Return-to-work (RTW) perceptions and attitudes are predictive for future work participation in workers with mental health issues.
To identify what RTW perceptions and attitudes occupational health professionals recognize in sick-listed unemployed workers with mental health issues and how these perceptions and attitudes can be systematically assessed.
Four focus group sessions, each involving five-six different occupational health professionals, were held. The audio records were transcribed verbatim and coded by two researchers independently. A thematic analysis was conducted.
Professionals recognized RTW perceptions and attitudes in sick-listed unemployed workers with mental health issues. These perceptions and attitudes were described as characteristics of three modes in a process regarding RTW: the passive, ambivalent and active RTW mode. A passive RTW mode includes perceptions about not being able to work and an expectant attitude. The ambivalent RTW mode is characterized by uncertainty and ambivalence regarding RTW with a desire for occupational support. Workers in an active RTW mode have positive RTW perceptions and show job search behavior. A main theme was the flexible nature of RTW attitudes and perceptions, with workers switching between the passive, ambivalent and active RTW modes. For the assessment of the RTW mode, the professionals preferred personal contact, possibly with support of a tool. This enables them to ask specific questions and to observe non-verbal signs.
Recurring assessments of the RTW mode can be helpful in identifying unemployed workers with mental health issues at risk of long-term sickness absence and for starting targeted RTW interventions.
Mental disorders are highly prevalent in the working-age population and lead to substantial costs for society due to sickness absence, long-term working disability and unemployment [1–4]. In member countries of the Organization for Economic Co-operation and Development (OECD) 30–50% of all disability claims are due to mental disorders . In the Netherlands, workers without an employer, such as unemployed and temporary agency workers (hereafter called unemployed workers), receive a disability pension if they are unable to work due to illness under the Sickness Benefits Act. A large proportion (approximately 40%) of the sick-listed unemployed workers experience mental health issues . Unemployed workers are a vulnerable group within the working population. Compared to workers with permanent contracts they tend to have a lower socioeconomic position, encounter more psychosocial barriers and have worse health [6, 7]. Moreover, during sick leave their access to occupational health care is limited  and after sick leave they often do not have a job to return to. Therefore, return to work is certainly more challenging for unemployed workers [6, 8]. A mere 12% of all sick-listed unemployed workers return to work (RTW) within 1.5 years in the Netherlands . This is rather concerning, because most people with mental illness do wish to engage in work [4, 10] and it is well-known that employment contributes to mental health and wellbeing . Re-employment is also beneficial for workers with mental illness: next to financial security, employment provides daily structure, social contacts, de-stigmatization, and also enhances mental health, general wellbeing, self-esteem and sense of identity [12–14]. While remaining unemployed can contribute to poverty and social isolation, possibly leading to further increase of mental health issues . Thus, to enhance mental and social wellbeing of unemployed workers with mental health issues and to diminish working disability costs, it’s important that these workers receive occupational health care to help them return to suitable and meaningful work.
To stimulate RTW and prevent long-term disability more knowledge is required about how to better support sick-listed unemployed workers with mental health issues. Therefore, it’s important to obtain more insight into what factors contribute to successful RTW. Then, potential barriers for RTW can be identified and targeted occupational health care interventions can be arranged. In the last few decades, several contributing factors for RTW in workers with mental disorders have been identified. These are not solely health-related factors (such as the severity of the disorder), but also work-related (for example quality of occupational care) and personal factors [16–18]. The worker’s own expectation about RTW is an example of a personal predictive factor: positive expectations are associated with (future) work participation, while negative or uncertain expectation are predictive for long term sickness absence [17, 19–21]. A specific and extensively evaluated concept regarding RTW expectations is self-efficacy. Self-efficacy is a judgement regarding one’s own ability to succeed in a specific behavior . Applied to RTW, self-efficacy can be explained as the belief that workers have in their own ability to meet the demands made by a RTW . The RTW self-efficacy is also associated with future work participation of workers with mental health problems [24–28].
RTW expectations including self-efficacy, referred to as RTW perceptions in this article, can contribute to the attitude of an unemployed worker towards work participation. Recently, Audhoe and colleagues  identified three types of attitude towards RTW based on in-depth interviews with sick-listed unemployed workers with mental health issues: A “frozen” attitude with negative RTW perceptions, an ”active” attitude with positive RTW perceptions and an “insightful though passive” attitude. This third group has insight into barriers for RTW and they have plans regarding how to overcome these barriers. However, these workers do not implement these solutions and intentions . It’s not yet known to what extent occupational health professionals, who are responsible for the occupational support of unemployed workers, recognize these types of attitude and corresponding perceptions regarding RTW among their clients.
Knowledge about RTW perceptions and attitudes of unemployed workers with mental health issues is important for occupational health professionals to identify those workers at risk of long-term sickness absence  and to optimize occupational counseling regarding the individual workers’ RTW perceptions and attitudes. Besides evaluating mental health symptoms, professionals should explore the workers’ beliefs about RTW. If needed, targeted RTW counseling or interventions can be arranged. This could be a specific psychological intervention focused on RTW [30, 31], but might also indicate that another intervention is required to target underlying medical, psychological or social problems. It is crucial to be aware that RTW perceptions and attitudes can be explained by a variety of factors including the influence of mental health symptoms , social support [32–34], employment status  and sickness absence . Furthermore, other potential barriers for RTW can be present and should be considered too. The identification of the potential barriers, including the workers’ RTW perceptions and attitudes should be conducted with the goal to provide tailored occupational health support.
