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U NI V E R S IT Y O F CO PE NH AG EN
D E P A R TM E N T O F P SY C H O L OG Y
PhD thesis
Yun Ladegaard
Work-related mental disorders
A quantitative and qualitative investigation of employees and managers
experiences at the workplace and in the Workers’ Compensation System
Supervisor: Paul Maurice Conway, Janne Skakon, Bo Netterstrøm and Annie Høgh
27. March 2018
1
Indhold
LIST OF ORIGINAL PAPERS ........................................................................................................... 3
THANK YOU ...................................................................................................................................... 4
DANSK RESUMÉ ............................................................................................................................... 5
ENGLISH SUMMARY ....................................................................................................................... 7
INTRODUCTION ............................................................................................................................. 10
1. BACKGROUND - WORK-RELATED MENTAL DISORDERS .............................................. 12
1.1. Definition of work-related mental disorders ........................................................................... 12
1.2. Extent and Costs...................................................................................................................... 13
2.3. WRMD in the Workplace and WCS ....................................................................................... 13
2.4. A. WRMD in the Workplace .................................................................................................. 15
2.5. B. WRMD in the WCS ........................................................................................................... 16
2.6. C. Interaction between the Workplace and WCS ................................................................... 18
3. AIM OF THIS THESIS ................................................................................................................. 22
4. MATERIALS AND METHODS ................................................................................................... 23
4.1. Study I ..................................................................................................................................... 23
4.2. Data collection for Study II and Study III ............................................................................... 27
4.3. Study II .................................................................................................................................... 33
4.4. Study III .................................................................................................................................. 34
4.5 Study IV ................................................................................................................................... 35
5. RESULTS ...................................................................................................................................... 38
5.1. Study I ..................................................................................................................................... 38
5.2. Study II .................................................................................................................................... 41
5.3. Study III .................................................................................................................................. 43
2
5.4. Study IV. ................................................................................................................................. 46
6. DISCUSSION ................................................................................................................................ 47
6.1. Summarizing selected results .................................................................................................. 47
6.2. Challenges for line managers .................................................................................................. 48
6.3. Physical diseases handled better than WRMD ....................................................................... 49
6.4. Stakeholder involvement—Health and Safety—and Union Representatives ......................... 50
6.5. The type of WRMD matters .................................................................................................... 51
6.6. Interaction between the WCS and Workplace ........................................................................ 52
6.7. Does the WCS harm employees?—contradicting findings..................................................... 55
6.8. Strengths and limitations ......................................................................................................... 58
7. CONCLUSIONS ............................................................................................................................ 62
8. IMPLICATIONS OF THE THESIS .............................................................................................. 64
8.1. Practical implications .............................................................................................................. 64
8.2. Implications for future research .............................................................................................. 66
REFERENCES................................................................................................................................... 68
APPENDIX 1. PAPER I .................................................................................................................... 78
APPENDIX 2. PAPER II ................................................................................................................... 89
APPENDIX 3. PAPER III ............................................................................................................... 105
APPENDIX 4. PAPER IV ............................................................................................................... 128
APPENDIX 5. QUESTIONNAIRE ................................................................................................. 147
APPENDIX 6. ADDITIONAL ANALYSIS ................................................................................... 163
3
LIST OF ORIGINAL PAPERS
This thesis is based on the following original papers:
Paper I
How do line managers experience and handle the return to work of employees on sick leave
due to work-related stress? A one-year follow-up study
Ladegaard Yun, Skakon Janne, Elrond Andreas Friis, Netterstrøm Bo
PUBLISHED IN The Journal of Disability and Rehabilitation. Online 2017. (Appendix 1)
Paper II
How do Danish workplaces handle work-related diseases?—Experiences of employees with
notified occupational diseases in the Workers’ Compensation System
Ladegaard Yun, Thisted Cecilie, Gensby Ulrik, Skakon Janne, Netterstrøm Bo
PUBLISHED IN Tidsskrift for Arbejdsliv. December 2017 (Appendix 2)
Paper III
Employees with notified work-related mental disorders - experiences in the workplace and in
the workers’ compensation system
Ladegaard Yun, Skakon
Janne, Ståhl Christian, Netterstrøm
Bo
SUBMITTED TO The Journal of Occupational Rehabilitation. 2018. (Appendix 3)
Paper IV
Is the notification of an occupational mental disorder associated with changes in health, income and
long-term sickness absence?
Ladegaard Yun, Conway Paul Maurice, Eller Nanna Hurwich, Skakon
Janne, Maltesen Thomas,
Scheike Thomas and Netterstrøm Bo
DRAFT FOR The Scandinavian Journal of Work, Environment and Health. 2018. (Appendix 4)
4
THANK YOU
This PhD is not the work of a single person, but the product of several fruitful collaborations. It has
been a fantastic journey working with great people who have taught me so much. I would especially
like to thank my wonderful supervisors, Janne Skakon, Bo Netterstrøm, Annie Høgh, and Paul
Conway. Thank you to all of my co-authors, including Andreas Elrond, Cecilie Thisted, Christian
Ståhl, Ulrik Gensby, Ann-Louise Holten, Mille Mortensen, Nanna Hurwich Eller, Thomas
Maltesen, and Thomas Scheike. For engaging in so many long and inspiring discussions, I am
grateful to my colleagues at the Department of Psychology, University of Copenhagen, former
colleagues at the Department of Work and Environmental Medicine, Bispebjerg Hospital, as well as
colleagues in the field.
I would also like to thank all of the organisations that contributed to this project, including the
Danish Labour Marked Insurance, All Department of Occupational Medicine in Denmark, the
Danish Working Environmental Authority, Danish municipalities, unions, employer organisations,
insurance companies, and experts in the area, as well as the Danish Work Environmental Fund for
financing the research projects. Thank you to Janni Brixen for helping to circulate these research
results to impact practice, and to Marlene Buch Andersen at the Faculty of Law, Malene Friis
Andersen, and Thomas Clausen from the National Research Centre for the Working Environment,
Marianne Vammen and Anne Katrine Buch for their feedback during the process.
I would like to thank my family, Janus Hoon Jang, Senja and Bruce, Anette, Jens, and Sofie
Ladegaard for their loving support during this process.
Finally, it is with the utmost gratitude and respect that I thank all the employees and managers who
spent time taking interviews and surveys or talking about their experiences, feelings, vulnerabilities,
and uncertainties—this dissertation is dedicated to you.
It is my hope that this research will contribute to the politics and practice affecting work-related
mental disorders and the continuous work to ensure safe and healthy working conditions as well as
qualified and dignified treatment and rehabilitation of sick employees.
Yun Ladegaard
Copenhagen Marts 2018
5
DANSK RESUMÉ
FORMÅL: Hvad sker der, når medarbejdere bliver syge med en arbejdsrelateret psykisk lidelse?
Afhandlingen er fokuseret på arbejdspladsen, arbejdsskadesystemet og samspillet mellem de to, set
fra medarbejdere og mellemlederes perspektiv.
Studie I: Hvordan oplever og håndterer mellemledere situationen, hvor en medarbejder er blevet
sygemeldt med en arbejdsrelateret psykisk lidelse? Studie II: Hvad sker der på arbejdspladsen, når
en medarbejder bliver syg på grund af en arbejdsrelateret sygdom? - Hvem er involveret, og bliver
medarbejdere med arbejdsrelaterede psykiske lidelser behandlet anderledes end medarbejdere med
ryg eller hudsygdomme? Studie III: Hvordan oplever medarbejdere med en anmeldt arbejdsrelateret
psykisk sygdom arbejdspladsen og det danske arbejdsskadesystem? Studie IV: Er en
arbejdsskadeanmeldelse af en psykisk lidelse associeret med ændringer i helbred, indkomst eller
langvarigt sygefravær?
METODER: Forskellige metodiske tilgange blev brugt i studierne, på grund af de forskellige
aspekter, der ønskes udforsket. Studie I: Interviews med mellemledere (N=15) og opfølgende
interviews et år efter (N=8). Principper fra Grounded Theory blev anvendt i dataindsamling og
analyser. Studie II: Spørgeskemabesvarelser fra medarbejdere med anmeldt arbejdsrelateret psykisk
lidelse (N=436), arbejdsrelateret rygsygdom (N=202) eller arbejdsrelateret hudsygdom (N=132),
blev sammenlignet via Chi-Square tests, og spørgeskemaernes åbne svarkategorier blev analyseret
gennem selektiv kodning. Studie III: Interviews (N=13) og spørgeskemabesvarelser (N=436) fra
medarbejdere med anmeldt arbejdsrelateret psykisk lidelse blev analyseret vha. principperne fra
Grounded Theory og Chi-Square tests. Studie IV: Sammenligning af registerdata fra anmeldte
(N=699) kontra ikke-anmeldte (N=296) patienter med psykiske lidelser, i ændringer i helbred (antal
besøg hos egen læge, udskrevet psykofarmaka), langvarig sygefravær og årlig indkomst.
Opfølgningen var året efter udredningen på arbejdsmedicinsk afdeling. Poisson-regression og
betinget logistisk regression blev benyttet i analyserne.
RESULTATER: Studie I: Mellemledere anerkender problemer i arbejdsmiljøet, men kan skifte
fokus til medarbejderes personlige problemer, når en medarbejder bliver syg med en
arbejdsrelateret psykisk lidelse. Mellemledere kunne opleve krydspres mellem
strategiske/forretningsmæssig målsætninger og de relationelle aspekter, når de skulle hjælpe den
sygemeldte tilbage, samt manglende organisatorisk støtte. Organisatorisk støtte såsom retningslinjer
6
og adgang til professionel hjælp samt oplevet god kommunikation med den sygemeldte var vigtigt.
Studie II: Når en medarbejder blev syg af en arbejdsrelateret psykisk lidelse, oplevede flere
medarbejdere, sammenlignet med medarbejdere med arbejdsrelaterede rygsygdom eller hudsygdom
at: Arbejdspladsen håndterede forløbet omkring deres sygdom dårligt, manglende forebyggelse i
arbejdsmiljøet, flere havde dårlige oplevelser med centrale aktører på arbejdspladsen. Mange
genoptog arbejdet for tidligt og mange var arbejdsløse 2-4 år efter arbejdsskadeanmeldelsen. Studie
III: Forebyggelse i arbejdsmiljøet var et af formålene bag arbejdsskadeanmeldelser af psykiske
lidelser, men medarbejderne oplevede et individuel fokus på arbejdspladsen og i
arbejdsskadesystemet. Ledelsen blev ofte oplevet negativt, og arbejdsmiljørepræsentanten og
tillidsrepræsentanten var ofte ikke involveret. Ændringer i arbejdsmiljøet og inspektion fra
Arbejdstilsynet var sjældne, og mange medarbejdere oplevede utilstrækkelig information i
arbejdsskadesystemet, samt fandt spørgeskemaerne svære at udfylde. Medarbejdere med anerkendte
(kontra afviste) arbejdsskadesager eller PTSD (kontra depression eller stress) havde oftere positive
oplevelser. Arbejdsskadeanmeldelser kunne være en hindring for tilbagevenden til arbejdet, især for
medarbejdere med anerkendte anmeldelser. Studie IV: Der blev ikke fundet nogen sammenhæng
mellem arbejdsskadeanmeldelser af psykiske lidelser og ændringer i helbred, indkomst eller
langvarig sygefravær ved den etårige opfølgning. Et signifikant fald i indkomst blev observeret for
både anmeldte og ikke-anmeldte medarbejdere med psykiske lidelser.
KONKLUSIONER: Arbejdspladser bør støtte mellemledere og sikre inddragelse af relevante
aktører og et højt kompetenceniveau hos de involverede. Derudover er én koordineret, systematisk
tilgang til kortlægning og interventioner mod psykosociale risikofaktorer i arbejdet nødvendig.
Medarbejdere med arbejdsrelaterede psykiske lidelser bør ikke rådgives mod at få lavet en
arbejdsskadeanmeldelse alene af hensyn til deres helbred. Der er dog plads til forbedringer af
arbejdsskadesystemet både i forhold til klar kommunikation, udformningen af spørgeskemaer,
arbejdsgiverhøring mv. ift. anmeldelser af arbejdsrelateret psykisk sygdom. Derudover er der behov
for et stærkere samspil mellem lovgivnings- og forsikringssystemet og arbejdspladsen for at kunne
anvende information om psykosociale belastninger, som kan risikere at føre til arbejdsrelaterede
psykiske lidelser, systematisk i forhold til forebyggelse. Arbejdsskadeanmeldelser kan være en
værdifuld kilde her.
