Experiences of workers with long-term disabilities on employer support throughout the RTW process in The Netherlands: a qualitative study

Abstract

Purpose

The aim of this qualitative study was to explore ways that employer support influenced successful return to work (RTW) in workers with disabilities.

Methods

We conducted a semi-structured interview study among 27 workers with disabilities in the Netherlands who received a partial disability benefit two years after sick leave and who continued working in paid (part-time) employment after a period of long-term sickness absence (> 2 years). We analyzed data by means of thematic analysis.

Results

We identified four types of employer support that were experienced as factors of successful RTW: 1. Supervisor accessibility; 2. Supervisor engagement; 3. Supervisor strategies; and 4. Supervisor-initiated work accommodations. More specifically, during the preparations for RTW phase, the supervisor’s active role involved having a positive and open attitude toward facilitating RTW; during the initial RTW phase, the supervisor’s role involved being creative in finding solutions for work accommodations; and during the sustained RTW phase, the supervisor’s role included helping workers who still needed changes in their work situations.

Conclusion

The elements of successful employer support reveals that the pressure on the shoulders of the supervisor is high. Future research should further investigate whether supervisors need more phase-specific training from their organization.

IMPLICATIONS FOR REHABILITATION

• The support of the employer is found to be crucial to help workers on long-term sick leave to return- to and remain at work.

• Supervisors may need more training in skills relevant for RTW, not often having faced cases of long-term sick leave.

• An important precondition for supervisors to apply these skills is the provision of resources for work accommodations, which should be provided by the employer.

Keywords:

• Social support
• supervisor
• worker with disabilities
• return to work
• qualitative research

Introduction

Over the last decades, many countries have reformed their disability policies because of a rise of spending on full disability benefits of long-term sick listed workers who had residual work capacity [1]. Advances in disease management, coupled with an ageing workforce and trends to delay retirement, were contributing to these rising numbers of workers facing a work disability [2,3]. As a result, the eligibility criteria of disability benefits were tightened, and employers were incentivized to encourage work participation of this vulnerable group of workers. Employer support is an important facilitator in the Return to Work (RTW) process of workers with disabilities [4]. Based on our recent systematic review [5] employer support encompasses a range of factors including the provision of work accommodations, social support and on a higher level the role of organizational culture and policies and practices. Supervisors play a crucial role in the implementation of accommodations within the work organization [6]. A supervisor can provide modified work, facilitate access to corporate resources, and communicate a positive message of concern and support [7]. A study on workers who had partially returned to work after sick leave showed that during the RTW process these workers were met with sufficient understanding and social support from their supervisors [6]. Workers on long-term sick leave appreciate contact with their supervisors and workers who had discussed work adjustments with their supervisors to facilitate their return to work experienced better supervisor support than those who did not have these discussions [6]. Identification of workers at risk of receiving inadequate support during the RTW process may enable interventions to improve support and RTW outcomes [8].

RTW is best seen as a process [9] and can be divided into different phases: preparing for RTW, initial RTW and sustained RTW. These phases are in line with earlier research where complex RTW process has been approached as different phases before. For example, Corbière and colleagues distinguished 10 key steps in the rehabilitation process, throughout three RTW phases: beginning of sick leave, preparation of the RTW phase and the RTW and follow up phase [10]. Since in line with Dutch legislation, preparation of return to work starts very early in the process of sick leave, for the present study situated in the Netherlands it is not of added value to consider the beginning of sick leave phase separately. Instead, the RTW phase can be approached as the phase focussing on initial RTW, and sustained RTW. Especially sustained RTW is often not taken into account in research as this requires a longer follow up duration.

Insight into how workers experience employer support during the different phases of the RTW process is of relevance, because workers’needs of employer support could possibly change during a long RTW trajectory. Although there are some studies investigating RTW as a process, most of these studies did not investigate the whole RTW trajectory from the onset of sick leave until the application for disability benefit [4,6,11–15]. These studies mainly investigated the RTW preparation phase or initial RTW phase of RTW and as a result, did not provide insights into the role of the employer for workers who underwent a disability claim assessment. A study about the supportive role of supervisors in the return to work process of employees on long-term sick leave (>8 weeks) showed that maintaining communication and helping workers with structuring their RTW process are valued leadership qualities [14]. In addition, during the initial RTW phase, workers appreciated improved comprehensive RTW guidance of supervisors, which facilitated successful RTW processes [11]. However, these studies were mainly interested in perceived barriers and facilitators of the work environment to RTW and did not focus specifically on the role of employer support.

