Abstract
BACKGROUND:
In Europe it is commonly accepted that psychosocial hazards may influence the mental health of employees. However, mental disorders such as depression are generally not acknowledged as an occupational disease covered by the workers compensation system. Studies indicate that workers compensation claim processes may affect employee’s health negatively due to a demanding case process. If filing a workers’ compensation claim can harm the employees’ health, it is highly relevant to pay attention to employees with mental health claims, as they are most likely vulnerable and face a very low chance of compensation.
OBJECTIVE:
This study investigates how employees with work-related mental disorders experience the process of seeking workers compensation from the Danish Workers’ Compensation System.
METHOD:
Interview (N = 13) and questionnaire (N = 436) data from claimants were analysed.
RESULTS:
Analysis showed that even though many employees wished for the claim to influence the conditions at the workplace, there seemed to be a lack of preventive health and safety initiatives in the workplaces. Central stakeholders such as health and safety representatives were often not involved. Management involvement was often experienced negatively, and the Danish Working Environment Authority rarely conducted workplace inspections. Employees experienced inadequate information about the workers’ compensation process and experienced a lack of coordination between stakeholders.
CONCLUSION:
A more supportive and coordinated approach in the Workers’ Compensation System is recommendable. The processes in the system could be evaluated using the Social Insurance Literacy concept, to ensure sufficient support of the claimants and reduce potential harmful aspects of the process.
Introduction
Mental disorders are related to functional disability in all domains of functioning [1]. They are a common cause of work disability [2], and represent a major risk factor for long-term health complaints [3], job loss [4] and early withdrawal from the labour market [5].
In Europe it is commonly accepted that psychosocial hazards may influence the mental health of employees [6–9]. The International Labour Organization has acknowledged that psychosocial hazards can cause occupational disease. However, mental disorders such as depression are generally not acknowledged as occupational diseases covered by the workers’ compensation system (WCS) in most countries, and there is no general consensus on the question of recognition of mental health claims[10].
When an employee develops a work-related disorder, the issues involving return to work (RTW) are complex and multifaceted [11], and various systems affect the employee’s recovery and options for RTW [12, 13].
Research shows that the Workplace – and Legislative/Insurance Systems do interact in relation to sick employees [14] and this may have both health inhibiting and health promoting elements [15]. However, the interactions between the Workplace System and Legislative/Insurance Systems have not been much explored in relation to employees with work-related mental disorders (WRMD) [14].
In this study we look at two systems. The Workplace System and the Legislative/Insurance System (in this case limited to the Danish WCS), in relation to employees suffering from WRMD.
Workers’ compensation claims
A growing number of workers’ compensation claims of mental disorders, such as work-related stress or depression, have been registered in Europe [10]. In Denmark, these types of claims are among the most common [16]. However, the recognition rate in this group of diagnoses is low, only 7% in 2020, which was the lowest recognition rate across the diagnostic groups [16]. The large number of rejections is primarily due to the multifactorial nature of mental disorders [10] and the difficulties of establishing a causal relationship between occupational exposures and mental health outcomes [17, 18].
The Danish workers’ compensation system
In Denmark physicians and dentists are obligated by law to notify if they have a suspicion that a disease may have been caused by working conditions [19]. The claims are submitted to the Danish Working Environment Authority and the Danish Labour Market Insurance. Thus, the workers’ compensation claims serve both as information to preventive initiatives, where the Danish Working Environment Authority receives information about working conditions, believed to have led to disease/injury. And secondly, the Labour Market Insurance assesses whether the disease/injury can be recognized and whether compensation can be granted to the employee [19].
The Danish WCS was established in 1898 as a no-fault system, meaning that sick employees are entitled to receive compensation without proving fault against the opposite party. The system was developed to insure employees with physical diseases or injuries. The system is financed by employers and can compensate employees working in Denmark for permanent injury, loss of earning capacity, expenses towards treatment, medicine etc., compensation for loss of breadwinner and transitional allowance to dependents in case of death [20]. The WCS exists in parallel with the healthcare system, the social security system, and the sickness insurance system which provides income replacement and support for the return-to-work process for citizens in Denmark [10]. Claims are typically reported by health care professionals such as general or occupational physicians or psychologists. Thus, a claim will typically be based on a professional evaluation of the mental disorder as being at least partly caused by working conditions [21].
