Key words
review - meta-synthesis - return to work - mega-ethnography - qualitative evidence
synthesis - chronic illnesses
Schlüsselwörter
Review - Meta-Synthese - Return to Work - Mega-Ethnografie - Qualitative Evidenzsynthese
- chronische Erkrankungen
Introduction
Chronic health conditions are a major cause of work disability and health-related
early retirement. In the European Union, more than one third of the people aged
45–54 years and nearly half of the people aged 55–64 years reported
suffering from a persistent health problem in 2019 [1]. The aging of the workforce will further increase the prevalence of
chronic health conditions in the coming decade [2]
[3]. Moreover, chronic diseases
may occur together [4].
Though work participation provides financial security and may have a positive effect
on health and health-related quality of life, people with chronic health conditions
are less likely to participate in the workforce, particularly if they are affected
by more than one chronic health condition [5].
Furthermore, studies have revealed an increased risk of sick leave [6]
[7]
[8] and early retirement of
employees with chronic conditions compared with people without a chronic condition
[5]
[9]
[10]
[11]
[12].
In Germany, almost one in five retirements is due to a health problem, with mental
disorders, musculoskeletal disorders, cardiovascular diseases, and cancer accounting
for almost 80% of disability pensions [13]. Although several systematic reviews suggest that effective
interventions exist to support the occupational participation of people with chronic
health conditions, particularly when they directly involve the workplace [14], equal participation of people with chronic
conditions appears to remain a challenge.
A growing number of qualitative studies has examined return to work (RTW) in people
with chronic health conditions. With a focus on the perspectives and experiences of
these people and/or other actors involved in RTW process (e. g.,
health care professionals, employers, and relatives), these studies have provided
a
detailed picture of RTW mechanisms and dimensions, facilitators, and barriers for
different disorders. However, because generalizability and transferability of single
qualitative studies (each conducted in a certain context with a specific design and
methodology on a particular sample) are limited, qualitative meta-syntheses (QMS)
have been conducted in recent years. By aggregating, integrating, and reinterpreting
the findings of various qualitative studies, QMS can give a broader and deeper
understanding of the phenomenon under research, generate new knowledge
(e. g., by theoretical abstraction and development of conceptual models or
middle-range theories), and provide more robust evidence for practical
recommendations [15]
[16]
[17]
[18]
[19].
Like most primary studies, QMS on RTW are predominantly focused on a certain disorder
[e. g. 20–23], although the overlapping findings of several QMS
indicate that many mechanisms, barriers, and facilitators are generic rather than
specific to particular diagnoses. Hence, we aimed to identify generic RTW
mechanisms, barriers, and facilitators and conducted a systematic search for QMS on
RTW in people with different chronic health disorders, to synthesize their findings
via meta-ethnographic approach (like Toye et al. [24] did in their mega-ethnography of qualitative evidence syntheses
exploring the experience of living with chronic nonmalignant pain) and – if
possible – to derive a generic RTW model and to develop recommendations for
RTW strategies in general.
Research questions
As outlined in our study protocol on PROSPERO [25], our mega-ethnography was guided by the following three
questions:
-
Which key concepts, middle-range theories, or conceptual models regarding RTW
and its facilitators and barriers in people with chronic health conditions
have been developed by meta-syntheses of qualitative studies examining the
RTW experiences/perspectives of people with chronic health
conditions, and/or of other actors relevant to the RTW process
(e. g., employers, health care professionals, relatives)?
-
Which of these findings are generic, and which are specific to a certain
disease?
-
Which middle-range theory or conceptual model can finally be derived based on
the findings of the single meta-syntheses?
Methods
To find existing QMS, we conducted a systematic literature search. QMS that met our
inclusion criteria were formally described and assessed. We subsequently
accomplished our qualitative evidence synthesis by applying the meta-ethnographic
approach [26], adapted for our purpose of
synthesizing existing QMS instead of primary studies. We chose this interpretative
approach because we wanted to go beyond a simple summary of primary studies,
striving for some conceptual or theoretical innovation.
Since we conducted a literature review and synthesis of already published studies,
we
did not apply for an ethical approval.