In the Netherlands, employers are obliged to pay the salary of their workers during the first 2 years of sick leave and have the responsibility to be actively involved in the RTW process. This implies that for workers with long-term sick leave RTW is a trajectory with different events occurring during these different phases, and in which workers could have different needs concerning support. Moreover, the longer the trajectory, the higher the likelihood of changes in management and supervision during the different phases [14]. To consider the long duration of the RTW process, and potential changes in supervisors, a focus on workers with disabilities who have experienced with all three RTW phases, the RTW preparation phase, initial RTW and sustained RTW after the disability claim assessment would shed more light into what kind of support is perceived as important during these different phases.

Within this context, the aim of this study is to explore ways that employer support influenced successful return to work (RTW) in workers with disabilities. We selected workers who continued working in paid employment after their disability assessment.

Methods

Design

This qualitative study used thematic content analysis approach [16]. We used the Consolidated Criteria for Reporting Qualitative Research [17].

Ethical considerations

We received ethical approval from the Medical Ethical Review Board (METc) of the University Medical Center Groningen (201800691). Prior to beginning semi-structured interviews with workers, we obtained their written informed consent. All workers approved audiotaping of the interviews, and their use for scientific research after anonymization.

Selection of workers

We selected workers who had been assessed by the insurance physicians, had partial residual work capacities, were receiving (partial) disability benefits due to long-term mental or physical disabilities, and were able to understand the Dutch language. We interviewed workers in 2019 who experienced 2-year RTW trajectory from 2017 to 2019 because the RTW trajectory until the disability assessment is two years in the Netherlands. The Social Security Institute for Employee Benefit Schemes (UWV) sent information letters to 200 workers. These letters included information on the aim of the study, the interview procedure, the inclusion criteria, and how to sign up (registration form, or an e-mail or phone call to the researcher). After registration, workers were screened for study eligibility by answering several questions, using Qualtrics, mail, or telephone. Around 60 workers indicated their willingness to participate in an interview. Of these workers we selected 30 workers. We used purposive sampling to recruit workers employed in different sectors and different sizes (small, medium or large). Purposeful sampling is a technique widely used in qualitative research to identify and select information-rich cases in order to use limited resources most effectively [18]. This involves identifying and selecting individuals, or groups of individuals, who are especially knowledgeable about or experienced with a phenomenon of interest. After selection, some workers decided not to participate anymore, which resulted in 27 participating workers.

Procedure

In-depth interviews with the workers were conducted face-to-face and one interview by telephone. JJ (female, MSc, PhD student) conducted all interviews and had not previously met the workers in person. The workers had no connection with the executive research institute. Before being interviewed, workers filled in a short questionnaire to provide background information about: (1) their sector of employment, (2) their function, (3) the date of disability benefit assessment, (4) the type of disability, (5) their number of years of experience in this job, (6) their company size, and (7) whether the employer was insured for sick leave costs (yes/no). Based on a previous systematic review [5], the research team collaborated to construct an interview (Supplementary File 1). The interview guide comprised mainly open-ended questions with subsequent probes to obtain more in-depth insights in workers’ experiences with actions that employers had taken during the different RTW phases: RTW preparation phase, initial RTW and sustained RTW. This classification in different RTW phases was based on literature adapted to the Dutch situation. The interview guide was pilot tested after which we rephrased the opening question. After each interview, the interview guide was updated when new topics arose [19,20]. The interviews lasted 60–120 min. Data collection stopped after reaching saturation (i.e., when no new concepts emerged during interviews).

Analyses

Interviews were audio-recorded, transcribed verbatim and entered in Atlas.ti 8.4 for analysis. We used qualitative thematic analysis to guide the research analyses [21].

