Background
Work is central to an individual’s health, identity, social role, and status [
1]. Long-term sickness absence is challenging for the individual, their employer, and society [
2]. Despite various targeted efforts to increase return to work (RTW), there are no conclusive results on what is an effective RTW approach [
3‐
5]. However, it has been suggested that social support, motivation, and self-efficacy play a central role in the RTW process [
6‐
8].
Planning how and when to RTW after long-term sick leave is difficult for the individual worker, and adhering to a RTW plan may also be challenging [
9]. Support and encouragement from RTW professionals, such as social insurance caseworkers and health care professionals, may empower and enable the sick-listed worker to RTW [
10]. Two important predictors for RTW are social support and self-efficacy [
11,
12]. Self-efficacy is the belief in ones’ ability to achieve a given goal or task [
13]. Support from RTW professionals may positively affect the sick-listed workers’ self-efficacy and help them achieve their RTW goals [
14]. This suggests that focusing on sick-listed workers’ self-efficacy and establishing a positive and respectful relationship between the sick-listed worker and the RTW professional may be a successful approach for improving RTW [
14].
Motivational interviewing (MI) has been suggested as a possible approach to promote these factors in a RTW process [
15]. MI is a client-centered and directive counseling method aimed to facilitate intentional and behavioral change. The method was first developed for treating alcohol abuse [
16], and it was later shown to be effective in various clinical settings and in short interventions [
17‐
20]. MI has been found to be effective by only single sessions [
21] and even in small doses of 15 min [
20], and can therefore be offered as an early low-intensity intervention. In MI, it is essential that the counselor seek to establish a collaborative partnership with the client and use communication skills to strengthen the client’s motivation for change [
16]. In Norway, the Norwegian Labor and Welfare Administration (NAV) recommends that their caseworkers apply MI when counseling sick-listed workers in the RTW process [
22]. Only a few studies have evaluated the effect of MI on RTW for sick-listed workers, and evidence of the method’s efficacy as a RTW intervention is lacking [
15,
23]. However, a recent study found that the use of MI led to more sustainable RTW compared to traditional rehabilitation for patients with musculoskeletal complaints [
24]. Moreover, a Swedish study found that unemployed long-term sick-listed individuals experienced their encounters with RTW professionals using MI as positive [
14]. These findings suggest that MI may be useful in a RTW context. However, research on how sick-listed workers experience MI counseling in a RTW context and how this affects their RTW process is lacking. Therefore, the aim of this study was to explore sick-listed workers’ experiences with MI in the RTW process.
Results
The participants had some common features, which were not related to their experiences during the MI sessions, but were instead related to their backgrounds before participating in the sessions. These participants had little or no knowledge about being on sick leave or what it entailed in terms of rights, obligations, and possibilities. Their RTW plans varied in terms of RTW strategies, the involvement of employers and helpers, the level of detail in the plan, and whether it was written down or agreed upon orally. Workplace adaptions were important when describing what could enable them to RTW, while the lack of workplace adaptions was disabling for the RTW process. The participants’ experiences of the MI sessions could be categorized into three themes: (1) relationship with the MI caseworker, (2) normalizing sick leave, and (3) adjusting RTW strategies. The first theme describes how these participants experienced their relationship with the assigned MI caseworker. The second theme is about how the participants discussed their situation as a sick-listed employee with the MI caseworker. The third theme concerns participants’ experiences of the content during the MI sessions.
Relationship with the MI caseworker
The participants had few expectations regarding the involvement of NAV in their RTW process. They expected that NAV would be absent during their RTW process, at least during the first 6 months of sick leave, and that any activity directed towards them would be about controlling their entitlement to sick-leave benefits. They also expected that NAV would be hard to reach and experienced that receiving messages or letters from NAV was insufficient in terms of motivating the sick-listed worker in their RTW process.
