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Review Scand J Work Environ Health 2006;32(4):257-269 doi:10.5271/sjweh.1009 Systematic review of the qualitative literature on return to work after injury by MacEachen E, Clarke J, Franche R-L, Irvin E; Workplace-based Return to Work Literature Review Group Affiliation: Institute for Work & Health, 481 University Avenue, Suite 800, Toronto, Ontario, M5G 2E9, Canada. [email protected] The following articles refer to this text: 2010;36(6):515-516 2011;37(2):99-108 2011;37(5):359-362 2012;38(2):93-104 Key terms: injury; meta-ethnographic approach; occupational health; qualitative literature; return to work; review; social relations; synthesis; systematic review; work organization This article in PubMed: www.ncbi.nlm.nih.gov/pubmed/16932823 Scand J Work Environ Health 2006, vol 32, no 4 257 Review Scand J Work Environ Health 2006;32(4):257269 Systematic review of the qualitative literature on return to work after injury by Ellen MacEachen, PhD, 1, 2 Judy Clarke, MSc, 1 Rene-Louise Franche, PhD, 1, 2 Emma Irvin, BA, 1 the Workplace-based Return to Work Literature Review Group 3 MacEachen E, Clarke J, Franche R-L, Irvin E, the Workplace-based Return to Work Literature Review Group. Systematic review of the qualitative literature on return to work after injury. Scand J Work Environ Health 2006;32(4):257269. Objectives This paper reports on a systematic review of the international qualitative research literature on return to work. This review was undertaken in order to better understand the dimensions, processes, and practices of return to work. Because return to work often includes early return before full recovery while a person is undergoing rehabilitation treatment, physical recovery is embedded in complicated ways with work- place processes and practices and social organization. These process-oriented dimensions of return to work are well described in the qualitative literature. Methods This systematic review of the literature covered peer-reviewed papers that focused on musculoskele- tal and pain-related injuries and were published in English or French between 1990 and 2003. Findings from papers meeting relevance and quality criteria were synthesized using the meta-ethnographic approach. Results This review found that return to work extends beyond concerns about managing physical function to the complexities related to beliefs, roles, and perceptions of many players. Good will and trust are overarching conditions that are central to successful return-to-work arrangements. In addition, there are often social and communication barriers to return to work, and intermediary players have the potential to play a key role in facilitating this process. Conclusions This paper identifies key mechanisms of workplace practice, process, and environment that can affect the success of return to work. The findings illustrate the contribution that qualitative literature can make to important aspects of implementation in relation to return to work. Key terms meta-ethnographic approach; occupational health; social relations; synthesis; work organization. 1 Institute for Work & Health, Toronto, Ontario, Canada. 2 University of Toronto, Toronto, Ontario, Canada. 3 Kimberley Cullen, John Frank, Sandra Sinclair, Rhoda Reardon, Anusha Raj, Donald Cole, Victoria Pennick. Reprint requests to: Dr E MacEachen, Institute for Work & Health, 481 University Avenue, Suite 800, Toronto, Ontario, M5G 2E9, Canada. [E-mail: [email protected]] Return to work is a practice that was introduced by many workers compensation boards in North America and Europe throughout the 1990s. Return to work is seen as good practice because it promotes better recovery, leads to less time off work for the worker and lower compensation premium costs for the employer, and it contributes to better management of compensation costs for workers compensation assurors (13). Return-to-work practices differ in important ways from earlier approaches of vocational rehabilitation. A key characteristic of return to work is early return to the workplace before full physical recovery. This approach means that workers are back in their workplace in some capacity, often modified, while they may still be under- going treatment such as physiotherapy, and taking med- ication such as painkillers. With return to work, disa- bility and rehabilitation have become domains of the workplace (4). Health care management has become embedded in complicated ways with workplace man- dates such as productivity, and with the complexities of workplace social organization. This systematic review was undertaken to produce a better understanding of the dimensions, processes, and practices of workplace-based return to work. Although return to work is policy in many jurisdictions and it dif- fers from earlier vocational rehabilitation practices, there has been little systematic assessment of how re- turn to work works. For instance, we know little about the social organization and experience of players in- volved in return to work, including the processes, pri- orities, problems, and successes in return to work. This paper reports on the results of a systematic re- view of the international literature on qualitative re- search concerning return to work. We examined