We found that RTW coordinators described their roles in the return-to-work process in four broad categories, as: trustworthy, experts, detectives, and assessors of worker motivation. For each role, we considered the position of RTWCs within their organizations, and the implications of their discourse with regards to the worker. We describe how RTWC’s perspectives of their roles are important because they impact the RTW process and workers.
RTWCs as Trustworthy
RTWCs in our study often spoke about the importance of developing supportive relationships with workers. We found this reflected a discourse of trust, with RTWCs identifying their position as meriting workers’ trust. As noted by one WCB RTW coordinator, “…building some rapport and trust is pretty critical” (Kim). Some RTWCs described their role as easier when trust was established and workers shared information with them:
“...information helps us to help you when you’re ready to go back to work... we do normally start out with getting that medical information from the doctor. If we don’t have it from the doctor, most people are pretty open to telling us what their medical condition is.” (Erin, Insurance company)
A challenge for RTWCs was that not all workers were willing to share confidential information. A RTW Coordinator who worked for a WCB noted that a worker’s professional background could impact their willingness to communicate openly:
“I find that in certain professions, there’s a higher resistance to [sharing confidential information]. So, say for example more of the alpha-based types of occupations like the police officers, they really don’t want to share that much because of the extent of stigma” (Rachelle, WCB).
Other RTWCs described workers as being less open when sensitive health issues were at stake:
“I mean, they’re sensitive cases … people tend to be very guarded and protective, as they should be, and then they come to the table, and they’ve also had significant trauma, so they have trust issues” (Meghan, WCB).
“There’s a fear about too much information being shared … being viewed as a broken toy… being viewed as damaged” (Shanice, WCB).
While some RTW coordinators seemed to recognize how institutional and social forces factored into workers’ openness and willingness to share, they still placed the onus on the individual worker to do so. RTWCs saw themselves as trustworthy professionals looking to assist in the RTW process and they saw workers sharing health information as facilitating a timely and smooth RTW process.
The question arises, how much the judgement of RTW Coordinators be trusted given that their motivations may not inherently align with workers. Despite the RTWC stance that they are a professional, neutral party in the RTW process, they also had their job to do and they were held to the expectations of their employers. For instance, a RTWC embedded within a work organization described how her manager kept tabs on cases to ensure that coordinators were applying sufficient effort to get workers back to their jobs in a timely manner:
“There definitely are pressures (laughs) for sure, from upper management … A manager may say, ‘Look, they’ve been off for six months, but they don’t have the medical.’” (Kelsey, work organisation)
RTWCs in our study acknowledged that trusting them may be challenging for some workers; however, with few exceptions the coordinators still expected workers to share and be open with them.
Return to Work Coordinators as Experts
Coordinators exercise judgement and discretion in RTW processes [14] as they navigate complex situations, communications and negotiations between stakeholders, including workers [7, 10, 15]. The challenge is: how is RTWC discretion applied in practice and how are decisions made when multiple options are possible? In our study, RTWCs described having to make many decisions about workers RTW trajectories (e.g. duration of work absence) using a variety of input (e.g. doctors’ advice, worker’s needs, workplace accommodations offered).
Although RTWC’s emphasized the importance of getting input from the worker about accommodations, they were situated as experienced experts who were able to discriminate between workers’ actual needs and worker ‘preferences’. This had important implications for how they supported workers.
In the following example, a RTWC explicitly described worker input as an important starting point important for considering the RTW process, but that this input did not necessarily determine the final job accommodation arrangements:
“Right, I mean, sometimes the employee’s already told us, ‘I need this, and I can’t do this’, …. Definitely – I see it as a reference and a guiding point, and an important one at that. … I find it helpful to address it like, ‘I know you were asking for this, but you know what, I think we have a different option, and it’s this’.” (Fanny, work organization).