Systematic literature search
We conducted the systematic literature search in September 2019 and – for
an update – in June 2021 in the following databases: PubMed,
Epistemonikos, CENTRAL, and PsycARTICLES. We searched for QMS on RTW in people
with chronic health conditions that were published in English or German.
Our search strategy combined search terms to identify RTW papers (based on the
search strategy used by Van Vilsteren et al. [27]), and search terms to identify QMS (based on the search strategy
used by Ring et al. [17]). We used
synonyms and related terms to comprehensively capture both core concepts
(i. e., RTW and QMS). Our strategy for searching in PubMed also included
controlled vocabulary (i. e., MeSH terms).
MB, who is experienced in conducting systematic reviews, managed the development,
pilot testing, and adaption of our search strategy. Together, we specified a set
of 10 relevant QMS that were already known to us and that, at the very least,
had to be identified by our search strategy. The final search strategy (adapted
to each database) is available as supplemental material to our study protocol
via PROSPERO [25].
The study selection was guided by the following inclusion criteria:
-
Study type: QMS and full text available;
-
Objective/focus of the meta-syntheses: The RTW
experiences/perspectives of people with chronic health
conditions and/or of other actors relevant to the RTW
process;
-
Language: English or German;
-
Publication date: January 2000–7th of September
2019/1st of August – 4th of
June 2021 (update)
We selected the studies (QMS) in two steps. As a first step, BS and MS
independently screened the titles and abstracts of all retrieved papers and
checked them for the inclusion criteria. In the case of divergent judgments, the
papers in question were included for full-text screening. In a second step, BS
and MS again independently reviewed the full texts of all selected papers. Where
judgments differed, a third person (EvK or NR) decided about inclusion.
Data extraction and quality assessment
To get an overview of the selected QMS, we described them by using a data
extraction sheet developed on the basis of the ENTREQ statement [28] and the eMERGe meta-ethnography
reporting guidance [29]. The data
extraction sheets were filled out by pairs (each responsible for a certain
number of the included QMS) and subsequently presented in a joint meeting to
validate them consensually. A list of all aspects that were covered with the
data extraction sheet is available in our study protocol on PROSPERO [25].
Because there is no instrument to assess the methodological quality and
trustworthiness of QMS [30], we developed
such an instrument based on ROBIS, an established tool for assessing the risk of
bias in systematic reviews [31]. The
developed tool comprises 16 questions in four domains and is available as
supplemental material
(http://dx.doi.org/10.1055/a-2129-2731). Since
there is an ongoing debate on how and with which criteria the methodological
quality of qualitative studies should be assessed [32]
[33], we focused on basic and more technical indicators (e. g.
a clearly formulated research question/aim, a rigor proceeding in all
steps of literature search and synthesis, and a transparent presentation of
findings), and thus followed the approach of existing checklists and appraisal
tools for primary studies using qualitative research designs and methods [34]
[35]
[36].
After developing and testing the instrument, we applied it to appraise all
selected QMS. Each member of our team assessed the QMS for which he/she
had already carried out data extraction. Therefore, each study was assessed by
two members of our team independently (the data extraction pair). The individual
appraisals were presented and – in case of divergences between the two
assessors – agreed upon by consensus in a joint meeting.
Against the backdrop of the above-mentioned ongoing debate, we decided to not
exclude QMS on the basis of the appraisal’s results.
Synthesis of the included meta-syntheses
To synthesize eligible meta-syntheses, we adapted the meta-ethnographic approach
by Noblit and Hare [26], which includes
the following three steps to synthesize primary qualitative studies:
-
Extraction of the primary studies’ first-order concepts
(codes/categories/themes);
-
Translation of these concepts into second-order interpretations
(cross-cutting concepts); and
-
Development of a third-order synthesis (new concept, conceptual model,
middle-range theory, another form of analytical abstraction).
It should be noted, that the usage of terms ‘first, second and third
order’ is used differently by some authors [e. g. 24]. Following
Schütz [37], the first-order term
can be used also for the common-sense interpretations of the persons under
research. The concepts of the primary studies’ authors then are already
second-order, and their translation into cross-cutting concepts third order
interpretations. Thus, the final result of a synthesis would be scored as fourth
order interpretation.
