Implementing a collaborative return-to-work program: Lessons from a qualitative study in a large Canadian healthcare organization

1.1 Return to work responsibilities in Ontario

Employers in Ontario, as in all Canadian provinces, must meet stringent standards to accommodate employees with disabilities. These obligations are established in federal and provincial human rights legislation and have consistently been confirmed by judicial case law [23]. The organization’s RTW program was developed in a context where disability income security benefits are provided by two insurance payers. Employers in Ontario are required to obtain insurance coverage for work-related injury and illness from the publicly-administered single-payer workers’ compensation agency. Additionally, the employer provides a long-term disability insurance plan for employees who are disabled by non-work-related conditions.

1.2 Background to the program

The RTW program discussed in this study was implemented in the organization in 2012 in an attempt to address the organization’s high rates of sickness absence and poor levels of return to work following absence. Prior to its adoption, the organization did not have explicit policies and procedures for supporting those on sickness absence to return to work. The program was aimed at better facilitating RTW after sickness absence, regardless of whether the absence was work-related or not, and at collaboration between different stakeholders, particularly union representatives and the employer. It was developed by a steering committee made up of representatives from the employer, relevant unions, and external expertise from supporting organizations (disability prevention and occupational health service to provide consultation on program development). The authors were asked by the organization to be involved as independent evaluators and were therefore not part of the program’s development or implementation.

The RTW program has numerous aspects, detailed in Table 1 against previously identified components of disability management programs. It is comprehensive in that it includes all components identified in Gensby et al’s (2012) systematic review [8] and in the Institute for Work and Health’s ‘Seven Principles of RTW’ (2007), a report that drew on research to develop important principles for workplace-based RTW systems [7]. Information about the RTW program was disseminated to staff via brochures and by providing information to managers to cascade through their teams. Managers attended a short session on the introduction of the program prior to its implementation.

The distinctive aspect of the organization’s program was the recruitment of RTWCs. These individuals were appointed by each of the three unions representing workers in the health system, so that every returning worker would have a representative from their own union as their RTWC. As well as including union representatives in the development and planning phases of the RTW program, this course of action was taken as an innovative way of trying to integrate the involvement of labour and management to work towards the common goal of RTW. In unionized workplace settings, it is common to provide access to union representatives for disabled employees, but having them written into the RTW policy formalizes their role in the process and encourages labour-union collaboration, something that is frequently cited in the disability management literature as being an important aspect of RTW (e.g. [6, 24]). Some RTWCs have taken on this role as an additional responsibility aside to their main job, with agreed time out of work. Other RTWCs were ‘dedicated’ to the role in that they have committed most of their time to union work, and the bulk of it is RTW. All remain employees of the organization. RTWCs attended a one-off five-day training course run by external partners, which covered issues related to the program and involved tutorial-based learning as well as practical training e.g. roleplaying different scenarios. The RTWCs work alongside the organization’s Occupational Health and Safety (OHS) Department, who hold overall responsibility for managing the RTW process. All are involved in the RTW meetings, which are held for workers whose return-to-work requires modified duties or modified hours.

2.1 Research design

The study presented here is one aspect of a larger evaluation of the RTW program where the authors have combined qualitative and quantitative approaches to explore processes and outcomes, taking a pragmatic approach. Here we discuss the findings of the qualitative research that was undertaken to explore how managers and RTWCs viewed the new RTW program in practice. Data were generated through semi-structured interviews, which allowed the interviewer flexibility to explore issues that were raised by the participants. The main objective of the interviews was to facilitate the participants to discuss their own experience of the RTW program. Ethical approval was obtained from the Health Sciences Research Ethics Board, University of Toronto (protocol reference 28503).

2.2 Recruitment of participants

An independent contractor at the organization identified all those who took part in a RTW case in 2012 and sent them an email to ask if they consented to having their contact information passed on to our independent research team. Table 2 shows the process of contact. Contact information for managers and RTWCs agreeing to an interview was forwarded to us, and following informed consent, twenty managers and ten union RTWCs were interviewed (Table 3). Through discussion among the research team, it was felt that data saturation was reached, with the managers after around 15 interviews; each were bringing up similar issues and no new themes were evident. At this stage no more managers were recruited but pre-arranged interviews were kept. It was not possible to recruit more than the ten RTWCs. This ten represented each of the three unions and included some RTWCs who were ‘dedicated’ to the role and others who retained their full time job and worked on RTW cases less frequently. Although the research may have benefitted from further interviews with RTWCs it was felt that interesting and sufficient themes were arising, which were complimentary to the findings of the interviews with managers, and which could be analysed to provide useful guidance on organizational RTW programs.