7
ENGLISH SUMMARY
AIM: To explore what happens when employees become ill with a work-related mental disorder.
This thesis focuses on the Workplace System, the Workers’ Compensation System, and the
interaction between the two systems, applying the perspectives of employees and line managers.
KEY QUESTIONS: Study I explores how line managers experience and handle situations in which
employees are sick-listed for a work-related mental disorder. Study II analyses what happens in the
workplace when an employee develops a work-related disease: who is involved? Is work-related
mental disorders handled differently from other types of work-related conditions? Study III explores
the experiences of employees with notified work-related mental disorder in the workplace and
Workers’ Compensation System. It compares the responses of employees with rejected and
recognised claims and those of employees with different diagnoses, such as PTSD, depression, or
stress related illness. Study IV examined if workers compensation claims of mental disorders are
associated with changes in health, income, or long-term sickness absence.
METHODS: Various methodological approaches were used in these studies, because of the diverse
range of aspects studied. Study I: Interviews with line managers (N=15) and one-year follow-up
interviews (N=8) were carried out and analysed using a grounded theory approach. Study II:
Questionnaire responses from employees with notified cases of work-related mental disorders
(N=436), work-related low back pain (N=202) or work-related skin diseases (N=132) were
compared using Chi-squared tests;
open-response questionnaire categories were analysed using
selective coding.
Study III: The interviews (N=13) and questionnaire responses (N=436) of
employees with notified cases of work-related mental disorders were analysed using a grounded
theory approach (for the interviews) and Chi-Square tests (for the questionnaire responses). Study
IV: Register data of patients with notified (N=699) and non-notified (N=296) mental disorders were
compared to identify changes in health—measured through GP visits, prescriptions of psychotropic
drugs, long-term sickness absence and annual income. Follow-up were carried out one year after the
initial examination. The prospective association between notification status and the four possible
outcomes was examined by means of Poisson regression and conditional logistic regression.
RESULTS: Study I: Line managers acknowledge problems in the work environment but may also
8
focus on personal circumstances when an employee develops a work-related mental disorder. The
lack of a common understanding of stress creates room for this shift in focus. Line managers
experience cross-pressure, discrepancies between strategic and relational considerations, and a lack
of organisational support in the return-to-work process. Organisational support, guidelines,
knowledge, and good communication were found to be essential for the return to work. Study II: In
comparison to employees with work-related low back pain or skin diseases, employees who develop
a work-related mental disorder are more likely to have a negative experience of workplace
management, encounter a lack of prevention in the work environment, had negative experiences
with workplace stakeholders (managers and health-and-safety representatives), and resume work
too early. Many employees are unemployed 2–4 years after notification. Study III: Prevention in the
work environment was an aim behind workers compensation claims of a mental disorder, but
employees often experienced an individual focus in the workplace and Workers’ Compensation
System. Managers were frequently experienced negatively, while health-and-safety or union
representatives were often uninvolved. Changes in the work environment and workplace inspections
were rare; many employees received inadequate information from the Workers’ Compensation
System and found compensation schemes difficult to fill out. More employees with recognised
claims or PTSD had positive experiences in the workplace than employees with depression or
stress-related disorders. Workers’ compensation claims could be an obstacle for RTW, especially
for employees with recognised claims. Study IV: The study findings showed that there was no
association between notifications of an occupational mental disorder and changes in health, income,
or long-term sickness absence one year after the initial medical examination. A significant decrease
in income was observed among both notified and non-notified employees with a mental disorder.
CONCLUSIONS: Organisations should provide support for line managers and ensure the
involvement of relevant stakeholders with high-level competences. There is a need to coordinate
information and to assess systematically the psychosocial hazards that can lead to work-related
mental disorders. Employees with mental disorders should not be advised against filing
compensation claims in concern for their health, still there is room to improve the Workers’
Compensation System. Strengthened interactions between the legislative/insurance and workplace
systems are needed to enable information about psychosocial hazards to be used systematically to
prevent work-related mental disorders. Workers’ compensation claims are a very valuable source in
this matter.
7
THESIS OVERVIEW
Work-related mental disorders
A quantitative and qualitative investigation of employees and managers experiences at the workplace and
in the Workers Compensation System
Study I
How do line managers
experience and handle the
return to work of employees
on sick leave due to work-
related stress? A one-year
follow-up study
Study II
How do Danish workplaces
handle work-related
diseases?—The experiences
of employees with notified
occupational diseases in the
Workers’ Compensation
S
y
ste
m
Study III
Employees with notified
work-related mental
disorders - their experiences
in the workplace and
Workers’ Compensation
System
Study IV
Is the notification of an
occupational mental
disorder associated with
changes in health, income
and long-term sickness
absence?
COPEWORK STUDY Project Workers’ Compensation System
Main findings
Lack of a common
understanding of stress;
LMs acknowledge
problems in work
environment but turn focus
to personal circumstances
in relation to WRMD.
LMs experienced cross-
pressure, discrepancies
between strategic and
relational considerations,
and lack of organisational
support in the RTW
process.
Organisational support,
guidelines, knowledge, and
good communication were
essential for RTW.
Main findings
More employees with
WRMD compared to low
back pain or skin diseases
reported:
Negative experiences at
the workplace in relation
to their disorders;
Lack of prevention in the
work environment;
Negative experiences with
workplace stakeholders
(managers and health-and-
safety representatives);
Resuming work too early.
Many were unemployed 2–4
years after notification
Main findings
No association between
notifications of an
occupational mental
disorder and changes in
health, income, or long-
term sickness absence
were found one year
after the initial medical
examination.
A significant decrease in
income was observed for
employees with both
notified and non-notified
mental disorders
Main findings
Prevention in the work
environment was a goal;
Individual focus in the
workplace and WCS;
Encounters with managers
were often experienced
negatively
Health-and-safety and
union representatives were
often not involved
Changes in the work
environment and
workplace inspections
were rare
Inadequate information
from WCS, compensation
schemes were hard to fill
out
WCC could be an obstacle
for RTW
More employees with
recognised claims or
PTSD had positive
experiences
Qualitative and
Quantitative data
Interviews (N=13) and
questionnaire responses
(N=436) from employees
with notified mental
disorders
Quantitative data
Register-based study of
patients with notified
(N=699) vs. non-notified
(N=296) mental disorders
Quantitative data
Questionnaire responses
from employees with
notified:
Mental disorders (N=436)
Low back pain (N=202)
Skin disease (N=132)
Qualitative data
Interviews with line
managers (N=15)
One-year follow-up
interviews (N=8)
Conclusions
Organisations should provide support for line managers and ensure the involvement of relevant stakeholders with high-level
competences. There is a need to coordinate information and to systematically assess information about psychosocial hazards
that can lead to work-related mental disorders. Employees with mental disorders should not be advised against filing
compensation claims; but there is room for improvement in the Workers’ Compensation System. Interactions between the
legislative/insurance and workplace systems must be strengthened so information about psychosocial hazards can be used to
systematically prevent work-related mental disorders. Workers’ compensation claims are a very valuable source in this matter.
LM—Line managers, WRMD – Work-related mental disorders, RTW- return to work, WCS – Workers’ Compensation System WCC-
workers’ compensation claim.
10
INTRODUCTION
ONE PHD THESIS – DATA FROM TWO PROJECTS
From 2010 to 2013, I was employed at the Department of Occupational and Environmental
Medicine at Bispebjerg University Hospital, Denmark, engaged in the Copestress Project, a
randomised controlled trial that tested different types of treatment programmes for employees sick-
listed due to stress [1,2]. One part of this project involved exploring what had happened at the
workplaces of the sick employees; this exploration was called the COPEWORK study. The sick
employees were asked if we could contact their line managers and health-and-safety representatives
for interviews on this topic. During the interviews, it became apparent that, although the employees’
illnesses had been caused solely or partly by the working conditions and both managers and health-
and-safety representatives confirmed that there were severe problems in the work environment,
often no preventive initiatives were implemented in the workplace [3]. The sick listings were
perceived as a private matter and health-and-safety representatives were seldom involved [3].
Physicians in Denmark are obliged to file a worker’s compensation claim, if they suspect that an
employee is ill due to the working conditions. During the project, physicians discussed whether or
not it was useful to file workers’ compensation claims [4]. There were an assumption that these
claims were a waste of time and energy for sick employees (in 2010, only 4.9% of notified cases of
occupational mental disorders were recognised [5]; even fever were awarded compensation). In line
with this a newly published Danish scientific article had suggested that notification of an
occupational disease in Denmark could increase the risk of work disability; for this reason, the
Danish Workers’ Compensation System should ensure that only workers with a high chance of
receiving compensation were notified [6]. By contrast, a Danish expert rapport was published
suggesting that the legal obligation to notify should be extended to include psychologists, in order
to prevent the under-reporting of mental disorders [7]. It was puzzling to find that the experts in this
field disagreed on how best to handle claims. If there were problems managing work-related mental
disorders in the workplace, workers’ compensation claims could be part of the solution; however,
they could also contribute to the problem by putting an extra burden on sick employees. This area
had never been fully explored in a Danish context. In 2013, Project Workers’ Compensation System
received funding from the Danish Working Environment Research Fund to investigate the question
of whether (and why) workers’ compensation claims were harming employees’ health. The project
used various research methods to explore the subject from different angles.
11
This thesis is based on data derived from two research projects: the 2010–2013 COPEWORK study
and the 2013–2018 Project Workers’ Compensation System (illustrated in Figure 1). The thesis
focuses on ‘what happens when employees develop a work-related mental disorder from the
perspectives of both employees and managers.
Figure 1. Project/thesis overview. The aims, positions, and relationship of the two studies, as
related to the systems in the ‘Arena of Work Disability’.
12
1. BACKGROUND - WORK-RELATED MENTAL DISORDERS
Challenges in the psychosocial work environment are key issues in the current labour market
[8,9]
.
Psychosocial risks, such as work-related stress and workplace violence, are widely recognised
as major challenges to occupational health and safety; there is comprehensive evidence of the
impact of psychosocial hazards on a number of mental health outcomes [10]. E.g. there is robust
evidence that high psychological demands, low decision latitude (job strain), [11,12] and bullying
[11,13] have a significant impact on mental health and the development of mental disorders. In
addition, an increased risk of depressive disorders has been found among employees exposed to an
effort-reward imbalance [14]. Employees exposed to work-related violence have an increased risk
of developing mental disorders [15,16]. There is also a link between the psychological demands of a
job and the likelihood that the job holder will develop depression [17]. The International Labour
Organisation has acknowledged that psychosocial hazards can cause occupational disease [18].
However, mental disorders like depression are rarely acknowledged to be occupational diseases
covered by the Workers’ Compensation Systems in most countries [19]. For this reason, employees
who develop work-related mental disorders are often worse off than employees with work-related
physical diseases when it comes to financial compensation and access to treatment [20]. Mental
disorders are related to functional disability in all domains of functioning [21]; they are
a common
cause of work disability
[20]
, unemployment
[22]
, and lower income
[23]
. They also
represent a
major risk factor for early withdrawal from the labour market [24]. The consequences for sick
employees are therefore extensive
.
1.1. Definition of work-related mental disorders
In this thesis, the term
work-related mental disorders
(WRMD)
refers to a mental disorders
defined by the ICD 10- classifications:
post-traumatic stress disorder (PTSD) (F.43.1), acute
stress reaction (43.0), adjustment disorders (F43.2), depression (F32 and F33), disorders of
personality and behaviour (F62) [25]. In addition, (stress) symptoms registered by the Occupational
Medicine Department or the Labour Market Insurance are also included within this term. WRMD is
defined as mental disorders that can be attributed at least partly to adverse working conditions.
However, the m
ultifactorial nature of such disorders [26–28] can make it difficult to document a
causal relationship between work place exposures and the disorder. Thus,
WRMD is
not
equal to
an occupational mental disorder recognised in the Workers’ Compensation System (WCS).
