Debbie Cohen MD, FRCGP FFOM, FRCP Joanna Allen, BSc (Hons) MSc, Melody Rhydderch, BSc (Hons), MSc, PhD, C Psychol and Mansel Aylward, CB, MD, FFOM, FFPM

From the Centre for Psychosocial and Disability Research, Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom

OBJECTIVE: To investigate the conversation between line manager and employee about return to work to inform the development of an online interactive educational programme for line managers to improve the effectiveness of their discussions.

DESIGN: An inductive qualitative approach, using the principles of action research and motivational interviewing were adopted. The results informed the development of the educational programme for line managers.

SUBJECTS: Middle grade line managers in a large public services employer in the UK.

METHODS: Four discussion groups were conducted over a period of 8 months. Line managers explored the challenges of the return to work interview, analysed their interactions with employees and constructed the content of an educational programme. Multiple methods were used to build engagement with participants, including video and role-play.

RESULTS: Nine line managers were recruited across 3 business areas. Managers recognised that their conversations focused on the organisations’ policies and procedures and the outcome, rather than the interaction. They recognised the strength of shifting style to shared decision-making and guidance rather than process and instruction. These communication strategies were depicted in the educational programme.

CONCLUSION: The content and flow of the return to work discussion is of high importance and influences employee behaviour and return to work outcomes.

Key words: return to work; sickness absence; shared decision-making; competencies; active listening.

J Rehabil Med 2012; 44: 677–683

Correspondence address: Debbie Cohen, Centre for Psychosocial and Disability Research, Primary Care and Public Health, Cardiff University, 53–54 Park Place, Cardiff CF10 3AT, Wales, UK. E-mail: cohenda@cf.ac.uk

Submitted August 19, 2011; accepted February 28, 2012

INTRODUCTION

The impact of sickness absence on organisational productivity is significant. In the UK the average employee takes 7–8 days of sickness absence per year with the cost to business estimated at £13–15 billion (1). Recent findings have shown that lower levels of organisational performance are associated with higher levels of sickness presence and absence (2). There is also evidence from a study of the National Health Service in the UK that there is a strong relationship between staff health and wellbeing, performance and patient safety (3). Higher rates of sickness absence are often associated in particular with poor line manager or supervisor support, and the line manager employee relationship has a major impact on employee wellbeing (4–6). Supporting people back into work in a timely and sensitive manner has benefits for both the employer and employee. Return to work (RTW) after a period of absence can be therapeutic (5). There is a window of opportunity between 1 and 6 months where appropriate interventions and support to return to work is most likely to be successful (7). Once an employee is absent from work for 6 months, the probability of returning to work successfully reduces rapidly (5).

A coordinated approach to return to work and rehabilitation between key players; individual employees, healthcare professionals and the employer has been shown to be of high importance (8). Waddell et al. (5) summarised the key principles of vocational rehabilitation as: early intervention, professional support, and adopting the bio-psycho-social approach. Workplace focused interventions and a proactive approach by the temporary provision of modified work have been shown to have a significant role and be cost effective (9).

Training and organisational approaches that increase participation in decision making and problem solving, and improved communication have been found to be most effective at reducing work related psychological ill health and sickness absence (10).

Competency frameworks for line managers in the UK (11) and for workplace coordinators in the USA have been developed (12). These highlight the importance of good communication, listening skills and the ability to negotiate. Other studies have highlighted the tension that can occur in these conversations and the potential pitfalls if communication fails (13). Interventions that focused on the interaction between employer and employee that facilitated communication and shared decision making have been recognised as being of high importance (6).

The line manager in the UK has responsibility for short-term absence. Employees are expected to inform their manager when they are sick. Organisational policy would expect the line manager to keep in touch by phone with the employee whilst off sick. Once the employee was fit to RTW they would be expected to attend an interview with their line manager. The aim of the interview would be to facilitate the RTW. The line manager’s role is to review the employee’s attendance past and present, inform the employee of attendance policy and the system of ‘warnings’ for excessive absences and signpost to the employee the appropriate support services available within the organisation, e.g. occupational health, financial or personal advice. It is up to the line manager to use their discretion as to whether they ‘issue a warning’ and/or make adjustments to facilitate the RTW.

