The Importance, Measurement and Practical Implications
of Worker's Expectations for Return to WorkThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Disabil Rehabil 2015; 37 (20): 1808–1816 ~ FULL TEXT
Amanda E Young, Elyssa Besen, YoonSun Choi
Liberty Mutual Research Institute for Safety,
Center for Disability Research,
Hopkinton, MA, USA.
Purpose: Workers' own expectations for return to work consistently predict work status. To advance the understanding of the relationship between RTW expectations and outcomes, we reviewed existing measures to determine those which we felt were the most likely to capture the construct.
Method: A comprehensive search of the work-disability rehabilitation literature was undertaken. The review of the measures was conducted in three steps: first, a review of terminology; second, an examination of whether a time reference was included; third, an evaluation of ease of comprehension, and applicability across contexts.
Results: A total of 42 different measures were identified. One of the most striking findings was the inconsistency in terminology. Measures were also limited by not including a time reference. Problems were also identified with regards to ease of understanding, utility of response options, and applicability in a wide variety of research and applied settings.
Conclusions: Most previously used measures contain elements that potentially limit utility. However, it would seem that further development can overcome these, resulting in a tool that provides risk prediction information, and an opportunity to start a conversation to help identify problems that might negatively impact a worker's movement through the RTW process and the outcomes achieved. Implications for Rehabilitation Return to work is an integral part of workplace injury management. The capture of RTW expectations affords a way to identify the potential for less than optimal RTW processes and outcomes. A mismatch between an injured worker's expectations and what other stakeholders might expect suggests that efforts could be made to determine what is causing the injured worker's concerns. Once underling issues are identified, work can be put into resolving these so that the worker's return to the workplace is not impeded.
Keywords: Measuring expectations; return to work; risk prediction; work disability.
From the FULL TEXT Article:
Introduction
With an increasing number of studies finding that medical condition incompletely explains return to work (RTW) following occupational injury, the role of psychosocial influences has come into question. [1, 2] Of the psychosocial variables that have been examined, “expectation” has consistently been found to relate to outcomes. [3, 4] Researchers throughout the world have found that workers' predictions of future work status are related to the outcomes they achieve. Examples include studies from Canada [5–12], USA [13–16], Europe [17–24] and Australia. [[25, 26]
This phenomenon has not only been observed in numerous geographical and social settings, but also across a variety of health conditions, disability durations, and methods of scientific inquiry. A recent example was an investigation into RTW following carpal tunnel release [16] that found a worker's RTW expectations explained 36% of the variance in time to a return to modified duties (mean of 11.8 d) and 18% of the variance in time to a full RTW (mean of 18.9 d). At the other end of the research methodology spectrum, a qualitative study of chronic work disabled patients (off work for 18 months or more) found that negative expectations were perpetuating factors for long-term sickness absence. [27]
While study results indicate a relationship between expectations and RTW, to date, there has been a lot of diversity in the way researchers have defined and operationalized the concept. Issues related to expectations of the clinical course of the condition, for example, whether the patient was progressing as he or she expected, or what was the expected change in the condition or injury [28, 29], have been mixed with issues of future functioning measured through the expected time until return to usual activities [28], and/or the expected time to return to usual job. [30] Past research suggests that RTW outcomes can be affected by expectations pertaining to recovery from symptoms, re-injury, financial support, workplace support, compensation, and medical treatment. [6, 9, 11, 31, 32] In addition, there is research indicating that people with negative expectations about their recovery from low back pain have significantly greater odds of being absent from usual work. [3] Although we believe that RTW expectations are an aspect of general recovery expectations, we also feel that directly evaluating RTW expectations has important practical uses. In order to refine our understanding, it would seem that measurement should be narrowed in scope to specifically assess RTW expectations separate from more general recovery expectations. For this reason, we have chosen to focus this effort on workers' expectations for RTW. An additional consideration when interpreting the literature on expectations for RTW is that the focus has not always been on what the worker expects. Past research has included assessments of workers' healthcare providers. [33, 34] While we agree that asking about the expectations of other RTW stakeholders would likely prove insightful, for the current purposes, the focus is on the expectations of the injured worker.
