Abstract
BACKGROUND:
In the complex interaction between individual and environmental factors the return to work self- efficacy (RTWSE) plays a key role. RTWSE is the belief in the capacity to meet the demands required for RTW.
OBJECTIVE:
The purpose of this study was to explore how individuals on sick leave experience their RTWSE.
METHOD:
A modified phenomenology method was used. This perspective is useful in qualitative research to understand complex phenomena such as RTWSE. It was designed as an interview study and nine individuals participated in the age from 30 to 60 years.
RESULTS:
Four main themes with a total of ten sub-themes emerged from the analysis showing different aspects of RTWSE. The experience of working capacity in terms of health perception and the general sense of self-efficacy shaped the more specific RTWSE. The pursuit towards an active and fulfilling life and regaining control together with autonomy and the experience of support from others influenced the RTWSE.
CONCLUSIONS:
RTWSE is a global phenomenon reflecting the experience of vital parts of the life-world. RTWSE is about working capacity, but also concerns engagement in a meaningful occupation, being independent and participating. A holistic approach is therefore needed in order to strengthen self-efficacy.
Background
Work is an important occupation whereby people organise the world they live in and sick leave has a major impact on peoples’ everyday life [1]. Phenomenological experiences or lived experiences of occupations, such as work, are of growing interest in occupational science [2]. The phenomenological approach is useful in examining the way occupation presents itself. Occupation is understood in terms of the qualities of experience that individuals describe rather than the theories that categorise occupation in self-care, productivity and leisure. With this approach vocational rehabilitation will focus on the individual’s subjective experience of engagement in daily life. The focus on subjective experience also enhances the client- centred theory within occupational science [3]. In the present study, the understanding of the individual’s subjective perspective has been the fundamental approach to comprehend the beliefs about returning to work.
Absence from work due to sickness not only affects the individuals and their daily life, but also costs society large sums [4–6]. One important aspect affected during a period of sick leave is the return to work self-efficacy (RTWSE) [7, 8]. In order to understand RTWSE, the concept of self-efficacy needs to be understood as it is the foundation. In understanding self-efficacy, it is easier to understand any other activity connected to it. Self-efficacy is considered to belong to a basic self- perception [9]. The psychologist Bandura [10] has described the concept of self-efficacy as an individual’s opinion about their ability to organise and implement actions to achieve a specific performance. This self-efficacy in working through various activities is the basis for the individual’s motivation and behaviour [11]. The level of motivation an individual experience in taxing activities is closely related to self- efficacy beliefs [12]. Bandura [10] uses the concept of self-efficacy as part of a social cognitive theory. In this theory, human action is understood as an interaction between behaviour, cognition, and environment [13]. Bandura [10] connects the concept of self-efficacy to specific activities and situations. In this study, self-efficacy is connected to the activity of return to work (RTW) and is defined as the belief in the capacity to meet the demands required for RTW [14]. Meeting job demands has also been identified as one of three underlying subscales in the development of a RTWSE scale together with modifying job tasks and communicating needs to others [15]. In more recent research, the concept of self-efficacy is also used in a more general sense. General self-efficacy is about an individual’s assessment of their ability to handle different situations in general [16, 17].
The process of returning to work is influenced by many factors. In a systematic literature review, approximately 100 different factors were identified as influencing the possibilities of returning to work [5]. Demographic aspects that hinder a return to work are being female, increasing age and low education [18]. The time aspect is also an important factor: the longer the period of sick leave, the greater the probability of not returning to work [18]. Research suggests that 90% of workers with musculoskeletal diseases return to work within two months. However, for those workers who are still on sick leave after 6 months, less than half return to work [19]. Work-related psychosocial factors such as low job control, high psychosocial demands and high work-stress also negatively affect the return to work [16, 20]. Additionally, organisational factors that facilitate return to work are an early and coordinated rehabilitation [21]. The employer’s attitude is of importance: a positive attitude can help the employee to return [20]. Effective communication and the credibility of the actors involved are also important [22, 23]. The individual’s feeling of being treated respectfully, feeling supported and being involved in decisions are also important to the process of returning to work [24].
