Background
Self-efficacy is an interesting factor to consider in the return-to-work (RTW) process of workers, because unlike other factors that predict RTW (e.g. age, gender) it can potentially be influenced. Self-efficacy is the individual’s conviction that one has the ability to successfully perform a certain behavior [
1]. According to Bandura’s self-efficacy theory, enhancement of an individual’s sense of self-efficacy is an essential mechanism of change [
2]. Psychological interventions arising from this theory are based on the assumption that individuals who are seeking help have a low sense of self-efficacy. The main aim of this help should therefore be to restore self-efficacy. Most effective interventions to restore self-efficacy involve working on one or more of the five elements that construct beliefs that an individual has about his or her abilities: vicarious, imaginal, and performance experiences, verbal persuasion, and physiological and emotional states [
2]. Of these five elements, performance experiences have been shown to be the most powerful. For example, success at a task or behavior strengthens self-efficacy expectations for that task or behavior [
2].
Recent studies have shown that an individual’s level of work related self-efficacy at the start of the sickness absence is an adequate predictor of time until actual RTW [
3‐
5]. In seeking an understanding of how to facilitate the recovery and RTW process, many studies have tried to identify factors that influence the time until RTW for workers with mental health problems. Frequently identified factors that have been found to be related to later RTW are: depression, anxiety disorders, burnout, co-morbid mental health problems, older age, low education, history of previous sick leave, high job stress, reorganizational stress, threat of unemployment, and part time work [
6‐
15]. Factors related to an earlier RTW include: higher self-efficacy, active problem-solving coping strategies, lower age, frequent communication with supervisor, and quality and continuity of occupational care [
6,
8,
3,
16,
17]. With regard to gender, mixed outcomes have been found [
6,
11,
12].
The Netherlands Society of Occupational Medicine developed a guideline entitled “The management of mental health problems of workers by occupational physicians” in 2001 and revised it in 2007 [
18]. The recommendations and interventions that are included in this practice guideline for occupational physicians address a combination of four of the five elements that are supposed to restore self-efficacy according to the theory of Bandura. In general the use of evidence based guidelines is considered to be effective to improve the patient care [
19,
20]. However, previous studies on the use of this Dutch guideline showed that despite their positive attitude towards this guideline, actual guideline adherence of occupational physicians was minimal [
21,
22].
For a larger study aiming to enhance occupational physicians’ adherence to this guideline, a training was developed. This training entails techniques for the OP to get grip on the elements and interventions that contribute to enhance work related self-efficacy in workers sick-listed with common mental disorders. Sickness absence due to common mental disorders, such as depression, anxiety disorders, and adjustment disorders, is a problem in many Western countries [
23]. Long-term sickness absence in particular leads to substantial individual suffering, and high societal and financial costs [
24,
25]. The present study aimed to evaluate the effects of this intervention to enhance guideline adherence of occupational physicians on RTW self-efficacy and on the association between RTW self-efficacy and actual RTW.
Research questions
1) Does the intervention to enhance guideline adherence of occupational physicians lead to increased RTW self-efficacy in workers three months later, as compared to workers guided by occupational physicians who did not receive the training (i.e. care as usual)?
2) Does the intervention to enhance guideline adherence of occupational physicians modify the association between RTW self-efficacy of workers, as measured shortly after a first consultation with an occupational physician, and actual RTW status three months later?
Discussion
To our knowledge, this is the first study showing that RTW self-efficacy in sick listed workers can be positively influenced during the first months of sickness absence in a real-life occupational health care setting. The present study showed that the RTW self-efficacy in workers was significantly increased by the intervention, and that RTW status did not influence the increase of RTW self-efficacy. Furthermore, the intervention did not influence the predictive association between the level of RTW self-efficacy at baseline in workers with common mental disorders and RTW status three months after the start of occupational health care. Workers with higher RTW self-efficacy scores at baseline experienced a full RTW significantly more often than did workers with lower RTW self-efficacy baseline scores. Personal factors, mental health factors, or work-related factors at baseline did not influence this association.
The association found between RTW self-efficacy at baseline and actual full RTW three months after the first consultation with an occupational physician is consistent with the findings of previous studies concerning the predictive value of RTW self-efficacy for full RTW [
3‐
5]. In contrast to the findings of Lagerveld and colleagues [
4], no association between RTW self-efficacy and a partial RTW was found. However, the mean overall RTW self-efficacy scores at baseline were higher in Lagerveld’s study than they were in the present study (3.8 vs. 3.4). Since the workers in Lagerveld’s study had higher RTW self-efficacy scores at baseline, which is indicative of an earlier RTW, the workers in that study were probably already partially at work three months later, while the workers in our study were still on sick leave at that time. So, this difference in results regarding partial RTW might be explained by the difference in baseline scores. Another explanation for not finding an association between RTW self-efficacy and partial RTW might be a lack of power. Although 22 % of the workers experienced partial RTW, 128 participating workers in our sample might be too little to find an association between RTW self-efficacy and partial RTW.