First, JJ (re)read the transcripts ensuring a holistic understanding of each interview. Then, JJ developed a first draft of the codebook after coding the first five transcripts, which was then discussed with MA (female, PhD, social scientist). JJ coded all transcripts using open and thematic coding which was verified by MA in order to improve credibility. Any differences between the researchers were discussed and resolved in consensus meetings. In the next step, data were interpreted, categorized and divided into themes. This was an iterative process of reading, categorizing, and refining. In this process, we used constant comparison and found that workers’ experiences differed during the three RTW phases (RTW preparation phase, initial RTW and sustained RTW). We then coded the data also according these three phases to be able to have a closer look into the differences between these three phases. Then, the research team (JJ, SB (female, PhD, occupational health scientist), MA, CB (female, PhD, occupational health scientist) discussed and refined the division of themes until they had reached consensus. In the final step, defining and naming themes, phrasing of themes was tailored to the research question. Subsequently we investigated how the experiences within themes differed over time, and investigated relationships between themes and differences within themes, like opposite perspectives. To enhance trustworthiness [22] and to illustrate the findings, we added representative quotes from the workers, translated by a native English speaker. During the whole research process, JJ kept memos to record reflections.

Results

Sample describing

Half the number of workers included in this interview study is female and most of the workers were aged 55 or older. The workers were all from different organizations and employed in different regions in the Netherlands, in i.e., the health sector, government, industry, or education. Most of the workers had long-term physical disabilities. Many workers worked 20–24 h after the disability claim assessment. Half of the number of workers were employed in large organization (>1000).

Themes related to employer support

After data analysis of how participants perceived employer support during a RTW trajectory of two-years follow-up, we identified four themes. The themes related to employer support were: (1) supervisor accessibility, (2) supervisor engagement, (3) supervisor strategies and (4) supervisor-initiated work accommodations. The analyses resulted in several sub-themes. Within each theme, we described the content in chronological order, corresponding with the three RTW phases: RTW preparation phase, initial RTW and sustained RTW. Table 1 provides an overview of the themes and subthemes, and the corresponding phases.

Table 1. Overview of themes and RTW-phases.

Themes	RTW Phase
	Preparations for RTW	Initial RTW	Sustained RTW
Supervisor accessibility	Contact via mail, phone or visits is helpful in staying in touch. Finding a balance.	Transparent communication about work adjustments
Supervisor engagement
Active involvement	Positive and open attitude	Positive attitude is appreciated (e.g., implementing work accommodations)	Positive attitude is important when changes in work or health situation affecting their job. Treated in same way like co-workers
Personal involvement	Compassion Focus on worker’s needs	Intention to do his/her best to guide RTW trajectory	Personal approach less important. Supervisor or employer representatives not always involved.
Supervisor strategies
Protection		Balance between protection and activation Setting boundaries	Protective and setting boundaries
Providing leeway	Receiving time and freedom	Receiving time and freedom
Supervisor-initiated work accommodations
Facilitating work accommodations	Considering possibilities for work accommodations	Considering possibilities for work accommodations	Role employer is considered as less important
Decision-making		Following mandatory legal steps Out of the box thinking Joint decision-making

Supervisor accessibility

Many workers described how they experienced the accessibility of their supervisors. They mentioned the type of perceived contact and how this affected their RTW process. During the RTW preparation phase, many workers received mail, phone calls or visits from their supervisors. They found this helpful, primarily for staying in touch with the workplace. Contact with supervisors is about finding balance between when (or when not) workers need contact:

“They say you really have to stay in contact with your immediate supervisor, but sometimes it’s enough. Because then you stay in contact with your work. Otherwise, you just sit at home, I found that difficult. And that’s why you have to find out, where do you connect, where don’t you connect, are you getting only the information, or not.” (Female, 41–50 years, health care sector)

Workers not receiving this kind of attention from supervisors also stated that the way supervisors communicated with them complicated their RTW process. These workers did not experience transparent communication about possibilities for work accommodations, and expressed feeling that more possibilities were available, but finding in the end, that this was not the case:

“Before I got sick we had just had a switch in managers so I had actually never had contact with the manager. The manager had also never tried to contact me in these 11 months. So we did it mainly with the team leader. And with the team leader I made working arrangements and activated a parking pass.” (Female, age unknown, health care sector)

“Don’t give people during a whole year the impression that they are welcome at their own work station and then when the time comes, put a stop to it, when it was already clear for a long time [that return to the previous job was no longer feasible].” (Female, age unknown, health care sector)

Supervisor engagement

The analyses revealed two types of supervisor engagement: active involvement and personal involvement.

