Insurers’ perspective on barriers and facilitators for return to work after occupational injuries

Abstract

BACKGROUND:

Despite the importance of the legislative and insurance systems in the return to work process after an occupational injury, the perspective of the insurer on what influences return to work has rarely been documented.

OBJECTIVE:

To understand the barriers or facilitators for return to work, from the perspective of the insurer.

METHODS:

A comprehensive qualitative approach was used. Semi-directed interviews were done with nineteen (19) insurers (claims adjudicator and rehabilitation case manager) from a Canadian workers’ compensation board. A thematic analysis was done using QDA Minor Software.

RESULTS:

Fourteen themes (e.g. family reaction, quality of work relationship) were classified into four categories representing the main stakeholders: worker with disability, workplace, healthcare system and compensation system. Emotional, cognitive, and adaptive reactions from the worker and his family were identified. We observed that good work relations and support practices, lack of access to medical resources, focus on the employee’s ability, and complexity and consequences of the compensation process are the main barriers and facilitators from the insurers’ perspective. Many of the perceived elements are coherent with the compensation system’s administrative and legal context.

CONCLUSIONS:

The results enable us to better understand the insurers’ perspective regarding what influences return to work. It reinforces the necessity to consider the administrative and legal context to better understand the insurers’ perspective.

Keywords

Qualitative research workers’ compensation insurance work disability return to work

1 Introduction

Work disability after an occupational injury can lead to negative consequences for the employee and his family, but also for the employer and the society [1 –5]. From a financial point of view, according to the International Labor Organization [2], the direct and indirect costs related to occupational injuries represent 4% of GDP, worldwide. Also, the compensation and rehabilitation process can be a significant source of financial insecurity, stress, and suffering for the employee [1, 6]. Due to the significant consequences of being unable to work, it is important to better understand the elements that promote or delay return to work.

According to Schultz et al. [7], the main factors mediating the relationship between impairment, disability and return to work that come out of empirical studies on the subject are linked to individual resources and workplace-related factors. Likewise, evidence adds up, suggesting that the factors that hinder or promote return to work after low-back pain and common mental disorders are mainly linked to personal and work-related psychosocial factors [8, 9] and to illness [9]. Among the individual factors, strong evidence was found to the effect that the employees’ recovery expectations and the self-reported pain influence return to work for employees with acute low back pain [10], positive expectations concerning return-to-work consistently predicted earlier return for employees with common mental disorders [9] whereas for organizational factors, lack of social support at work, a physically demanding job, as well as little latitude would be strong predictive factors of disability across health conditions [11]. Also, the context of each system, as well as the political, financial, and legal contexts, are increasingly considered to better understand what influences return to work [12 –15]. Overall, the empirical evidence converges toward the fact that return to work is linked with psychosocial, workplace, social, and societal factors [16]. Moreover, this knowledge encourages consideration, not only of the employee, but also of the many stakeholders involved in the return to work process [17].

Since the early 2000s, with the development of the disability paradigm shift [18, 19], taking into account the four main stakeholders involved with the employee, has broadened the understanding of what influences return to work. Many empirical studies try to better understand the barriers and facilitators that are present during the return to work process, by documenting their specific perspective with qualitative methods [20]. Some studies show that the stakeholders’ perspective on return to work is influenced by their role, actions and goals [12 , 21]. Those researches have shown that, although the stakeholders want a return to work, other goals are also set, such as aligning rehabilitation services with current laws, as well as financial demands[12 , 22].

Whereas the compensation system and its stakeholder perspectives are in several studies [1 , 23], very few have documented what the compensation board players think about what actually affects return to work. Some have included it in a multiplayers sample, others study their interventions [24, 25] or their roles, competencies, activities, and the challenges they face [21 , 26–28], while others study the compensation board players from a “disability regardless of cause” system [29]. Although these studies are relevant, few present the unique perspective of players from a compensation board using a “cause-based” system [23]. Furthermore, these results must be used with precaution, considering the specific nature of each compensation system feature [30].

Compensation systems are well-known in literature for being key players in the return to work process. They cover a wide range of compensation, rehabilitation and return to work rules and processes [31, 32]. Their main concern is to facilitate return to work, minimize the financial and human costs of the disability, and reduce the risk of prolonged disability [21, 33]. As highlighted by Lippel [31], the “cause-based systems”, notably present in Anglo-Saxon jurisdictions as in Canada, U.S. and Australia, generally share some common characteristics, although each region has its own jurisdiction. Based on a “no-fault” insurance system, the accident is accepted as a normal fact, and access to compensation does not require proof of the employer being at fault. The injury must have occurred out of, or during the course of normal work to be compensated. The amount of compensation is based on the pre-injury salary.

In Canada, each province has a public organization that administers the rehabilitation and compensation program, the workers’ compensation board (WCB) [31]. Return to pre-injury work conditions is the primary goal. These organizations are in charge of receiving premiums from employers, distributing benefits to workers, and managing the rehabilitation process for occupational injuries (care, rehabilitation, and payment of compensation).

In the province of Quebec (Canada), this organization has exclusive authority to apply procedures and make decisions based on the law [34]. The employer, who is a key player, must keep the employee’s job available for a determined amount of time, and cooperate with the employee’s return to work process [31]. The right to return to work ensures that the employee keep his usual or an equivalent position, or another appropriate job, available within the company. All decisions made by the insurer can be appealed by the employee or the employer (e.g. internal review, external appeal board).

