The nature of positive encounters between disabled workers and insurers in the return to work process

Abstract

BACKGROUND:

Previous research regarding interaction between disabled workers and insurers indicates that encounters between these parties are predominantly negative in nature and may result in psychosocial harm for workers. Further research is required to investigate positive interactions to foster return to work after illness or injury.

OBJECTIVE:

To explore and conceptualize perceived positive encounters between disabled workers and insurers in order to identify the mechanisms that support successful rehabilitation outcomes.

METHODS:

This qualitative study explored the experiences of twenty-four disabled workers who had undergone an occupational rehabilitation process. Data were collected with in-depth semi-structured interviews, transcribed, coded, and analyzed using inductive content analysis.

RESULTS:

Four main themes arose from the 24 key concepts relating to the positive encounters: (1) process flow, (2) customer orientation, (3) information and guidance, and (4) service attitude. The results also reveal that perceived positive encounters promote the return to work not only directly, but also indirectly by improving the informants’ motivation, which has previously been found to be one of the most significant factors explaining the outcomes of rehabilitation.

CONCLUSIONS:

The positive relationship between disabled workers and insurers during an occupational rehabilitation could be better understood through a conceptualization of perceived positive encounters. Underlining the importance of positive encounters and their ability to improve the rehabilitee’s motivation may contribute to better support methods for the return to work.

Keywords

Disability insurance return to work insurer role rehabilitation motivation

1 Literature review

In the last few decades, the scope of research on the return to work has expanded from predominantly medical approaches to a more holistic view incorporating psychological and sociocultural aspects. At the same time, the rehabilitation process itself has gained more attention, and scholars have taken greater interest in a systems approach by examining the role of stakeholders –most often employers and co-workers, insurance companies, healthcare providers, and specific compensation systems –in the return to work process [1 –6]. The current evidence suggests that positive encounters between different stakeholders and disabled workers may improve rehabilitation outcomes [6 –11], whereas negative interactions may result in considerable psychosocial harm to disabled workers [2 , 12–13].

The majority of earlier research related to encounters between insurers and workers within the rehabilitation and return to work process is related to the workers’ compensation system, since other causes of disability do not qualify for insurance compensation in countries that rely on cause-based income support systems for workers [4 , 13–15]. However, several countries have a disability-based income support system with no need to show the causation of disability. Hence, there are also studies that explore the encounters between sick-listed workers and social insurance office staff within the disability-based insurance systems [12 , 16–17]. According to the results of these studies, encounters and interactions between insurers and workers are similar regardless of the differences in compensation systems.

The data of this study is gathered from Finland, where there is both a cause-based workers’ compensation system and a disability-based sickness and disability insurance. If there is no causation of disability, the earnings-related insurance system pays compensation for loss of earnings during the rehabilitation and disability of those who are currently working or have an extensive work history. The administration of the earnings-related disability benefits is decentralized to several authorized pension providers, which include pension insurance companies. These insurance companies are responsible for administratively managing the disability compensation claim: they assess eligibility for benefits and rehabilitation measures, manage costs, and oversee the process of returning to work. Insurers are also responsible for the coordination of occupational rehabilitative activities [18]. Thus, the role of the pension insurance company in Finland is similar to the role of workers’ compensation insurers.

The workers’ experiences of the entire return to work process has been studied quite extensively [1 , 19–20]. In addition, there are a few empirical studies with a narrower focus dealing with the positive and negative encounters between disabled workers and insurers within the workers’ compensation system [4, 21] or between disabled workers and social insurance officers [12 , 22–24]. Furthermore, Kilgour et al. [2] have conducted a systematic review focusing on encounters between injured workers and insurers in workers’ compensation systems. According to this systematic review, most interactions between workers and insurers are described as cumbersome, frustrating, and demeaning, whereas positive interactions involving respectful, understanding, and supportive attitudes were reported less frequently [2].

Some key concepts relating to the encounters between disabled workers and insurers can be found in the previous studies. First, there is evidence of perceived claims manipulation and hurdles to medical treatment and occupational rehabilitation by insurers [2 , 25]. Second, the issue of poor legitimacy is raised in various studies [2 , 21]. The insurance representatives seem to have suspicious attitudes regarding the credibility of claims, so the return to work process involves stigmatization, surveillance, and disputes regarding compensation [2 , 19]. Both claims manipulation and mistrust can be explained by the conflicting objectives and incentives of the insurers and workers, since the insurer’s primary motivating factor is to minimize the costs of claims [26].

Third, the studies also report a lack of professional expertise, including incorrect information and disrespectful treatment by insurance representatives [13 , 25]. In addition, a majority feels lonely and unsupported in the rehabilitation process [6, 20] and the encounters with insurers are described as random; after years of silence, there might be sudden pressure to make rushed decisions [1–2]. Another deficiency concerns communication. Getting in touch with the insurance representatives is difficult, and face-to-face contact with them is often impossible. The interactions often occur in writing, but letters sent by the insurer are perceived to be impersonal and formal; they are often filled with legalistic jargon and are thus hard to understand. [1–2 , 16]. On the viewpoint of the insurers, the complexity of the compensation process can lead to a misunderstanding as well as disinformation and cause a negative view of the system [27].

Another major theme concerning encounters between disabled workers and insurers is the claimant’s lack of control in the rehabilitation process. Disabled workers feel excluded from decision-making, while insurers unilaterally determine the timing and modes of retraining or working without consulting the claimants or introducing alternative work prospects [2 , 19]. A number of studies also show that disabled workers lack information about their rights in the compensation system and the processes of claims and rehabilitation, which only intensifies feelings of helplessness and being at a disadvantage [2 , 21].