13
1.2. Extent and Costs
Today, no surveillance system exists to adequately capture the extent of WRMD on a national or
international level [10]. Current estimates rely primarily on self-reported surveys, which do indicate
widespread and extensive problems.
Twenty-five percent of employees in Europe state that they
experience work-related stress
during most or all of their working hours and that their work has
an adverse effect on their health
[8]
.
Psychosocial hazards and their associated effects on health
impose a significant financial burden on individuals, organisations, and societies [29]. Estimates
from the United Kingdom show that 526000 employees experienced work-related stress,
depression, or anxiety in 2016/2017, resulting in 12.5 million lost working days. Work-related
stress, depression, or anxiety accounted for 40% of work-related illness and 49% of all working
days lost in 2016/17 [30]. The cost in Europe of work-related depression has been estimated at
nearly €617 billion per year, covering absenteeism, presenteeism, loss of productivity, health-care
costs, and social welfare costs [31]
.
A literature review of the cost of WRMD in different European
countries has concluded that there could be major economic gains at the societal level if
psychosocial hazards in the workplace could be prevented [29].
In Denmark, 16.9% (in 2016) of employees report being exposed to negative psychosocial factors,
while, at the same time, having symptoms of stress or depression [32]. J
ob strain has been
estimated to result in one million days of sick leave and early retirement for 2500–3000
employees; approximately 1400 Danish employees die every year due to job strain. It has been
estimated that these factors cost the health care system DKK
686 million annually; the costs of
lost
production are estimated at
DKK 11.969 million annually [33], and in 2015, workers’
compensation for recognised claims of mental disorders cost 622 million Dkr. (83.5 million Euros)
[34].
2.3. WRMD in the Workplace and WCS
When an employee develops a work-related disorder, various systems affect that employee’s
recovery and options for returning to work (RTW) [35,36]. The Sherbrook Model is an evidence-
based work disability management model originally developed for employees with musculoskeletal
pain. The model illustrates the arena of work disability (Figure 2), incorporating various systems
14
and levels within the systems, which have been shown to affect the RTW process of sick employees
[36].
Figure 2. Arena of Work Disability
The Arena of Work Disability. Adapted from Loisel et al. 1994 [36]
Each system includes various stakeholders, who can interact (e.g. the employee, his or her family,
union representative, employer, healthcare provider, insurer, and others). They may have different
positions and assumptions that can result in different interpretations and actions in response to the
RTW process [37]. The different systems in the Sherbrook Model interact; [38] for example, the
Legislative and Insurance System may influence the employee (Personal System); access to health
care (Health Care System) or the cost to the employer of sick-listed employees can influence the
employer’s willingness to accommodate the employee’s RTW (Workplace System).
The objectives of this thesis are to study two systems in the model, illustrated by the dotted lines in
Figure 2, The Workplace System and the Legislative and Insurance System (in this case limited to
WCS), in relation to employees suffering from WRMD. The following section will focus on
WRMD in: A) the Workplace System, studied from the perspectives of both employees and
managers; B) the WCS; and C) The potential interaction between the workplace and the WCS,
15
when a worker’s compensation claim of an occupational mental disorder has been filed. The later
will be analysed from the perspective of employees as well as by analysing register-data and
discussions of selected factors in the workers’ compensation process such as employer hearings,
economical incitements and workplace inspection procedures.
2.4. A. WRMD in the Workplace
Psychosocial hazards are acknowledged by companies as an area of concern [18]. Nearly 80% of
managers in a European survey have expressed concern about work-related stress, while nearly 20%
consider violence and harassment to be a major concern [8]. However, fewer than 30% of European
workplaces have procedures to deal with psychosocial hazards [8]; more than 40% of European
managers consider psychosocial hazards to be more difficult to manage than hazards in the physical
work-environment [8]. Finally, the Second European Survey of Enterprises on New and Emerging
Risks (ESENER II) has concluded that managing WRMD and psychosocial risks remains one of the
most challenging issues in occupational health and safety. This survey has identified problems with
difficult patients, customers, and pupils, time pressures, a reluctance to talk openly about issues and
psychosocial risks, in risk assessments as barriers for addressing psychosocial risks [39].
2.4.1. RTW for employees with WRMD
Much of the variability on whether or not employees succeeds in RTW depends on what happens in
the workplace [40]. Studies have found that work-related disorders can be handled very differently
in different workplaces and a range of workplace stakeholders can be involved in the RTW process
[41,42]. Workplaces tend to focus on the early phases of RTW, while preventive interventions that
relate to the general work environment seem less formalised [41,43]. Studies have found that
support and interventions may appear to a larger extent for employees with physical conditions than
on employees with mental disorders [44]. This may indicate that employers consider it more
difficult to modify work environments to accommodate employees with mental disorders. A meta-
review has suggested that the past experiences and expectations of the future for employees with
common mental-health disorders are likely to affect the RTW process. Employees suffering from
WRMD may be reluctant to return to the workplace if they don’t believe that the working
conditions that caused the disorder have been changed [45]. An employee often struggles to
maintain his or her self-image as a competent employee and therefore rush the RTW or resuming
his or her tasks too quickly [45]. Employers have also been shown to be critical of employees with
16
mental disorders and their workability [46,47]. In addition, employers are sometimes reluctant to
approach psychosocial risks because they lack either resources, such as time, employees, or money,
or awareness, training, technical support, or organisational guidance and sensitivity towards
psychosocial risks [8]. Mental disorders caused by working conditions are often perceived as less
legitimate than e.g. the sudden death or illness of a spouse; this attitude can affect the social support
that employees receive [48]. A lack of social support may decrease an employee’s chances of
making a successful RTW, since social support is crucial to the RTW process [49].
2.4.2. Line managers and WRMD
Line managers are the most important stakeholders in facilitating the RTW process [49–52]. Flach
et al. have found that a lack of support from supervisors is associated with job loss during sick leave
[53]. Line managers are in a position to support workers who are absent due to mental disorders
through a combination of support, guidance, and permanent or temporary changes in work tasks
[51]. However, studies have suggested that managers may lack the necessary knowledge and room
for action to achieve a successful RTW for long-term sick-listed employees [51,54,55]. A gap has
been identified between companies’ intentions and actual behaviour when implementing initiatives
to secure a successful RTW [8,56]. However little is known about the experiences of line managers
with employees on sick leave due to a work-related mental disorder. More research is needed in this
field [51,54,55].
2.5. B. WRMD in the WCS
Most Western countries
have insurance systems that compensate employees for disability, wage
loss, and medical expenses [57]. Europe has seen a high increase in workers’ compensation claims
due to WRMD [19]. In Denmark, there has been a
50.5%
increase in workers’ compensation claims
for occupational mental disorders
from 3.107 claims in 2010 to 4.676 claims in 2016
[5]
. This
increase may represent a dilemma since the literature also indicates that workers’ compensation
claims may harm sick employees.
2.5.1. The Danish WCS
The Danish legislation requires physicians to notify all physical and mental diseases suspected of
being caused by working conditions
[4]
. Denmark is one of the only European countries to include
mental disorders on its List of Occupational Diseases
[19]
. Other mental disorders are recognised
17
under a complementary system. Currently, post-traumatic stress disorders (PTSD) and depression
are the two most commonly recognised disorders [58]. However, only few claims of
occupational
mental disorders
gets recognized e.g. i
n 2016, 4.1% of notified occupational mental disorders were
recognized
[5]
. This low number is a result of the medical research that underpins Danish Labour
Market Insurance decisions, which has so far demonstrated only a limited correlation between
workplace conditions and mental disorders
[58]
. In addition, the m
ultifactorial nature of mental
disorders [26–28] can make it difficult to document a causal relationship between workplace
exposures and a diagnosed disorder.
2.5.2. WCS may harm employees’ health and labour market attachment
Studies have shown that the workers compensation claims of an occupational disease may have the
unintended side effect of increasing the risk of work disability [6]; workers’ compensation claims
have been linked to a worse prognosis [59–61], a worse recovery, [62] and health-related job losses
[63]. A meta-analysis of accidents has found that the mental health of people involved in
compensation claims is less likely to improve than that of people not involved in compensation
claim processes. No studies have shown any association between compensation claims and positive
health outcomes [64]. However, the epidemiological research in this field has been criticised for
methodological weaknesses that raise questions about the studies’ conclusions [65–67]. Researchers
continue to call
for further research, pointing out plausible explanations for the association
between compensation-related factors and poorer health outcomes
[64]
.
Recently, meta-syntheses and meta-analyses have been conducted to explore workers’
compensation processes. Employees perceive the claim process to be stressful, [65] while
interacting with key actors in the compensation system, such as insurers [68] and health-care
providers, [69] can negatively affect the recovery of claimants. Further administrative hurdles that
impede workers’ compensation claims have been associated with higher mental health complaints
[65].
Although studies in this field have investigated a broad range of diseases and injuries, so
far, I have
only been able to identify one scientific study that has focused exclusively on employees with
notified occupational mental disorders. It was based on interviews in an Australian context
with four stakeholder groups: employers,
general practitioners
,
sick employees, and
compensation agents. The employees’
mental health claims were found to be complex to
18
manage and associated with conflicting medical opinions, stigmatisation, and the risk of
developing secondary problems during the recovery process
[70]
.
Most studies of the effects of claims processes have been carried out in North America or Australia.
The noted effects on health and labour market attachment may be less prevalent in a European
context, where a different insurance system provides income replacement, health care, and support
for the RTW process. An employee’s income and access to health care is not completely dependent
on the outcome of his or her compensation claim. There is consequently very limited understanding
of the experiences of employees with WRMD in WCS and of WCS’s effect on notified employees
in a European/Scandinavian context.
2.6. C. Interaction between the Workplace and WCS
International research suggests that the workplace and insurance/legal systems do interact in
relation to sick employees, [71] and this may have both health inhibiting and health promoting
elements [72]. However, the interactions between the workplace and legislative and insurance
systems have not been much explored in relation to employees with WRMD; these interactions are
also highly dependent on specific jurisdictions. The following section describes three possible ways
for worker compensation claims to directly impact workplaces: 1) by eliciting a workplace
inspection from the Working Environmental Authority [73]; by eliciting an employer hearing [74];
and 3) by providing financial incentives in relation to claims [34].
2.6.1. Inspection by the Working Environmental Authority
In Denmark,
workers’ compensation claims are submitted to both the Danish Working
Environment Authority and the Labour Market Insurance, which serve two functions. First, the
Danish Working Environment Authority receives information about the working environment
that is believed to have caused the disease; this information can be used to prevent further cases
in the worksite or industry. Second, the Labour Market Insurance assesses whether the disease
can be recognised and compensation awarded
[73]
. Thus, workers’ compensation claims may
make an important contribution to prevention.
Serious limitations have been identified in relation to the Danish Working Environmental
Authority’s use of workers’ compensation claims of occupational diseases, and the extent to
which inspectors can adequately inspect and make decisions relating to the psychosocial work
environment
[75]
.
19
The limitations of the Danish Working Environment Authority
1.
The Authority has a very limited use of the workers’ compensation claims in general, as
its computer system only select cases for its inspectors to examine, if two or more
employees from the same workplace have reported the same occupational disorder in
the same half year
[76]
. Otherwise, the notifications are not examined
1
.
2.
A worker’s compensation claim cannot provide the basis for a decision by the Authority
on the psychosocial work environment. Most decisions concerning the psychosocial
working environment are based on employee statements made during Authority
interviews
[75]
. An inspection can be carried out on the basis of several notifications of
occupational mental disorders, but the Authority's decision will depend on whether the
employees selected for interviews are willing to make critical statements about their
workplace experiences. Studies have shown that employees are unwilling to criticise
their employers during inspections, if the employees fear reprisals
[77,78]
.
3.
The Danish Working Environment Authority
must also ensure that employees remain
anonymous. This can result in the Authority opting not to carry out an inspection
if
they judge that an employee’s anonymity cannot be maintained.
4.
