Return to Work: The Workplace Perspective

Recommendations for workplaces

These recommendations outline actions to be taken by target users and goals to be achieved to establish a healthy and sustainable return to work (RTW) for workers with a MSD or CMD.

They are also intended to provide constructive support for a healthy and sustainable RTW process. They highlight the knowledge (principles, essential activities, approaches) as well as the interventions and actions to be carried out by the actors concerned in order to significantly improve your practice, to achieve optimal practices.

Principles for a healthy and sustainable RTW

• Specify the roles and responsibilities of the different categories of actors as well as the actions required from them during the different RTW stages;
• Promote concerted action through collaboration and communication between the different actors (worker, workplace, qualified professionals, insurer) around the common objective of sustainable RTW;
• Plan and coordinate on an individual basis the actions to be carried out according to a predefined schedule.

Optimal practices in the workplace

• Develop clear policies and procedures on the role, responsibilities, strategies and expected actions of the relevant actors, based on your organization’s needs and resources;
• Inform relevant actors of the existence of these policies and procedures and the obligation to follow them in all cases of RTW;
• Provide training and information to supervisors and co-workers on health and RTW, as well as on the attitudes and behaviours (know how to be and know-how) to adopt;
• Offer structures and spaces that promote flexibility and creativity during meetings aimed at developing RTW plans and encourage the involvement of the worker and other stakeholders in the process, while taking into account the worker’s progress over time;
• Designate a person to plan and coordinate RTW;
• Establish a RTW plan, including:
  • the development of an appropriate solution with the worker, the immediate superior and the coworkers
  • the allocation of personnel in the team
  • an effective communication plan between the actors, including the planning of contacts to be made with the worker
  • monitoring the worker’s progress over time;
• Identify and implement workplace accommodations adapted to the worker’s situation;
• Evaluate and re-evaluate (over time) the balance between the worker’s abilities and the job demands and adjust the RTW plan as needed;
• Call upon qualified professionals to intervene with workers in complex situations.

Workplace practices for a healthy and sustainable RTW

As illustrated in Figure 8, workplace practices first refer to organizational culture (e.g., values, myths, beliefs, attitudes, etc.) to support a healthy and sustainable RTW.

This organizational culture influences the formulation of organizational policies and procedures, which are implemented through organizational strategies and, subsequently, through specific actions (at a certain stage and for a particular group of actors) leading to workplace accommodations.

Here is an example of an action by the supervisor at the RTW planning stage to help understand the process: The supervisor must inform the other actors about the conditions for implementing the RTW plan with workplace accommodations.

• Organizational culture, policies and procedures
• Organizational strategies
• Actions
• Workplace accommodations

Distinguish between types of practices (best, current, optimal)

Figure 9 – Conceptual framework illustrating the relationship between best practices, current practices and optimal practices in the workplace (text and figure adapted from Nastasia et al. – 2017)

This conceptual framework highlights the dynamic process in which optimal practices are the result of integrating and adapting best practices, based on research findings, into the current practices of organizations. These optimal practices take into account the particularities of each workplace (contextual elements). To be successful in this process, several steps are necessary. First, it is essential to establish what are the best practices. While best practices have not all be scientifically proven (which is a significant challenge), they are currently supported by the theoretical and empirical literature in the field. Second, it is necessary to determine what is currently being done in RTW, identify gaps in what is being recommended, and then develop solutions to reduce these gaps. In this section, we present these solutions, i.e., optimal practices.

Each individual practice, even if performed by a single RTW actor, contributes to the overall improvement of the RTW process. Get involved!

Organizational Culture and Policies

Culture

Organizational culture represents a way of thinking, feeling and acting that the company adheres to (e.g., principles, social codes, values). It is defined by executive management and reflected in policies and procedures. For example, if executive management prioritizes the well-being of its workers, OHS will be a priority for action by the organization and preventive measures will be put forward (e.g. workplace accommodations).

A commitment to OHS demonstrates respect for all members of the organization. This commitment can extend to integrated prevention, from primary prevention (first injury) to tertiary prevention (long-term disability).

Note: To learn about the benefits of healthy and sustainable for both employers and workers, please refer to the Employer’s Guide to Return to Work, pages 1 and 2.

Policies

Policies target the organization’s objectives in terms of RTW. They reflect the organizational culture and guide the actions of those involved in RTW in their activities. They also demonstrate its commitment to achieving them. These policies must be clear and harmonized with the laws, the employees’ collective agreement and the organization’s management practices. They can be part of a global health strategy.

