Long-term sickness absence is a problem in Sweden and many other European countries. Long-term absence has negative consequences for the employee, employer, and society as a whole. For the employee, long-term absence is often associate with poor health, worsening financial circumstances and social stigmatisation, while for the employer and society, long-term absence of employees leads to administrative, financial and practical challenges (Selander, Reference Selander2006). The most frequently occurring diagnoses for sick leave in Sweden are associated with stress-related symptoms (National Board of Health and Welfare, 2009; Swedish Social Insurance Agency, 2016). Such symptoms as depression and anxiety are often referred to as common mental disorders (CMD; cf. Andersen, Nielsen & Brinkmann, Reference Andersen, Nielsen and Brinkmann2012; Noordik, Nieuwenhuijsen, Varekamp, van der Klink, & van Dijk, Reference Noordik, Nieuwenhuijsen, Varekamp, van der Klink and van Dijk2011; Pittam, Boyce, Secker, Lockett, & Samele, Reference Pittam, Boyce, Secker, Lockett and Samele2010).
Women are overrepresented among the long-term sick (Swedish Social Insurance Agency, 2009, 2012), which is interesting, and can be seen as part of a paradox. Women are more often on sick leave, utilise more health care and report lower perceived health than men. At the same time, they live longer. In a study by Holmgren and Ivanoff (Reference Holmgren and Dahlin Ivanoff2004), this phenomenon is highlighted and discussed. One factor is linked to the heavy workload for Swedish women. Swedish women have become part of the labour market to almost the same extent as men. However, their unpaid work; for example, child care and household duties, has not decreased proportionally (Hagqvist, Gillander Gådin, & Nordenmark, Reference Hagqvist, Gillander Gådin and Nordenmark2012). As such, the total workload is greater for women than for men. In addition, psychosomatic symptoms resulting from the interactive effects between paid and unpaid work are more pronounced for women than for men (Hall, Reference Hall1992). However, there is also research pinpointing that women’s sickness on account of work might be underestimated, due to the well-known negative effects of unpaid work and responsibilities at home. That is, sickness due to work might be (wrongly) defined as being related to gendered structures and the impact of the workload at home (Verdonk, de Rijk, Klinge, & de Vries, Reference Verdonk, de Rijk, Klinge and Vries2008). Another factor to keep in mind is the segregated labour market with women working in less healthy environments (Verdonk et al., Reference Verdonk, de Rijk, Klinge and Vries2008). Horizontally, gender segregation concentrates women in public employment, providing education, social service, health care and child care, while men are employed in the private sector. Vertically, however, women are generally found further down in the job hierarchy and seldom in more advanced positions, irrespective of the employment sector. All these factors affect both health development and sickness absence, in addition to the possibility of returning to work (Holmgren & Ivanoff, Reference Holmgren and Dahlin Ivanoff2004; cf. Verdonk et al., Reference Verdonk, de Rijk, Klinge and Vries2008).
In order to prevent long-term absence from occurring, and to facilitate return to work (RTW), considerable effort is devoted to workplace-based disability management (DM). During the last 20 years, research on DM and RTW has increased, which has resulted in a significant growth of knowledge regarding the types of factors occurring at different levels in the rehabilitation process that hinder and facilitate RTW for ill or injured workers (Rinaldo & Selander, Reference Rinaldo and Selander2016). Such factors are related to individual demands (e.g., individual work capability, responsibilities, self-efficacy; Andersen et al., Reference Andersen, Nielsen and Brinkmann2012; Holmgren & Ivanoff, Reference Holmgren and Dahlin Ivanoff2004; Noordik et al., Reference Noordik, Nieuwenhuijsen, Varekamp, van der Klink and van Dijk2011); social support (e.g., gradual RTW, accommodations; Cowls & Galloway, Reference Cowls and Galloway2009; Holmgren & Ivanoff, Reference Holmgren and Dahlin Ivanoff2004; Noordik et al., Reference Noordik, Nieuwenhuijsen, Varekamp, van der Klink and van Dijk2011; Saint-Arnaud, Saint-Jean, & Demasse, Reference Saint-Arnaud, Saint-Jean and Demasse2006); systems related to the process of RTW (social insurance, occupational rehabilitation etc.; Cowls & Galloway, Reference Cowls and Galloway2009; Hillborg, Svensson, & Danermark, Reference Hillborg, Svensson and Danermark2010; Noordik et al., Reference Noordik, Nieuwenhuijsen, Varekamp, van der Klink and van Dijk2011); and timing for return (Saint-Arnaud et al., Reference Saint-Arnaud, Saint-Jean and Demasse2006; Verdonk et al., Reference Verdonk, de Rijk, Klinge and Vries2008). For an in depth meta-analysis of opportunities and obstacles related to RTW for employees with CMD see Andersen and colleagues (Reference Andersen, Nielsen and Brinkmann2012), or Ervasti et al. (Reference Ervasti, Pentti, Oksanen, Ahola, Vahetera and Virtanen2017), who provide a review of factors influencing RTW specifically after depression-related absence.
