The interactive process of negotiating workplace accommodations for employees with mental health conditions

Abstract

BACKGROUND:

Implementing workplace accommodations is an effective means of retaining employees with mental health conditions. However, the process is poorly understood and poorly documented.

OBJECTIVE:

The purpose of this research is to explore the interactive process of negotiating workplace accommodations from the perspective of employees with mental health conditions and workplace stakeholders.

METHODS:

We interviewed employees across Canada who self-identified as having a mental health condition requiring accommodations, and six stakeholders at various workplaces across Canada who are involved in providing accommodations. Data were analyzed using a qualitative descriptive approach to identify key themes.

RESULTS:

The findings highlight that the process of negotiating accommodations is non-linear, interactive, and political. The process is shaped by organizational and political factors and collaboration between stakeholders.

CONCLUSIONS:

The negotiation process is a combination of social, relational and political factors. Clear and accessible accommodation policies, workplace awareness and specific workplace training on how to implement accommodations are needed to optimize the accommodation process for all involved.

Keywords

Mental illness work disability organizational culture

1 Introduction

Workplace mental health problems are associated with significant economic and social burden in Can-ada, resulting from workplace stressors, increased absenteeism and decreased productivity [1, 2]. Workplace accommodations are modifications to the work environment and/or job requirements and providestrategies to enable employees with mental health conditions to perform their job tasks despite the experience of continuous or episodic disability [3]. However, employers often fear that accommodations are costly and unsustainable [4 –7].

Canadian employers have a duty to accommodate employees with disabilities under the Canadian Human Rights Code. While the accommodation process to support employees with physical disabilities has been well documented, the process of accommodating employees with a mental health condition can be more ambiguous and not well understood [2 , 9]. Different workplace conditions are necessary to inform workplace disability policies, and guide and educate managers, human resource professionals, co-workers, disability management professionals and employees with mental health conditions who are seeking support in their work roles [10]. Therefore, increased understanding about how to develop, implement and evaluate accommodations are needed.

A scoping review by McDowell and Fossey [10] of literature published between 1993 and 2013 identified the types of accommodations often adopted to support workers with mental health conditions. The authors found that flexible scheduling, support from employers, support from co-workers and stakeholders, modified job duties and modified employee training were the most common accommodations reported in the literature. Other accommodations for employees with mental health conditions noted in a study by Wang et al. [11] included regular meetings with supervisors, exchanging tasks with coworkers and individualized training. Some studies have also considered accommodations in the context of recruitment, employee retention and hiring practi-ces [12], while other studies have sought to explore the perspectives of employers in hiring and accommodating employees with mental health conditions [13]. Missing from the literature is an exploration of how employees with mental health conditions and stakeholders involved in the provision of workplace accommodations experience the accommodation process, and how accommodations are negotiated within the workplace [9, 10]. A better understanding of the accommodation process can provide insight into how to improve employee retention, work performance, absenteeism, and overall workplace culture and morale [2, 10].

An additional challenge to the accommodation process is the misconception that accommodations are very costly [10 , 14]. In reality, the majority of workplace accommodations for employees with mental health conditions have little or no incremental hard costs to the organization. Rather, the existing evidence on the costs and benefits of accommodations by Schartz, Hendricks and Blanck [15] highlighted that accommodating employees with any type of disability has numerous benefits that outweigh the costs for the organization. Another study by Solovieva, Dowler and Walls [6] identified several workplace benefits to implementing accommodations, reporting that accommodating employees with disabilities is valuable for businesses, as well as for workers and coworkers. A report by the Mental Health Commission of Canada [16] exploring the costs and benefits of retaining employees with mental health conditions within five diverse Canadian workplaces demonstrated a multitude of tangible and intangible benefits to organizations as a result of efforts to accommodate workers with mental illness. These benefits included: improved employee retention, creating an inclusive and positive workplace culture, improved productivity, and reduced absenteeism [16]. Thus, the preponderance of evidence suggests that implementing accommodations is beneficial for employees with mental health conditions as well as for organizations. However, there remains little understanding of how the process of negotiating accommodations for employees with mental health conditions unfolds from the perspective of all those involved.

Within the broader literature on the experiences of employees with disabilities, the process of negotiating accommodations is described as an interactive process that requires input, action and decision making from multiple stakeholders, including the employee [7, 17]. While negotiating accommodations has been defined as an interactive process between multiple stakeholders, there is a very limited understanding of how that negotiation process unfolds. The accommodation negotiation process can be described as somewhat of a “black box”. The purpose of this study is to describe that “black box” by examining the experiences of various employees with mental health conditions and workplace stakeholders involved in negotiating accommodations.

2 Methods

A qualitative description approach was adopted to understand how workplace accommodations are negotiated between employees with a mental health condition and workplace stakeholders [18]. A des-criptive approach aims to develop a detailed understanding of a phenomenon about which there might be little knowledge, and then interpret the findings that emerge while staying close to the lived experiences of participants [18]. It provides the opportunity to understand a phenomenon from the unique perspectives of those with lived experience [18]. This approach provided flexible strategies to explore the process of negotiating accommodations by uncovering who is involved, what the negotiation process entails, and why it is experienced as it is by each perspective [19].