Given the proliferation of research into RTWexpectations that has occurred over recent years, a review of measures used to assess the construct appears warranted and timely. To advance and refine the understanding of the relationship between RTW expectations and outcomes, we set out to review existing measures with the aim of determining those which we felt were the most likely to capture the construct. The review of measures is focused on those that have been used to gain an understanding of what injured workers “expect” their future employment outcomes to be. Measures were reviewed within the context of recommendations of an earlier review of recovery expectations, which called for a measure that is specific and time-based. [4] In addition, measures were assessed by the study team for ease of understanding, face validity, and practical application.
Method
A comprehensive search of the work-disability rehabilitation literature was undertaken to identify studies that included a measure of RTW expectations. The search strategy included review of the PubMed and PsychINFO databases from inception through April of 2014. The search terms used in the current review included any variant of “expect” (i.e. “expect*”) combined with any of the following phrases: “return to work”, “work disability”, “length of disability”, “sick listed”, “duration of disability”, “disability duration”, “occupational disability”, “work reentry”, “work re-entry”, “work preparation”, “work absence”, and/or “sickness absence”. To keep the search focused on injured workers' expectations, we included the additional requirement of having one of the following individual qualifier terms: “self”, “patient's”, “worker's”, “individual's”, “patients”', “workers”', or “individuals”'. In addition, relevant manuscripts were searched in an effort to identify additional relevant studies that were not found during the database search. The database search yielded a total of 325 articles in PubMed and 146 articles in PsychINFO for which we checked the abstracts. Studies were included in this review if they included an assessment of a worker's expectations regarding RTW, which was operationalized as returning to any work in any capacity (i.e. with no reference to hours, duties or restrictions).
In addition to the search outlined above, we conducted searches of the PubMed and PsychInfo databases using the search terms “return-to-work” or “RTW”, and “expectations” and omitted the requirement of having an individual qualifier term included. This resulted in the identification of seven additional articles (six from Pubmed and one from PsychInfo). When selecting the papers, we excluded studies focusing on workers' general recovery expectations that were not work-related, studies examining physicians' or rehabilitation clinics' expectations for RTW for their patients, and studies examining expectations about work ability once having returned to work. We also excluded articles that were not in English.
When planning and conducting the review, we consulted the literature for guidance regarding applicable theoretical underpinning that we could use to evaluate tools. Although there have been many studies addressing expectations for RTW, it would seem that the inclusion of the measure has grown informally or organically, rather than being informed by a theoretical framework. As such, evaluating measures on theoretical grounds was not possible. Alternatively, we chose a linguistic and practicability approach. The review of the measures was conducted in three steps. First, we examined the specific terminology used to assess RTW expectations. If a single item is to be used, we felt it would be best to use terminology that was as concrete and unambiguous as possible. Given that our aim was to identify a measure that we felt was most likely to capture an understanding of workers' RTW expectations, the decision was made to review the terminology previously used to identify that which we felt was the most likely to tap the construct.
Although it is possible, and likely, that terms such as “anticipate” and “predict” capture expectations, for the current purpose, we deemed the term “expect” (or some variant of this term such as “expectations” or “expecting”) to be the least ambiguous and have the greatest face validity. The second step of our review focused on whether a time reference was included in the measure. Simply asking workers if they expect to RTW provides little information about when this RTW may occur, and in turn, how to best facilitate this RTW in a timely fashion. As such, to increase the utility of measures of workers' expectations for RTW, and consistent with earlier recommendations [4], we deemed it important that a time reference be included. The third step involved our assessment of the instruments that used the term “expect” (or some variation) and included a time reference. Specifically, we evaluated each measure for ease of comprehension, utility of response options, and applicability across a broad range of contexts. Beyond this three-step process, general concerns with the reviewed measures with regards to their ability to capture workers' expectations for RTW are discussed.