Around one-fifth of all Danish employees are employed in organisations in which the
Authority
cannot inspect the psychosocial working environment, due to collective
agreements or Occupational Health and Safety Certifications
[75]
. Although audits can
take place, these have been harshly criticised for methodological limitations when used
to identify psychosocial risks. The auditors lack necessary competencies and methods of
assessing psychosocial risks and psychosocial risk management
[79].
5.
Finally, the Danish Work Environmental Authority follows the Method Committee’s
recommendations,
which in practice means that the A
uthority
does not deal with cases
caused by any of the following factors:
A)
an overall management decision about the
company; B) interactions between management, employees, or their representatives; C)
interactions between the employees; or D) conditions external to the company
2
.
1
A few exceptions exist, e.g. cases of severe chemical exposure, but they are not related to WRMD [76].
2
Bullying and sexual harassment are exempt from the Method Committee’s recommendations; the Working
Environmental Authority can make decisions on these
[76]
.
20
2.6.2. Employer hearing
In addition to workplace inspections, employers may interact with the WCS during employer
hearings. During the compensation process, if the Labour Market Insurance examines the case, the
employer may be contacted and asked to confirm/deny/provide a perspective on workplace
exposure relating to a claim. This process is not anonymised: the exposure described in the claim is
sent to the employer, whose response is communicated directly to the Labour Market Insurance and
the sick employee. Employer hearings are perceived as part of the insurance case, but the
potentially harmful or preventive aspects of such interactions have not been studied.
One potential
positive result of a hearing is that an employer becomes aware of psychosocial risks, perhaps
initiating preventive initiatives. However, such hearings could also cause adverse effects, since
the perception of psychosocial risks is somewhat subjective; the employer’s perspective and
interests may conflict with those of the sick employee.
2.6.3. Economic incentives in relation to workers’ compensation claims
Effect on employers’ insurance premiums
The WCS in Denmark is a no-fault system financed by employers [80]. The system exists in
parallel to the health-care and social security systems, protecting
employers from lawsuits
[81]
.
In
Denmark, employers are obliged to provide two types of workers’ compensation insurance.
Industrial accidents are covered by private insurance companies; in this case, there is a potential
experience rating, which means that insurance companies can increase premiums following
industrial injuries. Occupational diseases are insured through the Labour Market Insurance, with
fixed rates determined by the industry in question. High-risk industries attract higher premiums, but
the premiums do not depend on the prevention level provided by the individual employers or
compensation claims. According to the Economics of Tort Law, [82] this provides only a weak
incentive for employers to invest in preventing work-related diseases, as the premium offers no
financial rewards for doing so [34].
The extent to which Danish regulations in the field of Workers’ Compensation Law, Working
Environmental Law, and Tort Law incentivise organisations to prevent work-related mental
disorders and injuries has been studied in a newly published PhD thesis from the Faculty of Law,
University of Copenhagen, Denmark. The researcher concludes that, even though the 2013
Danish
Working Environment Act covers both physical and
psychosocial work environments, the
21
employer incentives for preventing work-related mental disorders/injures are smaller than those for
physical diseases and injuries. The probability of fines and sanctions are lower for psychosocial
risks and work-related mental disorders; the fines imposed in cases involving psychosocial work
environments are smaller than those involving the physical work environment [34]. Thus, the laws
do not create sufficient incentives to create effective prevention in the psychosocial work
environments.
The interactions between the workplace and the WCS can be summarised as follows. Workers’
compensation claims for occupational mental disorders are likely to have a relatively small impact
on prevention at the workplace. There is little chance of inspection and the few inspections that do
take place rarely result in decisions. Employer hearings may have a positive effect—making
employers aware of psychosocial hazards. However, they may equally have a negative effect,
damaging the relationship between the employer and sick employee. Finally, employers’ insurance
premiums are determined by industry and unrelated to the specific employers level of prevention or
workers’ compensation claims for occupational disorders.
22
3. AIM OF THIS THESIS
The aim of this thesis was to explore what happens when employees gets sick from a work-
related mental disorder.
The thesis focuses on the Workplace System, WCS, and the interaction between the two systems,
applying the perspectives of employees and line managers.
The following key questions have been explored:
Study I Title: ‘How do line managers experience and handle the RTW of employees on sick
leave due to work-related stress? A one-year follow-up study’
The specific aim was to explore the ways in which line managers experience and
handle situations in which employees are sick-listed due to work-related mental
disorders.
Study II Title: ‘How do Danish workplaces handle work-related diseases?—The experiences of
employees with notified occupational diseases in the Workers’ Compensation System’
The specific aim was to study what happens in the workplace when an employee
develops a work-related disease—Who is involved? Are work-related mental
disorders handled differently from other types of work-related diseases?
Study III Title: ‘Employees with notified work-related mental disorders—experiences in the
workplace and Workers’ Compensation System’
The specific aim was to explore the experiences of employees with notified work-
related mental disorders in the workplaces and WCS, ascertaining the extent to which
such experience depended on the claim decision (rejected, recognised) or diagnosis
(PTSD, depression, stress-related disorders).
Study IV Title: ‘Is the notification of an occupational mental disorder associated with changes
in health, income, and long-term sickness absence?’
23
The specific aim was to examine the extent to which workers compensation claims of
mental disorders are associated with changes in health, income, or long-term sickness
absence.
4. MATERIALS AND METHODS
The articles included in the thesis are based on data drawn from two Danish research projects, the
COPEWORK study (data collected in 2011–2012) and the Project Workers’ Compensation System
(data collected in 2013–2014). The thesis also makes use of 2009–2014 data from national
registries. Given the diverse range of aspects studied, the articles use a number of different
methodological approaches, including semi-structured interviews, questionnaire surveys, and
register-based analyses.
The following section describes the materials and methods used in Studies I, II, III, and IV.
4.1. Study I
The data consist of semi-structured interviews with line managers conducted at two time points with
a follow-up of one year. The interviews focused on the line managers’ experiences when an
employee becomes sick-listed due to work-related stress. All interviews were carried out using a
grounded theory approach.
4.1.1. Grounded Theory Approach
Grounded theory is a qualitative methodology developed to understand phenomena about which
little is known. [83] For this reason, it is particularly appropriate for exploring the experiences of
line managers whose employees have been sick-listed due to work-related stress; limited research
has been conducted on this topic and the findings depend on the culture and legislative context.
Grounded Theory enables researchers to understand complex social processes; [84] its methods can
be used to carry out research in a diverse range of studies, whether or not the aim is theory
development [85]. The grounded theory approach consists of systematic but flexible guidelines for
collecting and analysing data [85]. A core characteristic of grounded theory research is that data
collection and analysis are closely interrelated to engage with the studied phenomenon as deeply as
24
possible. Analysing the collected data influences the strategy of data collection and vice versa [83]
because data collection and analysis happen simultaneously in an iterative process. A detailed
description of the data collection method used in Study I is described under 4.1.3. Data collection
and analysis – interviews with managers. According to grounded theory, data collection and
analysis should continue until no new information is gained, known as the point of theoretical
saturation [83].
4.1.2. Participants and procedure
Figure 3. The COPEWORK Study, data collection 2011–2012
Line managers (LM)
Managers were recruited through their sick-listed employees, who took part in a randomised
controlled trial that tested different types of stress treatment programmes [1,2]. The 197
3
employees
participating in the trial were asked whether they would allow researchers to contact their managers
for an interview. The employees were referred by GPs for stress treatment in project Copestress and
they fulfilled the following criteria: (1) on full- or part-time sick leave; (2) employed or self-
employed; (3) having had significant symptoms of stress for months, and (4) motivated to
participate in a stress treatment project. Participants were excluded if they (1) currently abused
alcohol or psychoactive stimulants; (2) were diagnosed with a major psychiatric disorder, or (3) had
a significant somatic disorder assumed to be the primary cause of their stress condition.
Of this group, 56 employees allowed us to contact their managers. All 56 employees had
experienced at least one major work-related factor, such as high work pressure, poor management,
3
Study I [86] mistakenly cited 210 employees instead of the correct number of 197 employees in the published article.
However this error has not affected the study findings.
25
or a generally poor psychosocial working environment leading to sick listing (assessed by a
psychologist or occupational physician during the treatment). Eighty-eight percent of the employees
had experienced three or four work-related stress factors that led to sick-leave (for additional
details, see [3]). Of the 56 managers contacted, 36 agreed to participate and 3 ultimately dropped
out. Figure 3. illustrates the process of data collection.
The saturation point was reached after 15 interviews in the first interview round and 8 interview in
the follow-up round; these interviews formed the empirical basis of Study I. The rest of the
managers who agreed to participate filled out an online questionnaire developed using the interview
guide. In addition, 26 health-and-safety representatives from the various workplaces agreed to
participate and were either interviewed or given a questionnaire to complete. The questionnaire data
from the managers and health-and-safety representatives, as well as the interview data from the
health-and-safety representatives, has been presented in a Danish report: ‘COPEWORK—
COPESTRESS Workplace Study’ [3].
Comparing participants and non-participants
Data from the sick-listed employees whose workplaces participated in the study was compared with
data from other employees in the stress treatment programme who did not agree to participate (refer
their manager), using the following parameters: gender, occupation, and employee’s rating of
his/her psychosocial work environment, assessed using the ‘The Copenhagen Psychosocial
Questionnaire’(COPSOQ) [87]. The following differences between groups were found: employees
whose managers participated in the interviews or survey had more days of sick leave (80.6 days vs.
an average of 68.5 days); more were employed in academic positions and more of the employees
had returned to work at the end of the treatment. The employees scored their workplaces more
favourably in the COPSOQ for ‘vertical trust’ (trust in management). However, the general
COPSOQ scores from employees participating in the project (n=197) were significantly below the
Danish population average [3]. measured using 3517 Danish employees [88]. Thus, the
participating managers were perceived more positively by their employees than non-participating
managers.
26
4.1.3. Data collection and analyses—Interviews with managers
The baseline data collection was conducted in 2011 and consisted of one-hour individual interviews
at the manager’s workplace, in the manager’s office, or in a meeting room. A second researcher
attended five interviews as an observer, with the interviewee’s permission. This allowed for
subsequent internal reflections on the interview form and content [89].
After one year (2012), eight of the managers received follow-up interviews lasting 30–60 min, after
which the saturation point was reached. The follow-up interviews were used primarily to further
investigate coded themes from the baseline interviews. Some of the preliminary findings were
presented by the researcher during the interviews; these findings were conveyed in the form of
verbal statements by the interviewers such as, for example, ‘managers tend to focus on their
employees’ private circumstances or personalities to explain stress related sick-leave’ or ‘managers
experience a lack of organisational support when an employee is sick-listed as a result of stress’.
Managers were given the opportunity to reflect on these findings [89]. The follow-up interviews
were also used to record whether the employee had returned to the workplace or not, and the
managers’ own reflections on the process. For workplaces that did not participate in the follow-up
interviews, information on whether employees returned to work was obtained from a randomised
controlled trial in which the employees received stress treatment.
The interview guides included factual as well as explorative questions. Table 1 shows the themes in
the final version of the interview guides used in baseline and follow-up interviews with managers in
the COPEWORK study.
Table 1. Themes in the interview guide for manager interviews
The interview guide for baseline interviews included background information on the managers and the
managers’ perspective on the following areas:
Workplace conditions and the causes of employee stress
Reflections on preventing stress in the working environment
Experiences of handling situations in which employees were sick-listed due to stress
Experiences with the RTW process and thoughts and feelings about the process
Reflections on supportive and inhibiting factors in organisations, with respect to facilitating the RTW
27
process for employees with stress
Reflections on the challenges and dilemmas associated with stress and the RTW process.
The interview guide for the one-year follow-up interviews also included the following topics:
Events and occurrences in the workplace since the last interview
The return-to-work status of the employee
A dialogue about preliminary findings/hypotheses
Interviews were recorded and transcribed verbatim and the transcripts were anonymised. The
interview transcripts were analysed using Grounded Theory principles to identify the main themes.
An initial open coding, followed by a sequential transcript review, was conducted. Codes that
described processes, actions, thoughts, and feelings were generated. The core codes described ways
in which managers experienced and handled situations in which employees were sick-listed due to
work-related stress. Selective coding identified codes that were frequently mentioned or stood out
as being particularly important. The analyses were supported through extensive memo-writing [85].