Several instruments have been developed for the identification of RTW perceptions (predominantly focused on self-efficacy) to predict RTW in employed workers [23, 37–40]. However, it is not yet known what RTW perceptions and attitudes occupational health professionals specifically recognize in those workers who are unemployed and sick-listed due to mental health issues, and to which extent they distinguish the three types of attitude that were found by Audhoe et al. . Subsequently, instruments, such as questionnaires based on self-report or to be used by professionals during a consult, can be developed for the identification of these perceptions and attitudes in this vulnerable group of workers.
The current study primarily aimed to identify the perceptions and attitudes about RTW that occupational health professionals working at a social security institute recognize in sick-listed unemployed workers with mental health issues. In this study, mental health issues refer to all types of mental health symptoms due to specific mental disorders (such as depressive or anxiety disorders), but also as a result of stress-related issues (for example due to stressful social circumstances). Secondly, we investigated to what extent these occupational health professionals recognize the three types of RTW attitudes described by Audhoe et al. . Furthermore, we explored how, when and by whom RTW perceptions and attitudes should be assessed during sickness absence.
We chose a qualitative method based on focus group interviews with professionals working at The Dutch Social Security Institute: the Institute for Employee Benefits Schemes (UWV). UWV is responsible for the occupational health care and disability pensions of unemployed workers in the Netherlands. A focus group is “a carefully planned discussion designed to obtain perceptions on a defined area of interest in a permissive, non-threatening environment” . This type of data collection enabled us first to explore the views of the professionals about RTW perceptions and attitudes, through interaction and discussion , and thereafter to determine to which extent these professionals confirm the previous findings of Audhoe et al. . Furthermore we openly explored the preferred assessment method for the identification of RTW perception and attitudes.
All items of the consolidated criteria for reporting qualitative research (COREQ) were used . To enhance the quality of evidence we used both investigator triangulation and methodological triangulation [44, 45]. The study was conducted by a research team including four researchers, two of them (YS, KN) were intensively involved in data-collection and data-analysis. Intra-method methodological triangulation was achieved by collecting different types of qualitative data (transcripts, notes including observations and debriefing forms) to better understand the findings . The Medical Ethics Committee of the Academic Medical Center of Amsterdam UMC determined that no ethics committee approval was required for this study (trial number W17_283 # 17.335).
We recruited 5–8 experienced professionals who are responsible for the occupational health care of sick-listed unemployed workers at UWV for each focus group. These professionals worked at distinct locations in the Netherlands, ensuring diversity of work processes and distributions of tasks among them. Participants with different professions were included to represent the multidisciplinary occupational health teams. In the focus groups, the types of professionals were mixed to enhance interaction between them. Most participants were colleagues of each other, but were not working together in existing teams. The professionals included were (1) insurance physicians or insurance physicians in training, labor experts, occupational health nurses, or RTW coordinators, (2) were employed at UWV, (3) had at least 3 years of experience with sick-listed unemployed workers with mental health issues, (4) were able to speak and hear without difficulty, and (5) were able and willing to give informed consent. We did not specify exclusion criteria. Informed consent was obtained from all individual participants included in the study.
Managers of four UWV locations were informed about this research project and asked if they would allow their professionals to participate in a focus group session. All professionals at these offices received a personal request from the local manager or staff physician and an invitation mail with additional information about the research project. The manager or staff insurance physician informed the researcher (YS) about the professionals who were interested in the study. The researcher (YS) then contacted them with practical information and provided them with a summary of the results of the previous study of Audhoe et al. . We deliberately chose to send them these study results to ensure the same level of knowledge prior to the focus group interviews. This was necessary because of our aim to confirm the findings, but also because these results are well known among several occupational health professionals at UWV.
We conducted four focus group sessions, each at a different UWV office, between November 2017 and January 2018. These offices were located in four cities across the Netherlands. The duration of the sessions was approximately 1.5 hours. Data-saturation was reached after the fourth focus group session, meaning that we did not identify any new major themes during the last session. Therefore, additional sessions were not necessary. One researcher (YS) acted as moderator and a second took notes (KN). The moderator posed the questions, kept the discussion on track and encouraged all participants to contribute. The note-taker documented detailed information about the discussions including observations of non-verbal behavior. She also summarized the main themes in the middle and at the end of each session and occasionally asked explanatory questions. After the sessions, the researchers discussed their observations and notes through debriefing. All sessions were recorded on a digital audio recorder. The written notes, debriefing forms and digital audio records were stored at the secured digital research file on the departments’ drive.
