Facilitators and Barriers Return to Work in Working People with Serious Mental Illness: A Qualitative Study


 Background: Many factors affect return to work (RTW) in employees and workers (hereinafter referred to as working people) with serious mental illness (SMI). Identifying these factors can prevent long-term sick leave absence and work disability. Aim: The current study was conducted to identify facilitators and barriers RTW in working people with SMI admitted to a psychiatric hospital and clinic affiliated with the Hamadan University of Medical Sciences, Iran.Methods: A qualitative study was conducted in 2020 on 27 participants with SMI, families, supervisors, managers, and mental health team members. The participants were selected through purposive sampling. Data were collected using in-depth and semi-structured interviews. A total of 40 interviews were conducted face-to-face and fallow-up by the telephone. The interviews were based on a conventional content analysis approach.Results: Two main themes emerged, including social support and RTW's challenges. Social support consisted of four main categories: emotional support, information support, instrumental support, and supervisor's flexibility. RTW's challenges consisted of two main categories: personal obstacles and general issues.Conclusion: We found that two facilitator and barrier factors including social support and RTW's challenges affected the RTW process in working people with SMI. Identifying facilitator and barrier factors gives us comprehensive information to use in RTW programs and developing policies RTW in working people with SMI.


Introduction
Mental illnesses are also common among people who are working (1). Working people with serious mental illness (SMI) are notably susceptible to sick leave's adverse effects, work disability, losing purpose, and a higher risk of social isolation (2,3). The distance from work increases the risk of unemployment, poverty, and deteriorated mental health conditions. Moreover, all these decrease the chance of returning to work, as having a job increases one's health and social participation and improves their work quality (4).
Over the past two decades, the knowledge has increased about acquiring and maintaining a job in people with SMI. By introducing a wide range of occupational rehabilitation programs, researchers attempt to help these people nd and maintain a job. However, return to work (RTW) in working people with SMI has received less attention (4)(5)(6). Bejerhom and Areberg (2014) maintained that some people with SMI receive no RTW support program. In these cases, people with SMI tries to RTW without receiving any help (7). Through this process, they might be in uenced by their family members' decisions or concerns about discrimination or stigmatization at work. Therefore, many of them refuse to RTW despite sick leave' adverse effects (8,9) Notably, there are differences between countries in terms of labor laws, sick leave policies, and support for working people with SMI, which all affect RTW (10).
Notably, RTW is a dynamic process as a result of workers' interactions and the work environment in speci c cultural, social, and economic factors. To better understand the RTW process and the RTW program's development, we need more extensive knowledge about factors in uencing RTW. Thus, more information is required about families, workplaces, healthcare systems, and society in general (11,12).
Despite the high prevalence of mental illness in working people, there has been no speci c RTW study in Iran. As a developing country with unique cultural, social, and economic factors, Iran has its differences with developed countries. Following the international sanctions against Iran, vulnerable and debilitated groups face more challenges in accessing rehabilitation services (13). There is a lack of information about RTW in working people with SMI, and qualitative studies are more e cient in understanding factors affecting RTW (14). Besides, the knowledge obtained from qualitative studies can create new insight into the variant effects of facilitators and barriers. Such knowledge can prevent the risk of long-term sick leave and debilitation in this group of people (2). The current study was conducted to identify facilitators and barriers RTW in working people with SMI admitted to a psychiatric hospital and clinic a liated with the Hamadan University of Medical Sciences, Iran.

Design and study setting
In this qualitative study, to gain access to the participants' medical history and employment condition, the researchers visited the Farshchian Psychiatric Center (Sina) a liated with the Hamadan University of Medical Sciences, clinics of the hospital, and psychiatrists' o ces. Based on theoretical sampling, other study settings included the participants' workplaces, the Welfare Organization, the Imam Khomeini Relief Foundation, and the Iranian Society Supporting Individuals with Schizophrenia.