The conceptual framework of this study is based on the case-management ecological model [18, 19]. According to this model, the disability situation is a complex phenomenon influenced by the different stakeholders (patient, healthcare providers, workplace, insurer, etc.) from major systems involved during the return to work process. This model makes it possible to situate the insurer’s perspective regarding the professional and institutional context linked to the compensation system. It also situates their point of view regarding a dynamic process involving the other players and the systems with which they work throughout the process. Also, like many studies [7 , 35], return to work is conceptualized in this article, as proposed by Young and al. [36], not only as an evolving process that includes the outcomes (ex. return to work in the pre-injury work environment) but also as a “dynamic process involving multiple phases and encompassing a range of actions and related outcomes that are of varying interest to stakeholder groups”. This concept helps consider the diverse and evolving aspect of the insurer’s interventions and goals, specifically those linked to compensation and to return to work practices throughout the process.

Considering the importance of the role of the workers’ compensation board during the return to work process, as well as its legal and administrative contexts, our premise is that insurers have interesting and specific knowledge and understanding related to what influences the process during return to work, especially regarding legislative, administrative, and rehabilitation interventions, and considering that their actions are related to other main stakeholders. In this sense, their perspective can contribute to shed light on the obstacles and facilitators that have not yet been mentioned much in literature. The goal of this study is to better understand what can facilitate or hinder return to work after an occupational injury, from the perspective of workers’ compensation board players, regarding their actions in their specific context during the return to workprocess.

2 Methodology

This study uses a comprehensive qualitative approach [37, 38]. This epistemological approach is characterized by the study of the phenomenon from the participant’s subjective perspective. It is based on the postulate that human and social phenomena are meaningful for everyone. The comprehensive approach aims at understanding the participant’s context as well as his social and personal characteristics. It therefore doesn’t aim at identifying explanatory causes, but at understanding the phenomenon from the participant’s perspective [39]. This contextualization process is still used for the treatment and analysis of interviews. This type of analysis is inspired by the iteration principles of the grounded theory data analysis process [40]. It allows a comparison between data collection and analysis to ensure coherence and an adequate representation of the results with the data. This method puts the investigator in a comprehensive position where categorization changes throughout the process. In this study, the comprehensive approach provides a better understanding of the participants’ perspectives concerning what influences the return to work process from the perspective of their work experience in the unique legislative and administrative context of a workers’ compensation board.

The sample is made up of claim adjudicators and rehabilitation case managers (named in the present study “insurer”) from a WCB (Quebec, Canada). These players were chosen because they have a key role in the return to work process in a legislated compensation system. They are directly involved in the compensation and return to work practices and they work with the main stakeholders (employee, the employer, and the healthcare providers) [41 –44]. Also, access to the population has been facilitated by another large study already taking place, led by some authors [45]. This large study used a sample of claim adjudicators and rehabilitation case managers involved with risk prolonged disability files. For this large study, they were selected for a qualitative part because of their previous participation from the initial quantitative part of the large study protocol [45]. After an agreement with the organization, the objective of the present study has been added to the large study protocol (qualitative part).

A convenience sampling model is preferred to select participants. After sending out an information document to the regional offices of the WCB, the organization sent a list of volunteers to the research team. Two people proposed their services after having been informed of the study by colleagues. Volunteers were contacted by telephone. Twenty people agreed to participate. Two inclusion criteria were used to select participants: 1) having one year of experience or more in the occupied position; 2) working on at risk files “with link to employer”. One participant was excluded from the analysis since he worked only on files “without link to the employer”. The final sample used for analysis consisted of 19 people (n = 19).

Semi-structured interviews took place from November 2013 to February 2014. All interviews were conducted in French. They enabled a better understanding, based on the point of view and the sense that the participant gives to the situation, while taking into account the participant’s context [46]. A team of two, composed of a claims adjudicator and a rehabilitation case manager, treats employee files. Interviews were held with one (n = 3) or both (n = 16) members of the team per the participant’s availability or preference. All interviews were held by videoconference, as participants were spread throughout a vast territory.

The research team created the interview guide. An initial question enabled us to better understand the participants’ work and professional environment. Two general and descriptive questions enabled us to understand their point of view on what can facilitate or hinder return to work. Then, two sub-questions enabled us to explore which can influence the return to work from the focus of their interactions with the main actors and a last sub-question enabled us to explore solutions to obstacles and possible improvements to return to work process. This article focuses exclusively on the analysis of the general objective of the study of what can facilitate or hinder return to work. During the interviews, clarifying sub-questions and reformulations enabled us to dig deeper and be more precise. At the end of the interview, participants were invited to add elements that were not, or barely mentioned. Finally, socio-demographic data was compiled. The interviews lasted between 70 to 90 minutes.

A pre-test of the interview guide was conducted [46, 47] with four participants (two interviews), i.e. 21% of the total sample. Comments on how the interview went, as well as about the guide, were collected. No significant changes were made to the initial interview guide. These interviews were kept for analysis.

The interviews were transcribed ensuring participant anonymity. The first author did a thematic analysis using QDA Minor software (version 4.0.12). Thematic analysis [39] allows to categorize the data into themes representative of the participants’ perspective. First, in a discursive examination, the main elements named by the participants are identified, and second, we establish parallels, complementarities, oppositions or divergences between the themes. Finally, the panorama of themes materializes in the form of a thematic tree. Continuous thematization was preferred to obtain a rich and detailed analysis [39]. Verbatim transcription was done using an ascending method, i.e. from themes to sections, with a focus on naming the themes rather than on classification [39]. The verbatim transcription is themed to ensure an exhaustive analysis. The analysis focused on the peculiar perspective of participants about what influences return to work.

