Study design

A qualitative research design with semi-structured group interviews was used. The group interviews were analyzed with a modified grounded theory, illustrating social processes and generating the development of a theoretical model. Grounded theory is suitable when a new intervention is evaluated and complex conditions about health and illness are studied [30, 31], such as in our study including persons with SED. Grounded theory is theoretically based in social constructivism, and the grounded theory method used in this study is inspired by the methodology of Charmaz and symbolic interactionism [30]. Symbolic interactionism is a dynamic theoretical perspective that assumes that people construct identities, social rules and reality through interaction [30].

Ethical statement

Ethical approval was confirmed by the Regional Ethical Review Board in Umeå, Sweden (2015/49-31Ö). All participants received verbal and written information about the study before deciding on participation. Participants were informed that their participation was voluntary and that they could withdraw at any time without declaring a reason. Participants were assured confidentiality and anonymity in presentation of the results. After participants agreed to participate, they signed a written consent form.

Study context and participants

The study was conducted at the Stress Rehabilitation Clinic at the University Hospital of Umeå, Sweden. The clinic specializes in rehabilitation of persons with SED. The treatment was based on a 24-week multimodal rehabilitation program, including a dialogue-based workplace intervention with convergence dialogue meetings intended to promote RTW. Participants were recruited from the multimodal rehabilitation program.

The multimodal rehabilitation program included group-based cognitive behavioral therapy (CBT) to support behavioral changes and to develop strategies to promote health. The CBT groups consisted of eight persons in each group who met weekly for 22 three-hour sessions. Each person had two individual meetings with the group leader to set and evaluate individual goals. Examples of individual goals could include development of strategies to improve one's capability to handle stressful situations, manage high workloads, set limits or take regular breaks. The multimodal rehabilitation program was previously evaluated in randomized controlled trials [32, 33].

Between March and October 2016, 24 persons from seven CBT groups in the multimodal rehabilitation program were asked to participate in group interviews [34]. The persons included in this study each had a confirmed diagnosis of SED [6], were between the working ages of 18 to 60 years, had current employment, and were on at least 50% sick leave.

Fifteen persons (13 women and two men) agreed to be interviewed; nine declined. The seven group interviews were composed from within the CBT groups, which meant that study participants in each group interview knew each other. One group consisted of three participants and the remaining six groups consisted of two participants each. The participants were between 33 and 56 years of age, nine worked with people, three worked with things, and three worked with data.

The dialogue-based workplace intervention with a convergence dialogue meeting

The dialogue-based workplace intervention with a convergence dialogue meeting was a structured three-step interview model with follow-ups, and was performed and organized by a rehabilitation coordinator at the Stress Rehabilitation Clinic. The intervention aimed to facilitate dialogue between the participant and supervisor responsible for rehabilitation at the workplace, and other involved stakeholders in the RTW process. The rehabilitation coordinator’s role was to be a liaison between involved persons in the intervention. The rehabilitation coordinator had specific knowledge about SED and social insurance medicine, and was educated and trained in implementing convergence dialogue meetings through a written manual and practical guidance from experienced personnel in the research group and with a background in occupational health.

The first step in the structured three-step interview model was an individual interview of the participant by the rehabilitation coordinator. At that point, the participant gave informed consent to contact the supervisor. In the second step, the supervisor was interviewed at the Stress Rehabilitation Clinic, by phone, or by video link. The structured interviews included questions about expectations and concerns for rehabilitation, perceived main causes for the participant´s sick leave, possible ways to adjust the work situation, suggestions on how to facilitate RTW, and motivation and confidence for RTW. In addition, the supervisor answered questions about systematic work environment issues, access to occupational healthcare and if specific actions were planned. In the third step, the rehabilitation coordinator performed a convergence dialogue meeting with the participant and supervisor. The participant could invite a representative from the workplace or trade union. The convergence dialogue meeting lasted for about 1.5 hours and the focus was to frame constructive solutions to facilitate and prepare for a sustainable RTW process. The interview guide to the structured three-step interview model is attached as (S1 and S2 Appendixes). The convergence dialogue meeting built upon a health promotion approach (Fig 1).

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Fig 1. The health promotion approach used in the convergence dialogue meeting.

https://doi.org/10.1371/journal.pone.0234897.g001

This approach focused on the work environment, including physical, organizational and social factors, when discussing work tasks in relation to work ability. Participant and supervisor perspectives were taken into consideration in adjusting work tasks that might help facilitate RTW. Adjustments were made primarily on the basis of common problems in SED, such as reduced cognitive ability and the need to balance activity and recovery at work.