Participants
As a qualitative study, the participants were recruited through purposive sampling with maximum variety.
In purposive sampling, the researcher looks for participants with rich experiences about the phenomenon under study who are willing to share their experiences (15). Participants in this study were working people with SMI willing to participate in the study. One inclusion criterion was people with a de nite diagnosis of SMI based on DSM5 in their medical history. By de nition, SMI refers to mental, behavioral, or emotional disorders creating severe functional disorders that mostly intervene with one or many major life activities. Most cases in this category are schizophrenia, bipolar disorder, schizoaffective, and signi cant depression disorder (16, 17).
Other inclusion criteria were being an adult and conscious, having a job before developing SMI, being discharged from the hospital, being in the recovery phase, having a job at least 28 days continuously, and having the ability to communicate and express experiences, feelings, and reactions. Based on the International Labor Organization regulations, which are accepted in Iran, one has a job if they work for at least one hour per week in return for cash or non-cash salary (18). Individuals with alcohol and drug addiction problems or those with mental and developmental disorders were excluded.
The participants included working people with SMI (15 person) with RTW experience who entered the study using purposive sampling. Based on analyzing the study's collected data and obtaining rich information about returning to work (19), other participants, including 3 family members, 1 manager, 2 supervisors, and 6 health care team members. The participants' maximum variety was ensured in terms of age, gender, education level, type of disease, workplace, job condition, RTW length, different worker and employee groups (public and private), experiences, and SMI. After 24 interviews, data saturation was achieved, and the three last interviews yielded no new data. The demographics of the participants are listed in Table 1. Data collection and analysis The study was conducted from 9th February 2020 to 20th December 2020. The rst author (MM) with the experience of working in psychiatric department checked the participants' medical documents. The third author (AG) as an experienced psychiatrist con rmed the documents. Then, the rst author (MM) called the participants and arranged the interviews. The interviews were face-to-face as semi-structured and indepth interviews held in the rst researcher's o ce. The interviews re-read by the research team members and discussed to determine the validity of the interview guideline questions. Two interviews were conducted as a pilot initiative and guide for the questions, which were not included in the analyses.
Each interview started with an open general question. The participants were asked questions like "what caused the facility in your RTW?" and "what caused the delay in your RTW?" Also, Probes were used to encourage participants to elaborate on: " Can you please tell me more about that?"," what's your mean?", and "Can you give me an example?". Also, participants were given the opportunity at the end of the interview to add further information that was not asked them during the interview.
The researcher also took note of her observations as eld notes. Each interview lasted 30-45 min. To gain rich information, informal and telephone interviews were also conducted along with formal interviews. A total of 40 interviews were conducted with 27 participants. Interview analysis was carried out while collecting data. By emerging codes and primary concepts, more speci c and modi ed questions were added to the interview guide. Qualitative conventional content analysis was used for data analysis.
The researcher transcribed each interview based on Erlingsson & Brysiewicz's qualitative content analysis approach (20). Semantic units were determined for analyzing the interview scripts followed by open coding (live or interpretive). Three of the researchers repeated the coding process cautiously. The codes were compared and categorized based on similarities and differences to obtain subcategories. The researchers attempted to classify subcategories with the highest homogeneity into one category and to form themes by combining categories. The interviews were analyzed using MAXQD 2018. The four criteria of con rmability, dependability, trustworthiness, and credibility were used to determine data's validity and reliability (21).
In this study, the researchers' long-term engagement, maximum diversity in sample selection, appropriate interaction with participants, integration of information, and checking the data by the participants helped to increase the credibility. The reliability or consistency of the ndings was assured by writing memos as soon as possible, using peer reviews, and re-reading the entire data. Con rmability was obtained by avoiding any bias, and reaching agreement on codes and themes by all research team members. To enhance transferability of the data, the entire process of research and the work carried out along the study path were clearly and precisely written to allow others to follow the research path and the characteristics of the study population. Transferability was also assured by providing direct quotes and examples, rich explanations of data, and scienti c consultations with expert university professors. When preparing the study report, we used the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. The research team of this study includes ve researchers with backgrounds in Psychiatric Nursing, Psychiatry, and Occupational Therapy, all of whom have previous experiences of qualitative studies.

Findings
A total of 900 initial codes were extracted and categorized into 32 subcategories and six categories. Eventually, two main themes of social support and RTW's challenges were revealed (Table 2). The participants mentioned that they received support from families, friends, and co-workers. For instance, parents would lower tension among family members and create a more peaceful environment for people with SMI. Moreover, spouses would motivate people with SMI to RTW by giving hope and coping with the patients' low spiritual condition. A working participant said: "…My mother says that I should RTW; she says that I forget about the mental illness when I am talking to others; she tries to motivate me…" (P.3). In addition to the families, co-workers and friends can also be supportive. One of the working participants added: "…My co-workers knew about my mental illness and would try to help me by telling me to control myself, forget about the troubles, and things like that…" (P1).

Category 1.2: Informational support
This category re ected the support that family members, supervisors, and psychiatrists would advise working people with SMI to decide RTW. For instance, one of the participants' spouses advises her husband on how to talk to his supervisor to convince him to RTW. One of the participants' supervisors talked about her recommendations, "… That nurse called me (supervisor) after her recovery and said that he did not want to come to work… but she wanted to keep her work. I said if you do not have a shift, the nurse manager will consider absenteeism. He asked me for helping. I told him to send me her sick leave documents and I will show them to the nurse manager…" (P19). Also, the participants noted that they would consult their psychiatrist about RTW and the psychiatrist usually talks about occupational stresses and that they should decrease the workload.