studies maceache.pmd 8.8.2006, 11:49 257 258 Scand J Work Environ Health 2006, vol 32, no 4 Systematic review of qualitative return-to-work literature to determine what they could say about how return to work is organized and practiced and, on the basis of this knowledge, what could lead to best practices for return to work. We defined workplace-based return-to-work studies as those that focus on early return to work (ie, before full recovery) and that take into consideration the workplace environment or the range of key players in the process of workplace-based return to work, such as compensation adjudicators and physicians. This review was part of a larger, mixed-method review in which qualitative and quantitative reviews were conducted concurrently; the relationship between the two compo- nents was examined and has been reported elsewhere (5, 6), as are the results of the quantitative synthesis (7). 4 The following questions guided the review of the qualitative research: What are the social and organizational dimensions of workplace-based return to work? What are the challenges for workers, employers, and health care providers in the return-to-work process? How can key players in return to work contribute to optimal return-to-work practices? Systematic reviews of qualitative research studies are a growing phenomenon in the health literature (8 12). This form of synthesis may be emerging because, as models of evidence-based decision-making develop, policy-makers and other decision-makers realize they need evidence that is broad based in order to make de- cisions that are both appropriate and implementable. While quantitative studies can measure the effectiveness of return-to-work programs, well-conducted qualitative studies can shed light on dimensions of this practice, as well as on the needs and behavior of workplace parties and other actors in the process. The strength of the qual- itative studies reviewed in this report is that they iden- tify the presence and nature of key player interests in return to work, examine day-to-day workplace realities of return-to-work programs, and describe physical, so- cial, and organizational contexts in which return to work occurs. Overall, this synthesis offers a realist perspec- tive of return to work because it takes an explanatory focus and seeks to unpack the mechanism of how com- plex programs work in particular contexts and settings (13). Methods Search process The qualitative articles were retrieved from an initial search for qualitative and quantitative studies involving processes and practices related to workplace-based re- turn to work and interventions aimed at improving re- turn-to-work outcomes for workers with musculoskele- tal or other pain-related conditions. The final selection of qualitative articles was made using the following in- clusion and exclusion criteria: (i) the study explored the experiences of any of the various players immediately involved in workplace-based return to work, such as employers, co-workers, health care professionals, com- pensation management professionals, and injured work- ers; (ii) the study used recognizable qualitative meth- ods 5 ; and (iii) the study focused on work-related musc- uloskeletal and pain-related injuries 6 . Peer-reviewed papers published in English or French between 1990 and 2003 were included in the search. The sources of these papers were the electronic databases MEDLINE, EMBASE, CINAHL, PsycInfo, Sociologi- cal Abstracts, ASSIA (Applied Social Sciences Index and Abstracts), and ABI (American Business Index); other sources included peer-reviewed reports from well- established research centers such as the Workers Com- pensation Research Institute in the United States, the IRSST (Institut de Recherche Robert-Sauv en Sant et en Securit du Travail), and the Institute for Work & Health in Canada. Quality assessment and data extraction A modified version 7 of a qualitative assessment frame- work developed by researchers based at the National Centre for Social Research (14) in the United Kingdom was used to assess the methodological quality of the papers reviewed (see the appendix for the questions used in the quality assessment). This qualitative research as- sessment tool was preferred over others because it was engaged with concepts central to qualitative research. In keeping with the iterative and creative nature of qual- itative research, this tool was a guideline for the sys- tematic consideration of papers rather than a checklist for procedure. The tool was sensitive to theory, inter- pretation, and the focus of qualitative research on what and how questions rather than on hypothesis 4 This systematic review was conducted by the Institute for Work & Health in 2004 partly in response to a request from the Workplace Safety and Insurance Board of Ontario. 5 For instance, in several cases, a study abstract identified a study as qualitative, but a closer reading of the study found that it was actually a narrative description of a quantitative survey. 6 Nonpain-related conditions that were excluded were, for example, mental health and permanent disability. 