However, research into understanding the detail of the RTW conversation and the content of these discussions is currently an under-researched area. The aim of our study was to investigate the content of the conversation between line manager and employee following a period of short-term absence. In the UK ‘short term sickness absence’ is defined as a period of absence lasting less than 4 weeks. The aim was to develop an online interactive educational programme for line managers at a large well-established organisation in the UK about improving the RTW discussion after a period of short-term absence. The programme would introduce to the line managers skills and strategies that included active listening to support a more effective conversation. This also included an interactive tool called a ‘desk aid’ that highlighted the processes that were embedded in line managers training in the chosen organisation.

Whilst appreciating the importance of organisational context, processes and procedures, of interest to this research was how the principles of motivational interviewing (MI) (14) could be deployed to increase engagement with the project and bring about behaviour change within the organisation and individual line managers. This was specifically in relation to attitudes to the RTW conversation. This paper describes the main findings from the qualitative study that informed the development of the educational programme.

METHOD

This study took place within one large UK organisation. An inductive qualitative approach was taken to gain a comprehensive understanding of the interactions between the employee and line manager when discussing RTW following a spell of absence lasting less than 4 weeks.

Qualitative approaches are frequently used to explore complex interactions and this methodology has been used successfully to understand the conversation between primary care practitioners and their patients about work and health (15). The principles of action research were also adopted. Action research lends itself to intervention design and development. Inherent in this method is that the design and content of the research is continually negotiated with participants. To build engagement and develop ownership of any new intervention must also recognise and manage resistance to change. MI uses skilled listening to help guide participants from a position of resistance and ambivalence to engagement and ownership (14). It has previously been successfully applied to conversations in other contexts designed to encourage and promote individual behaviour change (16), but never before used to enhance line manager conversations with employees. The principles of MI were employed in developing the content and flow of the discussion groups, described in more detail below.

The chosen data collection method for understanding the content of the conversations was a series of discussion groups with line managers conducted over an 8 month period.

Discussion groups differ from focus groups in that the same group of individuals contribute to a series of meetings as opposed to a one off focus group. Eight to 12 participants are considered an effective number for a discussion group. Discussion groups are better suited to action research. They allow the researchers to build a rapport and engage with participants more effectively over time by building relationships and developing a shared understanding about beliefs and attitudes to issues. Discussion groups allow participants to speak freely, to tell their story and are flexible enough to allow the researcher to rephrase and redirect questions based on the issues that arise (17). Ideas can be challenged, extended and developed in a way that offers rich data to the researcher (17).

Middle grade line managers who have responsibility typically for 10–30 staff were recruited to the study. The participants were recruited from 3 geographical areas: South London, Kent, and Cardiff. These areas were determined by employee numbers, diversity of the business and interest expressed from senior managers in the project. A sampling frame was created to ensure participating managers were recruited from areas with high and low absence rates across the organisations business areas. Senior management distributed information sheets describing the project to line managers in the selected geographical areas.

Those interested in the study were asked to email the research team directly. Senior management were blind to those who responded. The aim was to systematically select 8–12 participants from a larger sample of those that expressed interest into the study.

Four discussion groups were conducted over a period of 8 months. Consent was obtained at the first meeting. Three discussion groups took place at the Centre for Psychosocial and Disability Research (Cardiff University) and one at the conference centre owned by the organisation.

A framework for the discussion groups was constructed. In line with action research principles, during the last half hour of each discussion group participants were asked to discuss two questions. How might the next meeting evolve and what activities might help inform the process? A debrief session was undertaken at the end of each discussion group with the principal investigator and the research team and reflective notes were made. The outcomes of each meeting informed the activities of the following meeting. The discussion groups were audio recorded and field notes taken. Key activities were also video recorded.

Multiple methods were used to build engagement with the discussion group participants. Meeting 1: ‘What are the core challenges facing managers in their management of sickness absence?’ The aim of Meeting 1 was to consider the typical RTW discussion and explore the challenges in managing the conversation. Role-play with an actor was used to enhance engagement and support the listening process for the researchers. To increase face validity prior to the start of the meeting a researcher (JA) worked with a senior manager to construct scripts based around an employee attending a RTW discussion. The interaction was video recorded.