In the above situation, a worker’s expressed needs were regarded as a “reference” by the RTWC and not necessarily as something to be prioritized. RTWCs in this study appeared to position themselves as the party that ultimately determined what constituted a legitimate worker need during their recovery and RTW process. Despite their varied backgrounds, RTWCs described themselves as having the expertise and ability to demarcate the appropriate parameters for the RTW situation. However, their stance in interviews suggested that their practice could also invalidate the worker perspective. For instance, in the example below a RTWC made a distinction between what a worker “may want” versus what the insurance company recommended. While the RTWC mentioned that he could accommodate a worker’s preferences for a meeting he was clear to distinguish this from the needs that the insurance company deemed necessary:
“The person is just coming back, just wants to know what day one, day two, day three, what that’ll look like for them. And for some reason sometimes they want a meeting for that. We can still make that happen, as well, but from our perspective, we only recommend it when we identify a need” (Ian, insurance company).
While RTWCs acknowledged the importance of determining workers’ needs, some also explained that workers were sometimes unable to distinguish between what they wanted and what they required:
“…we seek the employee’s feedback on things that they think that might helpful because they are the one that has to work, and they are the centrepiece of it … There are times that people indicate what they would like rather than what they need, and, of course, where possible, we’ll provide both. But we have to make sure that what they need is the priority” (Fanny, work organization).
Some coordinators also saw their role as adjusting workers’ expectations about the return-to-work process and work accommodations. For example, a coordinator with a workers compensation board described threatening workers with cessation of benefits if they do not accept the modified work offered:
“Maybe the worker doesn’t like the modified work that is being offered to them. … the expectation on my part is that you take it and usually that’s sufficient. If they push back further then I would say, “Okay, just so you are aware– if you decline this safe suitable work your case manager may adjust your benefits”. Like, we’re not going to pay you to not take this work because you don’t like it” (Jesse, WCB).
In another example, a RTWC suggested that doctors misguide workers regarding their work ability. In this case, the RTWC discounted the expertise of the treating healthcare professional and positioned herself as the expert, over-riding the physician’s recommendation for an extended absence period:
“In general, I would say the biggest challenge is trying to get the employees to be open about what they think they can and cannot do at work. They tend to sort of, you know, hear their doctor say ‘You’ll be off work for eight weeks’, and then, you know, that’s in their mind” (Erin, Insurance company).
In all, RTW Coordinators in our study saw themselves as experts who could determine an appropriate RTW plan. While they spoke of the importance of developing rapport and establishing trust to enable a timely RTW, this relationship appeared to primarily benefit the coordinator in their role. Although getting worker input was highlighted by coordinators as central, this was only one source of input. In some cases when this conflicted with business interests, RTWCs framed workers as misinformed or having unrealistic expectations in which case, their expertise superseded.
RTW Coordinator as Detectives
RTWCs also viewed their role as involving investigation. In these instances, RTWCs described the need to manage workers who they characterized as possibly attempting to take advantage of the RTW system. Some RTWCs described scrutinizing details about the workers’ activities, claim history, and medical evidence. Some also viewed their role as judging if a worker’s case for work absence was legitimate based on the information they had gathered. In some instances, RTWCs described concerns that workers may be manipulating the work absence or workers’ compensation system, by feigning or exaggerating illness or symptoms. For example, a RTWC characterized some workers’ propensity to exaggerate, stating that medical information sometimes did not “…match the severity of what the employee is telling us” (Cassandra, Insurance company). Another said workers sometimes magnified their symptoms or might “…discount the level of progress they are experiencing” (Kumar, Insurance company) in an attempt to postpone RTW.
Arbitrary diagnoses were another strategy described by RTWCs to suggest that some workers medicalized their desire to be off work. In one case, a RTWC differentiated between illegitimate claims and “true depression” and suggested insufficient or ambiguous medical evidence and a lack of specialist involvement were signs that a worker just wanted to be off work or was avoiding workplace issues. The RTWC was concerned about workers making a conscious choice to take advantage of an organisation’s sickness policies, which he explains as “secondary gains”:
“When they can get a benefit – stay off work and get a benefit, especially if it’s a high benefit, and they want to look after their kids, or they want to get extended vacation out of country- because we look at the attendance management side of things, and we see patterns emerge. But they’ll always go off for depression because it’s hard to manage, right? But then you correlate that with other pieces of information, like their attendance, the patterns of absences, lack of medical information, still doing their activities of daily living. So, this is … what I mean by secondary gain – that there’s a monetary gain to be had. (Cory, work organization)
Another RTWC spoke of workers seeking “secondary gains”, referring to these workers as “outliers” but regularly present: “I mean, there’s always going to be the outliers and people that may have secondary gains in mind” (Teresa, 3rd party).