“Merely receiving a letter from NAV does not feel as if they take an interest in you. If NAV had more contact with people, they would be able to push people in the right direction [back to work]…” – Female (age 60)
However, when meeting the MI caseworker, their negative expectations about NAV changed. The sick-listed workers experienced a satisfying and supportive relationship with the MI caseworkers, whom they described as skilled, trustworthy, and with a kind but professional appearance.
The MI caseworkers were described as both accommodating and informative; the latter description was due to ability to provide tailored alternatives in RTW strategies for the sick-listed workers. The MI sessions were an arena where they felt acknowledged and cared for. The MI caseworkers asked questions about several aspects of their lives that could be related to their situation as a sick-listed worker, and they appeared attentive when listening. For participants, the personality of their MI caseworker appeared to be matched to their own in terms of sense of humor, expressive communication style, and personal interests. This allowed them to appreciate their relationship with the MI caseworker.
“….She was accommodating, caring and professional. Yes, I think they had chosen the right person for me there.” – Female (age 54)
Having a face-to-face encounter with a MI caseworker was emphasized as important to the sick-listed workers. Not only did they receive support from the MI caseworker, but they also appreciated the MI caseworker’s ability to enable and motivate them. Sometimes, the MI caseworker lacked expert knowledge about the participant’s type of work, but by being curious and interested in the story of the sick-listed worker, the MI caseworkers appeared to quickly comprehend their situation at work.
Normalizing sick leave
When faced with questions about the cause of their sick leave from colleagues, their employer, or NAV, the sick-listed workers had to offer a good reason or an explanation for their sick leave. The need for explaining and defending the necessity for sick leave came from the fear of being viewed as someone who did not want to work. This was even more pertinent when being sick listed due to mental disorders. It was easier to talk about and explain a physical illness that was visible to others. One participant that was on sick leave due to a mental disorder had to provide an alternative story to her colleagues.
“I told someone that I was on sick leave due to back problems, but I’m actually seeing a psychologist. It feels good to talk with someone [psychologist] and clear your head, and I need help doing that.” – Female (age 45)
Knowing that their sick leave led to higher workloads for their coworkers and extra strain on the employer caused guilt. Even when on graded sick leave, thus relieving the potential strain on both the employer and their coworkers, the guilt remained.
“It felt like I can’t leave work now, somehow, because I’ve only been here for two, two and a half hours. It felt completely wrong, I felt that it wasn’t okay, I felt guilty about it. I find it difficult to just leave work. I have to be there at least for half a day before I feel like I can go home” – Female (age 33)
In a difficult situation where participants experienced stigma and guilt, the MI sessions served as an arena for normalizing and providing legitimacy through support from the MI caseworker. The MI caseworker and the sick-listed worker talked through negative thoughts about the stigma and guilt of being sick listed. The MI caseworker explained how common these thoughts were and that the accompanying feelings were normal. Receiving support from a MI caseworker gave legitimacy to the participant’s need for sick leave, and it led to acceptance of this problematic situation. The participants could also discuss concerns about how their illness affected their relationships with their spouses, friends, and children, as well as time for leisure activities. Receiving support from the MI caseworker about all aspects of their RTW process was enabling in terms of transitioning into talking about their RTW strategies. The stigma and guilt that were experienced as barriers in the RTW process were reduced through the dialogue in the MI sessions.
Adjusting return to work (RTW) strategies
During the MI sessions, the participants received personal feedback about their RTW plan from the MI caseworker, who offered information about their rights and obligations as sick-listed workers, as well as possible future economic benefits from NAV. Since the sick-listed workers had little prior knowledge about what NAV could offer, they experienced gaining insights about available support and measures from the MI caseworker as useful and often incorporated it into their RTW plan.
… I didn’t know how to relate to it, because I had never been on sick leave before. I knew very little about NAV, you know, I had never been in contact with NAV. So, I didn’t know anything, but I got a lot of useful information from her and about what NAV has to offer.” – Male (age 57)
The individually tailored information and the support provided by the MI caseworker helped participants to reorient their perception towards workload, work tasks, and working time. The possibility of adjusting their time spent at work and the amount of work they produced was highlighted as new and important information that led to a successful change in their RTW strategy. For one participant, NAV made her aware of the possibility of being present at work full time, while still being on 50% sick leave. This enabled her to work at her own preferred pace and still produce 50% of her expected full-time workload.
