Summary

In Québec, under the Act Respecting Industrial Accidents and Occupational Diseases (AIAOD), all workers who sustain employment injuries that cause them permanent physical or mental impairment are entitled to the rehabilitation that their condition requires, with a view to their social and occupational reintegration. The AIAOD also provides such workers with a right to return to work when they are again fit to perform their jobs. Organizations and workers alike are thus directly concerned by the implementation of appropriate, sustainable, and effective return-to-work (RTW) solutions. While the recent literature tells us much about the evidence-based principles for healthy and sustainable return to work (best practices), few studies to date have documented actual workplace practices in this regard for workers with musculoskeletal disorders (MSDs). The overall goal of this study was to assess possible discrepancies between evidence-based best RTW practices and actual workplace practices, and then to suggest possible improvements. The following specific objectives were defined: (1) determine, based on the literature, the best practices for fostering sustainable RTW and preventing long-term disability among workers with MSDs; (2) describe actual RTW practices and identify the conditions facilitating their implementation in Québec workplaces; and (3) assess the discrepancies between the best practices recommended in the evidence-based literature and actual practices in workplaces, and ultimately to propose ways for improving the transfer from theory to practice.

An integrative literature review was conducted to achieve Objective 1. This is a specific review method that synthesizes the theoretical and scientific literature to provide a more in-depth understanding of a given phenomenon. Based on a systematic search for literature reviews, scientific reports, and practice guides developed for workplaces on the topic of RTW interventions, the researchers in this study were able to describe what is currently known and recommended in research on the best practices of this type, and, using an analytical grid with pre-established categories, to identify the main strategic elements applicable to the Québec context.

To achieve Objective 2, a qualitative multiple-case study design with various nested levels of analysis was used to identify, from complementary data sources, the policies, procedures, and practices of four organizations operating in two different activity sectors. A case (called an “organization case” in this report) includes all the formal and informal RTW procedures and practices, as well as the conditions facilitating or hindering RTW, in a given workplace. Three units of analysis were examined for each organization case. The first consisted of all the written documents collected from the organization. These documents underwent content analysis to establish the formal RTW procedures. The second unit of analysis consisted of the viewpoints of the key players involved in a general way in the RTW process, as documented in interviews. Content analyses of these interviews helped to clarify the informal procedures, actual practices, and conditions facilitating or hindering the RTW process in general and to describe the gaps between what the organization prescribes in its formal and informal procedures and what occurs in actual practice. The third and last unit of analysis consisted of a set of RTW situations, described on the basis of interviews with workers and other players involved in the RTW. The actions taken in each RTW situation were described, synthesized, and then compared with elements prescribed in the organization’s formal or informal procedures. Intra-organization case analyses were performed to describe the procedures and practices, and the conditions facilitating or hindering RTW, in each organization case. Inter-organization case analyses were then performed to identify similarities and differences between these elements, depending on the different organizational contexts. A total of 45 interviews were conducted with 32 key players (workers, administrator/counsellor responsible for internally managing disability claims and RTW [referred to in this document as disability RTW administrator/counsellor], supervisors, preventionists, union representatives, etc.) for all the organization cases. The practices and conditions involved in the concrete RTW situations were described on the basis of the semi-structured interviews conducted with 14 workers and 21 key players involved in their RTW.

To achieve Objective 3, the main elements of the best practices, extracted from the evidence found in the literature (Objective 1), were compared with elements of the organizations’ actual practices (Objective 2) in order to produce a qualitative description of the discrepancies between what is recommended and what is actually done.

The results of the literature review revealed that a number of publications concur about the effectiveness of workplace intervention. While numerous interventions of this type have been proposed and evaluated by the authors, few studies have established an effectiveness relationship between any specific workplace intervention strategy and the RTW. General characteristics of organizational policies and procedures, as well as strategic elements of workplace interventions (activities, strategies, and resources), were extracted from the literature in order to compare the best practices recommended in research with the actual practices of the participating organizations.

Based on the multiple case study, we were able to describe the actual practices for each organization case in its particular context. Several major findings emerged from this description. First, the activities outlined in the organizational policies and procedures were consistent with the legal provisions of the AIAOD (right to RTW, temporary assignment, rehabilitation, etc.). However, other essential activities not stipulated in the AIAOD were found to be theoretically understood by most of the players, but rarely applied in reality. Next, a gap was also found between what was written or formally recognized as the organization’s procedures and what was done in actual practice in the workplace. A last finding concerned the diversity of these practices. For instance, specific actions (e.g., assigning the worker to light tasks, making sure a temporary assignment involves gratifying work, having the worker gradually resume job tasks) taken by one or more players (supervisor, disability and RTW administrator/counsellor, worker, etc.), attitudes fostering communication and cooperation among all internal and external players involved in the worker’s RTW process, and concerted action by the supervisor and worker regarding work adjustments and accommodations were all procedural elements that were applied differently, depending on the varying conditions found in the organizations. The lack of formalization of organizational policies and procedures could explain this wide variation. Formal procedures (e.g., accident investigation and temporary assignment) were applied in different ways, even when the players appeared to be familiar with the procedures. The lack of formalization of other procedural elements (e.g., contacting the worker as soon as possible after the accident; choosing, planning, implementing, and following up on the RTW solution, etc.) left room for a wide range of practices within a given player category (supervisor, disability and RTW administrator/counsellor, union) and within a given organizational context.