The moderator started each session with an explanation of the research project and the aims of the study. The participants were then informed about the confidentiality and audio records of the interview and signed an informed consent form. The focus group sessions were divided into two parts: the first part started with an open explorative discussion about the type of RTW perceptions and attitudes that the participants recognize in sick-listed unemployed workers with mental health issues, thereafter the participants were explicitly asked to which extent they recognize the three types of attitude as described by Audhoe et al. . In the second part the participants openly discussed the methods they prefer to use for the assessment of the RTW perceptions and attitudes (Table 1).
|Recognition of RTW perceptions and attitudes||1. What type of perceptions and attitudes towards RTW do you recognize in unemployed workers with mental health issues?|
|2. To what extent do you recognize the three types of attitude: the ‘frozen’, ‘insightful though passive’, and ‘active’ attitude?|
|Preferred method for the assessment of RTW perceptions and attitudes||1. How can these RTW perceptions and attitudes be assessed?|
|2. When should these RTW perceptions and attitudes be assessed?|
|3. Who should administer this assessment?|
The audio records were transcribed verbatim. We anonymized the transcripts by using corresponding numbers instead of the participants’ names. We used the six-phase approach of Braun and Clark [46, 47] for a thematic analysis. Thematic analysis is a qualitative method for systematically identifying, organizing and offering insight into patterns of meanings (themes) across a data set. The purpose is to identify those themes relevant to answer our research questions in an as much as possible value-free approach instead of being theory-driven. Although one of the study goals was to further explore the previous findings of Audhoe et al. , these findings were not considered to be a theoretical framework. In the first phase we listened and re-listened to all audio records and read and re-read the transcripts, notes and debriefing forms to familiarize ourselves with the data. Secondly, we coupled initial codes to text phrases from the data. One researcher (YS) and one research assistant coded the transcripts independently using MAXQDA software. Afterwards, we discussed the codes until consensus was reached. In the event of persisting disagreement, a third researcher (KN) was consulted. In the third phase we (YS, KN) set out to identify themes. This involved reviewing the coded data to identify areas of similarity and overlap between codes. We reviewed all themes in the fourth phase by collating text phrases on a theme, re-reading, discussing and creating a thematic map. In the fifth phase we generated clear definitions and labels for the themes. The themes were interpreted to answer our research questions. Finally, we chose illustrative quotes to explain our themes (sixth phase). Afterwards we translated the final Dutch themes and quotes to English.
We conducted four focus group sessions of five to six participants, which included six insurance physicians, four nurses, six labor experts and five RTW coordinators. None of them dropped out, but one participant within the second focus group entered the sessions twenty minutes late. The number of years of experience with unemployed workers with mental health issues ranged from three to thirty years (Table 2).
|Focus group||Number of participants||Gender||Occupationa||Years of experience (range)|
|A||5||3 F, 2 M||1 IP, 2 0N, 1 LE, 1 RC||3–25|
|B||5||2 F, 3 M||2 IP, 1 0N, 1 LE, 1 RC||4–30|
|C||5||3 F, 2 M||1 IP, 1 0N, 1 LE, 2 RC||4–16|
|D||6||3 F, 3 M||2 IP, 3 LE, 1 RC||6–14|
aIP = insurance physician, ON = occupational health nurse, LE = labor expert, RC = RTW coordinator
The identified themes are presented according to the two main topics of the sessions: 1) recognition of RTW perceptions and attitudes and 2) the preferred method for assessment of these RTW perceptions and attitudes. A summary of the themes of these topics is presented in Table 3 and 4.
|Passive||Beliefs about not being able to do anything||Focus on symptoms or treatment|
|Negative||Assumptions that daily activities are the maximum achievable||Inadequate coping strategies|
|Impassive||Beliefs about not being able to work yet||Externalizing|
|Frozen||Beliefs about work being harmful||Dependency on others|
|Expectant||Assumptions about being in need of rest||Avoidance|
|Anxious||Beliefs about lack of work perspective due to their personal situation||“Exhausted heroes”|
|Desperate||Fear of relapse|
|Resistant||Severe mental illness|
|Unmotivated||Lack of adequate treatment|
|Advice of others to slow down|
|Low socioeconomic status|
|Negative working experiences|
|Grief reactions after losing a job|
|Negative effects of Sickness|
|Benefits Act system|
|Ambivalence||Uncertainty about their ability to work||Lack of insight into problems|
|Change of attitude||Uncertainty about how to RTW||Relapse due to contextual problems|
|Less passive||De-identification with mental health issues||Positive influence of SSA professional|
|Job search behavior||Beliefs of being in need of support for RTW|
|Willingness to RTW|
|Active||Beliefs about being able to RTW||High level of education|
|Overactive||Beliefs about work being beneficial||High socio-economic status|
|Job search behavior||Beliefs about being able to get there||Working history|
|Willingness to RTW||Not wanting to receive a sickness benefit anymore||Labor market perspective|
|Personal contact||Face-to-face contact|
|Contact by telephone|
|Observation of attitude|
|Assessment interview||Daily activities|
|Readiness for RTW|
|Expectations of future|
|0-10 rating scale|
|Questionnaire||Questionnaire as checklist|
|Questionnaire to monitor the process|
|Questionnaire before first consultation|
|Information from other professionals||Multidisciplinary team meeting|
|Notes in client file|
|Combination of sources|
3.1Recognition of RTW perceptions and attitudes
The participants stated that they often recognize RTW perceptions and attitudes in sick-listed unemployed workers with mental health issues. They generally described an impeding attitude as workers being passive and negative regarding RTW.Impeding perceptions are typically about not being able to work yet.