Based on the conceptual framework, thematization places themes into four categories: employee’s system and personal coping skills; work environment and system players; healthcare system and major players; and workers’ compensation system. For example, the section on work environment categorizes the themes associated with the employee’s pre-injury work environment, including work conditions, union aspects and administrative measures to facilitate return to work. This section helps categorize the themes relating to the work environment players (e.g. supervisor, colleagues, union), including work relations, attitudes and actions of actors perceived by the insurer as having an influence on return to work.

Throughout data collection and analysis, there were meetings with the research team comprised of researchers from various disciplines, to solicit their reactions about preliminary results. Subsequent interviews made it possible to develop certain emerging themes and to verify the plausibility of preliminary analyses with participants. Checking data collection with thematic analyses increased the quality of data, their interpretation, and their comparison to existing literature [48], and ensure data saturation [49].

3 Results

3.1 Participants’ characteristics

Table 1 reports the characteristics of the participants. Nineteen (19) participants were interviewed, mostly women (n = 18∖19); aged 45 and under (n = 16∖19) and having between 1 and 6 years’ work experience (15∖19). Participants were from different administrative areas, with approximately 37% (n = 7/19) from an urban area.

Table 1
Participants’ characteristics

Claims adjudicator (n = 8) Rehabilitation case manager (n = 11) Total (N = 19)

Sex

Men 0 1 1

Women 8 10 18

Age

25 to 35 years 4 8 12

36 to 45 years 3 1 4

46 to 55 years 1 0 1

56 to 65 years 0 2 2

(33.6) [7.0] (37.6) [11.5] (35.9) [9.9]

Professional experience in current position

Less than 3 years 6 3 9

3 years to less than 6 years 1 5 6

6 years and more 1 3 4

(2.9) [1.9] (4.5) [3.5] (3.8) [3.0]

	Claims adjudicator (n = 8)	Rehabilitation case manager (n = 11)	Total (N = 19)
Sex
Men	0	1	1
Women	8	10	18
Age
25 to 35 years	4	8	12
36 to 45 years	3	1	4
46 to 55 years	1	0	1
56 to 65 years	0	2	2
	(33.6) [7.0]	(37.6) [11.5]	(35.9) [9.9]
Professional experience in current position
Less than 3 years	6	3	9
3 years to less than 6 years	1	5	6
6 years and more	1	3	4
	(2.9) [1.9]	(4.5) [3.5]	(3.8) [3.0]

Notes: (mean) and [standard deviation].

3.2 Elements influencing return to work

Fourteen themes that influence return to work were identified. The following results report these fourteen themes from the perspective of insurer representatives. Each theme is described with sub-themes and verbatim. Results are summarized in Table 2 with themes for each main stakeholder and their system. The sub-themes representing barriers and facilitators are underlined in the results section. Each quote cited in this article has been translated from French to English by the authors.

Table 2
Synthesis of main themes influencing return to work from the insurer’s perspective

Categories Themes influencing return to work

Employee’s system and personal coping skills • Emotional and cognitive reactions

• Problems and stressful events in personal life

• Family reactions

• Importance of working

• Coping strategies

• Socio-professional and socio-demographic characteristics

Work environment and the system players • Quality of work relationships

• Culture and management practices

• Work characteristics

• Safety group

Healthcare system and its major players • Messages or interventions

• Medical and professional resources

Workers’ compensation system • Compensation

• Work-injury process

Categories	Themes influencing return to work
Employee’s system and personal coping skills	• Emotional and cognitive reactions
	• Problems and stressful events in personal life
	• Family reactions
	• Importance of working
	• Coping strategies
	• Socio-professional and socio-demographic characteristics
Work environment and the system players	• Quality of work relationships
	• Culture and management practices
	• Work characteristics
	• Safety group
Healthcare system and its major players	• Messages or interventions
	• Medical and professional resources
Workers’ compensation system	• Compensation
	• Work-injury process

3.2.1 Elements linked to the employee’s system and personal coping skills

3.2.1.1 Employee’s emotional and cognitive reactions

For several insurers, when the employee feels pain or is worried about increasing his pain or his injury, this can make it more difficult to return to work-related activities, including temporary assignment1 [50] or rehabilitation activities. Insurers use different terms for what facilitates return to work when in the presence of pain: learning to manage pain, pushing oneself, doing physical therapy exercises, facing the pain head on, pushing past the pain, keeping a certain number of activities, living with pain, and staying active.

Some insurers believe that an employee who feels unable to return to work, even before his return to work assessment is completed, is a major obstacle to the process. They explain that the link with the employer can weaken, the employee can lose confidence in his ability to work and be less involved in his physical and professional rehabilitation. Some insurers report that the employee’s worries about his injury (overestimating the seriousness of the injury, anticipating serious consequences, not understanding medical aspects) can also slow down the return to work process.

Some insurers will mention how difficult it is to intervene to facilitate return to work when the employee expresses resentment toward a situation that he sees as unfair. For example, an employee can think that his employer is responsible for his accident because of negligence regarding work health and safety. Interventions aiming at a return to pre-injury work conditions and requiring the employee and the employer’s collaboration will then be more difficult to put in place because of the employee’s fears regarding his safety or his deteriorating relationship with his employer.

