Nineteen factors related to RTW-ES were identified after analyzing arguments and grounds of LE's derived from two CLBP cases. Twelve of these 19 factors can be fitted within a single domain of the ICF model. The factor functional capacity is related to 'activities'. Factors in the personal domain related to RTW-ES include age, educational level, competencies, tenure, attitude, self-efficacy and illness perception. Factors in the environmental domain related to RTW-ES are work-relatedness of the sickness absence, job availability, the relation between employer and employee, and employer's attitude. The remaining seven factors can not be fitted within the ICF model. These factors are categorized under intervention (i.e. training/education, job offerings, professional advice), job accommodation (i.e. temporary/modified duty, change of employer), and measures (i.e. assessment, monitoring).
To compare our results with other studies with regard to generalization, no literature about the relation between factors found in research on RTW and factors related to the assessment of RTW-ES was available [4
]. We decided to compare the factors found in this study to the existing literature on factors related to RTW to investigate consistencies and differences between the factors related to these outcomes.
The 19 factors found to be relevant to RTW-ES in CLBP patients in this study are mostly consistent with literature on RTW. For example, the relation between a higher age, educational level and attitude of the employee and RTW has also been found in literature [26
], however, the interpretation and direction of the relevant factor can be different when considering RTW-ES. Literature concerning RTW in patients with CLBP states that the remaining functional capacity is strongly related to RTW after sickness absence [27
]. It can be assumed that this is also a reason to take functional capacity into account when assessing RTW-ES. Fewer efforts can be undertaken when an employee with limited capacity is involved. If the employee has limited remaining capacity, efforts to RTW could be considered less useful. Nevertheless, it can also be assumed that more efforts should be undertaken to promote RTW of employees with limited functional capacity, as it will be harder for them to RTW. Another example is the effort of offering temporary or modified work. Research on RTW in CLBP has found that RTW increases the well-being of the sick-listed employee [16
], and that temporary work shortens the time to RTW [28
]. Literature has also shown that the lack of modified work is related to the transition from acute to chronic LBP [30
], and the availability of modified work might therefore be relevant when the effort sufficiency during the RTW process is assessed after two years.
According to LE's, investigating and offering temporary or modified work is related to RTW-ES, but they state that non-temporary work is preferred over temporary work.
When considering RTW-related outcomes, both RTW and RTW-ES can be of interest to the RTW process [4
], but the literature of RTW can not simply be transcribed to RTW-ES. For example, undertaking an effort (e.g. offering training or education) can be considered essential to RTW-ES because it influences factors relevant to RTW-ES (positive attitude of the employer, self-efficacy of the employee), regardless of whether the training has proven to be effective to RTW. In our previous research we have examined the strength and relevance of factors related to RTW-ES and RTW among employees applying for disability benefits after 2 years of sickness absence [4
], and have investigated the comparability of the factors related to these two outcomes. We have concluded that different factors are relevant to RTW-ES and RTW, but the relationship between employer and employee is relevant to both. The lack of similarity between these outcomes can be explained by the relative independence of the outcomes. For example, RTW-ES can be sufficient or insufficient, regardless of RTW outcome. For example, when the RTW outcome is sufficient, the RTW efforts are assumed to be sufficient as well. However, RTW outcome can be sufficient despite lack of RTW-ES, and in cases where RTW efforts are sufficient the RTW outcome can be negative.
A strength of this study is that this is the first study that explores the implicit knowledge used by professionals to assess RTW-ES. Using a focus group method has proven to be an intensive but effective method to collect the implicit knowledge of LE's. In order to gather a wide range of arguments, grounds and factors, two focus groups have been assembled, each using a different case. Moreover, to ensure the quality of the results, we have used a method to collect arguments which was as close as possible to being a natural situation while maintaining standardization. This way, the arguments collected by each LE could be used for group-wise discussion.