When drafting return to work policies, we suggest that you include the following elements:

• Define the target clientele;
• Define the organization’s expectations toward the immediate superior, the employee and the union or union representative, if applicable;
• Describe the attitudes that the supervisor should have towards the employee’s team;
• Write the procedures to follow when returning to work;
• Draft a support guide for (1) workers who are unable to work, (2) supervisors and (3) other stakeholders (HR, co-workers, union representative, etc.), as needed.

Note: For more details on each of these points, consult the “Entreprise en santé” (in French only) approach.

A healthy and sustainable return-to-work policy is a reflection of the organizational culture (commitment).

Organizational Procedures

Procedures are the actions that must be taken in a sequential manner to achieve the desired result (in this case, a healthy and sustainable RTW. They must answer the questions Who, What, When and How. A participatory approach with representatives from each department is required to align these procedures with policies (upstream of the process) and organizational strategies (downstream of the process). You can also integrate scientific evidence (or empirical evidence where it is not yet available) into your practice. The actions identified here, as well as the proposed workplace accommodations, are useful sources of information for formulating your procedures, which will be adapted to your context.

Of course, it is necessary to disseminate and promote adherence to these policies and procedures among the stakeholders, i.e., the organization’s departments and services (human resources, production, maintenance, health and safety department, etc.) as well as all groups of return-to-work stakeholders (manager, supervisor, worker, human resources advisor, return-to-work case manager, union representative). To do this, you will need to train key players in the organization on certain elements.

Note: For additional information and concrete examples of how to write policies and procedures, please consult the following document: Employer’s Guide to Return to Work.

The Workplace organizational policies and practices questionnaire will also provide you with relevant information. A recent example (Mustard et al., 2017) is a successful disability management policy that includes:

1. an emphasis on early contact with the worker;
2. the designation of disability case managers;
3. the inclusion of supervisors in the development of RTW plans ;
4. the provision of education and training to managers and supervisors;
5. the integration of union representatives in RTW planning by acting as RTW coordinator (five days training required).

Organizational strategies

An organizational strategy is a set of actions that, carried out individually or collectively, are directed towards the same goal in order to solve a particular problem. These actions may refer to several actors and process steps.

In order to help you plan and coordinate all of the actions necessary for a healthy and sustainable RTW, here are some important elements to consider:

Concerted action

Collaboration between the organization’s external (clinicians, insurers, health and work professionals, etc.) and internal (supervisor, human resources, union representative, co-workers, etc.) stakeholders allows for the mobilization of a common objective despite divergent interests or different conceptions of RTW.

Examples:

• Involve the worker in the development and implementation of the RTW plan to facilitate consensus on modifications, workplace accommodations and return-to-work conditions;
• Involve the supervisor in the development and implementation of the RTW plan in order to leverage the supervisor’s knowledge and experience of the workstation and production requirements;
• Designate a person responsible for coordinating the actors involved in the implementation of the RTW plan.

Effective communication

Coordinating the efforts of all actors in the organization (including the worker) requires effective communication among them.

Examples:

• To achieve communication that leads to results, provide structures and spaces for discussion (e.g., an informational meeting or an OHS committee);
• Express feelings and expectations and listen to those of others without judgment. See “Better communication for a healthy and sustainable RTW” and the “Communication Between Workplace Stakeholders” vignette.

Training for the actors involved

Educate and train oneself on the issue of work disability. It is a question of ethics and responsibility of the actors involved. Be on the lookout for training activities, in all their forms (symposiums, conferences, specific courses or certificates in training institutions) and target the members of your organization who could benefit from them.

Core Activities in Case Management

A core activity is an action or set of actions directed toward a common goal (RTW or prevention of prolonged disability) and carried out by an individual or a group of individuals. For example, collaboration with the worker is essential for a sustainable return to work and job retention. It involves actions on the part of both the supervisor and the other actors who share the same objective, and this at different stages of RTW. The IWH (2014) sets out seven principles (or core activities) for a successful RTW based on a systematic review combining quantitative and qualitative data (Franche et al., 2005; MacEachen, Clarke, Franche, Irvin and Workplace-based Return to Work Literature Review Group, 2006):

PRINCIPLE 1: The workplace has a strong commitment to health and safety, which is demonstrated by the behaviours of the workplace parties.