3.2.1.2 Problems and stressful events in personal life

For many insurers, comorbidity can contribute to slow down the return to work process. These employees can have more difficulty functioning within the system’s intricacies, to mobilize, and take part in the necessary steps to ensure their recovery and facilitate return to work.

Previous depressions, burnout, etc. These are major risk factors. They are already more fragile, and an additional challenge is added to the rest (Insurer 17)

Also, for some insurers, family problems that occur during the return to work process (or that sometimes stem from it), such as separation or illness of a family member, can hinder the return to workprocess.

3.2.1.3 Family reactions

Some insurers say that they try to be aware of what the employee’s family members say, as well as their attitudes (spouse, parents, friends, etc.) to better understand what can influence return to work. Particularly, certain family members can encourage the employee to move or to return to work, whereas others can be afraid that he may worsen his injury. Family members can have a negative effect on the level of confidence between the employee and the insurer or to get information.

He [the spouse] will comment during the interview. “You don’t have to answer that.” He will hinder this relationship of trust, I think. He will often redirect questions. Or prevent us from getting the information that we need. (Insurer 11)

However, the family’s support during the return to work process seems to facilitate things. Insurers mention that certain family members will listen to the employee, and encourage him during treatment, or make sure that he doesn’t isolate himself.

3.2.1.4 Importance of working for the employee

Most insurers agree that when work holds a positive and important place in the employee’s life, this can facilitate return to work. When the employee likes his job, and values his roles as an employee, he will be more active and involved during the process, to facilitate his rehabilitation and return to work. Conversely, an employee who lacks interest for the position he held at the time of the injury is an element that can hinder return to work. Some insurers notice a lack of interest in some situations such difficult work conditions (monotonous work, unrewarding, demanding), work that is considered as temporary by the employee (example: student) or pre-injury work that does not reflect the employee’s professional goals.

Also, certain insurers consider that the employee can develop a lifestyle desynchronized from work demands, i.e. the longer the absence lasts, the more the employee’s active lifestyle slows down. The social roles that are preferred by the employee will change. For certain insurers, the employee can develop other habits during his absence from work, without him realizing this, such as taking on household chores and family-related tasks, seeing friends during the day, waking, and going to bed late, etc. This desynchronization can require extra effort when the employee returns to work, thus slowing down the process.

It’s insidious, and sneaky. Sometimes, we tell our workers “do you realize that for three months, you’ve been getting up at 10 o’clock?”. We make them realize that, sometimes, they can’t even see it themselves. (Insurer 8).

3.2.1.5 Employee’s coping strategies

Certain insurers believe that an employee who is active and proactive during the return to work process will facilitate things by influencing details regarding treatment and by being involved in the different aspects of his rehabilitation. For example, some insurers explained that certain employees take care of their own follow-up with healthcare providers during the process or contact their employer directly to implement certain temporary measures for return to work. Many insurers describe the active and proactive employee as follows: is active, takes charge, stays informed, contacts the healthcare providers, is active at home, motivated and involved in his rehabilitation. Conversely, a passive employee will tend to slow down the return to work process for certain insurers. A passive employee is described as letting other players who are involved in the return to work process take charge, while not being very involved in his own treatment plan.

3.2.1.6 Employee’s socio-professional and socio-demographic characteristics

When a return to pre-injury work is not possible, it seems that certain socio-professional and socio-demographic characteristics, such as a limited level of education, a unique work experience, manual skills, advanced age, as well as difficulty to communicate in French, can negatively affect the employee’s level of employability or the training potential, and can make it difficult to integrate him into a new job.

3.2.2 Elements linked to the work environment and to the system players

3.2.2.1 Quality of work relationships

Most insurers mention the quality of the relationship between the employee, the employer, and colleagues as having an important effect on return to work. Insurers explain that a conflictual relationship with the employer and colleagues will complicate the insurers’ efforts to facilitate return to work. Seniority and a good work performance are elements that facilitate a quality work relationship and help in the implementation of measures facilitating return to work.

Some things said by the employer and colleagues during the employee’s absence can seem inconsequential and humorous. However, insurers explain that these declarations can increase the employee’s feeling that his injury, accident, or the legitimacy of the duration of his absence may raise certain doubts. These types of situations can lead to tense work relations.

When an employee has been bringing in his papers every six months and someone says “Well, why are you such a baby (fragile)?” or things to that effect, as time goes on, the more damage it can do [...] because it creates tension. This is not a regular thing, but we still witness colleagues judging the actions of injured employees. (Insurer 8).

Concerning the legitimacy of the absence, some insurers noticed that doubt expressed by the employer can lead to a medical-legal process. When this happens, some insurers notice a deterioration in the relationship of trust between the employer and the employee.

3.2.2.2 Culture and management practices in the work environment

An open culture with flexibility and support from the employer regarding measures facilitating return to work is an element that is mentioned by certain insurers. For example, the employer can adjust the job description so that the employee can progressively return to his work environment. Some management practices for return to work seem to contribute to maintaining good communication and a relationship of trust between the employer and the employee, two elements that facilitate return to work, for theinsurers.

And when the employer’s follow-up is not simply “OK, you have your doctor’s papers to justify your absence.” When it’s more “But, how are you?” There appears to be a true concern. This can make all the difference for the employee. (Insurer 10)

However, some insurers mentioned that a lack of openness and flexibility on the employer’s part could slow down the return to work process. For the insurers, a conflictual relationship between the employer and the employee can explain this, as well as a management style that focuses mostly on financial aspects.