In previous research, hindering and facilitating factors for RTW were most often identified by using deductively designed studies, with job return as a dependent outcome variable. Fewer studies are based on more inductive research strategies, with a greater focus on the employees’ own perspectives regarding job return, clearly illuminated by Andersen, and colleagues (2012) in their metasynthesis of qualitative research on RTW among employees with CMD, where the authors point out ‘the need for more high-quality research on RTW for employees with CMD that takes contextual factors into consideration’ (Andersen et al., Reference Andersen, Nielsen and Brinkmann2012, p. 102; see also Cowls & Galloway, Reference Cowls and Galloway2009; Honey, Reference Honey2000; Landstad & Åhrberg, Reference Landstad and Åhrberg2017). The lack of analysis of qualitative data within the field is surprising, also since several studies indicate that employees’ own perceptions and beliefs do have an effect on actual job return (Lötters & Burdorf, Reference Lötters and Burdorf2006; Nieuwenhuijsen, Verbeek, de Boer, Blonk, & van Dijk, Reference Nieuwenhuijsen, Verbeek, de Boer, Blonk and van Dijk2006; Plana, Lopez, Martinez, Delclos, & Benavides, Reference Plana, Lopez, Martinez, Delclos and Benavides2012; Seing, MacEachen, Ståhl, & Ekberg, Reference Seing, MacEachen, Ståhl and Ekberg2015).
The aim of the study is to investigate the perceptions of female employees on long-term sickness absence due to CMD, from the perspective of their stories outlining what would best help for RTW. The objective is, firstly, to increase deepened knowledge in the field of research on RTW. Secondly, to improve DM to better meet the needs of these women.
Method
Data Collection
Data were initially collected through a survey issued to employees at a municipality in Sweden who, in May 2016, were, or during the previous year, had been, on long-term sickness absence (exceeding 60 days). The principal aim of the survey was to investigate perceived support from the supervisor in the RTW process. The total number of employees at the municipality was 5,107, and the survey was sent by regular mail to those on long-term sickness absence (n=280). The survey was presented in Swedish and included questions with multiple-choice response alternatives. As the final question in the survey, the respondents were asked, in their own words, to define what they perceived would be the best help for their RTW. Of the 204 surveys that were returned (response rate 73%), 62 came from women with CMD. The results in this study are based on the material from this group of women, of which 56 answered the open-ended question that is the focus of this particular study.
The Research Ethics Committee of Mid Sweden University reviewed the study and raised no objections from an ethical point of view.
Analysis Method
The material analysed consists of participants’ written responses to the question: ‘What measures would best help you to return to work?’. In most cases, the answers consisted not only of short responses specifically defining facilitating factors, but also answers that were presented as stories about situations related to long-term sickness absence. That is, roughly categorised, a quarter of the answers consisted of short bullet points directly answering the question (e.g., ‘redeployment’ (56), another quarter of the answers consisted of responses in complete sentences (e.g., ‘To get work daytime, as it is also better staffed’ (47), and the remaining half of the answers consisted of detailed stories. In the latter half, the participants provided comprehensive details about barriers and needs interwoven within the situation; for example:
The workload for preschool teachers is far too big. More comprehensive measures are needed to reduce this. Much sick leave is caused by this and also because many seek out the profession. Changed rules around return and more custom work tasks are required. Work tests are now carried out according to a certain time schedule determined by the Swedish Social Insurance Agency. If the time schedule does not work, they think they should try other tasks. (33)
Such stories are here classed as narratives, which can be subsequently used for narrative analysis. In many cases, responses are independent accounts, with a beginning, middle, and end, even if the language used is often brief, nonspecific and/or presented in bullet points. Participants refer to supervisors, workmates, and officials at the Swedish Social Insurance Agency, as well as a range of contacts within occupational health care, physiotherapists and the like, revealing the nature and formation of social relationships in various contexts. As a result, responses that may appear neutral at first glance become more personal; in some cases because the absence of a specific person directs the text towards social relationships which, in many cases, are dysfunctional (compare with Peterson & Langellier, Reference Peterson and Langellier2006, who underline that narratives allow us to understand how social relationships are formed).