People may talk about what they believe in or support, but as the old saying goes, “actions speak louder than words.” Research evidence has shown that it is ‘behaviours’ in the workplace that are associated with good return-to-work outcomes. They include:

• top management investment of company resources and people’s time to promote safety and coordinated RTW;
• labour support for safety policies and return-to-work programming (for example, demonstrated by inclusion of RTW job placement practices in policies/procedures and/or the collective agreement); and
• commitment to safety issues as the accepted norm across the organization.

PRINCIPLE 2: The employer makes an offer of modified work (also known as work accommodation) to injured/ill workers so they can return early and safely to work activities suitable to their abilities.

Accommodating work is a core element of disability management, leading to favourable outcomes. However, arranging appropriate accommodated work requires many considerations. An awkward fit of the worker with a modified work environment can contribute to breakdown of the RTW process and should be avoided. In a published guide for employers (Stock et al 2005), the Montreal Public Health Department states that, where possible, it’s ideal to return a worker to his/her own work area where the environment, people and practices are familiar. In some cases, it will be helpful to employ the services of someone with ergonomics expertise. Ergonomic worksite visits should also be considered a core disability management component. This would mean that when RTW planners are encountering difficulty in creating an appropriate modified job, ergonomics expertise should be made available.

PRINCIPLE 3: RTW planners ensure that the plan supports the returning worker without disadvantaging coworkers and supervisors.

RTW planning is more than matching the injured worker’s physical restrictions to a job accommodation. Planning must acknowledge RTW as a ‘socially fragile process’ where co-workers and supervisors may be thrust into new relationships and routines. If others are disadvantaged by the RTW plan, it can lead to resentment towards the returning worker, rather than cooperation with the RTW process. Two examples illustrate where RTW plans may cause problems:

Example 1.
The injured worker may have to deal with co-workers who resent having to take over some of his/her work and, therefore, feel that the worker has managed to get an ‘easier’ job.

Example 2.
Supervisors may be required to fulfill production quotas in spite of accommodating a returning worker, and may not have the work that such accommodation requires fully acknowledged. Workplaces that create individual RTW plans that anticipate and avoid these pitfalls will probably have better outcomes.

PRINCIPLE 4: Supervisors are trained in work disability prevention and included in RTW planning.

Supervisors were identified as important to the success of RTW due to their proximity to the worker and their ability to manage the immediate RTW work environment. Educating managers and supervisors in areas such as safety training or participatory ergonomics was also found to contribute to successful RTW. When supervisors are left completely out of the RTW planning process, they feel ill equipped to accommodate returning workers. Positive results are reported from a program in which supervisors were given ergonomics and safety training, and taught how to be positive and empathetic in early contact with workers, as well as how to arrange accommodations, follow up and solve problems on a regular basis.

PRINCIPLE 5: The employer makes early and considerate contact with injured/ill workers.

‘Early’ contact is a core component of most disability management programs, and thus associated with better RTW results. Contact ‘within the first week or two’ should be seen as a guideline only, as the actual time-frame may vary depending on the worker’s specific situation. Ideally the contact is made by the immediate supervisor as this helps the worker to feel connected to his/her workplace and colleagues. The contact should signify that the employer cares about the worker’s well-being, and should not involve issues such as discussing injury causation or blame.

PRINCIPLE 6: Someone has the responsibility to coordinate RTW.

Successful RTW programs involve a RTW coordinator whose responsibility is to coordinate the RTW process. The learn more, click here. The coordination role may be performed by someone in the company or by someone external. In either case, this coordination role involves:

• providing individualized planning and coordination that is adapted to the worker’s initial and on-going needs;
• ensuring that the necessary communication does not break down at any point; and
• ensuring that the worker and other RTW players understand what to expect and what is expected of them (12).

RTW players include workers, co-workers, supervisors/ managers, health-care providers, disability managers and insurers. As noted in Principle 2, consideration of the needs of these various players will facilitate the RTW process and help to ensure its success.

PRINCIPLE 7: Employers and health-care providers communicate with each other about the workplace demands, as needed, and with the worker’s consent.

Contact between workplaces and health-care providers reduced work disability duration. This contact may range from a simple report sent back to the workplace, to a more extensive visit to the workstation by a health-care provider. The degree and nature of the contact between the workplace and health-care providers can vary depending on individual circumstances, including:

• a paper-based information exchange (e.g. information on job demands and/or work accommodation options sent to the family doctor by the employer);
• a telephone conversation about work and job demands (initiated by either party); and
• a workplace visit by a health-care provider to view the work activities and converse directly with the supervisor or employer.