“My plan was to return to work in full-capacity, but I was on 50% graded sick leave at the time, so I worked half days for a while. I didn’t know until the [MI] caseworker told me that it’s not about how many hours you are at work, it’s about how much work you produce. So now, I can be at work an extra hour a day and still have time to do my exercises as a part of my rehabilitation. I don’t have to work more, but I can spend more time on doing it.” – Female (age 52)
Another important RTW adjustment was in terms of the RTW pace. Whereas some experienced recommendations of a slower approach, others experienced that the MI caseworker endorsed a faster pace. Receiving tailored advice from the MI caseworker on their RTW pace was considered important for a successful RTW process.
“My plan was to return to work full-time three months after the operation, I thought that I would be ready for it. My [MI] caseworker thought that wasn’t such a good idea, and she suggested that I had a more cautious approach. I now realized that she was completely right, and that it probably was a good reminder for me to listen to my body and take the time I needed to return to work. Retrospectively, If I hadn’t taken it easy, I wouldn’t have handled it [RTW] and probably gotten worse.” – Female (age 47)
However, if the sick-listed worker was not in need of information or adjustments to RTW, the MI sessions were not experienced as useful. One participant experienced that the MI caseworker challenged his already mapped out RTW plan, which made him reconsider the quality of his original plan. The participants said that they could talk with the MI caseworker about what could happen if they were not able to RTW and what they could do when feeling ambivalent towards their choices during the RTW process. Discussing their ambivalence with the MI caseworker was enabling in terms of their actions towards RTW, where adjustments in RTW strategies were made to varying degrees.
Discussion
The results from the present study show that the participants experienced a good relationship with the MI caseworkers during the MI sessions. Talking with the MI caseworkers helped the participants normalize their situation as sick-listed workers, reduce the feeling of guilt, and reduce the stigma they experienced. Receiving personal feedback about their RTW plan, either to support their current plan or to reflect upon potential changes to their plan, increased their experienced RTW self-efficacy.
Previous studies have shown that sick-listed workers consider insurance officials to be distant, lacking trust, and questioning the sick-listed workers’ credibility, which may lead to powerlessness during the RTW process [
10,
33]. Positive encounters were described in a previous study [
33], where the professionals asked what the sick-listed workers wanted and where the participants were treated with respect. In the present study, the sick-listed workers described having a positive and good relationship with the MI caseworkers. This is in line with the findings from a similar study in Sweden, where sickness benefit officials offered a counseling session with unemployed long-term sick-listed workers using a MI approach [
14]. Support and encouragement from various professionals may empower and enable the sick-listed worker to RTW [
10], and by establishing a good relationship the RTW professional may help the sick-listed worker to overcome obstacles during the RTW process [
34]. Despite differences in characteristics, the sick-listed workers in the present study experienced MI as a positive intervention. This may be because the MI sessions were driven by their expressed needs, in combination with creating a good relationship. In MI, the relationship between a counselor (e.g., MI caseworker) and a client (e.g., sick-listed worker) is characterized by acceptance and empathic understanding from the counselor [
35]. Forming a good relationship with the client is one of the cornerstones of MI. Having a good relationship can elicit and strengthen the persons’ own reasons for change and their plan of action [
35]. Studies have also suggested that the relationship between a counselor and a client is important to the outcome of the treatment [
36]. From a RTW professional’s perspective, building an alliance is reported as important to facilitating RTW for sick-listed workers [
37].