As we conducted a mega-ethnography (i.e. a qualitative meta-synthesis of
qualitative evidence syntheses ), we adapted the above-mentioned steps in the
following way:
-
Extraction of the second-order interpretations and third-order syntheses
of the included QMS, i. e., their cross-cutting concepts as well
as their key concepts, conceptual models, middle-range theories, or
other final synthesizing results/products (the second-order
interpretations were extracted for a better understanding of the
third-order syntheses);
-
Translation of these synthesizing results/products into one
another (into cross-cutting terms/concepts), by comparing and
contrasting them and finding a common language; and
-
Development of our own third-order synthesis by rearranging and
reinterpreting the translated core findings of the included
meta-syntheses.
The first step was again realized in pairs and validated consensually. BS
performed the second step by translating the synthesized
results/products of the included QMS into preliminary cross-cutting
terms/concepts. The pairs checked whether these cross-cutting
terms/concepts represented the findings of their meta-syntheses.
Together, all authors finalized the cross-cutting terms/concepts and
developed a third-order synthesis.
Results
Systematic literature search
As the flow chart shows ([Fig. 1]), our
systematic literature search on September 7, 2019, revealed 2,021 papers. After
merging the databases and removing duplicates, 1,899 papers remained. After
screening titles and abstracts, 31 papers seemed to be eligible and thus were
selected for full text-screening. Finally, 19 QMS met all inclusion criteria and
were selected for our mega-synthesis. Our update on June 4, 2021, revealed 673
papers (without duplicates). The two papers selected during
title/abstract screening did not pass the full text screening. Among the
19 selected QMS was a paper by two members of our team (BS and MS) published in
2018. Two other members of our team (EvK and RH) performed data extraction,
quality assessment, and the first synthesizing step for this QMS.
Fig. 1 Flow chart.
Table 2 (available as supplemental
material under:
http://dx.doi.org/10.1055/a-2129-2731) contains
the extracted key data as well as our quality ratings of the 19 selected QMS.
They were published between 2006 and 2019, mainly by European authors. Five QMS
examined RTW in people with musculoskeletal disorders or chronic pain, four in
people with acquired or traumatic brain injuries, four in people with cancer,
two in people with mental disorders, one in people with spinal cord injury, and
three in mixed samples. The majority of the QMS (11 of 19) focused solely on the
perspective of the affected individuals; seven QMS addressed the affected
individuals and/or other actors relevant to RTW process, and the
remaining QMS focused solely on the perspective of health care professionals.
All included QMS conducted a systematic literature search; the most frequently
used method to synthesize the selected primary studies was the meta-ethnographic
approach (12 of 19 QMS), followed by thematic analysis/synthesis (4 of
19 QMS). Thirteen QMS scored 14–16 (out of 16 possible) points in our
quality assessment, five scored 11–13 points, and one scored 9 points.
Most methodological limitations were related to an inappropriate search strategy
and an increased risk of bias due to the selection and quality assessment of the
studies (only one person selected and assessed the studies).
Mega‑ethnographic synthesis
During the first step of our mega-ethnography, we extracted the core
cross-cutting themes and categories, conceptual models, and other synthesizing
results/products of the included QMS (see Table 2, column 5) and summarized the
information that was given by the authors to describe, explain, and discuss
their findings.
Through systematic comparison and reciprocal translation [26] – step two of our
mega-ethnography – we could identify and describe a set of key
cross-cutting themes/concepts ([Table
3]), which…
Table 3 Cross-cutting themes/concepts, their
descriptions, and the relevant references.
|
Cross-cutting theme/concept
|
Description
|
QMS that contribute to the theme/concept
|
|
RTW is multifactorial
|
RTW depends on various interdependent and intersectional
factors that can be grouped into:
|
[20]
[21]
[22]
[, 38]
[39]
[41]
[43]
[44]
[51]
|
-
health-related/medical/biological
factors (impairments and functional aspects);
-
personal/psychological factors (perceptions,
attitudes, behaviors); and
-
environmental/social factors (work and
family, social/societal context,
health/rehabilitation system, regulations,
and laws).