Following every 2–3 interviews, the data were analysed and emerging themes were used to revise
the interview guide. In this way, themes that were found to be central were explored and developed
further, while other themes were excluded.
4.2. Data collection for Study II and Study III
Study II and III both analysed data collected within the Project Workers’ Compensation System.
The data collection procedure used in this project is presented first, followed by the specific
procedures and analyses used for Study II and III, which are described separately.
4.2.1. Data collection in Project Workers’ Compensation System
Figure 4 illustrates the Project Workers’ Compensation Systems’ research design, showing the data
analysed in Study II and III.
28
Phase 1
Phase 2
Phase 3
Phase 4
Interviews
Employees with
WRMD
Notified
N=13
Stakeholder interviews
N=23
Recruitment
From BBH* and OUH**
Sick employees referred to medical
examination
Interviews
Employees with
WRMD
Not notified
N=7
Interviews
Employees with low
back pain
Notified
N=2
Interviews
Employees with skin
diseases
Notified
N=1
Transcription and analysis
Development of questionnaire
Questionnaire pilot testing
Randomized selection from the Danish
Labour Market Insurance
Employees with notification in 2010-
2012
Questionnaire distributed
Employees with skin
diseases
Recognized claim N=200
Rejected claim N=200
Questionnaire distributed
Employees with low back
pain
Recognized claim N=200
Rejected claim N=200
Questionnaire distributed
Employees with
WRMD***
Recognized claim N=321
Rejected claim N=400
Response rate
60.5 %
N=436
Response rate
50.5 %
N=202
Response rate
33.0 %
N=132
Study II
Study III
Study III
*BBH—Bispebjerg University Hospital, Department of Occupational and Environmental Medicine
**OUH—Odense University Hospital, Department of Occupational and Environmental Medicine
*** Since post-traumatic stress disorder (PTSD) was the only mental disease on the List of Occupational Diseases (diseases on
the list are processed differently from diseases not on the list [19]), the selection of employees with work-related mental
disorders was randomised using four subgroups: Recognised claims (recognised claims excluding PTSD (N=121, i.e. all
claims that fulfilled inclusion criteria) + recognised claims including PTSD (N=200)). Rejected claims (rejected claims
excluding PTSD (N=200) + rejected claims including PTSD (N=200)).
Figure 4. Data collection in 2013–2014 from the Project Workers’ Compensation System
Data analysed in Study II and Study III are illustrated
29
The following section describes the four phases of data collection from the Project Worker’s
Compensation System.
Phase 1—Stakeholder interviews
Interviews (N=23) were conducted with different stakeholders in the Danish WCS.
Strategies for
conducting elite interviews [90,91] were applied during this phase of data collection, meaning that
the interviewer actively engaged in discussions, provided ‘facts’ and additional or contrasting views
during the interviews to challenge the interview and gain a degree of power symmetry in the
relationship between interviewer and interviewee [89].
The following stakeholder interviews were carried out: Group or individual interviews with health-
care professionals from all occupational medicine departments in Denmark. Interviews with
central stakeholders from the Danish Working Environmental Authority, the Danish Labour
Market Insurance,
the Confederation of Danish Employers (DA),
Danish municipalities, unions,
an insurance company, a law firm, and a member of the Board of Industrial Injuries.
The
stakeholder interviews were analysed using the grounded theory approach, with initial coding
followed by focused coding and memo writing throughout the whole analytical process [85]. The
focus was on factual information as well as descriptions of the different WCS processes and
political positions. The stakeholder interviews provided preliminary knowledge, information about
different stakeholders in the system, various political views in the WCS, information on the use of
notifications in stakeholder organisations, and professional opinions about the potential impact of
compensation claims on notified employees. Additional health-care professionals shared their own
experiences and practice in relation to compensation claims for work-related mental disorders, as
well as their views and interpretations of the legislation in this area. Information gained during the
stakeholder interviews informed the development of the interview guide for employees and the
development of the questionnaire survey.
Phase 2—Interviews with employees with work-related disorders
Employee interviews were collected during 2014 using the grounded theory approach.
Interviews were collected in 2–3 chunks, after which they were analysed. This produced emerging
themes and the interview guide was revised. Some themes identified as central were explored and
developed further; others were discarded during the data collection and analysis.
30
Employees were recruited by occupational physicians and psychologists at the Department of
Occupational and Environmental Medicine at Bispebjerg University Hospital and Odense
University Hospital in Denmark. This led to 13 semi-structured interviews of employees with
notified WRMD and 7 interviews of employees with non-notified cases of WRMD. There were
also two interviews with e
mployees who had notified low back pain and one with an employee
with a notified skin disease. Participants were contacted by phone by the first author; they were
asked whether they wanted to be interviewed in their homes, at a nearby place, at the Department of
Occupational Medicine, or at the University of Copenhagen. Participants filled out a consent form
before the interview and were given the opportunity to withdraw their data at any point.
Each
interview lasted approximately one hour and focused on the employee’s experiences in the
workplace before and after being sick-listed. It covered experiences with different stakeholders
in the workplace and WCS, the expectations and motivations behind the claim, and the WCS
process. Interviews were recorded, transcribed verbatim, and coded in NVivo10 using open and
selective coding and memo writing.
[85]
Phase 3—Development of the questionnaire survey
Based on preliminary findings from the employee and stakeholder interviews, a questionnaire
was developed. It was pilot tested in accordance with the principles established by Boynton
[92]
. Initially, five employees with notified occupational disorders filled out the questionnaire and
were interviewed about each item; this process cast light on the ways in which they interpreted
and chose to answer the questions. Based on their feedback, the questionnaire was revised. Next,
13 employees tested an online version of the questionnaire using the software programme
SurveyXact and provided feedback, after which the final version was developed.
The final questionnaire consisted of 40 questions and a number of sub-questions; both scales
and open-response categories were used. Table 2 shows selected items from the questionnaire,
which is relevant for the studies in this thesis. The full questionnaire is shown in Appendix 5.
31
Background information Gender, age, citizenship, educational level, current occupation
Health - Self-rated health, current
- Self-rated health before the notified disorder
Work ability - Self-rated work ability, currently
- Self-rated work ability before the notified disorder
Occupation - Current
- At the time of the notification
Type of employment At the time of notification (e.g. time-limited, permanent, hourly wage
earner, self-employed)
Return to the same workplace Currently employed at the same workplace as at the time of notification
- If not why? (e.g. fired, quit, period of employment ended)
Sick-leave Sick-leave in relation to the notified disorder (e.g. long term >8 weeks,
short term <8 weeks)
Workplace management
How did your workplace handle the process when you became sick
?
(e.g. well, badly)
Workplace knowledge of the workers’
compensation claim
Did the manager at your (former) workplace know that you had a disorder
notified to the Danish Labour Market Insurance?
Changes in the work environment Were any changes made to your working environment as a result of your
disorder?
Workplace stakeholders
How significant were the following people at your former workplace
during the process of getting sick and having a
workers’ compensation
claim
?— top management, line manager, union representative, health-
and-safety representative, colleagues (e.g. positive, neutral, negative)
Inspection by the
Danish Working
Environment Authority
Has the Danish Working Environment Authority carried out an
inspection at your workplace as a result of your claim?
- If yes or partially—how did you experience the inspection?
Motivation behind the workers’
compensation claim
What did you primarily hope to gain as a result of your compensation
claim? (e.g. compensation, prevention, registration as a precaution)
The compensation process
Did you feel adequately informed about the workers’ compensation
Table 2. Selected items from the questionnaire used in Project Workers’ Compensation
System
32
process?
Compensation schemes
What was it like filling out the compensation schemes (e.g. easy,
neutral, hard)
Negative effect of the workers’
compensation claim
Did the process in relation to the workers compensation claim hinder or
delay your return to the labour market?
Phase 4—Distribution and collection of questionnaires
In 2014, employees with a notified occupational mental disorder, notified low back pain or
notified skin disease (notified in 2010–2012) were randomly selected from the Danish Labour
Market Insurance database.
A
n employee could only be included once; workers with pre-
existing claims were excluded. The
only accepted WRMD on the 2014 List of Occupational
Diseases was PTSD; the processing of PTSD claims was therefore somewhat faster and smoother
[19] than the processing of other WRMDs. Selected employees with WRMD were therefore divided
into four groups: 1) recognised claims excluding PTSD (N=121); there were only 121 registered
claims, after the inclusion criteria; 2) recognised claims including PTSD (N=200); 3) rejected
claims excluding PTSD (N=200); rejected claims including PTSD (N=200).
Employees with low
back pain were divided into two groups—
recognised claims (N=200) and
rejected claims
(N=200); e
mployees with skin diseases were divided into those with
recognised claims (N=200),
and those with
rejected claims (N=200).
In December 2014, the selected employees were contacted by letter and asked if they wanted to
participate in the survey. Included in the letter were a description of the study and a personal
code for the online questionnaire. After a month, a follow-up letter that included the personal
code for the electronic questionnaire, the questionnaire in paper form, and a stamped, addressed
return envelope were also mailed.
Out of the 1521 employees selected, 770 completed the questionnaire. The response rate varied
between the three types of occupational diseases, with 60.5% of employees with WRMD
responding, alongside 50.5% of those with low back pain and 33% of those with skin diseases. Chi
2
tests were used to test the differences between respondents and non-respondents in a dropout
analysis (ref: Study II)
. Among the responders, significantly more women, people over 55,
33
education/health-care industry workers, and participants with stress-related mental disorders
completed the questionnaire (ref: Study III).
The implications of the response rate for the studies
findings are discussed in 6.8. Strengths and Limitations.
4.3. Study II
4.3.1. Participants and procedures
The data analysed in Study II consisted of questionnaire responses from employees with WRMD,
work-related low back pain or work-related skin diseases, collected within the Project Workers’
Compensation System. The study compared the experiences of employees with different work-
related diseases and explored whether workplace management and stakeholders’ involvement
differed in accordance with the type of work-related disease.
4.3.2. Analysis
The questionnaire responses (N=770) were divided into three diagnostic groups: Mental disorders
made up 56.7% (8.2% post-traumatic stress disorder (PTSD), 12.5% depression, 36% stress etc.—
including Stress without specification, adjustment disorders, anxiety, and non-specified psychiatric
disease). Low back pain made up 26.2%. Skin diseases made up 17.1% (11.4% toxic eczema,
3.5% allergic eczema, 2.2% other skin diseases). The diagnoses represented the final diagnostic
formulation recorded in the Labour Market Insurance register in relation to first claim decisions.
The questionnaire responses given by the participants in the three diagnostic groups were analysed
using descriptive statistics and tested via Chi-square tests to identify any significant differences
between the groups.
Responses to the open-response categories were analysed using selective
coding.
As there were significant differences between employee characteristics in the three diagnostic
groups, additional chi–squared tests were carried out to test differences in responses by industry
(service, education/health, industry/crafts/agriculture, police/defence/jail), self-reported health at the
time of response: good health (excellent, very good, good) and bad health (less good, bad), age (<40
years, 40–55 years, > 55 years), compensation claim decision (recognised, rejected) and gender
(female, male). The results of these tests are shown in Appendix 6.
34
Other methods, such as a logistic regression, were considered, but no dichotomisation of the
questionnaire response categories was possible, since merging varied response categories (positive,
neutral, negative, not relevant, etc.) would result in misleading results.
4.4. Study III
4.4.1. Participants and procedures
Study III combined analyses of interview data from employees with notified WRMDs (N=13) with
analyses of the questionnaire data from employees with notified WRMD (N=436). The aim was to
explore the experiences of
employees with notified WRMD experiences in the workplace and
Danish WCS.
Since the data collection process has been described in 4.2. Data collection for
Study II and Study III, this section only provide additional information.
Interviews
Interview participants (N=13) were recruited by physicians and psychologists at two Danish
Occupational Medicine Departments from 2 January 2014
onwards
.
The inclusion criteria were as
follows: significant symptoms as a result of an occupational mental disorder, having notified
an WRMD and being employed when the disease started.
Exclusion criteria
:
Current abuse of
alcohol or psychoactive stimulants, major psychiatric disorder or significant somatic disorder
assumed to be the primary cause of the mental disorder or the person being potentially
unpredictable or dangerous.