Results
Ultimately, 57 papers were selected for inclusion in our review. In four cases [8, 33, 35, 36], the authors did not provide details of the measure used. In the remaining cases, the question(s) used to assess RTW expectations was contained within the manuscript, but in some instances, response options were not detailed. These, together with response options (if detailed), are summarized in Tables 1–3. In all, we identified 177 authors that had published on the topic, using a total of 42 different measures. In seven cases, these measures were reported more than once: in four cases, the measure had been reported in two manuscripts; and in three cases, the measure had been reported on three times. In general, measures that were reported more than once came from the same or similar authorship groups, and in four cases, multiple reports were due to multiple manuscripts reporting on one data set. Among the studies we assessed as eligible for inclusion in our review, we did not find a measure that had been used on more than one occasion by different researcher groups. [Note: The Orebro Questionnaire has been used by different researcher groups [e.g. 64–67]; however, when findings are reported, there was no mention of expectations for RTW. As such, they were either not captured in the search criteria, or deemed ineligible for inclusion because they did not reference the concept of interest, as was the case in the study by Bergstro¨m et al. [67] which reported measuring “expectations for work ability” (exact wording not provided).]
In Table 1, we present measures that used terminology beyond a variant of the word “expect” in their assessment of RTW expectations. Researchers have asked questions using a variety of other terms including: think, certain(ty), likely/likelihood, believe/belief, predict(ion), estimation of chances, opinion, and feelings. The most frequently used alternative to “expect” was “think”, see for example Heyman's et al., who asked: “When do you think that you will be able to work fulltime again?”. [41] Prior researchers also quite commonly asked about certainty; for example, Franche asked participants: “How certain are you that you can succeed in getting back to work?”. [38] Similarly, Turner et al., asked participants how certain they were that they would be working in 6 months. [15, 57] In a number of cases, researchers added an uncertainty component to their question, for example: “When do you think you are likely to return to work?”. [56]
Table 2 reports the measures that used the word “expect”, but did not include a time reference. Response options varied. Some measures assessed expectations for RTW as a simple yes or no question. [62] While this may be useful for identifying individuals who never expect to RTW, they have limited applicability because of the lack of specificity with regards to timing. In addition to the yes or no options, respondents have also been given the option to indicate that they were unsure/uncertain. [63] Within this context, it is challenging to understand the meaning of the response “uncertain”. Interpretation of the study's findings suggests that Schonherr et al. also struggled with this issue, in that they ended up reducing responses to a dichotomization (positive versus negative expectations). There were also instances where respondents were asked to respond using a scale. For example, Matheson et al. [61] asked respondents to rate on a 7-point scale from “definitely return to work” to “definitely not return to work”, the degree to which they expected to RTW.
The measures that include both the word “expect” and include a time reference are presented in Table 3. Although these measures include both components, most still have their limitations. These include using a time reference that is limited to the next weeks or months [22, 26, 71, 72] and not allowing for the option of not expecting to RTW. [16, 68, 76] Of the three remaining measures, interpretability is potentially limited due to the mention of both a RTW and normal leisure activities in the same question [76], the coding of “neither agreeing nor disagreeing” as “uncertain” [73, 74], and asking about duration of sick leave rather than time frames for RTW. [23]
Beyond the limitations outlined above, we had a number of additional concerns with the way RTW expectations have been measured. To summarize, these include:
Not asking what the individuals themselves expect will happen in their specific case [e.g. 60]
Referencing expected abilities (i.e. ability to do a task) as opposed to being able to do that task within the context of their work environment [13, 68–70]
Focusing on recovery, rather than RTW [5, 9, 39, 40, 58]
Not being specific with regards to what “[having] no expectations” would mean [71]
Choosing an outcome with significance that is different from, or beyond returning to work [e.g. 6, 9, 38, 62]
Choosing an outcome that is not applicable to a broad population [e.g. 53]
Wording that might be difficult for some workers to understand [e.g. 8, 26]
Despite the aforementioned concerns, there were several measures that we felt had positive features. In particular, we ranked highly the measure used by Cowan et al. [16] in their prospective study of persons returning to work after undergoing carpal tunnel release. The reasons for this are as follows. First, as it relates to our assessment criteria, it is specific to returning to work, but not too specific, meaning it is likely to have wide applicability. It also has the advantages of containing the word “expect”, and it has a sensitive timeframe component. In addition, in multivariate testing, the researchers found that the measure was the best predictor of both return to modified work, and full RTW. However, while the measure has these advantages, the question does not allow for an “I do not expect to return to work” option, nor does it allow for the assessment of how certain the worker is that their expectations will be realized.