|
|
Beside the term multifactorial, QMS also used the terms
multidimensional and bio-psycho-social to describe the
complexity of factors, that have an impact on RTW in people
with chronic health conditions.
|
|
RTW is highly interactive and has multiple stakeholder
|
RTW is highly interactive because it takes place in an arena
of different actors and stakeholders (who are located
in/represent different systems):
|
[20]
[21]
[22]
[23]
[38]
[39]
[41]
[42]
[44]
[45]
[46]
[47]
[48]
[49]
[51]
|
-
the person with the chronic health condition;
-
significant others, like spouses, relatives, friends,
primary caregivers, etc. (direct social
environment);
-
health care professionals, like general
practitioners, therapists, etc. (acute and
rehabilitative health care system);
-
employers, line managers, supervisors, human
resources managers, colleagues, etc., and
occupational health care providers (working sphere);
and
-
actors from insurance agencies, who bear the
financial risk of non-RTW (social security
system).
|
|
These actors and stakeholders shape the RTW process
(purposively or unwittingly) through their attitudes,
behaviors and (inter-)actions, which are guided by own
(sometimes conflicting) interests, aims and logics (with
respect to the interests, aims, and logics of the underlying
systems).
|
|
RTW is a process
|
RTW is an evolving process rather than an outcome. This
process can be of shorter or longer duration, with ups and
downs as well as drawbacks, and – taking
sustainability into account – does not end with the
point of reentry into work (which has to be well chosen).
Instead, the RTW process ends gradually by developing stable
work participation, and it can have different
outcomes/goals (continue to work in the old job,
taking up an adapted or new job in the old company, taking
up a new job in a new company, working full or part time
etc.), which must be defined (and sometimes adapted) during
the process.
|
[20]
[22]
[38]
[–]
[40]
[47]
[48]
[50]
[51]
|
|
RTW is embedded in an individual’s life and working
history
|
RTW is embedded in the biography of the individual and thus
is influenced (positively or negatively) by the individual
life and working history (e. g., former illness
experiences, job qualifications, and experiences), the
actual private and occupational situation (e. g.,
family obligations, relation to supervisor and colleagues),
and previous ideas and plans about the own future
(e. g., pursuing a career or dedicating oneself more
to family or retiring as soon as possible).
|
[20]
[38]
[40]
[43]
|
|
RTW is embedded in a certain social and societal context
|
RTW is embedded in a certain social and societal
context/framework and thus is influenced (positively
or negatively) by political, legal, economic, cultural, and
normative conditions (e. g., quality of health care
provision, disability rights, social insurance regulations,
labor laws and labor market situation, illness
representations, and stigmas).
|
[20]
[21]
[22]
[23]
[38]
[]
[]
[]
[]
[]
[43]
[45]
[58]
[49]
[51]
[52]
|
|
RTW affects a person’s identity and the further
coping with the illness
|
RTW runs parallel and interdependently to the processes of
coping with the disease and reforming one’s own
identity. RTW is influenced by coping with the illness
(because unsuccessful or maladaptive coping for example can
hamper a successful and sustainable RTW) and, vice versa, it
influences further coping (e. g., by making good or
negative experiences with altered abilities at work). It is
also affected by the pre-illness identity and self-image of
the person (e. g., as a valuable worker), which can
be threatened by the disease and its consequences on
abilities. Experiences during the RTW process have a
significant impact on (an often declined) self-confidence,
self-esteem, and self-efficacy, and thus on the process of
building up a new coherent and stable self-image.
|
[20]
[21]
[22]
[23]
[40]
[43]
[44]
[46]
[47]
[50]
[]
[52]
|
|
RTW factors are consequences of the disease
|
The consequences of the disease include functional
limitations and a reduced or altered work
ability/capability/performance/capacity
due to physical and mental symptoms of the disease (and
sometimes also due to therapy side-effects).
|
[20]
[21]
[22]
[23]
[39–]
[]
[]
[42]
[44]
[48]
[49]
[51]
[52]
|
|
(Long-term) symptoms that fluctuate, flare up, and are
invisible or unpredictable in terms of frequency and
intensity are described as the most challenging, often
evoking feelings of uncertainty, leading to a lack of
understanding/mistrust and making it hard to set up
a RTW plan.
|
|
A clear diagnosis and assessment of altered work
ability/capability/performance/capacity
and knowledge about the diseases and its symptoms can help
to gain certainty and understanding and to form a legitimate
and solid basis for RTW strategies/measurements.
|
|
Most of the included QMS do not explicitly describe the
consequences of the diseases, considering it as a given and
focusing on other factors of RTW. Nearly no QMS
distinguishes
verbally/theoretically/conceptually between
the terms work
ability/capability/performance/capacity.