Various aspects of self-efficacy play an important role in the compound process of returning to work but it is only since the early 2000’s that the individual’s own expectations and beliefs about returning to work have been studied in more depth [22, 26]. Amick et al [27] found that increased self-efficacy in combination with a supportive workplace were the most important factors for returning to work after 6 months [27]. Katz et al. [28] discovered that self-efficacy was important for returning to work after 2 and 6 months but after 12 months support from the workplace was more important and self-efficacy was no longer significant [28]. Dionne et al. [29] realised that increased self-efficacy had a large preventive effect after an unsuccessful attempt to return to work [29]. Busch et al. [30] found that low self-efficacy was the most important factor for long-term sickness [30]. A low self-efficacy more than doubled the risk of further sick leave [30]. A qualitative study within occupational science focused on the perceptions of possibilities of returning to work with chronic musculoskeletal disorders [31]. It showed that work environment, health and disability systems were recognised as most important in developing these perceptions [31].
The limited but growing research available shows that RTWSE is important in the process of returning to work [7, 32]. The literature indicates various connections between self-efficacy and return to work. However, it is still not clear how the interplay between RTWSE and sick leave works and whether RTWSE, itself, is essential compared to other factors that also affect the return to work. It is also unclear how individuals on sick leave experience this situation as there is still little research based on the individual’s own experience of RTWSE [33]. As the links between RTWSE and sick leave are still not clear it is an area requiring further research.
Occupational science offers an understanding of the complexity of the return-to-work process. In occupational transitions, as from sick-leave to return-to-work, the ability to participate in a meaningful occupation changes the meaning of it and by participation in meaningful occupations individuals are supported in their life transitions [34–36]. Occupational science also shows a strong link between occupations and identity and socially valued roles as a worker influences an individual’s identity even more [37, 38]. Self-efficacy is a part of this identity.
For the professions encountering and dealing with questions concerning the individuals’ RTWSE, it is important to better understand this phenomenon. There is a need for further studies with a qualitative approach, based on a holistic occupational perspective of lived experience. In order to raise awareness and deepen the understanding of the RTWSE, understanding the perspective of the individual on sick leave, is important. It is also of interest to gain a deeper understanding of the interplay between RTWSE and sick leave.
The purpose of this study was to explore how individuals on sick leave experienced their RTWSE.
Method
A qualitative approach inspired by phenomenology was used as the theoretical framework for this study. The phenomenological perspective is useful in qualitative research in order to understand complex phenomena based on subjective experiences and people’s lived experiences [39]. RTWSE is such a phenomenon from which the perspective can be valuable and contribute to a deeper understanding. The method described by Malterud [40] was used for processing and analysis [40]. The study was designed as an interview study.
The study was reviewed and approved by the Regional Ethical Review Board in Gothenburg 2011, ref: 542 – 11.
Participants
The eligibility criterion for participation in the interview study was to be able to understand and speak Swedish as the interviews were the foundation for subsequent analysis and interpretation. Participants in the study would also have to be on full time sick leave at the time of the interview since the purpose of the study was to explore the participants’ RTWSE. To obtain a rich description of experiences a variety in demographic aspects as well as the reasons and the length of sick-leave was important [37].
Nine individuals participated; six women and three men. They were aged from 30 to 60 years with the median age of 45 years. Seven participants were cohabiting or married and two were single. Five participants had children of varying ages. One of the participants had an immigrant background.
The professions represented were: truck driver, student, archivist, salesmen, self-employed, preschool teacher, journalist and construction worker. Two of these participants were unemployed at the time of the interview.
The participants had been on full-time sick leave for periods of between three months and two years. Two participants had previously been on part-time sick leave for one year and nine years respectively. By way of stating their reasons for being on sick leave five participants stated physical and mental illness, two blamed road accidents and three declared chronic fatigue syndrome. Three participants stated physical illness only due to rheumatic disease, traffic or industrial accidents. One participant stated mental illness only in the form of severe anxiety.
