Feasibility evaluation of a return-to-work program for workers with common mental disorders: Stakeholders’ perspectives

Abstract

OBJECTIVE:

This study aimed to evaluate the feasibility of a newly developed return-to-work program for workers with common mental disorders from the perspective of stakeholders (insurers, employers, unions, and workers).

METHODS:

We used a sequential mixed design. First, we conducted a survey to evaluate the levels of stakeholder agreement with the program’s feasibility. Second, we conducted a number of independent, homogeneous-group discussions or individual interviews to deepen stakeholders’ reflections and allow co-construction of a shared perspective of the program’s feasibility.

RESULTS:

Overall, the stakeholders (insurers (n = 6), employers (n = 7), unions (n = 8), and workers (n = 3)), agreed partly to totally with the feasibility of the specific/intermediate objectives, components/tasks, and duration of the components. They identified obstacles that could hinder program implementation. These obstacles pertained mainly to employers’ contexts, e.g., difficulty/impossibility of offering job accommodations. They also proposed facilitators to counteract most of these obstacles. Diverging views were found regarding both the role of union representatives and health professionals in the program, and for the duration of the components.

CONCLUSION:

Overall, the program was perceived as feasible to implement, provided that the potential factors discussed are taken into account. The next step will be to evaluate its implementation in real practice settings.

Keywords

disability workplace intervention stakeholder role program evaluation return-to-work sick leave.

1 Background

Sick leaves due to common mental disorders (CMDs) such as depressive-, anxiety-, trauma- and stress-related disorders account for nearly 30% of all compensation claims [1], and 25% of these leaves last more than six months [2]. Longer sick leaves are recognized as complex health problems that require specific intervention such as workplace interventions [3]. Effective workplace interventions are multi-domain interventions, i.e., interventions that include components of at least two of the three broad domains in work-disability prevention: (1) health-focused, (2) service coordination, and (3) work modification [3]. The Therapeutic Return-to-Work (TRW) Program, originally designed for workers at risk of prolonged sick leave due to musculoskeletal disorders, includes health-focused, service coordination, and work modification components [4]. Its adaptation to the CMD context has been recommended by Briand et al. [5], who acknowledged that the action mechanisms and components of the TRW Program were consistent with recommendations for facilitating the return-to-work of workers with CMDs [5]. Therefore, the TRW Program was adapted to the CMD context (TRW-CMD Program) based on knowledge acquired from both the scientific evidence and a consensus group of multidisciplinary health professional experts. This led to the production of detailed models (named “logic models”) of the TRW-CMD Program that reflect both theoretical and multidisciplinary health professionals’ perspectives [6].

The TRW-CMD Program qualifies as a “complex intervention” since it contains a number of interacting components, depends on the context, and involves –apart from workers and multidisciplinary health professionals –other stakeholders, namely insurers, employers, and union representatives [7]. Their involvement in the TRW-CMD Program implies recognition that their views of the return-to-work process may diverge and lead to diverse, even conflicting, perspectives [8 –10]. These divergences then have the potential to hinder implementation of the program in real practice settings and result in various documented implementation challenges such as communication difficulties between stakeholders and conflicting perceptions of roles [11 –14]. Aside from aspects related to the complexity of the TRW-CMD Program, its innovative nature represents another implementation challenge, as stakeholders might be less accustomed to the intervention than to usual care [13].

Factors related to stakeholder involvement may thus potentially undermine the program’s implementation in real practice settings [15], and it was therefore deemed advisable to investigate these factors beforehand by conducting a feasibility study [16, 17]. Feasibility studies are advocated at an early stage of the development of an intervention to improve its design and future implementation [17]. The feasibility of an intervention corresponds to its capacity to be operationalized in its own context [16]. Before implementing the TRW-CMD Program, the questions to be asked are “Are these specific/intermediate objectives feasible in real practice settings?” and “Can these components/tasks be implemented in real practice settings?” [16]. According to Bowen et al. [16], answering these questions will address one of the eight areas of focus of feasibility studies: implementation. For these authors, examining the implementation area of focus makes it possible to identify possible hindering or facilitating factors and to determine the resources needed for implementation [16]. Our feasibility study of the TRW-CMD Program therefore aimed at identifying the factors that should be taken into account before implementing the program in order to increase its implementation potential [16, 17].

The objective of this study was to evaluate the feasibility of the TRW-CMD Program from the stakeholder perspective. For this study, the term “stakeholder” included (unless otherwise specified) insurers, employers, union representatives and workers. The pursuit of this objective constituted the second step of a broader study, whose first step involved adapting the TRW-CMD Program from theoretical and multidisciplinary health professionals’ perspectives [6] and whose third step involved its implementation in real practice settings [18].