Such a distinction could express more precisely the
relatedness of abilities to demands and help to improve
assessments and RTW measurements – which has to
consider both sides: abilities and demands.
|
|
RTW factors include RTW motivation & coping
strategies
|
A high RTW motivation is an RTW facilitator, as the
individual strives to get back to work. The underlying
motives are manifold, comprising the different meanings and
functions of paid work (income, structure, social belonging,
distraction, feelings of competence, sense of purpose and
contribution, etc.). Moreover, RTW is associated with
recovery and getting back to normality.
|
[20]
[21]
[22]
[23]
[39]
[40]
[41]
[43]
[44]
[47]
[4952]
|
|
RTW motivation can be diminished by uncertainty about
one’s own abilities, by low
self-esteem/confidence/efficacy (due to
functional limitations and altered abilities), by
demotivating attitudes and behaviors of significant
others/relevant actors, and by unmet expectations
and frustrating experiences at work (work failure).
|
|
People with chronic diseases have to cope with symptoms, side
effects of therapies, functional limitations, altered
abilities, and the effects that these things (might) have on
their identity/self-image and on their private and
working life. They have to accept the disease and its
consequences, adapt to their changed abilities, developing a
new positive self-image and reorganize their private and
working life. Some people with chronic diseases reevaluate
their life priorities, reducing work aspirations to reach a
better/new work-life-balance.
|
|
Knowledge about the disease and its consequences, about
therapy options, and active involvement in setting up
treatment and RTW plans are crucial for an adaptive coping
(help to feel competent, taking control).
|
|
Health/illness representations have a strong impact
on coping with the disease and on RTW. If work is associated
with the disease as a cause or a risk of worsening, this
might lead to late or non-RTW. A (too-)high RTW motivation
otherwise can result into getting back to early.
|
|
RTW factors include social support in private and working
live
|
Attitudes, expectations, and behaviors of significant others
in private (family members and friends) and in working life
(supervisor and colleagues) and the amount of social
– practical and emotional – support they
give to the person concerned can facilitate or inhibit the
RTW process.
|
[20]
[21]
[22]
[23]
[, 38]
[]
[]
[]
[52]
|
|
People with chronic diseases emphasize the importance of
perceiving genuine interest and empathy, understanding and
trust (being believed), good will, and respectful treatment.
Social support is crucial for them. It helps them to cope
with the disease and its consequences.
|
|
Reactions and social support at the workplace highly depend
on the (perceived) causes of the disease and sick leave as
well as on the relationships before the disease and the
“workers value” to the team/company.
It also depends on how the disease/sick leave, the
RTW process, and possible work adaptions are communicated
and implemented in the working unit.
|
|
Here, the supervisor plays a decisive role, as he/she
can act as an advocate of the disabled worker, seeking
understanding on the side of the colleagues while making
sure that they are not adversely affected by adaptions.
Conflicts can arise when there is expectation mismatch; when
altered abilities and/or work adaptions cause
unequal workloads/inequalities between team members;
and when the disease, sick leave, and limitations are
questioned by the supervisor and/or colleagues. This
mistrust causes labeling, stigmatization, and
discrimination.
|
|
RTW factors include adaptability of the working
environment
|
Work(place) adaptions (e. g., changes in work
schedules/working hours and days, changes in tasks
and job content, changes in workload, physical adaptations,
offering assistive technologies and job coaching, etc.) and
gradual RTW are seen as helpful/essential for a
successful RTW. Work(place) adaptions require knowledge
about the disease and its consequences and are ideally based
on a professional assessment of work capacity, capability,
and performance. They have to be tailored to the individual
needs, considering the wishes of the person (active
involvement), be regularly tracked and flexible to altered
needs, and have to be well communicated in the
team/working unit.