P6-D: The majority don’t even contact us directly; they are truly very passive.
The participants also indicated that they recognize the three types of attitude: the “frozen”, “insightful though passive” and “active” attitudes. The “frozen” and “insightful though passive” attitudes are most frequently seen in unemployed workers with mental health issues. Some stated that there are some workers that need to be stimulated and some that need to be slowed down regarding RTW.
P5-D: Well, I think that (. . .) the classification of unemployed workers, I think, we do recognize this; I recognize this, speaking for myself. Hmm, but mostly people with the frozen attitude. Hm . . . They don’t see future prospects, stay focused on their symptoms . . .
A main theme in all focus group sessions was that the attitudes and perceptions are not fixed; they can change over time. A person’s attitude on RTW can alternate between the three specific types of attitude.
P2-D: I don’t think that this is static; I think that those, those er... types of attitudes can alternate.
P5-D: Yes, they shift, hopefully (. . .)
This change of attitude can occur in both directions, towards a more passive or a more active attitude. The participants stated that they observe this change in a worker’s attitude during follow-up consultations. They often notice the attitude becoming less negative and passive over time.
P5-B: I noticed that he was doing better somehow, like..., that, that, our conversation was smoother, er.. he wasn’t so passive anymore or er... like, the negativity was gone.
However, they also observe a regression into a passive attitude due to personal problems orwork-related disappointments. The participants do think that the attitude can be influenced by social security professionals. Personal contact or starting a RTW intervention can result in a shift towards a more active attitude. They also stated, though, that in some of the unemployed workers a negative attitude towards RTW can be persistent.
Several participants volunteered the information that the attitude towards RTW is not related to the type of mental health issues. They even experience the same perceptions and attitudes in unemployed workers with physical problems. Instead, the participants are of the view that in most cases the attitude is about how people deal with their symptoms.
P2-A: it’s not really about the symptoms but er... how people deal with them.
However, they did mention that serious mental health problems such as a severe depression can contribute to a negative attitude.
3.1.1Characteristics of typology: the RTW modes
Our findings largely confirm the three types of attitude identified by Audhoe and colleagues. Thus, the features of the RTW perceptions and attitudes will be displayed according to this classification. However, we decided to rename the types of attitude according to the main characteristics as put forward by the participants in our focus groups: the passive, ambivalent and active RTW mode. These RTW “modes” are overarching concepts referring to the changeable character of attitudes and perceptions in a process regarding RTW. The participants also described underlying causes of the RTW modes. These causes are additional signals that may contribute to the distinction between the three modes. Therefore, we choose to categorize the characteristics of the RTW modes as attitudes, perceptions and underlying causes. These are described in Table 3 and in the section 3.1.2. passive RTW mode, 3.1.3. ambivalent RTW mode and 3.2.4. active RTW mode.
3.1.2Passive RTW mode
22.214.171.124 Attitudes The participants stated that many unemployed workers with mental health issues are passive towards RTW and activities to enhance recovery. They hardly initiate activities. The participants also referred to this attitude as being impassive or frozen. These workers may still be in a state of shock about what happened to them.
P4-A: . . . In the beginning, the shock phase, when there is nothing [. . . ] flabbergasted, in shock about what happened to them.
P2-A: A kind of paralysis.
The unemployed workers give the impression of expressing negativity about everything. The participants mentioned that they observe this negativity through verbal and non-verbal communication.
P1-C: I’m afraid to do it, I can’t do it, etcetera, everything is negative. Whatever you say.
P3-C: Whatever you do, yes.
P1-C: A radiation of negativity, verbally, non-verbally, even breathing [laughing].
They also described a negative attitude as being anxious or desperate. Additional characteristics might be frustrations, negative emotions and physical signs of tension and stress.
126.96.36.199 Perceptions The participants mentioned specific impeding perceptions about RTW and recovery associated with a passive attitude. They mentioned that several unemployed workers think that they are not able to do anything or anything more than their current daily activities. They can be persuaded that they need rest and should focus on treatment first. The willingness for RTW can be low, because of this assumption of not being able to work.
P5-C: There are people who claim, “No, I won’t do that at all, no, I won’t do anything, I can’t, I can’t do anything at all at the moment”.
The unemployed workers might assume that their situation will not get any better and that employers will not hire them. However, a few participants also reported that they believe that some workers are less motivated because they are accustomed to live on benefits and do not imagine that work can be beneficial.
188.8.131.52 Underlying causes The participants listed several underlying mechanisms or situations that can cause impeding perceptions and a passive attitude towards RTW. See Table 3 for an overview of all themes.
Focus on symptoms: Unemployed workers often seem highly focused on their symptoms and treatment, according to the participants. They can be persuaded that they should get better first before they can start with RTW activities.
