Facilitating job retention for chronically ill employees: perspectives of line managers and human resource managers

Chronic diseases are increasingly prevalent among people of working age in Europe [1, 2]. In the Netherlands, about one third of the working population (37%) has a chronic disease [3]. Musculoskeletal, respiratory, gastrointestinal, and cardiovascular conditions are common, as are skin diseases, diabetes, mental health problems, hearing disorders and cancer [4]. Chronic diseases do not go away. Other common characteristics are that they usually require regular medical care and self-management and that they may limit what one can do [5]. Many chronically ill workers (30%-60%) feel more or less restricted by their condition at work [4, 6‐8], and they are more likely to exit their job prematurely than their healthy colleagues [6, 9‐15]. Early job discontinuation can lead to negative health and socioeconomic outcomes for the individual [15, 16] and increased costs to employers and society [2, 10, 17]. To reverse these problems, recent EU and national social and employment policies are encouraging employers to facilitate continued employment for employees with long-term health problems and disabilities [16, 18, 19].

In the Netherlands, the responsibility for the provision of work disability benefits has shifted from the state to the employer in 2002 [3]. In response to this policy shift employers have established new programs to promote job retention for employees who are ill. In the past occupational physicians and occupational health services were mainly responsible for the development and implementation health and safety programs in Dutch companies. Today, line managers (LMs) and human resource managers (HRM) are playing an increasingly important role in workplace health management. A similar development is taking place in other countries [20]. In recent years, many large and medium-sized organizations in the Netherlands have created "social medical teams" at the level of departments, which have the task to implement and monitor organizational health and safety policies and procedures. In addition to an occupational physician, the department's LM and HRM constitute the core members of these teams. At present, in most Dutch organizations job retention programs are mainly focused on reducing the levels and duration of sickness absence. Employees who are on sick leave for more than two weeks are typically required to make a return-to-work plan together with their LM, while occupational physicians and HRM have the role to advice the two parties on feasible job adaptations that may be needed to implement these plans. The available statistics indicate that there has been an over-all decrease in absenteeism and work disability rates in the Netherlands since 2004. At the same time, however, an increase of work disability rates has been observed among employees with some chronic conditions (mental health problems and musculoskeletal disorders) [2, 21].

Frank and Cullen have characterized active absence or return-to-work management as secondary prevention, which occurs after illness or disability has occurred and aims at reducing long-term disability [22]. Disability research suggests, however, that the retention of chronically ill workers requires a more pro-active approach, combining secondary prevention with primary prevention [23‐27]. According to Frank and Cullen, "primary prevention aims at reducing the risk of injury or illness before the absence occurs (while the person is still healthy). This aim is generally accomplished by modifying factors known to increase the risk of work disability by directly controlling a specific hazard or set of hazards, for example by increasing a worker's skills or modifying the work environment" [22].

Internationally, occupational health researchers and practitioners have developed models and interventions for workplace based primary and secondary work disability prevention [23, 24]. Moreover, in recent years Dutch occupational physicians have developed guidelines for the prevention of work-related problems for a number of chronic conditions, together with general practitioners and medical specialists (e.g., depression, musculoskeletal, respiratory and cardiovascular conditions) [28]. However, several authors have noted that the guidance employees with chronic health conditions is still a largely neglected topic in the professional (human resource) management literature and training [5, 29, 30].

HRM and LMs have different functions and tasks within the organization. HRM usually occupy a staff function. They have the responsibility to ensure that employees become and remain valuable to the organization. They deal with issues related to people management such as compensation, hiring, performance management, organization development, safety, wellness and disability management, benefits, employee motivation, communication, administration, and training. The role of HRM is changing. In the past they were primarily responsible for personnel management. More recently, HRM departments are also becoming a strategic partner for the chief executives of an organization. In this role, HRM professionals contribute to the development of and implementation of organization-wide business plans, policies and objectives [31].

The LM is primarily responsible for organizing and supervising the work and productivity of a team or a department. Typical tasks of the LM are managing operational costs, providing technical expertise, organizing work allocation and rotas, monitoring work processes, checking quality, dealing with customers/clients, measuring operational performance. At present, also many of the personnel management tasks that were formerly performed by HRM have been devolved to the line manager, such as the recruitment and hiring of personnel, performance appraisal, coaching, resolving disputes and the implementation of health disability management policies [32]. LMs are most likely to receive the first requests for accommodations from employees with health problems. But it has been recognized that the successful implementation of such accommodations requires adequate coordination between LMs and other professionals, including HRM and occupational health services [27, 33]. Organizational studies have observed that there may be a gap between what is formally required by an organization's HR policy and what is actually delivered by LMs [34]. For instance, a case study from Cunningham and colleagues in four organizations in the UK found that HRM and LM may have very different perspectives and practices as regards to the protection of job-security for workers who are on sick leave. More concretely, the authors observed that LMs were not always able to comply with HR guidelines in this area, because they were confronted with conflicting policy requirements, weaknesses in training, lack of support from relevant human resources and occupational health specialists and various work and budgetary pressures [33].