The authors, a professor in Rehabilitation science with pervading knowledge of the field, and an associate professor in Sociology, with through experience regarding analysis of qualitative data (including narrative analysis), conducted the analysis together. During analysis, both researchers’ read over the material several times before working together to pinpoint relevant themes. Participants’ responses were coded and sorted, with the material categorised and divided up. This involved a process of interpretation and reinterpretation. The analysis here involved two steps, whereby we initially explored themes which form the accounts in the findings and, based on these, studied these findings in a broader sense, including not only how the participants describe measures for RTW, but the whole stories expressed in the material. The second step of the analysis aims to pinpoint collective narratives, or storylines (Gergen, 1988; Keady et al., Reference Keady, Clarke, Wilkinson, Gibb, Williams, Luce and Cook2009) that underpin the material, while considering how these are linked to the themes occurring. Here, it was possible to draw distinctions for different sections of the material, which, in various ways, belong to the themes and storylines arising. However, it is important to note that the themes and storylines discussed here are not entirely separate, rather, they should be considered mutually overlapping (similar to the findings of Gergen Reference Gergen1998, and Keady et al., Reference Keady, Clarke, Wilkinson, Gibb, Williams, Luce and Cook2009).
Responses that were translated from Swedish are presented in quotation marks. The participants’ identification numbers are provided in brackets, immediately after each response.
Results
The analysis is presented here. Firstly, we provide a brief overview of the thematic issues related to the specific question about what perceived would be the best help for RTW, and secondly, the storylines are presented.
Thematic Issues Regarding Measures That Could Help Facilitate Return to Work
On analysis of the findings, the following supportive measures defining what the participants found would be the best help for RTW were identified as measures relating to working hours, boundaries, understanding, patience and starting over.
∙ Working hours. This theme includes accounts of measures relating to working hours and the extent of work, including issues relating to tailored working hours, control over working hours and the need for shorter working hours.
∙ Boundaries. The second theme encompasses measures around boundaries and easing workloads. Some measures are purely practical and, in many cases, involve physical adaptation of working tasks. Other measures raised concern prioritisation of working tasks, with participants stating they need help to limit and prioritise working tasks. Finally, the material also contains findings concerning the need to highlight all aspects of work and provide a degree of flexibility.
∙ Understanding. The third theme that emerges from the findings is concerned with understanding. According to participants’ responses, a key consideration which facilitates RTW is to be listened to. Professional support, for example, from occupational health care, is highlighted in many cases, but the clearest theme is the need for individual supervisors to show interest and understanding.
∙ Patience. This category includes accounts relating to the rate at which RTW takes place. Participants highlighted the need for a gradual increase in working hours following the period of sick leave. Prominent within this theme as a whole is the desire to get well in peace and quiet.
∙ Starting over. An impression emerges of workplaces with poor work environments in which participants feel insecure. The findings suggest the need for measures allowing participants to switch jobs, and/or workplaces. Participants also talked about the need to take their individual skills and assessment of their situation into account, despite the reduction in working capacity due to sickness.
Storylines Relating to Working Situations and the Process of Rehabilitation
In this section of the analysis, we attempted to identify collective narratives based on the participants’ whole stories in which the answers on what would be the best help for RTW are embedded. According to this analysis, three different storylines are prominent in the findings. Interestingly, the answers from the participants about what would make it easier to RTW are not limited to facilitating measures, but includes overall stories focusing on problems also regarding the possibilities to RTW. The following storylines are named in line with how the participants collectively expressed themselves: It feels like too much, Things are moving too fast, and I have to get out of here!.