On the contrary, positive encounters between insurers and disabled workers seem to be very limited. However, a few studies report about continuous personalized services, timely payments, received referrals for medical services, and improved access to treatment because of claim status. Furthermore, some disabled workers have experienced feelings of being respected, understood, supported, and well-informed [14 , 21].

Overall, encounters between insurers and disabled workers are characterized by negativity, which may be explained by the partly conflicting incentives of the system. The insurer’s primary incentive is to return the disabled worker to work for the least cost. Furthermore, the insurer’s incentives include determining the cause of the disability in cause-based insurance systems. Thus, it may be in the insurer’s interest to find a justification for rejecting a claim or putting pressure on the disabled worker to comply with the insurer’s demands [28]. Another explanatory factor for the dominance of negative encounters is the selection of study groups in previous research. Most studies focus on long-term claimants who have encountered difficulties in returning to work and are therefore more challenging to rehabilitate. Presumably, the overall experience is more negative among such claimants, which is also reflected in the perceived nature of encounters with insurers.

With this negativity surrounding the encounters between disabled workers and insurers, we need more information about positive experiences and success stories in order to duplicate and generalize the beneficial strategies to other claimants. Both the theories [5, 9] and empirical evidence [10 , 29–31] suggest that a positive relationship with insurer during RTW-process may improve the worker’s chance of and vice versa. Thus, the understanding of positive encounters is vital to improve the practices and outcomes of occupational rehabilitation. This study explores the encounters between disabled workers and insurers within an earnings-related pension scheme in Finland in order to enhance our understanding of the lived experience of positive encounters during the return to work process. The research questions are as follows: (1) What kind of encounters are perceived of as positive between disabled workers and insurers during the return to work process? (2) Through what mechanisms do positive encounters lead to a successful return to work? Besides its theoretical value, this study has also practical implications, since it reveals how insurers may foster a return to work among disabled workers through positive encounters.

2 Methods

2.1 Participants and data selection

The analysis was based on 24 semi-structured interviews conducted in 2018 with people who had completed an occupational rehabilitation process in 2015. The informants were recruited among those who had responded to a questionnaire sent a year earlier and given their permission be contacted for further research. The original survey was sent to 1,428 people in 2017. This sample was obtained from an online service called KuntoutuNET, used as a communication tool between subscribers and producers of rehabilitation services belonging to the service network of occupational rehabilitation in Finland. The sample included all the closed cases in the online service during the year 2015, i.e. were in the state of “final summary”, “final summary approved” or “archived”. The sample size was 2,264 individuals and may be considered representative. The response rate of the survey was 30%(n = 668), and 447 respondents gave permission to be contacted for future research. The subjects and their contact details were obtained from the KuntoutuNET online service maintained by a service network for occupational rehabilitation in Finland.

This study exploited criterion-based purposive sampling, where informants were chosen because of their particular characteristics (socio-demographic, experience-related, or outcome-related), since it was essential that a sufficient number of people with different characteristics and experiences were selected from among the respondents. The following factors were used in purposive sampling: employment situation and self-reported work ability after rehabilitation, life situation before rehabilitation, age, sex, and diagnosis.

The purpose of occupational rehabilitation is to improve chances for disabled individuals to earn an income in the future and prevent permanent disability. Thus, the employment status after rehabilitation is most often used as a measure of success. However, the self-rated health or ability to work after rehabilitation can been seen as an equally important measure of success, since it predicts the employability in the future. In this article, we used both of these success measures. The final sample included eight respondents whose self-reported work ability improved and who were employed after rehabilitation (= “rehabilitation succeeded”), eight respondents whose self-reported work ability improved but who were unemployed after rehabilitation (= “rehabilitation both succeeded and failed”), and eight respondents whose self-reported work ability did not improve and who were unemployed after rehabilitation (= “rehabilitation failed”). The division of the respondents into these three groups can be seen in Table 1.

Table 1
Description of the participants of the study

= “rehabilitation succeeded” = “rehabilitation succeeded and failed” = “rehabilitation failed”

Informant number Age Gender Informant number Age Gender Informant number Age Gender

1 30 Female 9 28 Male 17 38 Female

2 34 Male 10 33 Female 18 46 Male

3 37 Male 11 47 Female 19 47 Female

4 45 Male 12 52 Female 20 56 Female

5 46 Female 13 53 Male 21 57 Male

6 52 Female 14 53 Female 22 58 Female

7 53 Female 15 53 Female 23 60 Male

8 56 Male 16 61 Female 24 61 Female

= “rehabilitation succeeded”	= “rehabilitation succeeded and failed”	= “rehabilitation failed”
1	30	Female	9	28	Male	17	38	Female
2	34	Male	10	33	Female	18	46	Male
3	37	Male	11	47	Female	19	47	Female
4	45	Male	12	52	Female	20	56	Female
5	46	Female	13	53	Male	21	57	Male
6	52	Female	14	53	Female	22	58	Female
7	53	Female	15	53	Female	23	60	Male
8	56	Male	16	61	Female	24	61	Female

The informants consisted of 15 women and 9 men. The age range of the informants was 28–61 years old and the median age was 52 years (see Table 1). The majority of informants suffered from musculoskeletal disorders (54%) and one-third suffered from mental disorders. The remainder of the diagnoses included, for example, cardiovascular diseases and cancer. Before the rehabilitation, the informants’ life situations varied from working (n = 4) to unemployed (n = 4) and from sick leave (n = 13) to disability pension (n = 3). Consequently, the sample includes informants with different background factors, rehabilitation experiences, and outcomes in order to ensure the diversity of experienced encounters with insurers.