Lack of support and solidarity from colleagues, especially when temporary solutions are implemented, was reported a few times as a factor that slows down the return to work process. Misunderstanding of temporary return to work solutions by colleagues, as well as preconceived ideas about the disability, seem to produce tension in the work environment, as well as a feeling of injustice from colleagues in terms of task assignation. A competitive attitude at work was also mentioned as potentially compromising solidarity and support amid coworkers.

3.2.2.3 Work characteristics

A few insurers mentioned that some of the employee’s work characteristics do not help the implementation of measures facilitating return to work. These unfavorable elements can take on different forms: a work environment that is far from the employee’s residence, a work environment that offers little job variety and/or the available positions are incompatible with the employee’s functional limitations, or the work is seasonal. These work characteristics seem to delay the moment where the employee can progressively take on certain tasks, therefore slowing down his return to work.

3.2.2.4 Safety group

For insurers, several similarities regarding vision, objectives and functioning exist between safety grousp2 [51] and the WCB. These similarities can promote return to work. Notably, safety groups can promote temporary assignment measures to the employer. And thanks to their knowledge of the return to work process, safety group insurers can inform the employer of current rules and regulations, thus encouraging the employer’s commitment to measures facilitating return to work. However, for some insurers, safety groups can also sometimes complicate managing the return to work process by acting as an intermediary between the employer and the WCB, or by using a management method that privileges using medical-legal processes.

3.2.3 Elements linked to the healthcare system and to its major players

3.2.3.1 Messages or interventions

Divergent messages about the required interventions received from the insurer and the healthcare providers are described as possibly influencing the return to work process. For example, several insurers use lingo that is based on the employee’s ability, rather than impairment. Insurers explain that they foster interventions that mobilize and activate the employee toward returning to his professional activities. One participant describes the importance of explaining to an employee “that it is not because I have a disability that I don’t have skills” (Insurer 13) to facilitate return to work. However, it seems difficult to stick to this message when certain healthcare providers sometimes use an approach that focuses more on the disability itself or on the therapeutic process. Some insurers explain that prolonged medical exams or therapeutic treatments prescribed by the treating physician, although useful or necessary during return to work, can contribute to keep the employee in a passive state as, for example, regarding taking actions to facilitate his return to work, reinforce his perception of being disabled, or develop the belief that all pain must be gone before returning to work.

Some messages from healthcare providers can make interventions by the insurer aimed at mobilizing the employee toward a return to work more difficult. It may require the use of a second medical opinion or a workplace visit with an occupational therapist to analyze possible interventions with regard to physicians’ opinions to promote return to work.

Because, as soon as we suggest things, whether it’s a temporary assignment or a progressive return plan, they will say: “My doctor told me that I was disabled and should change careers”. [...] We must work much harder to convince the patient. And it doesn’t always work. We must get a second medical opinion that will help counteract the situation. And even then, we face delays and costs. (Insurer 2)

For some, these situations contribute to a lack of unified message from the insurer and the healthcare provider and can create confusion for the employee. This confusion can make a return to work intervention more difficult, notably to a pre-injury position.

Because if the messages are different, and we’re not headed in the same direction, this can be confusing for the employee, as well. And we won’t achieve the expected results. The objective must be known to all concerned. If we are working toward returning to a temporary assignment, a gradual return or something else, this must be clearly stated and understood. (Insurer 3).

3.2.3.2 Medical and professional resources

Some insurers mentioned that difficult access to certain medical resources could lead to delays and a lack of follow-up. Some employees live in rural areas and must travel to the city to seek treatment or see a specialist. Many insurers agree that not having a family doctor complicates the employee’s process. For example, an employee who has no family doctor has no “stable medical follow-up plan” (Insurer 15) or “logical sequence” (Insurer 2) in his file. The lack of time in the medical consultation for some insurers can reduce the quality of follow-up with the employee, especially upon re-entering the work environment. This lack of time can limit the information received from the physician, which can lead to a misinterpretation of the medical situation by the employee.

The lack of medical resources can also lead to delays in the access to treatment, or to assess the employee’s health status. These delays increase the length of the employee’s absence. Insurers notice that this can also slow down the implementation of measures facilitating the employee’s physical and professional rehabilitation, thus slowing down return to work. Insurers notice that these situations can create frustration and a feeling of helplessness in the employee, the employer, and the WCB insurer. When facing a lack of medical resources and important delays, a few participants have mentioned that seeking medical treatment (ex.: surgery, magnetic resonance, medical tests) in the private sector (ex.: an employer who pays for a medical test) for certain cases can sometimes speed up the return to work process, although turning to the private sector is not encouraged by the compensation board.

Finally, a few insurers have mentioned the effect of having professional service contracts with organizations or healthcare professionals (ex.: rehabilitation clinic, psychologist, physical therapist, guidance counselor, etc.) during the return to work process. A participant explains that a “good resource” can efficiently facilitate return to work. Some participants explained that they have more control with these contracts over the choice of interventions and goals. Also, a positive collaboration, encouraging information exchange, can be established when regular service contracts are taken with an organization or a professional. For example, they can require regular follow-ups and establish intervention goals that align with those of the compensationboard.

It usually makes things quite easy, because we oversee the service. We set the goals. I think that what’s important about that is to always ensure a regular follow-up on operations (Insurer 11).

