injury Compensation Schemes: A System Mapping Study

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

Scoping Review of Work Disability Policies and Programs

Purpose: This scoping review identifies the foci of research articles that address government laws, policies and programs designed to foster labour market integration of people who, due to illness or disability, face challenges entering or staying in the workforce. Method: A systematic search of English-language peer-reviewed articles published between 2000 and 2014 yielded 14,474 articles. Title and abstract review identified 723 included articles that addressed government-led programs, policy or legislation on work integration and/or income support after injury, illness or impairment. These were sorted by theme, work disability program or policy, disability type, jurisdiction and year published. Results: The number of articles published that address work disability laws, policies and programs increased steadily. Most articles addressed disability in general. Among articles with a specific health focus, mental health was the most common. Research gaps are identified for mixed method study designs, chronic and episodic conditions, illness and cancer, and for work disability policy studies outside of North America, Northern Europe and Australia. Conclusions: We find a growing number of published articles about work disability and policy and identify specific areas where is a need for further research.

Examining occupational health and safety vulnerability among Canadian workers with disabilities

OBJECTIVE

To compare workers with and without disabilities on their reported workplace hazard exposure and the presence of occupational health and safety vulnerability factors.

METHODS

Working-aged adults in Ontario or British Columbia were recruited to participate in a cross-sectional survey (n = 1988). Self-reported measures included demographic factors, work-related variables, perceived level of activity limitation at work, and presence of work safety vulnerability factors utilizing a novel framework.

RESULTS

Reporting a disability at work was significantly associated with greater hazard exposure than those without a disability. In addition, those reporting a disability at work were more likely to be employed in conditions where hazard exposure was combined with inadequate policies and procedures, or hazard exposures were combined with inadequate empowerment.

CONCLUSIONS

Work safety vulnerability is one way that health inequalities can be perpetuated even among those with disabilities who have found work. Our results suggest that employers and policy makers need to focus on assessing and addressing hazard exposures and targeting occupational health and safety resources in the workplace in a way that includes workers with disabilities. Implications for Rehabilitation Workers with disabilities experience greater hazard exposure than those without a disability. Those with moderate and severe disabilities reported occupational health and safety vulnerability, suggesting that workplace accommodations should be available to a broader range of disability levels. It appears that, above and beyond standard safety procedures, providing workplace accommodations for people with disabilities may further reduce their hazard exposure and improve their safety.

Conceptualizing the dynamics of workplace stress: a systems-based study of nursing aides

Background

Workplace stress is a complex phenomenon that may often be dynamic and evolving over time. Traditional linear modeling does not allow representation of recursive feedback loops among the implicated factors. The objective of this study was to develop a multidimensional system dynamics model (SDM) of workplace stress among nursing aides and conduct simulations to illustrate how changes in psychosocial perceptions and workplace factors might influence workplace stress over time.

Methods

Eight key informants with prior experience in a large study of US nursing home workers participated in model building. Participants brainstormed the range of components related to workplace stress. Components were grouped together based on common themes and translated into feedback loops. The SDM was parameterized through key informant insight on the shape and magnitude of the relationship between model components. Model construction was also supported utilizing survey data collected as part of the larger study. All data was entered into the software program, Vensim. Simulations were conducted to examine how adaptations to model components would influence workplace stress.

Results

The SDM included perceptions of organizational conditions (e.g., job demands and job control), workplace social support (i.e., managerial and coworker social support), workplace safety, and demands outside of work (i.e. work-family conflict). Each component was part of a reinforcing feedback loop. Simulations exhibited that scenarios with increasing job control and decreasing job demands led to a decline in workplace stress. Within the context of the system, the effects of workplace social support, workplace safety, and work-family conflict were relatively minor.

Conclusion

SDM methodology offers a unique perspective for researchers and practitioners to view workplace stress as a dynamic process. The portrayal of multiple recursive feedback loops can guide the development of policies and programs within complex organizational contexts with attention both to interactions among causes and avoidance of adverse unintended consequences. While additional research is needed to further test the modeling approach, findings might underscore the need to direct workplace interventions towards changing organizational conditions for nursing aides.

Return-to-Work Within a Complex and Dynamic Organizational Work Disability System

Background Return-to-work (RTW) within a complex organizational system can be associated with suboptimal outcomes. Purpose To apply a sociotechnical systems perspective to investigate complexity in RTW; to utilize system dynamics modeling (SDM) to examine how feedback relationships between individual, psychosocial, and organizational factors make up the work disability system and influence RTW. Methods SDMs were developed within two companies. Thirty stakeholders including senior managers, and frontline supervisors and workers participated in model building sessions. Participants were asked questions that elicited information about the structure of the work disability system and were translated into feedback loops. To parameterize the model, participants were asked to estimate the shape and magnitude of the relationship between key model components. Data from published literature were also accessed to supplement participant estimates. Data were entered into a model created in the software program Vensim. Simulations were conducted to examine how financial incentives and light duty work disability-related policies, utilized by the participating companies, influenced RTW likelihood and preparedness. Results The SDMs were multidimensional, including individual attitudinal characteristics, health factors, and organizational components. Among the causal pathways uncovered, psychosocial components including workplace social support, supervisor and co-worker pressure, and supervisor-frontline worker communication impacted RTW likelihood and preparedness. Interestingly, SDM simulations showed that work disability-related policies in both companies resulted in a diminishing or opposing impact on RTW preparedness and likelihood. Conclusion SDM provides a novel systems view of RTW. Policy and psychosocial component relationships within the system have important implications for RTW, and may contribute to unanticipated outcomes.