2.1 Data collection

We used purposive sampling strategies to recruit individuals between the ages of 18 and 60 years old who were employed, or recently employed (in past 3 years), in a Canadian workplace. Participants included: a) workers who sought workplace accommodations for mental illness, and b) stakeholders involved in the process of negotiating workplace accommodations (including managers, disability management professionals, human resources staff, occupational health and safety staff). Participants required sufficient English language skills to participate in an in-depth interview without a translator. Ethics approval was obtained from a combined University-Hospital Research Ethics Board.

Initial recruitment was done by emailing individuals who had responded to a prior e-blast sent to employees of Canadian organizations, inviting their organization to participate in a study about workplace accommodations. Some individuals did not meet the criteria for the original study but expressed interest in participating in future research opportunities about workplace accommodations for people with mental illness. Additional participants were sought by asking our network of researchers involved in workplace mental health and work disability to distribute the study poster. Study participants were also asked to forward the study poster to others who might be interested. Sampling aimed for maximal variability to recruit multiple stakeholders with different experiences and perspectives on workplace accommodation practices.

In-depth semi-structured interviews were conducted with each participant, asking them to describe their experiences requesting and negotiating accommodations at their workplace, including the types of accommodations that were available to them, the people who supported them, the nature of the support they received, and any barriers to receiving support. Data collection and analysis occurred in an ongoing, iterative process, with initial analysis used to inform and refine the subsequent data collection,interviews [20].

2.2 Data analysis

The interviews were transcribed verbatim, coded and analyzed using the recursive, six-phased thematic analysis outlined by Braun and Clark [21]. A predominantly inductive approach to thematic analysis was undertaken, to explore what was in the data in relation to participant experiences with negotiating workplace accommodations [21]. Transcripts were uploaded into and coded on Dedoose [22], a cloud-based mixed-method research software that can be used to categorize and sort textual data. The interview recordings were re-listened to, and interview transcripts reread in order to become familiar with the data [21]. Codes were created through multiple readings of the data. Initial line-by-line coding, followed by focused coding and the development of cluster diagrams, or thematic networks, were conducted in order to develop themes that captured the complex experiences described by participants [23]. Initial codes were considered tentative and reflexive notes were taken. Once initial codes and sub-codes began to emerge, more focused coding was used to explore and determine which codes could be merged or developed into themes that captured the experiences of participants as they negotiated accommodations. Codes within each transcript, between transcripts, and in between different types of participants were compared and contrasted to uncover patterns and describe key relationships unfolding from multiple perspectives. Initial themes were shared with the research team and with participants to refine and further develop key concepts [20]. Throughout the coding phase, reflective journals were written to keep track of significant patterns and ideas that emerged. Cluster diagrams, or thematic networks were drawn in order to construct a visual, flexible starting point for developing and filling in themes, and illustrating the relationships between them [23]. Rich quotes from the participants that illustrate each theme are presented to depict that the findings are based directly in the data [24].

3 Results

After describing the participants interviewed for this study, three central themes that describe the accommodation negotiation process are outlined: 1) the negotiation process is non-linear; 2) the negotiation process is social and interactive, and; 3) the negotiation process is political. Lastly, we describe the supports and challenges experienced in the process of negotiating accommodations.

3.1 Participants

Twelve participants were interviewed for this study: six workplace stakeholders with experience in negotiating accommodations with workers with mental illness, and six employees with experience in attempting to access and negotiate accommodations for themselves as a result of mental health issues. The participants were from diverse Canadian workplaces, including a hospital, a residential building, an academic institution, a not-for-profit organization, a mining firm and an aviation company. Participants were employed at organizations of varied sizes; three small organizations (1–99 employees each), three mid-sized organizations (100–499 employees each) and six large organizations (500 + employees each).

Workers with a mental health condition who participated in this research ranged in age from 25 to 61 years of age. There were five workers who identified as female and one who identified as male. At the time of the interview, the participants were employed in a range of positions, including health administrator, caregiver, communications officer, security guard, geologist and mental health manager. The six workplace stakeholders were interviewed to provide insights into the negotiation process from an organizational perspective that extended beyond the individual workers’ experiences. Five stakeholders identified as female and one identified as male. At the time of the interviews, the stakeholders held a range of positions related to negotiating accommodations including health services manager, disability management firm CEO, and director of mental health. Table 1 2 provide a summary of the participants. Pseudonyms are used throughout the presentation of the findings to protect the confidentiality of the participants.

Table 1
Demographic table of employee participants

Pseudonym Age Gender Employment Status Work Sector Size of Organization Accessed Accommodations? Who did you go to?

Employees

Tom 30 M Part time; Security guard Security personnel Small No; attempted unsuccessfully Direct supervisor

Wendy 25 F Part time; patient administrator Health administration Mid Yes Occupational health and safety coordinator; manager

Brenda 61 F Full time; Geologist Mining and exploration Mid Yes Manager, department VP

Kaitlyn 54 F Full time; family caregiver, previously hospitality industry Caregiving, previously service sector Small No Multiple managers

Julie 50 F Full time; mental health manager Not for profit organization Large Yes Direct supervisor &HR

Ariel 25 F Full time; Communications assistant Healthcare Large Yes Direct supervisor &HR