Procedure
The participants were recruited from the primary health care rehabilitation centres in Gothenburg. During the period from October 2011 to January 2012, occupational and physical therapists at each unit were informed of the study’s design and purpose. They in turn informed the target group both verbally and in writing. Individuals of interest to the study were then contacted by the research team and asked for their participation. Information about voluntary participation was provided, and that the participants could withdraw at any time. The participants signed a consent form before the interviews started. The first author conducted all the interviews. Five interviews were conducted in the Sahlgrenska Academy, Gothenburg University, two at a primary health care rehabilitation and two at the participants’ home. The interviews were conducted from November 2011 to January 2012 and lasted between 50 to 70 minutes each. Each interview was taped and transcribed into text by the author. Technical difficulties occurred during one interview and the last 11 minutes were not recorded. The individual therefore answered some additional questions in writing a few weeks later.
The interviews were semi-structured with open questions about the participants’ views on returning to work, what obstacles and possibilities they faced and their ability to influence their situation with the purpose to explore the participants’ lived experiences of RTWSE.
Analysis
The analysis was based on the modified phenomenological method described by Malterud [40]. The analysis was conducted in four recommended steps: to get an overall impression, to identify meaningful units, to abstract the content and to summarize the content. The hermeneutic circle, that is, to interpret the text by commuting between parts of the text and the text as a whole, was used as an analytical tool. In this way parts were validated in relation to the whole throughout the analysis process [40]. The analysis was carried out by the authors in close collaboration and with regular discussions. Discussions about the analysis were also conducted in regular seminars with colleagues.
In the first step of the analysis, an open and transparent interception was made in order to get an overall picture. To get a sense of the whole several readings of each interview followed. It was important to try to bracket preconceptions in order to read the interviews with an open mind and still having the purpose of the study in focus. Preliminary themes on the individuals’ experiences of the RTWSE were formulated.
In the second step, each interview was separately analysed. A total of approximately 700 meaningful units were identified, describing different RTWSE experiences. A coding process followed where the meaningful units were sorted into sub-themes and themes for each interview. A decontextualisation stage was conducted wherein parts of the texts were extracted and compiled with texts from other interviews describing the same phenomenon. Throughout this process, themes and subthemes were adjusted.
In the third step, the content of each theme and sub-theme was abstracted. The meaningful units belonging to each theme and sub-theme were then combined and condensed. Condensation meant that the content was densified and the actual content of the meaningful units was translated into a more general and abbreviated form. In this step of the interpretation the condensates still represented notes in progress. Also, in this step, themes and subthemes were adjusted.
In the fourth step, there was a contextualisation as the condensed texts were summarized under each theme and sub-theme. Summarize meant synthesizing the condensed text to develop credible descriptions. The summaries consisted of descriptions of the experiences of RTWSE. They represented the last step in the interpretation and formed the results. Finally, the summaries were verified to the full transcript of the interpretation in order to reflect the original context and to be as reliable as possible.
Results
The experience of the working capacity in terms of health perception and the general sense of self-efficacy shaped the more specific RTWSE. The pursuit towards an active and fulfilling life and regaining control together with autonomy and the experience of support from others influenced the experience of RTWSE. The RTWSE was embedded in this larger context. RTWSE is a global phenomenon that reflects the individual’s experience of the whole context and the meaning to which they ascribed this whole.
Four main themes with a total of ten sub-themes emerged from the analysis. The RTWSE can be illustrated as a tree in Fig. 1. The roots consist of the main themes that together affect the actual tree symbolising the RTWSE.
The RTWSE is symbolised by a tree. The roots are the four main themes influencing self-efficacy: experience of the working capacity, pursuit of an active and fulfilling life, pursuit of regaining control and autonomy and experience of support from others.
Experiences of their health and the sick leave in itself affected the RTWSE. Furthermore, it appeared that the general sense of self-efficacy shaped the more specific RTWSE. Two sub-themes formed the main theme that dealt with individual’s experience of their working capacity.
