Occupational Medicine Advance Access originally published online on December 18, 2007
Occupational Medicine 2008 58(2):88-93; doi:10.1093/occmed/kqm138
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Return-to-work policies in Finnish occupational health services
1 Work and Mental Health Team, Finnish Institute of Occupational Health, Topeliuksenkatu 41aA, FIN-00250 Helsinki, Finland
2 Cochrane Occupational Health Field, Knowledge Transfer Team, Finnish Institute of Occupational Health, PO Box 93, 70701 Kuopio, Finland
3 Statistics Team, Finnish Institute of Occupational Health, PO Box 93, 70701 Kuopio, Finland
4 Finnish Institute of Occupational Health, Topeliuksenkatu 41aA, FIN-00250 Helsinki, Finland
Correspondence to: Jos H. Verbeek, Knowledge Transfer Team, Finnish Institute of Occupational Health, PO Box 93, Kuopio 70701, Finland. Tel: +358-304747289; fax: +358-304747221; e-mail: jos.verbeek{at}ttl.fi
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Abstract |
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Aim To describe return-to-work services for employees on sick leave offered by Finnish occupational health services (OHS).
Methods Finnish OHS are surveyed every 3 years. Respondents are asked if they offer services to facilitate return to work (RTW), and if so, to describe them. The description was qualitatively analysed using the Atlas-ti programme to find the themes that best describe the services. We also studied characteristics of OHS predicting a return-to-work policy.
Results Of the total sample of 969 occupational health units, 95% responded to the survey. Forty-one per cent reported offering services for facilitating RTW after sick leave. The service usually consisted of occupational physician examination of employees on sick leave for 
6 weeks. This was followed by a joint discussion between employee, physician and supervisor, which could result in work accommodation or a work trial period. There was a substantial variation, with only 10% mentioning a joint meeting and 13% mentioning a work trial period or work accommodation. Return-to-work policies were more frequently found in the OHS that served only a few employers, provided more group activities and collaborated more with employers and research institutes.
Conclusion Less than half of Finnish OHS offer return-to-work services of which the contents show wide variation that is not in line with current scientific evidence. A guideline project for return-to-work practices is needed to fill the gap. More research is needed to best define monitoring and screening practices for workers on sick leave.
Keywords Disability evaluation; occupational health nurse; occupational physician; sick leave; vocational rehabilitation
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Introduction |
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Return to work (RTW) after sickness absence is an important problem for patients, physicians and employers alike. After long lasting illness in particular, such as cancer or illness with severe limitations such as rheumatoid arthritis, many patients experience problems upon RTW [1,2]. For physicians, their tasks and roles are often unclear and even confusing [3].
Occupational health services (OHS) deal with RTW in most countries of the world, although in different ways. For example, the main task of occupational health physicians (OHPs) in The Netherlands is to assess and guide patients in RTW issues, whereas in Finland, OHPs provide preventive and curative care. In addition, any physician in Finland can write sick leave notes. The Finnish OHS law states that the official task of OHS is to maintain and promote employee work ability and functional capacity and to ensure that disabled employees can cope at work. They are required to provide advice on treatment and vocational rehabilitation in particular [4].
Little has been written about the contents and best strategies of RTW [5]. Hulshof et al. [6] commented in their review of evaluation studies of OHS interventions that RTW interventions were probably the most prevalent but least evaluated.
In addition, even less is known about the practical arrangements that are made in OHS for locating workers in need of help and who provides help. In Finland, there is some guidance for employers on the principles for supporting a safe and timely RTW, but there are no clear guidelines for OHS. Therefore, we felt that to further shape and develop return-to-work policies in OHS, it would be helpful to describe the current practices and factors that influence them in Finland [7].
In Finland, OHS are regularly surveyed so as to enable the monitoring of the developments in the structure, processes and output of services [8]. Questions on RTW policies were included in the latest survey, which allowed both a qualitative and quantitative analysis.
We used this OHS survey to answer the following questions:
- What proportion of Finnish OHS offer services to facilitate RTW after sick leave?
