In this section of the paper we will address our first question: What are the predominant workplace intervention components in the scientific and grey literature and what evidence-based RTW determinants do they address? We will also provide a summary of the comments provided by the special employer panel regarding the challenges they saw for the design and implementation of workplace-based interventions.
Results from Non-Cochrane Systematic Reviews
Research conducted at the work group, department or organizational level that was included in the non-Cochrane systematic reviews tended to address workplace determinants more commonly than personal determinants. The most frequently included intervention component identified in the studies assessed by these reviews is case management with worker and employer communication regarding RTW (found in 6 of the 8 reviews). Changes to workplace equipment (5 reviews), work design or organization (5 reviews) and working conditions (4 reviews) were also common. Interventions with components that change work relationships (3 reviews) or financial and contractual arrangements were least common (2 reviews). Table
3 summarizes intervention components and RTW determinants addressed by the studies in the reviews. The most frequently addressed RTW determinants were work organization and support (found in 6 of the 8 reviews) and physical job demands (5 reviews). The least frequently addressed RTW determinants are psychosocial job demands (2 reviews), worker attitudes and beliefs (2 studies), worker behavior (2 reviews) and perceived support (2 reviews).
Table 3
RTW determinants and intervention components in non-Cochrane systematic reviews
Study | (a) workplace or equipment | Physical job demands | Psychosocial job demands | Work organization and support (supervisor/coworker support) | Employer’s attitudes/practices and beliefs regarding RTW | (a) worker’s attitudes and beliefs about work disability (expectations, self efficacy) |
(b) work design or organization | (b) worker’s behavior regarding RTW (fear avoidance, coping) |
(c) organization including working relationships | (c) perceived support by the worker |
(d) changes to work environment (noise/vibration/etc.) | (d) Medical symptoms (e.g., pain, stress, anxiety, depression) |
(e) work conditions (financial/contractual) |
(f) case management with worker and employer (face-to-face worker-supervisor communication about RTW) |
| a, b, c, d, e, f, | Y | Y | Y | N | c, d |
| f | N | N | Y | N | none |
| a, b, c, d, f | Y | N | Y | Y | none |
| a, b, d | Y | Y | Y | N | a, b, d |
| a, b, c, d | Y | Y | Y | Y | none |
| f | N | N | N | N | c, d |
| f | N | N | Y | N | c |
| a, b, c, d, e, f | Y | N | Y | Y | a, b |
Six systematic reviews focused on interventions that targeted primarily musculoskeletal disorders (MSDs). Two reviews specifically sought workplace intervention research targeting mental health conditions. The MSD studies will be discussed first. Carroll et al. [
39] conducted a systematic review to determine if interventions involving the workplace are more effective for RTW than interventions that do not have a workplace component. They identified 9 studies that primarily assessed interventions for low back pain, and concluded that simply involving the workplace is not enough. Palmer et al. [
42] and Schandelmaier et al. [
44] drew similar conclusions, suggesting that RTW coordination (collaborative planning among stakeholders to implement work modifications) is more consistently effective than other intervention types. Similarly, Gensby et al. [
9] assessed the nature and effectiveness of workplace disability management programs on RTW. They found 13 studies, but concluded there was insufficient data to determine if the programs overall (or specific components of them) are effective. Gensby et al. also found that most interventions targeted MSK injuries and were conducted in blue collar or health care sectors. Nevala et al. [
45], focused their review more narrowly on workplace accommodation as the intervention, but included a broad range of health conditions and study designs. They concluded that there is some evidence that specific types of work accommodations (such as vocational counselling, changes to work schedules and work organization) are effective for workers with physical disabilities, but there is less evidence supporting work accommodation for cognitive disabilities. Finally, Odeen et al. [
41] assessed the effectiveness of “active” workplace-based interventions on RTW. Active interventions are those that encourage activity and where the goal is behavioral change. Seventeen studies were included in a qualitative synthesis. The authors found limited evidence that active interventions are not generally effective in RTW. However, there was some evidence that graded activity, the Sherbrooke model and CBT could reduce work absence. They concluded that only interventions involving consultation and consensus between stakeholders combined with subsequent work modification offers consistent, positive results.