Category 1.3: Instrumental support
A major part of social support was in the instrumental support category. Financial support by family members or taking a loan from the Welfare Organization was notable. Self-employed people usually need nancial support to RTW. For instance, one of the participants' mother who had a supermarket noted: "… my boy used to work with his father, and after the mental illness, we helped him to open a new store. He also asked for a loan of Rls.100.000.000 from Imam Khomeini Relief Foundation…" (P18). Another type of instrumental support was the assistance offered to working people with SMI by co-workers and supervisors. A supervisor may help working people with SMI maintain their jobs during sick leave, or coworkers might undertake their co-worker's tasks during their absence. Moreover, psychiatrists also help these individuals by issuing health or sick leave certi cates. Some of the participants mentioned that having their relatives at work facilitated their RTW. For instance, they lobbied with the supervisor to facilitate the RTW of their relatives and the supervisor usually accepted their request. One of the participants' supervisors stated: "His psychologists (P6-nurse) strongly supported him using his position in the organization. He called me frequently and asked us to let him back… I could not say No…" (P20).
Healthcare teams, organizations, and the government support the RTW of people with SMI by improving the public culture about mental illness and alleviating the stigma. For instance, a psychiatrist explains that educational programs should be developed to change the attitudes of family members, especially spouses, toward people with SMI to reduce the stigma of mental illness. Healthcare systems and organizations should provide such educations. The government has also approved regulations for supporting people with SMI. These regulations extend premium exception for employers who recruit people with SMI. About SMI employees, an organization manager stated: "… An order has come from the ministry and in it, managers are asked to support SMI employees … therefore, I have recruited a psychologist to help these employees…" (P22).

Category 1.4: Supervisor's exibility
The supervisor's exibility was another social support for the participants that facilitated their RTW. A group of working participants expected to RTW after proving that they regained their mental health. Some working participants' characteristics made the supervisor accept such requests, such as long work history, a positive work record, and awareness about the participants' poor living conditions. These considerations convince supervisors to accept RTW requests, adjust the work schedule, and prepare a suitable mental condition for working. One of the participants added: "…after recovery, I asked the supervisor for RTW… given my long and positive work record, my request was accepted and I back to work as a substitution teacher to ll the places of those who miss a class. I also receive the full salary, despite less work and a better work condition… I spend most of my time at home…" (P5).
Theme 2: RTW's challenges RTW's challenges were another factor experienced by the participants in the RTW process. This theme included two categories of personal obstacles and public issues.

Category 2.1: Personal obstacles
Some of the participants mentioned that they faced personal obstacles in the RTW process, which restricted or delayed their RTW. One of the participants explained that while preparing to RTW, he was still feeling the symptoms. "… As military personnel, I have to RTW after sick leave period; however, I do not feel that I like it…, it is a real bore" (P4).
Some of the participants noted that they had particular characteristics that were not suitable for work. For instance, they were not that mind sharp at work, preferred isolation, were shy, preferred seclusion, and did similar things. These characteristics affected their chance of RTW and delayed it. Some of the participants were continuously worried that the employer might nd out about their mental problems. They felt worried about whether they were capable enough to do their tasks at work, and that they may be blamed by their employers if they did not have enough ability; these concerns decreased their selfcon dence. They were also worried about preserving their mental health at work including the fear of recurrence of the mental disease at work, inability to control the residual symptoms of the disease, and the medication side effects. All these experiences and many other factors created a dark image of RTW in their mind, causing them to lose motivation to RTW. One of the participants explained, "… the Previous failure sometimes makes one not feel like going back to work …" (P11).

Category 2.2: Public issues
Like other society members, the participants had their general and more prominent public or social problems. As a result, they may become hesitant to RTW and delay it. While some of the participants received nancial support from their families and the Welfare Organization, some others struggled with nancial problems while attempting to RTW. Furthermore, the country's poor economic condition due to sanctions and the COVID-19 pandemic intensi ed such nancial problems. One of the working participants' spouses explained: "…My husband can handle the work, but nancial problems do not allow him to work fulltime. When the US dollar price surges high suddenly, he cannot supply the materials he needs for work. Therefore, he cannot accept orders as much because he cannot supply the material…." (p16).
The participants also had social problems that restricted their RTW. For instance, some organizations had negative attitudes toward working people with SMI or could not decrease the workload due to inadequate workforce. Moreover, the Welfare Organization had its limitations and complained about the lack of adequate public funding or the large number of applicants. It claimed that it could not cover all applicants, which made applicants dissatis ed. There were also extensive bureaucratic structures like bank regulations that prevented an easy and smooth RTW. One of the participants added: "… I went to Welfare Org. after recovery, but they had closed their workshop because of COVID-19 and there was no job for me. I applied for a loan to buy a small carpet workshop. They referred me to a bank, and the bank told me that I need an o cially employed public worker as guarantor. I have nobody for this and I do not know what to do…" (P10).
We designed a conceptual model to clarify the obtained themes, categories, and subcategories (Fig. 1).