1.1 The TRW-CMD Program

The operational logic model of the TRW-CMD Program describes how it functions in terms of its four components and specifies the expected duration of each component [6]. Briefly, the first component is the Work Disability Diagnosis Interview (WoDDI), which consists in the initial evaluation of workers and serves to identify the main factors that contribute to prolonging sick leave. The second component is the Preparation for Therapeutic Return-to-Work (Preparation-TRW), which consists in setting up favorable conditions for the worker in the workplace. The third component, the Therapeutic Return-to-Work (TRW), aims at developing the worker’s working capacities in the workplace, while offering supportive coaching by a health professional. Finally, the Maintenance at Work (MAW) component is optional and is offered when the worker has returned to regular work, but still has difficulty applying the acquired knowledge and skills at work. The MAW is designed to help prevent relapses. The model also describes tasks that should be performed by health professionals during each component, in collaboration with workers and other stakeholders.

The theoretical logic model of the TRW-CMD Program shows its action mechanisms as well as its long-term goal and objectives [6]. The model is based on four interrelated specific objectives working together to “restore, develop and maintain the worker’s work performance and ensure that the prerequisites to the return-to-work are in place” (general objective). These four specific objectives are to “promote concerted action by the stakeholders and the worker,” “improve the worker’s work capacities,” “reduce the obstacles in the work environment,” and “consolidate the worker’s acquired knowledge and skills at work.” Three to six intermediate objectives are specified in the model for each specific objective.

2 Methods

2.1 Ethics statement

This study was approved on October 8, 2013 by the Research Ethics Committee of the Centre Hospitalier Universitaire de Sherbrooke (CHUS) in Sherbrooke, Quebec, Canada (project no. 13–154). All participants provided written informed consent.

2.2 Design of the study

We used a sequential mixed design [19] to evaluate the feasibility of the TRW-CMD Program from the stakeholder perspective. We adapted a two-phased approach that involved conducting: (1) a survey using a self-administered questionnaire, and (2) a number of independent and homogeneous-group discussions [20]. Group discussions potentially generate rich data by allowing co-construction of a shared group perspective [21]. In the event that a given group could not be formed, we planned instead to conduct an individual interview [22] with each participant of the intended group.

2.3 Participants

Four convenience samples were constituted. Workers were recruited by multidisciplinary health professional experts who had participated in a previous phase of the broader study [6]. The inclusion criterion was having completed a return-to-work process following a CMD-related sick leave of at least six months. Other stakeholders were recruited using various contact lists belonging to CAPRIT, a research unit of the research center at the Charles-Le Moyne Hospital affiliated with the Université de Sherbrooke (Quebec, Canada). The inclusion criteria for insurers were having a minimum of two years of experience and having been involved, during the past year, in the return-to-work process of at least five workers with a CMD. The inclusion criterion for employers and union representatives was having been involved, during the past year, in the return-to-work process of at least one worker with a CMD or in a return-to-work management committee. We aimed to recruit 6 to 12 participants per group, as recommended for this type of group [20, 21].

2.4 Data collection and analysis

2.4.1 Phase 1: Survey using a self-administered questionnaire

The clarity of the documentation explaining the TRW-CMD Program’s logic models and the self-administered questionnaire were pre-tested with four individuals (one representative per stakeholder group), and no modifications were required. The questionnaire and the documentation on the logic models were mailed to all participants. They were each asked to complete the self-administered questionnaire and return it within two weeks. The ques-tionnaire comprised one open-ended question on human resources that should be involved in the TRW-CMD Program, and ten questions documenting the level of agreement with the feasibility of (1) the specific/intermediate objectives (4 questions); (2) the components/tasks (4 questions); (3) the duration of the components (1 question); and (4) the TRW-CMD Program as a whole (1 question). Levels of agreement were rated on a 5-point Likert scale ranging from 1 (totally disagree) to 5 (totally agree) [23]. The scores served to calculate the percentage of participants, per group, that disagreed (scores ≤2), partly agreed (scores = 3) or agreed (scores ≥4) with the feasibility of the specific/intermediate objectives, components/tasks, and duration of the components. For each question with a level-of-agreement rating of ≤3, we asked the participants for a maximum of five comments. This allowed us to collect information on questions that obtained a “partly agree” rating or less, in preparation for the group discussions/individual interviews.

