Returning to work (RTW) after a leave of absence involves the cooperation of a variety of stakeholders beyond the worker and their employer, including health care and insurance professionals, human resources personnel, and sometimes union representatives. These voices must reach an agreement on a multitude of issues, ranging from the appropriate timing of RTW to workplace accommodations to modified responsibilities. According to the US Bureau of Labor Statistics (U.S. Bureau of Labor Statistics, 2020), workers with chronic illnesses report both their need for accommodations and a general lack of understanding about disabilities in their organization as significant barriers to sustaining their employment. On a larger scale, 45% of workers in Canada with disabilities felt the need to return to work earlier than they planned because of the pressure exerted by their employer (Benefits Canada, 2019), which may in turn decrease the sustainability of RTW over the long term Basak S., (2021).

Across conditions studied in a variety of industries and populations, additional barriers to sustainable RTW include pain severity, depression, and activity limitations (Cancelliere et al., 2016). Factors that appear to support long-term RTW include greater efforts to coordinate the process effectively, as well as multidisciplinary interventions that involve the workplace and external stakeholders.  

Aims of the Study

Workplace disability research has examined the existing structures within leaves and RTW, as well as the relationships between stakeholders involved along the way. However, less attention has been paid to the sustainability of RTW for all parties involved. How are workers with disabilities and their employers managing in the longer term? What makes sustaining RTW feasible, and what are the challenges? To address these questions, we must also consider how workplace leave differs by disability type. The present study assesses gaps and barriers in sustaining work re-engagement, with the hope that this will drive the development of improved resources for everyone involved in the RTW process. In addition, considering both industry and disability-specific contexts will help ensure that new interventions are created with the capacities and constraints of each workplace in mind. 

As suggested by the Accessibility for Ontarians with Disabilities Act (AODA) (Kovac et al., 2020), this study will consider disability as an umbrella term – covering any physical limitations (including chronic disease), mental health, learning, cognitive and intellectual developmental disabilities, environmental sensitivities, vision and hearing impairment, substance addictions and workplace injuries. In the context of the workplace, a disability may best be thought of in terms of its impact on a workers ability to perform job tasks in both the short and long term. Operationalizing the definition in this way invites a variety of different perspectives to the conversation, from those experiencing acute physical injuries to those with episodic and invisible conditions.

C. Stockdale, K. Karoli, J. Goyal, and F. OHagen declare that they have no conflict of interest to disclose, financial or non-financial.

To address these research aims, we conducted focus groups with management/HR personnel (i.e., people who are involved in an RTW) as well as interviews with researchers/practitioners (i.e., researchers who study the field of workplace and disability and practitioners who help with RTWs) and employees (i.e., people with lived experience of returning to work after a leave of absence due to disability). Recruitment methods for each sample are discussed in each of the following subsections. Once screened, all participants were given a letter of information about the study to sign, which served as a consent form. Participants were informed that the session would take between 60 and 90 minutes (focus groups) and 30 and 60 minutes (interviews). Sessions were conducted over Zoom or Microsoft Teams. Following their interview, participants were given an honorarium in the form of a $50 e-gift card of their choosing. Transcripts of the focus groups and interviews were generated with Zoom and Microsoft Teams, edited by a research assistant, and uploaded to NVivo for qualitative coding. This was done through a thematic analysis, described by Braun and Clarke, (2006). Details of the methods used for each of the study arms are discussed below. 

Focus Group Methods

Management and HR personnel were invited to participate in focus group sessions and were screened for eligibility, where the following inclusion and exclusion criteria formed the basis of our sample: 

Inclusion 

1. Direct experience supporting workers 
2. Direct experience supporting workplace parties who develop or administer programs, policies, and procedures for supporting workers 

Exclusion

Individuals without current experience in RTW and supporting workers, directly or indirectly. In the focus groups, the following questions served as a guide for the conversation:

1. What do you see as the major challenges to workers staying in the workplace following RTW from a physical or mental health problem?
2. What would help to support your efforts in helping workers sustain employment?
3. How would these supports be best incorporated into your organization?

Interview Methods

Researcher/practitioner and employee participants were invited to participate in private interviews. Researchers and practitioners were primarily identified and recruited through professional networking relationships of one of the research team members (FO) and the network and community of the Work Wellness Institute. Specifically, we contacted individuals in these professional networks and communities who could be considered potential participants for the study or who could help in recruiting potential participants (i.e., snowball sampling). Meanwhile, employee participants were recruited through social media posts (i.e., LinkedIn, Facebook, Instagram, and Twitter) and an institutional newsletter. All interview participants were screened for eligibility, and the following inclusion and exclusion criteria formed the basis of our sample: 

Inclusion 

1. Involved in the development of resources to help workers RTW following sick leave or the onset of episodic disability or their use (researchers and practitioners) or
2. Have experienced sick leave and returned to work (person with lived experience). Through open-ended qualitative interviews, we asked participants to broadly reflect on the following questions related to their RTW experience. 