2.3 Data collection

Two researchers separately conducted semi-structured interviews in August-October 2013, when the program had been in place for around 18 months. A topic guide was followed with general themes about the RTW program: responsibilities of key actors; contact with the worker; monitoring the worker’s progress; access to information needed to be involved in the RTW process; and an overall assessment of the program. Interviews were flexible to allow for discussion of topics relevant to the participant. Interviews lasted approximately one hour, recordings were transcribed verbatim, and transcripts were checked and de-identified, with pseudonyms assigned.

2.4 Analysis

Thematic analysis was conducted by the two researchers who conducted the interviews and constant comparison was made. The authors ensured that the data analysis was rigorous by double coding of the transcripts, and continuous analysis meetings throughout the process, to discuss emerging themes and any differences in coding. Framework was used as an analytical tool for thematic analysis because of certain key features: it aids data management, concepts remain grounded in the data, it allows flexibility, it provides a tool for retaining the original context of each part of data after they have been synthesised, and is systematic [25]. Key themes were discussed and recorded and the data were indexed by theme on to a coding note for each participant. This was an iterative process whereby new themes were added as they arose in the data. Higher-level analysis involved exploring patterns within the thematically-organized data.

3.1 Organizational commitment (Principle 1)

RTWC and management participants were uniformly supportive of the organization’s commitment to improve disability management practices and endorsed the adoption of the program. They reported that the organization had a high sickness-absence rate and the effort put into disability management was supported. Some participants, managers in particular, did express the view that the employer had a poor track record of organizational change and had reservations that the implementation of the program would receive sufficient funding and resources to ensure its success. As an example, they noted the OHS department’s high caseload combined with the lack of staff in the department, and voiced concern that delays in RTW were inevitable. RTWCs and managers had positive views of the principle of employer and union collaboration embedded in the RTW program, yet also noted the inherent challenges in realizing such collaboration in practice.

3.2 Early contact with the worker (Principle 5)

There was confusion around best practice for initial contact with absent workers. On one hand managers wanted to show their support but on the other they did not want to overstep the mark and be perceived as harassing the worker. For example, Barbara (manager) said “I really have a hard time sometimes knowing if I’m invading somebody’s personal space, privacy by phoning or would that make them feel better?” This feeling was commonly reported by managers, who said there was a lack of guidance around appropriate contact with workers off sick. Likewise, RTWCs were critical of some managers who they felt were causing distress to absent workers by calling them before they had returned to work.

3.3 Return-to-work coordinator role (Principle 6)

Views on having union representatives as RTWCs were generally positive. However, managers were sometimes frustrated that delays were caused by having to wait for a RTWC to be available for the meeting, particularly when the worker expressed a preference to develop a RTW plan without the participation of a RTWC. Participants spoke of uncertainty about the specific roles and responsibilities of the RTWC. Some expressed the view that the RTWC role had not been fully developed. Barbara (manager) talked about it as being a “flash in the pan” idea–one that had not been followed through. This view was reflected in some of the RTWC interviews, where participants expressed uncertainty of their own role, in particular there was confusion around their title, as they and the managers referred to the OHS staff as the co-ordinators of the RTW program. It was the OHS staff who did the initial organisation and management of each case and who chaired the RTW meetings. It was not clear who was responsible for supporting sustained RTW following the initial RTW phase.