It Feels Like Too Much
When the material is analysed in more detail and we attempt to identify the central narratives, we can clearly see that one of these is the narrative It feels like too much. This storyline is related to the Working hours and Boundaries themes.
This storyline is characterised by struggling to cope with fatigue, expressed as It feels like too much. This means a story articulating the need for shorter working hours, and the issue of when work is scheduled (cf. Working hours). As a result, being allowed to work during times of the day when workplaces are less busy reveals not only what would be the best help to facilitate RTW, but also the nature of the working situation prior to the sick leave. The findings partly explain the importance of when working hours are scheduled, with circumstances at specific workplaces varying over the course of the day. Explicit pictures are painted of the variable level of intensity over the day; for example, ‘to work during the day, when there is better staffing’ (173). This storyline also implies that certain working hours affect health more than others, with working alone, for example, a cause for concern. In this context, the need for structure and easing workloads is pinpointed. The work performed prior to being on sick leave is described as being far too stressful, or as one person puts it: ‘a more reasonable workload is needed’ (103).
The material provides an account of complex working tasks, where participants are expected not only to handle challenging core activities but also become engaged in related issues (cf. Boundaries). In this context, participants expressed a wish to ‘work with specific tasks and get help to organise them’ (52). One participant mentioned how their RTW had been made easier by focusing on core working tasks, with other activities, such as cleaning and meetings about related activities, being removed. Another, who returned to work either fully or partially, expressed this clearly, saying: ‘I was allowed to return to work and do my job, rather than cleaning and taking part in meetings about food, culture and the environment, etc.’ (73). Many peripheral working tasks, primarily administrative, take time away from core activities (children/education or care provision). With regard to boundaries and adaptation of working tasks, some participants mentioned how other people (supervisors and colleagues) could help improve the situation.
The accounts occurring in this storyline also include a number of perceived demands. Not only are primary demands relating to working circumstances highlighted (cf. Boundaries), but there is also a clear pattern of secondary, system-related demands relating to the sick leave. In this context, when it is expressed that It feels like too much, perceived demands from the Swedish Social Insurance Agency, above all, mean that the participants feel pressured to RTW quickly. Other system-related demands concern lack of communication with individual supervisors or other representatives of the employer, as well as pressure on individuals to oversee coordination of the parties involved during the sick-leave period, that is, the employer, Swedish Social Insurance Agency and occupational healthcare representatives. In addition to such demands, this storyline also details how individuals put pressure on themselves to arrive at a viable working situation by moving on and starting to look for new work during the sick-leave period. All in all, an impression is formed of a complex working situation involving too many duties and unclear parameters for the individuals concerned.
Things Are Moving Too Fast!
The second prominent narrative in the material as a whole includes accounts of what it is like to be on sick leave due to mental health issues. This storyline is connected to the themes Understanding and Patience.
This storyline demonstrates that getting well takes time, and that the individuals involved understand this. Here we have a story about time and patience in general terms, revealing a considerable need for patience; for example, ‘Being allowed to increase my working hours in a manageable way, without being thrown into full capacity after not working at all’ (128). In this participant’s response, they talk about being ‘allowed’ to increase their working hours in a ‘manageable’ way without being ‘thrown in’ at the deep end. This indicates that they are almost expecting problems to arise. Much of the material also concerns the barriers participants experience when it comes to gradually increasing their working hours. ‘I find it really hard when the Swedish Social Insurance Agency puts the pressure on. I’m now working at 25%, which works fine. Soon I’ll move up to 50%, and then five weeks later, 75%. This feels like too much of a challenge’ (162). The individual’s understanding and acceptance of the time it takes, or will take, in order to get well, contrasts sharply with the perception of external pressure to speed up the recovery process. This storyline shows that one is expected to RTW quickly, and includes accounts of events that clearly demonstrate how the individual’s need to be given more time conflicts with the employer, the Social Insurance Agency and/or doctor who sanctioned the sick leave, all of whom pressure the individual into returning to work more quickly.