|
[20]
[21]
[22]
[23]
[38]
[]
[]
[]
[]
[]
[44]
[46]
[48]
[50]
[51]
|
|
The implementation of work(place) adaptions greatly depends
on the possibilities and resources given in a certain
company, its general health policy and already established
occupation health strategies, the size of the company, the
type of the job, as well as on the
willingness/goodwill/understanding of the
employer/supervisor. The age (i. e.,
remaining working years) and
status/position/value of the worker, the
availability of other skilled employees on the labor market,
the sympathy/relationship between supervisor, and
the person concerned are further key factors. Work(place)
adaptions are not only a question of technical matters;
there is also a question of communication.
|
|
RTW requires a holistic, person-centered, and systemic
approach, and a designated coordinator
|
Because successful RTW depends on various bio-psycho-social
factors, it needs a holistic (multimodal and
multiprofessional) approach that addresses all these factors
in assessment and evaluation as well as in
therapy/treatment and support. A holistic
assessment/evaluation has to involve (1) information
on the disease and its consequences, (2) information about
the person and his/her personal
situation/needs/interests and the
biographical background, and (3) information about the
individual working place and the possibilities for adapting
this working place or the working situation in the company.
An intervention strategy has to be defined by a combination
of medical and vocational aspects.
|
[20]
[21]
[22]
[23]
[38]
[]
[]
[]
[42]
[44]
[45]
[47]
[48]
[52]
|
|
The underlying approach has to be tailored more to the
individual needs than to existing systematic borders and
responsibilities, and thus requires flexibility. The person
has to have an active role in managing the RTW process. This
improves empowerment and autonomy. Furthermore, it is a core
element for a successful RTW process because the individual
is taking control regarding defined steps and taking
decisions, which supports regaining normality and forming a
new identity.
|
|
Moreover, RTW is not an individual problem: It requires a
systemic approach to ensure the described balancing act
between conflicting interests on the one hand and sufficient
participation of all actors on the other hand.
|
|
Because RTW is a highly interactive process, taking place in
an arena of different actors and stakeholders with different
(sometimes conflicting) interests, there is a need for
coordination.
|
Abbreviations: QMS, quantitative meta-syntheses; RTW, return to work.
characterize RTW in people with chronic health conditions as
-
a process rather than an outcome,
-
multifactorial and interactive, as well as
-
embedded in an individual biography and a certain social and societal
context;
represent key RTW barriers and facilitators like
outline RTW effects on the person’s identity and the further handling
of the illness; and last but not least
recommend how RTW strategies should be designed, i. e.
-
holistic,
-
person-centered,
-
systemic, and
-
coordinated.
Besides the symptoms and direct consequences of the disease that vary from
disorder to disorder, the identified cross-cutting themes/concepts seem
to be generic and are therefore highly relevant for the RTW process in
general.
In step three of our mega-ethnography, we rearranged and integrated these
cross-cutting themes into the following principals of RTW in people with chronic
health conditions (third-order synthesis):
-
RTW is a multifactorial and highly interactive multistakeholder
process, embedded in the individual’s life and working
history, as well as in a determined social and societal
context.
-
The RTW process affects the person’s identity and the further
coping with the illness.
-
The RTW process is not only shaped by the direct consequences of the
disease, the RTW motivation, and individual coping strategies; it is
also particularly shaped by the adaptability of the person’s
working environment and the social support in private and working
life.
-
Therefore, RTW is not only a problem of the individual, but also a
matter of the social environment and system, requiring a holistic,
person-centered, and systemic approach as well as a designated
coordinator.
Based on these RTW principles, we developed a generic RTW model ([Fig. 2]).
Fig. 2 RTW model.
It displays RTW as a process, which runs parallel and interdependently to the
process of coping with the disease and reforming one’s own identity, and
thus emphasizes how significant RTW is for the affected person. People with a
chronic disease have to cope with the condition and its impact on abilities and
different areas of life (including paid work). They have to incorporate these
consequences into their pre-illness identity, and thus, have to realign former
(i.a. work-related) self-images. The course and success of RTW is influenced by
these challenging tasks, which themselves are strongly affected by the
experiences made through the RTW process (e. g., good or negative
experiences with altered abilities at work).
