At the start of the program most participants expressed frustration regarding being sick-listed, external anticipations as well as hindrances towards returning to work, and described hope that the program would provide them with the skills and techniques necessary to cope with health problems and being able to return to work. At the end of the program the participants described that they had embarked upon a long process of increased awareness. This process encompassed four areas; an increased awareness of what was important in life, realizing the strain from external expectations and demands, a need to balance different aspects of life, and return to work as part of a long and complex process.
Discussion of results
Most participants talked about discovering new personal values or re-discovering old ones. That persons participating in occupational rehabilitation appreciate being encouraged to focus on important personal values and needs has also been found elsewhere [
36]. For instance, persons sick-listed due to mental health problems have described that reflecting on what is valuable in life and focus on life goals instead of symptoms, is necessary to be able to live a satisfactory life [
37]. The results in the present study showed that the participants contrasted the more “internal” values with “external” expectations and demands from other people and society as a whole. The experiences of strong demands to function and work normally were during the program extended to life as a whole, and the participants had started the work to balance these external demands with personal values.
Many authors have described and discussed a balance between work on one hand, and non-professional parts of life on the other - often called the work-life-balance [
38‐
40]. While work in pre-industrial times was closely linked to family and personal life, work after the eighteenth century became separate from “private” leisure time [
41]. Authors have pointed to a “modern” division between private and public, as well as between life in the family/community and the engagement in work [
41] (page 16). Although a new “merging” of work and private life might be seen due to technological development, we often think of work and leisure as two separate life arenas, where sick-leave is only possible in the work arena. In the present study, the participants did not divide their lives in work on the one hand and the rest of life on the other. Instead, they described incongruence, and a potential conflict, between external expectations/demands and internal personal values.
An important question when discussing the findings is whether the rehabilitation program has “highlighted” this conflict by transforming the initial sense of frustration and pressure to return to work into focusing on the meaning of life outside work. Virtanen and colleagues conducted an ethnographic study of sickness absence and whether absence could be understood as a practice, not only based on the individuals’ health, but also on the rules of the community they belonged to [
42]. The authors argued that attitudes to work also were an expression of the attitudes which are rooted in the participants’ community. In the interviews at the start of the program, the participants focused on finding a solution to health problems and sickness absence. In accordance with the findings of Virtanen and colleagues’, one might ask whether the rehabilitation program has acted as a “community” which has communicated the importance of attending to desired qualities in life. Focusing on desired qualities of life is also in line with one of the main aspects of the ACT approach [
23]. The program might thereby have induced a shift in perspectives on work. It is therefore reasonable to ask whether the program, including the rehabilitation therapists, have focused adequately on the return to work process.
Crooker and colleagues have similarly described that the balance between work and life outside work is influenced by the individual’s value system [
40]. Values are described as a belief that “a specific mode of conduct or end state of existence is personally or socially preferable to an opposite or converse mode of conduct […]” (page 399). Crooker and colleagues further describe that the intensity of a value, i.e. how strongly held they are, might influence the experience of a balance with work and the rest of life. In addition, the authors describe that there might be congruence – or lack of congruence – between the values of the individual and members of different domains in this individual’s life. In the present study the newly discovered or re-discovered values seem to be incongruent with the external demands experienced by the participants. In light of Crooker and colleagues’ description of values, the participants’ long-term priorities seem to be strong, yet incongruent with the other values, in this case the society’s anticipation of them returning to work.
Previous studies have also found a conflict between desired qualities of life outside work and the values in the workplace, especially during the return to work process. In a study exploring Dutch women’s perceptions of work and sickness absence the women described a big gap between their realization of limitations in their work capacity and the expectations and demands at the workplace [
43]. The recognition of the gap was attributed to the rehabilitation programs the women had participated in, a program that solely focused on the women’s personal work values without adjusting the work environment. As return to work is a complex process which extends beyond the individual and includes many different actors [
44], working with the individual’s desired life values alone might not be sufficient for a successful return to work process [
43].
The results in the present study showed that while work and absence from work was described as a major problem in the initial interviews, the focus in the follow-up interviews was on the process of awareness which the participants had been introduced to. Compared to the sense of pressure and frustration the participants expressed in initial interviews, most of the participants had achieved a more patient and somewhat “sober” attitude towards unrealistic expectations for a “quick fix” to return to work. Return to work was instead described as one of many aspects of a large, complex and more long-term process, and as one of several aspects in a multi-faceted view on life. This multi-faceted view of life is in line with previous research showing that participants in rehabilitation programs do not distinguish between work, family and the rest of life, but rather view them as parts of a whole [
36]. This also corresponds with professionals’ perceptions of the return to work process. A Swedish study showed that professionals providing occupational rehabilitation programs perceived return to work as a long-term process which extended beyond the rehabilitation program [
45].