Meeting 2: ‘Exploring the interaction between the line manager and employee’. In Meeting 2 participants explored the language and style of conversation that was commonly used by line managers. Two actors were employed to bring the conversation ‘to life’. They were asked to focus on the language participants used and reflect this accurately in their role play. Participants coached the actors to play a line manager and an employee having a typical conversation. Participants observed the interaction and were asked to focus on the use of language, the style of the conversation and the outcome of the interaction. Actors were asked for their feedback about how they felt during the conversation. Guided by the researchers participants then considered how the content and the outcome could be improved. Finally participants coached the actors again to implement these improvements and reflect on the changes. Meeting 3: ‘What might an intervention look like?’ Meeting 3 explored the potential content of the educational programme. Participants considered the priorities that were needed to make the programme successful. Between meetings 3 and 4, a pilot educational programme was constructed. Meeting 4: ‘Review of the educational intervention’. Meeting 4 reviewed the pilot for face validity and accuracy of content. Audio recordings of the discussion groups were transcribed verbatim. Analysis followed an inductive thematic approach. Initial themes were generated by the researcher (JA). The themes were reviewed (DC + MR) following an iterative process until the final themes were agreed. The results informed the content and design of the educational programme. Ethical approval for this study was granted by the School of Psychology ethics committee Cardiff University (EC.08.04.01.1703).

RESULTS

Fifteen line managers expressed interest in the study. In order to meet the sampling framework as closely as possible purposeful sampling was also employed. The final sample consisted of 9 line managers covering South London, Kent and Wales (8 men and 1 women). Eight of the 9 line managers attended every discussion group. The final sample represented all the business areas within the organisation.

Discussion Group 1: What are the core challenges facing line Managers in their Management of sickness absence?

During the session line managers explored their normal conversation and behaviour and the challenges they faced in managing the RTW discussion. Five main themes emerged: Conflict, Knowledge, Ownership, Experience and Support. The 5 themes and supporting quotes are shown in Table I.

These themes highlighted the difficulties line managers faced when dealing with RTW discussions. There was strong agreement amongst the participants that managers felt under pressure to complete the RTW paper work quickly without giving enough importance to the discussion or it’s setting. Participants commented that whilst clear guidance notes on the company protocol were helpful, this led to discussions being conducted in a ‘process driven’ manner. It was suggested some managers adopted this ‘process’ or ‘tick box’ approach as it got the ‘job done’ and allowed them to shy away from broaching difficult issues that may arise during the discussion. Participants described how fear of conflict and lack of knowledge were some of the reasons for not dealing with these issues. Participants recognised that this inconsistent approach by different managers in itself could lead to confrontation and conflict within the workforce. Conflict also occurred with blurring of boundaries where managers at times acted as friends rather than managers during RTW discussions. Participants recognised a gap in the training for line managers. RTW training focused on knowledge and process and omitted any practical skills and attitude development. Participants acknowledged that line managers may need more support from their peers when conducting difficult RTW discussions.

Discussion Group 2: Exploring the interaction between the line manager and employee

During the session participants were encouraged by the facilitators to compare existing common and aspirational better practice scenarios by working with actors from neutral perspective. They recognised 5 key improvements in the better practice scenario (Table II). These revolved around key aspects of communication, e.g. listening, gathering information, eliciting concerns and providing information. The themes that emerged included: assertiveness in a caring and controlled manner; detailed exploration of the employees perceived problems; using active listening; a more relaxed approach; active support; and discussion about available services and resources.

Participants reflected that RTW discussions that were carried out in a more ‘professional manner’ had a positive effect. They described this professional approach as one where they listened more carefully and showed they were listening (active listening). This left the employees feeling valued with a sense of participation in a fair process. Being professional also included ‘setting the scene’ by finding a quiet room and focusing on the employee by e.g. turning off mobile phones and arranging seating appropriately. The skilful interactions involved in listening were a recurrent theme. RTW discussions were often difficult interactions. Participants described how managers needed to be equipped with the appropriate skills to manage confrontation or sensitive issues. There was consensus that a lack of skills could leave line mangers feeling they were not ‘in control’ of the conversation. Listening first and checking understanding led the conversation to have a ‘more relaxed feel’ but still allowed the manager to feel in control. Active listening and shared decision making helped employees to develop ownership about their absence which in turn improved outcomes for employees and managers. Participants recognised simple tasks and skills that everyday line managers could use to enhance and make the conversation more effective. This included knowledge of the support services offered by the company and in the locality.

Discussion Group 3: What might an intervention look like?