The claim process may be harmful for the employee
Several studies have indicated that the workers compensation claim process may have the unintended side effect of increasing the risk of work disability due to the claim process [22]. Furthermore, studies indicate that the process might contribute to a worse prognosis [23–25], reduced recovery [26], and risk of health-related job loss [27]. However, epidemiological research in the field has been criticized for methodological weaknesses [28, 29]. International qualitative studies and reviews have concluded that the workers’ compensation claim process is often perceived as stressful by sick employees [28, 30–33]. Interactions with key stakeholders in the compensation system, such as insurers [30, 34] the workplace and health care providers [35, 36] can influence employees’ recovery negatively. Furthermore, administrative hurdles related to workers’ compensation claims have been associated with increased mental health complaints [28, 33].
Aims and research questions
If filing a workers’ compensation claim may potentially harm the claimants’ health, there is a strong incentive to pay attention to employees with notified occupational mental disorders since claimants tend to be vulnerable and face a very low chance of recognition and compensation.
The aim of this study is to explore the experiences of claimants with mental health claims in the Danish WCS and in the workplace regarding two main areas.
1) The participants’ conceptions of the WCS process and of the interactions between involved stakeholders (including the workplace) and 2) Possible differences in perception of the WCS process depending on diagnosis and outcome (rejected or recognized claim).
Methods
An exploratory sequential mixed-method research design was applied for data collection, which is characterized by starting with an explorative qualitative study which inform development of a questionnaire and a quantitative study [37]. First, the field was explored through semi-structured interviews (N = 13). Subsequently, the generalisability of the most salient findings was examined in a larger population through a questionnaire-based survey (N = 436). All participants had a mental health claim registered in the Danish WCS.
Interviews and inclusion
Thirteen exploratory semi-structured interviews were conducted, each lasting approximately one hour, with interviewees having a mental health claim. The interviewees were recruited from the 2nd of January 2014 onwards by occupational physicians at the Department of Occupational and Environmental Medicine at Bispebjerg University Hospital, Denmark. Background information about the interviewees is presented in Table 1.
Characteristics of 13 interviewees with mental health claims recruited from an occupational medicine department, interviewed in 2014
Characteristics of 13 interviewees with mental health claims recruited from an occupational medicine department, interviewed in 2014
Inclusion criteria were defined as follows: Significant symptoms due to a work-related mental disorder, which has been filed as a workers compensation claim. The disorder had to be diagnosed by a health professional according to ICD-10 [38] and the employee was employed when the disease started. Exclusion criteria were defined as follows: Current abuse of alcohol or psychoactive stimulants, major psychiatric disorder or significant somatic disorder assumed to be the primary cause of the mental disorder, the person being potentially unpredictable or dangerous. Participants were contacted by phone by the first author and interviewed in their home or at the University of Copenhagen. Participants completed a consent form prior to the interview, with the opportunity to withdraw their data at any time.
The interviews focused on the participants’ experiences of the development of the mental disorder, the processes at the workplace including experiences related to the workplace stakeholders, the way the workplace handled sick leave and RTW, the process in the WCS, various stakeholders in the WCS, including the Working Environment Authority, and the participants expectations and motivation behind the claim. Interviews were recorded, transcribed verbatim, and coded in NVivo 10 through open- and selective-coding, and with memo writing following the principles from Grounded Theory [39].
The questionnaire was designed on the basis of the interview data and pilot tested according to the principles set out by Boynton (2004). First, five employees with mental health claims tested the questionnaire and provided feedback. Based on the feedback, the questionnaire was revised. Second, 13 volunteers recruited through Facebook tested the online version of the questionnaire and provided feedback, which led to the final version used in this study.