- How do those that offer return-to-work services describe the contents of and concepts behind these services?
- What OHS characteristics are related to the provision of return-to-work services?
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Methods |
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The questionnaire survey on OHS in Finland was conducted in 2005 as a part of the national follow-up system commissioned by the Ministry of Social Affairs and Health. The main question of interest was formulated in the questionnaire as follows: ‘Does your OHS have an agreed practice for the monitoring and facilitation of RTW after a period of longer sick leave?’ The answer options were yes or no. If yes, the respondent was asked to briefly describe the practice.
RTW practices were defined as interventions that aim at optimizing RTW after sick leave. All three authors went through the open answers to define common themes in the answers to the question on RTW practice. It was agreed that the following aspects of the intervention would be of interest for its description:
- What is the legal or the contractual context in which the interventions are carried out?
- At what point during sick leave is it agreed to intervene? For example, are employees who are on sick leave for longer than 30 days contacted?
- What kind of practical arrangements are made to start the intervention? For example, are sick workers called in to visit the OHS?
- Who provides the intervention? For example, occupational physician, nurse or other staff?
- What does the intervention consist of? For example, health examinations, meeting with supervisor and physician?
- What kind of concepts do the respondents use to describe the contents of RTW service? For example, health examination, work trial?
- What kind of decisions do the interventions lead to? For example, written advice to the employer.
One of the authors (J.H.V.) coded the text according to these themes using the Atlas-ti computer program and another author (H.V.) checked the coding process. This led to changes of the original coding in 71 instances. The codes were then assigned to one of the above themes, and each theme was described in both qualitative terms and the frequency with which it occurred.
We calculated frequencies for having a return-to-work policy and analysed relations with other features of the OHS by means of cross-tabulation and chi-squared tests and used SAS.9.1.3 for the analysis. We wanted to know how the RTW practices were related to the size and staff of OHS, other OHS activities, collaboration practices, knowledge and quality management and collaboration in sickness absence and rehabilitation issues. After univariate analysis, we used the significant variables for a logistic regression analysis at category level, thus avoiding models with too many variables at the same time. Based on the significant odds ratios (ORs) in the logistic regression analysis at category level, we chose the variables to be put in a final logistic regression model.
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Results |
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In April 2005, the questionnaire was mailed to all known OHS (n = 784) in Finland. After tracing some small units back to their main services, these amounted to 760 separate services that consisted of 969 separate units. After a reminder in May to June, a total of 719 OHS (95%) consisting of 910 separate units (94%) responded. Non-respondents to the first questionnaire were interviewed in September to October 2005 by phone with a shorter abridged version, which did not include the question about RTW (n = 71). A total of 38 respondents did not answer the main question of interest regarding RTW (n = 38) and thus were not included in our final sample, which consisted of 610 respondents. Most of the respondents were nurses in charge of administration.
The total number of workers served by these OHS was 1.82 million persons of which 1.78 million were salaried workers and 46 000 were entrepreneurs.
The sample of OHS that responded to our question on RTW policies did not differ with respect to organizational model, location or the number of employers and employees served by all OHS in Finland (Table 1).
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Forty-one per cent of all OHS in our sample offered RTW services. The kinds of services for RTW that will be delivered are stated in the OHS annual action plan. However, many also state that the practices are completely dependent on individual needs.
In Table 2, we present the results of our qualitative analysis of the description of the content of RTW services that were used. In general, workers were called in to the OHS after 1–2 months of sick leave. The OHP and the occupational health nurse were the main care providers. The contents of the intervention typically consisted of a health examination or a work capacity evaluation, aimed at further helping decision making for RTW. The needs assessment was often carried out in the form of a joint meeting including the worker, the physician and the supervisor. Possible outcomes of the health examination or the meeting were that the workplace had to be accommodated or that a work trial period had to be organized. However, there was substantial variation in the described practices.