Pseudonym	Age	Gender	Employment Status	Work Sector	Size of Organization	Accessed Accommodations?	Who did you go to?
				Employees
Tom	30	M	Part time; Security guard	Security personnel	Small	No; attempted unsuccessfully	Direct supervisor
Wendy	25	F	Part time; patient administrator	Health administration	Mid	Yes	Occupational health and safety coordinator; manager
Brenda	61	F	Full time; Geologist	Mining and exploration	Mid	Yes	Manager, department VP
Kaitlyn	54	F	Full time; family caregiver, previously hospitality industry	Caregiving, previously service sector	Small	No	Multiple managers
Julie	50	F	Full time; mental health manager	Not for profit organization	Large	Yes	Direct supervisor &HR
Ariel	25	F	Full time; Communications assistant	Healthcare	Large	Yes	Direct supervisor &HR

Table 2

Demographic table of stakeholder participants

Pseudonym	Gender	Job Role	Sector	Size of Organization	Duration of Job Role	Experience negotiating accommodations
			Stakeholders
Margerie	F	Director, client relations	Disability management firm; for profit	Small	1 year; 10 + years in disability management	Yes, with a focus on MI, return to work and disability claims
Jared	M	Health services manager	Travel, transportation industry	Large	4.5 years	Yes; responsible for temporary and permanent accommodation
Samantha	F	Managing director	Disability management firm; for profit	Small	20 years	Yes; hired by organizations to manage accommodations for physical and mental health conditions
Debora	F	Director	Mental health services; not for profit	Large	11 + years	Yes; developed return to work and accommodation plans for workers with mental health conditions
Elizabeth	F	Occupational health nurse	Academic institution	Large	N/A	Yes; accommodates workers returning to work after physical and mental health sick leave
Kate	F	Disability manager	Healthcare	Large	20 + years	Yes; accommodates and facilitates return to work for short- and long-term absence; physical and mental illness

3.2 The accommodation negotiation process

The findings from this research highlight a complex negotiation process, starting when the employee with a mental health condition requests an accommodation to support them in their work role. The first theme highlights the social and interactive nature of the negotiation process. The second theme characterizes this process as non-linear and comprised of both formalized practices that are routine, and pre-established within the organization’s policies, and informal practices that occur on a case-by-case basis, and may be implicitly known to some workplace stakeholders, but not always to employees. The third theme presents the process as political, where access to support is influenced by various internal and external forces including employee position and status in the workplace, seniority and the decisionmaker’s perceived return on investment for the organization. The fourth theme illustrates the forces influencing the negotiation process, and highlights the factors that are experienced as helpful, and those that are experienced as challenging, for both employees and stakeholders.

3.2.1 A social, interactive process

This theme illustrates the social, interactive nature of the negotiation process; interactions and collaboration between the employee and stakeholders were reported to be essential for accommodations to be negotiated and implemented successfully. Two tiers of stakeholders and their potential roles were identified, and tensions around unequal employee-stakeholder interactions were discussed.

Employees and stakeholders described the accommodation negotiation process as an interactive pro-cess that unfolds through collaboration between the worker and both internal and external workplace stakeholders (see Fig. 1). Internal stakeholders were those in the workplace, while external stakeholders were those outside of the workplace. The participants described how multiple workplace stakeholders interact with and support the employee at various points in the negotiation process. Debora, the director of a workplace mental health organization, explained that a negotiation process with the employee at the center is more likely to be successful, as it enables the employee to feel empowered and involved in supporting their own success. She reported seeing the negotiations as “more supporting and coaching an employee to come up with their own solution.”

Fig. 1

Map of 2 tiers of stakeholders involved in the negotiation process.

Internal stakeholders were actively part of the discussions, negotiations and implementation of acco-mmodations. Internal stakeholders included direct supervisors, union representatives, occupational hea-lth and safety staff, human resources staff, other health service professionals, disability management consultants and/or return-to-work coordinators. Internal stakeholders also included co-workers who work directly with the employee receiving accommodations and who may be affected by the workplace accommodation. External stakeholders were reported by some managerial participants to have a less dir-ect role in negotiationg accommodations for the emp-loyee; they often assisted the internal stakeholders in guiding the accommodation process or providing support to the employee. External stakeholders incl-uded the employee’s health providers, the employee’s family members, and/or religious advisors.

The employee’s first point of contact in the accommodation process seemed to depend on many factors including the structure of the workplace, the availability of supports, the worker’s employment status, access to a trusted confidante, and the overall workplace culture. The first point of contact was often the direct supervisor or manager but could also be someone in human resources. A number of workplace stakeholders and employees reported that if employees don’t feel comfortable disclosing to their supervisor, they may turn to someone else who they trust, or refrain from disclosing altogether. Debora stated:

Ideally, they would go to their direct supervisor or manager but . . . that person (supervisor) is not always supportive. And so then we talk about all the other people that are available. So, the union rep if you are in a unionized environment, occupational health profession- if there is a nurse or a doctor. It could be human resources, it could be a senior leader, and it could even be like health and wellness people or disability management.

The interactive nature of the accommodation pro-cess was reported to be especially important during the decision-making stage, where stakeholders made decisions either formally or informally on whe-ther the accommodation request would be granted and how. The decision-making was reportedly infl-uenced by an ongoing discussion between the employee and stakeholders, medical evidence, the employee’s functional limitations and needs, job du-ties, and adherence to the workplace policies. Several employees and stakeholders at mid-sized or large organizations reported meeting with multiple stakeholders such as HR staff, occupational health staff, managerial staff and union members both before and after an accommodation was granted and implemented. Some employees at smaller organizations or organizations without a department responsible for work disability reported that the negotiation process involved fewer stakeholders but still unfolded as a social, collaborative process. In smaller organizations, direct managers were often the primary decision-maker.

