This study highlights how individuals with chronic WAD struggle to return to work, and reflects some of the sadness the participants expressed over a changed self-image and work role. The participants were motivated to work and had developed a range of strategies to handle work demands. They related that having emotional and practical support from managers, co-workers, family, health care professionals and others was important; however, their experiences of support varied. Participating in a neck-specific exercise programme, and thus being acknowledged and receiving information about WAD, positively impacted their work ability. These findings will be further discussed in relation to the developmental and dynamic process of return to work [26] and the holistic model of work ability [27].
The focus of this study was on work ability and the work situation from the perspective of individuals with chronic WAD. As suggested in the developmental process of return to work, workers pass through a series of phases when returning to work, including the experience of injury or chronic illness, being off work, and re-entering work, as well as maintenance of work ability and advancement at work [26]. The participants in this study described a bumpy and uphill road to return to work, which included setbacks and going on/off work. This supports the model that workers move non-linearly between the mentioned phases [26]. The findings underscore that individuals with chronic WAD need to feel understood and acknowledged by their managers, colleagues, family, health care providers and other stakeholders during this process. According to previous studies, this bumpy road may be explained by different strategies to cope with fluctuations in symptoms, but also by poor self-efficacy [28], a mismatch between stakeholder expectations [29, 30] and/or insufficient support from health care [17, 19, 31], the SIA [17, 19] or employer [32, 33]. Our findings show how the support for return to work for individuals with chronic WAD can be strengthened.
As anticipated from the work ability model, a balance between the individual’s human resources (their health and functional capacities, competence, values, attitudes, and motivation) and work (demands and content of work, work environment, community, and management) is crucial [27]. A poor balance between human resources and work decreases the person’s work ability. In addition, the balance is also affected by the environment outside of work, such as family and the close community [27]. The narratives from the participants in this study support that health and functional capacity are an important dimension affecting (though not altogether determining) work ability. Participating in a neck-specific exercise programme could mean receiving a tool for managing symptoms at work, being able to perform work tasks more efficiently and working more hours.
These results are in line with previous findings from quantitative data on symptom reduction [34] and work ability [14] after neck-specific exercises. In contrast to previous experiences with health care providers, the participants in our study also described feeling understood and acknowledged by the physiotherapists involved in the study. This meant that their injury was “legitimized”; they received information and a treatment plan; and the exercises reduced their symptoms. This type of acknowledgement may be related to the term “validation”. As suggested by Linton [35], validation in pain communication functions to soothe negative affect by acknowledging the patient’s experience and thereby increasing disclosure to promote problem solving and shared decision making. The importance of being understood by health care professionals [15], and of receiving information and support to understand and cope with one’s situation, has previously been highlighted in qualitative studies in individuals with WAD [13, 16, 17, 19]. Feeling believed and getting validation of the whiplash injury is considered a necessary step in the recovery process [17], with implications for return to work as suggested by the findings in this study. According to a previous meta-analysis, better management strategies to support return to work and daily life in general are needed for individuals with WAD [18]. Our findings suggest that, with better health care support, including validation, information, and an individually tailored, neck-specific exercise programme and treatment plan, individuals with WAD can be empowered and their return to work can be less difficult.
Human resources, as mentioned above, consist also of a person’s inner values and attitudes as well as factors that motivate them in their working life [27, 36]. A wish to participate in working life has previously been described by individuals with WAD [19, 31]. In this study, the participants all expressed a strong motivation to work. Work was an important part of their identity and they put a lot of effort into maintaining their working life. They described balancing between different strategies to handle work demands using active and passive coping strategies to handle their symptoms. This pattern is in accordance with other studies on patients with WAD [31], emphasizing the need to unravel self-efficacy beliefs, emotions, coping strategies, as well as expectations to better support individuals with WAD in the process of returning to work [18].
The aforementioned model of work ability suggests that, within the dimensions of work, management and leadership have the strongest effect on work ability. Managers are suggested to play a key role in influencing the balance between the resources of the individual and work by organizing the work according to the requirements and capabilities of the individual [36]. Sustainable return to work after musculoskeletal disorders and common mental disorders is influenced by an interplay of multiple factors, among which the most consistent evidence was found for support from leaders and co-workers [33]. The importance of emotional and practical support, in terms of timely work adjustments and ergonomics, from the manager was highly emphasized in the interviews as contributing to participants’ ability to work, as was also the importance of being part of a working environment with occupational health services, a good psychosocial climate, and co-worker support. However, not everyone was given this support. These findings highlight the importance of strengthening a supportive communication between the manager, co-workers and the individual during the return to work process.
Setting return to work as a priority in the rehabilitation of individuals with WAD is strongly recommended in the literature [37]. As acknowledged in the model of work ability [27], in previous research [10, 37, 38] as well as in this study, symptom reduction is important but it is not a prerequisite for work ability and successful work integration. Rather, work ability is affected by the balance between the individual’s resources and work as well as the environment outside of work. This study has provided management strategies to support the ability to work for individuals with chronic WAD, and suggestions on how to incorporate a healthy and sustainable return to work in the rehabilitation of individuals with WAD, thereby helping to make the process smoother.
Methodological considerations
This study has some strengths and limitations, which need to be considered when interpreting the results. Credibility was demonstrated by the fact that the research team had good scientific knowledge and clinical experience of treating patients with WAD, and of sick leave and return to work, as well as previous experience in conducting qualitative studies. The interview guide was pilot-tested, which further strengthens credibility. The sample size was guided by information power [25]. A recruitment of 15–20 participants was planned, and during the research process a sample of 17 participants were deemed to be sufficiently large and varied to elucidate the aim of the study and contribute to new knowledge. We included more women than men, which is consistent with the gender distribution in chronic WAD [2]. The data were systematically analysed using conventional content analysis and keeping the analysis close to the text [22]. To strengthen confirmability, the entire research team held consensus discussions throughout the analysis process, and the findings, including supporting quotations, were approved by the research team.
The researchers are all physiotherapists and all are women. We have been aware of our perspectives during the data collection and analysis, and have strived to correctly convey the participants’ perspectives in the results. The checklist for reporting of qualitative studies [39] was used to improve transferability. The findings from this study may serve as a starting point for further research on strategies to support the return to work process among individuals with WAD from the perspective of the individual, workplace and health care provider.