What Facilitates Return to Work? Patients Experiences 3 Years After Occupational Rehabilitation

Many of the RTW group participants expressed that being on sick leave was like losing their footing in life. Work represented an important arena for identity. They felt valuable and work represented a psychosocial well being in addition to a social network. Being on long-term sick leave implied starting to doubt this identity. They lost an important arena for social network and they started to feel uncertain and vulnerable. One woman stated:

“Who am I if I am not a teacher anymore…”

Many also expressed that identity did not seem to be permanent. One man expressed it like this:

“I understood that it was possible, I did not have to be the person I am now (a patient) for the rest of my life.”

Many of the RTW group participants expressed that they spent time trying to find out what was important to them in their life and how they could prioritise to manage both family, work and leisure time. Many realized that they had not lived a life in accordance with their own values and had perhaps underestimated their own needs. One woman said:

“I learned to give priority to what I wanted – what was of importance to me. I made a list of priorities - what I spent my time doing and what was important for me to do”

The RTW group participants expressed that the rehabilitation programme had encouraged them to reflect on what was important to them, and they realized that they had a choice in life. They increased their awareness of living in accordance with own values. Many of them had experienced being trapped in their own thoughts, and the programme stimulated them to make new reflections regarding own values. This gave them increased awareness of own will and own choice rather than doing what they thought other people expected them to do. One woman expressed it like this:

“I sat down to double check my goals in life. Is it necessary? Who am I doing it for? What do I accomplish? And what will be required of me to do it?”

By self-reflection they started a changing process that resulted in increased awareness of how to live in accordance with own values. Many of the RTW participants also described that they reduced their own work demands. One man in his fifties put it this way:

“I had to learn about mechanisms in myself that promoted my burned-out situation. I was very proud; I pressed myself to achieve good results, very difficult for me not to succeed in everything I do. I had to understand this about myself. I now have a more relaxed attitude; I feel safer within myself… I have learned to know my body, to listen to it – so I don’t work like a dog any more, I do not exploit myself ruthlessly”

Increased self-awareness also facilitated a change in thoughts about own health situation. The RTW participants realized that they could continue to focus on illness and health limitations, or they could choose to focus on own resources and possibilities. Their choice affected the level of energy they experienced and the direction they wanted to take. A woman expressed it like this:

“The fact that there are things that I can do and that focus should not be on what I can’t do. Even if I wanted to I couldn’t return to my job as an aircraft mechanic. So I could sit down and be depressed, or I could choose to focus on everything I actually can do. My focus has been on finding things I can do and not grieve over what I cannot do.”

On the other side, the DP group participants expressed the view that their illness was outside their own control, and that they had to get well before even thinking of working. Irrespective of own behaviour and attitudes, the disability pensioners had a strong focus on diagnosis and illness and the need of a specific treatment to get well. They felt helpless; no matter what they did, the pain was still there, and the pain had to be relieved before even thinking of RTW. They regarded themselves more as passive pawns than in charge of their own situation.

At the clinic the inpatients were divided into groups, and counselling and training were provided both individually and in groups. Belonging to a group was stated to be of great importance, both the formally organized groups and self-organized groups. Listening to other peoples stories made them able to draw parallels to their own life and in this way increase their own understanding. Discovering that other people were in the same situation and they were not alone with their experiences, enhanced a feeling of companionship and security. Many of the participants had interpreted their situation or complaints as very special, and as a sign of their specific illness. Discovering that other people were in a similar situation or had similar experiences contributed to normalization of their own situation. To be able to share their story gave them a broader perspective on their own situation and a feeling of not being alone. Sharing of stories with other inpatients made them also realize that they were useful for other people and they could challenge each other and learn from each other’s experiences. Different aspects of belonging to a group appeared during the interviews. The participants who had returned to work emphasized being each other’s sparring partners and this facilitated their own reflections and self-understanding. One man expressed it like this:

“I tried to look into myself seriously, and I was challenged by the others, especially by the other participants. So adding up the counselling (by the professionals) and the input from the other participants was a very good coaching situation for me.”

Views on this differed as the DP group participants emphasized to a larger degree the social aspects of the group and the feeling of being in the same boat. Group membership also helped the participants to feel confident together with other people and dare talking about difficult aspects of life. Many had been isolated during their sick leave period and had experienced difficulties in talking to people or take initiative to be together. Coping with the social companionship in the group gave them increased confidence with regard to the social companionship at work.

Negative experiences with the group sessions also appeared. Some of the participants in the DP group experienced the counselling group meetings as too challenging and demanding, and they experienced the meetings as a personal defeat. For them it was difficult to be in a group with people that were motivated for RTW and therefore received support from the professional team. This reinforced negative feelings within themselves, and they felt like losers.

Some RTW participants underlined that support from the employer contributed to a successful RTW, while lack of support could have the opposite effect. Changing own behaviour and thinking was the most important factor, but support and adjustments at the workplace was also mentioned as a prerequisite for a successful RTW. One woman put it like this:

“I had a fantastic employer who paved the way for my return. He asked me if I could do this or that. They were fantastic at the workplace. They put so much effort in keeping me so I got a lot of confidence – when they take the chance I have to do my bit.”

