Return to Work for People with Common Mental Disorders: Insights into the Implementation of a Collaborative Program in a Specialized Mental Health Hospital.

Purpose Common mental disorders (CMDs) are a major cause of sick leave. Return-to-work (RTW) interventions providing mechanisms that support the participation and collaboration of the different stakeholders appear promising in these circumstances. The Therapeutic Return-to-Work (TRW) Program offers such mechanisms designed to enable affected workers to fully reintegrate into their jobs on a sustainable basis. This study evaluated the feasibility of implementing this program for workers with CMDs, within a specialized mental health hospital. Methods The study was conducted using a multiple case design and three main data sources: (1) the worker's medical file, (2) the log completed by the clinicians, and (3) individual interviews with stakeholders. Data were analyzed using a qualitative approach. Results Twelve workers between 32 and 60 years old, mostly women with complex mental health profiles working in large enterprises, participated in this study. Three main observations were made regarding the TRW Program implementation: (1) eight cases were characterized by complete or virtually complete implementation; (2) no explanatory factor could be identified for the different implementation levels; (3) eight cases achieved RTW success (RTW to the original job or another job), which appears partially attributable to the high level of program implementation. Conclusions: The TRW Program seems highly promising for supporting the return to work of workers with CMDs. However, studies identifying the factors likely to influence the implementation process in different health service contexts and specifying the scope and nature of the program's actual impact on RTW outcomes should be conducted before larger-scale implementation takes place.

Ethnocultural Minority Workers and Sustainable Return to Work Following Work Disability: A Qualitative Interpretive Description Study.

Purpose This article provides a state-of-the-art review of issues and factors associated with the sustainable return to work (S-RTW) of ethnocultural minority workers experiencing disability situations attributable to one of four major causes: musculoskeletal disorders, common mental disorders, other chronic diseases or cancer. Methods Using an interpretive description method, an integrative review was conducted of the literature on ethnocultural factors influencing S-RTW issues and factors associated with these four major work-disability causes. An initial review of the 2006-2016 literature was subsequently updated for November 2016-May 2021. To explore and contextualize the results, four focus groups were held with RTW stakeholders representing workplaces, insurers, the healthcare system and workers. Qualitative thematic analysis was performed. Results A total of 56 articles were analyzed and 35 stakeholders participated in four focus groups. Two main findings emerged. First, belonging to an ethnocultural minority group appears associated with cumulative risk factors that may contribute to vulnerability situations and compound the complexity of S-RTW. Second, cultural differences with respect to the prevailing host-country culture may generate communication and trust issues, and conflicts in values and representations, in turn possibly hindering the establishment of positive relationships among all stakeholders and the ability to meet workers' needs. Being a woman in these groups and/or having a lower level of integration into the host country's culture also appear associated with greater S-RTW challenges. Conclusions Based on our findings, we recommend several possible strategies, such as the cultural humility model, for preventing differences from exacerbating the already significant vulnerability situation of some ethnocultural minority workers.

Building a Common Language to Facilitate Discussion Among Stakeholders in Work Disability: A Consensus Group Approach.

PURPOSE: Work disability stakeholders may not share the same understanding and solutions among themselves or with researchers, causing misunderstandings and hindering collaboration regarding solutions for preventing work disability. To reduce such differences, this study sought to build a common vocabulary among stakeholders and researchers, using a transdisciplinary research framework. METHODS: A consensus method based on a constructivist approach was used. A theoretical sampling method was applied to identify researchers or stakeholders representing one of the four systems in the work disability paradigm. A preliminary set of definitions for key terms was assessed using a Web-based questionnaire. It documented participants' level of agreement with each term's inclusion and relevance in the field, and the clarity of the definition, while soliciting suggestions for other terms or clearer definitions. Disagreements were discussed at group meetings, yielding consensus on the final terms and definitions. RESULTS: Eleven stakeholders representing patients, employers, unions, healthcare professionals, and legislative and insurance systems, along with 10 multidisciplinary researchers, participated. The questionnaire yielded initial consensus on the inclusion and definitions of 49 terms, and 109 suggestions mostly for modified definitions (average = 6 suggestions/term). Two preliminary terms were excluded and three terms were added. Ultimately, 80 terms and their definitions yielded consensus. CONCLUSIONS: The process we used to build a common vocabulary was carried out within a transdisciplinary framework. It required a constructivist approach, promoting idea exchanges among participants and co-construction of generally agreed results. The results were rooted in local contexts, thus ensuring the same reference points, regardless of participants' different understandings.

How does Gender Influence Sustainable Return to Work Following Prolonged Work Disability? An Interpretive Description Study.