2.2 Data collection

The method of data collection was in-depth semi-structured interviews with open-ended questions. The interviews were relatively free-form discussions guided by the researcher, and the informants were able to expand on issues they considered important. This method enabled a thematic focus and the comparability of the interviews. The interview guide covered the informants’ experiences before, during, and after rehabilitation. At the end of an interview, the informants were given the chance to evaluate the successes and failures of the whole process, the activities of those involved, and the determining factors of the outcomes. For this study, the following interview themes were the most relevant: the nature of encounters and interactions with the insurer, the successes and failures of the insurer within the rehabilitation process, and the connections between positive encounters and a successful return to work.

The interviews were conducted in July 2018. They lasted from 19 minutes to 63 minutes, and they were all conducted by the author. Three pilot interviews were organized to test the relevance of the interview guide, but only minor changes were made. Hence, the pilot interviews were also included in the final analysis. All interviews were digitally recorded and transcribed verbatim. However, some minor corrections have been made to citations to improve readability. The informants were contacted about one week before the actual interview. They were informed about the research goals, methods, and the use of data. Their anonymity was guaranteed, as their names will not be published in any research-related context. At the same time, all the informants gave permission to use their gender and age as identification in the studies.

2.3 Data analysis

Processing the transcribed interview material involved three stages: classification, analysis, and interpretation. In practice, these steps overlapped. As is typical for qualitative analysis, the data and the research problems were in close dialogue with each other, and analytical questions were formed and refined as the material was explored. In the classification phase, the material was systematically reviewed based on the research problem and the starting points of the key concepts utilizing inductive content analysis (see [32]). Content analysis is “a research method for the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns” [33].

In this context, inductivity refers to the fact that the different categories of the phenomenon being studied were created as far as possible based on data, not on a pre-formed theory. This study used an inductive approach in order to avoid wasting a large amount of new information that might have occurred if the material had been heavily examined under the guidance of previous studies and theories. Inductive content analysis was chosen as knowledge of positive encounters between rehabilitees and insurers is fragmented and somewhat limited [32]. However, qualitative analysis is always guided by research questions, and the researcher cannot lose his previous knowledge, thoughts, and theoretical observations in the process.

The inductive content analysis was performed in several steps. Initially, the author listened to the recordings and read the interview transcripts repeatedly to gain a comprehensive view of the whole data. The next phase was data organization, which included open coding, category creation, and abstraction. The grouping of the data started by constructing sub-categories based on open coding. Gradually the number of categories was reduced as the themes were grouped under higher order headings, and quotations were added in order to illustrate each category. The data were read repeatedly by testing and refining the parses generated at different stages during the analysis. All analyzed interviews were also compared with each other in order to validate the categorization.

3 Results

Nearly all respondents described some positive encounters with insurers during their occupational rehabilitation. However, the overall experience of encounters was much more positive among those who had successfully returned to work, the encounters perceived of as positive were similar in every group and eventually, four main themes arose from the key concepts relating to the positive encounters: (1) process flow, (2) customer orientation, (3) information and guidance, and (4) service attitude.

3.1 Process flow

A high-quality compensation process with a good flow was considered the main task of insurers and a source of positive encounters. The process flow consisted of high-quality decisions, the smooth progress of the rehabilitation, and accurate compensation. The detailed construction of the first theme is shown in Fig. 1.

Fig. 1

Perceived positive encounters related to process flow.

The decisions made by the insurance companies were reported in almost all interviews, be they for positive or negative reasons. For many informants, the most positive encounter with the insurer was a positive claim settlement decision. When the decision lived up to their expectations, the informants were satisfied with the insurer and the decision felt rightful: “a positive decision, you got what you were entitled to” (informant 5). However, also negative decisions could be appreciated and felt to be rightful, if they included adequate, rational, and understandable arguments: “It was always justified and I understood why something was compensated for or not” (informant 3). After a positive claim settlement decision, the most important task of the insurer was considered to be accurate compensation. If the compensation was both timely and correct, the overall satisfaction with the insurer was high. As a few informants put it: “The money always came as it should” (informants 5 and 13) and “There was never any problems with paying, so that went well” (informant 14).

Several informants also perceived the smooth progress of the rehabilitation process as source of positive encounters. Insurers were seen as responsible for the progress of the rehabilitation, since all the decisions and the majority of the guidance came from them. Many informants described how the insurer contacted them immediately after the application was filed, all the decisions came quickly, and the rehabilitation process progressed rapidly from the initial rehabilitation plan to implementation. One informant summed it up: “Everything worked splendidly in the process. Whatever it was, everything happened in a few days, with no delay whatsoever.” (Informant 6)

Besides the speed of the progress, the informants also valued the active participation and continuous contact of the insurer. The checks and reminders during the rehabilitation in particular were considered process enhancing. Furthermore, the active management of everyday matters appeared to be important: “They (the insurer) always sent a notice in advance if I had to do or deliver something. They also used reassurances of received applications and text messages about the timing of the payment.” (Informant 16)

3.2 Customer orientation

Some of the most positive encounters between disabled workers and insurers were related to the second main theme, customer orientation. Customer orientation consisted of proper consultation, genuine empowerment, and thoughtful consideration. The detailed construction of the second theme is shown in Fig. 2.

Fig. 2

Perceived positive encounters related to customer orientation.

Customer orientation (or the lack of it) was evident from the very beginning of the rehabilitation process. Positive encounters included a proper consultation where the background, wishes, and emotions of the disabled worker were carefully reviewed. Here, the listening skills of the insurer’s representative were appreciated. A comprehensive background check was described to include the mapping of disabled worker’s study, work, and medical history and the current life situation. In addition, both psychological and aptitude tests conducted by the service provider were found to be useful. As part of the background check, informants described how their wishes and dreams were also heard: “Then there comes a man who is... is just for me. Listened to what I wanted and . . . and then we wondered together what is it that I needed and wanted.” (Informant 16) In addition, some informants brought up the significance of their feelings and emotions. They may have experienced feelings of depression, fear, and insecurity, and discussing these concerns with the insurer was important.