P2-B: . . . an attitude of, er, “Leave me alone. I want to focus on my recovery and after that, then, er, I will focus on return to work.”
The participants also stated that the absence of treatment due to long waiting lists or limited insurance and money can further contribute to a passive attitude. Moreover, when the workers do receive treatment they often get the advice to slow down and take some rest. Their family or friends may also tell them to be careful.
Unhelpful coping strategies: Unhelpful coping strategies for dealing with symptoms and problems were also frequently mentioned by the participants. Some the workers do not know how to overcome their current situation. They perceive to have little agency over their situation. The participants also stated that some workers seem to hold other people responsible for their problems and perceive themselves to be victims. And they sometimes assume that professionals should solve their problems. Additionally, they stated that some workers had pushed themselves beyond their limits in their last job. These workers are described as perfectionists who have difficulties with setting boundaries and accepting their disabilities (“exhausted heroes”). Eventually they break down and sometimes these workers express feelings of deserving time for rest.
P3-B: Yes, the exhausted heroes, we see them a lot, exhausted heroes [. . . ] sub assertive, not able to stand up for themselves, unable to say no, who do what others tell them to do and go beyond their limits to please others.
Negative work experiences
The participants indicated that some workers appear hesitant about RTW because they fear relapse or failure. They seem to think that RTW activities will be too stressful. Previous negative work experiences, in particular losing a job, are often described as an underlying cause of mental health issues and attitude towards RTW. Some participants compared this to a grief reaction.
P5-A: These are people who have always worked and had good jobs (..) reorganization, losing the job, becoming unemployed, hmm . . . well, returning to work, but to work they weren’t used to: less salary, less qualified, et cetera (. . .)
P4-A: It’s a grief reaction.
P5-A: It’s imaginable.
Contextual factors: Contextual factors were also listed as an underlying cause of impeding RTW perceptions and attitudes. Financial problems and low socioeconomic status are often described, but also differences relating to language or culture, addictions and family problems. The participants stated that workers often face an accumulation of these problems including losing a job, and do not know how to overcome all of this.
P3-B: These people were already unemployed, don’t see how all these problems can be overcome, are desperate, have debts, er . . . addictions, and so on.
e. Sickness Benefits Act system: Another theme in the focus group sessions was the influence of the Sickness Benefit Act system on the attitude towards RTW in some unemployed workers. The participants stated that waiting months for a first consultation or the inability to reach a professional by phone contribute to a passive RTW attitude. They also mentioned that unemployed workers might show a different attitude in a consultation with an insurance physician than in their meetings with other professionals because of the fear of losing their disability benefit.
3.1.3Ambivalent RTW mode
184.108.40.206 Attitudes Several unemployed workers do not show a fully active or passive attitude towards RTW, according to the participants. Their attitude appears ambivalent, because they are in the middle of the process towards a more active or passive RTW attitude or because they just switching between attitudes from one moment to another.
B2-A: The switching attitude, er (. . .) but the passive behavior isn’t present all the time. Sometimes they are active and sometimes they aren’t.
The participants mentioned that a main difference between a passive and an ambivalent RTW attitude is the presence of job search behavior.
P5-D: but then you have them searching on the internet, because, because people with a frozen attitude don’t even do that. You showed them the possibilities, you can do this or that, and if they take action then they are somewhere in shifting towards a different mode.
220.127.116.11 Perceptions The unemployed workers with an ambivalent attitude show desire for RTW but they also seem uncertain about their ability to work and how to go back to work, according to the participants. They are in the dark about how to do this and are convinced that they need someone to help them RTW.
P1-D: I think that most people do want to work in the end, but they just don’t know how to get out of being unemployed.
Some participants stated that some workers are able to de-identify with their mental health issues. They let go of the assumption of being their illness.
P2-A: Well, they are more aware of their symptoms, behavior, themselves and their symptoms, instead of being those symptoms, they say: “I’ve been diagnosed with depression” instead of “I am depressed”.
18.104.22.168 Underlying causes The participants mentioned certain mechanisms that can lead to an ambivalence towards RTW. At first, they stated that lack of insight into their problems prevents workers from knowing how to deal with these problems and how to RTW. They also listed that it seems difficult for workers to become more motivated towards RTW due to contextual factors such as financial problems. Unsolved social problems can contribute to relapse of illness and negativity.
P4-A: I think that it’s difficult for people to become more positively minded due to all contextual factors.
P5-A: And when they become less depressed, there is great chance they will fall back into negativity . . .
P1-A: . . . they relapse . . .
P5-A: . . . because these problems are still unsolved: relational problems, debts.
Finally, the participants indicated that professionals working at a social security institute can positively influence the RTW perceptions and attitudes of the worker, leading to a switch from a passive RTW attitude towards a more active RTW attitude. When their problems are listened to and their symptoms are acknowledged, a worker’s RTW attitude becomes less negative. They also mentioned that the professionals can influence the perceptions and attitudes by showing the worker some future perspective by providing information about RTW support or starting interventions focusing on activation and motivation.