Discussion
The current study was conducted to determine facilitators and barriers RTW in working people with SMI admitted to a psychiatric hospital and clinic a liated with the Hamadan University of Medical Sciences, Iran. As the ndings showed, two facilitator and barrier factors, namely "social support" and "RTW's challenges," affected RTW in working people with SMI. The ndings showed that two factors affected working people with SMI at different levels, including personal, family, work, and society levels. Some of these factors were supportive and facilitating factors, while others created challenges to RTW. In line with this study's results, Habtamu et al. (2015) showed that a broad factors including a range of clinical symptoms and non-clinical symptom factors (e.g., supportive factors and socioeconomic conditions of society) affected RTW in working people with SMI (22).
In the present study, facilitator's factors in uencing RTW in working people with SMI included the support they received from families, friends, co-workers, and supervisors. However, the emotional support and encouragement of working people alone are not enough. They need to receive guidance, advice, and recommendations to RTW, and most importantly, all people related to them need to help practically. Dunn et al. showed that workers with SMI needed at least one supporter to RTW, given that the mental illness lowered their performance at work. Employers, co-workers, families, and mental health team members are not the same for all working people. However, these supports create hope and motivation in working people with SMI to improve their skills, self-con dence, and capabilities to nd jobs suitable for them. When working people with SMI demonstrate that they are eager to work, they prepare the context for receiving supports (23).
This study showed that RTW in the participants was not straightforward and linear; employers and managers and, in general, the public did not want working people with SMI back to work, even if they expressed willingness to RTW. The path, in practice, was full of challenges, including personal and public troubles. Personal troubles were related to the participants' conditions in their environment, while public issues affected the whole society, and not only the working participants.
Ebueny et al. explained that people with mental illnesses dealt with challenges affected by many factors. These factors are in constant ux and dynamic interaction with each other. Depending on positive or negative factors in the local environment, people with SMI might be able to RTW and maintain their job (24). Some of them able to RTW might experience social supports in their path. In contrast, others might face in exible supervisors, the lack of coordination in organizations, and unclear laws. There is an ambiguity in regulations and supportive attitudes so that not all stakeholders have identical performance to support workers and workers themselves need to deal with challenges (25). Evidence has shown that people with SMI, especially in countries with low-and moderate-income levels, deal with broad and multiaspect political, economic, social, and cultural limitations. Negative reactions and exaggerated fears in families, supervisors, co-workers, and society about mental illnesses create agony for people with such diseases and trouble society. Since society is forced to give up on these workforces' bene ts, this highlights the necessity of social support and cultural works for people with SMI at different individual, family, work, and society levels. People with SMI need a combination of supportive factors (22,(26)(27)(28).
A few limitations are notable in this study. This qualitative study was carried out based on available samples, as the transferability of ideas was more critical than their generalizability. The highest diversity in the demographics and RTW length was ensured to widen factors' variation. Moreover, supplementary interviews were conducted with families, employers, and mental health team members. Despite the limitations, the study developed a background for further studies by identifying fundamental factors. As a result, the study prepared the background for interventions to improve the RTW process in people with SMI.

Conclusion
We found that two facilitator and barrier factors including social support and RTW's challenges affected the RTW process in working people with SMI. Social support proceeded RTW, while RTW's challenges restricted or delayed RTW in working people with SMI. Identifying facilitators and barriers gives us comprehensive information to use in RTW programs and developing policies RTW in working people with SMI.

Declarations Ethics approval and consent to participate
The study is part of a more comprehensive study for a Psychiatric Nursing Ph.D. dissertation approved by the Ethics Committee and Research Council of Technology and Technology, the Hamadan University of Medical Sciences (IR.UMSHA.REC.1399.504). All methods were carried out following the institutional guidelines and regulations and conforming to the ethical standards of the declaration of Helsinki. All the participants were informed about the study's objectives and stages. Participation was entirely voluntary.
The participant signed an informed consent form for audio recording the interviews. The participants could leave at any stage of the study.

Consent for publication
Not applicable in this study.
Availability of data and materials