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As regards the provider of the intervention, in addition to physicians and nurses, two OHS mentioned that they had specialized rehabilitation advisers responsible for RTW, three mentioned physiotherapists and one referred patients to the Finnish Institute of Occupational Health.
Health examinations were mentioned in 34% of the answers as the content of the services. Sometimes it was in relation to the needs assessment, but most often the objective or the outcome of the examination was not stated. At one end of the spectrum were OHS that stated that workers can only RTW after a health examination by the physician who first decided on sick leave. At the other end of the spectrum were OHS who already had RTW practices in place, aimed at work accommodations and a work trial period for workers after longer periods of sick leave agreed in a joint meeting with the supervisor. Part-time RTW was mentioned only by one OHS.
Another important concept which emerged was that the RTW practice should specifically be carried out as a joint process between supervisor, worker and occupational health personnel, preferably through a meeting.
Most often, the OHS invited employees on longer sick leave to visit the physician or the nurse. In many cases, the invitation was organized through the workplace, where the supervisors were supposed or recommended to refer workers on sick leave to the OHS. The length of sick leave leading to an invitation varied from 2 weeks to longer than a year, and in many cases respondents did not mention what kind of criteria they use for long-term sick leave. Two OHS used a system that made an inventory of the workers on longer sick leave four times a year. Some invited workers only in cases of serious disease or after rehabilitation. Many used the concept of surveillance, where they monitor those on sick leave and call them in based on the criteria mentioned above.
The following characteristics of OHS were related to having a RTW policy more often: less employer clients, a smaller number of employees to serve and more nurses in the OHS. The number of physicians and psychologists did not make a difference, but having several physiotherapists and occupational hygienists was more often related to RTW policies (figures not shown).
An RTW policy was more likely in OHS where the physician and nurse were involved in other OHS activities, such as workplace surveys, health check-ups, workplace surveys, workplace safety meetings and group activities, and where there was a higher number of curative care appointments with nurses. The provision of curative care by physicians did not show variation with having an RTW policy, but appointments due to workplace accidents or occupational diseases by both physician and nurse did associate with RTW policy.
OHS tended to have an RTW policy more often when there was active multiprofessional collaboration within the OHS unit in the planning of joint work in OHS, the services of client organizations and in the monitoring of the effects of interventions and when there was active collaboration in health check-ups, follow-ups of disabled workers and referrals to rehabilitation centres. We did not find a relation with RTW policy for other collaborative activities of OHS staff, such as carrying out the workplace surveys or assessment of work ability.
There was more often an RTW policy if OHS used internet and communication technology applications; for example, monitoring the health status of workers, monitoring sickness absence, follow-up of expenses, follow-up of one's own working time or for the follow-up and monitoring of the quality of services.
An RTW policy was more common among OHS which had an internal annual activity plan, when OHS could use the sickness absence data of employers for quality management and when they annually made a written OHS unit action plan.
A RTW policy was more likely if there were guidelines for detection of rehabilitation needs. In 71% of OHS units, there were jointly agreed guidelines for referrals to medical/vocational rehabilitation. If OHS collaborated more often with employers, safety organizations, private insurance companies, research institutes and educational organizations, there was also more likely to be an RTW policy.
In the final logistic regression model that adjusted for the joint influence of all important variables, the following four variables best predicted having an RTW policy in the OHS: a small number of employers served (OR 2.4 95% confidence interval 1.7–5.3), a high level of activity in group lectures by physicians (OR 3.5 95% confidence interval 1.1–11.3), frequent collaboration with employers (OR 4.7 95% confidence interval 1.5–14.6) and frequent collaboration with research institutes (OR 5.4 95% confidence interval 1.7–17.8).
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Discussion |
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We found that there was a current RTW practice after sick leave in 41% of Finnish OHS. The practice can be best described as the invitation to a health examination of workers that are on sick leave for about 6 weeks by the OHS. This is partly followed by a joint discussion of occupational physician, supervisor and employee. Work accommodation or a work trial is part of the procedure only in a minority of cases. There was also wide variation in the descriptions of the RTW practices: a smaller number of employers served, more lectures and group activities by OHPs, and better collaboration with employers and research institutes were associated with having an RTW policy in the occupational health service.