Accounts claiming Things are moving too fast can be understood in relation to the need to be listened to and respected in this context (cf. Understanding). Participants talk about ‘listening without making demands’ (5) and the need for ‘an understanding of the great anxiety I felt about returning to work after being sick’ (63). In some cases, being listened to and understood are mentioned in general terms, but sometimes participants define who is doing the listening. One participant says ‘it’s nice to have a supervisor who listens and doesn’t make demands until I’m fully fit to work’ (75), while another thinks that ‘listening to and having a dialogue with your employer is an important measure’ (99). This story also reveals a measure of uncertainty. One of the participants, citing a supervisor who fails to meet the employee’s need for understanding, comments: ‘I think there’s a greater chance of ending up on sick leave if you feel insecure, and not listened to, by a supervisor who thinks he/she is superior’ (183). The story focuses on individual support, although working groups as a whole are also highlighted. The findings imply that individual support can be reinforced by helping the entire group, as mentioned here: ‘When my department talked about the issue of stress as a group, it made it easier to not only blame only myself.’ (52). The findings also reveal the importance of feeling needed at work, which is demonstrated by the following response: ‘That your supervisor rings and asks how you are. Contact from a workmate. To be told I was of value to the employer. To have someone tell me I was missed’ (26).
The Things are moving too fast storyline is mainly concerned with the perception that it is difficult to be allowed to get better in ‘peace and quiet’ (193). Despite lack of support forming a central strand of the storyline, conversely, support from supervisors and working groups also emerges as a key factor enabling a successful RTW.
I Have To Get Out of Here!
One powerful storyline concerns the need and desire to start over, move to a new workplace and, in some cases, change professions. A sense of hopelessness can be discerned in the material. The prevailing narrative here is that a return to the participant’s regular place of work is simply out of the question. This storyline relates to the themes Starting over, and, to a certain degree, Working hours and Understanding.
Among the responses that convey feelings of hopelessness, starting over is described as the only way to move on. As one person puts it: ‘Returning to my old workplace isn’t an option. I’m currently looking to find new work’ (168). The story also reveals why starting over is seen as a vital help in order to successfully RTW. Here we can identify a range of factors that develop the theme in slightly different ways. There are feelings of hopelessness, accounts of the organisational potential for making a new start and short accounts described as linked to how it is simply not viable for the employee to return to the working conditions, tasks and/or workplace that applied prior to the period of sick leave (cf. Working hours). An impression forms in the storyline of workplaces with a poor work environment, where participants feel insecure. In the following response, the participant talks about the measures that would encourage their RTW. They do not explicitly cite offensive behaviour at the workplace, however, reading between the lines, it is clear this workplace is affected by an adverse psychosocial work environment. The participant talks about the importance of ‘working somewhere you can feel secure’ — in fact, a safe, secure workplace is identified as one of the key conditions for a successful RTW: ‘Moving to a workplace where I feel secure among my workmates, with a positive work environment. And that the supervisor also has work environmental responsibility (with regard to stress, offensive behaviour and the Swedish Work Environment Act)’ (133).
This storyline mostly paints a negative picture, with particular focus on dissatisfaction with individual supervisors. There is the suggestion of bullying, offensive behaviour and other types of victimisation that are directly linked to the workplace the participant left when being placed on sick leave. The story reveals the need for a workplace where supervisors listen, understand and get involved (cf. Understanding). This communicates a need for something that does not exist, with an absence of support also cited. Accordingly, this narrative is concerned with the issue of loneliness. Besides a lack of managerial support, an absence of assistance from workmates is also mentioned, which serves to create a sense of insecurity at work. Besides shortcomings in the psychosocial work environment, this narrative enables a greater understanding of how lack of staff and disparate working tasks can affect the individual. The impression here is that the situation is perceived to be very serious, as well as impossible to change, which means the employee (themselves) will end up seeking a new job in order to have any chance of returning to work again. This storyline also relates to the content and nature of work. Participants say that ‘being allocated different working tasks’ (30) would be the best way of helping them RTW. Among the examples highlighted, there was also a need for reduced responsibility where participants identify a new start, through a new job or a change of workplace, as the only solution, either from a physical perspective or to avoid a negative psychosocial work environment (when asked what measures would best enable RTW).
However, the need to move on to a new workplace and/or new working tasks is not only associated with hopelessness. Here there is also a positive impact, with narratives revealing how sick leave gave participants the opportunity for reflection and provide a renewed sense of initiative. Therefore, a central aspect of this storyline is the need for measures that ensure autonomy is maintained during the sickness period. One participant talks about the need for ‘an understanding of my skills outside the field of health care’ (119), while another expresses a similar wish: ‘That the employer could acknowledge my skills and experience outside the profession, and be more flexible and open to my suggestions on how best to return to work’ (170).