There was discussion about alternate approaches to staffing the RTWC role: whether each union should have a dedicated RTWC working full time on cases rather than relying on a number of RTWCs who would participate periodically. The RTWCs who had other full time jobs in the organization reported that they did not have as much accountability for the returning workers. For example, Bonnie (RTWC) said: “well I figure that if a person has a problem they will come to either me or go to the coordinator [Occupational Health and Safety] or whatever”. RTWCs who participated periodically reported that they did not have the opportunity to build up experience in the role and felt they could not make best use of their training; “if you don’t put it into practice right away, you lose a lot” (Jill, RTWC). The ‘dedicated’ RTWCs were more proactive and seemed to have more knowledge of the process, including the nuances evident in the compensation side of RTW. On the other hand, having a RTWC from the returning worker’s department was viewed positively as they were better able to contribute to the RTW plan in “finding the work that stays within his scope” (Tony, manager). Managers and RTWCs had similar views when weighing the advantages and disadvantages of ‘dedicated’ versus periodical RTWCs.

3.4 Creating a return-to-work plan (Principles 2 and 3)

Some participants talked about the RTW plans being very generic, “kind of cut and paste, it seems to be kind of the same for everybody in a sense” (Kara, manager), or “cookie-cutter” (Evelyn, RTWC), rather than being flexible to account for individual differences. Managers reported that some workers did not necessarily need to go through all of the steps in the plan; some could have progressed more quickly than others. Manager and RTWC participants noted a tension between creating RTW plans that are specific to the needs of individual workers yet general enough to be consistent and manageable.

Some participants, in particular but not explicitly RTWCs, noted a disappointment that the focus of discussion during RTW planning meetings tended to be on restrictions rather than on the work participation potential of the worker. Although a focus on “ability” (rather than “restrictions” or “disability”) was declared in the RTW program policy document, participants noted that the tools were not in place to facilitate this. For example, the physician’s Functional Ability Form (FAF) used in the RTW meeting to help determine RTW, is based on restrictions, not abilities. Also, there were reports from both managers and RTWCs that the FAF assumes that a RTW plan will be progressive, an implicit assumption of a linear recovery, when this is not always the reality. Many people simply “won’t fit in that piece of paper” (Jill, RTWC). There was a clear tension between capturing comprehensive information, the available tools, and the time required to do so, given the workloads of those involved.

3.5 Support returning worker without disadvantaging co-workers (Principle 3)

Most participants said that it would be beneficial for co-workers to be informed of a worker’s restrictions during modified duties. Co-workers provided with information about restrictions would then not expect returning workers to do certain duties, would not resent them, or think of them as indolent. Teamwork is required: “you can’t live in isolation in healthcare” (Helen, manager), and effective team work requires awareness of issues, such as co-workers’ restrictions. Participants noted the conflict between transparency and confidentiality in communicating to co-workers about restrictions. It was said that “there has to be a balance between privacy and what you communicate” (Liz, RTWC), but there did not seem to be any guidance on how best to deal with this issue, meaning that some managers did not feel it was their place to communicate to co-workers about restrictions. As Jacqui (manager) said: “it is up to the employee to divulge their restrictions. Because truly I can’t go and tell somebody what someone’s restrictions are because that’s a breach of confidentiality.”

Participants spoke of the difficulty they had in making sure there is an appropriate accommodation for the returning worker, making sure that the co-workers are not burdened, and that the highest standard of patient care is upheld. In terms of co-workers, if working with someone on modified duties there is the opinion that it makes “the load harder” (Bonnie, RTWC), whereby co-workers have to “pick up the slack” (Jill, RTWC). Managers also reported this problem, for example, Christine said: modified workers can make it “hard on the people that are having to work around” them. As well as causing irritation and potential for a hostile working environment, participants said that it could lead to a higher risk of injury to co-workers, and have a knock-on effect for patient care.

These concerns were not evident when the modified workers were supernumerary in their department, for example because co-workers generally “love it because now they have a spare pair of hands” (Leah, manager). However this brought up a different challenge: balancing worker/patient safety and budget. The issue of whether workers should RTW as core members of staff or as supernumerary to department requirements provoked much discussion. Although some of the RTWCs did have an appreciation of managers’ budgets others were of the opinion that it was the managers’ problem to solve and not theirs. This opinion was more evident in departments where the manager-worker relationship was frictional in the first place, or where the workers were disillusioned with their manager’s behaviour: “so he cuts the staff on the floor, we work harder, he gets the bonuses. And then he complains about his budget. We don’t care about it anymore” (Sam, RTWC). This raised concerns that the incentives given to managers were not conducive to a positive workplace, and did not put managers in position to make the best decisions. However, some RTWCs reported that managers did care about their workers, but that they were in a challenging situation given that their job success was judged in budgetary terms:

“That’s generally what the problem is [Okay] budgetary restraints more so than not wanting to follow the labour laws or anything, that’s not generally, it’s usually money” (Bonnie, RTWC).