2.4.2 Phase 2: Group discussions – Individual interviews

Based on the data from phase 1, a number of independent, homogeneous-group discussions were held. The homogeneity of each group was important to foster a discussion around the same issues, needs, and interests [21]. The group discussions lasted a maximum of three hours, and were moderated by the first (EM) and third (MJD) authors of this study. Before each group discussion, comments from participants about level-of-agreement questions rated ≤3 were transcribed and anonymized in a document that was then distributed to all participants in their respective groups. The moderators began by presenting these comments in order to discuss, first, aspects of the models that obtained a partial or lower level of agreement. This exposed participants to other points of view and enabled co-construction of a shared group perspective on the feasibility of the TRW-CMD Program. When time permitted, aspects of the models that obtained a high level of agreement were discussed to elicit more details. In cases where it was impossible to hold a group discussion, individual interviews were conducted by the first author of this article (EM) with each participant of the intended group. Individual interviews lasted a maximum of one hour and were initiated by asking the interviewees for their respective comments on questions where their level-of-agreement was rated ≤3. Questions that obtained a high level of agreement were sometimes discussed when time permitted.

Each group discussion/individual interview was recorded and transcribed verbatim. The transcripts were coded by the first (EM) and third (MJD) authors of this article using Atlas-ti software [24] and a coding grid that included a priori and emerging codes identifying themes. Intercoder differences were discussed to clarify ambiguities and allow the coders to reach a consensus [25]. Intra- and inter-group content analyses of the transcripts were performed to identify convergences and divergences. These analyses resulted in the identification of factors that could potentially undermine the feasibility of the TRW-CMD Program.

3 Results

3.1 Participants

Participant recruitment took place between April and August 2014. Figure 1 presents the study flowchart. Fifty individuals eligible for participation in the study were contacted, and 24 of these participated in both phases of the study. Non-participation was due to unavailability (six insurers, four employers, three unions, two workers) and to call returns after the end of the recruitment period (two employers, six unions). Drop-outs were attributable to schedule conflicts (one union, one worker) and to difficulties in completing the self-administered questionnaire due to the presence of residual CMD symptoms that limited concentration (one worker). As the workers lived in three different regions of Quebec (Canada), we conducted individual interviews rather than group discussions with all workers who agreed to participate in the second phase of the study. The participants’ characteristics are presented in Table 1. The participants were mainly women, except for the union representatives, who comprised equal numbers of females and males. The participants’ ages ranged from 29 to 59 years, and their job experience, from 0.5 to 34 years.

Fig. 1

Flowchart of the study.

Table 1

Participants’ characteristics

	Insurers	Employers	Union representatives	Workers
Gender	F (n = 5), M (n = 1)	F (n = 7)	F (n = 4), M (n = 4)	F (n = 2), M (n = 1)
Age median (range)	39.5 (32–59) years	37.0 (29–60) years	52.0 (34–59) years	55.0 (43–58) years
Experience median (range)	5.5 (4–10) years	10.0 (2–12) years	3.3 (0.5–24) years	30.0 (15–34) years
Job title	Rehabilitation	Health Office (n = 5)	Union representative	Psycho-educator (n = 1),
	counsellor (n = 6)	Human Resources (n = 2)	(n = 8)	Coordinator (n = 2)

3.2 Feasibility of the TRW-CMD Program – Phase 1

Participant agreement with the feasibility of the specific/intermediate objectives and components/tasks of the TRW-CMD Program are presented in Tables 2 and 3. As illustrated in Table 2, overall, the percentages of stakeholder agreement with the feasibility of the specific/intermediate objectives related to “reducing the obstacles in the work environment” were lower than for the other specific/intermediate objectives. Globally, as evidenced in Table 3, the feasibility of the components/tasks was rated lower by employers. Participants submitted 34, 50, and 28 comments to be discussed within the insurer, employer, and union representative groups respectively. Four to six comments were made by each worker. Overall, this represents an average of five comments per participant.

Table 2
Participant agreement with the feasibility of the specific/intermediate objectives, by stakeholder group and level

Specific objectives Intermediate objectives Insurers Employers Unions Workers

(n = 6) (n = 7) (n = 8) (n = 3)

≤2 3 ≥4 ≤2 3 ≥4 ≤2 3 ≥4 ≤2 3 ≥4

Promote concerted action by stakeholders and worker a) Ensure communication between worker and stakeholders; % 0 16.7 83.3 14.3 14.3 71.4 0 25.0 75.0 0 0 100

b) Ensure that worker/stakeholders understand each other’s issues/interests regarding the return to work; n 0 1 5 1 1 5 0 1 7 0 0 3

c) Foster a positive attitude to the return to work among worker/stakeholders.

Improve worker’s work capacities d) Restore worker’s general health/quality of life /healthy lifestyle; % 0 0 100 14.3 28.6 57.1 0 37.5 62.5 0 0 100

e) Improve stress management/problem-solving skills; n 0 0 6 1 2 4 0 3 5 0 0 3

f) Improve communication skills;

g) Improve work self-efficacy;

h) Improve physical performance at work;

i) Improve cognitive performance at work.

