Workplace accommodation in return to work after mild traumatic brain injury

2.1 Study design

This qualitative case study was carried out in 2017–2020. The data include a sample from a randomized controlled trial (RCT) that compared the effectiveness of combining manualized cognitive rehabilitation (compensatory cognitive training) and supported employment (SE) with treatment as usual (TAU) on RTW outcomes [40] The interventions were provided in the specialist healthcare service and in real-life competitive work settings for employees with mild to moderate TBI in eastern Norway [41]. Since the main statistical analysis did not reveal between-group differences at the 12-month follow-up [42], the present study investigates accommodation in RTW processes for patients from both study groups.

The Norwegian Regional Committee for Medical and Health Research Ethics (REC no. 2016/2038) approved this study. Informed consent was obtained, and further assurances of confidentiality were given to the study participants prior to the interviews.

2.2 Procedures

After enrolment in the RCT, the first 45 employees with TBI who had returned to work were asked to participate in the case study. To be included as a case, the person with TBI consented to participate and accepted that their managers were interviewed. Thirty-eight cases were included at T1. The employee was the main informant in each case and was interviewed first.

Interviews took place at two time points. Interviews at T1 took place one to three months after RTW, while interviews at T2 took place 12–16 months after T1. Information from different perspectives (employee versus manager) was collected at both time points. The interviews lasted for 1–1.5 hours and were audio-recorded and transcribed verbatim.

Employee and manager interview guides were based on adapted questions (work environment, workplace conflict, social support, management) from the Copenhagen Psychosocial Questionnaire [43]. Questions on present work situation, changes in work situation due to TBI, actual work accommodation, challenges in work accommodation, and knowledge of TBI were added.

2.3 Data material

Sixty-four interviews with employees with TBI and 45 interviews with their managers were conducted.

Table 1 shows the distribution of informants with TBI, by background variables. Note that the group of informants with TBI consisted of individuals in both subordinate and leading positions (managers).

In 13 of the included 38 cases, the employees with TBI held a leadership position at T1. Gender distribution among the employee informants was even, but there was an overrepresentation of persons from the private sector doing white-collar work. The informants represented several areas/industries in the public and private sectors such as financial services, retail, education, non-governmental organizations, public administration, building and construction, restaurant, health institutions, social services, and insurance. There was an uneven distribution of informants in the manager and employee category at T1. At T2 some of the informants had changed their position. A more detailed overview of the informants is presented in Appendix 1.

Table 2 shows interview dropout rates.

The highest dropout rate was among managers, as 31 of the potential manager interviews did not take place for various reasons; the informants with TBI did not want their managers to be interviewed or the managers themselves did not want to participate or were unavailable. Twelve of the employee interviews did not take place due to informant unavailability.

The analysis proceeded in seven steps and was based on a comparative case study approach [44]. First, researchers analyzed four of the employee interviews separately through margin notes and open coding [45, 46]. Second, the coding was compared and discussed in the research team. Third, a codebook was constructed, tested, evaluated, and adjusted twice. Fourth, the NVivo 9 software program was used to code all interview transcripts according to the codebook. Fifth, the codes were fitted into a matrix of main analytic categories (including background variables: gender, position, RTW status, sector, industry, white collar/blue collar), and sorted by 1) case identification number, 2) time point, 3) position (employee/manager), and 4) intervention/control group. This provided opportunities for performing both (sixth) a comparative case analysis focused on case internal developments and (seventh) a thematic cross-case analysis.

The main analytic codes/categories were a mix of theoretically based initial assumptions and insights from work environment and work inclusion research in combination with the use of codes derived directly from the empirical data. We analyzed the data material on the assumption that psychosocial and organizational factors at work that are generally considered to be health promoting [47] will be equally important in RTW processes. From a support perspective, we understand the RTW process not simply as a matter of how individual characteristics correspond with institutional guidelines, workplace policies and practices, but rather as a function of the workplace’s competence in customizing accommodation [29, 39].

All interviews were deidentified during transcription and all cases were assigned a number.

Accommodation in the organizational work environment, either at T1 or T2 or both, was mentioned in all 38 cases, including those where the employee with TBI had returned to a full-time position at T1. At T2, accommodation in the organizational work environment was also mentioned by 12 of the 19 employees working in full-time positions. These accommodations largely concerned the employee’s work tasks, position and working hours, the organization of work and work demands, and physical arrangements.