The experience of health and the impact of sick leave
The individuals’ experience of their ill-health and of being on sick leave clearly shaped the RTWSE.
“I’m afraid this will not work, I’m really afraid that it will not work. And it’s because of my arms. When it comes to my back, it’s been around for so long that I have very good control over it. I know that pain and I know what to do and how to behave before the working week starts. But as for my arms, I feel I have no control at all. I do not know how much I can or can’t do.”
Being on sick leave for an extended period was experienced as a further crisis that influenced health. The individuals described their long-term sick leave as devastating and felt that their situation left them feeling incomplete. The lack of good health and the effect of the sick leave, in itself, created a lower RTWSE.
Conversely, the experience of having successively regained good health and the ability to manage the crisis of enforced sick leave created an increased RTWSE.
The experience of general self-efficacy
Specific RTWSE was based on a general sense of self-efficacy. It was considered important to maintain self-belief. Following previous experiences in life, or during the current sick leave, individuals felt that they had to effect a change. They took an active decision to be responsible for their lives instead of viewing themselves as victims of circumstances.
“I believe it’s about me: - absolutely. The idea and that insight definitely helped me to get a job, though I felt really bad, and I felt that there is no one to help me, it’s only me who can help myself. As long as I believe that someone else will help me nothing happens. Everything depends on me and nobody else! That’s how I think and I don’t expect anyone else to help me. “
Having a good RTWSE was expressed as being obvious towards being able to work and be active. One individual described it as follows: “I have always worked and will always work. There is no one in my family who does not work.”
The RTWSE could commute due to an individual’s current sense of vulnerability. Difficult experiences, earlier in life, were revisited again and needed healing. A lower RTWSE was expressed as the uncertainty over the ability to cope with a job or even find a job. At the same time, the individuals expressed a need for change and a willingness to improve their self-efficacy by affirming their strengths.
Pursuit of an active and fulfilling life
The individual’s RTWSE increased alongside the will to be involved in a job and in society in general, and to feel that their work was meaningful. This main theme had two subthemes.
Wanting to participate
A need to feel part of the workplace community and, moreover, society shaped people’s RTWSE. To be away from home and meet with adults other than their own family was important. One individual put it: “To be in a context wherein one accomplishes something, that, I think, is incredibly... life affirming."
Previous experiences of good team spirit where everyone supported each other and where everyone was needed in the workplace were seen as an expression of a good working collaboration. Being together gave people a sense of strength. Working enabled a sense of participation both at work and in society in general. The RTWSE was strengthened by the desire to feel this participation.
To feel meaningfulness
It was important for the RTWSE that the individuals’ employment felt meaningful. If the work was enjoyable and stimulating it created the desire to return. A meaningful and stimulating job with work tasks based on each individual’s qualifications created a sense of being a valuable and unique personality. Working with other people who can see possibilities and enjoy changes is viewed as fulfilling. The ability to take responsibility and be in control over one’s working hours is also seen as empowering. One individual described it in these words:
“I’d rather have people around me who see opportunities, who think it’s positive when things are changing so we can do things in a new way. It’s like that everywhere, there will be changes and things are done in new ways.... When meeting people and seeing opportunities I mean something, I can assist and find opportunities together with others. ”
Wanting to have a meaningful job was a driving force that strengthened the RTWSE.
Pursuit of regaining control and autonomy
The individuals thought it was necessary to create structure in their everyday life and to maintain strategies for returning to work in order to regain control over their lives and experience greater autonomy. Importance was also placed on being financially independent in order to gain a greater self-sufficiency. This main theme contained three sub-themes that helped to shape the RTWSE.
Gaining structure in everyday life
Work offers routines, creating a sense of security in everyday life. It was important to try to maintain similar routine during the period of sick leave to rebuild structure and security. An absence of routine during sick leave could, on the other hand, imply an experience of chaos and inefficiency.