Reduce obstacles in the work environment j) Prepare a work environment that offers the worker a therapeutic margin of manoeuvre; % 0 83.8 16.7 14.3 14.3 71.4 0 25.0 75.0 0 66.7 33.3

k) Promote the adoption of a supportive role by worker’s supervisor and co-workers; n 0 5 1 1 1 5 0 1 7 0 2 1

l) Recognize conflictual situations at work and look for adapted solutions.

Consolidate worker’s acquired knowledge and skills at work m) Assist worker in transferring knowledge and skills to all work tasks; % 0 33.3 66.7 0 14.3 85.7 0 0 100 0 0 100

n) Assist worker in managing problem situations related to staying at work; n 0 2 4 0 1 6 0 0 8 0 0 3

o) Guide worker in communicating accommodation and support needs required to stay at work.

Specific objectives	Intermediate objectives	Insurers	Employers	Unions	Workers
Promote concerted action by stakeholders and worker	a) Ensure communication between worker and stakeholders;	%	0	16.7	83.3	14.3	14.3	71.4	0	25.0	75.0	0	0	100
	b) Ensure that worker/stakeholders understand each other’s issues/interests regarding the return to work;	n	0	1	5	1	1	5	0	1	7	0	0	3
	c) Foster a positive attitude to the return to work among worker/stakeholders.
Improve worker’s work capacities	d) Restore worker’s general health/quality of life /healthy lifestyle;	%	0	0	100	14.3	28.6	57.1	0	37.5	62.5	0	0	100
	e) Improve stress management/problem-solving skills;	n	0	0	6	1	2	4	0	3	5	0	0	3
	f) Improve communication skills;
	g) Improve work self-efficacy;
	h) Improve physical performance at work;
	i) Improve cognitive performance at work.
Reduce obstacles in the work environment	j) Prepare a work environment that offers the worker a therapeutic margin of manoeuvre;	%	0	83.8	16.7	14.3	14.3	71.4	0	25.0	75.0	0	66.7	33.3
	k) Promote the adoption of a supportive role by worker’s supervisor and co-workers;	n	0	5	1	1	1	5	0	1	7	0	2	1
	l) Recognize conflictual situations at work and look for adapted solutions.
Consolidate worker’s acquired knowledge and skills at work	m) Assist worker in transferring knowledge and skills to all work tasks;	%	0	33.3	66.7	0	14.3	85.7	0	0	100	0	0	100
	n) Assist worker in managing problem situations related to staying at work;	n	0	2	4	0	1	6	0	0	8	0	0	3
	o) Guide worker in communicating accommodation and support needs required to stay at work.

≤2: disagreed; 3: partly agreed; ≥4: agreed.

Table 3

Participant agreement with the feasibility of the components/tasks, by stakeholder group and level

Components	Tasks	Insurers			Employers			Unions			Workers
		(n = 6)			(n = 7)			(n = 8)			(n = 3)
		≤2	3	≥ 4	≤2	3	≥ 4	≤2	3	≥ 4	≤2	3	≥ 4
DSHT	•Phone call to insurers to formulate a communication plan;	%	0	16.7	83.3	0	28.6	71.4	0	12.5	87.5	0	0	100
	•Phone call to insurers to validate employer’s and union representative’s openness for the TRW.	n	0	1	5	0	2	5	0	1	7	0	0	3
Pre-TRW	•Phone call/meeting with employers/union representatives/insurers to discuss their respective issues/interests regarding the return-to-work;	%	0	16.7	83.3	14.4	42.8	42.8	0	37.5	62.5	0	100	0
	•Phone call to employers to validate the previous worker’s work performance;	n	0	1	5	1	3	3	0	3	5	0	3	0
	•Phone call/meeting with insurers/employers/union representatives to discuss possible job accommodations for the TRW;
	•Phone call/meeting with insurers/employers/union representatives to discuss the possibilities for workers to receive support from supervisor/co-workers;
	•Phone call to insurers/employers/union representatives to identify, if applicable, conflict situations at work;
	•Meeting with the workers/employers/union representatives to discuss remediation strategies aimed at resolving identified conflict situations at work.
TRW	•Accompanying workers at workplace, at different times, according to the TRW plan;	%	0	0	100	14.4	42.8	42.8	0	25.0	75.0	0	0	100
	•Phone call/meeting with insurers/employers/union representatives for follow-up of worker’s therapeutic margin of manoeuvre, and adjustment, if necessary, of the TRW plan and/or support plan;	n	0	0	6	1	3	3	0	1	7	0	0	3
	•Phone call/meeting with insurers/employers/union representatives for follow-up, if applicable, of the remediation strategy plan.
MAW	•Phonecall to insurers/employers/union representatives to guide them in the support they may provide to workers with consolidation of acquired knowledge and skills.	%	0	16.7	83.3	28.6	28.6	42.8	0	12.5	87.5	0	0	100
		n	0	1	5	2	2	3	0	1	7	0	0	3

≤2: disagreed; 3: partly agreed; ≥4: agreed.