Some of the managers reported that the RTWCs, and occasionally the OHS contact, did not appreciate their point of view.

“And it has a budgetary impact that they’re not responsible for, but they’re driving it, so how do I balance my budget but balance the need for the early RTW plan” (Pat, manager).

There was a tension between duty to accommodate and the budgetary pressures of running a successful organization, further complicated by the need to maintain a high standard of patient care. In interviews it came across that managers generally respected that they had a duty to accommodate and that ultimately the situation was beyond their control. Some reported that the extra budget could be justified because of their obligation “to provide a safe and ethical environment” for workers (Robert, manager). This was particularly apparent if the message of it being a ‘safety-first’ organization was being filtered down from senior management: “She really pushed safety first, safety first ‘we are in a financial crunch but safety first”’ (Robert, manager).

3.6 Independent medical assessment

An important theme that emerged from the interview data that falls outside of the principles of RTW is that of the Independent Medical Assessment. One aspect of the RTW co-ordination that the union RTWCs did not have control over was that of co-ordinating the medical assessments, which was done by the OHS department. This highlighted reports of distrust, and there were clear tensions between the RTWCs and the OHS department as a result. There was an opinion expressed by some RTWCs that the OHS department would request independent medical assessments of workers because they did not trust or like the results of the assessment provided by the worker’s physician. Rather than engage in open communication with the workers’ healthcare provider about workplace demands, Independent Medical Assessments were sought. Talking about whether they were justified, Mary (RTWC) said: “No, I don’t think so, like I mean if your doctor is saying you can come back to work, you’ve followed with your doctor for a long time, your doctor knows you better than any other doctor does.”

In contrast to the perspective of RTWCs, managers largely welcomed the use of Independent Medical Assessments. While mangers agreed that there were some workers who were not returning to work quickly enough, some offered the interpretation that this was because the workers were abusing their sick time, for example noting “patterns of people that have taken three summers off in a row” (Angela, manager). It is important to note that managers were only talking about a minority of their staff who “take advantage” (Paul, manager); they also talked about workers who were extremely dedicated to their jobs and to RTW. However, the expectation of sick leave was seen by some as being cultivated within the culture of the organization. Therefore, addressing this issue is not necessarily a straightforward task; “bad habits die hard” (Robert, manager).

3.7 Mental health

Another theme throughout the interviews that is not specifically aligned to any individual RTW program guideline, but important to discuss here, is the type of health condition or disability that caused the workers’ absence from work. Participants reported that it was more difficult to support returning workers with mental health conditions than those with physical health conditions. This was largely because participants reported that they did not feel comfortable dealing with mental ill health, meaning that “no-one’s really owning these cases” (Claire, manager). With physical injuries “there are black and white ways of figuring out whether you are better or not” (Christine, manager), it’s not so clear-cut for mental health issues “cause if you can’t read them, I mean if it’s a physical limitation it’s easy to fix, if it’s an emotional one I find it’s a lot harder” (Helen, manager). Also, although not limited to mental health, the unpredictable and episodic nature of mental health also made it difficult; conditions that were prone to flare up were described as a “constant battle” (Leah, manager).

Some RTWC participants said that they did not have the training to make appropriate suggestions for people returning to work with mental health conditions. They also said that other staff had a poor understanding of mental health, and this was substantiated in the interviews. Specific guidance on appropriate accommodations for mental health disability episodes was thought to be missing from the RTW program. For example, the FAF, on which the RTW plan was based, did not provide adequate space for limitations related to mental health; there was a distinct focus on the physical aspects of health.

3.8 Tensions evident in the RTW program: perspectives and practicalities

Although there were positive views on the implementation of a collaborative RTW program, there were aspects of it that caused tensions and often left managers and RTWCs unsure of how to progress their RTW cases. These can be split into practicalities about the RTW program that managers and RTWCs were equally frustrated with, and issues related to deeper problems stemming from having multi-perspective involvement, and the trust issues that may go along with this. The following discussion considers what we can learn from these tensions.