The second category of customer orientation is genuine empowerment. If proper consultation focuses on gaining a hearing, genuine empowerment focuses on the inclusion of disabled workers in the planning and implementation of occupational rehabilitation. A few informants described how they had made a significant contribution to the rehabilitation plan, which empowered them and added a sense of equal partnership with the insurer. If the wishes and needs of the disabled workers were genuinely pursued, the encounter was rated as highly positive. “How could he look at my situation so personally? He did not give any general answers, but answers to my situation. We were able to make a rehabilitation plan that was completely suitable just for me.” (Informant 4) Participation in the rehabilitation measures, such as work trials or training leading to an occupation, was usually taken for granted, but a continuous dialogical connection with the insurer and participation in the evaluation debates concerning the progress of the rehabilitation and validity of the rehabilitation plans were highly valued.

Customer orientation was also evident in the insurer’s decisions and debates that included thoughtful and personal consideration of the disabled worker’s situation. This perceived customer orientation in decisions appeared in several ways among the informants. For example, the decision about compensation for loss of earnings could be made for as long as reasonable at once, additional compensation could be granted for a sudden demand, and the timing of the rehabilitation measures could be altered according to the disabled worker’s needs. The use of “common sense” (informant 6) by the insurer was reflected in these experiences of fairness, and it was praised by the informants. The insurer’s flexibility formed the other subcategory of thoughtful consideration. A remarkable number of informants acknowledged the ability of the insurer to easily modify the decisions and processes to respond to the altered circumstances. In addition, earlier decisions could, for example, be reversed in the light of new information. “But the insurer was actually doing very well in the sense . . . that even though they once promised it and then reversed it, they were still able to reverse that negative decision again. So I thought it was a pretty great job.” (Informant 11)

3.3 Information and guidance

The third main theme related to the positive encounters between disabled workers and insurers was information and guidance. Several informants described having received flawless information and comprehensive guidance from the insurer. The detailed construction of the third theme is shown in Fig. 3.

Fig. 3

Perceived positive encounters related to information and guidance.

According to the informants, a high-quality information flow consists of sufficiency, rightfulness, and understandability. Generally, the insurers seemed to answer all the questions asked well, but even more valuable was the spontaneous information about the different possibilities for rehabilitation and compensation. An open approach and generous knowledge sharing led to the insurer being seen as an ally rather than an opponent. “I was very well informed about what rehabilitation services are available. They (insurer) were always so open and told me everything. There was no situation, like . . . in which I would have realized afterwards that I could have received some compensation.” (Informant 4)

Both the quantity and quality of the information were considered important. First, informants expected to receive rightful information from the insurer. Expectations of rightfulness were mostly fulfilled and several informants acknowledged the expertise of the insurer. The second indicator of information quality, understandability, was clearly harder to achieve. However, a few informants felt that all the information (including written decisions) was easy to understand.

According to the informants, insurers were specifically successful in offering guidance. Most of all, accessibility to guidance was praised. The insurers were well within reach, the informants “always got help when needed” (informants 1, 5, 17, and 21), and their “call requests were answered promptly” (informants 7 and 10). Moreover, most informants had their own contact person at the insurer, and this practice was valued (informants 3, 10, 18, and 21) and desired by those who did not have such a contact (informants 1, 13, and 20).

The continuity of guidance was also highly valued; continuous contact with the disabled worker from the initial steps throughout the rehabilitation process to post-control was perceived as highly positive. If the rehabilitation outcome was positive, a farewell card or wishes were considered positive: “The insurer said that it was the end of our collaboration, but if there was anything else that I needed, they could still help. In my opinion, it worked out well. And then that little thing, when the Christmas card from the service provider came the next Christmas, it was such a nice thing.” (Informant 15)

The informants also brought up the nature of the guidance, and above all, the activating touch of the insurers. Many felt that their insurer gave them the needed push to achieve their goals. Especially when the informants had to make choices about rehabilitation measures and apply for a job or study right, the active guidance from the insurer promoted the process. Some described this as feeling they were “forced to action,” and some used a more subtle expression, such as saying it felt they were “helped to move forward.” One informant stated, “Yeah, it kind of provoked me when the insurer contacted . . . When you are in pain at the beginning, and then somebody like kicks your ass . . . tells you that you have to do something now. So it really showed the direction and got me moving.” (Informant 8) This activating guidance was seen as purely positive and process-enhancing by the informants.

3.4 Service attitude

The fourth main theme related to the positive encounters between the disabled workers and the insurers was the customer service attitude of the insurer’s representatives. Experiences of the service attitude varied greatly among the informants. However, the kindness of customer service staff was the single most frequently mentioned positive encounter with the insurers during the rehabilitation process. Several informants mentioned a particular employee by name and sent personal thanks to them. The insurer’s representatives were considered to be kind, encouraging, and appreciative. The detailed construction of the fourth theme is shown in Fig. 4.

Fig. 4

Perceived positive encounters related to the customer service attitude.

