Translation and initial cross-cultural adaptation of the tool for support-gradual return-to-work for persons with chronic musculoskeletal pain to the Swedish setting

1 Introduction

Chronic musculoskeletal pain (CMSP) lasting over 3 months, including neck/shoulder and back pain or generalized widespread pain such as fibromyalgia (FM), affects 10.4% [1] to 20% of adults [2–4]. CMSP hinders daily activities, including employment and workdays lost [3]. Work-related issues result in negative outcomes for employees, reduced productivity for both employees and employers, and has a significant impact on society [5]. Individuals with chronic pain commonly face disruptions in their work tasks, which may manifest in cognitive challenges, like difficulty focusing, affective issues such as reduced tolerance, or physical limitations like decreased stamina [6].

Reintegrating individuals suffering from chronic pain into work is challenging, demanding collaborative efforts from various stakeholders. In Sweden, this includes officers from the Swedish Social Insurance Agency (SSIA) and Swedish Public Employment Service (SPES) who may be engaged in vocational rehabilitation. Additionally, employers, case managers from Occupational Health Services, rehabilitation coordinators, occupational therapists (OTs), and healthcare physicians are part of the Return-To-Work (RTW) process in healthcare, as referenced in this study [7]. The SSIA assess the need for RTW interventions and coordinates the process with other stakeholders [7]. Research on stakeholders’ experiences found that health professionals’ efforts to facilitate individuals’ RTW were hindered by a rigid system, excessive bureaucracy, and a lack of coordination and collaboration among involved parties. This highlights the importance of each stakeholder in understanding their roles and responsibilities in the RTW process [8].

In 2019, Sweden introduced broader employer responsibility guidelines aimed at helping employees with illnesses to remain active in the labor market. This expanded employer responsibility entails facilitating the process by adjusting job tasks and the work environment, along with the obligation to document a rehabilitation plan [7]. Support from the employer, for example, in the form of increased cooperation through regular contact between the workplace and the employee was reported as a facilitator of RTW, while absence of support was considered a barrier [9].

Furthermore, on a broader international scale, employers from various jurisdictions have indicated that they lack the necessary tools to effectively manage the RTW process [10]. Individuals with CMSP often face insufficient support from employers during RTW [11], and this sentiment is also reported by employers themselves [12, 13] Workplace factors, like adjustments and strategies, positive colleagues, and employers, outweigh individual predictors for RTW [9]. Timely problem reporting and open communication between employers and employees are crucial. Frequently, essential accommodations can be pinpointed through discussions between the employer and the employee [14]. Communication gaps about pain may stem from employees’ assumptions regarding consequences or employers’ willingness to talk about it. For instance, employees may fear the possible consequences of sharing their problems with management. The extent to which employers are willing to discuss pain is linked to the overall openness within the organizational culture regarding the topic. Employers’ competences in pain management are also likely to play a significant role. Some employers express a lack of confidence in their abilities to support employees with pain. Employers also express a desire for more structured conversations with employees about the work environment and pain. This suggests that establishing formal structures for discussing pain issues could be advantageous for pain prevention [12]. Using a structured tool such as GRTWswe can be a solution to fulfilling the employer’s responsibility [7] required by the employer in Sweden.

There is a need for Swedish-specific instruments for the RTW process that foster collaboration and structured work situation reviews, which are easy to follow up. The adaptation of a Canadian tool to address relevant cultural aspects is useful for wider adoption. A well-defined and clear procedure for RTW is a key factor supporting RTW [15], as it enhances collaboration and understanding between employers and employees [16]. The Tool for Support-Gradual Return to Work (TS-GRTW) can aid in this RTW process [10].

The concept Margin of Manoeuvre (MM) emphasizes the importance of allowing employees to develop effective work methods that meet production requirements without compromising their health. This concept underpins the designed tool [15, 17]. The TS-GRTW includes a 21 pages instruction guide and a two-sided planning worksheet. Ten sections build up the planning worksheet and the headings are as follows: 1, restrictions/recommendations issued by the attending physician; 2, planned work schedule; 3, work tasks identified; 4, productivity expected; 5, anticipated obstacles or difficulties; 6, ways to offset these difficulties; 7, worker’s level of confidence regarding the work plan for the week; and 8, signatures. These eight sections are completed at the beginning of the week. The remaining sections, 9–10, are answered at the end of the week and are entitled: 9, attainment of production objectives; and 10, increase in discomfort level [10].