Researchers and Practitioners

1. What are the current challenges faced by employers in supporting sustainable work for workers affected by disabilities?
2. Are there different challenges in different sectors? Among workplaces of different sizes? For different conditions? For different actors in the workplace?
3. What are the challenges and opportunities in developing resources to support workplaces?
4. What are the challenges in implementing resources to support the workplace?
5. What are the barriers to access for employers to such resources?
6. What resources are you aware of and or have accessed that are designed to support sustainability for workers affected by disabilities? 
7. How adequate are these resources? Where are there gaps?
8. What role would/should the curation of resources play? 
9. What makes for a high-quality resource? 
10. How do you judge the quality of resources? 
11. Are you aware of any quality assessment protocols for such resources?
12. Where do you see the field going/progressing?

Individuals with Lived Experience

1. What challenges did/have you faced in staying at work? 
2. What was helpful for you in remaining at work? 
3. What would you recommend to employers to support sustainable work for their employees?

Theoretical Domains Framework Mapping

During the analysis of both the interviews and the focus groups, the Theoretical Domains Framework (TDF) (Atkins et al., 2017) was employed to map the results thematically. The TDF is an implementation research tool that helps identify barriers and facilitators in programs and resources. Although most frequently used within healthcare, the framework has been adopted across research sectors and has even been used to detect patterns in scoping and systematic reviews  (Lindsay et al., 2018). The TDF is comprised of the following 14 domains: behavior regulation, beliefs about capacity, beliefs about consequences, emotion, environment, goals, intention, knowledge, memory, attention & decision processes, optimism, reinforcement, skills, social influence, and social & professional role. The adoption of these specific domains is founded on over 30 theories of behavior and behavior change. The present study identified the TDF as a useful tool to define gaps from a variety of perspectives and to make meaningful comparisons.

Three focus groups were held with one to four people in each. In the focus group with one person, more participants were scheduled to join but were lost to attrition. In total, 7 people participated (n=7). Focus groups ranged in length from approximately 30 to 80 minutes. In total, 6 interviews were conducted with researchers and practitioners, and 11 interviews were conducted with individuals with lived experience, for a total interview sample size of n = 17. The interviews ranged from 16 minutes to 90 minutes. When mapped to the TDF, some findings overlapped across participant groups, and others diverged. Often, the facilitators and barriers were different sides of the same coin; the lack of a facilitator was viewed as a barrier. Thus, facilitators and barriers to sustained RTW are presented together as overarching themes. Fig. 1 illustrates the major themes, along with their convergence and divergence across participant groups.

Fig. 1: Theoretical Domains Framework across Study Arms. Chart representing the pattern of TDF domains across the study arms: focus groups, interviews with researchers and practitioners, and interviews with workers with lived experience. Each theme will be described in detail and with context in the following subsections.

Environmental Context and Resources

All groups noted how the Environmental Context and Resources play a role in supporting a sustained RTW. The majority in each group described how work culture was viewed as either a barrier or facilitator to sustained RTW, depending on whether it was a supportive (i.e., positive) or unsupportive (i.e., negative) environment. Examples across all groups included descriptions of having a flexible work environment where workload or hours could be adjusted if necessary.

Social Influence

Across all participant groups, social influence was a recurring theme. Particularly, participants noted how stigma can negatively impact returning to work. As one researcher/practitioner participant noted:

“Some managers at least dont see people with common mental disorders as valuable workers, they see them as a hindrance to meeting their [Key Priority Indicators] KPIs, so I think thats an attitudinal problem that we unfortunately still see in the workplace” – Researcher/Practitioner Participant 01

Stigma was brought up concerning chronic and mental health disabilities and not physical disabilities. 

A participant with lived experience noted

“When I came back after maternity leave, everyone knew I been pregnant and they wanted to talk about the baby and how youre feeling, all that stuff. Coming back after a mental health leave, nobody wants to talk about it.” – Participant 03

Participants from across the groups described how reducing stigma as a barrier could be achieved through efforts from the employers side such as creating an environment where employees feel respected.

Knowledge

Participants from the HR professional/management and researcher/practitioner groups identified knowledge as being a barrier to supporting employees with disabilities to sustain an RTW.  An HR professional/ management participant expressed:

A lot of managers are kind of apprehensive about how to approach [employees with a stigmatized disability]. I think that boils down to not having enough information and resources available to know what it is to do. – Focus Group Participant 03

Participants in the HR professional/management and researcher/practitioner groups felt that having more tools, resources, or learning sessions could help to overcome this gap in knowledge.