Active involvement

Many workers mentioned the importance of active involvement on the part of supervisors. During the RTW preparation phase, workers found it helpful when supervisors displayed a positive and open attitude towards the possibilities for returning to work. In the first phase, some workers were on long-term sick leave and were unable to make agreements with the supervisor about RTW. Workers appreciated having their supervisors play an active role in the RTW process, doing their best to be of help:

“And then you also notice that the supervisor naturally stands up for you one way or another, that he says of course there is the will to return to work. And then their attitude is, first see what you can manage, because then I wasn’t fully back to work.” (Female, 51–60 years, health care sector)

In the initial RTW phase, workers also appreciated it when supervisors are positive about RTW activities. Supervisors can demonstrate their involvement by actively implementing work accommodations suited to the needs of the worker. Some workers mentioned wanting such a supervisor, but having a supervisor who lacked this involvement resulted in a negative impact on the RTW process:

“But in the end, of course I wanted to get back to work and began to see what I could do, because in my experience a position would always be made for you. Something that was suitable for you. And then I discovered that in this case that wasn’t true at all. That was a big disappointment.” (Male, 51–60 years, governmental sector)

Some workers mentioned that a positive approach of supervisors after disability assessment is relevant only if changes are made in the work situation, like changes in health conditions affecting their job or changes in the work ethic of the organization. Many of them no longer wanted special treatment and wanted to be treated in the same way as their co-workers:

“Then you had the performance review, and every year he [former department head] said, ‘we are really not so happy with having people work from home.’ Then I said, ‘but if it’s necessary I will just come every day. No problem.’ [Former department head:] ‘No, not you. You can work from home, if you don’t feel well. Or if you think, today it’s not going well, then you can work at home.’ But I keep saying: ‘I don’t want that, because I don’t want special treatment, you know.’” (Female, 51–60 years, health care sector)

Personal involvement

Workers also appreciated personal involvement of their supervisors. They expressed appreciation that the supervisors showed compassion when they were on ‘sick leave’, and that they focused on what the worker needed instead of only on what was best for the business. Further, during the initial RTW phase itself they also considered personal involvement of supervisors necessary, but more in the sense of knowing that the supervisor intended to do his/her best to guide the RTW trajectory in a favorable way for the worker. During and after the disability assessment, however, workers considered a personal approach less important. During this phase, some workers made their choice as to whether to involve their supervisor or other employer representatives. One worker gave the following example:

“I did have contact with the occupational physician once or twice after that, always on my own initiative. Once because I thought it was time again to have a quick check that everything was going as it should. Let’s say in the phase when I was gradually getting adjusted to 50% and, a final situation had been reached in that respect. And once because I met him in the street and said: ‘How is it, everything okay?’ ‘Everything’s fine.’ And then I thought, everything isn’t fine at all, I’ll do a little consultation anyway because on the street you don’t go around telling people what’s not OK. There’s really enough that’s not OK. …. And I thought, well let me inform the employer, or occupational physician a little more carefully about the situation so that when I come back maybe in a year or so, he won’t be shocked.” (Male, 61–70 years, governmental sector)

Workers who had experienced several supervisors described differences between these supervisors to illustrate the importance of active and personal involvement:

“Well, we just recently got a new department head. Nice but very businesslike. Young woman and, just businesslike…. Interviewer: Yes, what do you mean with businesslike? Participant: Well, she didn’t have to, because I never really ask for extra attention because I am sick. But like my other [former] department head, he already had the doctor’s visits in his head. Well, I don’t need that from her [new department head], because that’s not at all necessary. But with him [former department head], he was concerned with me.” (Female, 51–60 years, health care sector)

Some workers mentioned that during the first phase they were assigned a new supervisor or interim manager who had no personal knowledge about or experience with the worker, and was therefore less involved. However, during the initial RTW phase some were given new supervisors who used a more personal approach and provided positive feedback and compliments. This helped workers to improve their self-confidence, which was helpful in the RTW-process.

“[Regarding first team leader] I really felt kind of abandoned. [emotional] I was, I think, also kind of angry or so, and I felt almost exploited because I had worked so hard. That that was no longer possible. I was always sensitive to stress and I mentioned it a thousand times. And then things go wrong and then there’s no time to manage things. I felt that very quickly. However, the other team leader was almost a real coach. What I really needed at that time. That gave me back a bit of self-confidence, I think. And that step by step I could try things, and also in a new department.” (Female, 41–50 years, governmental sector)

Some workers reported that, due to a lack of personal approach and supervisors’ lack of awareness of the kinds of accommodations suitable to their needs, they eventually had to hire a lawyer to ensure that they could continue working in the workplace.