In the follow-up procedure for sick leave in Norway, caseworkers at the NAV operate as both RTW professionals and as controllers of sickness benefits [
38]. This double role can be a conflicting paradox [
34] that may hinder a good relationship [
10]. In the present study, participants did not report that MI caseworkers controlled their rights to sickness benefits during the MI sessions, which indicates that this was not a barrier to forming a good relationship during the MI sessions. Having positive and supportive encounters with health care personnel and significant others (e.g., NAV caseworker) has been shown to be important in what long-term sick-listed workers experience as successful RTW processes [
39]. This is in accordance with findings in the current study, which indicates that using MI may be beneficial for a successful RTW process. Experiences from the Swedish insurance system have shown that caseworkers who are on a tight schedule might focus more on assessing the sick-listed worker’s right to receive benefits instead of focusing on their individual needs. Ståhl et al. [
40] claims that there is a distinction between a correct and a good decision, where a correct decision is made in accordance with legislation while a good decision takes into account dignity, autonomy, and individual needs. They argue that it is necessary to make exceptions to rules to make good decisions [
40]. In the spirit of MI, the counselor should be able to give up their expert role and support the client’s autonomy and expertise in his or her own decisions regarding change [
35]. Thus, applying the MI approach when counseling sick-listed workers in a RTW process could arguably be one of these good decisions.
Work is important for an individual’s self-confidence and self-esteem [
33]. In the present study, being absent from work due to sick leave led to feelings of guilt, even when being on grade sick leave. Garthwaite [
41] found that the need to validate illness was important for sick-listed workers, and the search for legitimacy was a large part of their current lives. Similar to the current study, being on sick leave included a search for legitimacy. Gaining acceptance from others about their situation can make it easier for the sick-listed worker to accept their own absence from work. This is in accordance with a previous study [
42], where the decision to disclose or not disclose an invisible illness was difficult and disclosing the illness could lead to both support and experiences of stigma. The acceptance and support that the participants received from the MI caseworkers in the present study helped them to reduce feelings of guilt, stigma, and perceived barriers to RTW. Self-understanding and viewing oneself as an active agent is necessary to taking control of ones RTW process [
39]. Similarly, in MI the client takes an active part in his or her process of change, in this case, the RTW process.
In the MI sessions in the current study, the sick-listed workers received personal feedback about their presented RTW plan, such as adjusting their RTW pace, workload, work tasks, and working time. The role of a MI practitioner is not to provide answers and solutions to the client, but to recognize and support the client’s insights and capabilities of providing solutions to his or her own challenges [
43]. Hence, when the sick-listed workers in the current study perceived RTW adjustments as positive and useful, it is based on insights and reflections from the sick-listed worker, that were elicited, reflected, and summarized by the MI caseworker. Merely discussing their situation with MI caseworkers may also result in increased awareness of the sick-listed worker’s own capacity, which, arguably, is a component of self-efficacy [
44]. Norlund et al. [
45] state that self-efficacy, the belief in ones’ ability to achieve a given goal or task, affects thought patterns that could be barriers to returning to work. Furthermore, receiving positive feedback from others may also increase the individual’s self-efficacy [
45]. In the current study, when the MI caseworker established a supportive relationship with the sick-listed worker and gave feedback to their thoughts and insights on their RTW plan, this may have strengthened the sick-listed workers self-efficacy, which is known to increase the likelihood of RTW [
11,
12].
Strengths and limitations
A strength of the current study was the use of semi-structured interviews, which allow the participants to explain and describe their situations and experiences of the MI sessions and the RTW process. This study used a broad exploratory approach with a heterogenous sample to uncover the different experiences and nuances. Both the analysis and preliminary results were presented and discussed with all the authors to strengthen the interpretations and validate the results. Interviews were conducted from 2 to 4 months after the MI sessions, and the participants may have failed to recall information and details about their experiences. Furthermore, there is a risk that the sick-listed workers could have held back information in the MI sessions if they feared there could be consequences for their benefits. However, none of the participants expressed such barriers in the interviews. The current study recruited participants from a RCT, with a response rate of approximately 8%. From this sample, the current nested study had a response rate of 55%. This indicates a selection bias, where participants could be more motivated in general, not necessarily representing the variances in the experiences of the MI sessions. Thirteen of the sixteen recruited participants were women. However, we did not find any gender differences in terms of how they experienced the MI sessions.
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