7 The modification to this framework eliminated a question that pertained specifically to evaluation research and provided additional space for reviewers to record comments and impressions of each aspect of the study under review. maceache.pmd 8.8.2006, 11:49 258 Scand J Work Environ Health 2006, vol 32, no 4 259 MacEachen et al testing (1519). The framework involved 17 questions based on four principles, that research should (i) con- tribute to advancing wider knowledge and understand- ing, (ii) provide a defensible research strategy that can answer the questions posed, (iii) demonstrate rigor through systematic and transparent data collection, anal- ysis and interpretation, and (iv) demonstrate credibility with well-founded and plausible arguments about the significance of the data generated. Each paper was reviewed independently by two ex- perienced qualitative researchers and assessed to be low, medium, high, or very high in quality. (See table 1 for the validity assessment guidelines.) In cases of discrep- ancy, the reviewers discussed the paper until consensus was achieved. If a consensus could not be reached, a third reviewer was consulted. In five cases in which the reviewers were either authors of, or associated with au- thors of, papers to be assessed or a French language re- viewer was required, the papers were given to external reviewers for assessment. Data extraction proceeded for the papers assessed as being of medium, high, or very high in quality. The ex- traction included descriptions of the research question, theoretical orientation, study method, sampling and study context, analysis, reflexivity 8 , and findings. (See table 2 for the data extraction components.) It was con- ducted by two researchers who organized and worked on the quality assessment. Each independently complet- ed data extraction, after which meetings were held to discuss extraction completeness and relevance. Synthesis of studies The meta-ethnographic approach (20) was used to syn- thesize the data of the papers included in the review. This approach has been used in other systematic reviews of qualitative health literature (21, 22) and is useful be- cause its inductive approach transcends differences in qualitative methodologies and epistemological para- digms. The meta-ethnographic approach involves the following three levels of analysis: first-order concepts, second order interpretations, and third-order syntheses (21). First-order concepts are those identified in the orig- inal studies. Second-order interpretations are cross-cut- ting key concepts that encompass more than one of the studies being synthesized. Third-order analyses in- volve a synthesis of key concepts toward a line of argu- ment. The synthesis is arrived at through a process of reciprocal translation and constant comparison of con- cepts across studies; its purpose is to arrive at findings on a given conceptual theme for which the results are greater than the sum of the parts (22). The translation of studies into one another encourages the considera- tion of ideas, concepts, and metaphors across studies and, in doing so, provides explanations not articulated in the literature. In this synthesis, data extraction provided first-or- der concepts in the original studies that were relevant to return to worksuch as promotion of early return. Second-order interpretations were developed through the building of eight key concepts, each of which Table 1. Quality assessment guidelines. Rating Requirements Low Data too invariable, due to inadequate analysis or sampling strategy; data do not ring true and it appears that the authors had super- imposed their own set of ideas Medium Analysis descriptive in nature and somewhat thin in describing context and detail, leading to appearance of superficiality High Descriptive but including a more adequate level of analysis, with consideration of context, presentation of a more nuanced picture of study participants and the complex environment in which they function Very high Required a theoretical focus, with consideration of the internal processes involved in creating the situation that was being described (for example, links to macro structures), and with an explanatory value that could be transferred to other research arenas Table 2. Data extraction components. Research question What is the research question? Is the research question answered? Describe Theoretical orientation Describe stated (or implicit) theoretical orientation. Describe if or how theoretical orientation is applied in the analysis Study method Identify if method includes either/and: interviews (include what type), focus groups, case study, document review, mixed design, other (specify) Sample and Describe sampling strategy, number and type of participants, how participants were recruited, geographic locale and time study context frame of study, workplace types included Analysis Describe stated (or implicit) analytic process Reflexivity Describe stated (or assessed) reflections on how methods or theory or sampling approach impacted outcome Study findings Provide detailed description of study themes and issues; describe how and why study is relevant to workplace-based return to work 8 Reflexivity in this instance refers to how the authors explain the relationship between the context and events of the data-gathering processes of the study and the study findings. maceache.pmd 8.8.2006, 11:49 259 260 Scand J Work Environ Health 2006, vol 