Claimants with a mental health claim registered from 2010–2012 were selected through a random withdrawal by the Danish Labour Market Insurance, from their database. Since post-traumatic stress disorder (PTSD) was the only mental disease on the List of Occupational Diseases (diseases on the list are processed differently from diseases not on the list), the selection of employees with work-related mental disorders was based on a random selection using four subgroups: Recognised claims (recognised claims excluding PTSD (N = 121, i.e., all claims that fulfilled inclusion criteria) + recognised claims including PTSD (N = 200)). Rejected claims (rejected claims excluding PTSD (N = 200) + rejected claims including PTSD (N = 200)). In total 321 claimants with a recognized claim and 400 claimants with a rejected claim where withdrawn out of a total of 11070 claimants [16]. Claimants with pre-existing claims filed before the mental health claim were excluded. In December 2014, the claimants were invited to participate in the study. This was done by letter, which included a description of the study and a personal code to an online questionnaire. A month later, a reminder was sent out, where the option to fill in the questionnaire on paper was included. Of those contacted, 60.5% responded. In Table 2 the sociodemographic, employment characteristics, diagnosis and claim status among the 436 participants are presented.
Sociodemographic and employment characteristics, and claim status among the 436 participants
Sociodemographic and employment characteristics, and claim status among the 436 participants
1PTSD, F43.1. 2Depression, F33 and F32. 3Adjustment disorder etc. covers: Adjustment disorders, F43.2-F43.9 (n = 161), Stress without specification, Z.73.3 (n = 96), Anxiety, F41 (n = 4), and nonspecified psychiatric disease (n = 16) (World Health Organization, 1992). Exp = expected value in post-hoc test. *Shown to be significant and less than 0.01 in post-hoc test and Bonferroni correction of significance level 0.05. **Shown to be significant and less than 0.05 in post-hoc test and Bonferroni correction of significance level 0.05. ***Two groups (<1 year and 1-9 years with regard to seniority and public work or studying with regard to current work situation) where pooled due to small expected observations/frequencies in the groups.
The questionnaire consisted of 40 questions and several sub-questions; both scales and open-response fields were applied. Questionnaire data were analysed with SPSS version 28.0.1.1 using chi-square tests (type 1 error value of 0.05) to examine the differences between responders and non-responders in the dropout analysis. Differences between employees with different diagnoses and recognized vs. rejected claims were also tested using chi-square tests. When comparing more than two groups in the chi-square analysis and in the case of a significant result, the standardized residuals were used to perform a post-hoc analysis to specify significant groups. Bonferroni correction of significance values was used to control for type I error [41].
The answers to the open-response fields were analysed through selective coding.
A dropout analysis (Table 3) was conducted on background data from the claimants, withdrawn by the Danish Labour Market Insurance, from their database. The analysis showed that the respondent group was significantly older and contained more women and more workers diagnosed with stress-related disorders compared to dropouts. Additionally, there were differences in relation to industries. No significant differences were found in relation to recognized claims.
Characteristics of 436 participants with mental health claims who completed the research questionnaire and 285 claimants who did not
Characteristics of 436 participants with mental health claims who completed the research questionnaire and 285 claimants who did not
Exp = expected value in post-hoc test. *Shown to be significant and less than 0.001 in post-hoc test and Bonferroni correction of significance level 0.05. **Shown to be significant and less than 0.05 in post-hoc test and Bonferroni correction of significance level 0.05.
The results from the interviews (for background information on interviewees, see Table 1) and the questionnaire responses (see the results in Table 4) are presented in four themes: 1) Prevention in the work environment as an intention. 2) Problems poorly handled in the workplace. 3) Experiences in the Danish WCS. 4) Experiences of the interaction between WCS and the workplace, focusing on the ‘challenges in relation to workplace inspections and the experience of ‘being treated as the problem’.
Assessment of factors related to the workplace and workers’ compensation system made by 436 claimants with mental disorders
Exp = expected value in post-hoc test. *Shown to be significant and less than 0.001 in post-hoc test and Bonferroni correction of significance level 0.05. **Shown to be significant and less than 0.05 in post-hoc test and Bonferroni correction of significance level 0.05.
Even though Danish legislation requires physicians to notify a disease, if it is suspected to be caused by the working conditions, most of the interviewees perceived the workers compensation claim as an active choice.
In the questionnaire survey, 49.5% of all participants answered that they wanted documentation to prove that they had been sick due to work, and 23.9% of the participants indicated that financial compensation was one of the most important purposes of the claim while 51.1% of the respondents answered that one of the most important purposes of the claim was to prevent something similar happening to other employees in the future. This was especially the case for participants diagnosed with adjustment disorder and depression while the percentage was lower (34.9%) than the expected estimate (in the post hoc analyses) among participants with PTSD (Table 4, A). In the interviews it became apparent that most of the interviewees already knew that they would probably not receive any compensation. Although they were still hoping for recognition and compensation, they had a strong focus on the problematic working conditions and found it important to make a compensation claim to draw attention to the problems.