Roles and responsibilities of the actors involved

The actors are specified according to the context and resources of the organization (size of the company, unionization, sector of activity, geographical location, etc.). Depending on these contextual elements, the organization may call upon internal resources or, by default, external resources (professionals, OHS consulting firms).

The roles and responsibilities of the actors specified below must be defined by the organization according to its context and resources. A role is a function of one or more individuals within the framework of a specific objective, related to the organization’s mission. The best known example is the distribution of work among team members in order to achieve productivity and quality objectives. A responsibility is one or more tasks expected and possibly measured by organizational indicators, related to a specific role assigned to an individual in the performance of his/her duties in an organization. Conducting accident investigations is an example of a responsibility.

Individual RTW approach adapted to the organizational context

Actions to be carried out in the workplace by all the actors involved, including the worker

An action is a concrete fact carried out individually or in interaction with other actors. In order to help you understand the worker’s situation in relation to your company’s needs, we suggest actions that can be carried out at each stage of the return-to-work process.

To date, in Québec, the RTW process for workers with a MSD or CMD is conceptualized in six stages (Durand et al., 2014):

• Time off and recovery period;
• Initial contact with the worker by the workplace;
• Evaluation of the worker (abilitys) and his job (demands);
• Development of the RTW plan with accommodations;
• Work resumption (day 1);
• Follow-up of the RTW (in the following weeks).

This approach emphasizes the importance of evaluating the worker in relation to his or her work situation even before the implementation of workplace accommodations.

Some stages may be iterative. For example, evaluations or selections of workplace accommodations can be repeated until the desired balance is achieved. Thus, healthy and sustainable RTW is conceived as the result of a dynamic process in which the actors communicate with each other regularly.

Actions or workplace accommodations  must be initiated promptly and without delay as soon as the worker is taken into care. However, they must be carried out with discernment. It is important to act at the “right time”, i.e. when the positive effects on the worker’s health outweigh the negative effects encountered. This requires taking into account all the elements of the context (biological, psychological and social), including the work environment (its problems, needs and available resources).

Although these tables are presented by category of actor, it is essential to look at the actions of other actors in order to promote collaboration and cooperation, which are fundamental to a healthy and sustainable RTW. Here are the steps in this process in which the main categories of actors are involved, although some more specific actors may sometimes be involved in other steps, as described in the tables (information adapted from Durand et al., 2014).

Ressources

CSA Z1011:20 Standard

A new Canadian standard (CSA Z1011:20) exists to guide employers towards the implementation of a “Workplace Disability Management System”. This standard presents a macroscopic vision and has the advantage of being generic, i.e. it applies to all organizations (small, medium or large) and to all health problems leading to work disability. However, this standard does not provide more specific information on the factors that influence work disability, the most effective interventions or the best practices to promote a healthy and sustainable RTW, based on research evidence. Our website provides this information and can therefore be considered complementary to this CSA standard, but for MSDs and CMDs only.

WSCC Employer’s Guide

The Employer’s Guide to Return to Work outlines the steps to take when a worker is injured and how to create and implement individualized RTW plans. This guide is often cited as an example to follow.

Organizational Policies/Practices Questionnaire

The Workplace Organizational Policies and Practices Questionnaire is used in research that assesses organizations for organizational policies and practices in the workplace. The statements in this questionnaire provide examples of elements that are deemed important to consider in organizational policies or practices.

Guides for a Healthy and Sustainable Return to Work

In order to assist you in your reflection and to allow you to select the approaches that are closest to your objectives, we present you with the guides that we feel are the most useful to date. It’s up to you!

 Vignettes (Case Studies)

Three vignettes (case studies) have been prepared to place the lessons promoted on this site in contexts that are intended to be as realistic as possible. These vignettes describe how a situation can develop during the six stages of the RTW process, and then draw out learning points in terms of the strengths and weaknesses of managing these cases.

• MSD vignette: Adele, dealing with back pain disability
• CMD Vignette: Chloe, dealing with a disability related to intense stress at work
• Communication Vignette: Example of possible (and desired) communication between the various RTW actors

Appendices

Appendix 4.F – Return to Work Planning

Appendix 4.G – Better Communication for a Healthy and Sustainable RTW

Appendix 4.H – About Disclosure: Steps for Managing Personal Information

Appendix 4.L – About the RTW Coordinator

Appendix 4.O – Integrated Prevention Management: A Way Forward?