The instruction guide consists of a description of the origins of the tool and its underlying concepts. Furthermore, a brief description in the form of answers to the questions “for whom”, “when”, “how”, and “why”, as well as its limitations are included. Finally, a figure illustrating each step of the TS-GRTW is followed by examples, instructions, and practical advice [10].

Supervisors’ ability to support RTW is closely linked to communication, policies, and organizational factors, with their attitudes playing a key role in the process [18]. The planning worksheet is designed for joint use by employees and employers, promoting regular follow-up and enhancing collaboration. It helps counteract passivity on both sides during a RTW process.

Our objective was to develop a Swedish version—the GRTWswe—for implementation and integration into the Swedish labor market’s RTW process. This involved translating, culturally adapting, and assessing the appropriateness and utility of a Canadian tool called TS-GRTW with occupational therapists (OTs) active in RTW in areas with individuals with CMSP.

The concepts of appropriateness and utility refer to the perceived fit, relevance, or compatibility of the innovation or evidence-based practice for a given practice setting, provider, or consumer; and/or perceived fit of the innovation to address a particular issue or problem [19], and the clinical relevance, support for decision making, ability to facilitate/improve communication, application, potential for implementation, and transferability [20].

2 Methods

3 Results

Thirteen OTs initially agreed to participate, but three later withdrew due to work-related time constraints. Ten participants completed the questionnaire, and among these, one chose not to take part in the group consultation. Consequently, nine OTs attended the group sessions, with five in the first meeting and four in the second.

Four OTs worked in specialist care (Pain and Rehabilitation Clinics), four in primary care, and two in Swedish Public Employment Service (SPES). Participants’ mean age was 49 years, ranging from 42 to 57 years, and the mean length of time participants had spent collaborating with persons with chronic pain and RTW was 9 years, ranging from 1.3 to 22 years. The participants represented five geographical areas in Sweden. Characteristics of the participants are presented in Table 1.

Health care OTs have a broad range of responsibilities, including reconciliation meetings with various parties such as SSIA, physicians, and rehabilitation coordinators. They also engage in direct collaboration meetings with employers. These professionals visit workplaces to assess needs and develop strategies for individuals to RTW successfully or to establish a sustainable work situation. The OTs at SPES have reported assessing work ability within real workplace settings and conduct numerous on-site visits to evaluate and implement workplace adjustments and test different work aids.

Table 2 displays the mean agreement scores from the expert committee, the ten OTs; all of whom scored >3. However, comments were provided concerning content, wording, and contextual aspects within the Swedish setting.

The group consultations revealed a new category—Format and Clarity—which addressed language, wording, tool length, and visual appeal in addition to the existing categories of Appropriateness and Utility.

Our aim was to develop a Swedish version, GRTWswe, for implementation and integration into the Swedish labor market’s RTW process. This involved translating, culturally adapting, and assessing the appropriateness and utility of a Canadian tool called TS-GRTW.

The key findings indicate the need for revisions in the Swedish version of the instruction guide and planning worksheet. These changes are required due to contextual and cultural disparities between Canada and Sweden, especially in organizational structures, reference frameworks, and policy documents used in various vocational rehabilitation units. To begin, one cultural factor influencing the RTW process are the varying roles and responsibilities of different actors in different countries. In the original planning worksheet, a physician provided restrictions/recommendations for the employee. In Sweden, the SSIA has the main responsibility for the RTW process, assessing the needs of RTW interventions and coordinating the process with other stakeholders. The SSIA investigates the need for work-oriented measures and coordinates efforts from health and medical care services (i.e., OTs and physicians), the employer, SPES, social services, and other actors to enable the person to return to work or to look for work. This may, for example, refer to participating in a reconciliation meeting called by the SSIA. Consequently, in the planning worksheet, the ‘responsible physician’ should be changed to be based on a “plan for RTW from SSIA”.

All participants expressed a sense of unfamiliarity with the current 4-point scale used to rate level of discomfort and would prefer a scale with which they were already familiar. Scales commonly employed in pain rehabilitation within Sweden typically encompass 11-point structures, such as visual analogue scales, highlighting a prominent aspect for positive progress, and these are used both in research, in quality registers and in clinics. To address this and increase familiarity with the scale in the Swedish version, we will revise the 4-point scale of section 10 in the original version and adopt an 11-point scale instead, ranging from ‘no discomfort’ to ‘worst imaginable discomfort’. We will be able to evaluate the change to an 11-point scale and the usability from a user perspective in a forthcoming study that is set to commence in workplaces soon.