Another strength lies in the universal phrasing of the grounds mentioned by the LE's and the factors derived from these grounds. Discussions focused mostly on the applicability of the ground, i.e. if the ground could apply to all imaginable cases. For example, reorganization might not in all cases limit job availability for the sick-listed employee. Of course, some grounds (e.g. regarding the responsibilities of the employer) can be viewed in context: Dutch legislation requires the employer to undertake all efforts necessary to promote the RTW of the employee. However, these efforts are not specified, and mostly the procedural aspects and the relation between RTW efforts and RTW results are described in detail. Moreover, efforts to promote RTW are beneficial to RTW regardless of the legislatory consequences (financial or otherwise). A good employer-employee relationship is beneficial to RTW [7
] and is important to RTW-ES regardless of whether the employer will experience financial consequences.
Also of interest when considering efforts relevant to RTW-ES are the assessability (possibilities for discussion) and modifiability (possibilities of alteration) of factors. For example, no assessment is necessary for the factor age, which is also not modifiable. Self-efficacy, however, is a factor which is open to discussion and should be assessed by a professional, and is also modifiable.
A limitation might be that only two cases concerning CLBP were used. Using more cases or different cases might have yielded more factors. However, we feel that by selecting two cases which each concerned CLBP, but with different backgrounds and RTW processes, we have enhanced the opportunity to gather different arguments and discuss factors in an effective way. Furthermore, LE's from two Dutch SII's were included in the study. We do not know whether these LE's are representative of their occupational group. Future studies are necessary to reproduce and expand our findings. Another limitation related to the focus group method might be our use of actors for the roles of several stakeholders. However, our priority was to provide a standardized but realistic situation, which we feel we have achieved by training these actors to portray each stakeholder.
A further point of discussion might be that no factors related to 'disease', 'functions', and participation were mentioned by the LE's. The lack of factors fitted within these categories can be attributed to the Dutch context, where disease and functions are investigated by the Social Insurance Physician (SIP) and other medical specialists. LE's mainly consider the participation as an outcome, and investigate aspects related to activities, taking personal and environmental factors into consideration when assessing RTW-ES. Also, some factors that are relevant to RTW have not been mentioned by LE's (e.g. gender, work requirements, family support), and have not been discussed.
Furthermore, by categorizing the factors derived from the focus group study in the ICF model an attempt was made to provide a clear overview and improve comparability. The categorization of the factors related to actions (e.g. measures, intervention or accommodation) was subject of debate. The ICF model is used to classify components of functioning and disability, while the actions are focused on changing one or more of these components. Moreover, using the ICF model for actions is a complicated process, and requires reduction of actions into a series of observations which could be categorized in the ICF model. [14
]. The availability of training would be a factor related to the environmental domain, but the offering of the training and the effect of the training has an effect on several components (e.g. educational level, competencies, attitude and job availability).
The relevance of this study lies in that it is one of the first studies to investigate factors relevant to RTW-ES [4
]. The results found in this focus group study will provide an overview of factors relevant to the assessment of RTW-ES. The assessment of RTW-ES will remain a unique and multifactorial decision making process performed by a professional (i.e. the LE) based on the information which is available and the context it is placed in (e.g. legislation). However, providing factors relevant to the assessment of RTW-ES to the professionals who perform this assessment might make the assessment more evidence-based and could contribute to a more systematic approach of the assessment of RTW-ES.
Further research is required to investigate whether the results of this study can be replicated within a different context (e.g. another country, different focus group members), and whether they are relevant in cases where the patient has a disease other than CLBP (e.g. depression), or in cases where the patient has diagnosed comorbidity. In this study, the relevance of factors has been investigated, but no distinction has been made on the association itself, e.g. whether older or younger age is relevant to RTW-ES, and in what way. Further research could elaborate on the direction of the association. Also of interest to further research is whether the professionals all consider these factors during a similar assessment, and whether the interpretation (e.g. the importance of a factor in a specific case) is comparable. It should be investigated whether the introduction of the results found in this study (i.e. an evidence-based protocol) will contribute to a more systematic approach by the professionals assessing RTW-ES. Also, if professionals have access to similar information for the assessment of RTW-ES, this could benefit the reliability of the assessment and the argumentation used in the decision-making process.