Occupational health researchers and practitioners have argued that the retention of chronically ill employees requires a pro-active approach, combing primary prevention, with active absence management (secondary prevention). LMs and HRM are increasingly important stakeholders in workplace health and disability management. Disability researchers have shown that each stakeholder group may have its own perspective on disability management issues and that the perspectives of all stakeholders need to be taken into account if programs are to be effective [34, 35]. Thus far, little is known about the perspectives of HRM and LMs on what is needed to facilitate continued employment for chronically ill employees. Given their different roles in the organization, these perspectives may differ [33, 36]. Towards this background, the aim of this study was to explore and compare the perspectives of Dutch LMs and HRM on what is needed at the workplace to facilitate job retention for chronically ill employees.

Because there has been no previous research on the perspectives of HRM and LMs on factors that may facilitate job retention for chronically ill employees, the use of qualitative methods to elucidate their viewpoints was warranted [37]. In this study we selected concept mapping as a research method because it is a structured qualitative approach that can be used in small groups to elicit and map out ideas from participants about complex issues [38, 39]. The concept mapping methodology typically consists of the following steps: In the preparation step, the research team decides on a focus question. In the generation step, participants are asked to develop a set of statements (ideas) that address the focus. In the structuring step, participants are asked to structure their ideas by sorting the statements into categories that make sense to them and by rating them according to importance. During the representation step the first analysis is done. This is the process of taking the sort and rating input and "representing" it in map form. In the fifth step, the interpretation step, the researchers stimulate the participants to develop their own labels and interpretations for the various maps. In this study, Concept Systems software version 4.0 was used to support data entry and analysis [40].

Twenty-seven professionals participated in the study: 17 HRM (63%) and 10 LMs (Table 1). One-third of the participants reported they had received some kind of training in the management of employees with ill health. Of the 13 participants who had worked with employees with a chronic illness, 11 reported they had encountered difficulties in doing so.

The brainstorm session yielded 35 statements expressing the thoughts of the participants on what is necessary in order to ensure that chronically ill employees can continue to work. The four statements with the highest mean ratings (1 = low, 5 = high) for LMs were: "Mutual trust between employees and managers" (4.4); "The organization should reflect on what it means to be a good employer for chronically ill employees" (4.2); "Chronically ill employees must make decisions for themselves" (4.1); "An employer must be able to make demands on chronically ill employees" (4.1). The four statements with the highest mean ratings for HRM were: "Mutual trust between employees and managers" (4.5); "Good contact between manager and employee" (4.4); "The employer must realize that the employee should not continue to work in a situation that is no longer healthy" (4.4); "There must be good contact between manager, occupational physician and employee" (4.3).

Analysis of the sorting activity revealed that each group sorted the statements into a set of six distinct thematic clusters, referring to conditions they perceived as necessary to ensure that chronically ill employees can continue to work. Tables 2, 3 describe the clusters and the corresponding statements with median priority ratings for the clusters and mean priority ratings for the items, for LMs and HRM respectively. (Additional File 1 Figure S1 and Figure S2 depict the concept maps for LMs and HRM, respectively.)

In this qualitative study concept mapping proved to be a useful method to elicit perspectives of HRM and LMs on what is needed to facilitate continued employment for chronically ill workers. The brainstorming session allowed participants to generate their ideas about this issue. The rating and sorting procedures gave them an opportunity to structure those ideas.

We found both similarities and differences between the views of LMs and HRM on what may facilitate job retention for chronically ill employees. Mutual trust between the manager and the employee was rated as the most important statement by both groups. Four thematic clusters were mentioned by both groups; two uniquely by LMs; and two uniquely by HRM. LMs saw "good employee/manager cooperation" as the most important starting point for enabling job retention. For HRM the most important starting point was "corporate policy and culture". This may not be surprising, given the differences in professional responsibilities and job content between the two groups.

The strength of our study is that it builds directly on the experiences and ideas of immediate stakeholders. The study has also limitations. One limitation is that concept mapping allows the inclusion of only a limited number of participants [38]. In this study our selection was limited to 10 LMs and 17 HRM who worked in a variety of medium- or large-sized Dutch companies. About one third of the participants had received some kind of training in managing employee health. However, the career effects of chronic illness had not been addressed during this training. Indeed, most respondents indicated during the meeting that they did not know how many people at their own workplace were living with a chronic health problem. This corresponds with findings from a qualitative study on sickness absence management among LMs and HRM in the UK by Munir et al. [48]. Most participants said during first the group session that they joined the project because they wanted to learn more about chronic disease management at the workplace. It is possible that HRM and LMs with more experience in disability management would have generated other statements and concept maps. It should also be noted that the list of statements used for the rating and clustering procedures was generated by participants of the first concept mapping meeting, all of whom worked for an institution of higher education. It is possible HRM and LMs working in other contexts would have created other statements because culture differences between companies can be important. These specific characteristics of the study population should be kept in mind in interpreting the results. Furthermore, we saw that the mean priority ratings of the thematic clusters were very close to each other, varying from 3.9 to 3.1 for LMs and from 4.2 to 2.9 for HRM. In interpreting these results it should be kept in mind that the concept mapping methodology uses the rating of statements and clusters mainly as a way to support participants in structuring their ideas, and not for making statistical inferences. We also observed that all the statements were regarded as rather important (mean ratings were ≥ 2.5 on a five point scale). This may be understandable, because the statements were constructed by participants themselves. However, the method of data collection and analysis were rigorous and consistent, and the results are plausible in the light of the available literature on chronic disease management.