The convergence dialogue meeting resulted in a written plan that included goals, actions, follow-ups, and division of responsibility between the participant and supervisor. The supervisor was responsible for initiating continuous follow-ups. The written plan functioned as an agreement between involved parties and was revised if duties or work hours changed, or if the goals needed to be adjusted based on the participant’s abilities. A copy of the written plan was distributed to the participant, the supervisor, and the Social Insurance Office. The rehabilitation coordinator made a follow-up at least once and then as needed during the multimodal rehabilitation program.

Group interviews

Group interviews were done after the dialogue-based workplace intervention with convergence dialogue meetings and the multimodal rehabilitation program were finalized. Organization of the group interviews was inspired by focus group methodology [34]. A psychologist and an assistant (occupational therapist or physician) performed the group interviews. None of the interviewers was involved in the participants’ rehabilitation. The group interviews followed a semi-structured guide, including questions related to starting the return to work process, design of the intervention, convergence dialogue meeting, role of the rehabilitation coordinator, feasibility of the plan, and future expectations. Each group interview lasted about 1–1.5 hour, was audio-recorded, and transcribed verbatim.

Data analysis

Data from the transcribed group interviews were analyzed using a modified grounded theory method with a focus on constant comparisons [30, 31]. The modification entailed all interviews being completed before the analysis process started, rather than the traditional emergent design.

In the first step of the analysis, two of the researchers (the first author and SK) uninvolved in data collection read the transcripts carefully and listened to the recordings repeatedly. Ideas that related to the emerging results were continuously written down in memos that were used in the analysis. Both researchers performed separate open coding of the transcripts using the Open Code software [31]. This means that the transcripts were read line by line and paragraph by paragraph. Important information was given a code with a low level of abstraction. The two researchers regularly discussed the open codes in relation to the interview transcripts, and this ensured that the emerging analysis was grounded in the empirical data. The researchers independently compiled open codes with similar content into categories on a more abstract level. Axial coding was used to indicate relationships between the categories. Codes and categories were discussed with a third researcher (AFW) who had read a small sample of the interviews. After this step, a theoretical coding process was undertaken. The aim was to build a theoretical model. Categories and memos were interpreted once more, with higher abstraction to sensitize concepts that were building the model [30]. Through the analysis process, triangulation between researchers with different backgrounds was used [31]. The research group had backgrounds in work rehabilitation, stress-related and pain rehabilitation, insurance medicine, psychiatry, gender science, physiotherapy, occupational health, pedagogy and education.

Emotional entrance

The first phase, emotional entrance, is comprised of three properties: vulnerability, anxiety/distress, and expectations. This phase represents the participants’ emotional experiences reflecting on their workplace as they start to prepare for RTW. We interpret this phase as visualizing the emotional exposure that people with SED experience related to the cause of their illness and the meaning of the work environment when planning for RTW.

Vulnerability captures participant experiences of personal failure, loss of control, and causing problems for colleagues and family. Participants were “ashamed of being exhausted” and blamed themselves for “being weak and not able to manage as much as others”. They found it difficult that they “not were able to handle the situation by themselves” and needed help. Participants felt sad that they had to change behaviors they thought might have caused their illness, such as engagement and responsibility at work. Overall, being in a vulnerable and emotional situation made them doubt their ability to return to work.

Anxiety/distress represented participant concerns about their relation to the workplace and the supervisor. Participants worried about what the supervisor might have told the rehabilitation coordinator in the individual interview, what the supervisor perceived as the reason for their exhaustion, and that they would be misunderstood. Their anxiety increased if they had experienced earlier failed attempts to RTW, if they had changed or had a poor relationship with their supervisor. Circumstances such as these contributed to distress before the convergence dialogue meeting. One participant described these expectations as “standing at the precipice”:

I think people stress themselves unnecessarily before the meeting. Of course, you don’t know, it's like you're standing at the precipice. You don't know what to expect. Then when you finally get into the meeting and you can get started, then you calm down. However, this kind of meeting is stressful because it stands for something, you have no idea of how it will be go, and how it will be received (Works with data, 50 year old).

An additional distress was if they distrusted the supervisors’ capability to understand, see, handle, and acknowledge problems related to the work environment. The participant below reflected on situations of “not being heard” and times when complaints about the work environment were not taken seriously:

I actually tried to tell my boss, while I was away, that there was no substitute for me, although I was working more than full time. The boss only said, “No, we’re just going to assign that out to everyone else”. But "everyone else" were those who didn’t have time to help me before, because they already had enough to do. They told me it was tough, but they did not say that to the boss, of course. But I tried to tell him that “they don’t feel good”. But he just answered, “No, no one has said anything to me. I've never heard it, so there is no problem.” (Works with things, 33 year old)

Expectations encompassed participant intentions to RTW. Participants were grateful for getting help, support and guidance in this process. They also told of excitement to meet with the supervisor in the convergence dialogue meeting.