“It’s extremely important to have routines. It becomes so clear when you don’t have any, that everything falls apart. Finally, you don’t have time to do anything because you have no routines any more. You get up, go to work and get home and it’s afternoon... It doesn’t have to be from Monday to Friday, and it doesn’t have to be the whole day. I could probably imagine not working full time but... just the feeling when Friday comes. Now it’s Friday, here comes the weekend. It’s a little comforting that the weekend comes. You lose it all! It’s just a grey sludge! There are no extra moments to enjoy anymore.”
To have or try to create a structure to everyday life was considered important and the work was perceived as a crucial element of this structure. To implement some structure was a driving force that increased the RTWSE.
Having strategies to return to work
The experience of living with some form of ill-health, limiting the individuals’ ability to work, created an awareness of a need for new strategies. It was viewed as very important to influence and to have their own ideas concerning their return to work. Developing different strategies for return to work provided a route to regaining independence and self-control in life. These strategies could involve, for example, a need to start working gradually, or to undertake customised work tasks, physical training, learning how to set boundaries, counselling or dealing with stress or pain.
The different strategies for returning to work were an expression of good self-efficacy and gave individuals the experience of being able to influence their life situation.
Sometimes, however, the strategies did not work particularly well, or there was a shortage of strategies because the individuals lacked knowledge about how society works.
“How to get into the labour market? I don’t know how to do it. It feels like a hindrance, the whole way through.”
To have had strategies that did not work, or to have experienced of a lack of strategies, created a low RTWSE.
To be financially independent
For each individual, becoming financially independent, was an important driving force to return to work. RTWSE grew with the will to become self-sufficient. Feeling controlled by authorities was viewed as hard, as was being dependent on benefits during sick leave.
“A lot of people told me to understand the Social Insurance Agency like an insurance I have paid for over many, many years. But it’s difficult for me to understand it like that because I feel I’m so controlled all the time. I don’t like to be controlled, I want to be independent. ”
To support oneself would revisit a greater autonomy and this increased the RTWSE.
The experience of support from others
The experiences of support from an individual’s own network was important, as well as the support from the workplace and society in general. Contact with various societal organisations shaped the RTWSE so it could both increase and decrease. This main theme had three subthemes.
The experiences of support from the individual’s own network
The experience of support and encouragement from family and friends was important for the RTWSE.
Individuals described having access to a business network as another important support mechanism that increased the RTWSE. Knowing that others believed in them, appreciated their experience and their abilities also increased their RTWSE.
Feeling unsupported by their own network, however, threw doubts on the individuals’ ability to work. When family and friends questioned if it was reasonable to work the individuals had to consider the pros and cons of their work situation more carefully.
“Some of my friends ask, “Should you work at all?” because they see how I feel physically when I work. At the same time, I feel better mentally when I’m working than when I’m not working so somehow it’s a question of balance.”
The experience of support from the workplace
Social support from the workplace, from both colleagues and managers was viewed as important for the RTWSE. Contact from the workplace during the period of sick leave gave individuals a feeling of being valued employees. It was important to feel safe and to feel welcomed back when returning to work. Good support from the workplace increased the RTWSE.
Lack of social support from the workplace negatively affected the self-efficacy to return to work. When the workplace didn’t communicate at all during an extended sick leave, the sense of being forgotten was created and one individual considered looking for alternative employment.
“Nobody got in touch with me when I was sick. No flowers, nothing, and I thought, well that’s ok. At the same time, what kind of workplace is that? Then during the sick leave last summer, I had my birthday, still nothing... no invitations to anything. Then I felt.... No, I don’t want to go back.”
The experience of support from the societal organisations
Experiences of the influence of society in the form of actions via different authorities concerning healthcare, the Social Insurance Agency or insurance companies had a major impact on self-efficacy. For some, the experience of the action was more positive than others, regarding the RTWSE.
Receiving the right support and help from the healthcare system was very important. With proper care and treatment, the hope to be able to work again grew stronger. One individual expressed his hopes concerning healthcare: “If I get the right care then I will surely be able to start working as soon as possible.”