3.1.4Active RTW mode
22.214.171.124 Attitudes The participants stated that a small number of the sick-listed unemployed workers with mental health issues show an active attitude towards RTW. These workers show active job search behavior because they are motivated for their RTW and think that working can have a positive effect.
P5-C: There are people who are very active and who think ahead and, er . . . trying to find a job, so it is, well . . . you can count them on the fingers of one hand.
They also indicated that some workers can be too active; they want to go too fast. These workers should be slowed down instead of being stimulated.
P5-D: When I think about some clients I’ve seen who are looking forward or who are motivated, ehm.. and who can be too idealistic sometimes and want too much too fast. Well, then you approach them from a different perspective. You have to slow them down.
126.96.36.199 Perceptions Unemployed workers in an active mode appear very motivated to RTW, according to the participants. They seem convinced of their ability to RTW and think that they will get there by themselves without support.
P2-A: There are people who always get there; they are convinced that they will get there by themselves.
The participants also stated that some actively minded workers do not want to receive a sickness benefit. They feel this hinders them in finding a job.
188.8.131.52 Underlying causes The participants also listed a number of elements that can contribute to positive perceptions and an active attitudes. They mentioned a high level of education, positive working experiences and a good labor-market perspective or high family socioeconomic status. They also said that some workers exhibit unrealistic expectations of future work.
3.2Preferred method for the assessment of RTW perceptions and attitudes
The participants mentioned several important aspects of the identification of RTW perceptions and attitudes (Table 4). Personal, face-to-face contact was often mentioned as the best method because of the possibility it affords professionals to observe non-verbal signals. They could, for example, observe anxiety and tension in the physical appearance and attitude of unemployed workers.
P3-B: We are all good at reading body language and... and... and how people talk and I mean that, the experience when you work with people; so that is the Fingerspitzengefühl.
P5-B: A big part . . . A big part is non-verbal, right?
P5-B: The way someone sits in front of you, like, it can be defensive or anxious –you just notice that.
Some mentioned that contact by telephone can also be informative. However, overall the participants expressed a preference for face-to-face contact. They also stated that face-to-face contact should be repeated to enhance the development of a relation.
The participants ask the workers some general and specific questions to identify their RTW perceptions and attitudes. These questions are, for example, about readiness for RTW, future expectations and daily activities. See Table 4.
The participants expressed different opinions about the advantage of a questionnaire. The advantages of a questionnaire could be that it triggers unemployed workers to think about RTW and to use it as a checklist for the RTW mode. They also stated that a questionnaire or checklist can be used to monitor the mode because, shifts can occur. Arguments against a questionnaire were, for example, the amount of information workers already have to provide, and the possibility of manipulation of information.
3.2.4Information from other professionals
They also mentioned that information in client files can provide insight into the RTW perceptions and attitudes - for example, if unemployed workers have not been showing up at consultations. Some participants stated that a multidisciplinary team meeting can contribute to insight into a workers’ perceptions and attitudes.
3.2.5Combination of sources
Many participants found a combination of sources such as personal contact, file information and team meetings important. In addition, they are convinced that every professional should assess the RTW mode because of the shifting character of attitudes and perceptions. Therefore, they think that this assessment is important during every consultation. However, some stated that unemployed workers with severe mental disorders or intensive psychiatric interventions should not be questioned about RTW.
The primary aim of this focus group study was to explore the perceptions and attitudes about RTW that occupational health professionals working at a social security institute recognize in sick-listed unemployed workers with mental health issues. Secondly, we investigated to what extend these professionals recognize the typology of attitudes described by Audhoe et al. . Furthermore, we explored how these RTW perceptions and attitudes could be systematically assessed. The participants recognized impeding RTW perceptions and attitudes, but also more positive and helpful ones. A main theme was the flexible nature of the attitudes and perceptions; these can change over time and can be influenced by professionals. The perceptions and attitudes are modes in a process regarding workers’ RTW. The participants distinguished unemployed workers who exhibit a passive RTW mode, an active RTW mode and those who are somewhere in-between. The passive RTW mode was characterized by negative perceptions about the workers’ own abilities, an expectant attitude, focus on symptoms and recovery, and fear or relapse if returning to work. The participants mentioned several underlying mechanisms to explain the passive mode, such as the presence of severe mental illness, unhelpful coping strategies, negative work experiences and the influence of contextual factors. Conversely, some workers show a quite active attitude, according to the participants. These workers expect to RTW by themselves and show active, and sometimes too active, job search behavior. The participants mentioned that these workers think that they are able to work and assume that RTW will be beneficial for them. A higher level of education, positive previous work experiences and self-efficacy are examples of reasons for an active RTW mode. Lastly, the participants described a RTW mode that is not fully passive or active, characterized by ambivalence and uncertainty about the individual’s ability to work and how to RTW. These workers express a desire for occupational support. According to the participants, contextual factors such as financial distress but also uncertainty about how to cope with their problems are mentioned as causes for ambivalence regarding RTW. In conclusion, occupational professionals recognize three RTW modes among unemployed workers with mental health issues: the passive, ambivalent and active RTW mode. The workers can switch between those RTW modes and corresponding perceptions and attitudes.