‘I think it is such an incredibly important issue; also, if the same thing happens to other people, I must set an example, because there are a lot of problems among teachers... and I would really like to stop it. It will also happen to someone after me’ (P12, teacher).
Problems poorly handled in the workplace
A total of 73.4% of the participants thought that their workplace had handled the process poorly when they became sick. A higher percentage of employees with PTSD and with recognized claims thought that the workplace had handled the process well, compared to the other groups (Table 4, B). Most respondents (46.6%) assessed the management’s handling of the process surrounding the disorder and the compensation claim as ‘negative’ (Table 4, C). In addition, the results showed that health and safety representatives were not involved in 50.7% of the cases even though an employee was sick with a work-related disorder, and when they were involved, employees experienced this negatively or neutral rather than positively.
This was also found in the interviews.
‘We (the teacher and some colleagues) have asked our health and safety representative and the union for help (to register violent incidents) ... but she has not reported it, just talked herself out of it, because she didn’t know how to report it. Then we went to the manager and asked for it to be reported, but he said it was supposed to be the health and safety representative, so we have been captured in their internal conflict’ (P5, teacher).
Only one interviewee out of the thirteen participants had experienced the health and safety representatives’ involvement as positive. The rest of the interviewees had the experience that the health and safety representatives were either not involved or involved in a negative way.
Colleagues and union representatives were perceived most positively (Table 4, C). Despite wanting the claim to have a preventive effect at the workplace, 55.0% of respondents in the survey answered that no changes were made in the working environment due to their work-related disorder. Only 12.4% answered that changes were made in the working environment, while 17.9% answered ‘somewhat’ (Table 4, D). Comments in the open fields in the questionnaires showed that ‘somewhat’ could mean inadequate changes, for example those only affecting the individual employee such as reducing or changing the employee’s assignments, rather than interventions in the working environment.
‘When I came back after 4 months, I started working in a different department. Now I’m back working in the same department again, and the psychosocial working environment has just gone worse’ (questionnaire response, office clerk).
Additionally, several responded in the questionnaires that they experienced not being involved in the decisions about the changes.
‘In my case, it was bullying ... from my closest colleague, and nothing was done to stop it... Management’s solution was to force me to be redeployed to another location in the municipality’ (questionnaire response, social worker).
However, among the participants in the questionnaire survey a larger percentage of participants with recognized claims experienced changes in the working environment compared to those with rejected claims (Table 4, D).
Experiences in the Danish WCS
Among the survey participants, 17.7% stated that the workers’ compensation claim process had either prevented or delayed them from being able to Return to work (Table 4, H). In addition, 41.1% reported that they had not been sufficiently informed about the process in the WCS, whereas more participants with recognized claims did receive sufficient information about the process (Table 4, F). Many participants (45.6%) noted that the compensation forms were hard to fill out (Table 4, G). In the interviews, several interviewees talked about technical issues as well as questions not fitting when applied to descriptions of psychosocial hazards. Their experience was that the forms were designed for physical exposures/diseases. A considerable amount of time and energy was invested in the claim processes to complete questionnaires, medical forms, etc.
‘I did not realize there were so many things, and so many papers (to fill out). I simply did not know before it started to flip through the door with papers and papers and papers’ (P10, factory worker).
‘I have not had the energy for it. It has been something like, ‘now you have to pull yourself together, today you will find out about this and this (information for the workers compensation claims forms)’ it has taken whole days to find out stuff’ (P1, undertaker).
‘Struggling to get well, but also having to struggle with these systems. Well, I understand people lose their spark, they cannot bear it. There are probably many who stop their claims because they give up’ (P8, waitress).
The interviewees often found themselves in challenging systems regarding both the WCS, the sickness insurance system and the healthcare system attending meetings, filling out forms and having to go to medical examinations, psychiatric assessments, visits to general practitioner, and perhaps treatment by a psychologist. Some were confused by the different systems and the lack of communication and coordination of information between these. Several mentions feeling treated like a number.