To have confidence in and support from the healthcare system increased the RTWSE.
The sensation of feeling safe when taking the first step towards work was felt as very important. Getting professional guidance and support increased this sense of security. It was vital that the authorities looked at all aspects of life and had a supportive attitude.
“I think it’s good that the social insurance system works with people in order to help them from not giving up. A lot of people certainly might feel “I can’t” because some days one can feel that “I can’t do anything.” But work has an important function. As a human being you keep going on, you keep your brain active by thinking and activating yourself. I also think that person by person and situation by situation should be considered in a completely different way than they do today.”
When various authorities made different assessments of the individuals’ work capacity the conflicting information created confusion and frustration. It was felt that it led to an extended sick leave process and created a strong distrust of the authorities. The experience of not being understood delayed the return to work and affected the RTWSE negatively.
Discussion
The purpose of this study was to explore how individuals on sick leave experience their RTWSE. The participants’ lived experiences of their RTWSE indicated a complex and dynamic phenomenon that could change over time. The first three main themes dealt with the individuals’ experiences and what they wanted to achieve by starting to work again and the last theme concerned how they experienced their environment. The RTWSE was embedded in this larger context. The choice of a tree to illustrate the RTWSE was to symbolise its dynamic and changeability. The roots of the tree provide it with nutrition and consequently the opportunity to grow stronger. RTWSE was similarly dependent on the roots that gave it nutrition and growth.
Working capacity
The individuals’ understanding of their health was of great significance with regard to how they viewed their own work capacity. In phenomenological thinking the body affected by illness is not only a biological organism but first of all a lived body, a body that is experienced and meaning- making. The body is not solely a vehicle for enabling various activities but has a life of its own. The body belongs to an individual in the same way that the individual belongs to their body and the two are inextricably linked [39]. Heidegger [39] describes the human condition as a being- in-the-world existence. Being-in-the world is to feel at home in the life-world. But to live is also a to-death existence that becomes clear during illness. In illness we lose the sense of being- in- the- world and a basic sense of homelessness breaks through [41, 42]. In the present study this emerged in the individuals’ perception of their health. When individuals felt that they could not trust their body and its capacity any more they experienced feelings of powerlessness and confusion that can be likened to the to-death presence. This became more pronounced and the feeling of fundamental homelessness developed [42].
In the present study, it was clear that the participants who had experience of earlier periods of sick leave related to such experiences, and that this affected the RTWSE in their current life situation. According to Bandura [10], it is the individual’s own experience that most strongly affects their self-efficacy. When an individual is capable of an activity their self-efficacy increases and when the individual fails the self-efficacy decreases. High self-efficacy increases individuals’ initiative and persistence. Individuals with high self-efficacy dare to tackle more challenging goals and handle adversity better than those with low self-efficacy [10]. However, the present study revealed a more nuanced picture of how the RTWSE was influenced by previous setbacks. There seemed to be interactions between the participants’ own self-efficacy and the ability to draw lessons from different experiences. Previous adverse experiences had a negative influence, but with a higher general self-efficacy combined with self-reflection the individual handled the situation more constructively and with greater confidence.
The way in which an individual perceives his or her physical capacity is also important for self-efficacy according to Bandura [10], although it will not have as much influence as the individual’s own experience. For example, physical signals at times of stress, anxiety, fatigue or pain cause negative self-efficacy [10]. Since health perception was an important element in the RTWSE, individuals experienced a varying degree of uncertainty in their work capacity due to their weakened state of health. An improvement in health was seen as an important element in returning to work. Another study has shown that improved health is an important aspect, but it is not sufficient for a return to work [43]. Many, but not all, return to work when health improves and some return to work despite their health not improving or even if it diminishes [43]. Various symptoms of illness and disability do not necessarily mean an inability to work [7]. This is understood from a broader perspective, based on a biopsychosocial model in which psychological, social and organisational factors play a role [43].