Other measures that had features that we felt made them likely to contribute to the understanding of the phenomenon included the measure used by Heymans et al. [41] as it includes a “no idea” response option (i.e. in response to being asked when the worker thought they would be able to RTW, they could respond “no idea”). However, we might caution against including this as the last option following a list of timeframes, as doing so has the potential to provide unsure respondents with an easy opportunity to “opt out”. In this regard, the measure by Sampere et al. [21] appears to have merit because it encourages people to “give an answer, even if it is only an approximation”. We also saw value in the measures that made an attempt to capture the likely multidimensional nature of the phenomenon. See, for example, the measure used by Schonherr et al. [63], which included three questions addressing any RTW, a return to a different job, or plans for vocational retraining. And although not exclusively focused on RTW, a potentially good model is the Expectations Recovery Scale, used by Schultz et al. [11], which asks about getting better, returning to usual activities, returning to work within a month, and returning to the pre-injury job. Finally, the inclusion of the phrase “all things taken into consideration” as used by Cole et al. [6], comes across as thought provoking, which may have the potential of resulting in a more sensitive assessment.
Discussion
The results of our review indicate that, to date, there is very little consistency in the way researchers have gone about measuring workers' expectations for RTW. Probably, the most problematic is that questions do not necessarily ask the individual to indicate what they “expect” will happen, but rather, they ask the respondent to report on feelings, worries, certainties, opinions, likelihoods, beliefs, fears and anticipations. [11, 15, 19, 21, 38, 41]
Although terms are clearly related and may potentially be useful for assessing the construct of interest, the lack of consistency does not facilitate comparison, nor does it indicate a strong conceptual base. It is our position that the term “expect” has the best face validity, in that it appears to be the most direct and unambiguous of all the available options. As such, we would recommend its use in future research attempting to ascertain workers' expectations for RTW. However, we are not aware of any data that indicates whether or not these alternative forms of the question perform differently, or elicit significantly different responses, and suggest that this should be a topic for research.
A major limitation with several of the measures reviewed was that there was no timeframe for RTW included in the questions, or if there was, a specific time reference was included that limited application across a broad range of RTW situations. When no timeframe is included, it is impossible to separate individuals who expect to RTW in 1 month from those who expect to RTW in 2 years. In order to have a measure of RTWexpectations that may be used for both practical and comparative purposes, including the measurement of the timeframe for RTWseems critical. In terms of advancing the understanding of the phenomenon, a difficulty with many questions previously used is that they reflect the interest of the specific researcher or stakeholder groups (e.g. return to unrestricted duties). While this makes sense within the context of a single study, it does not facilitate cross-study comparison.