‘Well, both with all the questions you are asked and all the doctor visits they require, and you have to go to the occupational medicine department. It makes you just feel questioned...are you sick or not, it makes you feel like a number ... I just think it’s important as a caseworker to keep in mind that it is actually people you are dealing with. One is not just a number. I hate to be transparent’ (P8, waitress).
‘Yes, it’s been confusing because I do not know what to do, what to write and what not to write. Especially now, when it’s send out (questionnaires) again, it’s almost the same they ask. So, I do not know why (curses) they want the same information again’ (P10, factory worker).
Experiences of the interaction between WCS and the workplace
Challenges in relation to workplace inspections
The interviewees were focused on the workers compensation claims’ preventive function and knew that their claims went to the Working Environment Authority, and for some, this was partly the motivation of the claim.
‘It (the compensation claim) was to get the Working Environment Authority to come and look at the working conditions ... The whole time I just expected that they would contact the employer, that they would simply look into it ... Why don’t the Working Environment Authority come out here? Is it because they think there are dead people all over the place?’ (P1, undertaker)
However, in the survey, only 8.3% were aware of any inspection being carried out by the Working Environment Authority (Table 4, E). More participants with recognized claims experienced inspections. These results were in line with the interview data, where some interviewees expressed that their workplace had had an inspection from the Working Environment Authority, however they experienced the Working Environment Authority’s inspection as inadequate and problematic.
Several of the interviewees described how management accompanied the Work Environment Authority around the workplace, which meant that the employees did not feel that they had an actual opportunity to add information and critical perspectives, especially if the problems experienced in the working environment involved management.
‘The Danish Working Environment Authority has been in my section. But they just walked through easy and without talking too much to the employees. So, they ... concluded that everything had been carried out by the book, everything was completely in order and fine, and they didn’t have any comments at all’ (P7, nurse).
‘So, the woman from the Danish Working Environment Authority says: ‘Is there anything wrong with you? ’And I just thought ‘should I say something now?’ But I could not bring myself to say anything, as I was also afraid of my manager, of course. So, I said ‘no’’ (P12, teacher).
One of the interviewees whose workplace had had a visit from the Work Environment Authority inspectors expressed disappointment about the Work Environment Authority’s lack of injunctions following the visit, which could be interpreted by managers and employees as a ‘seal of approval’ about the company’s working environment. However, this stood in sharp contrast to the interviewees’ experiences, and she expressed that it could signal the perspective that the employee on sick leave was not able to cope with the ‘approved working conditions’.
‘It was like a slap in the face when, during one of my night shifts, I read the e-mail (the workplace got a green smiley – approval from the Work Environment Authority) which had been sent around. It was like being told that, ‘because you don’t want to be physically assaulted every week by a boy, and be spat at, and have your hair pulled, and be kicked black and blue all over – then it’s just you whining and making up a load of rubbish.’ And then you get an email saying that everything was fine, and we should accept that it just goes with the job’ (P7, nurse).
Being treated as the problem
Within 2–4 years after the claim, 23.2% of the survey participants were still employed at the same workplace, while 39.2% were not part of the labour market. The survey showed that 52.4% of participants with PTSD and 47.9% of participants with depression reported that they were not part of the labour market but in the adjustment disorder etc. category this was the case for only 33.2% of participants, which was significantly lower than expected in the post-hoc analyses (Table 2).
More participants with recognized claims (26.5%, Table 4, H), than participants with rejected claims (9.9%, Table 4) felt that the claim process had hindered or delayed their return to the labor market. Instead of contributing to enlightening the problems in the work environment, employees with work-related mental disorders sometimes experienced being treated as ‘the problem’ themselves.
‘I sort of thought, ‘they’re spending more time trying to find out if there might be other things causing the problem than they are actually looking at the problem...’ Why don’t they go out and look at the workplace, why aren’t they out looking at how things are going there? If you don’t believe me, just drive out and take a look ... It’s like I constantly have to explain something about myself or have to prove something, I have to dig up stuff about my past ... I think it is tough’ (P1, undertaker).
They had to go through a demanding process delivering documentation to the workers’ compensation system to prove that they were sick due to the working conditions. At the same time, they experienced a lack of preventive health and safety initiatives at the workplace, even though the compensation claim was received by the Working Environmental Authority, and thus were supposed to contribute to prevention at the workplace.