An active and fulfilling life
A theory of occupation built on meaning has identified the dimensions of doing, being, belonging and becoming. These dimensions derive from clients’ perspective and enables occupational science to address such fundamental issues as meaning, purpose and self- perception [46]. In the present study the themes regarding an active and fulfilling life and regaining control and autonomy concern core assumptions in occupational therapy [46]. The dimensions of doing, being and becoming in occupation are helpful in understanding these themes [47]. The pursuit towards an active life and regaining control and autonomy concern the dimension of doing which includes purposeful and goal- oriented activities [46]. Doing as occupational engagement or participation is the traditional preoccupation of occupational therapy. The dimension of being is harder to understand and is less explored in both research and practice than the dimension of doing [2]. The pursuit towards a fulfilling life concerns the being. Being is about being true to ourselves and in essence, who we really are [47]. In phenomenology the notion of being is of central interest and has a theoretical depth that can inform occupational science [2]. Being is rooted in the individual’s consciousness, as well as feeling connected with other people and culture, that is, being-in-the-world. The notion of being enables a deeper understanding of how human occupations are experienced through being-in-the-world [2]. RTWSE in itself, as a global phenomenon, concerns the dimension of becoming. Becoming is about having visions of the future and exploring possible directions in life [46]. Becoming indicates a process and a change through time and RTWSE in the present study concerns the visions and expectations of the working capacity in the future.
Regaining control and autonomy
The concept of locus of control is closely related to self-efficacy and considered to belong to basic self-perception [9]. An individual experiencing an internal locus of control perceives that what happens depends on their own actions and that they exercise control over what is happening. Individuals who feel that what happens depends on the environment, such as fate or other individuals, are experiencing an external locus of control [9]. According to Bandura [10] self-efficacy will only increase if the individual perceives that it is his/her own commitment and ability that has yielded the result. An internal locus of control can consequently be considered as a prerequisite for a greater level of self-efficacy [10]. In the present study, it appeared that it was very important for the participants to feel that they took responsibility for their own lives. They wanted to make their own active choice, not wait passively for what various authorities would decide. Some described how certain life events before or during sick leave have forced them to take a stand on who should make decisions concerning their lives and they chose to reclaim an internal locus of control. Having regained an internal locus of control was experienced to increase the RTWSE. Other studies also demonstrate a relationship between a greater experience of an internal locus of control and the feeling of being ready to return to work [44, 45]. In a comparison however, it appears that the self-efficacy is the most powerful component of the two in its impact on a return to work [45].
Self-efficacy in different activities is not always obvious, but it is adjustable and changeable according to Bandura [10, 48]. There are many studies underlining the importance of targeted interventions on self-efficacy [4, 49]. Return-to-work self-efficacy scales have been developed for employees with mental health problems as well as musculoskeletal disorders in order to provide adequate interventions and predictions about RTW [14, 50]. The return-to-work self- efficacy scale for mental health problems has also been validated in a population with physical disabilities [14]. It was found that the RTWSE was a significant predictor of RTW in long- term sick listed employees with all- cause sickness absence [51]. In current research workers on sick leave are regarded as a single population despite the nature of the disease [52]. It is obvious that poor health is not always the main reason for longer sick leave. The return to work may be more hindered by the individual’s low self-efficacy and lack of adapted coping strategies. Because these can be changed, they are some of the key areas for occupational therapy [30]. In the present study it emerged that RTWSE was lower when there was a lack of strategies or strategies that had not worked in the past. A group with this difficulty may have a need for occupational therapy efforts directed toward self-efficacy and the development of new strategies [4, 30]. A randomised controlled trial demonstrated that occupational therapy improves long-term depression and RTW in sick-listed employees with major depression. The occupational therapy focused on a fast RTW and improving work-related coping and self-efficacy [53]. An occupational therapy practice model called Model of Occupational Self-Efficacy has also been developed to facilitate returning to work after brain injury. Occupational self-efficacy is described as a process in four steps that enables the brain injured individual to develop a personal belief that he/she can cope with various obstacles in life. The model focuses on improving occupational self-efficacy beliefs through occupational engagement in work-related tasks [54]. Further research is needed in how to improve occupational self-efficacy in practice. The present study may contribute to the existing knowledge and inform future occupational rehabilitation programmes.