To assess the RTW mode with corresponding perceptions and attitudes, the participants preferred personal contact, possibly supported by a tool such as a questionnaire. Personal contact enables assessment through verbal and non-verbal communication. The RTW mode should be assessed in every consultation by every professional because of the possibility of change and the importance of attitude and perceptions in the RTW process.
4.2Comparison with literature
4.2.1Typology of RTW attitudes and perceptions (RTW-modes)
The findings of the current study about the characteristics and typology of attitudes and perceptions regarding RTW are largely in line with the results of a previous qualitative interview study among this specific group of workers with mental health issues . We were able to further specify the characteristics of RTW attitudes and perceptions through focus group interviews with professionals working at a social security agency. These attitudes and perceptions correspond to three main modes in unemployed workers regarding a RTW. The RTW modes, as defined in the current study, show similarities with the stages of the “readiness for change” model developed by Prochaska . This is a behavioral change model primarily based on the modification of addictive behavior , but has been evaluated extensively for a range of other minor and major health behavioral changes, in the general population [50, 51], but also among people with physical  or mental illness [53, 54]. This model has also been used to improve mental health care. For example, an intervention with individualized guidance matched to the stage of readiness for change improved depressive symptoms, with larger effects for individuals in the pre-contemplation and contemplation stages of the “readiness for change” model . In the last couple of years there has been a growing interest in readiness for change regarding RTW [39, 56, 57]. The passive, ambivalent and active mode regarding RTW based on the current study rather correspond to the pre-contemplation, contemplation and acting stage. Another study about RTW also described the stages of readiness for change , showing that benefit recipients in “action mode” had the best employment outcomes. However, readiness for change regarding RTW is a complex concept, which can be influenced by several factors including interaction with the (occupational) health care system and insurance system , but also by mental health issues . For example, a passive attitude with feelings of being worthless and having a lack of future perspective certainly can be explained by the symptoms of a depressive disorder  along with undermined self-esteem and self-efficacy through self-stigma .
In summary, in our study professionals were able to recognize RTW perceptions and attitudes in sick-listed unemployed workers with mental health issues. These perceptions and attitudes are characteristics of the RTW mode and are supported by knowledge about health behavioral change.
4.2.2Changing RTW attitudes and perceptions
A main finding of our study is that the RTW attitude and corresponding perceptions can change over time. This was not described by Audhoe , but it seems plausible considering the (nonlinear) personal recovery process of people with mental disorders [60, 61] and influence of mental health symptoms on RTW perceptions . The ability to switch between different RTW modes also shows similarities with the “readiness for change” model [48, 56]. Actually, a meta-analysis showed that the progression from pre-contemplation to action stage is associated with changes in the validation of the desired behavioral change . Moreover, RTW perceptions (expectations and self-efficacy) are capable of improvement [24, 40] and this improvement is also predictive for actual RTW in workers with common mental disorders [24, 63–65].
The readiness for behavioral change depends on a person’s confidence in their ability to change [39, 56]. The confidence of a sick-listed worker in RTW requires beliefs about the value of the job. This can be difficult for unemployed workers, because they often need to obtain a new job while facing uncertainty about their work ability and income. Furthermore, mental illness and self-stigma may impact their self-esteem and ability to overcome barriers for behavioral changes, including RTW [59, 66, 67]. Uncertainty about their ability to work is a possible explanation for the passive or ambivalent RTW mode of unemployed workers with mental health issues. Though, based on our study, professionals do experience change in RTW mode in unemployed workers. This process of becoming ready for RTW could, however, work differently in unemployed workers compared to those who are employed. For example, a recent study by Lovvik and colleagues implicated that RTW expectations are more predictive for workers who are recently sick-listed compared to those on long-term benefits . Moreover, mental health symptoms can influence RTW perceptions  and because of under-recognition and under-treatment of mental disorders in workers on long-term sickness absence  it’s possible that this also impedes a change towards a more active RTW mode and actual RTW. However, a recent study indicated that readiness for change was a stronger predictor for RTW in adults with severe mental illness than psychiatric symptoms and cognitive functioning.
In conclusion, the changing character of the RTW mode as stated by professionals in the current study can be explained by the recovery process of mental illness and is generally in line with other research about readiness for RTW. However, it is important to be aware of the difficulty for unemployed workers with mental health issues to gain confidence in RTW. Occupational health professionals should support these workers in regaining confidence in RTW and help them obtain suitable work at the right moment for the worker, not only based on the RTW mode, but also compatible with the mental health status and personal circumstances of the individual.
4.2.3Assessment of RTW attitudes and perceptions
To our knowledge, this is the first study including results about the assessment method for RTW attitudes and perceptions in sick-listed unemployed workers with mental health issues. The results showed that personal contact is essential for the assessment of RTW attitudes and perceptions in sick-listed unemployed workers with mental health issues. Previous research about assessment methods for RTW perceptions, focused on expectations [38, 39, 57] and self-efficacy [23, 37, 40], mainly evaluated newly developed questionnaires filled out by the sick-listed workers themselves. However, interaction with a professional can influence the attitude and perceptions regarding RTW [56, 70]. Furthermore, several studies showed that interaction with a healthcare or social insurance professional enhances RTW [71–73].