‘I don’t feel that the systems interact well with one another. They oppose, no they may not oppose each other, but they oppose the one who is sick. That’s because it does not work...Our systems work in such a way, that it is more about hunting you, than it is about getting you back on track, it’s though’ (P1, undertaker).
Discussion
One of the most important motivations behind workers compensation claim was the hope that the claim would lead to preventive interventions at the workplace to prevent others from becoming sick in the future. A higher percentage of employees with depression or adjustment disorders etc. were motivated towards prevention compared to employees with PTSD where significantly fewer than expected were motivated by this aim. Stakeholders at the workplace such as health and safety representatives were often not involved, and if they were involved, more employees experienced it negatively than positively. Management involvement was experienced negatively by most employees. Employees rarely found that their claim resulted in a workplace inspection, even though this could be an important motivation behind the claim. Additionally, inspections leading to no decisions or injunctions could be experienced negatively by sick employees. Work-related mental disorders rarely led to changes in the work environment but a larger proportion of employees with recognized claims than expected (according to the chi square analysis) experienced changes compared to employees with rejected claims. Finally, almost half of the employees did not feel adequately informed about the process in the WCS, and found the claim process demanding, and compensation forms could be hard to fill out. More employees with recognized claims experienced that the claim process had hindered or delayed their RTW compared to employees with rejected claims.
Experiences in the workplace
In the current study, participants in the questionnaire survey reported negative experiences in relation to stakeholder involvement at the workplace, especially in relation to line manager and top management. Research shows that much of the variability on whether employees succeed in RTW depends on what happens in the workplace [42]. Studies have found that support and interventions may to a larger extent be available to employees with physical conditions than for employees with mental disorders [43]. Line managers have been identified as the main stakeholder in relation to RTW among sick-listed employees [44]. However, several studies propose that managers often lack both sufficient knowledge [45], confidence and organizational support to effectively manage the RTW process for employees with mental disorders [46].
Health and safety representatives were often not involved when an employee had a work-related mental disorder, and if they were involved, more survey participants experienced this as negative rather than as positive, perhaps due to the lack of competences, knowledge, or influence in relation to psychosocial risk factors. Research has suggested that the educational level of health and safety representatives in the area of the psychosocial work environment may be low or varied, and that their influence on preventive initiatives in the psychosocial work environment are rather limited [47]. If the health and safety representative have a low level of competence and influence it might explain why some employees with work-related mental disorders experience the stakeholder negatively. Additionally, managers have been found to perceive sick leave as something which should be handled between employee and manager, rather than on a workplace level [48]. This perception might explain why other stakeholders were often not involved.
Our study identified a lack of preventive initiatives in the workplaces. Research indicate that more than 40% of European managers consider psychosocial hazards to be more difficult to manage than hazards in the physical work-environment [49]. The lack of prevention may harm possibilities of RTW. A meta-review has shown that employees suffering from WRMD may be reluctant to return to the workplace if they do not believe that the experienced contributory working conditions have been changed [50]. Recognition and acceptance of the disorder as well as experiencing the disorder as legitimate and receiving social support is essential for the sick employees and their possibilities for RTW [51]. Our study indicates that education or training of managers and other stakeholders within the field of mental health, the psychosocial work environment and rehabilitation related to mental health problems is relevant in a Danish or Nordic setting.
PTSD vs. other disorders
Employees diagnosed with PTSD compared to employees with depression or adjustment disorder etc. seem to have had more positive experiences in relation to the workplace and the WCS. This might be related to the inherent difference in the nature of the exposure that may typically be associated with developing the various diagnoses [38]. For instance, PTSD is easier to objectively assess compared to adjustment disorders, where it can be difficult to identify the distinct contributing causes due to the variability of psychosocial hazards and the interaction between them [52]. This may partly explain why employees with adjustment disorders etc. or depression, more often had negative experiences in the workplaces than those with PTSD. Additionally, employees with PTSD were often employed in organizations (e.g., the military or the police) with access to professional organizational support, such as debriefing or psychological counselling.
Experiences in the Danish WCS
The results of this study indicate that the compensation process can be demanding, and that compensation forms for some were hard to fill out. Employees experienced an individualized focus in the WCS, where they had to prove that the disorder was caused by the working conditions and not a personal vulnerability. These findings correspond well to findings in other countries where interactions with WCS have been described as troublesome, especially regarding problems in understanding the insurance regulations and how to communicate in a vocabulary acceptable to the insurance system [34, 35].