For us, one of the most striking findings was the inconsistency in terminology. Because of this, questions regarding the construct being measured can be raised. More specifically, one might ask: Is the observed relationship a reflection of the worker's expectations, or are workers making predictions about their future work outcomes? Or put another way, does the observed phenomenon reflect expectancies as theoretically defined? For example, are they along the lines of what Vroom proposed in his Expectancy Theory [78, 79] where motivational force is said to be the result of expectancy, instrumentality and valance? Alternatively, are they more along the lines of “response outcome expectancies” as defined in the Cognitive Activation Theory of Stress (CATS) [80]? Or, are workers making predictions along the lines of what economists refer to when talking about rational expectations theory, where expectations are considered to be the best guess of the future (the optimal forecast) that uses all available information [81]? While this is a topic for further theoretical debate, if it is the later, then the importance of the use of the term “expect” can be questioned. However, it should be noted that a shift in this direction has labeling implications.
When conducting this review, we were conscious of earlier work indicating the role of uncertainty in the construction of RTW expectations. [72] Perhaps tapping this, we found that a number of the measures referenced certainty. [15, 38, 41, 53, 57] While we agree that an assessment of the degree of certainty would seem to be a useful inclusion, we wonder if certainty is analogous to expectation. Rather, as discussed by Janzen et al. [83], we suggest that a level of certainty can be assigned to an expectation, and that collecting this information is useful for both risk prediction and applied purposes. As it relates to risk prediction, the inclusion of a measurement of certainty could provide greater sensitivity and specificity. And as it relates to use in an applied setting, including a certainty assessment provides an additional opportunity to identify and potentially resolve unrecognized stumbling blocks.
It should be noted that the purpose of our review was not to criticize what people have done in the past; rather, it is to define a path for moving forward. It is not our assessment that previously used measures are invalid; rather, that they have limitations which mean they are unlikely to suit a broad range of needs. The questions posed by the previous researchers suited their purposes; however, in terms of being an explicit measure of RTW expectations, which has the ability to be applied in a wide variety of research and applied settings, from our perspective, all previously used measures have their limitations. So, with all the limitations associated with past measures, what is the best question to use when attempting to gain an understanding of RTW expectations? Cognizant of earlier recommendations [4], and the considerations outlined above, we propose that the following questions have value for advancing scientific understanding and for those working in the field:Q1 “Do you expect to go back to work?”,
Response options: “yes”, “no”, “unsure”. If “yes” or “unsure”, go to Q2
Q2 “If you had to estimate your timeframe for going back to work, what would it be?
Response options: “Time from today: _____days/weeks/months (circle one)”.
Q3 “How certain are you about your estimated timeframe for returning to work?
Response options: 11-point scale: (0) “Not at all certain” thru (10) “Extremely certain”
Or in an alternative form, moving away from expectations and towards the assessment of the worker's prediction:Q1 “Do you think you will go back to work?”,
Response options: “yes”, “no”, “unsure”. If “yes” or “unsure”, go to Q2.
Q2 “If you had to predict your timeframe for going back to work, what would it be?
Response options: “Time from today: _____days/weeks/months (circle one)”.
Q3 “How certain are you about your predicted timeframe for returning to work?”
Response options: 11-point scale: (0) “Not at all certain” thru (10) “Extremely certain”
While this measure has not yet been validated, we believe it shows promise as it is explicit in terms of asking the respondent what they expect, it is specific to work return, it is generic enough to have the potential to be applicable in a variety of settings, and it includes a time reference that should accommodate most needs. Further, it can accommodate wording changes that capture specific researcher/stakeholder needs (e.g. “Do you expect to go back to work full-time?”). Finally, and highly relevant to applied settings, it provides the opportunity to start a conversation about problems the injured worker thinks that he or she might encounter.
Although our search was extensive and identified numerous measures, the review has its limitations. First, with regards to face validity, which is based on the reader's subjective impressions of whether a question accurately measures a construct [84], the current exercise could have been strengthened through the inclusion of the impressions of additional stakeholders. In our view, the term “expect” (and its variants) appeared to be the term that was most likely to precisely capture workers' RTW expectations; however, it is possible that there are other terms that may also be used. Future research might consider other stakeholders' views of the terminology with the greatest face validity for measuring the construct. A second limitation is that we were unable to examine the predictive validity of the measures evaluated in this review. The outcomes used in the various studies we reviewed, as well as the analytic techniques, and the results reported in the respective studies limited our ability to assess whether certain measures were more predictive of worker outcomes than others. Finally, our review was limited to questions focusing specifically on workers' expectations for RTW, but it is likely that other individuals involved in the RTW process (e.g. medical providers, employers, co-workers) also have expectations that could prove to be telling. As such, questions geared towards these individuals may also be useful in identifying likely outcomes and facilitating the RTW process.