Questionnaire responses
Chi
2
tests was used to compare participants (N=436) with non-participants (N=285) in a
dropout analysis. Significantly more women participated, employees over the age of 40 years,
more employees with stress-related disorders and anxiety and less with PTSD. Finally, more
participants from
Education/health
and less from
Police/defence/jail.
No significant differences
were found related to recognised claims or financial compensation.
The sample was analysed comparing three diagnostic groups: Post-traumatic stress disorder, F43.1
(N=63). Depression F33 and F32 (N=96). Stress etc.: Adjustment disorders, F43.2–F43.9 (N=161),
Stress without specification, Z (N=96), anxiety, F41 (N=4) and non-specified psychiatric disease
(N=16). Diagnosis was the final diagnosis given in the Labour Market Insurance register in relation
35
to the first decision given on the claim. In addition, responses from employees with recognised
claims were compared to responses from employees with rejected claims.
4.4.2. Analysis
The interviews were analysed using a grounded theory approach (described in 4.2. Data collection
for Study II and Study III). The data collected through the questionnaire survey were analysed using
descriptive statistics, while the differences between the diagnostic groups and recognised/rejected
claims were tested using chi
2
tests.
The responses to the open-response categories in the
questionnaires were analysed through selective coding
[85]
.
4.5 Study IV
4.5.1. Participants and procedures
Study IV consisted of a follow-up study based on a sample of 995 patients examined at the
Department of Occupational- and Environmental Medicine of Bispebjerg University Hospital in
Copenhagen, Denmark, by physicians from 2010 to 2013. The aim was to examine whether
notification of WRMD was associated with changes in health, income, or long-term sickness
absence. Of the patients included, 699 had notified an WRMD, while 296 patients had an un-
notified mental disorder. To be included in the study, patients had to be 18 or older at baseline, alive
at the follow-up, and registered at the Department of Occupational and Environmental Medicine
with a mental disorder between 2010 and 2013, with complete data on the requested outcome
variables in the registers. All patients were referred following medical examinations by their general
practitioners, other medical specialists, union representatives, municipalities or workplaces, because
it seemed possible that the mental disorder had been caused by the working conditions.
For GP visits, prescriptions of psychotropic drugs, and long-term sickness absence, the baseline was
the calendar year of the occupational department medical examination. Disorders were either
notified during the examination or had been notified prior to the examination (normally no more
than two months before the examination). Thus the examination year was typically also the year of
notification. Follow-up took place the following year. The baseline for income was the calendar
year before the medical examination, while follow-up was the year after the medical examination. A
different income baseline was used to detect changes in income from before to after the employees
became sick.
36
Data were extracted from four registers by Statistics Denmark, the central authority on Danish
statistics. They were analysed on the Statistics Denmark server, in accordance with the United
Nations’ Fundamental Principles of Official Statistics [93].
GP visits Danish Patient Registry
Data on GP visits per year. GP visits were treated as a count variable, ranging from 0 to a
maximum of 7 visits per person.
Prescriptions of psychotropic drugs The Drug Registry
Prescriptions data included anxiolytics, sedatives, hypnotics, and antidepressants. This variable
was dichotomised into ‘no prescriptions’ and ‘any prescription’.
Yearly income Income Statistics Register
Data on total personal income were dichotomised into ≤ 300.000 and >300,000 Dkr/ year
(approximately 45,000 US dollars or 40.290 EUR). Apart from property income, ‘income’
included social benefits and all types of individual earnings per calendar year.
This cut-off point was chosen because the average Danish employee’s total personal income in
2009 was 368.922 Dkr/year. The average for employees at the lowest of the four levels of
employment was 306.789 Dkr, calculated by Statistics Denmark (20.9.2016).
Long-term sickness absence KMD registry
Data on long-term sickness absence were dichotomised into ≤ 30 days vs. >30 days.
The KMD registry records all sickness benefits in Denmark. An employer is entitled to
reimbursement for sickness absence when an employee is on sick leave for more than 30 days. For
this reason, sickness absence was dichotomised into over and under 30 days of sick-leave during
one calendar year.
In the analyses of sickness absence, patients were excluded from the analysis if they had an
interruption of the sickness benefits during the calendar year, which was not due to RTW.
Examples of interruption included retirement, a change from sickness benefits to unemployment
benefits, starting an education, or failing to comply with the rules for obtaining sickness benefits.
Of the participants, 327 were excluded at the baseline and 177 at the follow-up.
Confounders
The selected confounders were known risk factors for mental health, based on previous evidence:
gender [94–96], age, [97–99] diagnosis [17] and occupation [100,101]. All confounders were
registered during medical assessments at the Department of Occupational and Environmental
Medicine. As part of the examination, physicians made diagnoses in accordance with the
International Classification of Diseases (ICD-10) and noted the patient’s current job title. The job
37
titles were merged into six different occupational groups: 1) health care, hospitals, nursing homes,
home care, and social services; 2) children's institutions of all kinds, schools, colleges and
universities; 3) Restauration, kitchen, cleaning, trade, transport, and services; 4) administration,
communication, libraries, and museums; 5) police, military, prisons, and search-and-rescue work; 6)
manufacturing and construction.
4.5.2. Analysis
The distribution of baseline characteristics among notified and non-notified patients was compared
using a Chi-squared test. The distribution of outcome variables was calculated among non-notified
and notified patients both at the baseline and at the follow-up. The prospective association between
notification status and GP visits at the follow-up was examined by Poisson regression models using
Generalised Estimation Equations with robust standard errors. The prospective associations
between claim status and the three dichotomous outcomes (prescriptions, annual income, and long-
term sickness absence, were analysed using a conditional logistics regression. Due to the otherwise
small resulting groups, these three outcomes were dichotomised. Changes in outcome between
baseline and follow-up were examined in all categories; the association between notification status
and outcome was adjusted for time. Finally, the associations between time, gender, age, diagnosis,
and occupation were adjusted.
In preliminary analyses, the interactive effect of time, notification status, and the covariates of the
four outcomes were tested; none of these interactions were statistically significant. The statistical
software R (version 3.2.3) was used for all analyses.
38
5. RESULTS
This section summarises the results of the four studies that make up this thesis.
5.1. Study I
How do line managers experience and handle the return to work of employees on sick leave due to
work-related stress? A one-year follow-up study
1. Lack of a common understanding of stress: Several managers pointed out that the word ‘stress’
has no exact meaning, as it describes a range of conditions from being somewhat busy to feeling
seriously anxious and ill. Some managers found the broad use of this word problematic since it
was hard to know when to take action. Discussions of stress varied. In some organisations, stress
was not discussed at all; others had a more open dialogue. The majority of managers, either
directly or indirectly, described stress as being at least partly associated with personal weakness.
The lack of a common understanding of stress, its severity, and possible causes may discourage
employees from acknowledging stress-related problems and impede the implementation of
preventive stress interventions in organisations.
The results were divided into four themes:
1. Lack of a common understanding of stress
2. Shift in focus from work environment to the individual
3. Challenges experienced by managers during the RTW process
4. Supportive factors experienced by managers during the RTW process
‘Stress to me is the negative version [of being busy]. The problem nowadays is
that people use the word ‘stress’ randomly. Now everything is stressful... I
think people forget to distinguish between the negative and the positive. It’s
okay to be busy…You don’t become ill by being busy.’ (Line manager, IT
company, private sector)
‘No, we talk about being very busy, and about there
being a lot of pressure and people being fed up. That’s
what we talk about.’ (Line manager, Authority, public
sector)
39
2. Shift in focus from the work environment to the individual: Tough and demanding working
conditions involving large workloads, time pressure, tight deadlines, restructuring, or downsizing
were described by all managers. Several managers expressed frustration with having several
employees away from work with long-term stress-related absences. However, when talking about
who was responsible for specific employees on stress-related sick leave, there was a sudden shift
in focus. From talking about problems in the work environment, the focus changed to emphasising
the employees’ personal issues, such as family problems or psychological predispositions, such as
perfectionism or an inability to adapt to change. This shift occurred in most of the interviews. The
managers felt that periods of sick-leave due to WRMD should be handled privately between
managers and employees.
3. Challenges experienced by managers in the RTW process: More than half of the managers said
that they were affected emotionally when employees went on sick leave due to work-related
stress. They felt both sorry for the employee and guilty about not having been attentive enough
to prevent the situation. At the same time, they expressed frustration that the employee did not
ask for help earlier and considered the employee partly responsible for the situation.
The majority of line managers experienced cross-pressure due to opposing demands from
employees and top management. Co-workers sometimes feared that they too would become sick
due to stress and expected managers to improve their working conditions. Consequently, some
managers chose to cite personal reasons for an employee’s sick leave without that person’s
permission, as a way of avoiding blame and further demands from remaining employees. At the
same time, top management expected departments to comply with set goals and budgets, despite
‘I have an employee who is extremely dedicated to her work, very
detail-oriented, an incredibly good performer, the best colleague,
always ready to help, always willing to participate in projects. She
is the world’s best mother. She always picks up her children at 3
pm…When she celebrates birthdays, she will always make
homemade buns, homemade jam; they don’t have one birthday,
they have three. She visits her grandparents at the nursing home
at least every Thursday. She gets sick because of stress.’ (Line
manager, Insurance company, private sector)
‘We have a tendency to
say it’s something
private, so we just avoid
the
responsibility…There’s
a need to say it’s not our
responsibility.’ (Line
manager, Media
company, private sector)
40
having fewer resources, when one or more employees were sick-listed. Several managers were
pressured by both top management and co-workers to ensure a quick RTW of a sick employee.
Managers stated that it was difficult to take proper care of sick-listed employees, while at the
same time taking care of the remaining co-workers, who often had to cover the sick-listed
employee’s work. There was a discrepancy between the human-relationship perspective (a
manager knowing the employee personally, being empathetic, and trying to accommodate RTW)
and the strategic responsibility for economy and productivity. Managers had to consider both
when deciding whether the employee should be supported to return or be fired. Managers
described not having the time, support, or knowledge to implement preventive interventions in
the work environment; several managers functioned alone, with no access to organisational
support.
4. Supportive factors experienced by managers in the RTW process: Knowledge and prior
experience were described by several managers as their most valuable tools, preparing them to
handle both current and future stress-related problems. Good communication and a relationship
with the absent employee were also essential, as well as mutual trust and the ability to speak
openly about the causes and consequences of stress. In the vast majority of workplaces where
‘I think it's really, really hard, especially as a line manager…You
need to meet the goals that are set for you… and, on the other
hand, take care of a group of employees who are sick, have been
sick, or are at risk of getting sick.’
(Line manager, Kindergarten, public sector)
‘I wish there was a tool, something we could just pull out and say, ‘This is what
we’re going to do now’… There is a stress policy but let me say it loud and
clear... it’s like we do not want to have employees who are stressed and that’s it.
That’s all I have as a manager to relate to.’
(Line manager, Insurance company, private sector)
‘I take most of the responsibility, so I walk around feeling guilty,
thinking it’s probably me…that I'm not good enough. But the
responsibility is, of course, only half mine. It’s a shared
responsibility so the employee is also responsible.’
(Line manager, Kindergarten, public sector)
41
managers reported good communication and a positive relationship with the absent employee,
the employee returned. Managers working in the transportation industry often had clear company
guidelines and policies on sick leave and the RTW process, which included access to
professional guidance and the option to send employees for free psychological counselling to
improve their health; this was perceived as helpful. Differences were noted among some
managers with comprehensive experience and a minimum of 12 years of seniority. Such
managers were able to influence the decisions of top management regarding budgets and
productivity demands. In this way, they felt they could protect their employees from additional
work overloads. In workplaces where the managers described poor or no communication
between the manager and the absent employee, the situation often resulted in the dismissal of the
employee.
5.1.1. Summary: Study I
The line managers struggled with several dilemmas when an employee was sick-listed with a
WRMD. Feelings of guilt, discrepancies between strategic and relational considerations, and cross
pressure between productivity demands, the needs of colleagues, and the needs of the sick
employee’s needs were identified. Often the responsibility for supporting the sick employee was
left entirely to line managers, who lacked the knowledge, room for action, and organisational
support they needed to handle the situation. Despite acknowledging the problematic working
conditions, line managers tended to explain the sick leave by shifting the focus to the sick
employee’s own responsibility and personal circumstances. A lack of a common understanding of
stress created room for this shift in focus. In addition, the sick-leave itself was seen as a private
matter handled between the manager and employee. These circumstances may inhibit preventive
initiatives in the work environment.