In contrast with other studies, the present study found that the intervention significantly influenced the increase of RTW self-efficacy over time. Other studies [
40,
41] also found a significant increase of RTW self-efficacy over time but this was not caused by the interventions for occupational professionals to guide workers with mental health problems used in these studies. These interventions also concern some kind of problem inventory by the worker making a problem solving plan [
40] and/or reintegration plan by the worker [
41], homework assignments for the worker [
40] and guidance by an occupational physician [
40] or an occupational therapist [
41]. Unlike the current study one of the other interventions contained group meetings for the workers as well as individual consultations, and roll play experiences for the workers [
41]. However, there was one study that also found that the intervention significantly increased RTW self-efficacy, but this intervention was a training for workers with a chronic physical disease [
42]. Therefore, this intervention is less comparable to the interventions including a training for occupational health professionals to guide workers with mental health problems in the other studies. Considering these contradictory findings, it seems not easy to influence self-efficacy by the guidance of occupational health care providers. Therefore, more research on innovative interventions is needed to explore the ways in which RTW self-efficacy could be positively influenced.
Based on Bandura’s self-efficacy theory [
2], we expected that guidance provided according to the Dutch practice guideline for occupational physicians would contribute to an increase in RTW self-efficacy in workers with common mental disorders. This study showed that the intervention to enhance the guideline-based care provided by occupational physicians significantly increased RTW self-efficacy, as compared to care as usual. The elements in this guideline that contain strategies that are supposed to enhance RTW self-efficacy may indeed have contributed to the increase in RTW self-efficacy in workers with common mental disorders. These findings endorse the potential utility of measuring and seeking to increase RTW self-efficacy in the recovery and RTW process, and could be taken into account by occupational health care providers as they provide guidance to workers with common mental disorders.
Since RTW self-efficacy was only measured at baseline and three months later, we were not able to study the exact course of any changes in RTW self-efficacy within the first three months. It would be worthwhile to evaluate this short-term course of RTW self-efficacy levels and the potential influence exerted by occupational health care, since this can contribute to more knowledge about what happens early in the RTW process and about what might be useful in obtaining an earlier RTW. It would also be worthwhile to evaluate the long-term course of RTW self-efficacy levels and other factors related to an (earlier) RTW, as well as the influence of the training on the development of RTW self-efficacy and other factors related to RTW over time.
A limitation of this study was that RTW self-efficacy was measured after the first consultation with the occupational physician, so workers’ RTW self-efficacy scores could already have been influenced by the guidance of their occupational physicians. Due to the participant enrollment process, workers could only be invited and included in the study after their first consultation with an occupational physician [
26]. The first consultation included problem orientation, diagnosis, providing information about the recovery process, and if necessary some initial interventions which could contain elements that were supposed to restore self-efficacy. The first questionnaire was filled out by the worker as soon as possible after his or her first consultation with the occupational physicians. However, measuring RTW self-efficacy some weeks after the start of the sickness absence is comparable to the methods of other studies [
4,
5], and was the same for both groups. Nevertheless, RTW self-efficacy at baseline was significantly associated with the occurrence of an actual full RTW, and the intervention significantly influenced increases in RTW self-efficacy over time.
An important limitation of this study was that no objective information was available about the actual guideline adherence of occupational physicians after the training. The occupational physicians were randomly assigned to the intervention group or to the control group through which the influence of other factors on the increase of RTW self-efficacy was not obvious. Although the self-reported guideline adherence by the occupational physicians indicated that their guideline adherence was significantly improved after the training [Joosen et al., submitted, unpublished observations] and self-report measures are highly common in research, objective measures would be preferable and should be used in future research. Therefore, in current study it was not possible to point out which components of the intervention or the provided care contributed to the increases in RTW self-efficacy over time. More research on this important aspect will be needed to learn more about which parts of the guideline and the interventions that influence the recovery and RTW process.
Another limitation of this study was that only those occupational physicians and workers who were willing to participate in the study were included. Probably only occupational physicians who were most eager to improve their guidance of workers with common mental disorders or occupational physicians who were in need of educational credits applied to participate in this study. This might have caused selection bias. Nevertheless, the intervention significantly influenced increases in RTW self-efficacy over time.
This study shows that RTW self-efficacy can be influenced in a real-life Dutch occupational health care setting. Since occupational health care is organized differently in different countries [
43], more research is needed to evaluate whether RTW self-efficacy can be influenced in other settings.
Competing interests
JvdK was manager and main author in the development of the NVAB guideline. JvdK does not receive fees for the use of the guideline.
KvB, EB, MJ, JM, BT, and JvW declare that they have no conflicts of interest.
Authors’ contributions
KvB, JvdK, EB, MJ, BT, and JvW contributed to the conception and design of the study. JM and KvB performed the statistical analyses. KvB also performed the data collection and wrote the manuscript. KvB, JvdK, EB, MJ, JM, BT, and JvW revised and commented on the manuscript. All authors read and approved the final manuscript.