3.2.4 Elements linked to the workers’ compensation system

3.2.4.1 Compensation

Some insurers agree that the amount of compensation afforded to the employee can influence his motivation to return to work. This element refers to current compensation rules under studied system. The amount of compensation afforded to each employee is calculated according to different criteria such as the family situation, salary, and the minimum and maximum insurable amounts [34 , 53]. For example, some insurers have noticed that when an employee held a paid part-time minimum-wage job at the time of injury, he can obtain compensation that is equivalent or superior to his pre-injury salary [54]. However, compensation lower to a high pre-injury salary is mentioned as possibly encouraging return towork.

3.2.4.2 Work-injury process

The complexity of the compensation process can lead to a misunderstanding of measures, rights, obligations, and possible interventions for some stakeholders (ex.: the employee, healthcare providers, employer, etc.). Furthermore, for some insurers, employees with a lower level of education and who don’t have a sufficient grasp of French seem to have more difficulty understanding how the WCB functions. Some insurers have mentioned that a misunderstanding of the system, as well as disinformation, can cause the employee to worry and be wary during the process, and develop a negative view of the WCB. When faced with this lack of comprehension of the process by the stakeholders involved, some insurers say that they will try to explain the system, and supply information to facilitate the process.

Finally, a few participants explain how the medical-legal process can be useful to obtain information to facilitate return to work. However, some insurers mention that these measures can also sometimes hinder the process. Some insurers explain that medical-legal processes can slow things down and create delays, by degrading work relations and affecting the employee’s morale. The negative effects on the employee are described in these terms by insurers: the employee can feel that he is perceived as a liar; the employee is “hurt” and frustrated; he feels betrayed; and feel anxious.

We currently have an employee who loves her job. She is ready to return to work. But her ability to return to work is disputed. She was evaluated. [...] And she was sent to be evaluated again. The employee became extremely upset about this situation, and was recently hospitalized because it was too much for her to handle. (Insurer 19).

Some insurers have noticed that the employee seems to be less open to returning to his pre-injury work situation after a complex medical-legal process (e.g. second medical opinions, external appeal) because of mistrust towards the employer. When this occurs, it is important to be tactful to ensure collaboration and to maintain a good relationship, despite these processes.

At times, the employer or the safety group will contest certain decisions. The worker will see this as negative. It is often necessary to intervene and explain in such situations. Because there are certain safety group that contest all decisions systematically. Therefore, by explaining to the worker that this is an administrative process, sometimes this will work. But disputes can slow things down and throw fuel on the fire (Insurer 14)

These medical-legal processes can lead to medical assessments that don’t mainly have a therapeutic goal for the worker. For example, some mention that processes can be started by the employer for administrative or financial reasons (e.g. aiming at reducing compensation costs). The insurer can startmedical-legal processes to ensure that the return to work corresponds to the requirements of the jurisdiction within which compensation and rehabilitation are offered (e.g. disputing a diagnosis or consolidation) or gathering information to accelerate interventions because of a lack of communication with the worker or treating physician.

4 Discussion

This article presents the point of view of Canadian WCB insurers on what influences return to work. Analysis of results rests upon the case-management ecological model [18, 19] that highlights the importance of the different stakeholders and their systems and the interactions between stakeholders during the process. In this sense, results from this study make it possible to better understand the point of view of a WCB insurers characterized by a specific legal and administrative context.

4.1 Emotional, cognitive, and adaptive reactions from the employee and his family

Many elements identified by the insurers are logically linked to the empirical results and systematic reviews of disability predictive factors. In particular, the employee’s expectations regarding his inability to return to work [55], expectations of recovery [10, 56], satisfaction in regards to his work [10 , 58], age [56, 58], language [59, 60] and the presence of comorbidities [58]. In the current study, language was mentioned by the insurers as reducing employability as well as the ability to understand the complex compensation process. Having difficulty with the language used in the workplace is mentioned by the insurer and migrant workers in a few studies [1, 60]. These difficulties can lead to delays when managing compensation files for migrant clients, can reduce the worker’s employability, while making it more difficult for the worker to understand the complex compensation process.

Results show that insurers believe that the attitude of the employee’s family is significant during this process. However, in a systematic review led by Prang et al. [61], no significant link between family support and return to work was shown. To our knowledge, although certain studies have analyzed the effect of the disability and the compensation process on the family [1, 62], only one study focused specifically at the roles and attitudes of family members as factors related to return to work [63]. The study by Kosny [63] puts an emphasis on the family’s significant role during the compensation process, although this role is not formally considered by the compensation board. Results of the current study are in agreement with the importance of the family’s role and highlight the fact that the insurer will consider this aspect during the compensation process. The few studies focusing on this aspect of the compensation system, and the specific Quebec compensation context and administration, where family seems to be considered by the insurer during the process, could explain this misunderstanding of the family’s influence on return to work.

Some insurers have mentioned that employees sometimes seem to take on habits, and value other aspects or life roles than the role of “employee”, moving them away from the habit of going to work. Fougeyrollas and Roy [64] say that the disabled employee will choose a role according to his needs and context, so that he can take an active part in society. Conversely, the experience of work disability can cause social and professional disruption [1 , 66]. In particular, these difficulties can lead to questions about the significance of work compared to other areas of life, such as family and personal life [67].