During this session the original aims of the project (the development of an educational programme and desk aid) were reviewed. Participants reflected on the outcomes of the previous session and comparison of common and better practice.

To stimulate discussion about the educational programme, the participants were asked to describe what an effective RTW discussion should look like. There was clear consensus that the ‘process’ of a RTW discussion should be separated from the ‘conversation’. Participants described the importance of the manner and style in which these discussions were conducted. There was consensus that the RTW discussion should be managed in an assertive, caring and controlled manner. They described how they should move away from the tick box approach and instead think of the ‘process’ as a tool to prompt the manager and not ‘control the discussion’. Participants specifically noted the importance of using summaries and statements (active listening) in their conversations. They described how these skills gave the line manager the opportunity to explore issues in more depth, feel in control and clarify issues – so ‘ensuring everyone is kept in the loop’. Participants also recognised the importance of being proactive, and joint decision making with employees. They highlighted that this should not just relate to RTW issues but should also encompass general health and social issues.

The participants were then asked to consider the ‘core elements’ of the educational programme, which would focus on the discussion between employee and line manager. These emerged as: preparation, managing the interaction, managing ill health. Participants’ suggestions on how to address these are illustrated in Table III. Finally participants were asked to consider the top 5 areas of learning that should form the basis of the content of the programme and be illustrated through videoed scenarios. These are described in Table IV.

The discussion then turned to the desk aid. This was focused on key areas of information and resources that would support a line manager when conducting a RTW discussion. Although line managers were clear their role was not to manage medical problems they also recognised that signposting employees to timely appropriate health advice, e.g., leaflets on general back exercises for employees whose sickness certificate states absence due to low back pain, would be beneficial to the employees and support organisational policy and practice. Table V illustrates the suggested content for the desk aid.

Development of the educational programme

The educational programme was designed and developed based on the core elements, 5 key learning areas and suggested activities. This was achieved through two video scenarios (common practice and better practice) echoing the design of the discussion groups. The scenarios were developed in collaboration with the discussion group participants and project leads to increase face validity. The aim of the better practice scenario was to illustrate the benefits small changes in behaviour and communication styles can have when dealing with absence management. Audio and interactive elements were incorporated to increase managers engagement with the programme and to emphasise the key messages.

Discussion Group 4: Prototype review

The prototype educational programme and desk aid were reviewed. There was consensus that the educational programme clearly demonstrated the importance of an effective RTW discussion. Minor alterations only were suggested. The programme had high face validity for the participants.

The desk aid was also seen as a useful resource for line managers. It was described as user friendly, informative and functional.

Dissemination methods were discussed. There was general consensus that the educational programme should be incorporated into all new line managers training. It was also useful for managers who required extra support. Participants felt the programme should be offered to all employees. This would enable a more shared understanding of the challenges line manager faced, increase the importance of the RTW discussion and reduce conflict. Finally participants felt the programme was flexible enough to be used for group as well as individual learning.

DISCUSSION

This study set out to explore the interaction between the line manager and employee in the discussion about RTW and how the conversation could be improved. The main findings were that although processes and policies were recognised as important and integral to good absence management it was the ‘manner’ in which the discussion was conducted that was of high importance and influenced employee behaviour.

Poor conversations impacted on both the line manager and the employee. This was independent of the quality of the attendance management processes. Line managers found discussions about RTW and an employee’s health particularly challenging. The study demonstrated that line managers focused their conversations on the organisations’ policies and procedures and the desired outcome of the conversation or ‘result’, rather than the interaction. This often led to a dysfunctional interaction between line manager and employee with a poor outcome for both.

Of particular importance in the findings was that once the managers reviewed their normal ‘patter’ and its impact on the employee they were quick to recognise the strength of a shift in style and were able to see the importance of shared decision-making and guidance rather than process and instruction. They recognised that these skills increased confidence to move away from process and address the more difficult conversations they experienced.

The line managers identified key listening skills that they felt would improve their RTW discussions. This included phrases that enhanced the conversation and shifted it from conflict and resistance to engagement. Managers were able to quickly learn these simple changes to their conversations.