“We said that there might be other options available within the hospital and the immediately answered that that was not the case. Apparently, they had investigated that in their eyes. And the lawyer also said that, well, there is a lot that could be created in such a hospital. And they ultimately did so under duress from a lawyer.” (Female, age unknown, health care sector)

Supervisor strategies

Many participants mentioned examples of supportive supervisor strategies during the RTW proces, which could be organized under two subthemes: protection and providing leeway.

Protection

Many participants stated the importance during the RTW process of supervisor support that was a careful balance between protection and activation. Most of these workers indicated that their supervisors were mainly protective, setting boundaries for the workers during the initial RTW phase and after disability. This was mentioned mainly by workers who according to their social environment, were too active. A worker described one of the roles of the supervisor was to protect the worker from further injury during the initial RTW phase.

“He had regular talks with me, of course, about how it was going. They are obligated to do that, of course, assessment meetings and talks in case of illness. He often also said that you mustn’t go beyond your limits, because then you won’t be able to do anything anymore. That’s true, but that’s just your nature, you can’t do anything about it.” (Male, 61–70 years, educational sector)

Many workers expressed that the protection they experienced from supervisors, such as setting limits, helped them to stay at work and not falling out again:

“Because I am a person who keeps going on and if I don’t get things done that I, let me say it this way, it’s difficult to set limits. And if you go over your limits, always afterwards, you are confronted with yourself and then it takes, you really need a lot of time to get back a bit to the same level.” (Female, 51–60 years, financial sector)

Providing leeway

Workers appreciated receiving time to recover and to return to work fully. In addition, during the initial RTW phase, workers appreciated when they had freedom to decide when to work and which tasks to perform. These workers did not feel pressured, because their supervisors did not force them to RTW too quickly:

“I don’t know if I would have been at work sooner or that I might have stumbled and fallen back, but I am glad that I didn’t get pushed to go back to work before I felt up to it. And that I was taken seriously when I indicated that it wasn’t going well. That they said, well, see what you can do at home. That’s why at first we started to increase the hours at home all the way up to, – I think I was also doing sixteen hours at home, and then I went back to work. Gradually, but yes, it was done with mutual agreement. In any case without pushing. I also think they all saw that that would actually have been counterproductive to me.” (Female, 41–50 years, governmental sector)

Supervisor-initiated work accommodations

Many workers valued practical help from their supervisors, for example, when they facilitated work accommodations and collaborated with the workers in the process towards work accommodations.

Facilitating work accommodations

Some workers explained that thinking about mandatory steps in the RTW process is less relevant while they are still on sick leave and/or recovering from illness or surgery. Workers appreciated having their supervisors consider possibilities for work accommodations already in an early stage. They also appreciated it when supervisors allowed them to come to the office for informal contact with co-workers. In this phase, supervisors asked what the worker needed, but also what he/she needed to gradually return to work, such as a separate office:

“They said, if, for example you need to think about something, then you can go to a separate cubicle, or if you want to isolate yourself, then you can also go to a separate cubicle. I did that at first, but now I don’t think that’s necessary anymore.” (Female, 51–60 years, industrial sector)

During the third phase (sustained RTW), workers less often mentioned finding the role of supervisors in facilitating work accommodations important. However, workers who were assigned a new supervisor during this phase mentioned finding it helpful to have these supervisors know about which accommodations had been facilitated by their predecessor.

“So in that sense the function has been adapted a bit, that they take [task balance] into consideration. Although they did do that, but now since I have moved on past a couple of supervisors, I am the one who mainly has to take care of that. … I don’t think she [current supervisor] really is aware of it, that she actively has to take into account what I [supervisor] ask her [participant] to do or whatever.” (Female, age unknow, work sector unknown)

Many workers expressed that having more than one supervisor during the RTW trajectory had impacted the facilitation of work accommodation during the different phases. Workers assigned a new supervisor during phase 1 (preparations for RTW) or 2 (initial RTW) experienced more challenges with these switches than workers who got a new supervisor after the disability assessment. This is illustrated by the following quote:

“Getting back to those three team leaders – the first really cared. And gave all kinds of tips, advice, arranged things right away. The second had something [laughter], she didn’t know, ‘what should I do about this?’ She asked about it and then it was: ‘yes, yes, yes, yes’. And the third, she saw me working and doing things and she didn’t even notice that I said ‘What about this? What do we do about the 16 hours?’ Because at the time I was still receiving disability (WIA) benefits. ‘Oh, yes, yes, yes. Yes, that stays the same’.” (Female, 51–60 years, health care sector)

Decision-making with regard to work accommodations

During the initial RTW phase, supervisors followed the mandatory legal steps, but also thought ‘out of the box’ to find suitable solutions with regard to implementing work accommodations. Many workers mentioned that their supervisors involved their workers in the decision-making process, i.e., which work accommodation to be implemented. Together they made decisions about the type of work accommodation. Many workers said that they had collaborated with the supervisor in joint decision-making with regards to work accommodations:

“I feel very unproductive part of the time, but that’s part of the game, so to speak. We’ll find a solution. That is the situation with re-integration that we had, more or less experimentally, developed.” (Male, 51–60 years, agricultural sector)

Discussion

This study sheds some light on ways that employer support influenced successful return to work in workers with disabilities. We were able to explore ways that employer support influenced successful RTW thanks to our selection of workers who had managed to stay employed after their disability assessment. We focused on the kinds of employer support experienced by workers throughout their process from preparing for RTW to sustained RTW. Themes related to supervisory behavior and attitudes that were experienced as factors of successful RTW were: (1) supervisor accessibility, (2) supervisor engagement, (3) supervisor strategies, and (4) supervisor-initiated work accommodation, while taking into account differences between three RTW phases: RTW preparation phase, initial RTW and sustained RTW.

Our findings regarding elements of employer support are in line with those of previous studies, for example those regarding supervisor accessibility [6,12,23,24] and regarding supervisor engagement [25–28]. In our study, workers mentioned having contact with their supervisors through mail, phone calls, or visits during sick leave. They also mentioned finding it important during the process to have transparent communication about the actual possibilities for RTW. This finding corresponds with those of other studies that indicated the relevance of supervisor accessibility by focusing, for example, on the contact between workers and supervisors during sick leave. One study showed that workers appreciate supervisor contact: those who had personal meetings with their supervisors reported higher levels of supervisor support [6]. Another study on the relevance of supervisor skills during RTW mentioned the importance of being fair and honest in communicating with workers with disabilities [25]. Our study pointed out the importance of supervisor engagement, like active and personal involvement during the RTW process, and underlined the value of a positive and open attitude on the part of supervisors toward possibilities for returning to work and implementing work accommodations. Our findings further emphasized how supervisors’ personal involvement could be demonstrated by compassion and a focus on the needs of the worker, and not only on the interests of the business; it was about knowing that the supervisor was willing to do everything necessary to accomplish the RTW trajectory in a way beneficial to the worker. Our research confirmed that of previous studies underlining the importance and necessity of supervisors’ positive attitudes and empathic support for workers with disabilities during the process of RTW [24–28].

The supervisor strategies reported in our study included being protective and providing leeway. Previous studies also indicated the importance of setting boundaries, albeit in the context of the inability of workers to set boundaries in their work and RTW [29]. Further, we found themes related to supervisor-initiated work accommodations. These themes focused on methods of facilitating work accommodation and the need for collaboration between workers and supervisors to make choices as to which accommodations should be implemented. Most workers in the present study mentioned being actively involved in the process. Previous studies have also dealt with work accommodations, taking into account both formal and informal work accommodations. Formal work accommodations include changing working hours and tasks, and allowing working from home [5]; informal work accommodations include, for example, having co-workers temporarily assume (some of) the disabled worker’s tasks [30]. Further, our finding regarding the importance of good collaboration between worker and supervisor regarding work accommodations corresponds with that of previous research in which employers emphasized the importance, for RTW, of self-management for workers on long-term sick leave [30].