Supportive guidance

The second phase, supportive guidance, captured three properties: competence, coordination, and balancing power. This phase represented participant experiences of the role of the rehabilitation coordinator in the intervention and the convergence dialogue meeting. This phase explains the supportive qualities of personal guidance and structured support. Moreover, the rehabilitation coordinator’s neutrality was central to participant experiences of the convergence dialogue meeting.

Competence represents participant experiences of practical and emotional support from the rehabilitation coordinator in contacts with the supervisor and Social Insurance officials. Presence of the rehabilitation coordinator was described as having someone “on my side”, “backing me up” or “not being alone”. Specifically, the rehabilitation coordinator brought self-confidence to the meeting with the supervisor:

Participant: You get support. When you find yourself in this situation with your employer, you feel that you have someone on your side who is a support. If you did not have that support, you would not be as sure of yourself. That’s the most important part.

Interviewer: And this support, is it emotional or is it that something has been expressed (by the rehabilitation coordinator) to the employer that was important to you?

Participant: I think the most important thing is the emotional difference. There is certainly another support, but I think the most important thing is the emotional side, having someone to lean on. If the employer resists, then you have nothing to come up with as an employee, anywhere. If there is someone who can speak about the illness or whatever, well… of course it’s easier. I think so. (Works with data, 50 year old).

The rehabilitation coordinator’s specific knowledge about SED gave the participants confidence that they had someone who “gave voice” to their needs and present situation. An example is acknowledging impairments related to the diagnosis.

Coordination was central to participant experiences of supportive guidance. The rehabilitation coordinator made participants feel safe arranging and carrying out meetings, and keeping structure and pace by “holding the reins”. The rehabilitation coordinator also “made things happen” by being a deliverer, catalyst, or energizer. In the convergence dialogue meeting, the rehabilitator coordinator was helpful in prioritizing and organizing things when planning for RTW.

When we were all sitting there, the three of us reached an agreement. This is how it feels and…, it is roughly here where we should be when we start the return (to work process). In my case, I was the only person with my duties, so we started to have a little look at which ones I should pick out, what seemed suitable, what priority tasks had, and how much responsibility should there be, and… Well, that’s how it is. You slowly get going… (Works with data, 49 year old).

Balancing power represents experiences of the rehabilitation coordinator as a mediator who balanced relationships and questions of responsibility. Participants perceived the rehabilitation coordinator as supportive of the supervisor, which made it possible to improve poor relationships, as described below:

Even if you have a poor relationship, you need to come together in some way… It cannot get worse if you go [to the meeting] with a skilled mediator who is doing the talking and who sees both sides. The rehabilitation coordinator is prepared and knows what we both think. And then we meet and go through it, [the rehabilitation coordinator] brings order to the relationship (Works with people, 38 year old).

One participant thought the convergence dialogue meeting left him with the feeling of becoming the initiator and taking control of his situation. This was in contrast to some participants’ earlier experiences of being in “second place” or “one step behind”. This experience exemplifies the rehabilitation coordinator’s opportunity to balance power, and increase participant experiences of participation when planning for RTW.

However, participants experienced the rehabilitation coordinator’s role of balancing power as uncomfortable in situations that were demanding or required certain skills (such as being a calm and safe person, or experienced in handling difficult situations). One participant, who had previously experienced a complicated RTW process with severe conflicts with the supervisor and workplace, highlighted the rehabilitation coordinator’s difficult role and the need for having the “right education and engagement”, such as therapeutic conversational skills.

Empowering change

The third phase, empowering change, encompassed participant experiences of the intervention, such as carrying out agreements made in the written plan, follow-ups, and starting to have expectations for the future. This phase consisted of three properties: heading toward confidence, transferring knowledge, and improved collaboration. This phase explains personal progress toward RTW, as well as experiences of progress among supervisors and workplace colleagues.

Heading toward confidence represents experiences of being trusted and encouraged “to take steps forward” and how support from the intervention helped them to successfully RTW.

It was positive, because all the time I found it so hard to imagine that I could get back to work at all. I thought that I would have to leave. It was good that you managed to make small plans and find a solution that worked, it was great (Works with things, 33 years old).