In the current study, insurers mention the importance of “work values” and an “employee identity” as elements facilitating return to work. However, some studies show that the importance of work in an employee’s life is a predictive factor for return to work [56]. On this subject, Morin [68] mentions that the value of work is encouraged in an organizational context where human values are present and where the manager puts management practices in place to promote the personnel’s health, confidence and dignity. Positive social relationships at work can be added to these organizational elements. These elements are similar to the sense of belonging to the organization and positive relationships at work that were put into perspective by severalinsurers.

4.2 Work relations and management practices based on health and support

Many workplace characteristics identified by insurers are in line with the results of empirical studies on organizational determinants of return to work. A culture promoting employee health and support, specifically by showing openness and flexibility for accommodation measures, seems to facilitate return to work [69 –73]. Indeed, this type of culture would encourage the employer’s and colleagues’ active participation in the implementation of said measures [69, 70]. Furthermore, studies have shown the importance of accommodation measures, particularly temporary assignments and changes in work conditions, to facilitate return to work [10 , 74].

In the current study, several insurers have explained the importance of support in the workplace upon returning to work. The importance of this element stems from several studies [11 , 76]. In a systematic review, White et al. [11] have shown that the support of the employee’s colleagues and supervisor is a predictive factor of professional disability. However, according to Tjulin et al. [77], this support lasting longer than a few days depends on the colleagues’ willingness to take part in the return to work process [77]. Likewise, new forms of work organization and intensification can weaken the quality of work relationships, thus contributing to professional isolation, and influencing the type of support that the employee receives upon returning to work [78 –80]. These elements raise the importance of considering the relational and organizational aspects of work during the return to workprocess.

St-Arnaud et al. [81] state that the employee’s credibility and appreciation by his employer and colleagues could play a significant role. Likewise, medical-legal processes could reduce the level of trust between the workplace players and could have a negative effect on the quality of social interactions during the return to work process [1, 69]. In this sense, the presence of conflict or tension in the workplace before and during the period of absence could damage the relationships linking the employee and his work environment [57, 73]. In the current study, insurers have mentioned the complex interaction between the quality of work relations, maintenance of this link during the absence, and consequences on the sustainability of return to work.

4.3 Adequate access to medical resources

Some insurers have mentioned that difficult access to certain healthcare services and care, specifically for employees from rural areas, seems to make the return to work process more difficult. These elements are in line with the results of some studies [82] that show the influence of the employee’s area of residence on the return to work process [82, 83]. The type of industry and access to medical resources, as family physicians or specialists, are elements raised as possibly explaining these regional differences[82, 83].

4.4 Focus on the employee’s ability and to be active

In general, results of the analysis show that insurers believe that the employee who puts forth active strategies will facilitate his return to pre-injury work. On this matter, some reviews show that the employee who uses active strategies facilitate the return to work process [84, 85], as well as in his ability to solve problems [85].

The insurers’ description of an employee who is focused on getting back into action, proactive, and involved, is close to the definition in literature of the “contemporary patient” who is seen as autonomous, “a player in his own process”, informed, in charge of his recovery and health process [86 –88]. Wilson [89] mentions that the “good patient” is the one who is coherent with his healthcare providers, thus permitting a mutual level of understanding and less intervention time. Bureau and Herman-Mesfen [86] however mention that this belief can be motivated by other interests than the patient’s health, particularly the desire to delegate tasks. In the present study, for the insurers, these active employee attitudes seem to be ways to work on certain obstacles such as delays in healthcare services, or to facilitate the implementation of physical and professional rehabilitation measures, such as remaining physically active during their absence, or taking part in accommodation measures.

Some insurers explain the importance of encouraging the employee to be active despite a certain level of pain. In this sense, some believe that healthcare providers who encourage the employee to be active and return to his pre-injury work would encourage his return to work process. A study led by MacEachen et al. [90] reports on the practice of early return to work and the “harm versus hurt” principle. These investigators have concluded that this practice can affect the employee by resulting in a lack of awareness of the nature of his injury and his limitations. MacEachen et al. [91] further explain that moving toward a paradigm of ability can lead to neglect for certain aspects of the process, as well as to a lack of consideration of the personal experience of an employee with an injury. Finally, some studies [92, 93] have highlighted the lack of common message from insurers and healthcare providers, which influences the return to work process by creating a state of confusion for the employee.

4.5 Complexity and consequences of the compensation process

Concerning compensation amounts, some researchers have mentioned the influence of gains and losses (primary, secondary, and tertiary) linked to disability on motivation to return to work [65, 94]. A financial gain, help with household and family chores, as well as internal factors such as avoiding a conflictual work environment, could potentially slow down return to work [65]. It is important to mention that the amount of the compensation is linked to the administrative and legal context that is specific to the population studied, which tends to limit generalization of overcompensation as an element that may delay return to work, according to the insurers included in the current study.

The results from the current study shed more light on the influence of medical-legal disputes on return to work from the seldom studied perspective of the insurer. Whereas Lippel’s study [1] shows that the appeals process can sometimes be beneficial and therapeutic for the workers, the medical-legal disputes can also interfere with the recovery process by putting the employee in an inferior position compared to the WCB and the employer. Certain elements raised by the participants of our study in regard to these processes can be seen as causing delays, negatively affecting work relations, and having a detrimental effect on the workers. In the same sense, another study by Lippel [23] on the role of the doctors shows that the medical-legal process is seen as “artificially rigid” by doctors, and that they can feel stuck in the prescribed processes that don’t offer much worker support.

