We present stakeholders’ perceptions of (1) functions of the participatory supportive RTW program, (2) barriers for a successful execution of the program, and (3) facilitators for a successful execution of the program. We distinguished between perceived functions of the program’s separate components, i.e., integrated care, a participatory approach and direct placement in a competitive job. Subsequently, frequently mentioned barriers and facilitators for a successful execution of the program were summarized. We distinguished between perceptions by different stakeholders, when they had different points of view.
Perceived functions of the participatory supportive RTW program
Perceived functions of integrated care
The insurance physicians thought that the communication and cooperation between them and the clients’ healthcare provider(s) had improved after they had contacted the healthcare provider(s).
Insurance physician 1: “I believe that working together for a client can have a positive effect, because it leads to respect for each other’s discipline.”
Insurance physician 2: “It leads to interaction, while normally you ask for information and that’s it.”
Another perceived function of this component of the participatory supportive RTW program was a shift in paradigm by the healthcare providers from a disability-oriented approach to an approach in which work became more central.
Insurance physician: “My experiences were positive, because the healthcare providers became aware of the clients’ participation in the program and also responded positive to the focus on work resumption. So, this had opened the healthcare providers’ eyes and they were no longer solely focused on the health complaints of their clients.”
However, the insurance physicians not always thought it was necessary to contact the clients’ healthcare provider(s). One of the insurance physicians stressed that only sick-listed workers with mild (mental health) problems participated in the participatory supportive RTW program. Therefore, no conflicting advice could be expected. In case of more severe problems, the insurance physician would not have the client start with the program.
The clients indicated that work resumption was barely discussed with their healthcare providers. They also had not received any conflicting advice from their healthcare providers regarding their possibilities for RTW.
Client 4: “Of course he understood my situation. He told me: ‘You’re not fit. You’re not at your best. You should realize that your chances of getting hired are extremely small.”
Perceived functions of a participatory approach
The RTW coordinators and labor experts thought that it was important to actively involve the client in the creation of a RTW action plan and also believed that this participatory approach had actually led to a more active participation in vocational rehabilitation by the client.
Labor expert: “Normally we ask clients about their background and we discuss some obstacles, but then we mainly speak about limitations that were noticed by the physician. Now, clients had to come up with their own ideas about obstacles and suggestions to overcome these obstacles. This self-reflection was hard, but it helped to get them in another mindset.”
According to the labor experts and RTW coordinators, many clients were strongly involved in the identification of obstacles and finding solutions and suitable work. However, they also thought that the input of the clients varied.
Another function of the participatory approach, perceived by these stakeholders, was that it had helped clients to get a better understanding of their barriers and possibilities for RTW.
Labor expert: “I found it very surprising how clients already had made some important steps in the time between the meeting I had with them for the identification of RTW obstacles and subsequently the brainstorm session in which they discussed solutions to overcome these obstacles with the RTW coordinator, because it was clear for them what was the core of their problems and which of their problems they could influence.”
The clients did not mention these functions when they reflected on the counselling they had received by the SSA. From their perception, obstacles for RTW and solutions to overcome these obstacles had barely been discussed. They thought that they had received not enough counselling by the SSA, as was explained by one of the clients:
Client 2: “They assessed my capabilities and such. They also contacted the vocational rehabilitation agency. Then that part of the program started. And if there were any questions, I could contact them. But these did not really occur. We simply proceeded with the program and I did not receive any further support.”
Perceived functions of direct placement in a competitive job
All clients indicated that their participation in the participatory supportive RTW program did not result in RTW in a competitive job. Also the other stakeholders confirmed that the program in many cases did not have the intended result, as many of their clients were not placed in competitive employment.
When the case managers of the vocational rehabilitation agencies were asked what actually had been done after referral of the client to their agency, they explained that they had put in a lot of effort to place the clients in a suitable job. They stressed that they did more than solely job hunting, e.g., helping the client with the writing of their CV and preparation for a job interview.
When describing the support they had received from the vocational rehabilitation agencies, some clients told that the case manager had not taken their job preferences into account and they had been treated like numbers. Others indicated that they had been in regular contact with the case manager who had helped them with their CV and application letters. Some mentioned that the case manager also had contacted companies to look for job opportunities. As a result, some clients were more positive than others. Still, most of them emphasized that they had received too little support from the case managers.