Around these interdependent processes of RTW, coping with the disease and
reforming identity, we arranged the four factors, that according to our analyses
are central to each RTW process. Returning people can be confronted with more or
less severe symptoms and functional restrictions, apply adaptive or maladaptive
strategies to cope with these limitations and with RTW challenges, can pose
different meanings to work and be more or less motivated to get back to it, have
a varying amount of social support in private and working life, and are faced
with different possibilities of accommodations at work.
The last two components of the model illustrate the embeddedness of the RTW
process in a biographical and social context, and thus refer to the impact of
the individual life and working history (e. g., former illness
experiences, job qualifications, and experiences), the actual private and
occupational situation (e. g., family obligations, relation to
supervisor and colleagues), previous ideas and plans about the own future
(e. g., pursuing a career or dedicating oneself more to family or
retiring as soon as possible), and the political, legal, economic, cultural, and
normative conditions in which RTW takes place (e. g., quality of health
care provision, disability rights, social insurance regulations, labor laws and
labor market situation, illness representations, and stigmas).
Overall, the model mirrors the complexity of RTW, its multifactorial and
interactive character, and thus the need for holistic RTW approaches and a
coordinating body.
Discussion
The central aim of our mega-ethnography was to identify key concepts, mechanisms,
barriers, and facilitators of RTW in people with chronic health conditions that have
been found by former qualitative syntheses, and – if possible – to
develop a generic RTW model, from which recommendations for RTW strategies in
general can be derived. There are a number of QMS on RTW in people with different
chronic conditions, based on an even larger number of primary qualitative studies
that have identified a wide range of different factors that can hinder or foster
successful RTW. Besides some factors that vary from disorder to disorder –
for example, disease-specific restrictions of work ability – there are a
myriad of factors and mechanisms that are essential to RTW processes independent of
the underlying disorder. These factors and mechanisms, located on the micro-, meso-,
and macro-levels, are related to the person, to the individual’s immediate
private and work-related social environment, to the company that employs the
individual, to the health care and social welfare system and the legal and societal
framework. Together, these factors represent the processual, interactive, and
embedded character of RTW.
Because we wanted to develop a generic RTW model, we focused on key factors and
mechanisms and clustered them at a very formal and highly abstract level. The
theoretical benefit of this abstraction from a bunch of detailed and specific
qualitative studies and their syntheses is that typical characteristics of and
relevant factors in every RTW process can be integrated, grouped, and located in the
network of interactive relations and connected to the central key points within the
RTW process. Thus, the formal and abstract model can be used methodologically to
account for the most common RTW processes and its intersections with barriers and
facilitators. Furthermore, the model can easily be enlarged by adding specific
components within the more general features of the boxes of the model ([Fig. 2]). For practical purposes the model can
help to identify the individual needs in considering the core aspects in the
model.
Our model is neither the first nor the most comprehensive RTW model: Several models
exist, all with different purposes and basic assumptions. In their overview on
different models Knauf and Schultz [53]
identified (a) biomedical, (b) psychosocial, (c) ecological/case management
and economic, (d) ergonomic, and (e) biopsychosocial models. These models are
characterized by the perspectives of certain disciplines and professions (a, b, and
d), by a systemic approach (c) or based on overall multidisciplinary perspectives
(e). Based on this overview, our model overlaps with models (b) and (e) and, in its
systematic conception, it is close to model (c). Disregarding the epistemological
status of these models – Loisel et al. [54] presented an early scheme of relevant factors playing a role in RTW
– each model has implications for additional research, focusing on certain
factors and features and for agenda setting for practical purposes in the field of
supporting RTW.
Implications
In our model, RTW is rarely seen as an end in itself but rather as a very complex
process. It needs to be critically reexamined and redefined, and it needs to
manage both individual and social processes (e. g., at work)
simultaneously and in a holistic manner. Thus, the concept of RTW has to be
moved in the direction of a more nuanced person-centered and systemic approach
to ensure a holistic perspective regarding all factors and areas of life that
are relevant for RTW.