PURPOSE: A sustainable return to work (S-RTW) following prolonged work disability poses different challenges, depending on gender. This article provides a synthesis of gender differences in the issues and factors influencing the S-RTW of workers following such a disability. METHODS: Using an interpretive description method, an integrative review was conducted of the literature on gender differences in S-RTW issues and factors associated with four major causes of work disability. The initial review concerned the 2000-2016 literature; it was subsequently updated for November 2016-March 2020. To explore and contextualise the results, four focus groups were held with stakeholders representing the workplace, insurance, and healthcare systems and workers. Qualitative thematic analysis was performed. RESULTS: A total of 47 articles were reviewed, and 35 stakeholders participated in the focus groups. The prevailing traditional gender roles were found to have a major gender-specific influence on the attitudes, behaviours, processes and outcomes associated with S-RTW. These differences related to the (1) cumulative workload, (2) work engagement, and (3) expressed and addressed needs. CONCLUSIONS: The results highlight the importance of taking into account both professional and personal aspects when integrating gender issues into the assessment of workers' needs and subsequently into interventions.

Insights into the Sustainable Return to Work of Aging Workers with a Work Disability: An Interpretative Description Study.

Purpose A sustainable return to work (S-RTW) following prolonged work disability poses particular challenges as workers age. This article provides a synthesis of the factors and issues involved in a S-RTW process for aging workers following such a disability. Methods Using interpretive description methods, a critical review was conducted of the literature specifying return-to-work factors and issues for aging workers with regard to four major causes of work disability (musculoskeletal disorders, common mental disorders, cancer or other chronic diseases). The initial review concerned the 2000-2016 literature, and was subsequently updated for November 2016-December 2018. To further explore and contextualise the results of this literature review, four focus groups were held with stakeholders, representing the workplace, insurance, and healthcare systems and workers. Qualitative thematic analysis was performed. Results Fifty-five articles were reviewed and 35 stakeholders participated in the focus groups. Returning to work and staying at work appear to be particularly challenging for aging workers, who face notable issues and stigma concerning their ability to meet work demands, as well as their mobilisation and engagement in these processes. Such findings echo in many ways the main assertions of the literature on aging at work, except those regarding the transformation of capacities with aging, which is not mentioned in relation to workers with a work disability. The influence of healthcare and compensation systems on the S-RTW of aging work-disabled workers has also received little attention to date. Conclusions The results underscore that aging workers with a disability are frequently vulnerable in terms of their health or their jobs. Intersectoral efforts are needed to remedy this situation to keep them at work.

Development and Implementation of a Mental Health Work Rehabilitation Program: Results of a Developmental Evaluation.

Purpose Long-term work disability due to common mental disorders (CMDs) is a growing problem. Yet optimal interventions remain unclear and little is known about implementation challenges in everyday practice. This study aimed to support and evaluate, in real time, the development and implementation of a work rehabilitation program (WRP) designed to promote post-CMD return-to-work (RTW). Methods A 2-year developmental evaluation was performed using a participatory approach. At program outset, the researchers held five work meetings to revise the program's logic model and discuss its underlying change theory with clinicians. Data collection tools used throughout the study period were structured charts of activities conducted with workers (n = 41); in-depth interviews with program clinicians and managers (n = 9); and participant observation during work meetings. Quantitative data were analyzed using descriptive statistics. Qualitative data underwent thematic analysis using a processual approach. Results Three types of activity were developed and implemented: individual and group interventions targeting workers, and joint activities targeting partners (physicians, employers, others). While worker-targeted activities were generally implemented as planned, joint activities were sporadic. Analysis of the implementation process revealed five challenges faced by clinicians. Determinants included clinicians, host organization, sociopolitical context and resources provided by the evaluation. Conclusion The program studied is original in that it is based on the best available scientific knowledge, yet adapted to contextual particularities. The identified implementation challenges highlight the need for greater importance to be placed on the external, non-program context to ensure sustainable implementation in everyday practice.

Insurers' Influences on Attending Physicians of Workers Sick-listed for Common Mental Disorders: What Are the Impacts on Physicians' Practices?

Purpose In many jurisdictions, general practitioners (GPs) play an important role in the sick-leave and return-to-work (RTW) process of individuals with common mental disorders (CMD). Since it is insurers that decide on workers' eligibility for disability benefits, they can influence physicians' ability to act. The nature of these influences remains little documented to date. The aim of this study was therefore to describe these influences and their impacts from the GPs' perspective. Methods Semi-structured interviews were conducted with GPs having a diversified clientele (n = 13). The interviews were audio-recorded, transcribed verbatim and analyzed according to thematic analysis principles. Results The results indicated that the GPs recognized insurers as influencing their practices with patients on sick leave for CMDs. The documented influences were generally seen as constraints, but sometimes as enablers. The impacts of these influences on the GPs' practices depended on the organizational characteristics of their work context (such as limited consultation time) and other characteristics of their practice setting (such as lack of timely access to consultations with specialists). Conclusion The results brought three major issues to light: the quality of the information sent to insurers by GPs, the respect shown (or not) for workers' care preferences, and the relevance of the specialized services offered to support workers' RTW. These issues in turn reveal potential risks for workers, risks that need to be identified and recognized by all parties concerned if we are to come up with possible solutions.