Support from others
Occupational therapy acknowledges that participation in occupation is dependent on the environment [1]. In the occupational transition from sick leave to work support from the social environment is important [1, 55]. Existing research has focused mainly on how transitions are experienced by individuals without considering how these are embedded within and influenced by society [1]. In the present study self-efficacy was clearly affected by the social support. Family and friends, the workplace, and various authorities helped to shape self-efficacy. Several participants described frustrating experiences through not being understood in their contact with different authorities. In a qualitative study, it was found that it is important that both the clinicians, in this case, occupational therapists and physiotherapists, and the individuals on sick leave agreed on the objectives for their rehabilitation [56]. For clinicians, it was important to identify problems in order to create concrete goals. For the individuals on sick leave, it was important that the objectives and strategies for achieving such goals were consistent with their own understanding of their health and life situation [56]. Although clinicians and the individuals on sick leave had different perspectives, it was important to try to understand each other [56]. This is also supported in the present study. The finding is consistent with the key premise of occupational therapy being client-centred [3]. Another qualitative study examined the ways different authorities in Sweden cooperated in terms of individuals’ return to work [57]. This was conducted by studying the meetings attended by authorities, employers, and the individual concerned. It appeared that the meetings strengthened organisational boundaries rather than overcoming them and discussions were more about the different organisations’ needs than those concerning the individual. The results show the difficulties of the various actors in the Swedish welfare system to work, based on a holistic perspective and in jointly sharing the social responsibility of the individual on sick leave [57].
Strengths and limitations of the study
The phenomenological perspective presented an opportunity to deepen the understanding of and examine the underlying assumptions of the RTWSE. The perspective created the conditions for capturing the ambiguous and subjective meanings contained in the RTWSE and how it is shaped in interaction with the life-world [39].
In all research the credibility of the result needs to be tested. In order to create a credible record of this study the ambition was to describe every step of the research process as clearly as possible. The self-reflective stance advocated within phenomenology is important but also difficult and it has been critical to provide room for reflection [58]. To increase the credibility, the analysis was carried out by the authors in close collaboration and regular discussions with colleagues in seminars.
A limitation of the study is that only Swedish-speaking people were able to participate. One individual, however, had an immigrant background.
The sample was heterogeneous in terms of age, background and professions which was desirable in order to obtain a variety of views and to reflect different experiences of the RTWSE. A rich variation in data is more important than the number of participants and the data collected achieved this goal [59]. The majority of the individuals were female, possibly more men could have participated to strike an equal balance.
Regarding the implementation of the interviews, it has been a strength that the author, conducted and transcribed them. This has created an increased familiarity with the interview material, regarding not only what is said but also how it is said.
Conclusions
RTWSE is a global phenomenon that reflects the individual’s experience of vital parts of its life-world. Understanding RTWSE enables professionals to get an overall picture of the individual’s experience of returning to work.
Rehabilitation efforts need to be directed both on the individual level and in the social environment, this is in line with existing knowledge. In addition to existing knowledge the present study indicates that the individual level concerns strengthening self-efficacy by targeting working capacity, regaining an active and fulfilling life alongside control and autonomy. The social environment also needs to be incorporated in order to strengthen RTWSE. These findings derive from the individual’s perspective.
To understand RTWSE and to be able to work with it, further research is needed. An interdisciplinary research, with both quantitative and qualitative methods that explore the process of returning to work and the many elements that are affected is an interesting challenge for future research.
Conflict of interest
The authors report no declarations of interest. This study was supported by a grant from the Centre for Research and Development of Gothenburg and southern Bohuslän, Sweden.
Footnotes
Acknowledgments
The authors wish to thank the participants for their time and willingness to share their experiences.