Regarding the feasibility of the duration of the components, the insurers (100% or n = 6) and union representatives (87.5% or n = 7) agreed for the most part. The percentage of employers who agreed, partly to totally, was 57.2% (n = 4). The workers had varying opinions. Globally, most insurers (100%, or n = 6), employers (85.6%, or n = 6), union representatives (100%, or n = 8), and workers (100%, or n = 3) agreed, partly to totally, with the feasibility of implementing the TRW-CMD Program as a whole.

3.3 Feasibility of the TRW-CMD Program – Phase 2

The following paragraphs present the factors identified by stakeholders during the group discussions and individual interviews that could potentially undermine the feasibility of the specific/intermediate objectives, components/tasks, and duration of the components. These are followed by a description of the stakeholders’ perceptions of the involvement of human resources in the program, and of the program’s feasibility as a whole.

3.3.1 Feasibility of promoting concerted action

All groups acknowledged that many stakeholders should be involved in the return-to-work process of workers with CMDs. However, this was also cited as a possible obstacle to the feasibility of concerted action, as it increases the probability of different needs and expectations regarding the program. Nevertheless, all stakeholders recognized that ensuring good communication, sharing common goals, and displaying a positive attitude toward the return-to-work process are key factors in promoting concerted action among stakeholders.

“I find the program itself really good, but the obstacle I run into is that it involves the doctor, the insurance company, the medical department and Human Resources. It’s like [you need] a consensus: everybody has to agree to help the person.” (Participant in union representative group)

3.3.2 Feasibility of improving workers’ work capacities

For the employers and union representatives, the main obstacles to improving workers’ work capacities were residual symptoms, comorbidities, and/or functional limitations. They perceived these obstacles as potentially hindering workers’ recovery of their previous work capacities and thus hampering their return to the same job.

“When the person is reintegrated into work but has functional limitations, particularly mental health problems, it’s not easy in our workplace because it’s like an assembly line.” (Participant in union representative group)

3.3.3 Feasibility of reducing the obstacles in the work environment

For all stakeholders, the main obstacle to achieving these objectives was the difficulty, if not the impossibility, for some employers to offer job accommodations. More specifically, the insurers said that the most difficult jobs to accommodate in the CMD context are those with atypical hours, a heavy mental workload, specific production requirements, or those related to various types of customer services. The union representatives added that collective agreements could also limit the possibilities of job accommodations. The insurers and employers pointed out, however, that supernumerary assignments, i.e., returning workers to work as supplementary employees, may help to counteract the difficulty/impossibility of offering accommodations. Never-theless, all the employers and workers were concerned about the potential work overload that job accommodations can create for co-workers when supernumerary assignments are not available.

“It’s hard to ask co-workers to do a little more in order to give this person [the worker] a chance, because they’re already overloaded.” (Participant in employer group)

Another concern workers expressed about the feasibility of reducing the obstacles in the work environment was the possible negative effect of these objectives in that they may exacerbate stigmatization.

“To me, these are pretty delicate objectives. Why? Because it stigmatizes the worker in a certain way. It can be done, but you’ve got to be careful because there’s a fine line between [this and] stigmatizing someone based on his problem, his illness.” (Worker 1)

For all stakeholders, stigmatization was seen as possibly hindering the support given to workers throughout their return-to-work process. To reduce the risks of stigmatization and as proposed in the program, the workers recommended that they be involved in decisions concerning the reduction of obstacles in the work environment.

“It could be a gradual return to work, it could be things like that, but you absolutely have to consult the worker.” (Worker 1)

The employers and union representatives added that a possible obstacle to achieving these objectives was the difficulty of ensuring confidentiality, since information given to supervisors about workers’ capacities in preparation for their return-to-work may give them clues about their diagnosis.

“We definitely don’t tell them [the supervisor] the diagnosis [...] in our company, the managers [supervisors] mostly have nursing training, which for sure means that if I say the person [worker] has problems concentrating, they often put two and two together ... ” (Participant in employer group)

3.3.4 Feasibility of consolidating the workers’ acquired knowledge

The main concern with the feasibility of these objectives was the impossibility, for insurers, to pay for follow-ups of workers by health professionals after their return to a regular work schedule.

“If the person is back at work full-time, normally we consider that he has no more limitations or functional gaps. That’s why our responsibility often ends there, even if the person might benefit from continuing the program.” (Participant in insurer group)

To overcome this obstacle, the insurers suggested integrating these follow-ups into the treatment plans proposed by health professionals at the beginning of the TRW-CMD Program.