The concept of Social Insurance Literacy (SIL) represents a useful theoretical frame, which captures some of the communication dynamics embedded in the system. SIL is defined as the extent to which individuals can obtain, understand, and act on information in a social insurance system, related to the comprehensibility of the information provided by the system [53]. The concept focuses on how interactions between individuals and systems may influence the rehabilitation process and may be relevant in relation to the WCS. SIL addresses people’s financial, social, and cultural resources, and the capability of systems to handle the needs of claimants in their encounter with the system [53].
As such WCS systems may benefit from research addressing the central areas in the SIL concept with the aim of gaining knowledge about how to improve and simplify claim processes and provide support for claimants with limited capacities. This could contribute to reducing the risk of denying compensation for people who, with proper assistance, may qualify for it.
Interaction between workplace and the WCS
The claimants in the present study experienced the interaction between the WCS and workplace as quite limited. They seem to have had higher expectations of the interaction since the claims are sent to both the Working Environmental Authority and the Danish Labour Market Insurance, signaling communication and interaction.
Danish research has found three possible ways for worker compensation claims to directly impact workplaces: 1) by eliciting a workplace inspection from the Working Environmental Authority [54], 2) by eliciting an employer hearing [55] and 3) by providing financial incentives in relation to claims [56]. This research found that employer hearings may have a negative effect, damaging the relationship between the employer and the sick employee. They also found that the financial incentives in relation to claims, were very low [57].
In the following section the workplace inspection by the Working Environmental Authority will be discussed.
Inspection by the Working Environmental Authority
The current study showed that workplace inspections were seldom conducted following a worker’s compensation claim of WRMD. Serious limitations have been identified in relation to the Danish Working Environmental Authority’s use of workers’ compensation claims of occupational diseases, and the extent to which inspectors can adequately inspect and make decisions in relation to the psychosocial work environment [58]. The Working Environmental Authority makes very limited use of workers compensation claims for occupational diseases in general, as they often only select cases for inspectors to examine, if two or more employees from the same workplace have reported the same occupational disorder in the same half year [59].
Lack of coordination and interaction between systems
In our study the claimants could experience being treated as the problem in the workplace and in the WCS. And the interaction or lack of interaction between the systems could enhance this experience. The lack of inspections from the Work Environment Authority could be experienced by the claimants as if their claims are not being taken seriously. In the claim process, some claimants struggled with filling out forms, attending medical examinations as well as attending other meetings with e.g., municipality caseworkers, general practitioner etc.
Research shows that if systems interact to support sick employees, it increases the possibilities for return and staying in the labor market [14]. However systems are often operating in silos [14] and thus primarily focusing on their specific aspects of health or return to work. This may lead to the sick employee feeling caught in the middle, having to navigate between stakeholders, navigate in different rules, attending meetings, filling out similar forms from different stakeholders etc.
A more supportive and coordinated approach in the WCS is thus recommendable [14]. Cooperation, collaboration and knowledge transfer between union, employer and compensation system have also been found to reduce strains experienced by claimants [60].
Methodological considerations
Our study included interviews with 13 claimants and questionnaire data from 436 claimants with a mental health claim, thus it provides unique information about claimants’ experience of the claim process and the interaction between the different systems at play. The mixed-method design provides both in-depth information about the employees’ experiences and the possibility to generalize the findings to a larger sample [37].
Some limitations also need to be considered. In relation to especially interview data the phenomenon of social desirability, may have an impact on the data. Social desirability bias has to a lesser extent been attributed to surveys send by mail, than to personal or telephone interviews. Anonymity in questionnaire has also been found to limit this type of bias [61]. Thus, in the survey, we enhanced anonymity by letting participants either click on a link or return questionnaires in a paper version only marked with an ID number and not any personal information like name or address.