Most employees (31 of 38) resumed work gradually. Frequently mentioned accommodations entailed customizing and structuring work tasks (fewer or less complex, stressful, or demanding) and reduced concentration- and memory-demanding tasks. The most common accommodations regarding position and working hours entailed reducing working hours, flexible presence at work and avoiding work during especially busy working hours.

Common accommodations in the organization of work and work demands consisted of reallocating work tasks to others (co-worker, manager, or a substitute) and customizing work (adapting shifts, increasing the number of breaks, reducing the number of meetings, reducing or decreasing the number of digital meetings, limiting the work area, reducing customer contact, working from home, adjusting pace, and making use of compensatory labor resources). Accommodations that more directly influenced work demands consisted of modifying expected performance, prolonging deadlines, and reducing demands on earnings and delivery.

In 28 cases, employees with TBI and their managers mentioned physical arrangements in the work environment. These applied to light, noise, hearing and sight conditions, raising and lowering tables, and adjusting screens. Some cases also mentioned physical training and exercises, or special equipment such as massage chairs, rest mattresses and exercise tools. In seven cases, physical arrangements occurred only at T2.

3.2 Accommodation in the psychosocial work environment

We have identified two main categories of accommodation in the psychosocial work environment: social support from co-workers and supportive management. In only six of the 38 cases was accommodation in the psychosocial work environment not mentioned.

4.1 Accommodation in the organizational and psychosocial work environment

Some forms of workplace accommodation were implemented for all employees with TBI in our sample, both at an early stage and later in the RTW process, and regardless their degree of RTW. As noted by Kirsh et al. [35], workplace accommodation is not only about physical changes, but in a few of our cases physical arrangements became more prevalent late in the RTW process. This indicates that over time, physical arrangements (i.e., modifying light, noise, hearing and sight conditions, raising and lowering tables, and adjusting screens) might be easier to handle than other types of accommodation in the organizational and psychosocial work environment. In accordance with other studies [5, 25], we find that the most common forms of accommodation in RTW after TBI took place in the organizational work environment. Most of these accommodations, can be understood as modifications of work demands that largely correspond to what Kiernan and Schalock (49) identify as “job restructuring” and “work activities modification.”

Cleveland et al. point out that, historically, accommodations in the workplace “were reserved for the average worker in order to move him/her toward maximizing performance and productivity” [34, p. 77]. Research shows that employees with mental health issues face greater challenges associated with work performance than do “average employees” without these kinds of health issues. Employees with (mild) TBI may have emotional and posttraumatic distress symptoms [51, 52] that create challenges in the psychosocial work environment. As noted by Libeson [9], we find that employees with TBI in leading positions may experience significant changes when an alteration in position leads to a sense of loss of status. In our study, there are some examples of RTW processes that entail a change of position and status, both within the same work organization as pre-injury and in a new organization, and that entail both voluntary and involuntary changes.

4.2 The dual function of social support and supportive management

The employees with TBI in our sample worked in different positions and in different industries in the public and private sectors. Despite differences between cases, our study suggests that the relationship between manager and employee with TBI plays a vital role in handling or managing the RTW process, and that social support from co-workers and management is important. These findings correspond to a range of other studies [5, 48]. However, we also find cases where unwanted attention caused strain on the employee with TBI. As Kensbock et al. [53] have argued, accommodation at an individual level may unintentionally cause a stigmatizing individualization; what may have been intended as well-meaning support from co-workers can be perceived by the employee as unwanted focus on health issues.

Johansson et al. found that the patients’ “uncertainty about their efficacy cast doubt on their beliefs in improving their skills, balancing daily activities and work” [52, p. 423]. In some of the cases in our sample, we found that psychosocial challenges gave some of the employees with TBI as well as their co-workers a sense of insecurity. In turn, this may have incited qualitative changes in social relations at the workplace.

The dual function of social support from co-workers also applies to management support. Employees with TBI could perceive management as either supportive or unsupportive depending on the interpretation of the situation, the interaction between managers and employees, and on their condition from day to day. Supportive management is not necessarily the same as having shared definitions of situations and contexts. In some cases, managers, and employees with TBI disagreed on the qualitative aspects of management support, and sometimes they emphasized different aspects of support. Many of the cases in our sample indicated uncertainty among managers about how to deal with TBI-related challenges. We find that management without a trusting relationship with the employee with TBI, combined with lack of knowledge about TBI, may appear unsupportive to the employee with TBI. This emphasizes the importance of understanding RTW after TBI as contextual customization of accommodation to meet and balance the needs of the individual and the organization.