Accordingly, within the storyline I have to get out of here, there is something of a contradiction, as the new start is often considered the only alternative to be able to RTW, while also being described in positive terms, as a much-needed new start, with the period of sickness encouraging the individual to take the step towards a new working life. When a change of workplace is considered the preferred option, a need emerges for the municipality, as the employer with ultimate responsibility, to provide greater support for redeployment and, in particular, greater flexibility for a change of workplace based on the individual’s skills and experiences, rather than their specific profession. The findings reveal the need for a broader outlook and a greater commitment to redeployment, which may encourage the individual to completely change direction professionally.
Discussion
The analysis resulted in identification of five different themes defining supportive measures for RTW identifying what the participants themselves found would be the best help for RTW (Working hours, Boundaries, Understanding, Patience and Starting over) that, in turn, constitute the basis of three different storylines, in which supportive as well hindering factors are embedded (It feels like too much, Things are moving too fast and I have to get out of here). The results regarding facilitating factors relate to previous research on RTW among employees with CMD pointing out individual demands (Andersen et al., Reference Andersen, Nielsen and Brinkmann2012; Holmgren & Ivanoff, Reference Holmgren and Dahlin Ivanoff2004; Noordik et al., Reference Noordik, Nieuwenhuijsen, Varekamp, van der Klink and van Dijk2011), social support (Cowls & Galloway, Reference Cowls and Galloway2009; Holmgren & Ivanoff, Reference Holmgren and Dahlin Ivanoff2004; Noordik et al., Reference Noordik, Nieuwenhuijsen, Varekamp, van der Klink and van Dijk2011; Saint-Arnaud et al., Reference Saint-Arnaud, Saint-Jean and Demasse2006), the process of RTW (Cowls & Galloway, Reference Cowls and Galloway2009; Hillborg et al., Reference Hillborg, Svensson and Danermark2010; Noordik et al., Reference Noordik, Nieuwenhuijsen, Varekamp, van der Klink and van Dijk2011) and timing for return (Saint-Arnaud et al., Reference Saint-Arnaud, Saint-Jean and Demasse2006; Verdonk et al., Reference Verdonk, de Rijk, Klinge and Vries2008) as important for RTW (see also Ervasti et al., (Reference Ervasti, Pentti, Oksanen, Ahola, Vahetera and Virtanen2017), for a review of RTW, specifically related to depression, and Andersen and colleagues (Reference Andersen, Nielsen and Brinkmann2012) for a metasynthesis of qualitative research on the topic). Here women’s stories on RTW are discussed. However, previous studies have shown that RTW patterns for women and men are strikingly similar (von Celsing et al., Reference von Celsing, Svärdsudd, Eriksson, Björkegren, Eriksson and Wallman2012; Lidwall, Reference Lidwall2015).
In the following discussion, we focus on our three identified storylines. The narratives, found in responses from participants about what measures would be the best help for RTW, provided knowledge about supportive measures, as well as how the whole situation was experienced by the participants. For example, the storyline It feels like too much is understood as linked to the themes Working hours and Boundaries, and this storyline is underpinned by different kinds of perceived demands. Some of these demands derive from strict work-related tasks, while others are workplace related, although not related to the core working task, such as demands arising from different workplace groups/meetings, from work related administration, or from demands relating to additional tasks (e.g., cleaning, technical issues, etc.). Demands are also perceived from outside the workplace, such as the social insurance office and from society, similar to the results of Seing et al. (Reference Seing, MacEachen, Ståhl and Ekberg2015) pointing out that individuals on sick leave are seen as responsible for handling their sick leave and RTW. Such demands reflect the profound changes of work and labour market in Sweden, which emerged during the last decade (Ekberg, Wåhlin, Persson, Bernfort, & Öberg, Reference Ekberg, Wåhlin, Persson, Bernfort and Öberg2015; Seing et al., Reference Seing, MacEachen, Ståhl and Ekberg2015). In a DM context, it is interesting that the perception It feels like too much is primarily explained by factors not directly attributable to the employees’ working tasks, rather to factors occurring elsewhere, both in and outside working life. This storyline, illustrating perceptions of extended demands, can be related to previous research pointing out that psychological factors play a key role in RTW (Jensen, Stengaard-Pedersen, Jensen, & Nielsen Reference Jensen, Stengaard-Pedersen, Jensen and Nielsen2013; Magnusson, Nilsen, & Rheim Reference Magnusson, Nielsen and Rheim2007).