The basis for a good customer service experience is built on appreciation. Both respect and trust were noted in examples of positive encounters between insurers and the disabled workers. The informants were mainly treated with courtesy, and they felt respected and treated as an equal: “When you usually deal with government agencies, it’s a bit like being a customer only. But now I think they took me very nicely and equally and I didn’t feel like they were making a value judgment of me somehow.” (Informant 7) “As such a small citizen, I felt that I was still really important for them. And it felt pretty great.” (Informant 5)

The kindness of the customer service staff was also praised on many occasions. First, informants mentioned that the staff was willing to help them with various matters related to the rehabilitation. “He took care of my situation, and when I couldn’t handle something, he did it for me” (informant 16); “I got help and support and they guided me through the applications and everything. It was a very positive experience.” (Informant 24) Moreover, the informants were thankful for the friendliness, approachability, and kind atmosphere created by the insurer’s representatives. Some employees also showed compassion for their customers: “it was really empathetic, and he was so worried about my coping and well-being” (informant 24). Informants truly valued this kind of compassion in times of distress.

Some of the informants had very low self-esteem; they were insecure about their knowledge, skills, and ability to learn, and a few mentioned that they were actually afraid of the whole rehabilitation process. Thus, many clearly needed encouragement, and they received it from the insurer. Furthermore, the insurers’ representatives showed faith: “It was so positive in every way, the way they believed in me and believed that I was still able to perform some duties and find employment. That was so wonderful.” (Informant 3) On the other hand, the insurer’s representatives were described as reassuring, uplifting, cheering, and pushing when they tried to get the client motivated and the rehabilitation process moving forward. “It was kind of pushing forward, knowing I am not a miserable loser who just lies there at home, but can still rise. So I just wish that everyone had the same kind of cheering, someone to tell you that you can find something . . . that you are able to do something for a living.” (Informant 14)

3.5 The underlying mechanisms between positive encounters and a successful return to work

Towards the end of the interview, the informants were also asked to define the key factors to the success or failure of the rehabilitation. This question was used to analyze the nature of positive encounters more thoroughly, since it revealed whether the insurer’s actions were considered to have affected the outcomes of rehabilitation. In addition, the answer would also indicate the magnitude of the possible impact. First, the analysis showed that the factors promoting and hindering the return to work are interlinked, since the same factors may act as a promoter of the return to work when considered positive and as a preventer of the return to work when considered negative. Second, the results suggest that positive encounters between insurers and disabled workers may act as key factors in the success of the rehabilitation.

The most frequently mentioned key factors for the both success and failure of the rehabilitation were personal features; self-motivation was seen to be the most important determining factor for a successful return to work, whereas poor perceived health was held responsible for failures. However, immediately after these personal features came the process flow and customer orientation. Thus, the insurer’s role in determining the outcome of the rehabilitation was considered critical. When considering the four main themes of the positive encounters, there was a clear hierarchy between them. Based on the interviews, Fig. 5 shows the elements of positive encounters in order of perceived importance.

Fig. 5

The hierarchy of main themes related to the positive encounters.

The insurer was considered to have the greatest influence on the process flow of the rehabilitation, and the smooth functioning of the process was seen as the key issue in promoting the return to work. The basis of a successful return to work lies in the insurer’s decision on the claim; if the decision feels acceptable, the process starts and usually progresses without hurdles. The second part of smooth process flow is the accurate payment of compensation, which again prevents hurdles and enables concentration on the rehabilitation process itself. On the other hand, if the decisions and compensation do not work flawlessly, the rehabilitation may turn into a fight between the disabled worker and the insurer, and this may finally lead to poor outcomes, as described by a few informants.

The customer-oriented approach of the insurer was also considered to be one of the key factors for a successful return to work. Informants described how taking part in a proper consultation that involved being listened to, being engaged in the planning and implementation of the rehabilitation, and receiving respect regarding their needs and wishes usually resulted in a realizable rehabilitation plan that enabled their commitment and eventually led to a successful return to work. Conversely, if the informants were not genuinely included in the planning of the rehabilitation and they felt forced to take part in unnecessary or useless rehabilitation measures, the results were usually poor.

The third theme, information and guidance, was not usually considered a decisive factor in a successful return to work. However, sufficient, rightful, and understandable information was considered a prerequisite for the rehabilitation process to start and progress. Similarly, the customer service attitude was not named as the key factor for a return to work, but especially for those with low self-esteem and insecurities, the service attitude became a significant underlying factor contributing to the success of the rehabilitation.

As illustrated above, the encounters between insurers and disabled workers may directly affect the progress and outcome of the rehabilitation. However, the underlying mechanisms between the encounters and the return to work went beyond the direct effect. The majority of informants illustrated how the insurer’s actions significantly influenced their motivation, which was also considered to be the single most determining factor of the successful return to work. Berglind and Gerner [34] have analyzed the motivation for returning to work among those on long-term sick leave using action theory. Their analysis shows that the willingness to return to work is only one part of motivation. Will or desire is linked to perceived competence and experienced opportunities. Thus, besides the will or desire, a strong motivation requires a sense of competence (i.e., ability to manage) and faith in employment opportunities. These three areas of motivation were clearly visible in the informants’ stories.

The informants characterized a strong will or desire as persistence and determination: “where there is a will, there is a way” (informants 14 and 16). Furthermore, it was not believed that rehabilitation would succeed without determination. The second area of motivation, a sense of competence, seemed to be more rarely possessed and harder to gain than a strong desire to return to work. As mentioned before, many informants expressed anxieties in the early stages of the rehabilitation, and it became clear that without self-confidence, the return to work would be very difficult. The third area of motivation, faith in employment opportunities, also proved to be relevant for a successful return to work. There was no faith when new work duties or an occupation did not feel suitable, the employment situation in the sector was poor, or the informant was merely returned to a previous job without retraining. If there was no faith in employment opportunities, rehabilitation was usually interrupted.