“[...] If this could be included in the program when everyone is [still] involved, whether it’s included because it [follow-ups of workers on regular work schedules, by health professionals] doesn’t exist [...] One or two follow-ups that could be included, once the person is back at work full-time.” (Participant in insurer group)

3.3.5 Feasibility of implementing the components/tasks

The employers and workers were particularly concerned about the feasibility of the tasks for the Preparation-TRW, the TRW, and the MAW components. They explained that the main obstacle to their implementation was the time required of employers to carry out these tasks.

“Who’s going to take the time? Who’s going to do, you know, like a return-to-work interview?” (Worker 2)

Even though the employers agreed that it was important for them to be involved in the program, they stated that these tasks should be carried out by other stakeholders to reduce the demands on their time.

“Personally, I think [this means a] work overload [...] [But,] with a health professional helping a worker return to work gradually, I think that’s feasible.” (Participant in employer group)

3.3.6 Feasibility of the duration of the components

During the employers’ group discussion, after clarifying the contexts in which the program is recommended, they largely agreed with the feasibility of the duration of the components.

“I also answered no [...] because I found that 12 to 15 weeks made absolutely no sense. But then in a chronic context, well then, yes [it would].” (Participant in employer group)

Nevertheless, the employers and insurers ex-pressed concerns regarding the maximum durations of the components. They argued that health professionals could consider these maximums as an average time for returning workers with CMDs to work, which would significantly increase the program’s costs.

“She’s been on sick leave for five years, so we’re really happy that she’s coming back [to work] in 12 weeks. But I don’t think that should be the average [length of time].” (Participant in insurer group)

For their part, the workers were concerned about a possibly strict and inflexible application of the duration of the components, especially when determining the progression of return-to-work plans during the TRW component. They argued that determining the duration of components on the basis of their capacities and contexts was essential to fostering their healthy and sustainable return to work.

“The pitfall in the gradual return to work is always the straightjacket. First, it’s two days a week, then three days a week, and four days a week after that [ ... ] Why can’t I continue working at three days a week for longer? [ ... ] If you put me back at five days a week within a month, I might relapse.” (Worker 1)

3.3.7 Human resources

All stakeholders recognized the importance of the active involvement of workers, health professionals, insurers, and employers in the TRW-CMD Program. They particularly stressed the importance of involving supervisors in decisions concerning the return-to-work plans, as presented in the program documentation, given that they will be responsible for their implementation.

However, divergences were found regarding the involvement of union representatives. The workers stated that sometimes union representatives should be involved, but not always. For the employers and insurers, the involvement of union representatives in the TRW-CMD Program was perceived as potentially difficult to manage, as it would imply more relationships to deal with and typically divergent issues to consider. As one way of limiting this problem, they asked that union representatives not be systematically involved in the program, contrary to the proposal in the original program.

“Within an establishment, there are two, sometimes three, union accreditations, which means several different officers. [...] Lastly, that also represents another challenge for me, in terms of time management.” (Participant in employer group)

For their part, the union representatives considered their involvement essential, especially to ensure that return-to-work plans respect the collective agreement. Nevertheless, all stakeholders agreed that union representatives should be involved when workers ask for it. Moreover, they all identified three situations in which union representative involvement would be indicated: (1) presence of a conflict at work; (2) transfer of workers to another department; or (3) need to explain the advantages/disadvantages of a return-to-work plan to an ambivalent worker.

Divergences were also found regarding the in-volvement of health professionals in the program, more specifically, in the tasks that require communication with employers. In the documentation submitted to participants, it was explained that health professionals could communicate directly with employers to discuss, for example, the possibilities of job accommodations. Regarding this proposal, some insurers stated that communication between health professionals and employers was sometimes feasible, but should always be approved and coordinated by the insurers.

“When there are contacts with the employer, for us [the insurer], it sometimes happens that a health professional communicates with the employer, but usually, it’s through us. It’s either a conference call, [or] a meeting where we invite the therapist to come with the insured. But we don’t like to see a health professional communicate directly with the employer either. Nor do employers.” (Participant in insurer group)

The employers made no such stipulation during their group discussion. They even cited, as did some insurers, contexts where communication between health professionals and employers was indicated.

“I found it interesting that the health professional also calls the supervisor to see the other side [...]. If the worker says he’s having difficulties and then the supervisor says that things are going super well, I think we have a problem. And the opposite is also true.” (Participant in employer group)

“At some point, you also have to give employers a few resources to help the worker. [...] Personally, I’d like to see a little more of those people [health professionals] in direct contact with the employer.” (Participant in insurer group)

Lastly, the involvement of co-workers during the Therapeutic-Return-to-Work component was seen as problematic by all stakeholders, given the obligation to respect confidentiality. Nevertheless, they all recognized that co-worker involvement was important to support workers in their return-to-work process and that preparing co-workers was essential to ensuring an appropriate welcome back for returning workers.