A final example of RTWCs as detectives related to workers improperly requesting sickness absence following a negative performance review. For example, the RTWC below highlighted the potential for workers experiencing performance issues to claim that the criticism from their employer was detrimental to their mental health:
“If someone’s maybe getting constructive feedback, or a performance review where they’re not meeting expectations in a role. That’s now being twisted in, ‘Well, you know, because I’m not doing my job, this is impacting my mental health, and my employer’s not being caring or considerate, and they have no consideration for my mental health. Look what they’re doing to me.’ And that’s really not sort of the spirit and the purpose of trying to be more aware of mental health issues, in general, and how we can be supportive of people who have mental health issues.” (Frances, WCB)
In all, RTWCs considered one of their roles as assessing the legitimacy of workers entitlement to benefits. Although the coordinators saw some workers as warranting benefits and RTW support, they also sometimes framed workers as engaging in fraudulent behavior. However, in doing so, they may be overlooking the complicated and personal psychological aspects involved in taking the steps to seek workplace absence due to illness or injury. RTW coordinators used phrases such as “in denial” and “lack of engagement” to describe what they considered uncooperative workers; yet these descriptions also miss recognition of the potential that these perceived behaviors are directly related to a medical condition.
RTWCs as managing motivation
For RTWCs in this study, the ideal worker had an appropriate high level of motivation to RTW. Worker attitude and work enjoyment were seen as important components of motivation to RTW:
“...the big one that it really comes down to is motivation on the part of the employee and their attitudes towards things like return to work, also working in general. So 90 per cent of the people you work with, they want to go back to work and they have a healthy attitude about return to work, even if they’re not fully recovered and also you know, they enjoy their work, they have no issues with the work” (Kumar, Insurance company).
Many RTWCs associated motivation with workers ultimately wanting to be at work and consequently, actively engaged in the RTW process. For instance, one RTW Coordinator admiringly described workers who were “self-starters” and “pushing for” recovery:
“The people who generally come back to work are motivated and kind of self-starters, and they’re the ones that are kind of pushing for it” (Frances, WCB).
However, being overly motivated was problematic. RTWCs described struggling with some workers, such as highly motivated senior executives, who could endanger their health by returning to work too early:
“When we get a senior executive that has a cardiac event, and they want to go back to work the next week… and we’re like, ‘No …you need to take this time to get well… you need to make this your job’ ” (Amelia, 3rd party).
While RTWCs described motivation as willing participation in the RTW process, they also suggested that it could be problematic if the worker was too motivated. That is, workers should be motivated to follow the guidance of the RTWC but they should not exceed a participation level as it could complicate the guidance or authority of the RTWC. Interestingly, the timing of work return was described as under worker control, or a conscious choice for workers:
“Like … we have some people who are very motivated, and say, ‘I don’t want to stay home’, and they want to return to their regular life; versus some employees who don’t want to really come back that fast.” (Mary, 3rd party)
Most RTWCs in our study routinely described having to struggle with only a minority of workers who did not want to return to work; they saw most workers as wanting to go back to “their regular life”. However, those few under-motivated workers were problematic. One RTWC decried workers’ “lack of urgency” in returning to work:
“...dealing with contentious claims where there’s no participation on the side of the worker. There’s no sense of urgency on their part to mitigate their loss by participating in the process” (Cory, work organization).
Similarly, coordinating under-motivated workers was described as “pulling teeth”:
“Some it’s like pulling teeth you know, you can’t get, can’t get anything out of them [the worker]. So you are sending them a narrative to take to their care provider to get the answers that you need, because they don’t want to communicate with you” (Olivia, work organization)
One RTWC described insufficiently motivated workers as “...dragging that horse in the desert to drink water but it just doesn’t want to drink” (William, work organization).
In all, motivation was an important topic for RTWCs. Their jobs were easiest to manage if workers had enough motivation to be “self-starters”; however, returning too early was also inadvisable as it could lead to further illness or injury.