Recurrent assessments are needed to recognize changes in the RTW attitudes and perceptions. This is also in line with the latest developments in research about the mechanisms underlying predictive relationships between factors such as expectations and self-efficacy and desired behavior and health outcomes  –both for the purpose of gaining more knowledge about these dynamics and for adapting and developing suitable interventions.
4.3Strengths and limitations
The first strength of this study is that all types of professionals that are involved in the Sickness Benefits Act system in the Netherlands were represented in the focus group sessions. The mixed composition of the sessions fostered understanding of the different points of views of those professionals. These group interviews also enabled the participants to form their opinions through interaction. Another strength of this study was the data triangulation by using audio records, notes of observations and summaries and debriefing reports. A methodological strength of the data-analysis was the systematic approach of the thematic analysis of Clarke and Braun and also the confirmative and explorative approach of the study.
The mixed composition of the focus group sessions is also a limitation, however, because the professionals who participated in the sessions could have hierarchical positions in their workplace. The opinions of the higher positioned professionals could therefore have been dominant. Though, most participants did not work in actual teams together and we invited all participants to give their opinions and encouraging more modest participants to answer the questions. Furthermore, the participants were recruited by authority (their manager). This could have led to selection bias. Finally, the results may have been biased as we gave the participants information about the findings of a previous study  regarding types of RTW attitudes in advance. However, these types of attitude had already been presented to all occupational health professionals at UWV before and we wanted the participants to have the same knowledge at start of the sessions. Moreover, one of the aims of this study was to confirm and further explore the types of RTW attitude. Nevertheless, each session started with an open discussion about RTW perceptions and attitudes. Afterwards they were asked questions to confirm to which extent the participants recognized the previous finding. With this stepped-wise value-free approach we were able to confirm and further define the RTW attitudes and perceptions. We also identified some additional perspectives of the RTW attitudes and perceptions and we were able to determine the professionals’ preferred methods for the assessment of the RTW attitudes and perceptions.
4.4Implications for research and practice
The results of this study confirmed and further specified the attitudes and corresponding perceptions towards RTW. These attitudes and perceptions are indicators for the RTW mode of a sick-listed unemployed worker with mental health issues. We advise occupational health care professionals to assess the RTW mode recurrently in order to identify those workers who are at risk of long-term sickness absence and are possibly in need of specialized occupational counseling or psychological interventions, such as narrative enhancement and cognitive therapy (NECT) to reduce self-stigma and enhance self-esteem .
Future research needs to focus on the development and evaluation of applicable assessment tools. It is also important to develop interventions focused on altering impeding attitudes and perceptions or interventions focused on underlying medical, psychological or social causes. Furthermore, it is necessary to find out if workers react differently to interventions based on their RTW mode. Then, RTW interventions or specific elements of interventions can be adjusted to the RTW mode.
This study also revealed the importance of personal contact with sick-listed workers for the assessment of attitudes and perceptions of their RTW mode. Moreover, this assessment should be performed during each consultation because the RTW mode is capable of change and can even be influenced by professionals themselves. Therefore, assessment tools to assist the professionals during personal consultations need to be developed. We will develop and evaluate such a tool specifically for the assessment of the RTW mode of sick-listed unemployed workers with mental health issues in our next study.
Occupational health professionals working at a Dutch social security institute recognize perceptions and attitudes regarding RTW in sick-listed unemployed workers with mental health issues. These perceptions and attitudes correspond to three main RTW modes: a passive, an ambivalent and an active RTW mode. These modes are not fixed, but are phases in a process regarding readiness for RTW. The RTW mode can be assessed through the identification of specific characteristics of the perceptions, attitudes and their underlying causes. The recognition of the RTW mode is important for the identification of those who are at risk of long-term sickness absence and help to determine how to optimize occupational rehabilitation support given the particular RTW mode the person is in. If required, psychological interventions focused on RTW or on the underlying psychological problems can be arranged. The assessment of the RTW mode should be performed routinely through personal contact with the sick-listed unemployed worker, possibly supported by a tool.
All procedures followed were in accordance with the ethical standards of the responsible committee on research involving human subjects (institutional and national) and with the 1964 Helsinki declaration and its later amendments. The Medical Ethics Committee of the Academic Medical Center of Amsterdam UMC determined that no ethics committee approval was required for this study (trial number W17_283 # 17.335).
Informed consent was obtained from all participants before they were included in the study.
Conflict of interest
The authors declare that they have no conflict of interest.
Prof. J.K. Sluiter passed away before the manu-script was written. We would like to acknowledge her for her valuable comments and advice during the earlier stages of this study. We also would like to thank the professionals who participated in the interviews. Furthermore, we thank Wikkie Ramnarain Singh for assisting with the transcription of the audio records.
This study was supported financially by The Dutch Social Security Institute: the Institute for Employee Benefits Schemes (Uitvoeringsinstituut Werknemersverzekeringen, UWV). The funding organization played no role in the analysis and interpretation of data, in the writing of this article and in the decision to submit the article for publication.
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