“When I meet the people [co-workers], I tell them, “Good, the person [worker] is coming back to work. We’re going to support him, we’re going to help him. [...] So, at the same time, the people [co-workers can] prepare themselves.” (Participant in union representative group)

3.3.8 Feasibility of implementing the TRW-CMD Program as a whole

At the end of the group discussions and individual interviews, all stakeholders stated that the TRW-CMD Program was innovative. They stressed the importance of having access to such an intervention for workers on prolonged sick leave due to CMDs. They also considered that the TRW-CMD Program as a whole was feasible, provided that the potential facilitating and hindering factors discussed are taken into account when implementing the program in real practice settings.

4 Discussion

The objective of this study was to evaluate the feasibility of the TRW-CMD Program from the perspective of stakeholders, i.e., insurers, employers, unions, and workers. In general, the stakeholders agreed, partly to totally, with the feasibility of the specific/intermediate objectives, components/tasks, and the duration of the components. Thus, in their view, the adaptation to the CMD context of the TRW Program’s logic models, originally designed for workers with musculoskeletal disorders [6], appears feasible in real practice settings. The stakeholders nonetheless highlighted a number of obstacles that could potentially undermine its feasibility. They also proposed facilitators to counteract most of these obstacles. Three main findings emerged from the results of this study.

The first finding was that several factors identified as potentially undermining the program’s feasibility were related to the employers’ contexts. First, issues associated with respecting the confidentiality of the worker’s medical information were raised. Indeed, while all the stakeholders agreed that the worker’s diagnosis could not be disclosed to the employer, it was also pointed out that when information is being communicated about the person’s capacities, clues about the nature of the diagnosis are sometimes provided, possibly to the worker’s detriment. Similar issues have been reported in the literature [26 –28]. The same authors explain that it can be a complex task for employers to determine job accommodations and explain to co-workers why the returning worker‘s workload has been reduced without the risk of breaching confidentiality [26 –28]. The second potentially undermining factor concerned the difficulty some employers have in offering job accommodations, also a finding that is convergent with the literature. [26 , 29]. More specifically, workers with CMDs appear to benefit from fewer job accommodations than those with musculoskeletal disorders, possibly due to their widely varying needs [28]. Indeed, it appears more difficult for employers to offer general job accommodations in the CMD context [28]. Lastly, the third potentially undermining factor was the perception of a work overload for several of the employer’s resources as a result of the program’s implementation. This perception of a work overload is also documented in the literature. More specifically, for James et al. [30], the work overload perception held by Human Resources and/or Health Office employees may be linked to the fact that they generally fulfil several roles in addition to managing disability cases, and that insufficient time is often allocated for this responsibility. Similarly, this same perception held by direct supervisors which is associated with their lack of time to handle the additional workload involved in supervising a returning worker [31, 32], or to their lack of tools and training to properly support these workers [26 –28]. Lastly, like our study participants, some authors point out the possibility of a perceived work overload among the co-workers, who are obliged to perform tasks that the worker is unable to do during the return to work [26, 33].

The factors pertaining to the employers’ contexts during the return to work of workers with CMDs are therefore very concrete and must be taken into account when implementing interventions such as the TRW-CMD Program. The possible solutions proposed by our study participants, and which are convergent with those put forward in employers’ guidelines of many countries, therefore warrant consideration and suggest their applicability to these contexts. In fact, some authors even regard the worker as the person best placed to propose job accommodations [31, 34]. Likewise, some authors also propose involving health professionals during these returns to work as a way of reducing the direct supervisors’ workload [26]. Lastly, it is also recommended that supernumerary assignments be used to facilitate such returns after long-term sick leaves [28].

Our second finding was the diverging views of the roles that union representatives and health professionals should play in the TRW-CMD Program. First, while the program proposal suggested involving union representatives systematically in an active role with workers, particularly to facilitate implementation of their return-to-work plans, most of the employers and some insurers did not agree with this proposal. This diverging view is also mentioned by other authors [35]. Corbière et al. [35] pointed out that union representatives’ involvement in the return-to-work process of workers with CMDs varies considerably from one company to another. They stated that these variations appear to result from, among other things, the nature of the relationship between the union representatives and the absent workers, the union structure, and the agreements in place between the employer and the unions regarding their respective roles in coordinating returns to work [35]. These authors further state that these diverging views could explain the perceived ambiguity about the role that should be assigned to union representatives regarding these workers [35]. Yet, several studies stress the importance of involving them in worplace interventions [33 , 36]. However, the tasks in which their involvement would be desirable remain poorly documented in the scientific literature [33]. Our results therefore help to partially fill this gap, as the participants identified four situations in the CMD context in which union representative involvement would be acceptable for each of the stakeholders, i.e., when the worker requests their involvement, when there is a conflict at work, when a worker is transferred to another department, or when the advantages/disadvantages of a RTW plan needed to be presented to an ambivalent worker.