In contrast, some employees reported a much less collaborative experience of negotiating accommodations. Rather, they felt that their workplace was simply trying to adhere to organizational requirements, instead of collaborating to negotiate an ind-ividualized accommodation plan. In these cases, there was little reciprocal interaction. Instead, some employees explained that they followed the required steps to have their request for support considered, while workplace stakeholders gathered information, and proposed a plan that the employee was expected to accept. For example, Wendy, a part-time health administrator described being disappointed about how her accommodation request was discussed with her health and safety coordinator, as she expected more of a collaborative, reciprocal exchange:

I absolutely understand it as a two-way system, right? Me providing exactly what I need as a worker and for her to give feedback in terms of what she’s also found . . . . That discussion never happened, it was more so ‘hi, how are you feeling? Here are the things I would like . . . . We are done working on your accommodations’ . . . it feels a little like I was given the short end of the straw . . .

3.2.2 The accommodation negotiation process as non-linear

The findings highlight that the negotiation process may not always follow an anticipated linear trajectory, and challenges the idea that the accommodation planning process needs to always unfold in a sequential and formal fashion as prescribed by some workplace policies. Rather, the negotiation process, as described by participants, was often non-linear, osc-illating between formal and informal processes, and shaped by situational factors.

Employee and stakeholder descriptions of the negotiation process revealed a complex combination of formal and informal micro-processes that often followed a non-linear trajectory and depended on the needs of the worker, the nature of the work, and the nature of the workplace. For example, Kate, a disability manager at a hospital, described the variability in how the accommodation process can unfold: “it depends on the manager, it depends on the employee. It depends if it’s a good employee or not”.

A formal agreement for an accommodation was described by stakeholders as a written agreement outlining the nature and duration of the accommodations based on medical evidence about the employee’s restrictions and limitations, and the essential job tasks. Informal accommodation practices, on the other hand, were described by participants as arising through discussion and verbal agreement between the employee and their supervisor. Samantha, a director at a disability management firm, describes an example of an informal accommodation process:

When an employee goes to a manager, and says, “I’m not coping very well, can I just work until 3:00 every day for the next couple weeks, because I have to go see my dying mother, and I’m just –I can’t even concentrate by noon?” And they come up with this informal understanding.

Informal accommodations were sometimes preferred by stakeholders when the accommodation was perceived as relatively straightforward and temporary. Elizabeth, an occupational health nurse at an academic institution, reported that when an accommodation request is short term and temporary, her team “tends to steer away” from implementing a formal process.

Stakeholders expressed mixed views about whet-her or not accommodations should be formalized. On one hand, some supervisors and disability man-agement professionals reported a preference for formalizing accommodations by establishing responsibilities, timelines, stakeholder expectations and projected steps in a contractual agreement that had a clear, often linear, trajectory. These stakeholders reported that formalizing accommodations enabled them to establish the projected duration of the accommodation plan, protect the employee and decrease potential for miscommunications. Some stakeholders reported that balancing these priorities was necessary to protect the organization from hardship in the long term, to protect the employee from having an accommodation retracted by the organization down the road, and to set a precedent for other employees who may request accommodations in future. Other workplace stakeholders reported that their organization favored informal arrangements in most cases, despite the risk of increased vulnerability due to of organizational changes, the potential for miscommunication about the accommodations, and lack of accountability. According to these stakeholders, info-rmal arrangements were more fluid and flexible, which allowed for ongoing adjustments as needed. As described by Kate, a disability manager, the accommodation process did not always follow a linear, concrete steps:

I do have managers who make informal arrangements, which is totally fine with us. The difficulty is if the manager makes an informal arrangement that goes on for a long period of time . . . then the manager is like, ‘why am I doing this?’ The advantage of having it formalized is it tracks it and it makes it specific. I think there’s a lot of advantage to the informal accommodations when the manager and the employee have a good relationship.

An additional challenge that was associated with a formalized process was the requirement to disclose personal information to multiple workplace stakeholders. Some employees reported feeling vulnerable and self-conscious when multiple workplace actors were involved in negotiating the accommodations. This challenge was described by Wendy, a part-time employee at a large health services company; “with the two managers, the union representative, the coordinator and myself . . . it does kind of make me feel more vulnerable... I have some discomfort in it because I’m having to disclose this information to people that I’m not particularly close with.” In these circumstances, employees reportedly preferred an informal arrangement with just their supervisor that could be revisited as needed. The capacity to revisit and revise the accommodation plan was reported by stakeholders as particularly important in addressing employee mental illness, which was often episodic, with unique needs and restrictions. Therefore, a non-linear, flexible negotiation process was reportedly anticipated by many workplace stakeholders when accommodating employees with mental illness.