A major strength of the project was the multiple methods employed to understand the detail of the conversation between line manager and employee. Although discussion groups employ smaller number of participants than focus groups the participants recruited to this study were representative of line managers across the business. The methods used in this study allowed the dynamics and content of a typical conversation to be captured accurately. This provided both the researchers and the managers with insight into typical RTW conversations that previously had not been explored. The use of MI principles allowed the researchers to ‘come alongside’ the managers, listen carefully to their concerns and guide them towards their own solutions. Critical to shifting thinking seemed to be the creation of safe space by the facilitators to allow managers time to explore ‘typical’ behaviour alongside aspirational behaviour without judgement. The solutions devised by the managers themselves informed the content of an interactive programme that addressed listening skills alongside process. The emergent themes were captured in the scenarios and text of the programme. A further strength was that the methods used led to the development of a group of ‘champions’ with the organisation that felt they had learnt tangible skills and were motivated. Champions within an organisation are motivated individuals who feel they have ownership of and are engaged with the dissemination of good practice. In this study the participants became champions who supported the dissemination of the learning through the organisation. This enhanced sustainability of the intervention.

There were a number of limitations to the study. There was the possible presence of bias. The majority of recruited participants were self-selected. The discussion groups required line managers to be released from their normal working hours for three days over the time period of the study. It is possible that these managers had an inherent interest in the area of training and RTW and might have biased the discussion group data. The study was time limited and therefore it is possible that further themes could have emerged.

Studies to date have explored the benefits of work on an individual’s health (7) and the factors required for effective vocational rehabilitation (5). Effective communication between the line manager and employee has been shown to be one of the most important contributing factors to wellbeing (6). However, research so far has focused on policy, procedures and occupational health interventions. The report from Goldsmith University in the UK highlights the competency framework to support line managers activities in supporting RTW (18). It describes taking an ‘open and sensitive approach’ and guides the reader as to how to construct the conversations. Pransky et al. (19) also explicitly explored the competencies required of RTW coordinators in the US and Canada using a ranking exercise. Listening skills scored high among the necessary competencies. Krohne & Magnussen (20) looked at the decisions employees make when deciding whether to take sick leave in offshore catering workers. They concluded that an important factor was how the section leaders implemented company policy. Dekkers- Sanchez et al. (21) in their qualitative study looked at perpetuating factors for long term sick leave. They recognised the effects of poor, or perceived poor employer support as an important perpetuating factor of long term sickness absence. They commented that these are potentially modifiable. Haafkens et al. (22) explored factors that facilitated job retention in chronically ill employees. They explored both line managers and human resources managers perspectives and concluded that there were both similarities and differences in the two groups views about what facilitates job retention.

Shared decision making is recognised as an important element of the doctor patient consultation process (23). Elwyn et al’s study (23), which investigated shared decision making with trainee general practitioners, commented on the anxiety trainees expressed in dealing with uncertainty when involving patients with decisions. The authors concluded that it was skills and attitudes of the trainees that required further development if they were to be successful.

Cohen (24) described how an on line programme developed for GPs to enhance the return to work conversation in everyday practice was successful in improving importance and confidence in managing the consultation.

This study explored the content and flow of the interaction between the line manager and employee to improve the RTW discussions. It provided line managers with the ability to look specifically at ‘how’ they listened through the use of actors and scenario based learning rather than just the ‘concept’ of listening. The framework provided managers with a structure to the conversation based on everyday language and provided simple changes to improve listening skills. This approach allowed shared decision making for the line manager employee conversation more accessible and facilitated a more effective discussion and return to work. It helped increase ownership for the employee about their return to work and reduce conflict.

In addition, the study used the discussion group participants to champion the roll out of the educational programme and learning within the organisation. This provided a ‘bottom up’ approach and a sense that the learning was ‘their world’. It provided ownership to the programme and the learning, which enhanced behaviour change.

This study recognised that the many skills and methods used for training doctors and medical students in advanced communication skills can become part of a more diverse teaching of communication skills outside of the world of medicine. It also illustrates how a focus on enhanced communication skills and the details of a conversation improves line managers’ approach to and it’s consequent impact on attendance management. Importantly the study showed how the use of the principles of MI could be applicable in both developing engagement with line managers to consider new ways of working and support change in what often is entrenched behaviours in communication styles. The principles of ‘importance’ and ‘confidence’ about returning to work are further strategies that line managers with training could employ to support their management and understanding of spells of absence. These skills and strategies could complement the work of allied professionals who support RTW for both short and long term absences. Understanding the detail of conversation alongside process and providing simple training in this area are important issues for future policy and training development.

REFERENCES