Given the importance of the RTW policy in preventing long-term disability and the high number of people on a disability benefit in Finland, the proportion of OHS that report having a RTW policy is too low. There is evidence from systematic reviews that work disability duration is significantly reduced by work accommodation offers and contact between healthcare provider and workplace, by interventions which include early contact with the worker by the workplace, ergonomic work site visits and the existence of an RTW co-ordinator [9]. Our results show that for most OHS, these interventions are still lacking in Finland.
OHS serving a large number of employers, having too few physicians who are able to become involved in workplace surveys, group activities and the provision of information in workplace safety meetings, for example, need special attention and resources.
The contents of the services offered are partly structured according to a health model, as is shown by the idea of having a health examination. They are also partly structured according to a disability model where they involve the three most important players: employee, employer and occupational physician, to jointly discuss the problem of RTW. The latter is comparable to the concept of participatory ergonomics and in line with the evidence for effectiveness of RTW interventions [10,11]. We could not find any other aspects of theories on RTW in the current practice of OHS [10]. Along other lines, Kaiser has pointed out that RTW practices can have several functions such as support, control or health promotion [12]. If the practices are not transparent and focused correctly in various situations, the activities can be more disadvantageous than beneficial. In a small minority we saw that RTW was still regarded as a form of controlling sickness absence [13].
From the factors that were associated with having RTW services, it can be deducted that putting an effort into the issue of RTW is a sign of professionalism, which apparently does not go hand-in-hand with serving many employers at the same time. In spite of generally being regarded as beneficial, part-time RTW was not legally possible until 2007, which is reflected in the answers of the respondents [14].
We found only one other study in which RTW services offered by OHS are described and analysed [15], and thus feel that this is an important step towards the development of more effective services. The regular and structured surveys of Finnish OHS enable the monitoring of the services that they offer. This provides the unique possibility of evaluating and following changes in the services. The high response rate to the survey makes the results representative of OHS in the whole of Finland and avoids selection bias, where only the best organized services would respond. Another strength of our study is that we analysed the open-ended questions with a structured qualitative approach and increased the reliability of the interpretation by using two researchers.
The limitations of our study are that the results are based on one question only. In the qualitative analysis, we had to interpret the answers of the OHS. The survey question was not put into the questionnaire based on a preconceived idea of how RTW practices should be organized. However, this can also be seen as an advantage as it left ample room for the respondents to present their ideas. Thus, in general, we feel that the answers reflect the current practice of OHS fairly well.
Baril et al. [16] conducted a more elaborate qualitative study on RTW programmes in Canada. Their study revealed different success factors for RTW programmes, such as the importance of trust, respect, communication and labour relations. Kivistö and Virtanen [17] also found that organizational mistrust between supervisor and employee has an adverse effect on mental working capacity in the critical phase after sick leave. Brown et al. conducted a survey among Scottish teachers and described their experiences with RTW services. Only 11% of those who responded to the questionnaire had access to OHS, and the figures were similarly low for those who were offered part-time RTW by their employers. Thus, in this case also, the evidence is far from being implemented in practice [18].
In practice, this means that there is a compelling need to increase and improve RTW policies in Finnish OHS. The development of a general guideline based on the latest evidence on effectiveness of RTW policies seems the best way to bridge the gap between current practice and the ideal. The results of this study offer clear ideas as to how and where to join current practice and where to stimulate the development of a new practice system. In the next survey of Finnish OHS, the implementation of the guideline can be monitored.
Further research should focus on evaluating and developing RTW practices for OHS. Most evidence that is available on the effectiveness of RTW interventions is from studies that have been carried out outside OHS [19]. It is now time to shift and evaluate real practice.
Key points
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Conflicts of interest |
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None declared.
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Acknowledgements |
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We are grateful for the help of Marja Viluksela who was responsible for carrying out the survey.
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References |
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