Finally, the results suggest that encounters between the insurers and the disabled workers may either increase or decrease the motivation of the rehabilitee. As shown in Fig. 6, all key concepts relating to the positive encounters may also affect the rehabilitation outcomes indirectly by influencing the motivation of the rehabilitee.

Fig. 6

The indirect effect of positive encounters on rehabilitation outcomes.

The analysis reveals that a willingness to return to work could be strengthened by all the main themes related to the positive encounters; a smooth process flow, a customer-oriented approach, active information and guidance, and a good service attitude. On the other hand, the willingness to return to work can be diminished during the rehabilitation process especially when disabled workers feel that their needs and wishes are not materializing. The results also suggest that positive encounters may increase the disabled workers’ faith in their competence. According to the informants, self-confidence was best supported by active guidance, positive feedback, and encouragement. Conversely, it was weakened by a rude, malicious, and suspicious service attitude. Improved self-confidence also increased faith in employment opportunities.

In addition, active inclusion of the informant in the planning and implementation of the rehabilitation, the fulfillment of the informants’ needs and wishes, and an encouraging service attitude strengthened the faith in employment opportunities. If the informants were familiar with the new job or occupation and it was in line with their wishes, they better understood its physical and mental requirements and could evaluate them in relation to their own competence. Furthermore, they usually had some idea of the employment situation in the sector and their faith in employment opportunities was greater than among those who were not familiar or satisfied with the new job or occupation. Thus, the insurer has a significant role to play in supporting this area, as through rehabilitee inclusion and working life knowledge distribution, it is possible to significantly influence the disabled workers’ faith in employment, and hence support their rehabilitation motivation.

4 Discussion

Earlier studies indicate that most encounters between insurers and disabled workers are negative in nature and may even generate secondary psychosocial harm to the workers and hinder possibilities for recovery [see e.g. 2, 4]. Positive encounters are reported less frequently, and knowledge about their nature and effects remains limited. Thus, this qualitative study focused on the positive experiences of claimants in order to enhance understanding of the success factors and well-functioning strategies. The first objective of this study was to find out what kind of encounters are perceived to be positive during the return to work process. Altogether, analysis yielded 24 positive encounters that finally formed four main themes relating to the positive encounters between disabled workers and insurers: (1) process flow, (2) customer orientation, (3) information and guidance, and (4) service attitude.

Positive encounters including rightful and well-justified decisions, timely and correct compensation, fast progress, and continuous contact with the insurer formed the first main theme, process flow. Positive experiences related to the compensation process have rarely been reported in the academic literature. However, informants of Strunin and Boden [20] described relations with insurer that resulted in timely outcomes and informants of Hubertsson et al. [16] had experienced a continuous contact with the insurer during the process of rehabilitation. Thus, the results of this study support the earlier observations and broaden our understanding of the components of a smooth process flow during occupational rehabilitation.

The second main theme of positive encounters, customer orientation, appeared for example in proper consultation, respect for the informants’ life situation, needs and wishes, and the inclusion of the informants in planning and implementing the rehabilitation. The inclusion of the informants also emerged in the study by Hubertsson et al. [16], where participation in an ongoing rehabilitation was mentioned as a positive encounter. Furthermore, the feeling of being heard and understood in the middle of a complex situations have been previously reported by women in the sick-leave process [35]. This study contributes to the existing literature by revealing also the importance of the common sense and operational flexibility by insurer, which were highly appreciated as part of customer-oriented service.

The third main theme of positive encounters between disabled workers and insurers was information and guidance. Guidance is also mentioned as a source of positive encounters by Hubertsson [16], whose informants were thankful for being guided in the efforts to return to work. Similarly, informants in the study of Andersson and Mårtensson [35] were grateful of being guided in decision-making when their own capacity was lacking. This study found out that experiences of comprehensive guidance includes continuity, easy access and activating touch. The information provided by insurer is usually perceived negative, being for example incorrect, too formal or hard to understand [1–2 , 16]. However, several the respondents of this study had received sufficient, rightful, and understandable information, which were all creating perceptions of positive encounters.

The fourth main theme, customer service attitude, included positive encounters with helpful and compassionate representatives that elicited feelings of being trusted, respected, and cheered on. The customer service attitude has also emerged as a source of positive encounters between insurers and disabled workers in previous studies. In fact, most of the previously reported positive encounters were somehow related to the service attitude of the insurer’s representatives. The informants of these studies have noted feelings of confidence and trust [16, 22] caring and supportive relationships with the insurers [21, 24], and being recognized as a person [16].

Altogether, the informants of this study had mixed experiences of encounters with insurers, and the majority described both positives and negatives. However, the overall perception of the insurer’s activities seemed to be more positive than in previous studies and positive experiences extended beyond the customer service attitude and included several aspects related to the process flow, customer orientation, and information and guidance. Thus, the study revealed several previously unidentified insurer practices yielding to perceptions of positive encounters. The large amount of positive experiences might be explained by the criterion-based purposive sampling, which included informants with a successful return to work, whereas most of the previous studies focused purely on long-term claimants with difficulties in returning to work. Another explanation is related to the differences between cause-based and disability-based insurance systems. In the disability-based system, there is no need to prove the causation of the disability to justify interventions, so the justifications for rejecting a claim are more limited and rejections are altogether less common, resulting in fewer experiences of claims manipulation (compare e.g., [2]).

The second objective of the study was to identify the underlying mechanisms leading from positive encounters to a successful return to work. It was noticeable that the experiences were much more positive among those who had a successful rehabilitation. On the one hand, a positive outcome may sweeten the experiences of the rehabilitation process and actors, as demonstrated by one informant: “Well, in retrospect, it seems like everything went as well as possible, and nothing could have been done better. I suppose that at some point during the process . . . Maybe I could have thought of something negative then, but the outcome was so great that now there is nothing negative to say.” (Informant 4) On the other hand, positive encounters with insurers also foster positive outcomes, and several informants described the encounters with the insurance company as crucial to their success. This correlation has also been shown in previous studies [6 –9].