Practical applications
RTW is an integral part of workplace injury management. While knowing an individual's RTW expectations has value for risk prediction, beyond this, what the capture of RTW expectations affords is a way to identify the potential for a less than optimal RTW process. If there is an indication of a mismatch between an injured worker's expectations and what other stakeholders might expect, efforts can be made to determine what is causing the injured worker's concerns, and efforts can be made to resolve these so that the worker's return to the workplace is not impeded. For example, if the timeframe seems longer than one might expect based on the injured worker's medical condition, a case manager might follow-up with questions about why the injured worker thinks this is the case and if there is anything that can be done to help overcome the problems identified. This has the potential to identify opportunities for the implementation of an intervention to improve the worker's chances of an optimal RTW. For review of potential workplace-based interventions, see the work by Franche et al. [85]. On a cautionary note, although asking about RTW expectations appears to be a valuable tool for gaining an understanding of future outcome and factors related to it, it is important that questions about RTW expectations not be perceived negatively. When working with a person that is off work due to health condition, arguably the most important goal is to return the person back to health and work in a safe and timely manner. [86–88] With this in mind, when addressing the potentially sensitive topic of RTW expectations, it is important that interactions be respectful, helpful and non-confrontational. Otherwise, there is the potential to jeopardize the working relationship and compromise the RTW.
Future research and development
Although we suggest questions for the measurement of RTW expectations, these are still very much hypothetical. Future research, development and validation are needed. While we propose what is essentially a single item, future development might aim to capture multiple aspects of RTW including return to modified work, return to regular duties, and/or RTW in a different line of work. Additional items might include questions pertaining to estimations for a return to being able to successfully manage work demands, being able to achieve pre-work absence productivity and performance levels, and/or work without restrictions. In addition, future work might focus on addressing the theoretical debate: expectancy or prediction?
Although capturing an understanding of workers' RTW expectations has value for risk prediction, this information is of limited use to those attempting to improve outcomes for we lack an understanding of why people expect what they do. To date there has been limited investigation of what people take into consideration when forming expectations for RTW. Stewart et al.'s study of workers' construction of expectations for RTW in persons with sub-acute back pain and off work for 3–6 months [82] provides some insight. However, in this study researchers found that their participants were reluctant to express their expectations because they were uncertain if they would be able to RTW and if so, when and under what conditions. As such, rather than documenting the factors being taken into consideration when forming RTW expectations, the report is more about uncertainty and its origins. Stewart et al. reported that uncertainty originated from five dimensions.
These being:(1) perceived lack of control of the RTW process,
(2) a perceived lack of recognition by others of the impact of the injury,
(3) perceived inability to perform preinjury duties,
(4) fear of re-injury, and
(5) perceived lack of workplace accommodations.The question then becomes, do people consider factors over and above those provoking uncertainty when forming their expectations for RTW?
Further research is needed to address this question, and gain a better understanding of how expectations for RTW are formed.
Conclusion
To date there has been a lot of inconsistency in the way that workers' expectations for RTW have been measured. In addition, most previously used measures have wording difficulties that limit application and interpretability. However, it would seem that these can be overcome with relative ease, and with further development, we will have access to a tool that can provide an opportunity to start a conversation that could help identify problems that might not otherwise be identified. This, in turn, has the potential to facilitate triage, and ultimately, help those involved in RTW management to help their clients achieve their RTW goals.
Declaration of interest
Authors declare no conflict of interest.
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