Workers explained that the four overarching themes of employer support are important throughout the entire RTW process, but that during the three RTW phases the type and intensity of the types of support can differ. In all phases the supervisor’s active and personal involvement was perceived as a relevant element of employer support. But more specifically, during the preparation for RTW phase, the supervisor’s active role involved having a positive and open attitude toward facilitating RTW; during the initial RTW phase, the supervisor’s role involved being creative in finding solutions for work accommodations; and during the sustained RTW phase, after the disability assessment, the supervisor’s role included helping workers who still needed changes in their work situations. Workers further mentioned the protective behavior of supervisors, mainly during the initial RTW phase and after the disability assessment, when supervisors set boundaries to keep workers from going beyond their personal limits.

Strengths & limitations

An important strength of the present study is its selection of workers who had experience with all phases of the RTW process, and who had successfully managed to remain in the job market after their disability assessment. This gave us the opportunity to learn about different elements of supervisor support throughout the RTW process. Previous research has less often studied this specific group of workers. Another strength of our study is that we focused on employer support throughout the three different phases of RTW (RTW preparation phase, initial RTW and the period following application for disability benefits, sustained RTW). Furthermore, we used different techniques to improve the quality (i.e., credibility, confirmability and trustworthiness) of our study such as field notes, audit trail, intercoder reliability, peer debriefing, and providing illustrative quotes from several participants [31]. Different from quantitative research, generalizability is not key to qualitative research as this relates to a very specific sample. In qualitative research, transferability is an important aspect to consider [32]. In the Netherlands, we have a social security system that is very different from other countries as the employer is responsible for paying wages in the first two years of sick leave. However, we expect that the results of this study can be transferred to similar populations in other countries as key aspects of supervisor support we found in this study seem largely independent of social security systems. Recall bias is a potential threat to the validity of our findings, since workers were asked about their experiences in the RTW process by going two years back in time. Although some participants had difficulties remembering details, all participants did remember how the employer supported them. In addition, some participants took their personal RTW file during the interview being able to share exactly what happened and when. Another limitation is that we only included a few participants with mental disabilities. This may suggest that our findings might be in particular showing the elements of employer support in the RTW process for workers with physical disabilities.

Implications

This study shed light on ways that employer support influenced successful RTW during the different phases of RTW based on the experiences of long-term sick listed employees. These findings indicate the need for a routine that highlights early and continuous contact with the supervisor during the RTW process. These findings may help employers to establish well explained disability management policies and practices [33], to ensure that supervisors know about the different types of support that can be helpful in different phases of the RTW process to improve job modification and return to work efforts [33,34]. Not all supervisors possess the competencies needed to carry out this work effectively. Providing training to supervisors on how to communicate and assist employees on long-term sickness absence may help to facilitate a return to work [6]. Another option might be to involve certified disability management professionals and RTW coordinators to support the supervisors, as some of the leadership qualities could be possessed by these professionals instead of the supervisor [35,36]. These professionals may also be helpful if the supervisor leaves his job during the RTW process and a new supervisor has to take over this role.

Future research should focus on ways for organizations to coach supervisors in developing their skills for supporting RTW. Moreover, considering RTW as a process consisting of different phases, more research is needed on the type and intensity of support. In this study we focused on the perspective of the worker. Despite ample evidence of the importance of employer support in the RTW process of workers with disabilities, little is understood about how employers deal in practice with this role in the RTW process [25,30,34]. Considering perspectives of both supervisors and workers may provide a more complete picture on the role of the employer in the RTW process of workers with long-term disabilities [37].

Conclusion

This study provides insight into elements of employer support experienced as successful by workers with disabilities during preparing for RTW, initial RTW and sustained RTW after the disability assessment. Workers mentioned the following determinants of employer support related to the main themes: contact and transparent communication with the supervisor, active and personal involvement of the supervisor, protection and providing leeway by the supervisor; and facilitating support and collaboration in work accommodations. Our findings point to significant pressure on the shoulders of the supervisor, who needs to fulfill an all-round role. It is recommended that organizations support and coach their supervisors in the skills needed to support their workers on long-term sick leave. Our study also showed the relevance of focusing on the different RTW phases, because workers expressed that various aspects of the four overarching themes of employer support are important throughout the RTW process. Future research should further explore the different types of support throughout the different RTW phases and to investigate whether supervisors need more phase-specific training from their organization in how to approach these different RTW phases.

Author contributions

All authors contributed to the study conception and design. The analysis were performed by Joke Jansen and Manna Alma. The first draft of the manuscript was written by Joke Jansen and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Instituut Gak, under Grant number 2018-933.