Based on the results from the present study, a major question is whether Acceptance and Commitment Therapy, physical exercise and creating a return to work plan, as in this occupational rehabilitation program, is sufficient to induce sustainable return to work. A potential conflict between aiming to improve participants’ well-being and facilitating return to work has also been described previously [
45]. In a Swedish study, health professionals working with occupational rehabilitation of patients with low-back pain emphasized that improving participants’ psychological and physiological well-being should in turn facilitate return to work, but that this sometimes conflicted with the intent to reinforce the return process [
45]. A small qualitative study including women with stress-related health problems, who participated in a vocational rehabilitation program, showed that the participants found it easier to connect the experiences from the program to everyday life than to their job situations [
46]. Changing approaches in the private arena was experienced as easier than changing behavior regarding work, and making concrete action in the job arena was difficult. Hellmann and colleagues argue that well-being and work are interconnected and influence each other, and that focusing on just one of the factors can hinder the return to work process [
45,
46]. Haugli and colleagues interviewed persons with musculoskeletal and/or psychological health complaints who had taken part in an occupational rehabilitation program three years previously [
36]. They found that self-understanding and viewing oneself as an active agent was perceived as necessary to be able to return to work. In addition to an increased focus on values and resources, this included changing the self-understanding to being able to take control over the rehabilitation process as well as the return to work process.
In light of the findings in the present study it would be reasonable to ask whether return to work presupposes a full reorientation of all parts of a person’s life, as well as whether this is a privilege reserved for generous welfare systems, as in Norway. Another important question would be whether this reorientation and self-realization process could take place while the person is working. Some studies have shown that returning to work might be beneficial for the worker’s mental health and function [
47‐
50]. Authors have argued that training persons while they take part in normal working life might be beneficial compared to training them fully before entering the workplace [
51]. The method of Individual Placement and Support has for instance shown health benefits for persons with severe mental health problems [
52‐
55], and highlighted the benefits from being at work while struggling with health challenges.
The participants wanted to achieve a balance between different aspects in life, for instance between more external demands and expectations and the individual’s personal values. It thus seemed like all participants had a long-term goal of living “a good and balanced life” according to what they perceived as important in their lives. Holmgren and Ivanoff interviewed women who were sick-listed due to work-related strain, asking them about potential possibilities and obstacles for returning to work [
56]. The women described that finding and doing meaningful self-chosen and enjoyable activities was a strategy to master everyday life. These findings are in line with the results of the present study, where the participants have (re) discovered and are connecting to personal values such as social contact.
However, Holmgren and Ivanoff also showed that formulating goals for the future and strategies for achieving these goals, as well as regaining faith in one’s own competence was described as necessary to return to work [
56]. This resembles the concept of self-management of health problems, a concept that refers to how a person copes - or does not cope – with his or her health [
57]. Self-management includes five core management or coping skills; Problem solving, decision-making, resource utilization, forming a patient/provider relationship, and taking action. Taking action includes for instance to make and carry out a short-term action plan. While participants in the present study had made different action plans regarding several aspects of their life, few had made concrete work-related steps of action. Resembling the model of self-management, the Stages of change model describes how different stages in the change process influence the motivation, readiness, and capability of making behavioral changes [
58]. The Action stage in this model is the stage where persons are no longer contemplating whether to make behavioral changes but is taking concrete steps in modifying a behavior. The results from the present study indicate that the program has helped the participants to investigate and assess what they find important in life. It is however unclear whether the participants have achieved the ability to transform these personal values into concrete steps in the direction towards return to work. The results from this study are relevant for rehabilitation programs where the overarching goal is to improve the return to work process and eventually return to working life. The act of balancing the focus on exploring personal values with specific plans supporting return to work is a challenge for professionals working in occupational rehabilitation facilities.
Strengths and limitations
This is a quite large qualitative study including a total of 29 participants. Although the proportion of women versus men in the study sample resembles the participants at this occupational rehabilitation center, the results might not be representative for other groups of sick-listed persons. Large parts of the data collection were conducted by two researchers, one medical doctor with clinical experience from occupational rehabilitation and one public health researcher. This provided various preconceptions and thus strengthened the data collection. Data analysis was conducted in a group including all four authors, two researchers with medical background and two researchers within social science/public health. In addition, a third researcher with medical background (psychiatrist) participated in the initial analysis. The findings were discussed in the group to strengthen diversity during the interpretations of the data and in affirmation of the findings.
There are also some potential limitations. The sample of participants who took part in the interviews at the start of the program was not identical with the sample at the end. Six persons just participated in the first interview, while six just took part at the end. This might have influenced the results and the changes in perspectives during the program.
Focus groups use the group interaction to create discussions and thereby explore important themes, as well as revealing values or norms in the group [
59]. Individual interviews do not include discussions and interactions, but can be advantageous in exploring personal experiences and changes. The focus group interviews were conducted in the same groups that had worked together during the rehabilitation program. This was chosen since the participants already were familiar and we assumed that this would lead to spirited discussions. On the other hand, interviewing the participants in their therapy groups could have reduced the possibility for capturing any negative experiences. The participants might have had negative experiences with the program or with the group work in particular, which they did not feel comfortable voicing in these groups.
One medical doctor (SØG – conducted all interviews) and one researcher within public health (MBR – participated in four interviews) conducted the interviews. The choice of interviewers might have influenced the data collection by focusing more on the awareness process and less on return to work, possibly influencing the results.
It is important to keep in mind that the follow-up interviews were conducted at the end of the program - only 3.5 weeks after the rehabilitation program started. This time frame might not have been sufficient to allow for the necessary changes to have taken place, especially regarding return to work. Interviewing the participants at the end of the program did thus not allow for experiences after returning home from the rehabilitation center. More long-term exploration of the experiences after the program was beyond the sphere of this study, but would provide important indications on the following return to work process.