Participants described that following a written plan supported them in the practice of strategies they learned in multimodal rehabilitation. Examples include to “slow down”, “take breaks”, “breathe”, and “set limits”. Practicing such strategies was helpful in formulation of a realistic plan, such as finding balance in energy use during the day, prioritizing the amount of workload, and developing new routines. The written plan and follow-ups supported participants in efforts to “keep on track”, and recall adjustments that were made, and by whom. Writing down agreements and solutions clarified questions of responsibility and opened up the opportunity to “talk about” problems in the workplace. In addition, the written plan and follow-ups implied regular evaluations, which made it possible for participants to notice their own progress:

It's been great to be able, during the course of work to… discuss at meetings that this happened while I was working and it felt scary. And to find out why it happened and what can be done, and things like that. I think that it has made a huge difference between how you felt the first day or the first week when you worked, and how you feel today (Works with people, 37 year old).

Transferring knowledge represents experiences of changed approaches and behaviors among supervisors and colleagues. Participants thought the intervention educated supervisors about SED and related impairments, such as difficulty concentrating, memory problems or fatigue. In addition, participants experienced that supervisors increased their knowledge about work rehabilitation issues, for example making plans and agreements, or making relevant adjustments in the work environment. Increased knowledge raised supervisor awareness, and that contributed to an improved work environment and changed attitudes toward persons on sick leave. One participant describes how she had to revise her view of her supervisor:

Previously people thought…if you get sick, well, you have to look for a job somewhere else…. That you weren’t worth anything. That was my biggest fear….but it has just turned out the opposite. The talks and meetings have changed the way she [the boss] looks at those of us who are on sick leave and I’ve been treated incredibly well. I hadn’t expected this. I’ve also heard others at my workplace say they have also been treated better. I think she’s learned something from this too. Actually…I have been given backing, and she has met and spoken privately with the coordinator. The communication between us is now very different. She has followed up and checked how things are going, and what we have decided, which I don't think we would have done otherwise. (Works with people, 37 year old)

Participants described improved collaborations with the supervisor, workplace, and Social Insurance Office. Experiences of clarified roles and allocated responsibility for each person involved increased participant safety in RTW. Improved collaboration empowered participants to discuss weaknesses and implement relevant adjustments at the workplace. Participants felt that the Social Insurance officials trusted the intervention, and this also made them feel secure. Overall, participants experienced that the intervention had a “ripple effect” by positively influencing stakeholders involved in the process. Having good relationships with involved stakeholders facilitated RTW.

Nevertheless, participant expectations for the future also involved worries, for example about their ability to handle future challenges. One participant expressed the wish to have “a manual” to prevent failures or setbacks such as returning to sick leave:

Well, if you get a setback, maybe not having to call someone, but if there could be a manual for what to do. It's hard to find a manual that covers everything but… something for future generations… that there is something you can do, and whether to talk to your supervisor or not (Work with data, 50 years old).

To avoid failures and sustain changes, participants suggested having longer support or having an additional convergence dialogue meeting in the latter part of the intervention. They were also concerned about the handoff to primary care or occupational healthcare when they finished the multimodal rehabilitation program. One participant felt that participating in the intervention not had met her expectations because her exhaustion was related to her home situation rather than her workplace.

Strengths and weaknesses of the study

The study intervention was well-organized and performed in a clinical setting. This provided us with rich and varied interview data. The different backgrounds and work experiences of participants, together with participants’ familiarity with each other in the interview groups, facilitated an open climate for discussion of positive and negative experiences. On the other hand, familiarity within the groups may have hindered openness since the participants had already settled into roles in their respective multimodal rehabilitation group. Overall, the participants had positive experiences of the intervention. We are aware of that the combination of the intervention and the multimodal rehabilitation program influences interpretation of the findings. Yet, the combination seems to be beneficial as it contributed to opportunities to practice strategies and regularly evaluate participant progress in the rehabilitation process.

Triangulation between researchers was used to increase study trustworthiness and credibility [31]. The research group represented different areas of experiences and competencies. In addition, the analysis process was performed with researchers uninvolved in the data collection or multimodal rehabilitation program. The coding process was independently performed by the first and the third authors, and in close collaboration with the second author. All researchers were involved in the analysis process, building the theoretical model, and writing the manuscript. The results were thoroughly discussed between all authors and other groups of researchers who found the results to be credible. Therefore, we consider our results trustworthy.

Practical implications

In Sweden, a rehabilitation coordinator is available in all Swedish regions and in primary and specialty healthcare. Therefore, an advantageous dialogue-based workplace intervention could be implemented in the healthcare system and occupational healthcare settings. A similar intervention with an early workplace dialogue for persons with musculoskeletal disorders shows improved work ability over time [56]. In the future, exploring whether a dialogue-based workplace intervention could be used to prevent SED and stress-related disorders at workplaces would be interesting.