An advantage of the TS-GRTW is the evidence-based foundation and the core concept MM [10]. MM is a multidimensional concept and has been operationalized into six dimensions, namely, work context; employers’ requirements and expectations; means and tools; worker’s personal parameters; work activity; and impact of the work situation [16, 17]. Although some participants in the present study were not familiar with the concept MM, this is regulated for the Swedish labor market in The Swedish Work Environment Authority [26], where the definition of MM is described as: “the employer must ensure that employees have opportunities to influence the organization and implementation of their own work, so that they have sufficient movement variation and recovery”. The GRTWswe focuses on MM regulations in the Swedish RTW process. To enhance our understanding of MM in Sweden, we need to refine the Instruction guide for MM. It is essential to distinguish between this guide and the specialized initial margin of manoeuvre assessment guide for OTs [15, 16].

While the primary intention of TS-GRTW is for the tool to be employed by employers in conjunction with employees, the participants in this study recognized the potential to engage employees through various intermediaries, including OTs at specialty clinics and rehabilitation coordinators in primary care. These individuals can be seen as central coordinators who, during return-to-work meetings, establish connections with both employers and Occupational Health Care (OHC) representatives. Through this approach, they facilitate the implementation of the tool in various workplaces.

An interesting finding in this study was the agreement among participants to expand the tool’s target groups for employees regardless of diagnosis, and the clinical relevance of the tool to increase the transferability and usability of the tool. GRTWswe’s clinical relevance extends beyond chronic pain, accommodating return-to-work, unemployment, and new job situations, as well as aiding employers in supporting employees’ return, regardless of their diagnosis. This would also be in line with what Bouffard et al. [10] proposed regarding further developments of the TS-GRTW. According to the authors, there is a new trend toward developing tools in promoting a successful RTW that can be used for all types of diagnoses [10].

This study demonstrated that GRTWswe can help bridge the current gap in providing support to employers and employees during the RTW process. The tool encourages ongoing collaboration between supervisors and individual employees, facilitating communication, cooperation, and the creation of a shared plan through mutual decision-making [9]. In this study, the tool’s ability to enhance communication was highlighted during group consultations, similar to findings from the original Canadian version [10]. It was underscored that GRTWswe encourages communication among the parties involved. Enhanced communication and collaborative decision-making can also assist employers [7] in fulfilling their responsibilities within Swedish workplace context. In addition to fostering communication, the planning worksheet within GRTW promotes collaboration between the employer and employee [10]. TS-GRTW prioritizes continuous follow-up as a core objective, effectively addressing challenges that may arise during the RTW process through joint efforts. The importance of ongoing follow-up is underscored as one of the eight actionable strategies for facilitating employee progress in the RTW process [27], alongside crucial elements like assistance and planning. TS-GRTW conveniently integrates these essential steps. The study highlights how employees play a crucial role in managing their situation, emphasizing their responsibility, active involvement, and self-confidence. Motivation and their belief in their ability to handle pain also impacts collaboration [28]. This collaboration, in turn, can enhance self-efficacy, leading to improved outcomes [29, 30]. TS-GRTW can be seen as a self-management intervention, incorporating elements like goal setting, action planning, collaborative decision-making, and proactive follow-up [31]. Consequently, TS-GRTW strengthens self-efficacy, resulting in improved work-related outcomes. A supportive work environment plays a vital role in empowering individuals to engage in self-management strategies [31]. In summary, stakeholder agreement on a RTW goal and acceptance of an intervention plan that aligns task demands with worker capacity is crucial for successful RTW [32].

5 Conclusion

In summary, the study’s results highlighted strong agreement between the questionnaire responses and the outcomes of group consultations regarding the usability of the preliminary translated GRTWswe tool, demonstrating its suitability for application within a Swedish setting after some cultural adaptations. The tool offers distinct advantages by aiding both employers and employees. This is achieved through fostering communication, promoting collaborative efforts, and facilitating a structured process, all of which have promising prospects for establishing enduring and favorable work conditions. Moreover, there is potential to broaden the tool’s application to encompass other demographic groups encountering work-related issues, Additionally, diverse occupational groups beyond employers stand to gain considerable benefits from its application.

Ethical approval

The study was approved by the Swedish Ethical Review Board (Dnr 2021-06678-01).

Informed consent

The participating occupational therapists provided written informed consent, and the data were securely stored in a confidential database.

Conflict of interest

The authors declare no conflict of interest.