Our results also highlight diverging views of the role that health professionals should play with the employer. In fact, while employers and some insurers had a favorable view of the direct involvement of health professionals with employers, other insurers did not. This result is probably a consequence of the way in which the disability insurance system is organized in Quebec (Canada), where insurers are generally responsible for authorizing access to workplace interventions. In this context, it appears that the insurer assumes the role of RTW coordinator, as defined by Durand et al. [37]. According to these authors, this role is characterized primarily by responsibility for coordinating communication and actions among stakeholders [37]. For many authors, this coordination role is not necessarily assigned to insurers, and the person to whom it is assigned depends mainly on the implementation context [33 , 39]. Again according to Durand et al. [37], what is imperative is that the person responsible for RTW coordination be in close contact with all stakeholders involved and that any expectations regarding discussions among them be explicit enough to promote concerted action.

These diverging views of the roles highlights the potential difficulties associated with involving several stakeholders in the TRW-CMD Program, as mentioned by our study participants and by many authors [31 , 41]. To remedy this situation, Nastasia et al. [31] propose clearly defining and communicating each party’s roles and responsibilities as soon as implementation of the intervention begins. For these authors, this recommendation implies developing and implementing a communication plan aimed at determining how the necessary tasks will be divided up and informing all stakeholders of this division of labour, in order to facilitate the return to work of absent workers [31]. In this sense, the implementation of such measures should improve the feasibility of the TRW-CMD Program.

The third finding consisted of diverging representations of the durations proposed for the various components of the TRW-CMD Program. Our results in fact revealed the insurers’ fear that the maximum durations would be interpreted as being the ideal, whereas the workers feared that these durations were not personalized enough to match their needs. According to Young [41], these diverging representations could be attributed to the existence of different issues and interests among the stakeholders involved in workplace interventions, a finding also obtained by other authors [39, 42] in the work-disability prevention field. However, these authors found that the implementation of workplace interventions remained possible despite the existence of diverging issues and interests, but they stressed the importance of obtaining the agreement of all stakeholders on the return-to-work aim [39, 42].

4.1 Strengths and limitations

The strength of our study is that we consulted all categories of stakeholders usually involved in the return-to-work process of workers with CMDs. Although we found convergences among most of the participants’ comments and obtained data saturation for the main themes, it would be worthwhile to study stakeholders’ perceptions of the feasibility of implementing the TRW-CMD Program in more differentiated contexts, e.g., small/medium/large businesses, private/public insurers, or various ethno-cultural contexts.

The quality of information collected in a group discussion can be influenced by the group dynamics and participants’ charisma. Thus, some participants may have had difficulty expressing their opinions in the group discussions/individual interviews. Nonetheless, the first phase of the study, which allowed all participants to express their opinions, and the presence of an moderator/interviewer sensitive to nonverbal communications likely helped to minimize this possible limitation [21].

5 Conclusion

Feasibility studies are recommended during the development of complex interventions such as the TRW-CMD Program to improve their design and fu-ture implementation. In general, the implementation of the TRW-CMD Program is regarded as feasible from the stakeholder perspective, and no modification of the program’s logic models is required. However, the participating stakeholders highlighted a number of obstacles that could potentially undermine its feasibility, as well as possible facilitators to counteract most of them. It is therefore essential to take all these factors into account before proceeding to the next step of the broader study, i.e., implementation of the TRW-CMD Program in real practice settings.

Conflict of interest

Elyse Marois received awards from the Research Chair in Work Rehabilitation (J. Armand Bombardier –Pratt & Whitney Canada), the Institut de recherche Robert-Sauvé en santé et en sécurité du travail and the Fonds de recherche du Québec-Santé. A grant for the costs related to this study was received from the Research Chair in Work Rehabilitation (J. Armand Bombardier –Pratt & Whitney Canada). Elyse Marois, Marie-José Durand and Marie-France Coutu declare that they have no conflicts of interest.

Ethical approval

All procedures performed in this study involving human subjects were in accordance with the ethical standards of the Research Ethics Committee of the Centre Hospitalier Universitaire de Sherbrooke in Québec (project no. 13–154), and with the 1964 Helsinki Declaration and its later amendments, or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Footnotes

Acknowledgments

The authors wish to thank the participants for the time and effort they contributed to the study.

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