The storyline Things are moving too fast can be discussed in a similar context. There is a perceived lack of understanding and a need for patience. Getting well takes time! This is interesting, as it partially challenges the ‘the earlier, the better’ approach. A number of studies indicate that early rehabilitative activities facilitate job return (Marnetoft, Selander, Bergroth, & Ekholm Reference Marnetoft, Selander, Bergroth and Ekholm2001) and that delayed initiated activities lead to prolonged absence from work (Molinder, Durand, Desrosiers, & Coutu Reference Molinder, Durand, Desrosiers and Coutu2007), and, from a Swedish DM perspective, early activities and interventions are seen as a prerequisite for effective RTW. Yet perhaps this is not always the case? The results from the current study imply that emphasis should instead be placed on the timing of activities rather than early activities. Such reasoning relates to previous studies pointing out individual experience, arguing that professionals should support individual autonomy and consider personal resources for RTW (see Farholm, Halvari, Niemiec, Williams, & Deci, Reference Farholm, Halvari, Niemiec, Williams and Deci2017; Hansen, Edlund, & Henningsson, Reference Hansen, Edlund and Henningsson2006), adjust the timing of RTW (Kausto et al., Reference Kausto, Pentti, Oksanen, Virta, Virtanen, Kivimäki and Vahtera2017; Seing et al., Reference Seing, MacEachen, Ståhl and Ekberg2015), and take in to consideration specific workplace conditions for successful timing in RTW (Ekberg et al., Reference Ekberg, Wåhlin, Persson, Bernfort and Öberg2015; Huijs, Koppes, Taris, & Blonk, Reference Huijs, Koppes, Taris and Blonk2017).
The third and final storyline – I have to get out of here – relates to the theme Starting over, and, to a certain degree, Working hours and Understanding. The responses here convey feelings of hopelessness, and starting over is seen as the only way to move on. In many cases, returning to the old workplace is simply not an option. Moreover, this perspective is interesting in several ways from a Swedish DM perspective. According to Swedish laws and regulations, the employer and workplace are central arenas within RTW. Regarding ill-health prevention and DM, the employer is always obliged to ensure work can be carried out without the risk of ill-health or accidents, while the employer is to take all steps necessary to prevent employees from being subject to ill-health or accidents. The laws regarding employer responsibilities in RTW state that the employer must provide an organisation for rehabilitation and workplace adjustment, and also ensure that rehabilitation activities can be provided at the workplace. The employer must be able to offer work training and modified work as well as financial measures which can be carried within the organisation. It is clear that the employers’ role in DM and RTW is central, and this being the case, to a large extent, it is associated with the risk of the employee on sick leave resigning, and purposefully leaving the employer and all the security associated with being employed. Or, in other words, DM and RTW in Sweden are to a great extent built around the notion that ‘you should stick to your employer and get back to your old job’. The results from the current study challenge that assumption.
As can be seen in the discussion, the findings from the current study are to a large extent related to perceived demands (in life/working life), perceived control (in life/working life) and perceived support (in life/working life), which, in turn, bring to mind the well-established demand–control–support model initially developed by Karasek and his colleagues during the 1970s and1980s (for an overview of this background, see Theorell & Karasek, Reference Theorell and Karasek1996). In the original demand–control model, workplace stress is a result of how demanding a person’s job is and how much control the person has. Later, Johnson (Reference Johnson1989) included social support in the model, and according to the demand–control–support model (Karasek & Theorell, Reference Karasek and Theorell1990), workers with jobs characterised by high demands, low decision latitude and low social support run a greater risk of suffering stress or poor psychological well being (Häusser, Mojzisch, Nielsen, & Schulz-Hardt, Reference Häusser, Mojzisch, Nielsen and Schulz-Hardt2010; Johnson, Reference Johnson1989; Karasek & Theorell, Reference Karasek and Theorell1990; Theorell & Karasek Reference Theorell and Karasek1996). An interesting question is whether this well-established workplace stress model can also help us to understand the process of rehabilitation and RTW. After having analysed the data in the current study, the authors of the study, believe it can, and this is briefly discussed here.