5.2. Study II
How do Danish workplaces handle work-related diseases?—Experiences of employees with
notified occupational diseases in the Workers’ Compensation System
42
1. Process and prevention in the workplace: The results indicated that employers’ efforts and
preventive actions to accommodate sick employees varied, depending on the disease. Some
employers accommodated employees at the individual level but did not change the overall work
environment, even though the employee was sick because of the working conditions (54.5% in
total reported no changes). The study found that significantly more employees with WRMD
(68.8%) than employees with low back pain (46.5%) or skin diseases (16.7%) thought that the
workplace handled their illness badly. Employees with skin diseases (23.5%) more frequently
experienced preventive initiatives in the work environment than employees with WRMD
(12.4%) or low back pain (12.9%). In addition, 6.3% reported that the Work Environmental
Authority had inspected their workplaces even though an occupational disease was notified and
was registered by the Authority for preventive purposes [4].
2. Stakeholder involvement: Employees with WRMD had a much more negative view of top
management, line managers, and occupational health-and-safety representatives than employees
with low back pain or skin diseases. However, in most cases the occupational health-and-safety
representative was not involved in the process, (52.3%) irrespective of the type of disease. The
union representative was more often involved when an employee had a WRMD or low back
pain; however, this stakeholder was sometimes viewed negatively by employees. The study
found that more employees with notified skin diseases had more positive experiences of
stakeholders than employees with WRMD or low back pain.
3. Employment status 2–4 years after notification of the disease: Many employees felt that they
resumed work too early (35.1%). In general, 2–4 years after the notification, 23.2% of the
employees with WRMD, 28.7% of those with low back pain and 39.4% of those with skin
disease were employed at the same workplace. However, many employees with WRMD (39.2%)
The results are divided into three themes:
1. Process and prevention in the workplace
2. Stakeholder involvement
3. Employment status 2–4 years after notification of the disease
43
and low back pain (47.5%) were unemployed 2–4 years after the notification; for employees with
skin diseases, this figure was even lower (18.2%).
5.2.1. Summary: Study II
Employers’ efforts and preventive actions when an employee was sick-listed with a work-related
disease varied, depending on the type of disease. More employees with WRMD had negative
experiences with workplace managers and stakeholders; they seldom reported preventive initiatives
in the work environment, compared to employees with skin diseases or low back pain. Many
employees felt that they resumed work too early and were unemployed 2–4 years after the
notification. Workplace inspections related to workers’ compensation claims were rare, regardless
of the type of disease notified.
5.3. Study III
Employees with notified work-related mental disorders—experiences in the workplace and
Workers’ Compensation System
1. Prevention in the work environment was an aim:
One of the employees’ most important motivations behind the workers compensation
claims of mental disorders was the hope that the claim would lead to preventive
interventions in the workplace, preventing others from getting sick in future (51.1%). In
particular, more employees with depression or stress related sickness were motivated by the
possibility of prevention (depression 51.1%, stress 54.9%) than employees with PTSD
(34.9%).
2. Problems poorly handled in the workplace:
WRMD rarely led to changes in the work environment, but more employees with
The results are divided into four themes:
1. Prevention in the work environment was an aim
2. Problems poorly handled in the workplace
3. Challenges related to workplace inspections
4. Experiences in the WCS
44
recognised claims reported changes (yes 16.2%, somewhat 19.6%) than employees with
rejected claims (yes 9.1%, somewhat 16.4%). The employees experienced an
individualised focus in the workplace, focusing on themselves more than the problems in
the working environment.
Many employees thought that their workplaces had handled the process poorly when they
became sick (
68.8%
). Compared to the other groups, more employees with PTSD and
recognised claims thought that their workplaces had handled the process well. Stakeholders
such as health-and-safety representatives were often not involved (50.7%); when they
were, more employees experienced them negatively (17.4%) than positively (12.4%).
Management involvement was also experienced as negative by most employees (52.3%).
Colleagues and union representatives were perceived most positively.
3. Challenges related to workplace inspections
:
Employees rarely found that their claims resulted in a workplace inspection by the Working
Environmental Authority (8.3%), even when this was an important motivation behind the
claim. Sick employees sometimes had a negative experience of inspections that did not
result in any decisions.
‘We were sent to a seminar with a coach …the manager wanted us to be one big family. Then I said
‘it's not just about being a big family, it’s also about my daily life, and my private time, but she [the
manager] did not see it that way. She simply meant we should be available. We could go 13 days
without a day off and when I say 13 days it’s twenty-four seven. Try to work 13 days and be
available. You may be sitting at home with phones and computers, but you’re still on, right? And in
a split second, you have to be able to turn around and be in sorrow, not in sorrow, but you must talk
to people who are in sorrow.’
(Undertaker,
Funeral company,
private sector)
[Reaction to a workplace inspection leading to no decision] ‘It was like a slap in the face when,
during one of my night shifts, I read the e-mail which had been sent round. It was like being told
that because you don’t want to be physically assaulted every week by a boy and be spat at and
have your hair pulled and be kicked black and blue all over, that it’s all just me whining and
making up a load of rubbish. And to be told afterwards by the parents that everything you did
was wrong. And then you get an email saying that everything was fine [email from the managers
describing no decisions after inspection from the Working Environmental Authority] and we
should accept that it just goes with the job.’(Nurse, hospital, public sector)
45
4.
Experiences in the WCS:
T
he claim process was perceived as demanding; 41.1% of employees said they were not
sufficiently informed about the process in the WCS and several found the compensation
schemes difficult to fill out (45.6%).
Employees experienced an individualised focus in the WCS, where they had to prove that
the disorder was caused by the working conditions and not a personal vulnerability.
More employees with recognised claims (26.5%) than employees with rejected claims (9.9%)
felt that the claim process had hindered or delayed their return to the labour market. Within 2–
4 years after the notification, 23.2% of employees who completed the questionnaires were still
employed at the same workplace, while 39.2% were unemployed. There was a significant
difference between the diagnostic groups and most employees with PTSD and depression were
unemployed.
5.3.1. Summary: Study III
Prevention in the work environment was an aim of many workers’ compensation claims. However,
the employees experienced
an individualised focus in the workplace and WCS, where there
‘I sort of thought, they’re [the Workers’ Compensation System] spending more time trying to find out
if there might be other things causing the problem, than they are actually looking at the problem...
Why don’t they go out and look in the workplace, why aren’t they out looking at how things are going
there? If you don’t believe me, just drive out and have a look… you spend half a day there and you’ll
realise what’s going on… It's like I constantly have to explain something about myself or have to
prove something, I have to dig up stuff about my past … I think it is tough.’
(Undertaker, Funeral Company, private sector)
Employee: ‘I did not realise there were so many things, and so many papers [to fill
out]. I simply did not know before it started to flip through the door with papers and
papers and papers.’
Interviewer:
‘How have you experienced it, getting all these questionnaires?’
Employee:
‘Yes, it's been confusing because I do not know what to do, what to write
and what not to write. Especially now, when it's coming [questionnaires] again, it's
almost the same they ask. So, I do not know why [curse] they want the same
information again.’
(Factory employee, Production Company
company, private
sector)
46
were more focus on whether they had a personal problem than on the problematic work
environment. Changes in the work environment and
workplace inspections were rare;
stakeholders such as health-and-safety or union representatives were often uninvolved. When they
did get involved, this was not necessarily a positive experience for employees with WRMD.
Compared to
employees with rejected claims, depression, or stress, employees with recognised
claims and/or PTSD tended to have more positive experiences. The compensation process
could be demanding and compensation schemes were hard to fill out. 17.7% of participants
reported that the claim process had hindered or delayed their RTW. Most employees with
PTSD or depression were unemployed 2–4 years after the notification, compared to
employees with stress related sickness.
5.4. Study IV.
Is the notification of an occupational mental disorder associated with changes in health,
income, or long-term sickness absence?
Changes over time were significant for all outcomes: in particular, a decline was observed in GP
visits (HR 0.83 [95% CI: 0.80–0.86]), prescriptions of psychotropic drugs (OR 0.48 [95% CI: 0.35–
0.67]), and long-term sickness absence (OR 0.11 [95% CI: 0.07–0.17]) and annual income (OR 3.89
[95% CI: 2.87–5.26]) from baseline to follow-up.
No significant prospective associations between notification status and the four outcomes were
found in the model adjusted for time only (GP visits: HR 0.96, 95% CI: 0.92–1.00; prescriptions of
psychotropic drugs: OR 1.09, 95% CI: 0.52–2.28; low annual income; OR 1.84, 95% CI: 0.96–3.52;
high sickness absence: OR 0.49, 95% CI: 0.20–1.20). Insignificant associations were also
confirmed in the model, adjusted for age, gender, occupation, and diagnosis (GP visits: HR 0.99,
95% CI: 0.92–1.07; prescriptions of psychotropic drugs: OR 1.01, 95% CI: 0.42–2.42; low annual
income, OR 1.68, 95% CI: 0.83–3.42; high sickness absence: OR 0.52, 95% CI: 0.19–1.39).
5.4.1. Summary: Study IV
No association was found between WRMD notifications and health, annual income, or long-term
sickness absence. A significant decrease in income was observed for patients with both notified and
non-notified conditions. Specifically, the patients had an average decrease in annual income from ≤
300.000 Dkr. to >300.000 Dkr.
47
6. DISCUSSION
The main findings for each study have been summarised in the Results section. Here, selected
findings of the four studies are summarised and discussed:
• Challenges for Line Managers
• Physical diseases handled better than WRMD
• Stakeholder Involvement: Health and Safety—and Union Representatives
• The type of WRMD matters
• Interactions between WCS and the Workplace
- Workplace inspections
- Employer hearings—should we be concerned?
- Lack of prevention in relation to WRMD
• Do the WCS harm employees? – contradicting findings
- A comparison of Study III and Study IV
- Study III and IV compared to other studies in the field
Methodological strengths and limitations will also be discussed.
6.1. Summarizing selected results
The thesis contributes with various views on the management, stakeholder involvement, and claim
process experienced in the workplace and WCS when an employee become sick of a WRMD.
Overall, the process of facilitating RTW and implementing preventive solutions often seemed to be
left entirely to line managers, who did not necessarily have access to organisational support,
knowledge, or room for action. The workplaces lacked systematic procedures for supporting
employees with WRMD; despite acknowledging the problematic working conditions, line managers
focused on the sick employees themselves, attributing the illness to their own behaviour and
personal circumstances. Workplace stakeholders, including health-and-safety and union
representatives, were rarely involved. When health-and-safety representatives did become involved,
the employees tended to experience their input as negative rather than positive. The involvement of
union representatives was generally experienced as positive. Workplaces were better at handling
work-related physical diseases than WRMD. Workplace experiences may also depend on the type
48
of WRMD; for example, more employees with PTSD had positive experiences in the workplace
than employees with work-related depression or stress. Finally, a workers compensation claim of a
WRMD seldom resulted in an inspection from the Working Environmental Authority. Many
employees felt that they were not adequately informed about the workers’ compensation
process; they found the compensation schemes difficult to fill out. To the question on
whether
worker compensation claims can harm employees with WRMD, this thesis presents contrasting
findings. In Study III, employees reported that the WCS process had hindered or delayed their
RTW; by contrast, Study IV found no association between notifications and health, annual income,
or long-term sickness absence. This question will be discussed later.
6.2. Challenges for line managers
Line managers have been identified as the main stakeholders responsible for the RTW of sick-listed
employees [102–104]. However, Study I confirms the findings of earlier research, which has shown
that managers may lack the knowledge and organisational support to effectively manage the RTW
process [102–104]. Managers may feel poorly prepared and isolated, due to a lack of training and
support [105]. Studies have also found that managers focus on stress as an individual problem; this
attitude can be a barrier to preventive initiatives in the work environment [106]. Sharley and
Gardner [107] have found that a fear of seeming responsible for work-related stress can inhibit
managers from initiating stress management interventions. A focus on personality or individual life
circumstances as causes of stress can point towards solutions aimed at helping the individual
employee, such as psychological counselling (tertiary interventions). However, tertiary
interventions have been criticised for not being particularly effective for reducing workplace stress,
since they tend not to have favourable impact on the organisational level [108]. Thus individual
focused interventions should not occur alone [109,110]
.