[Supporting the return to work following sick leave for a depressive disorder: why and how?] / Soutenir le retour au travail après un arrêt de travail en raison d'un trouble dépressif : pourquoi et comment faire en soins primaires ?

Depressive disorders have become one of the main causes of sick leave in recent years. For the individuals concerned, the risk of long-term work disability is very real and generates considerable human and social costs, not to mention financial costs. Despite its importance, the issue of the return to work is rarely presented to primary care professionals, among others, as a priority to be factored into their clinical interventions. The latter thus have very few guidelines to help them choose the best intervention for promoting a timely return to work and may even question the relevance of such an objective.The purpose of this article is therefore to propose a set of reference points for primary care professionals by answering the following question: why and how should the return to work be supported following sick leave for a depressive disorder? The first part of the article provides an overview of current knowledge that supports the relevance of early intervention to the prevention of long-term work disability. The second part proposes a number of promising interventions for achieving this objective and feasible for primary care professionals. These proposals are based on recent research work by our team.

How do general practitioners contribute to preventing long-term work disability of their patients suffering from depressive disorders? A qualitative study.

BACKGROUND: Depression is a major cause of work absenteeism that general practitioners (GPs) face directly since they are responsible for sickness certification and for supervising the return to work (RTW). These activities give GPs a key role in preventing long-term work disability, yet their practices in this regard remain poorly documented. The objectives of this study were therefore to describe GPs' practices with people experiencing work disability due to depressive disorders and explore how GPs' work context may impact on their practices. METHODS: We conducted semi-structured individual interviews with 13 GPs and six mental healthcare professionals in two sub-regions of Quebec. The sub-regions differed in terms of availability of specialized resources offering public mental health services. Data were anonymized and transcribed verbatim. Thematic analysis was performed to identify patterns in the GPs' practices and highlight impacting factors in their work context. RESULTS: Our results identified a set of practices common to all the GPs and other practices that differentiated them. Two profiles were defined on the basis of the various practices documented. The first is characterized by the integration of the RTW goal into the treatment goal right from sickness certification and by interventions that include the workplace, albeit indirectly. The second is characterized by a lack of early RTW-oriented action and by interventions that include little workplace involvement. Regardless of the practice profile, actions intended to improve collaboration with key stakeholders remain the exception. However, two characteristics of the work context appear to have an impact: the availability of a dedicated mental health nurse and the regular provision of clinical information by psychotherapists. These conditions are rarely present but tend to make a significant difference for the GPs. CONCLUSIONS: Our results highlight the significant role of GPs in the prevention of long-term work disability and their need for support through the organization of mental health services at the primary care level.

How patients' representations of cystic fibrosis-related diabetes inform their health behaviours.

BACKGROUND: Although diabetes is a frequent complication of cystic fibrosis (CF), patients' behaviours tend not to comply with best practice recommendations. Using Leventhal's Common-Sense Model, we address this issue by exploring patients' representations of CF-related diabetes (CFRD) to better understand the discrepancy between patients' expected and observed health behaviours. METHODS: Semi-structured individual interviews were conducted with patients (n = 39) in six CF clinics in Quebec, Canada. These interviews were part of a larger research project on screening and management practices for CFRD. RESULTS: Illness representations differed between two groups of interviewed patients: (1) one group had either CF without dysglycemia or CF with impaired glucose tolerance; and (2) the other group had CFRD. Both representations were internally consistent and encompassed Leventhal's five dimensions of illness representation: illness identity, cause, timeline, consequences and control. CONCLUSIONS: Patients require specific information on CFRD. The screening phase could be a crucial time to help patients adjust their representations to fit the reality of CFRD.

[Multimorbidity and primary care: Emergence of new forms of network organization]. / Multimorbidité et soins primaires : émergence de nouvelles formes d'organisation en réseau.