4.6 Insurers’ perspective coherent with the compensation system’s administrative and legal context

In general, analysis shows that although the elements mentioned by the insurers aim at a return to work, the main objective of the WCB, i.e. return to a pre-injury position, seems to influence their perception of what will facilitate or hinder the process. The employee and his family who want him to return to his pre-injury work, will actively work together towards reaching this goal, and will focus on the employee’s ability, which are elements that will facilitate the process. As for the work environment, management policies, as well as an employer and colleagues who support the employee and the implementation of accommodation measures are mentioned as facilitating elements. Healthcare providers who focus on the employee’s ability to return to pre-injury work also encourage return to work. Eakin et al. [22] shed light on the fact that insurers and WCB practices exist within a legal and political context. Insurers play a “disciplinary” role with employees and employers, by aligning their interventions with current laws. Consequently, they must consider certain imperatives that might influence their decisions, such as productivity, impartiality, and solvency. Also, Bernhard et al. [91] show how professional practices in disability management are affected by the legal context of their jurisdiction’s framework. These elements raise the importance of considering the legal and administrative context when studying the elements that influence return to work.

4.7 Strengths and limitations of the study

The main strength of this study is its systematic and continuous iterative analysis of themes on the entire sample, i.e. the exhaustive quality of the analysis and collected material, performed with other investigators. First, the inductive method chosen, making it possible to observe the elements of a system to generate representative themes of an insurer’s environment. In this sense, this study lets us explore a large variety of elements involved in the return to work process. Also, going back and forth between data collection and analysis, as well as the analyzed data itself, brings quality, probability and depth to the different interpretations [48]. This method makes it possible to prepare ulterior data collection using previously collected data, to obtain additional details to better understand the observed phenomenon and to verify the accuracy and plausibility of initial analyses. This method makes it possible to ensure credibility and transferability of study results [48]. Also, focusing on one specific region (with a homogeneous legal context) allows to improve understanding of this aspect on the populationobserved.

A certain caution should be taken when interpreting what was said during this study. First, considering the sample’s characteristics, results show what influences return to work for an employee who has an active link with his employer. It is possible that the results from a sample comprised of different types of insurers, such as the ones who work with files where there is no active employment link, could have produced different results. Also, adding a step to communicate preliminary results to the participants, as well as a double-coding performed by another investigator, could increase the validity of interpreted results [48].

Clay et al. [30] argue that the compensation system’s legal aspects are critical to a comprehensive understanding of the return to work process, and it is important to compare results from studies with different compensation systems. Because differences noticed between states/regions, especially in Canadian WCB, carefully comparison between different studies about insurers’ perspectives on the return to work process [23 , 31] is required. As proposed by Clay et al. [30], we have reported the main schemes of financial, structural and administrative aspects relevant to the specific compensation systems that are applicable to this study. Work performed by Lippel in Canadian WCB have highlighted the possible differences in perception of the various players in regard to the specifics Canadian provinces compensation systems. For example, Lippel highlighted the significant presence of safety groups in certain compensation system that seem to favor employer disputes in order to limit costs [1]. Another study by Lippel [23] shows the differences in roles play by doctors within compensation systems seems to affect relations between doctors, the insurer, and the workers. In the same sense, the rules regarding access to compensation lead to differences concerning the types of injuries that will be compensated by the insurers [95]. In line with the conclusions of these studies, we must contextualize that the barriers and facilitators as perceived by insurers may be a reflection of the compensation system in which they work.

5 Conclusion

The study’s main objective was to understand what influences return to work following a work-related injury from the insurer’s perspective. The themes named by these players that influence return to work, stem from four main systems and their players who are involved in the return to work process. Emotional, cognitive, and adaptive reactions from the employee and his family were identified. Work relations and management practices based on the employer and colleagues’ confidence, open-mindedness, flexibility, and support seem to facilitate the interventions aiming at a return to pre-injury work. Adequate access to medical resources and a message from the healthcare providers and WCB’s staff focusing on the employee’s ability seem to facilitate the return to work process put forth by the players involved. The complexity of the disability situations that the stakeholders must work with, and in the application of different organizational policies and procedures, seem to slow down the return to work process. In summary, what comes out of the analysis is that many elements perceived by the players as having an influence on return to work are coherent with the administrative and legal aspects of the compensation system. This study sheds light on the lack of knowledge about the WCB staff’s perspective, despite their important role in the return to work process. Mainly, this study reinforces the necessity to consider the administrative and legal context in which the involved players find themselves during the return to work process to better understand their perspective regarding what may facilitate or hinder the process.

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

The ethics and research committee of the Institut de réadaptation en déficience physique de Québec (IRDPQ) has approved this project. All procedures performed in this study were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Funding

This research was supported by a scholarship and is a part of a larger study funded by a grant (099-828) from the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST).

Footnotes

In Quebec (Canada), a temporary assignment is used by the Workers’ Compensation Board so that the employer can assign (with the consent of the treating physician) the employee to production tasks that will promote rehabilitation until he is ready to return to his pre-injury tasks, or another appropriate job. The employee will thus maintain the same salary and benefits of the pre-injury position.

A safety group (called mutuelle de prévention in French in Quebec (Canada)) is a group of employers who join a mutual administration to benefit from better rates and promote prevention, rehabilitation and the return to work after occupational injuries.

Acknowledgments

The authors wish to thank Marie-Ève Schmouth and the Centre interdisciplinaire de recherche en réadaptation et intégration sociale ( CIRRIS) team for assistance during the research.

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