This study is unique in that it focuses on perspectives of LMs and HRM on what is needed to facilitate job retention for chronically ill employees. Most studies in this area have focussed on the perspectives and practices of LMs and HRM in disease absence or return-to-work management (secondary work disability prevention) [27, 33, 35, 48, 49]. James et al. [50] proposed an evidence-based conceptual framework for organizational dynamics that may enhance the return-to-work and job retention of ill workers. Several of the concepts that are included in this framework were also identified by our study participants (e.g., the establishment and implementation of a policy framework, the provision of rehabilitative support and coordination of the rehabilitative process). Other concepts from James' framework were not identified by the study participants (e.g., speedy identification of vulnerable workers, rights of workers to be represented by worker representatives (e.g., labour union) and the monitoring and review of existing policies). Many studies have identified the LM as the most central link between the organization and the employee and, consequently, as the most central stakeholder in workplace disability management [23, 24, 35, 48, 49]. A study by Cunningham et al. [33] indicated that LMs tend to take the responsibility for disability management on their own shoulders, without asking support from occupational or HRM services. In the present study a somewhat similar approach was reflected in the concept map that was generated by the LMs. They perceived "good cooperation between manager and employee" as the most important condition enabling job retention for chronically ill employees. The study by Cunningham et al. [33] emphasized the need for employers to provide adequate training to LM's in worker's health and disability management. This theme was also reflected in the concept maps of the LMs and HRM in this study. Corroborating with the views of HRM in the present study, studies on occupational disease and injury prevention and management have called attention to the importance of organizational level determinants (e.g., company culture and managerial style) as a facilitating factor for performing these tasks [23, 24, 51, 52]. Finally, some of the conditions which LMs and HRM perceived to be necessary for ensuring job retention for chronically ill workers are consistent with those identified by other stakeholders. For instance, previous studies found that chronically ill employees themselves and physicians also emphasized the importance of the presence of managers who are knowledgeable about the impact of chronic disease on the work situation, employees who take responsibility for keeping their job, good cooperation between the managers and employees, and collaboration with the occupational physician, and timely work adaptations, be it in a somewhat different terminology [43, 44, 53].

LMs and HRM are playing an increasingly important role in workplace health management. This concept mapping study provided insight into the perspectives of Dutch LMs and HRM on what is needed to facilitate continued employment for chronically ill employees. The extent to which these perspectives are shared by LMs and HRM working in other countries or organizational settings remains to be determined through other studies. Despite this caveat, we believe that the study provides information about topics that occupational health researchers and planners should take into consideration when developing job retention programs for chronically ill workers. Occupational health research has shown that work accommodations which have proven to be effective in facilitating the employability of chronically ill employees are not always applied at the workplace [e.g., [7]]. The statements and thematic clusters that have been identified in this study may be useful to explore factors that may inhibit or facilitate the application of such work accommodations by LMs and HRM. The study also offers some specific suggestions for occupational health practitioners. Within organizations, they have the task of to develop, supervise, implement or evaluate company health programs, but they also consult LMs and HRM on the guidance of individual employees. This study indicates that LMs and HRM view knowledge about the impact of chronic disease on the work situation as one of the basic requirements for guiding chronically ill employees. It could therefore be a task for occupational physicians to provide this information to these professionals, e.g. through in-company training.

This study identified both similarities and differences between the perspectives of Dutch LMs and HRM on conditions that may facilitate job retention for chronically ill employees. LMs and HRM identified four similar conditions: LMs and HRM must be knowledgeable about the impact of chronic disease on the employee; employees must accept responsibility for work retention; work adaptations must be implemented; and clear company policy. Two conditions were only identified by LMs: good manager/employee cooperation and knowledge transfer within the company. Unique conditions identified by HRM were: a company culture that facilitates trust and openness and organizational support. LMs perceived manager/employee cooperation as the most important mechanism for enabling continued employment for these employees. HRM perceived organizational policy and culture as the most important mechanism. These findings provide information about topics that occupational health researchers, planners and practitioners should take into consideration when developing job retention programs for chronically ill workers.