In this study, a central issue for a successful RTW process was increased self-understanding. The participants expressed that during the rehabilitation stay they had experienced a possibility for reconstruction of self. The participants who had re-entered work, emphasized the experience of increased awareness of own identity, values and resources as an important step towards work. They regarded themselves as competent and able to take control over own life situation and thereby control over the rehabilitation process. They focused on how they could manage everyday life despite pain rather than on pain relief and cause of illness. The rehabilitation programme helped them realize their own influence on the RTW processes. On the other hand, participants who had become disability pensioners externalised their problems and stated a view that the treatment outcome had been more dependent on external circumstances like the competence of the professional team or lack of support from employer. They focused on pain relief and expected passive treatment modalities to alleviate their pain, and getting well before returning to work.

Nygård [34] points out that a central issue when trying to understand our ways of handling the varied situations with which we are confronted, is how we interpret and construct ourselves i.e. what kind of understanding of self we bring to these situations. He emphasizes whether a person tends to construct himself or herself as an origin of behaviour—an agent—an inner-directed person or as a pawn—an outer-directed person who experience that there are someone or something outside who is in charge of control. Persons who for a long time have viewed themselves as pawns may find it challenging to change their role to a more agent—oriented person. Our findings are in accordance with Nygårds theories on agent-orientation [34]. Participants who had re-entered work after rehabilitation focused on how to live in accordance with own values and resources in spite of their pain and problems, they had control over own life situation, while the disability pensioners expressed that success after the rehabilitation was dependent on external factors like the team, the employer or pain relief. This creates a difference in the purpose for which treatment strategies are implemented. Explicit goal of pain reduction or improved pain management might be substituted by methods enhancing self understanding. This is in accordance with what Mc Cracken et al. [35] found in rehabilitation of patients with chronic musculoskeletal pain. Rehabilitation and RTW processes are described as taking control over everyday life, or as a desire and capacity to take charge of their life situation [36, 37]. Fjellman-Wiklund et al. [38] describes rehabilitation as a process where the “getting to know myself” and “how can I be the one I want to be” are basic conditions for a successful RTW. This study indicates that the way I comprehend myself can be reconstructed, and this is important in developing new strategies to handle life situation and the RTW processes.

Our self understanding might be decisive for our health and how we cope with illness and challenges in everyday life. The question is whether the individual perceives himself as an agent (internalising) or as a pawn (externalising).

The shift from surrendering the authority about their pain to health professionals to search for and find both authority and answers in themselves is a major shift in understanding. The participants told that active participation and time had been necessary for understanding and feeling comfortable to make this shift. They needed to experience and be assured that they had the answers within themselves. Being told by others was not enough. This demonstrates the importance of experience oriented learning when entering a process in order to change beliefs, behaviour and attitudes.

The participants acknowledged the group as an arena for learning. The social setting was an arena for practising new behaviour and recognition of own thoughts and emotions. The experience of “being in the same boat” contributed to normalization of symptoms and pain. This is in accordance with other studies that have found that group support seems to strengthen the empowerment and enhance the reconstruction of identity by providing opportunities for self-evaluation and comparison [39, 40].

Several of the participants had previously experienced distrust from health personnel and this had led to reduced self-confidence, a feeling of hopelessness and loss of work ability. Stories were told about being stigmatised and not taken seriously by health personnel. The rehabilitation team had legitimated and acknowledged their pain and problems and their social status as a person on sick leave. The impact of positive interaction with professionals regarding RTW has been underscored in previous studies [41, 42]. Svensson et al. [42] found that when persons on sick leave were asked about factors that hindered or promoted RTW in general, they indicated positive and negative encounters with healthcare and social insurance professionals as decisive. Examples of positive experiences comprised being believed, taken seriously and considered to be in the right, feeling that the professionals listened, that they were supportive and/or encouraging, and showed personal involvement and confidence in the person’s ability to work [42]. This is in line with our findings. However, in our study experiencing positive encounters without being challenged enough on own self-understanding and without enough support from significant others may seem to increase the risk of disability.

The experience of change in self-understanding and a successful RTW as described by the participants occurred as a result of self-reflection that led to increased awareness of own identity, values and resources. This process was not linear, but individual and complex, and was also related to interactions with significant others (like peer participants, employer, social welfare office etc.). The participants emphasized the employers’ belief in their capacity and resources and this facilitated the RTW process. Other studies also emphasize the importance of perceived social support in the RTW process [43, 44]. In this study the employers’ capacity and will to reorganize the workplace for the employees seems to be important but not sufficient for a successful RTW.

In this study we have back ground information of the participants’ gender, age and work status. Knowledge about education and previous employment might have been beneficial in the interpretation of our results. Studies have shown that socio-economic status like education and income may be important predictors for RTW [16, 45]. The participants who succeeded in returning to work might have had a higher education and possibly also higher capability of increasing own self-understanding. Our study indicated furthermore that the participants who did not succeed in RTW had a higher focus on biomedical causes of their illness and experienced less control of their own situation. This may also be explained by the individual’s level socio-economic status. The participants were asked about their experiences 3–4 years after their rehabilitation stay. The time factor may represent a recall bias in what was of most importance for their RTW process. The participants might also have had a recall bias remembering what could justify their own situation. None of the authors were involved in the rehabilitation of the participants, but LH presently holds a position at the rehabilitation center. The author’s interest and knowledge in the field will however have influenced the questions and dialogue in the semi-structured interviews and the analysis.