Overall, workplace stakeholders expressed that the negotiation process often unfolded as non-linear, rather than proceeding exclusively as either a formal or informal accommodation agreement. There was often oscillation between formal and informal processes, or concurrent formal processes and informal discussions depending on many situational factors, including: the organization’s practices and available resources, the needs of the employee, the nature and scope of the request, the relationships between the employee and stakeholders and whether the accommodation was expected to be temporary or permanent. An example of adjusting the negotiation processes based on situational factors was illustrated by Jared, a health service manager who stated that, in unionized workplaces, formalizing accommodations was a best practice approach because “the union members need to see that there’s been a valid, formalized, considered process”. Elizabeth, an occupational nurse in the Human Resources department of a large organization, describes the situational factors that might determine whether an accommodation should be formal or informal:

If it’s something in short-term and temporary, my recommendation would be just to manage it with the manager. But if it’s something that requires significant accommodation or like a rearrangement of the job duties . . . it would probably be best, just based on my experience, to have something on file already that will follow through even if the department changes or the manager changes.

When the accommodations were expected to be permanent or required a restructuring of the employee’s responsibilities, an overarching formal accommodation process was typically preferred by workplace stakeholders in order to establish accountability and have a document to refer back to with time. However, when the support was anticipated to be a relatively simple adjustment or short-term, some internal stakeholders reported a preference for negotiating accommodations informally, through discussion with the employee’s direct manager or supervisor.

3.2.3 A political process: Position and seniority impact access to accommodations

This theme illustrates that employees experience an unequal, varied ability to successfully and smoothly negotiate accommodations in the workplace. Factors that impact access to both specific accommodations and universal supports were identified and considered in context of the negotiation process.

The capacity to access and successfully negotiate accommodations varied across the employee participants, often depending on their work sector, and their position of influence, reflected by their job status and seniority within the organization. For example, many employees reported that flexible schedules and options to work from home would be helpful, but that these were not viable options in every workplace or for all employees. Some employees who were employed on a casual or temporary basis reported that when they approached workplace stakeholders to access universal supports or negotiate individualized accommodations, they were faced with uncertainty, as the workplace policies did not clearly outline what supports they were entitled to. For example, Wendy, a part-time, temporary worker described continued delays getting a light changed in her workspace that was causing her migraines, “if I were a permanent staff member, I wouldn’t have had to wait a month to have the light taken off.”

Several employees reported a disparity across employees in access to both universal supports (that are supposed to be available to all employees) and individualized accommodations, noting that there were differences depending upon job roles, status and seniority. For example, some part-time, contract, seasonal and temporary workers reported an implicit understanding that their access to supports may be more limited than full-time, permanent employees, and attributed it to a perception of their disposability within the organization. Kaitlyn, a seasonal employee who has worked in multiple service industry roles described this hierarchy: “The lower down the rung you get . . . the less ability you have to access those resources that you need. They only reserve those types of resources for people who are there permanently and we all know that.” Similarly, Tom, a security guard who worked on a casual basis, reported feeling “nervous and scared” to disclose his mental health condition and request an accommodation in case he was given fewer shifts; his position in the workplace was not stable, and his relationship with management was “very tough”. Tom reported that he never received support and was always “given the runaround” from whomever he asked. In contrast, Brenda reports a different experience as a well-reputed, senior employee at her company for many years:

We are allowed to come in anywhere between say, 6:30, and 9:00. And all this is to support my mental health. If I have counseling sessions, I always do them first thing in the morning, or after work. And they’re really flexible, I come in 9:00, 9:30, and nobody worries about it as long as I get my work done. And I often stay till 6:00, 6:30 if I’m on a roll . . . And they trust me, they know that I will do my best to get it done.

The disparity in access to supports for full-time, permanent employees in contrast to part-time, contract or temporary employees was attributed by some workers to how their organizations perceived the return on investment of providing accommodations. Accommodations were described by workers and stakeholders as resources expended by the organization, with a preference reportedly given to workers who were deemed a reliable return on investment. As described by Ariel, a full-time employee at a hospital, “what’s the point of them putting resources in you if you’re not even going to get that much better?” Kathy, a mental health manager described that from a stakeholder perspective, some employees were viewed as more valuable, less disposable and more worth the investment of accommodations than others. She further stated that while perceived return on investment does not completely determine who is able to easily access accommodations and support and who is not, it is an important factor that receives some consideration from stakeholders when negotiating accommodations. She states “I do think there is a blend between ‘do they like the worker?’, and if they like the worker, ‘is the inconvenience of them being off work worth investing in to have them come back?”

3.3 Workplace structures and supports experienced as helpful

This theme focuses on the workplace forces that were experienced as helpful by workers and stakeholders for a smooth, supportive negotiation process.

3.3.1 Genuine, shared intentions for employee success

A number of workplace stakeholders reported that successfully negotiating accommodations requires the reciprocal efforts of all parties, and a shared intention by all stakeholders to support the employee. These factors were emphasized by Debora, a disability manager and director of a workplace mental health firm:

A genuine intention to help [the worker] be successful at work on the part of everyone who is involved. That sounds simple but many people are just looking at pushing paper or they are looking at the disability . . . . They are really not considering the human being and what would make them successful.

3.3.2 Stakeholder dedication, empathy and experience level

The negotiation process was described by stakeholders and employees as a relational process; the worker and internal stakeholders need to be able to relate to each other and mutually fulfill their roles for a smooth negotiation process. Several employees reported feeling more supported and assured during the process when internal stakeholders, particularly their direct supervisor or manager, dedicated time to supporting them, invested in them as an employee, and showed empathy and understanding of their needs for accommodations. As described by Julie, a mental health specialist who required accommodations, management’s ability to recognize when an employee is struggling in their work and know about possible accommodation strategies provided a positive accommodation experience: “I had a manager who was trained, who understood, who was compassionate. And was willing to put in the blood and tears to work with me to get me back because she saw the value in the work that I did.”

