When workers need time off from their jobs because of a work-related injury, their recovery and return to work can be a complex process. The seven principles of successful return to work (RTW) were developed to provide some guidance on how to approach this process. The principles were developed by the Knowledge Transfer and Exchange (KTE) team of the Institute for Work & Health, in collaboration with the Workplace Safety & Insurance Board’s RTW team.
These principles pull together the messages from research, making them more tangible, says Jane Gibson, Director of KTE at the Institute.
We felt that the principles would be useful to a range of players in the field, including disability managers, employers, insurers and of course, workers.
Each principle has been shown to contribute to successful RTW, which was measured as a drop in the duration of a worker’s disability and in costs. The principles are based on findings from a 2004 Institute systematic review of RTW practices, as well as current research in the field. The review, conducted by IWH scientist Dr. Renée-Louise Franche and colleagues, provided particularly helpful insights, as it analysed both the quantitative and qualitative research.
The quantitative research answered the question, ‘What works’ and the qualitative answered ‘How does it work, in terms of the context and processes?’ says Franche.
The principles provide a starting point to engage organizations in a dialogue about RTW, as employers and workers can see how the principles apply to their setting, she notes.
These principles are related, and when more than one is in place, there is a synergy that strengthens the impact. Below is a description of the principles and a brief description of the research behind them. For the complete version and references, please visit www.iwh.on.ca/seven-principles-for-rtw.
Principle 1: The workplace has a strong commitment to health and safety, which is demonstrated by the behaviours of the workplace parties.
There is a saying that “actions speak louder than words,” and in the case of RTW, this is borne out by research. Certain actions or behaviours of employers, labour unions and others in the workplace are associated with good RTW outcomes. These behaviours include the following:
- Senior management has invested company resources and people’s time to promote safe and co-ordinated return to work.
- Labour supports safety policies and RTW programming. For example, RTW job placement practices might be included in policies, procedures and/or the collective agreement.
- A commitment to safety issues is the norm that is accepted across the organization.
Studies of disability management interventions, where there was strong union support, showed reductions in work disability duration and costs. In addition, qualitative studies indicated that a collaborative approach to RTW between labour and management helped ensure there was no conflict between the collective agreement and the RTW process. Andy King, a department leader for Health and Safety, United Steel Workers of America, has suggested that creating a RTW strategy could be a point of collaboration for organized labour and management.
Principle 2: The employer makes an offer of modified work (also known as work accommodation) to injured/ ill workers so they can return as early as is feasible to work activities suitable to their temporary abilities.
Accommodated work is a core element of disability management, which leads to favourable outcomes.
We all know work accommodation is critical, says Franche.
However, it needs to be acceptable to all parties involved, but most importantly to the worker and the employer. Several studies have shown that an awkward fit between the worker and a modified work environment can contribute to breakdown of the RTW process and should be avoided. In some cases it will be helpful to consult with an ergonomics expert. The systematic review also suggests that another core disability management component is ergonomic work site visits. When RTW planners face difficulty in creating an appropriate modified job, ergonomic expertise should be available.
Principle 3: RTW planners ensure that the RTW plan supports the returning worker without disadvantaging co-workers and supervisors.
Return-to-work planning involves more than matching the injured worker’s physical restrictions to a modified job. The planning must acknowledge that RTW is a “socially fragile process” in which co-workers and supervisors may be thrust into new relationships and routines. If colleagues are put at a disadvantage by the RTW plan, this can lead to resentment rather than co-operation.
Two examples illustrate where RTW plans may cause problems:
- When co-workers resent taking on tasks of the injured worker and feel that he or she has managed to get an “easier” job.
- When supervisors still need to fulfill production quotas while accommodating a returning worker, and there isn’t a full acknowledgement of the work that this requires.
Workplaces that create individual RTW plans that anticipate and avoid these pitfalls will have better results.
Principle 4: Supervisors are trained and included in RTW planning.
Supervisors are important to the success of RTW because of their proximity to the worker and their ability to manage the immediate work environment, according to the review. When supervisors are left out of RTW planning, they feel ill-equipped to accommodate returning workers.
Because RTW is not a static event, supervisors are in the best position to monitor changes, and explain or smooth over issues that arise in the work area, says IWH Scientist Ellen MacEachen, who led the qualitative part of the systematic review. Educating managers and supervisors in areas such as safety training or participatory ergonomics also contributes to successful RTW. Dr. Glen Pransky, director of the Liberty Mutual Research Institute for Safety in the U.S. reports positive results from an ergonomic and safety training program for supervisors. In this program, supervisors were also taught to be positive and empathetic in early contacts with workers, and to arrange accommodations, follow-up and problem solve regularly.
Principle 5: The employer makes early and considerate contact with injured/ ill workers.
“Early” contact is a core component of most disability management programs. It is associated with better RTW results. The actual time frame for making contact may vary, depending on the worker’s situation. Ideally, the immediate supervisor should make initial contact to ensure the worker feels connected to the workplace and colleagues. This contact should signify that the employer cares about the worker’s well-being, and should not involve discussions on the cause of injury or on laying blame. The worker’s general perception about the workplace and its concern for workers will influence how he or she responds to employer contact.
Early contact is most successful when pre-existing conditions in the workplace are positive, says MacEachen.
Principle 6: Someone has the responsibility to co-ordinate RTW.
Successful RTW programs involve an RTW co-ordinator, either based at the company or externally, to manage the process. This role involves:
- providing individualized planning and co-ordination adapted to the worker’s initial and ongoing needs
- ensuring that the necessary communication does not break down at any point
- ensuring that the worker and other RTW players understand what to expect and what is expected of them
Considering the needs of all players will facilitate the RTW process and help ensure its success.
Principle 7: Employers and health-care providers exchange information with each other as needed.
Contact between workplaces and health-care providers reduces the length of work disability, several studies showed. Depending on the situation, one or more health-care providers might be involved, including physicians, chiropractors, ergonomists or kinesiologists, occupational therapists, physiotherapists or nurses.
Health-care providers can play a significant role in the RTW process. The injured worker often looks to them for information and advice about their condition and return to work. When employers have contact with health-care providers, they are in a better position to understand the worker’s abilities and can be more confident about health and recovery decisions, says MacEachen. The more these players understand about the worker’s job and the workplaces’ ability to provide accommodation, the better able they are to advise workers and participate in informed RTW decision-making.
This contact may only be necessary in complex cases. It may include telephone conversations, written communication about job demands and/or work accommodation options from the employer to the family doctor, or a workplace visit by a health-care provider. In some cases a health-care provider may be involved in delivering a fully integrated clinical and occupational approach to RTW, including medical assessment, follow-up and monitoring plus job-site evaluations and ergonomic interventions. When family physicians lack time to consult with or visit the workplace, other rehabilitation and occupational health professionals – who may have more worksite experience – can act as a “bridge” between the workplace and health-care system.