Job demands and decision control predicted return to work: the rapid-RTW cohort study

Prolonged sick leave is a public health concern associated with social, health and economic consequences for the employee, as well as for the society [1]. For the individual, long-term sickness absence has been found to lead to social isolation and inactivity [2‐4], depressive symptoms [3, 4], impaired self-image [2, 3], reduced well-being [5], and increased risk of disability pension [6, 7]. The annual costs related to sickness absence in Norway have been estimated to approximately 36.4 billion NOK (approx. US $6.5 billion or US $1.300 per capita) [8]. To facilitate a fast and safe return to work (RTW) is therefore of importance.

Sickness absence and work disability are complex phenomenon that can be seen as an interplay between the sick-listed employee and several factors and arenas, both at, and outside, the workplace [9, 10]. The systems and stakeholders in, or related to, the health care services and the social security systems can affect the employee and the RTW process [9, 11]. But the behaviour of the sick listed employee and how he or she copes with the disability, is also affected by physical, cognitive and emotional factors, as well as social relations at the personal level [9, 11]. In order to help employees on long-term sick leave return to work, it is crucial to understand the wide spectre of factors that either impede or facilitate employee’s reintegration to the labour force [12].

A growing amount of research has revealed that some aspects of the work environment can contribute to higher levels of sickness absence [13‐16] and reduced probability of returning to work [17‐21]. In addition to focusing on organizational and physical aspects of the work environment [22‐25], studies also recognize the importance of psychological and social factors in a RTW process [17‐21, 26, 27]. The demand-control model is one of the most widely used models for describing the impact of the psychosocial work environment on employee health. The concept of demands and control was first introduced by Karasek in 1979 [28]. Psychological job demands refer to the work pressure and workload experienced in the job, whereas decision control (or decision latitude) is concerned with the breadths of skills usable in the job and the social authority each worker has over making decisions. In the model, it is proposed that the psychological demands interact with the degree of decision control, generating four distinctly different kinds of psychosocial work experiences—also known as job types; high-strain jobs (high demands and low control), low-strain jobs (low demands and high control), active jobs (high demands and high control), and passive jobs (low demands and low control). If the demands are perceived as high and the decision control is low, job strain occurs. If, on the other hand, high demands are combined with a high level of decision control, growth, motivation and learning occurs.

An increasing amount of research has examined the association between the psychosocial work environment and work participation. However, most of the studies have used specific study groups, and different measures of RTW. This has made the results hard to generalize, and no definite conclusion has been made regarding the impact of the work environment on sickness absence and RTW. Nonetheless, the research seems to point towards an association between high job demands and delayed RTW. For example, a recent synthesis of 27 systematic reviews concluded that having high psychological job demands is a risk factor for disability and work absence [14]. Other studies suggest that low decision control and limited work flexibility affects disability and absenteeism. For example, O’Neill et al. (2010) found that low decision control reduced the RTW rates after myocardial infarction [29], and Krause et al. (2001) found that low decision control alone reduced the chances of returning to work with up to 30% for employees sick listed due to low back pain [20]. The interference of high-strain jobs on RTW has been fairly well established, and numerous studies have documented that the combination of high demands and low control reduces the probability of returning to work [17‐21]. However, conflicting results have been found for the impact of the other three job types. Jansen et al. (2003) for example, found that the combination of high demands and high control (active jobs) had a positive impact on RTW [26], whereas Lidwall and Marklund (2006) found that the same combination was associated with long-term sickness absence in women [15]. These conflicting findings argue for more studies on how the psychosocial work environment affects RTW, using different populations. The aim of this study was therefore to assess the association between psychological work characteristics and time-to first RTW in a cohort of full - time sick listed employees participating in RTW programmes in Norway.

Eighteen months after the employees started the programme, 77% had returned to work. The median time-to first RTW was 80 days (mean 185; SE: 196).

Employees reporting high psychological job demands had lower RTW rates than employees reporting low job demands (p = .001), with a median of 105 days (mean: 222 days, Standard Error (SE): 15) versus 57 days (mean: 158, SE: 14), respectively. Employees who reported high decision control had significantly higher RTW rates than employees reporting low decision control (p = .013), with a median of 68 days (mean: 165, SE: 14) versus 102 days (mean: 218, SE: 15), respectively. Figure 1 presents the time-to first RTW for each job type. Employees in high-strain jobs (high demands and low control) had significantly lower RTW rates compared to employees in active (high demands and high control), passive (low demands and low control) and low-strain (low demands and high control) jobs (p = .005), with a median time-to first RTW of 207 (mean: 276, SE: 25), 79 (mean: 209; SE: 13), 65 (mean: 178; SE 25) and 50 days (mean: 170; SE: 23) for high-strain, active, passive and low-strain jobs, respectively.