Furlan et al. [
40] and Pomaki et al. [
43] assessed workplace-based interventions targeting mental health conditions. Furlan et al. [
40] looked specifically at interventions for depression. Twelve studies were identified, but the quality of evidence was low. This was primarily because the studies had a high risk of bias and there were few studies that assessed similar outcomes, which affected consistency and precision of evidence. The authors concluded that no single intervention targeting depression could be recommended as effective in RTW. Pomaki et al. [
43] considered a broader range of mental health conditions. They found 8 studies and concluded that facilitating access to clinical treatment and workplace-based high intensity psychological interventions improve work function, quality of life, and reduce costs associated with common mental health conditions. The evidence suggesting these interventions reduce absence was limited.
Grey Literature
The documents from the grey literature were of three broad categories: a) reports on case studies of employer organizations and business networks on managing general disability/chronic illness, b) reports on the cost/benefit of RTW programmes, corporate policies/programs for disability management and RTW, or c) international, national or regional codes/guidelines for RTW policies and RTW-guides from insurers. The audience targeted by the grey literature was generally human resource managers, disability, health and productivity managers, physicians, and/or RTW-coordinators and their teams.
Table
4 summarises the intervention components that were recommended in the grey literature. We found that in the included reports, RTW/WDP recommendations focused mainly on work/job design and work organisation (9 of the 16 reports). The predominant recommendations are the facilitation of the employee’s gradual return to work and the identification/provision of modified and transitional duties (10 reports). There is limited focus on workplace and equipment design with only three reports recommending changes to workplace/equipment design, with two of these reports specifically recommending ergonomic assessments. There is some (although limited) focus on RTW/WDP recommendations for case management with worker-supervisor communication (4 reports). The reports mainly highlight early and continuing contact with the worker during sick leave and RTW (3 of the 4 reports). RTW/WDP recommendations regarding working conditions (noise/vibration/etc.) and work environment (financial/contractual arrangements) are not mentioned at all in the included papers from the grey/employer literature
Table 4
Frequencies of recommended workplace interventions in the grey/employer literature, classified by Cochrane review categories
Changes workplace or equipment design | 3/16 |
Provide adaptations with input from the worker and with technical expertise [ 17] |
Provide ergonomic assessments [ 27] |
Incorporate ergonomic assessments [ 29] |
Changes work/job design and organisation including working relationships | 9/16 |
Have a policy to make a routine offer of modified duty [ 13] |
Support worker while not disadvantaging co-workers and supervisors [ 13] |
Provide modified work options [ 15] |
Identify transitional work opportunities [ 18] |
Develop a list of transitional duties [ 19] |
Make more effective use of job descriptions in the RTW process [ 20] |
Acknowledge and deal with normal human reactions [ 22] |
Update and analyze job descriptions [ 25] |
Create transitional RTW and prevention programs [ 25] |
Provide a supportive work environment [ 27] |
Provide more opportunities for transitional/limited duty positions [ 27] |
Create a “transitional work fund” [ 27] |
Implement a structured transitional work program that can provide effective RTW options and accommodation for both work-related and non-related problems [ 29] |
Changes in working environment (noise/vibration/etc.) | 0/16 |
Changes to the work conditions (financial/contractual arrangements) | 0/16 |
Case management with worker and employer (face-to-face worker-supervisor communication about RTW) | 4/16 |
Employer makes early and considerate contact with injured/ill workers [ 13] |
Employer contact should begin early and continue often through duration of the employee’s disability absence [ 18] |
Maintaining supervisor communication with your employee, WCB case worker and health care providers [ 19] |
Improve communication with employees about RTW [ 20] |
In the grey literature, evidence-based workplace determinants are reported approximately twice as often as evidence-based personal RTW determinants. Table
5 shows the types of evidence-based workplace determinants that were most frequently addressed in the grey literature: work organizational factors (15 of the 16 reports), physical job demands (13 reports), and employer RTW attitudes, practises and beliefs (12 reports). There is relatively less attention in the included grey literature for psychosocial job demands (9 reports). The evidence-based personal factors that are mentioned most frequently in the papers are medical symptoms (8 reports). Less attention is focused on worker’s RTW attitudes and beliefs (6 reports), worker’s perceived support (4 reports) and RTW behavior (4 reports).