The results suggest that positive encounters affect rehabilitation outcomes both directly and indirectly. The informants described how rightful and well-justified decisions enabled occupational rehabilitation and thereby their return to work. Similarly, they illustrated how a customer-oriented approach led to a realizable and suitable plan through which the return to work was possible. Furthermore, smooth process flow and customer-oriented approach were found to be the most important insurer-related promoters of RTW. However, the majority of informants also noted an indirect effect of the positive encounters on the return to work. This indirect effect was most visible when the positively perceived actions of the insurer improved the informants’ motivation.

Motivation has been found to be one of the most significant factors explaining the outcomes of rehabilitation (e.g., [36–37]). This study shows that positive encounters related to the process flow, customer orientation, information, guidance and customer service attitude might increase the customer’s motivation and indirectly support the successful return to work. Therefore, supporting the motivation of rehabilitees is also of paramount importance to the insurer. This study emphasizes the division of motivation into different areas, as in the study by Berglind and Gerner [34]: a strong will or desire to return to work, faith in one’s competence, and faith in one’s employment opportunities. Thus, efforts can and should be made to support all these aspects of motivation throughout the rehabilitation process to promote the successful return to work.

4.1 Research limitations

This qualitative study used an explorative approach to identify and analyze positive encounters between disabled workers and insurers during the return to work process. It should be noted that the data is based on a relatively small sample (24 interviewees) and the results might not be generalized as such to other groups. However, since this was a qualitative study, the richness of the information held by respondents was seen more important than the sample size [38]. Furthermore, the purposive sampling aimed to produce the richest possible data including respondents with different backgrounds and rehabilitation outcomes. Another limitation of the study is the timing, since both the survey- and the interview data were gathered after the occupational rehabilitation process. Thus, one must consider the possible memory errors and changes of opinions after time when interpreting the results.

To improve the validity of the results, the interview guide was developed together with the steering group of the service network of occupational rehabilitation in Finland. Furthermore, it was tested in a pilot interviews to confirm the comprehensibility and practicality of the questions. As described earlier, the perceived positive encounters were fairly similar among all respondents and became more consistent across larger number of interviews. This kind of clear saturation also promotes validity of the findings. Furthermore, the results regarding the nature of positive encounters and rehabilitee’s motivation were in line with the previous studies. However, the validity of the results could’ve been increased by adding a discussion concerning the preliminary results with the participants and a double coding performed by another researcher.

Further research is required to investigate the dependencies between different types of positive encounters and the successful return to work. This qualitative study cannot prove the causal relations between positive encounters and the return to work, so the analysis of the underlying mechanisms of positive encounters and the return to work remains preliminary. The significance of positive encounters in relation to other explanatory factors of successful rehabilitation should also be studied with quantitative methods. Moreover, it would be beneficial to explore the encounters between insurers and disabled workers from the insurers’ perspective in order to complement the understanding of this phenomenon.

5 Conclusion

This study enhances the knowledge of positive encounters between insurers and disabled workers by identifying 24 good practices and conceptualizing them into four main themes. It demonstrates the diversity of positive encounters and shows that they occur at many stages of the rehabilitation process. Above all, the smooth process flow and customer-oriented approach were considered as the key issues in promoting the return to work. Furthermore, the results indicate that positive encounters promote the successful return to work not only directly, but also indirectly through strengthening the motivation of disabled workers. Finally, the actors in occupational rehabilitation may benefit from exploiting the results of this study to foster the return to work of disabled workers.

Conflict of interest

None to report.

References

MacEachen

, Kosny

, Ferrier

, Chambers

. The “toxic dose” of system problems: why some injured workers don’t return to work as expected. J Occup Rehabil. 2010;20(3):349–66.

Kilgour

, Kosny

, McKenzie

, Collie

. Interactions between injured workers and insurers in workers’ compensation systems: a systematic review of qualitative research literature. J Occup Rehabil. 2015a;25(1):160–81.

Kilgour

, Kosny

, McKenzie

, Collie

. Healing or harming? Healthcare provider interactions with injured workers and insurers in workers’ compensation systems. J Occup Rehabil. 2015b;25(1):220–39.

Thornthwaite

, Markey

. Return to work after workplace injury: Injured workers, insurers and employers. Aust J Soc Issues. 2017;52(2):98–115.

Loisel

, Durand

, Baril

, Gervais

, Falardeau

. Interorganizational collaboration in occupational rehabilitation: perceptions of an interdisciplinary rehabilitation team. J of Occup Rehabil. 2005;15(4):581–90.

Nielsen

MBD

, Madsen

, Bültmann

, Christensen

, Diderichsen

, Rugulies

. Encounters between workers sick-listed with common mental disorders and return-to-work stakeholders. Does workers’ gender matter? Scand J Public Health. 2013;41(2):191–7.

Olsson

, Alexanderson

, Bottai

. What positive encounters with healthcare and social insurance staff promotes ability to return to work of long-term sickness absentees? Scand J Pub Health. 2016;44(1):91–7.

Lynöe

, Wessel

, Olsson

, Alexanderson

, Helgesson

. Respectful encounters and return to work: empirical study of long-term sick-listed patients’ experiences of Swedish healthcare. BMJ Open. 2011;1(2).

MacEachen

, Clarke

, Franche

, Irvin

. Systematic review of the qualitative literature on return to work after injury. Scand J Work Env Hea. 2006;32(4):257–69.