Studies have also shown that most
workplace efforts focus on the early phase of RTW, while interventions in the working environment
and efforts to adapt working conditions for sick employees appear less formalised and coordinated
[41,43]. The individual focus and lack of preventive initiatives in the work environment may hinder
the RTW, since employees with mental disorders are often reluctant to return, if they think that the
working conditions that led to the disorder have not improved [47].
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6.3. Physical diseases handled better than WRMD
One conclusion of Study II was that workplaces are best at handling work-related skin diseases.
Employees with low-back pain tend to have more positive experiences than employees with
WRMD. The findings of this study are in line with those of other studies, which have concluded
that work-related diseases are handled differently in workplaces depending on whether they involve
physical or mental health [44,46]. Employers have been shown to be more critical of employees
with mental disorders and their ability to work than of employees with physical diseases [46].
Workplace support and efforts for employees with physical diseases also appear to be better than
those offered to employees with mental diseases [44]. More employees with physical work-related
disease reported that their work-related disease and workers’ compensation claim resulted in
changes to the working environment (ref: Study II). It is not surprising that there are differences
between the experiences of employees with WRMD and those with physical work-related diseases,
an EU-OSHA rapport in 2012 concluded that: ‘The management of psychosocial risks in European
establishments appears to lag behind the management of general Occupational Safety and Health
risks’[111].
Main points
Managers who focus on their employees’ personal circumstances, as discussed above, and fail to
implement preventative initiatives in the work environment, may undermine the RTW of
employees with WRMD, as well as efforts to address psychosocial risks in the workplace.
Organisations should therefore provide support by minimising cross-pressure and insuring that
line managers who handle the RTW process have an adequate level of knowledge, access to
professional guidance, and room for action. Finally, a shared, formal understanding of work-
related stress and other WRMDs should be emphasised in the workplace.
Main points
Management and stakeholder involvement vary and most workplaces are
better at handling
physical work-related diseases than WRMD. The more systematic approach to assessing
environmental hazards after a physical injury in the workplace could provide inspiration for ways
to prevent psychosocial hazards, an argument that will be discussed in more detail in 8.1.
Practical Implications.
50
6.4. Stakeholder involvement—Health and Safety—and Union Representatives
Study II and III have found that health-and-safety representatives was often not involved, when an
employee had a WRMD. One explanation may be found in Study I, where managers perceived the
sick-listing of an employee due to work-related stress as a private matter that should be handled by
the employee and his or her manager. The lack of involvement of health-and-safety representatives
supports one of the main findings of this thesis: that information related to the causes of WRMD is
not used systematically to support the health-and-safety work of organisations. The lack of
stakeholder involvement is a problem because it is essential for the sick employee (and his or her
future RTW) for the disorder to be recognised and accepted, enabling the employee to experience
the disorder as legitimate and receive social support [49]. Employee representatives, such as health-
and-safety and union representatives, can play an important role in mobilising social support and
help from colleagues. However, in cases where health-and-safety representatives were involved,
more employees experienced this negatively. A Danish article suggests that the educational level of
health-and-safety representatives in Denmark, may be rather low or varying when it comes to the
psychosocial work environment [112]. A low level of competence may explain why some
employees with WRMDs experience these stakeholders negatively. Other studies have pointed out
that health-and-safety representatives may have limited influence in organisations, due to
insufficient power and the failure to integrate health-and-safety work into line management
decision-making [113,114]. Research also suggests that health-and-safety representatives face
significant challenges specifically in relation to psychosocial risks in the work environment, due to
political, financial, and regulatory changes that favour the individualisation of responsibility and the
marginalisation of collectivism, which includes issues involving psycho social-risks [115]. An
increased focus on the health benefits of work and an individual approach to WRMD, while largely
ignoring organisational causes, reinforces the problems associated with this movement [115].
Study II and III have found that union representatives are sometimes involved and that this
stakeholder can be experienced both positively and negatively by employees. One challenge faced
by union representatives in relation to WRMD is that conversations between employees and union
representatives are often covered by confidentiality; this stakeholder is not necessarily involved or
educated in health-and-safety work in organisations. Thus there is a risk that important information
about psycho-social risk factors leading to WRMD will not be accessed or used by the organisation.
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6.5. The type of WRMD matters
Study III has shown that employees with PTSD experience management and stakeholder
involvement more positively than employees with depression or stress related sickness. To my
knowledge, this comparison has not been made before. One can therefore only suggest possible
explanations for this difference. One explanation may relate to inherent differences in the nature of
the exposure that leads to various diagnoses.
PTSD (F43.1) following ICD 10:
‘Arises as a delayed or protracted response to a stressful event or situation (of either brief or long
duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive
distress in almost anyone.’ [116]
The exposure that results in PTSD is often possible to assess objectively. In this, it may resemble
the types of exposure that cause some physical diseases or accidents. It is therefore different from
adjustment disorders (F43.2) which, according to the ICD10 criteria, occur when an individual is
unable to adjust to or cope with a particular source of stress or major life event caused by outside
stressors; such conditions often develop over a longer period of time/exposure [116]. It is therefore
more difficult to identify the precise causes of adjustment disorders, due to the variability of
psychosocial risks and the interactions between them [19,117].
Disputes about responsibility and who is at fault may exist to a greater extent in relation to work-
related depression or stress, as opposed to PTSD. The dynamics identified in Study I, where
managers shifted the focus to the personal circumstances of sick-listed employees, may reinforce
Main points
The involvement of stakeholders in the workplace is therefore important in supporting the RTW
of employees with WRMD. However, such stakeholders need a high level of competence,
coordinated information, and a systematic approach to accessing information on the psychosocial
hazards that lead to WRMD. They must apply this information to preventive actions at the
appropriate organisational levels.
52
disagreements about the causes of work-related stress. Another reason why employees with PTSD
have more positive experiences in the workplace could relate to organisational factors. PTSD may
evoke more organisational support, knowledge, and perhaps less stigma. It may be a more socially
accepted disorder, associated with tough working conditions, such as experiencing a fatal attack
during military deployment or being physically assaulted at work.
Furthermore, employees with PTSD are often employed in organisations like the military or police,
with access to organisational support systems that provide debriefing and psychological
counselling. Some employees with PTSD are veterans, who, in Denmark, have access to a
comprehensive support system that includes specialised treatment facilities and support for
workers’ compensation claims.
6.6. Interaction between the WCS and Workplace
The Arena of Work Disability by Loisel and colleagues [36] (For more information 2.3. WRMD in
the Workplace and WCS) illustrates the way in which the Legislative/Insurance System and the
Workplace System can interact on several levels. The background section identifies three possible
ways in which worker compensation claims can have a direct impact on the workplace: by eliciting
a workplace inspection; through an employer hearing; and finally, by providing financial
incentives, such as insurance rates, in relation to particular claims. The last options will be
discussed more broadly in relation to the lack of prevention in relation to WRMD. These themes
will be discussed in relation to the findings of this thesis and other research in the field.
6.6.1. Workplace inspections
Study II and III have shown that workplace inspections are seldom conducted, following a worker’s
compensation claim of WRMD. Inspections are also rare in relation to work-related low back pain
or skin diseases.
Main points
It can therefore be concluded that organisational systems, support from line managers, and the
social acceptance of the WRMD may be better for employees with PTSD than for those who
experience work-related stress or depression.
53
The findings of this thesis confirm that
the Working Environmental Authority makes very
limited use of workers’ compensation claims for occupational diseases, as described in
2.6.1.
Inspection by the Working Environmental Authority.
Study III found that employees with
WRMD can have negative experiences in relation to workplace inspections. This reflects the
contrast between employee expectations (that a workers’ compensation claim will elicit a
workplace inspection, which will lead to a decision on the bad working conditions) and the
actions taken or not taken by the Work Environmental Authority. Sick employees viewed the
lack of an inspection or an inspection that did not lead to a decision as offensive—an example
of the employee being treated ‘as the problem’ and not taken seriously, either in the workplace
or in WCS.
These results are in line with the findings of a recent review, which noted that psychosocial
issues are rarely well dealt with by courts or inspectorates. Inspectorates are often under-
resourced, while inspectors are reluctant to enforce guidelines when there is a low likelihood of
conviction
[77]
. In addition, the Danish Working Environmental Authority has extensive
limitations on its ability to carry out inspections of the psychosocial work-environment
[75]
,
due the collective agreements and methodological limitations described earlier. This is very
problematic since inspections have been shown to have an impact on organisational efforts to
reduce psychosocial risks
[118]
.
6.6.2. Employer hearings—should we be concerned?
Study I found that line managers tend to defend themselves by focusing on their employees’ own
responsibility. This may result in disagreements with employees about the workplace exposures that
led to WRMD. In employer hearings, managers are asked to confirm or give an opinion on the
exposures described in the worker’s compensation claim. The managers response is sent to Labour
Market Insurance and the sick employee. Thus employer hearings can escalate or harden conflicts
between managers and their sick employees; managers may perceive the exposures described in the
claim as an accusation. The potentially defensive responses of the managers may likewise be
experienced negatively by employees. Thus, employer hearings may make the relationship between
a manager and employee more adversarial, affecting the level of managerial support provided to
sick employees wishing to RTW. Since manager support is essential for RTW [42,47,49], this is
54
highly problematic. Thus, the employer hearings that constitute part of a workers’ compensation
claim process may inhibit RTW for employees with WRMD.
In addition, legal considerations may make managers unwilling to confirm psychosocial exposures,
since confirmation could be used in a civil lawsuit against the employer. A non-confirming
response from a manager may be experienced as a lack of managerial support and demotivate the
employee from wishing to RTW. The credibility and consequences of employer hearings, as part of
the evidence in a workers’ compensation claim, as well as the ethical considerations relating to the
lack of anonymity both ways (claim exposures sent to managers and the manager’s response send to
the employee) is highly relevant to consider.
Since employer hearings are part of a claim, an employee who files a workers’ compensation claim
is not given the opportunity to opt out of this procedure, if he or she wants the claim to be
processed. There is therefore a risk that the
Danish employer hearing procedures contribute to the
underreporting of WRMD. Several studies have found an underreporting of WRMD in WCS
[7,119,120]
and have suggested that it may be caused by employees reluctance to file claims
because of the fear of stigma and blame associated with these claims from the surroundings
[7,119,120]
. Thus, the fear of reprisals undermining an already vulnerable position (being sick
and hoping to RTW) may prevent some employees from filing a compensation claim.
6.6.3. Lack of prevention in relation to WRMD
This thesis has found a lack of systematic assessment and prevention in Danish workplaces when an
employee develops a WRMD. Possible explanations the fact that WRMDs rarely lead to changes in
the working environment include the following: the lack of knowledge, organisational support, and
room for action (ref: Study I), a focus on the individuals’ personal problems instead of the working
environment (ref: Study I), a lack of stakeholder involvement (ref. Study I, II, III), and a lack of
workplace inspections (ref: Study II, III).
These findings are in line with the World Health
Organisation has reported that European workplaces show a lack of awareness of psychosocial risks
and an inability to deal with them [121]. Despite a growing number of initiatives and studies
targeting psychosocial risk management in Europe, these initiatives have not led to the expected
results [111].
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One explanation for the lack of prevention in work-environment in relation to WRMD, may be a
lack of financial inducements to encourage employers to prevent WRMDs. As described in 2.6.3.
Economic incentives in relation to workers´ compensation claims, the full costs of a WRMD are not
paid by the employer. The insurance rates covering occupational diseases are determined by
industry, not individual employers level of prevention. Andersen (2017) has argued that Danish
legislation has not created enough incentives for Danish employers to prioritise health-and-safety in
the psychosocial work environment and prevent WRMDs [34].
6.7. Does the WCS harm employees?—contradicting findings
The follow-up register Study IV showed no association between the health outcomes, annual
income, and notification status of employees with WRMD. This result co