A number of employees reported feeling more assured and comfortable during the accommodation process when their supervisor had some prior experience negotiating accommodations to support mental health conditions and had a good understanding of how to facilitate psychological safety at work. Debora, a workplace stakeholder, emphasized that internal stakeholders do not need to be mental health experts to effectively implement accommodations. Rather, the focus should be on supporting individuals to excel at work:

We do not want employers to become mental health experts. What their responsibility is, is to become aware of how they positively or negatively impact psychological health and safety. Their job is to help that person to be successful at work and link them to other resources that can help them with everything else.

Conversely, employees reported that the negotiation process could be distressing when they did not feel supported and guided by internal supports who have knowledge and experience related to accommodations. Wendy, a part-time employee at a health administration company described her qualms with the health and safety coordinator who was responsible for guiding the accommodation process:

Because she doesn’t seem to have a good idea of what exactly this treatment is, what it enta-ils . . . she can’t help guide me in terms of suggestions that she might have as a healthcare professional . . . So I’m kind of having to navigate things on my own. I don’t think I was ever provided suggestions of what she had found helpful . . .

3.3.3 Psychological health and safety in the workplace

A strong psychologically safe work environment was reported by stakeholders to foster a smoother, more supportive accommodation process. A psychologically safe workplace was described by workplace stakeholders as one that is inclusive, where employees feel secure in their job should they disclose their MI and their need for accommodations. Employees and stakeholders both described that psychological safety fostered open and honest discussions about mental health and wellness between workers and internal stakeholders. Furthermore, Debora, a mental health service director, described a psychologically healthy and safe workplace as one where “people are given the skill set to be able to speak up, to disagree in a respectful way” through mental health awareness training and policies that ensure fairness and protects against discrimination and harassment. Elizabeth, a stakeholder in an occupational health and safety role described a psychologically safe workplace as one that embraces inclusivity, “if you have a culture that’s supportive of inclusion and fairness and actually talks about accommodation, that can be very helpful”. Within a psychologically healthy and safe work culture, employees may be more likely to talk openly about their accommodation needs in the workplace.

3.3.4 Establishing clear accommodation policies and practices

Many of the employees who participated in this research reported being unsure of their company’s policies on accommodating mental health conditions, what they can realistically request or expect, or what their rights are during the accommodation process. Ariel, a communications coordinator at a hospital stated that she is “already going through enough stuff. If I’m asking for accommodation . . . the last thing I want to do is go see this small print of our collective agreement”. Thus, a lack of understanding of workplace accommodation practices can be an additional stressor for employees. Ariel and others noted that pamphlets and other resources in the workplace could be helpful to share information about accommodations. In addition, they felt that specific information about the rights and responsibilities of both employees and of the organization would be helpful when requesting, negotiating and implementing accommodations. Wendy, a part-time health administrator noted her uncertainty about accommodation policies at work, stating that, “they should have some sort of proper manual . . . ”

3.3.5 Maintaining communication during and after negotiating accommodations

Both employees and workplace stakeholders hig-hlighted the importance of maintaining regular communication among all stakeholders throughout the accommodation process. As reported by some managers and return-to-work professionals, maintaining constant contact with the employee provides opportunity for encouragement and support, while ensuring all stakeholders are kept informed about progress. It is often a time of stress and uncertainty, and workplace stakeholders were in agreement that checking in can be very helpful, reduce stress and allow the employees to ask questions about the process. Jared, a health services manager stated that his organization provides regular check-ins for employees receiving accommodations, to offer adjustments or improvements. Samantha, the director of a disability management firm noted that communication is particularly important when the employee is off work and attempting to return:

The tendency would be not to ever call them because you don’t want to bother them but it’s even more crucial that you do. Communication is number one, talking to the employer right away, telling their supervisors, “hey, by the way, I think this employee is coming back in two months.” Telling HR, “hey, be ready, we are going to do this.” Just keeping everybody in the loop.

3.4 Elements experienced as challenging during the negotiation process

This theme identifies and describes the factors that were experienced as challenging by employees and stakeholders while requesting and negotiating accommodations.

3.4.1 Stigma around discussing mental illness in the workplace

The lack of awareness, stigma and discomfort around mental illness from managerial staff and co-workers was described as a key challenge by employees and stakeholders, particularly while requesting, negotiating or attempting to implement accommodations. As a result, some workers reported that they feared disclosing their needs, disguised their need for support into something more acceptable, and often struggled in silence. Kaitlyn, a former part-time employee in the service industry described the struggle to hide her mental health condition at work at times when she really needed support, “it was kind of me disguising what was going on, like for instance I had a relative who died and I couldn’t go to my boss and say help, I’ve gotten lost in the deep end, I’ve gone little psychotic here, and it’s kind of really a rough week.”

Kaitlyn further described her tendency to “package” her need for support into something more acceptable due to how mental illness was viewed in the workplace, “because people still look at it as crazy . . . And crazy is something that those people don’t want to work with”. This negative discourse around supporting employees with mental illness is in contrast with how physical injuries and illnesses are viewed in the workplace. For example, Samantha, a disability manager, illustrated the disparity between workplace attitudes about physical disabilities and the inadequate discourse on mental illness, “so, it’s really a discomfort . . . . But we don’t have it with a broken leg, why do we have it with a broken mind? But people do.”