In the workplace stress model (Karasek, Reference Karasek1979) demands represent the psychological stressors in the work environment. These include factors such as interruption rate, time pressures, conflicting demands, pace of work, amount of work and the degree of concentration required (Karasek, Reference Karasek1979). The themes and storylines identified in our study include a large number of perceived demands, especially within the storylines It feels like too much and Things are moving too fast. In the original model, decision latitude refers to employees’ control over their tasks. This comprises both skill discretion and decision authority. Skill discretion outlines the degree to which a job involves a variety of tasks and opportunities to learn new skills and develop special abilities. Decision authority encompasses the employee’s capacity to make decisions about their own work, and their ability to influence their own working team. Aspects of control are, in many ways, included in all three storylines detected. In the model, support refers to issues such as whether the employee can talk to workmates during breaks, interact with workmates as part of their work, or whether they meet workmates outside of the workplace (Karasek, Reference Karasek1979). All three identified storylines include a large number of different aspects of support.
Moreover, much of the material reveals sequences, phrases and accounts that can be understood as an imbalance between perceived demands, control, and support. For example, the theme It feels like too much emerges in the findings, with participants explaining that things are actually so bad that one of the narratives arising alongside is I have to get out of here. What we see here is a clear imbalance between, on the one hand, demands and control, and on the other, social support. The analyses imply that demands are too great, not only regarding the pressure of work, lack of staff and heavy workload, but also when it comes to allocation of disparate working tasks, whereby participants find it very difficult to make time for administrative work linked to the core activities that are considered their main area of focus. In addition, we can also identify shortcomings regarding the perception of control, with individual working hours an important factor. Having no control over working hours, or not knowing the schedule for the forthcoming period, has a negative effect on employees. It is clear from the material that an imbalance exists between the extent of demands made and a perceived lack of control. In addition, a clear lack of support can be identified, with individual supervisors seen as the most important figure in this respect.
Measures facilitating RTW are those that help restore this balance. Many participants reported how, during the period of sick leave and subsequent RTW, they struck the right balance between all three of these areas, with the process as a whole running smoothly.
Conclusion
In this study, we have gained an understanding of the perceptions of female employees in Sweden, regarding long-term sickness absence due to CMD, in relation to what they perceive to be measures that would be the best help for RTW. The following supportive measures were identified: measures relating to working hours, boundaries, understanding, patience and starting over. As well, three different storylines were found to be prominent in the findings. Participants say ‘It feels like too much’, ‘Things are moving too fast’, and ‘I have to get out of here!’. These stories have provided a broad understanding of what female employees on long-term sickness absence due to CMD perceive to be most important for RTW. From a DM perspective, we have learned the importance of restoring the balance between demands, control and support — not only to prevent absence from work, but also to facilitate RTW after a long-term sickness.
Limitations
Here, analysis is based on a material collected among personnel working in one single municipality in Sweden; that is, results should be understood in relation to this specific context. As such, the sample cannot be understood as representative internationally, neither nationally. Thus, in Sweden, living conditions vary considerably between various contexts. Further, collecting subjective stories on RTW by one single question in a survey can be questioned. Narrative analysis of data based on face-to-face interviews will normally be criticised due to the interaction effects that might vary depending on who is the interviewer and who is the interviewee, whereas the story told depends on the specific situation of the interview. Here, such interaction effects are not the problem. Instead, the lack of face-to-face interaction can be questioned. For example, there is no possibility for the researchers to follow up uncertainties or inconsistencies in the answers. That is, what is written and how it is written is all that is available. However, anonymously answering a question in a survey where it is not possible to relate those answers to one specific individual can, on the other hand, be a strength of the study. Based on the storylines found, one can imagine that some responses should not be conveyed in a traditional face-to-face interview. For example, sensitive information on bullying in the work group might be difficult for an interviewee to talk about when individually recognisable.
Lastly, as in all research, one needs to ponder the influence on interpretations of researchers. In this case, we have been two senior researchers working together with the material, which strengthens the analysis, even though data might be misinterpreted or partly misunderstood due to the characteristics of data.