Table 5
RTW determinants mentioned in the grey literature
| Y | Y | Y | Y | Y | Y | N | Y |
| N | N | Y | Y | N | N | Y | N |
| Y | N | Y | Y | N | N | Y | N |
| N | N | Y | Y | N | N | N | N |
| Y | Y | Y | Y | Y | Y | Y | Y |
| Y | Y | Y | Y | N | N | N | N |
| Y | Y | Y | Y | N | N | N | N |
| Y | N | Y | Y | N | N | N | N |
| Y | N | Y | Y | Y | N | N | N |
| N | N | N | Y | N | N | N | Y |
| Y | Y | Y | Y | Y | Y | Y | Y |
| Y | N | Y | N | N | N | N | Y |
| Y | Y | Y | N | N | N | N | Y |
| Y | Y | Y | N | N | N | N | Y |
| Y | Y | Y | N | Y | NA | NA | Y |
| Y | Y | Y | Y | Y | Y | N | NA |
13/16 | 9/16 | 15/16 | 12/16 | 6/16 | 4/16 | 4/16 | 8/16 |
Special Panel Contribution
We identified five overarching themes in their discussion of RTW and disability management:
In addition to the five themes, the panel also pointed to the importance of de-medicalization, a shift in focus from the medical aspects of disease or illness to the functional abilities of the employee. It is important to understand both what an employee can and cannot do. Once the focus is on function rather than on the medical aspects, the workplace and supervisors are more natural collaborators in the development of the individual RTW process. The considerations and decisions are no longer just up to the physician, the workplace is recognised as important and performance management can replace disability management. One suggestion of the panel was to do outreach work with physicians to have them visit the workplace to understand the work and thus be able to suggest suitable accommodations that are beneficial to the employee, and sustainable at the workplace.
Finally, the panel considered the employees’ own engagement in the RTW process as another important issue. Employees with an active engagement in their RTW process are considered more likely to have a successful RTW process.
Differences and Similarities
Our second objective was to compare workplace interventions studied in the scientific literature with interventions recommended in the grey literature and comments provided by the panel, to understand similarities and important differences that may be useful in guiding future research. In conducting this analysis, we also found distinctions between the Cochrane studies and the non-Cochrane reviews. We note them here, though these are not the focus of our analysis. For example, the Cochrane studies were most often conducted at the individual level and included only RCTs. The non-Cochrane reviews included studies at the organization or group level and reflected a broader range of research methods (e.g., non-randomized controlled trials, cohort studies, qualitative inquiry).
Another interesting similarity between the scientific and practice literature is that intervention components rarely include changes to the physical work environment (noise/vibration, etc.) or working conditions (financial/contractual arrangements). This may reflect a gap in both research and practice for WDP/RTW, or it may be that interventions addressing these issues were not captured in the literature reviewed. Interventions that change the physical work environment may be discussed or assessed in engineering or occupational health and safety literature rather than the medical and disability management streams. Similarly financial/contractual intervention components may be assessed elsewhere, or they may be less common because employment terms and conditions are regulated by law and not easily manipulated in research or in practice.
A difference that is perhaps more notable because it falls within the workplace practice domain relates to case management. One of the most predominant intervention components we found in the Cochrane studies was case management with worker-supervisor communication as a key element in case management. These interventions are most often found in MSK-related research rather than in mental health or cancer research. Case management is not only used independent of diagnosis, but also across different social security systems and settings. In comparison, employer/health care provider communication with worker (early contact and continuity of contact) are mentioned in only four of the grey literature papers. As noted above, the grey literature focused almost entirely on changes to job design and work organization.
The scientific and grey literature were also similar in that little attention was paid to perceived support from supervisors and co-workers for returning workers. Only 4/16 grey literature papers, 7/14 Cochrane review studies and 3/8 non-Cochrane systematic reviews addressed this determinant. This is an important determinant and our analysis suggests that it requires greater attention in both research and practice.
A final point of comparison we would add is that in most of the grey literature included in this review, the main message is about productivity: reducing disability costs and increasing profit (e.g., articles 2, 12, 21). From an organizational point of view disability in a worker may threaten the worker’s performance, which is one important element of organizational success. This perspective is reflected in papers that provide cost/benefit analysis to make the “business case” for disability management programs (e.g., articles 7,16, 23). This productivity perspective is considered in many of the non-Cochrane reviews, which are more likely to measure productivity and performance outcomes. However, it is in stark contrast to the perspective in the Cochrane studies, which is about the disabled worker and his/her welfare. RTW interventions from the scientific literature are often developed by medical, disability and health psychology researchers and the research is focused on improving health and quality of life for the individual. Interventions are designed to help the worker return to work because this is what the prevailing paradigm says is good for the worker, not because it is good for the economy, society, or the company. These different perspectives are challenging, but provide insight into the need for new directions in research and knowledge translation.