3.4.2 Employer capacity

Negotiating and implementing accommodations was reported by a number of workplace stakeholder informants to vary depending on the organization’s administrative and financial resources, and sometimes, the priority and dedication given to mental health and wellness in the workplace. Some disability management professionals stated that smaller companies may lack the resources to formally guide and effectively implement accommodations. In such organizations, the direct manager may be the only person who is able to implement any support. However, if the manager lacks experience negotiating accommodations, they may have few resources at their disposal to support employees. As described by Elizabeth, an occupational health nurse at a large academic institution, “if you’re a manager and you don’t know how to accommodate, or even what your responsibilities are, if you don’t have additional supports within the organization, that can make it very difficult.” This situation may make employees in small organizations particularly vulnerable.

The findings from this research illustrate a complex negotiation process that unfolds between multiple workplace actors through various formal and informal workplace practices. Furthermore, this research identified a number of the workplace structures and supports that were experienced as helpful, and highlighted some of the challenges experienced while negotiating accommodations.

4 Discussion

This study provides insights into what occurs as employees with mental health conditions negotiate workplace accommodations by identifying and describing how this process unfolds. The study findings highlights that the negotiation process can be nonlinear, political, interactive and relational. While many workplaces mandate a sequential or stepwise, formal negotiation process, this study found that, in reality, many workers and other stakeholders experience the process as a combination of formal and informal interactions, with tensions that may arise related to accessing supports, trust, “pecking order”, seniority and work culture. These are all key elements of the negotiation process that have received limited attention in the context of supporting employees with mental health conditions. Previously, the accommodation negotiation process could be described as somewhat of a “black box”. The findings of this study have shed light on the “black box”; highlighting an interactive process that requires cooperation, collaboration and communication between employees, internal (workplace) and external stakeholders. This study has also identified facilitators and challenges experienced by employees and workplace stakeholders while negotiating accommodations. Specifically, an individualized, flexible approach, with shared efforts from the employee and stakeholders was found to be most helpful, along with a genuine intention to support the employee so they can successfully fulfill their work role.

These findings are consistent with existing research by St-Arnaud et al. [17] who found that stakeholder collaboration is a key factor in supporting employees with mental illness in Canadian workplaces. The current study expands on the findings by St-Arnaud et al. [17] by highlighting that employees experience a more positive negotiation process when workplace stakeholders are well informed about how to accommodate employees with mental illness and how to foster a psychologically healthy workplace. In particular, this study highlights that sufficient administrative and knowledge resources within the workplace to support employees requesting accommodations can improve the experiences of all stakeholders. However, the findings also highlight ongoing challenges that can be experienced during the negotiation process. Challenges include the stigma related to mental illness in the workplace, persuading senior management to “buy in” to mental health supports, and lack of financial and internal resources to support the employees’ needs.

This study shifts the focus to the experiences of employees who remain at work, and how they are supported while requesting and negotiating accommodations. There is limited literature focused on the workplace accommodation process for employees with mental health conditions. Rather, the existing literature focuses on drawing attention to the unmet needs of employees with mental health conditions that require accommodations, and identifying the common or reasonable accommodations available for employees with mental health conditions [10] with some literature addressing employer perceptions about the costs and benefits of accommodations [11, 14]. A longitudinal cohort study of adult employees in Alberta, Calgary [11] indicated that while 83%of employees with a diagnosed mental health condition, only 30.5%had received accommodations, highlighting the unmet support needs of employees with mental health conditions. The study further identified some accommodations that employees with mental health conditions reported would be helpful for them. A descriptive, longitudinal study by MacDonald-Wilson et al. [5] explored the reasonable accommodations provided to adults with mental health conditions placed in employment through supported employment programs. The study identified a number of common accommodations. While employers were concerned about the direct financial costs of providing accommodations, the costs of accommodations for mental health conditions were more often indirect costs in the form of flexible scheduling, support from job coaches and extra supervision or training. These studies highlighted that employees with mental health conditions require better support in the form of implementing accommodations. Our study addressed the process of discussing and negotiating those accommodations.

In accordance with findings by Gold, Oire, Fabian and Wewiorski [25] who reported a disparity between larger and smaller organizations in resources, cost consciousness and flexibility for accommodations, our study found that larger organizations may have greater organizational and financial resources available for accommodating employees with mental health conditions, and more structured policies and procedures to guide stakeholders and employees when requests for accommodation are made. In addition, the findings of this study highlighted some of the potential challenges faced by workplace stakeholders and employees with mental health conditions in smaller organizations. The existing literature demonstrates that specifically, some smaller organizations may have less capacity to modify job tasks, fewer resources, less access to specialized knowledge and training about accommodations, and less experience accommodating employees [26, 27]. Our study findings further support the identified need to address the potential constraints experienced by employees and managers at smaller organizations to successfully negotiate and accommodate employees.

This study found that there is a need for externally developed, accessible, tools for smaller organizations trying to support and accommodate employees with mental illness. Such tools exist, including those developed by Great West Life’s Workplace Strategies for Mental Health [28] and the National Standard of Psychological Health and Safety, developed, in part, by the Mental Health Commission of Canada [29]. Although some stakeholders are gaining more awareness of these tools and guidelines, and seeking to implement them in Canadian workplaces, a qualitative study by Shankar et al. [30] on employer perspectives of accommodating employees with mental illness reports that there is still limited evidence of changes in employer attitudes about hiring and accommodating employees with mental health conditions.