OBJECTIVE: This study was designed to analyse the adaptive strategies used by primary care professionals to provide more adapted and continuous services to patients with more than one chronic disease. METHODS: A qualitative case study was conducted in a primary care structure (GMF in Québec). Data were derived from two sources: semi-structured interviews and documents. Based on our thematic analysis of data, we illustrate the adaptive processes at play. RESULTS: Our analysis identified the challenges raised by the increased prevalence of patients with more than one chronic disease and how they influence adaptive strategic initiatives from professionals at the following levels: (1) the patients themselves, (2) the professional-patient relationship, (3) the relationships between professionals of the GMF (4) the relationships between the GMF and other healthcare organizations. The description of these phenomena illustrates the dynamic emergence ofa network form of organization. CONCLUSION: This phenomenon leads to transformation of the core of the healthcare production system. A deeper understanding of its emergence, impacts and management is necessary.

[Integrating mental health and addiction services: the encounter of two worlds]. / Intégration des services en santé mentale et en toxicomanie: processus de rencontre de deux mondes.

OBJECTIVE: The needfor integrated services to treat co-occurring disorders is now recognized. Specialised clinics have now been created for this purpose. This study analysed the integration process that occurred in a particular clinic in order to identify the strategies and means used and their overall impact. METHODS: We conducted a longitudinal case study. Data collection was based on three sources: semi-structured interviews, observations and documents. It took place over a period of 3years and covered the first 6 years of the clinic transformation process. We analysed data from a process perspective. The analysis was also validated by informants. RESULTS: Our analysis shows that the pursuit of integration is associated with important challenges at various levels: patient populations, professional practices, structural framework, inter-organizational relationships. These challenges were encountered right from the creation of the clinic. Various strategies and approaches were used to reduce the tensions raised by these challenges and had a considerable impact on the integration process. However, our analysis reveals that integration is an ongoing process that is never completely achieved. In fact, challenges are never completely resolved, but tend to be transformed, raising new tensions to which members of the organization respond with new strategies and means to ensure a continuing integration process. CONCLUSIONS: These resultsforce us to reconsider the integration of services, not as a fixed result but rather as an object of change emerging from a complex process with an unknown outcome. Four important implicationsfor practice are derived from these results.

Sensemaking: a driving force behind the integration of professional practices.

PURPOSE: There has been considerable effort in recent years to link and integrate professional services more closely for patients with comorbidities. However, difficulties persist, especially at the clinical level. This study aims to shed light on these difficulties by examining the process of sensemaking in professionals directly involved in this integration. DESIGN/METHODOLOGY/APPROACH: The authors conducted an eight-year longitudinal case study of an organization specializing in mental health and substance abuse. Different data collection methods were used, including 34 interviews conducted between 2003 and 2009, observations and document analysis. The authors performed a qualitative analysis of the data using a processual perspective. FINDINGS: This paper provides empirical insights about the nature of the sensemaking process in which professionals collectively participate and the effects of this process on the evolution of integrated services. It suggests that the development of integrated practices results from an evolutional and collective process of constructing meanings that is rooted in the work activities of the professionals involved. PRACTICAL IMPLICATIONS: By drawing attention to the capacity of professionals to shape the projects they are implementing, this study questions the capacity of managers to actually manage such a process. In order to obtain the expected benefits of integration projects, such emergent dynamics must first be recognized and then supported. Only then can thought be given to mastering them. RESEARCH LIMITATIONS/IMPLICATIONS: The fact that this is a single case study is not a limitation per se, although it does raise the issue of the transferability of results. Replicating the study in other contexts would verify the applicability of the authors' conclusions. ORIGINALITY/VALUE: This study offers a fresh perspective on the difficulties generally encountered at the clinical level when trying to integrate services. It makes a significant contribution to work on the dynamics of sensemaking in organizational life.

Integrating services for patients with mental and substance use disorders: What matters?

BACKGROUND: Over the past decade, practice standards have recommended that people suffering from both mental and substance use disorders receive integrated treatment. Yet, few institutions offer integrated services, and patients are too often turned away from psychiatric and addiction rehabilitation services. PURPOSE: The purpose of this study was to identify key factors in integrating services for patients with co-occurring disorders. METHODOLOGY: We conducted a process evaluation with the aim of identifying factors that enhance or impede service integration. First, we elaborated a sound conceptual framework of service integration. We then conducted in-depth case studies analysis using socioanthropological methods (interviews with managers and professionals, focus groups with patients, nonparticipant observation, and document analysis). We analyzed two contrasted forms of services integration, a joint venture and a strategic alliance, separately and then compared them. FINDINGS: The integrations achieved in the two cases were of different intensities. However, from our study, we were able to identify various levers and characteristics that affect the development of an integrated approach. Reflecting on the dynamics of these two cases, we formulated six propositions to identify what matters when integrating services for persons with mental and substance use disorders. PRACTICE IMPLICATIONS: The integration of services transcends debates on care models and must be focused on the patients' experience of care. The process should stimulate a learning experience that helps to align practices (normative integration) and to integrate teams and care. In this study, we identified a number of key conditions and levers for success.