Table 2 presents the results from the cox regression analyses, both unadjusted and adjusted. Having high psychological job demands (HR = .654; 95% CI: .513–.832), or being in a job with low decision control (HR = 1.297; 95% CI: 1.010–1.666) were both independent predictors of delayed RTW. Employees with low-strain jobs (HR = 1.811; 95% CI: 1.287–2.549) and passive jobs (HR = 1.599; 95% CI: 1.107–2.309) had shorter time-to first RTW compared to employees with high-strain jobs, whereas no difference was found for employees in active jobs.

The aim of this study was to assess the association between psychological work characteristics and time to first RTW after a RTW programme. The following results will be discussed: (1) reporting high psychological job demands increased the time-to first RTW, (2) reporting high decision control decreased the time-to first RTW, and (3) having high-strain jobs decreased the probability of returning to work early, compared to low-strain and passive jobs.

In accordance with previous studies [17, 20, 21, 27], reporting high psychological job demands was associated with delayed RTW in this study. Research on the impact of work on health has found that high job demands are not necessarily negative, in many cases high demands can lead to higher levels of motivation, learning and growth [39]. However, in a RTW situation it is possible that the work demands are perceived as extra demanding, as the employee might experience impaired job performance as a result of the disability [40, 41]. Furthermore, as high psychological demands are associated with the development of health complaints [20], it is possible that high demands induce a fear of recurring or worsening the health complaints for which one called sick to begin with, thereby reducing the chances of returning to work [26]. Consequently, having a job with high work demands might reduce the employee’s wish to return to work. A persons wish to return to work and beliefs of succeeding has been found to affect whether the employee returns to work or not [42‐44]. Johansson and Lundberg (2005) suggests that whether an employee is sick listed or not is a function of the decision to go to work, and that this choice is determined not only by the persons disability, but by a function of different factors outside the individual [45]. High job demands have been linked to fear-avoidance behaviour in other studies [46], which in turn has been associated with prolonged sickness absence and delayed RTW [46‐48].

Several studies have acknowledged the association between decision control and RTW [19, 20, 26, 49], and the association between low decision control and delayed RTW is well established [14, 20, 24]. These findings were further confirmed in this study. Decision control is concerned with the breadth of skills used in the job, and the social authority the employee has over using these skills to accomplish the work tasks [39]. High decision control can therefore be associated with a wider flexibility and more adjustment possibilities [4]. Having good adjustment possibilities and flexibility might make it easier for the disabled employee to regulate their work depending on their health conditions, thereby increasing the possibility of returning to work [50, 51].

Employees in high-strain jobs had decreased RTW rates compared to employees in low-strain and passive jobs. In earlier studies, low-strain jobs have been found to predict lower than average psychological strain and risk of illness [39], as the high levels of decision control allows the individual to respond to each workplace challenge optimally. In addition, as the pressure and workload is experienced as low in passive jobs, there is room for making work modifications despite the low decision control, thereby making it possible to return to work earlier than in high-strain jobs. In high-strain jobs, the employees’ decision control is low at the same time as the demands are high, restricting the adjustment possibilities in the job. Few adjustment possibilities have been found to correlate significantly with long-term sickness absence [4]. Furthermore, few adjustment possibilities restrict the use of different coping mechanisms when faced with stressful situations. As high-strain jobs are associated with excessive stress levels, remaining out of work can be considered a coping mechanism to avoid or reduce the stressful working conditions [52]. The strategy of avoidance, or restraint, is often overlooked as a potential coping strategy, as restrain from the stressor is not considered a good solution for coping with a stressful situation. However, under some circumstances it can be perceived as a necessary and functional response, as it might prevent the employee from acting prematurely and RTW before he or she is ready. As previously noted, high job demands have been linked to fear-avoidance behaviour in other studies [46], making this a plausible explanation for the delay in RTW.

Another possibility is that the work experience maintains or aggravates the employees’ ill health. High-strain jobs have been linked to impaired immune systems, and several physical disorders including musculoskeletal disorders, cardiovascular disease and even some forms of cancer [53‐55]. It is thus possible that the employee’s experience of work environment directly impacts the employees’ health and recurring sickness absence [15, 27], or that high levels of work-related stress impedes for the use of adequate coping behaviours of the illness the employee experiences, extending the sickness absence period.

The results from the study indicate that having high psychological job demands and low decision control were both independent predictors of delayed RTW up to 18 months after participation in a RTW programme. Being in high-strain jobs significantly reduced the RTW rates compared to low-strain and passive jobs. This study further underpins a growing number of studies highlighting the importance of perceived work conditions in a RTW process. Identification of employees who experience their work environment as challenging is therefore important in a RTW process, as it makes it possible to meet their challenges regarding workplace issues more effectively. RTW programmes should therefore include intervention components targeting the individual and/or the work environment. We also need to test the effectiveness of such components in rigorous intervention studies.