10.

Müssener

, Ståhl

, Söderberg

. Does the quality of encounters affect return to work? Lay people describe their experiences of meeting various professionals during their rehabilitation process. Work. 2015;52(2):447–55.

11.

White

, Green

, Ferguson

, Anderson

, Howe

, Sun

, et al. The Influence of Social Support and Social Integration Factors on Return to Work Outcomes for Individuals with Work-Related Injuries: A Systematic Review. J Occup Rehabil. 2019;29(3):636–59.

12.

Holmgren

, Rosstorp

, Rohdén

. Confidence in public institutions: A focus group study on views on the Swedish Social Insurance Agency. Work. 2016;55(1):77–91.

13.

Dean

A-M

, Matthewson

, Buultjens

, Murphy

. Scoping review of claimants’ experiences within Australian workers’ compensation systems. Aust Health Rev. 2019;43(4):457–65.

14.

Lippel

. Workers describe the effect of the workers’ compensation process on their health: a Quebec study. Int J Law Psychiat. 2007;30(4-5):427–43.

15.

Kosny

, MacEachen

, Ferrier

, Chambers

. The role of health care providers in long term and complicated workers’ compensation claims. J Occup Rehabil. 2011;21(4):582–90.

16.

Hubertsson

, Petersson

, Arvidsson

, Thorstensson

. Sickness absence in musculoskeletal disorders-patients’ experiences of interactions with the social insurance agency and health care. A qualitative study. BMC Public Health. 2011;11(1):107.

17.

Lynöe

, Wessel

, Olsson

, Alexanderson

, Helgesson

. Does feeling respected influence return to work? Cross-sectional study on sick-listed patients’ experiences of encounters with social insurance office staff. BMC Public Health. 2013;13(1):268.

18.

Finnish Centre for Pensions, FCP. Parties to the pension scheme. 2009. Availible at: https://www.etk.fi/en/the-pension-system/administration-and-supervision/parties-to-pension-scheme/ (3 April 2019.)

19.

Beardwood

, Kirsh

, Clark

. Victims twice over: perceptions and experiences of injured workers. Qual Health Res. 2005;15(1):30–48.

20.

Sager

, James

. Injured workers’ perspectives of their rehabilitation process under the New South Wales workers compensation system. Aust Occup Ther J. 2005;52(2):127–35.

21.

Strunin

, Boden

. The workers’ compensation system: worker friend or foe? Am J Ind Med. 2004;45(4):338–45.

22.

Müssener

, Festin

, Upmark

, Alexanderson

. Positive experiences of encounters with healthcare and social insurance professionals among people on long-term sick leave. J Rehabil Med. 2008;40(10):805–11.

23.

Upmark

, Hagberg

, Alexanderson

. Negative encounters with social insurance officers-experiences of women and men on long-term sick leave. Int J Soc Welf. 2011;20(3):309–17.

24.

Klanghed

, Svensson

, Alexanderson

. Positive encounters with rehabilitation professionals reported by persons with experience of sickness absence. Work. 2004;22:247–54.

25.

Black

, Matthews

, Millington

. Claimants’ views on total and permanent disability insurance claims. Qualitative Research in Financial Markets. 2019;11(2):244–59.

26.

Franche

, Cullen

, Clarke

, Irvin

, Sinclair

, Frank

. Institute for Work & Health (IWH) Workplace-Based RTW Intervention Literature Review Research Team. Workplace-based return-to-work interventions: a systematic review of the quantitative literature. J Occup Rehabil. 2005;15(4):607–31.

27.

Robichaud

M-M

, Truchon

, St-Arnaud

, Nastasia

. Insurers’ perspective on barriers and facilitators for return to work after occupational injuries. Work. 2019;63(1):81–97.

28.

Franche

, Baril

, Shaw

, Nicholas

, Loisel

. Workplace-based return-to-work interventions: optimizing the role of stakeholders in implementation and research. J Occup Rehabil. 2005;15(4):525–42.

29.

Nordgren

, Söderlund

. Being on sick leave due to heart failure: self-rated health, encounters with healthcare professionals and social insurance officers and self-estimated ability to return to work. Psychol Health Med. 2015;20(5):582–93.

30.

Nordgren

, Söderlund

. Being on sick leave due to heart failure: encounters with social insurance officers and associations with sociodemographic factors and self-estimated ability to return to work. Eur J Cardiovasc Nur. 2016;15(3):e27–e36.

31.

Collie

, Sheehan

, Lane

, Gray

, Grant

. Injured worker experiences of insurance claim processes and return to work: a national, cross-sectional study. BMC public health. 2019;19(1):927–12.

32.

Elo

, Kyngäs

. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107–15.

33.

Hsieh

, Shannon

. Three approaches to qualitative content analysis. Qual Health res. 2005;15(9):1277–88.

34.

Berglind

, Gerner

. Motivation and return to work among the long-term sicklisted: an action theory perspective. Disabil Rehabil. 2002;24(14):719–26.

35.

Andersson

, Mårtensson

. Women’s experiences of being in the sick leave process. Scand J Occup Ther. 2020;1-10.

36.

Maclean

, Pound

, Wolfe

, Rudd

. Qualitative analysis of stroke patients’ motivation for rehabilitation. Brit Med J. 2000;321:1051–4.

37.

Grahn

, Ekdahl

, Borgquist

. Motivation as a predictor of changes in quality of life and working ability in multidisciplinary rehabilitation. Disabil Rehabil. 2000;22(15):639–54.

38.

Patton

. Qualitative research & evaluation methods: integrating theory and practice. Fourth edition. Los Angeles: SAGE, 2016.