Client 1: “I had one meeting with her and she would set to work. Finally she called me and said: ‘I never hear anything from you’. I asked her: ‘But shouldn’t I hear something from you?’ Actually, I did not understand anything of it.”
The RTW coordinators of the SSA were responsible for monitoring the implementation of the RTW action plan. They also thought that the quality of the contracted vocational rehabilitation agencies differed a lot. They were dissatisfied with one agency, because of poor communication and involvement of this agency, but satisfied with another agency, because this agency started their job search very early after referral of a new client to their agency.
When clients were asked about their own participation in the program, they often indicated that they had been looking for job opportunities by themselves and had applied for several vacancies. They all wished to return to work. Some had found a voluntary job.
The case managers were quite positive about the cooperation by the clients in the search for a suitable job. However, in some cases they thought that the client could have participated more actively.
Perceived barriers for a successful execution of the participatory supportive RTW program
Poor collaboration between the Dutch SSA, the vocational rehabilitation agencies and the (mental) healthcare sector
The professionals of the SSA mentioned several barriers that were related to a poor collaboration between their service and the contracted vocational rehabilitation agencies and/or the mental healthcare sector.
One of the insurance physicians explained that, because of segregation of services by the SSA and the healthcare sector, it was sometimes difficult to get in touch with the clients’ healthcare providers.
Insurance physician: “That could be very time consuming. Some of the healthcare providers I could not reach by telephone. I even did not get their numbers. Once, the assistant of a general practitioner did not want to give me the number of a healthcare provider, because she was not sure that I was who I said that I was.”
Another example of a poor collaboration mentioned by the SSA professionals was that the vocational rehabilitation agencies often analysed obstacles and solutions for RTW, while this was already done by the SSA. During the application of a participatory approach at the SSA, an action plan for RTW was made. From the perspective of the SSA professionals, the RTW action plans were useful in the search for a competitive job, as these summarized the most important obstacles for RTW, preconditions for RTW and suitable work. However, they thought that the agencies made only little use of the information in these action plans. This was confirmed by the case manager of one of the contracted vocational rehabilitation agencies, who explained that it could sometimes be necessary to use a broader perspective:
Case manager of a vocational rehabilitation agency: “We talked with our client about what was discussed with the SSA, to see if this was still applicable. That was often the case. Sometimes we also considered other possibilities than the ones discussed by the SSA, so that we could use a broader perspective for our search. This was sometimes necessary, because we had to take the limited opportunities in the labor market into account.”
The RTW coordinators of the SSA also admitted that, mainly due to time constraints, after referral of the client to the vocational rehabilitation agency they often had only limited contact with the client and barely monitored the actual implementation of the RTW action plans.
Type of (health) complaints
According to all stakeholders the type of (health) complaints experienced by the clients sometimes hampered a successful execution of the participatory supportive RTW program. In other words, the participatory supportive RTW program was not always considered suitable. In case the program was not seen as appropriate, this was often related to the perceived severity of the client’s (mental health) problems.
The insurance physicians indicated that for clients with severe (mental) health problems, participation in the program early after sick-listing could be too demanding, because of its intensity and early focus on work, and they were afraid that it would worsen their complaints.
Insurance physician: “Often it concerned more complex cases, clients who needed attention on multiple aspects to improve functioning. In those cases, the program would have counteracted its purpose, because having to visit different professionals who ask different things would have been too demanding and intensive. It seems easy, but for some this is a huge task.”
One of the RTW coordinators emphasized that for clients who participated in the participatory supportive RTW program it could be very difficult to point out obstacles for RTW, as a consequence of their mental health problems:
RTW coordinator: “I believe that when you have serious mental health complaints, you can’t think clearly anymore. You don’t know exactly what has caused your complaints and what your capabilities are.”
Mentioned by both labor experts and RTW coordinators was the difficulty to come up with solutions for obstacles for RTW, when these obstacles were related to the experienced mental health problems.
Labor expert: “When someone has psychological problems it is more difficult to find a solution, then when someone faces a more concrete return to work obstacle”
Also the placement in a competitive job was according to many stakeholders sometimes hampered by characteristics of the clients, such as an older age, a large distance to the labor market, a lack of application skills, passivity and mental health problems. According to some, this could lead to feelings of uncertainty, which formed another major obstacle for RTW.