Social and Professional Role Identity

A theme from the HR professional/management group was centered around supporting the employee in their RTW as part of their professional role. Although this group mentioned they might not always have the resources or knowledge to perform adequately, it was part of their duty to support employees RTW. 

Memory, Cognition, and Decision-Making

Only the researcher/practitioner participant group mentioned how memory, cognition, and decision-making could help to support employees with disabilities in a sustained RTW. This overlapped with the knowledge theme, as participants described how tools and resources for employers need to be easy to use and not cognitively demanding, as described through this interview excerpt

“It needs to be almost a step-by-step guidance in how to go about doing it…it reduces the cognitive burden on the manager by literally…reassuring them they do not have to think about what to say.” - Researcher/Practitioner Participant 01

Skills

Additionally, only the researcher/practitioner group participants noted that employers need stronger skills to help support employees with disabilities in a sustained RTW. This was described by one interview participant through the following quote:

Employers are “not necessarily trained in how to deal with common mental disorders. They can kind of deal with a broken leg…[but], they dont understand common mental disorders and, what is needed to support workers with common mental disorders.” – Researcher/Practitioner Participant 05

Emotion

Only the employees with lived experiences noted that emotion was key as a facilitator to a successful sustained RTW. Likewise, the lack of emotion was viewed as a barrier.  As one participant described. 

“My co-workers made sure I was with them when they were going through things and theyd take me through the steps because Id missed out on a whole lot. That teaching made the process go faster and a lot easier.” – Participant 10 Lived 

Participants described how having emotional support from colleagues made a sustained RTW possible. This made the environment feel more emotionally safe to stay in and employees felt more comfortable about disclosing what their needs were. 

Across all perspectives included in this study (researchers/practitioners, management/human resource professionals, and workers with disabilities), a variety of similar themes emerged. Among these, participants felt that more heavily stigmatized disabilities (particularly mental health conditions) faced different challenges for sustained RTW compared to physical disabilities and acute injuries. Concerning support and resources for mental health, there are gaps in both the knowledge of these conditions as well as where to find appropriate workplace tools to support RTW for workers affected by them. A recent systematic review supports the pervasive influence of stigma on RTW, with studies suggesting that finding that workers are reluctant to discuss their disability and/or ask for accommodation primarily for fear of being stigmatized (Lindsay et al.,  2018). Facing stigma is an isolating experience and can be a significant barrier to RTW. When the social climate of the workplace is uninviting of disability, the ability to sustain a return may decrease, pushing workers with disabilities out of the workplace and into vulnerable economic positions. Such results have been observed in both workers with cancer (Stergiou-Kita et al., 2017) and in aging workers with disabilities (Durand et al., 2021). 

Perhaps the largest barrier observed and experienced by all the participants of this study, knowledge-related issues applied not only to stigma but also to conversations around what makes an effective resource and what accommodations can and should be used across disabilities. In the discussion surrounding knowledge, participants again noted that mental health conditions are difficult to navigate and are under-researched. Researchers and practitioner participants suggested that findings from studies about mental and invisible illnesses have some catching up to do when it comes to being incorporated into workplace wellness culture and policy, including RTW. The current lack of research integration has important consequences. Namely, employers lack the understanding of an employees experiences and need when it comes to mental health conditions, including what accommodations are appropriate and how best to suppor themt. Management/HR and lived experience participants echoed these thoughts, and the overall result is somewhat of a bidirectional relationship surrounding accommodations. Worker participants reported that their employers lacked sufficient knowledge about their mental health conditions needed to put supports in place for them following an RTW. On the flip side, management/HR participants noted that workers with disabilities themselves dont always know what accommodations they need to be comfortable, productive, and successful again in their workplace.   

By mapping the findings from each qualitative study component to the TDF, we were able to illuminate the overlap and disconnect from each participants perspective. All participant groups identified how the workplace environment and social influence could be a barrier or facilitator to a sustained RTW, but the specifics within these domains differed somewhat significantly. Workers with lived experience stressed the importance of emotional support in their RTW journey, but neither management/HR nor researchers/ practitioners participants identified this. Instead, management/HR felt that social and professional role identity plays an important part in sustained RTW. Researchers/practitioners argued that focusing on improving employers skills and continuing to develop tools for employers that are easy to use (i.e., to help ones memory, cognition, and decision-making) would improve a sustained RTW. Thus, a disconnect exists between what worker participants felt would best support their return and what employers and researchers felt would. Further research could explore the role of emotional support in sustained RTW, as well as effective interventions to help guide employers in providing that for a variety of disabilities. 