The response rate to the questionnaire survey was 60.5%. The findings might therefore have been more pronounced in both positive and negative directions had more individuals answered. The respondents were grouped to enable comparison of recognized and rejected cases. However, the percentage of participants with recognition were much higher than in the actual population distribution (the recognition rate for mental disorders was 4.1% in 2016) [62]. Since employees with recognized claims more often report changes in the working environment, the results of the study may have found fewer preventive initiatives in a representative sample of workplaces. A higher percentage of respondents with recognized claims reported that the claim process had delayed or hindered their RTW (26.5%, Table 4), compared to employees with rejected claims (9.9%, Table 4) although only the latter was significant in the post-hoc test. Thus, the number of employees experiencing this may be lower in a representative sample. Most claims get rejected in the beginning of the process. Thus rejected claimants often do not have to participate in all the demanding steps of the compensation process [32].
The study relied primarily on self-reported questionnaire data reported 2–4 years after the workers’ compensation claim, and many of the participants had 'lower self-reported health at the time of answering the questionnaire, which might have enhanced the risk of reporting bias [63, 64]. A dropout analysis and an additional analysis of potential confounders (not shown) (including gender, age group, educational level, industry, and self-reported health at the time of response) was carried out. These analyses did find differences in the questionnaire responses. However, most of the differences could be attributed to the distribution of attributes such as age and gender in a diagnostic group in which more men and employees in the category of police, military, prison had PTSD, while more women had adjustment disorder etc. The differences in the answers of employees with good and bad self-reported health were not significant, indicating limited reporting bias in relation to current health status.
The participants who completed the questionnaires had a workers’ compensation claim filed in 2010–2012, thus a question is whether these findings are still relevant in 2021. Since no major changes have been made in the WCS [16], or the Danish Working Environment Authority use of workers compensations claims [65], we expect the findings are still highly relevant.
Recommendations for practice
Workers’ compensation claims of mental disorders contain valuable information about current problems in the working environment, which could be integrated to a higher extent in the Work Environmental Authority reports. This information could be useful to inspectors in preparing and carrying out inspections and informing subsequent workplace interventions. Additionally, the processes in the WCS should be evaluated based on the experience of the sick employees and adapted to ensure that the system supports employees’ health, rehabilitation, and return to the labour market e.g. using the SIL concept.
This Study identified a lack of a systematic approach to psychosocial risks, which has also been found in other studies [66]. A possible way forward may involve applying a specific model of risk management that targets psychosocial risks, ensuring a systematic approach in the workplace. EU-OSHA has proposed a model that consists of a risk assessment, a translation of the risk information into targeted actions, the introduction and management of risk-reduction interventions, an evaluation of the interventions, and feedback on existing interventions and future plans for action [67]. This approach has been recommended by several influential organizations in Europe, including HSE in Great Britain, INRS and ANARCT in France, and EU-Osha 2002 [67]. Our results indicate that workers’ compensation claims of WRMD could be a valuable part of this model. A worker’s compensation claim could be a factor that elicits a risk assessment in the workplace.
Conclusion
Claimants with work-related mental disorders may believe that submitting a workers’ compensation claim will contribute to improve the working environment and thus prevent co-workers from getting sick from the perceived unhealthy psychosocial working conditions. However, preventive health and safety initiatives at the workplace seem to be limited and central stakeholders, such as health and safety representatives and union representatives, are often not involved. Furthermore, management involvement was experienced negatively by most employees. Workplace inspections were seldom carried out and this gave rise to several unfulfilled expectations on the part of the claimants.
Finally, the claim process was perceived as demanding, compensation forms could be hard to fill out, and many employees felt inadequately informed about the workers compensation process. This indicates a need to strengthen interactions between the legislative/insurance and workplace systems, enabling them to use information about psychosocial risks more systematically to prevent WRMDs. Workers’ compensation claims of WRMD can be a valuable source of information to include in workplace assessments and they could be used much more extensively by the Work Environmental Authority.
Ethical considerations
This study was approved by the Danish Data Protection Agency (J.nr. 2013-54-0519). The study did not involve any treatment or biological material and therefore did not require approval from the Regional Health Research Ethics Committee. Studies based solely on surveys and interviews are not required to inform the National/Regional Committee. Informed consent was completed by the participants.
Conflict of interest
The authors declare no conflict of interest.
Footnotes
Acknowledgment
The work was conducted with competent support from Cand. psych. Mette Sofie Stig Knudsen and Dr. Med. Nanna Hurwitz Eller is from the Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, Denmark. The study was funded by The Danish Working Environment Research Fund grant (40-2013-03).