The holistic perspective considers the interplay between the chronic health
condition – seen from a biopsychosocial perspective – to be
treated in multimodal ways by different professions, the actual limitations of
the patient, the respective impact on the work-tasks, and other relevant
dimensions [55]
[56].
The person-centered approach acknowledges the individual’s sense of
identity as well as the embeddedness of those returning to work into an
intertwined biography that is shaped by social support of family and friends as
well as work-related contacts, and by the consequences of the chronic health
condition and its subjective meanings.
The systemic approach reflects that RTW is a highly interactive process, taking
place in an arena of different actors and stakeholders. These actors and
stakeholders shape the RTW process (purposively or unwittingly) through their
attitudes, behaviors and (inter-)actions, which are guided by own and sometimes
conflicting interests, aims and logics. This can hamper successful RTW processes
and therefore indicate the need for a coordinating body. This coordinating body
has to be an impartial third or even non-party that acts as a RTW process
manager, moderating and mediating between all involved stakeholders. Such
process-oriented RTW coordination goes beyond a case management that focusses on
the affected person, acting as a personal supporter, gate keeper, broker and
advocate [57]
[58]
[59]. Future studies should analyze in more detail how a RTW
coordination has to be designed and which functions and roles a RTW coordinator
should have to improve RTW processes effectively and efficiently [60]. This might also help to explain, why
current evidence regarding case management and RTW is mixed at best [61]
[62].
Last but not least, the findings of our synthesis lead to the implication that
RTW strategies can be designed similar in core for different diseases.
Strengths and limitations
By conducting a mega-ethnography, we offer a comprehensive overview of
international qualitative RTW research and follow an innovative way to
generalize conceptual work resulting from QMS. Besides providing an RTW model,
we have enhanced the methodological discussion concerning the assessment of QMS
by providing a quality appraisal tool. However, we did not use the results for
the exclusion of studies or considered them systematically in our synthesis.
The innovation of our approach is the radical reduction in complexity. This has
to be considered in light of high complexities due to, for example, different
health provision systems and different labor markets in different countries.
Related to that, it has to be considered that the majority of the included QMS,
as well as the primary studies on which the QMS are based, were conducted in the
Western world. Except for the QMS by Magalhães et al. [45] and Neves et al. [47], the first authors were all from Europe
or North America.
Bibliometric analyses show that there is still a predominance of high-income
countries in medical or health-related publications even though the origin of
scientific articles in some leading medical journals has diversified slightly
over the past decades [63]. The reasons
for the underrepresentation of research findings from lower-income countries are
the general scientific infrastructure as well as publication barriers,
especially the costs associated with publishing articles open access and for
translation and editing services [64]. In
addition, the sociodemographic structure combined with the structure of the
economic sectors could also contribute to a stronger focus on RTW processes in
high-income countries.
Regarding the aim to develop a generic RTW model, we must remark that the
included QMS focused mainly on physical conditions, with only two focusing
solely and three focusing partly on mental disorders. Further selectivity can be
seen in the fact that a majority of the included QMS only reflected the
perspective of those returning to work and not explicitly on multiple
perspectives. Last but not least, we did not include the term
‘qualitative evidence synthesis’ in our literature search
strategy.
Conclusion
Despite the above-mentioned limitations, our mega-ethnography provides important
knowledge about generic factors of successful RTW processes. RTW is embedded in the
social and societal context and is part of an individual’s life path and
working history. Considering the individual’s perception regarding their own
limitations due to the chronic health condition, the individual’s coping
strategies and motivational structures, the perceived social support, and the
working environment’s willingness and potential to adapt work demands, RTW
has to be understood as a process with multiple actors and interests. A
person-centered, coordinated, systemic, and holistic approach seems to support such
an RTW process. This means that the precise activities in the rehabilitation process
should be orientated toward the individual needs of the person with a chronic
illness with regard to the specific life situation, motivations, and needs. However,
our analysis also shows that in the future, it would be worthwhile to emphasize at
least as strongly the role of the RTW coordinator, characterized as a mediator or
broker of different interests.