Limitations

This study was conducted with several limitations. Firstly, the study was not designed with any industry specificity; we did not collect any data on the industry that each participant was associated with, and therefore cannot address the scope of who these results apply to in a research field as large and variable as employment and the workplace. A demographics questionnaire was also left out of each of the study arms, which limits the meaningful distinctions that can be made between groups of people, as well as the reflections on their experiences and how they may intersect with any minoritized identities or social privileges.  

According to the WHO World Report on Disability, approximately 15% of people worldwide have a disability – representing an increase of 10% in the past 50 years. Compared to 13.7% in 2012, 22% of Canadas population identified as having one or more disabilities in 2017. 68% of Canadian workers with disabilities report needing time off from work because of their condition, but only 50% have insurance coverage. Research and policy development are still largely behind when it comes to the spike in reported disabilities around the world, which has left the working world with misunderstandings and misplaced expectations regarding not only sickness leave, but also the RTW process for these individuals. In this study, we present a broad overview of experiences with and opinions on sustainable RTW according to workers with disabilities, researchers/practitioners, and management/HR. Our work provides a jumping-off point for addressing additional questions about how each stakeholder in the working world both affects and is affected by disability. How are healthy co-workers navigating the changing face of disability in the workplace? How can policymakers lobby for the development of better programs and resources – ones designed with the wide spectrum of disabilities in mind, including invisible and mental illnesses? With reported disabilities on the rise (World Health Organization, 2011), cultivating a healthy working world for future generations of employees and employers will depend on our ability to answer these questions and many others. 

Across the multiple perspectives that made up this studys arms, the Theoretical Domains Framework allowed us to detect prominent themes and dissect their similarities and differences across participants. Through the TDF, we established the prevailing impact of stigma on RTW sustainability for a variety of disabilities. Moving forward, rewriting disability narratives to be both empowering and supportive for workers will require the collaboration of governments, researchers and practitioners, workers with lived experience, their co-workers, and their employers. Knowledge about and views on disability are often informed by ones surrounding social climate. In their work examining this, Coutu et al. (2022) found that in cultures where disability (especially mental health conditions) is framed negatively and shamefully, RTW for workers is both delayed and unsustainable. Others highlight the layered experience of stigma faced by immigrant and ethnocultural minority workers with disabilities including negative perceptions about not only their disability, but also about their ethnic and racial backgrounds, language, and cultural differences (Côté et al., 2020). The accumulation of biases can leave these workers disproportionately marginalized in the workplace. Future work should continue to examine how cultural attitudes shape disability perception in the workplace, as well as the intersection of marginalized identities with disabilities. In addition, we should measure the efficacy of RTW programs and resources for minoritized workers with disabilities, including whether they are designed with cultural sensitivity. Through the use of the TDF, the present study identified knowledge as a prominent barrier to sustainable RTW, but there is still much to be addressed within the conversation about disability knowledge. What pieces of disability knowledge are most important to have in the workplace? Are some workers with disabilities more affected by a knowledge barrier than others? Coutu et al. (2021) highlight the intersection between knowledge and social and professional roles in their study of women workers with disabilities. The authors comment on the multitude of responsibilities that women in the workforce are juggling between their personal and professional lives, and that the difficulty in managing their roles alongside their disability is often not known to their employers and managers. The authors found that women with disabilities had more difficulty securing workplace accommodations than men. When this happens, sustaining work becomes less feasible and happens less often – a result that has also been observed across women of visible minorities with disabilities, a further vulnerable group of workers (Coutu et al., 2022). Understanding the way that knowledge influences the sustainability of RTW for different working populations is an important first step, but theres still much to learn when it comes to accommodations. In Canada, assistance for physical disabilities and acute injuries is accounted for by workplace health and safety officers and government guidelines (Canadian Human Rights Commission, 2007; Government of Canada, 2019). Invisible disabilities and mental illnesses, however, may have an entirely different and unknown set of needs. In the context of these conditions, it may be less feasible to adopt a ‘one-size-fits-all all support program, resource, or set of accommodations. To address these statements and others, subsequent research should study specific disabilities and their needs to fill in the knowledge gap. 

The methodology was conducted and the paper was written by C.S. and K.K. The study was designed by F.O.H. in collaboration with C.S., K.K. and J.G.

This work was funded by Employment and Social Development Canada (ESDC) [501067].

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by Trent Universitys Office of Research and Innovation Ethics Board (April 30 2022, No. 27907). 

Informed consent was obtained from all individual participants included in the study. Participants signed informed consent regarding publishing their data.