4.3 RTW after TBI is often long-term and nonlinear

In our sample, supportive management seemed to be crucial to balance the needs of the workplace and the needs of the employee with TBI, in many cases with priority to employee needs in the first period of RTW. However, as time went by, the needs of the organization became the priority. We find that both supportive management and support from co-workers were most prevalent at the start of the RTW process. This is an indication that both the work organization and the social relations are worn down by the challenges of TBI over time. When the employee with TBI does not fully recover, the employee, co-workers and manager all face a difficult situation.

We see this as an indication that RTW for employees with TBI constitutes a competence challenge for the work organization that is similar to challenges in work inclusion efforts for “hard-to-place citizens” [54]. Several studies indicate that for vulnerable groups, such as people with mental health issues, job retention after placement or RTW is a challenge [29, 55]. Research on work inclusion emphasizes knowledge transfer of diagnosis-related challenges from the support system to the workplace [29, 56]. This study shows that this type of knowledge transfer is essential for managers in their efforts to tailor support for employees with TBI.

This study also shows that RTW is not always a linear development, that there may be changing needs for customization over a long period of time, and that more accommodation does not necessarily lead to higher percentages of RTW. This observation suggests that accommodation in the RTW process should not necessarily aim to move the employee with TBI toward maximum productivity performance as soon as possible [34], but rather toward customization that balances the needs of both the employee with TBI and the workplace over time. For people with reduced work ability, mastery in work may demand more customization, time resources and general effort from the work organization in order to balance the needs of the individual and the organization [39]. Accommodation in this perspective means continuous development of the person–environment fit and the work organization’s mastery and performance climate [48].

Although most employees with TBI in our sample resumed work gradually, we find that RTW is rarely a matter of a cautious start-up that gradually leads to the same job and position as before TBI [20, 21]. Even when employees with TBI achieved a 100% position at an early stage, our study shows that many needed support and customized accommodation over a longer period. As such, the most important indicators of successful RTW after (mild) TBI did not appear in the very beginning of the RTW process, but rather in the subsequent accommodation process in the work organization, which in our study meant 12–16 months after the first attempt at RTW. Since Watkin et al. found similar results [6], it may be important to develop an enduring support model [31, 38] to accompany RTW processes for employees with TBI, regardless of the start-up percentage of RTW.

As we have seen, a supportive work environment at an early stage of the RTW process may later shift in a more frustrating direction. Over time, co-workers and managers in several cases were suspicious that the co-worker thought he or she was sicker than what was the case. This may be related to a lack of knowledge about (mild) TBI, which is often described as an invisible injury [57]. Many of the informants among the managers in our sample referred to the invisible ailments of TBI which they experienced as different from other sick leave causes that they had encountered. Only a few managers expressed familiarity with the long-term aspect associated with TBI challenges. We suggest that lack of knowledge about TBI-related challenges easily, and perhaps also increasingly, generates unrealistic expectations, uncertainty, frustration, and conflict in the RTW process as time goes by. Moreover, the Norwegian welfare system provides employers with a 100% wage refund during the first 12 months of an employee’s sick leave, with subsequent reductions in economic provisions. This creates pressure on employees to return to work and, potentially, a decrease in management motivation to provide accommodation for employees in full-time positions.

A satisfactory work pace means that the demands of the job and the resources necessary to do the job are balanced [36]. Our study indicates that the ambition to implement and develop challenging accommodation often does not last and that over time, in practical RTW processes, intentions of accommodation in the workplace become more focused on the individual’s productive ability than on the social conditions for work performance. Similar observations have been made in research on work inclusion for vulnerable unemployed citizens: obtaining an internship or an easy access job is a different matter from job retention [29, 58]; long-term individual customization is a major challenge, regardless of diagnostic group.

Businesses with a high degree of workplace inclusion seem to differ from other businesses by having a higher degree of employer engagement [59]. In our sample, we find many examples of engaged and appreciative managers with positive attitudes and who show empathy toward the employee with TBI [5]. Engagement may be necessary but is apparently not sufficient for a successful RTW for many employees with TBI. To generate relevant accommodation over time, specific knowledge of TBI-related challenges, combined with work organizational competence [39] in accommodation adapted to changing needs, seem to be important preconditions for a successful RTW for employees with TBI.