The findings also suggest that tools, training and education could be more effective if they are provided to individuals at all levels of the organization. Thus, making resources available to senior management, middle managers and other employees could be beneficial. Most accommodations are developed and implemented rigidly following formal workplace policies and may not address problematic organizational culture that can make the accommodation process challenging for employees with a mental health condition [31]. A successful and sustainable accommodation plan requires attention to the social context in which the accommodation plans and tools are being implemented [31]. There is some evidence that organizational culture can contribute to symptoms of psychological distress in employees, and that a work culture that is responsive to employee needs is especially beneficial for employees with disabilities [32, 33]. However, there is a need for further focused research on how organizational culture may impact supporting and accommodating employees with a mental health condition.

An ongoing challenge is the misconception held by workplace management that accommodations for mental health conditions are costly, both financially and in time investment [4 , 5]. This study found that addressing these misconceptions is complex. One path forward is to persuade senior management to accept mental illness as a valid condition that requires resources and support; this can be addressed through workplace education that can be formal, such as workshops and courses, or more informal such as lunch and learn sessions [14]. While some workplace stakeholders report adhering to organizational policies around accommodations, employees seeking accommodations are rarely aware of these policies and practices, or their rights during the accommodation process [2]. It could be beneficial for more Canadian workplaces to establish clear and accessible resources that outline the accommodation process, the organization’s accommodation policies, and employee and stakeholder rights and responsibilities. An online or in office resource of this nature would be beneficial for employees seeking accommodations, those in the process of negotiating accommodations, and serve as an educational guide of best practices to stakeholders involved in the accommodation process.

4.1 Strengths and limitations

A key strength of this study comes from the unique insights about the accommodation process described by experienced stakeholders and employees in varied roles and workplaces across Canada. A key limitation of this study may be the small sample size of 12 participants. The sample size reflects the limited scope of this project and focuses on exploring varied experiences of the negotiation process, with the aim of constructing themes that meaningfully captured the lived experiences of the participants in relation to the research question [21].

Another limitation of this study is that many of the stakeholder participants self-identified as advocates for workplace mental health and were well versed in current policies and Canadian discourse on workplace disability. As such, the findings may not be generalizable to workplace stakeholders who may have less knowledge and experience with workplace accommodations and employee mental health. Furthermore, this study did not include the perspectives of coworkers, who were reported by employees to be key stakeholders during and after the accommodation negotiation process, and the data was limited to the experiences of participants at one point in time. Thus, the findings may lack insights on how co-workers as a key stakeholder group contribute to employees’ experience of negotiating accommodations, and how the experience of negotiating accommodations changes over time. An additional limitation of this study is the over representation of female participants, with 10 female participants and 2 males. More research is needed to explore gender differences in perspectives and experiences. Finally, data about race and income were not collected from participants to examine how these impacted their experience of negotiating accommodations. Further research is required to highlight how discourse on race, job type and income contribute to the accommodation negotiation process for employees with mental illness.

5 Conclusion

This study contributes to the literature on the process of negotiating accommodations for workers with mental health conditions in the context of a range of Canadian organizations. By shedding light on the elements of the accommodation process rather than the accommodations themselves, this study defines the negotiation process as one that is often non-linear, social and political. The findings indicate that when the black box of the negotiation process remains ambiguous, both employees and employers experience challenges around providing and receiving support and negotiating accommodations. The study also contributes insight into what is helpful and what is challenging for employees and stakeholders, and informs more supportive training, policies and practices surrounding workplace accommodations for employees with mental health conditions. The findings point to the need for clear, accessible policies and tools around requesting and negotiating accommodations that are available to both employees and workplace stakeholders. Such policies can inform, educate and guide stakeholders when an employee requests an accommodation and the negotiation process begins. There were unique challenges noted in small and mid-sized organizations, where there may be a need for externally developed, accessible and user-friendly tools to address their limited resources in structure, finances, knowledge of best practices and training to successfully accommodate employees with mental illness. Future research should be directed at exploring the successes and challenges of smaller organizations in supporting employees who require accommodations, and the specific needs of workplace stakeholders in smaller organizations. Although workplace accommodations have been shown to be beneficial and effective for supporting employees with mental health conditions, the findings of this work and existing literature highlight that employers continue to struggle with negotiating and implementing effective accommodations for this population [33]. By engaging employers and disability management professionals to adopt guidelines and tools to better accommodate employees, and fostering psychologically health safe workplaces, the work experiences and outcomes of employees with mental health conditions can be further elevated.

Footnotes

Acknowledgments

We would like to express our gratitude to Dr. Nancy Carter for her feedback and expertise in qualitative health research, which has been instrumental in shaping the emerging messages of this work.

Also, this work would not have been possible without the participants who shared with us their lived experiences, insights, struggles and triumphs. We feel honored to have been able to hear and share their stories.

Conflict of interest

None to report.

Funding

This research was completed as part of the requirements for a Master’s of Science in Rehabilitation Science by Sabrina Hossain at McMaster University. Sabrina Hossain received a graduate student stipend from the Centre for Research on Work Disability Policy (SSHRC partnership award # 895–2012–1017).

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