Client 4: “You have to compete with the rest of the world, while your own perception is that you’re not capable enough. That’s like being placed inside a boxing ring, together with professional boxers, while you’re still nothing.”
Case manager of a vocational rehabilitation agency: “…not searching for vacancies, because they were so insecure about their own capabilities that it complicated their job search. Every time they asked themselves: ‘Am I capable enough?’.”
One of the case managers believed that the presence of mental health problems sometimes resulted in passivity and a lack of motivation. According to this case manager some clients also placed great demands on a vacancy, which made it difficult to find a suitable job.
Some of the professionals doubted if the client was ready for RTW, given his or her mental health problems. They thought that these clients needed more training prior to placement in a competitive job, such as training in empowerment or application skills, to increase their confidence, skills and motivation.
RTW coordinator: “To be able to return to work, sometimes an increase of their mental resilience was necessary.”
All stakeholders indicated that a lack of time was an important barrier for a successful execution of the program.
The labor experts and RTW coordinators stressed that the application of a participatory approach was very intensive. On the one hand this gave them the opportunity to get a full understanding of the client at an early stage and to gain the client’s confidence in their counselling. On the other hand, it was time consuming and asked a lot from both professionals and clients.
An important obstacle mentioned by all stakeholders was a lack of capacity at the SSA or vocational rehabilitation agency, often resulting in limited time to execute the program.
RTW coordinator: “The workload at our department was high and we had to achieve several targets. Because there were no performance indicators for our participation in the Co-WORK study, often this work was done after other work was finished.”
As was illustrated in this last quote, the limited capacity was partly related to the study setting. The participatory supportive RTW program was not part of the daily practice of the professionals and there were often other competing priorities. Moreover, only a few professionals in the organizations were trained in the program. In this way, it was not always possible to schedule all steps of the program in accordance with the prescribed time frame, as was explained by one of the labor experts:
Labor expert: “In this way, every team member has to be available all the time. The workload was very high.”
The case managers found that the period of 2 to 3 months in which they had to place the client in a suitable competitive job was too short, especially when the client was still facing mental health problems.
Case manager of a vocational rehabilitation agency: “Given the problems of some people, or actually the majority of the people, a time-frame of 2 to 3 months appeared to be rather short sometimes. You want to get someone back on track very quickly, while sometimes there are serious complaints that get in the way and that need more attention.”
Also many clients stressed that the received support for their job search was too short in time.
Limited labor market opportunities
A frequently mentioned barrier was the limited availability of suitable paid jobs in the Dutch labor market during the execution of the program, caused by the economic recession at the time.
The labor experts and RTW coordinators thought that in this situation it was difficult to think of suitable work. A RTW coordinator explained that it was often difficult to convert the preconditions for RTW into a concrete job:
RTW coordinator: “You can wish to work on your own, because you can’t work together, or to get only one task at a time, or to have a break every ten minutes. Then you have figured out how you could function, but when you present these wishes to an employer, it is not realistic to think that they will offer you a job. Sometimes these work solutions may have been helpful, but they were not realistic to present to an employer.”
Many stakeholders acknowledged that the clients often had to compete with a large number of other job seekers and many of them believed that an employer was not willing to hire an employee who is not fully employable.
Perceived facilitators for a successful execution of the participatory supportive RTW program
Diminishing capacity needed
A facilitating factor mentioned by the labor experts was diminishing the number of professionals involved in the program, for example by letting the RTW coordinator perform all steps of the participatory approach. According to them, in this ways the capacity problem could be tackled.
One of the RTW coordinators and one of the case managers thought that involvement of the vocational rehabilitation agency in the development of the RTW action plan could have facilitated the search for a suitable job. Because of their knowledge of the labor market, the case managers could have helped matching the clients’ wishes and preconditions for RTW with opportunities in the labor market.
Creating opportunities in the labor market
Some clients, and also a few professionals, indicated that it would also have helped if the vocational rehabilitation agencies had already made some work arrangements with employers, including arrangements regarding therapeutic or sheltered workplaces. They stressed the importance of work and also of voluntary work, which could serve as a stepping-stone to more sustainable employment and help clients to become more self-confident.