Lastly, the multiple case study highlighted a number of similarities and differences among the participating organizations’ practices. Similarities were found in the implementation of the legal provisions regarding accident prevention (Québec’s Act Respecting Occupational Health and Safety, or AOHS) and the right to return to work (AIAOD), and were specific to the Québec context. Thus, the establishment of temporary assignments and the adaptation of work stations and jobs, even before medical consolidation of the injury, were rigorously applied in all the organizations. These provisions stem from legal obligations and reflect the chronicity prevention policies of Québec’s Commission des normes, de l’équité, de la santé et de la sécurité du travail (CNESST, or labour standards, pay equity, occupational health and safety board). Differences were associated with various elements of the organizational context. For instance, according to the players interviewed, a prevention culture that fosters dialogue between supervisors and workers helps not only to prevent other accidents of the same type, but also to accommodate workers as they progress toward a sustainable recovery. Moreover, it allows players to better prepare for RTW situations. In addition, the key players’ RTW experience with returning workers differed from one organization to the other. The more workers that the supervisors had to supervise, the more likely they were to have to deal with RTW situations. Conversely, those who supervised small teams rarely had to face such situations and, unless they were well equipped (training, procedures stipulating formally defined roles and responsibilities, etc.), they were ill-prepared to meet production requirements while also respecting the workers’ limitations.

The comparison of the best practices gleaned from the literature with the actual practices described on the basis of the multiple case study brought three types of discrepancies to light. They concerned the different ways of carrying out the activities essential to sustainable RTW, the structures and resources made available to the key players to facilitate the actions associated with these essential activities, and the lack of formalization of policies and procedures within the organizations studied. It would be advisable for these organizations to heed some key messages emerging from the highlighted discrepancies in order to come up with ways to improve the transfer of theoretical knowledge into practice. First, formalization of the organization’s RTW policies and procedures, along with providing players with information and training on the different actions to be taken, would help clarify their roles and responsibilities, as well as facilitate joint decision making about work adjustments and accommodations and about process improvement. Next, resources and structures that foster both the supervisor`s and worker’s involvement in choosing, implementing, and following up on the RTW solution would help take into account the fit between production requirements and the worker’s functional capacities, and establish a forum for dialogue conducive to work adjustments and accommodations. The RTW solution should be envisaged as soon as possible after the accident, taking into account tasks that are gratifying and meaningful for the worker, while respecting the progression in his capacities. Lastly, coordination by players in the organization and the carrying out of essential activities, such as communication and collaboration among all players (both internal and external), should promote the co-construction of an RTW solution that is appropriate and fair for both the injured worker and the other workers in the organization. To reduce the discrepancies between theoretical and scientific knowledge, on the one hand, and actual practices, on the other, organizations should consider four possible courses of action: (1) develop clear and formal procedures that specify the actions associated with essential activities in the RTW process, for the players and various stages/phases of the process; (2) promote structures based on communication and cooperation among all players concerned; (3) raise management’s and workers’ awareness of the importance of an early RTW; and (4) provide key players with training on the essential activities to be carried out to facilitate the RTW of workers compensated for MSDs.

These results offer a number of benefits. From a scientific standpoint, the synthesis of best practices highlights certain strategic elements (the main phases/stages in the RTW process, the actions needed by phase/stage and by key player) applicable at different levels of action (characteristics, principles of action, strategies essential to successful RTW) in the Québec context. At the same time, the multiple case study documents how the RTW process is actually understood and applied in the organizations. The comparison of the results of the multiple case study with the findings of the literature review brings to light a number of discrepancies and provides insight into the contextual elements underlying these variations in Québec organizations. To the best of the authors’ knowledge, this study is one of few to have compared what is recommended in research with what is applied in organizations in actual practice, using concrete RTW situations. Based on current knowledge, this study provides partial or possible solutions for managing workers in RTW situations following MSDs, taking into account the specific requirements of Québec legislation. From a practical standpoint, for the participating workplaces, the results of the study help clarify the strong points and the weaker areas where procedures and practices could be improved with regard to their impact on the RTW. This study could serve as the basis for a future study on the development/revision of the RTW procedure.