32, no 4 Systematic review of qualitative return-to-work literature encompassed at least 4 of the 13 studies reviewed. Key concepts were arrived at analytically; for instance, the key concept of trust and goodwill became relevant when some studies noted consequences of the absence of goodwillsuch as employer suspicions about effort and motivation in return to workand others contrib- uted to a positive picture of goodwillsuch as helpful or trusting relationships (see table 3 for the first-order and key concepts). The final analysis included a search for directly comparable findings, oppositional findings, and findings that contributed to a line of argument (21). The final analysis is not a summary or aggregation of findings, but is, instead, a re-interpretation of key con- cept findings according to how they relate to each oth- er on the main theme of workplace-based return to work and the questions guiding the review. Here, for exam- ple, our analysis identifies dimensions and challenges of return to work and, on the basis of these findings, Table 3. First-order and key concepts of the reviewed studies. (RTW = return to work) Concept Baril & Baril Baril Clarke Eakin Friesen Habeck Innes & Kenny, Lars- Nord- Roberts- Shaw Berthe et al, et al, et al, et al, et al, et al, Straker, 1995 son & qvist yates, et al, lette, 1994 2003 2002 2003 2001 1998 2002 (29) Gard, et al, 2003 2003 2000 (30) (31) (27) (15) (25) (35) (34) 2003 2003 (32) (23) (24) (28) (33) Trust and goodwill Firm social environment X X X X X X X X X Occupational bonding X X Trust about motivation X X X X X X Diminished social status X X X X Worker and the system Unsure about procedures X X X X X X X Unsure about admininistrative X X X X X language Feel vulnerable X X X X X X Contact with worker Nature of contact X X X X X Trust about motivation X X X X Provision of RTW information X X X X Employer-physician contact Accessibility X X X X X Promotion of early return X X Patient advocate X X Employers second-guess physicians X X X Modified work Co-worker burden X X X X X Asking for help X X X X Feeling fragile X X X Social dislocation X X X X X Finding modified X X X X X X Designing modified X X X X X X X X X Costs of modified X X X X X Inclusion in RTW planning X X X X X X X X Unions Seniority clauses X X X Advocate time off work X X Trust about motivation X X X X Development of RTW program X X X Supervisors Present day-to-day X X X Monitoring modified work X X X X X Injured worker advocate X X X X Manage co-worker relations X X X X X Role conflict X X X X Participation in RTW plan X X X X Organizational environments Fiscal well being X X X X X Active commitment to RTW X X X X X X X X Managerial consensus X X X X X Disseminating information X X X Building health and safety into jobs X X X X maceache.pmd 8.8.2006, 11:49 260 Scand J Work Environ Health 2006, vol 32, no 4 261 MacEachen et al develops an argument for key intermediary players who may contribute to optimal return-to-work conditions. In practice, this synthesis involved a review of all of the included papers, data extraction findings, and notes from review meetings that detailed comparisons across papers. The synthesis was conducted by the same researchers who organized and worked on the quality assessment and data extraction and who were familiar with the field of return to work. In addition, the qualita- tive systematic review process and findings were re- viewed by the larger steering committee of the mixed- method review project. (The study methods and foci are summarized in table 4.) Results Results of the search From the initial search of eight sources, 4124 studies were identified for possible inclusion in the qualitative or quantitative reviews. Selection of the qualitative stud- ies from among this first search involved a keyword search for the terms interviews, focus groups, ob- servations, qualitative, or qualitative methods. This process yielded 229 studies for which the full-text arti- cles were screened to see if they met the inclusion cri- teria. Fifteen qualitative studies were selected and pro- ceeded to undergo quality assessment (figure 1). Thirteen studies were judged to be of sufficient qual- ity to proceed to data extraction. (The studies proceed- ing to data extraction are listed in table 4.) At this stage of the review, most of the studies passed the quality as- sessment because we included studies of medium qual- ity (more on issues of quality follow) and because we had already screened out many studies with a quasi- qualitative design that did not stand up to methodologi- cal scrutiny. Altogether 7 of the 13 studies were judged to be of medium quality, 5 were of high quality, and 1 was of very high quality. Key concepts and meta-ethnographic synthesis Eight key concepts were identified across the 13 stud- ies. This section describes the key concepts and their relevance to the meta-ethnographic analysis. Role of goodwill among parties. A key concept and syn- thesis finding of this systematic review of qualitative studies of workplace-based return to work is that, wheth- er parties actually collaborate in the return-to-work process is dependent on goodwill and local culture, even when the procedures met the standards of good prac- tice, such as a proactive approach to injury (2325). The concept of goodwill was present in most of the studies reviewed, either in a discussion of its presence or men- tion of its absence. Goodwill is an intangible, but influ- ential factor that affects workplace ideas about the at- tribution of injury, the magnitude of resources allocat- ed to return to work and prevention (24, 26), the ability to negotiate the process successfully, and the level of creativity applied to planning and managing modified work (27, 28). The conditions for goodwill exist large- ly in the social environment of the firm. For instance, goodwill is more likely to exist when a worker has oc- cupational bonding or job attachment with employers and co-workers (29) or capital in the moral econo- my 9 of a firm (26). In these situations, the worker is sufficiently respected that workplace parties are moti- vated to make the necessary effort to create conditions for a successful return to work. Several studies examined the absence of goodwill and discussed the consequences of this absence. An ab- sence of goodwill exists among workers if they feel that managers or health care providers are not acting in their best interests and that other issues, such as cost savings and production statistics (26, 29, 30) and timely case closure, are an implicit priority. These conditions may undermine worker motivation to cooperate with return- to-work efforts (31, 32). In turn, employers may lack motivation to commit fully to return-to-work policies when they suspect that a worker has taken advantage of an injury to reduce effort at work. This atmosphere of suspicion can lead to social hardening or disillusion- ment about the feasibility of return-to-work objectives on the part of the employer, who may resolve to be less accommodating to injured workers (26). The studies showed that the social environment of a firm can affect worker recovery. Several studies found that, during the return-to-work process, injured work- ers experience diminished social status, feelings that they do not fit in, and a need to justify the genuineness of injury to their employers, co-workers, and friends (32). Workers also feel under scrutiny about the validi- ty of their injuries and their entitlement to compensa- tion and time off work (26). These social conditions may contribute to psychological trauma (32) and physical re- injury, as workers attempt to demonstrate the veracity of their injury by taking actions such as ignoring physi- cal restrictions or returning to work against medical ad- vice (26). Relations between the worker and the system. Several studies noted aspects of workers compensation and 9 Moral capital is a financial metaphor to illustrate informal social give-and-take commitments, expectations, and relationships in a workplace. For further explanation, see the report of Eakin et al (26). maceache.pmd 8.8.2006, 11:49 261 262 Scand J Work Environ Health 2006, vol 32, no 4 Systematic review of qualitative return-to-work literature Table 4. Summary of study methods and foci. (QA = quality assessment, RTW = return to work) Study Location Method Participants Recruitment QA Focus of study 1 Baril & Quebec, Qualitative component 16 employers, 4 workers and Companies selected from Medium Organizational Berthe- Canada of mixed-methods stu- compensation system representa- compensation files determinants of lette, 2000 dy; interviews, review tives (number not reported) in early RTW (24) of collective agreements 16 companies interventions 2 Baril et al, Three Interviews, focus groups, Workplace parties (65 employers, Sampled for variation in High Stakeholder per- 2003 (31) Canadian document review 25 workers) plus a variety of sta- workplaces (size, sector) ceptions about provinces keholders outside of workplace effective RTW (health care, vocational profes- sionals, insurance providers, union representatives) 3 Baril et Quebec, Mixed methods study Workers, employers, union repre- Worker sample chosen to Medium Stakeholder per- al, 1994 Canada (qualitative and quantita- sentatives, health professionals, represent different RTW situa- ceptions about (30) tive); former involved rehabilitation counselors (total tions, in 3 regions of Quebec rehabilitation of semi-structured interviews 68) injured workers 4 Clarke et Ontario, Semi-structured inter- 17 workplace parties (occupa- Sample chosen for variation High Stakeholder per- al, 2002 Canada views tional health nurses, physicians, in experience and company ceptions about (27) health & safety coordinators, size, based on information RTW process union representatives, administra- from municipal publications, tor); supplementary data from word-of-mouth, snowball workers, health care providers, sample, physicians in one compensation professionals city, local labor council 5 Eakin et al, Ontario, Semi-structured inter- 17 employers, 22 workers from Referred compensation Very Employer and 2003 (15) Canada views small business settings; board, health & safety orga- high worker exper- 4 compensation professionals nizations, community orga- ience of RTW in nizations, labor organiza- small business tions, medical and legal aid settings clinics and personal referrals 6 Friesen et Mani- Semi-structured inter- 11 managers, 4 union or worker Recruited on basis of their High Stakeholder al, 2001 toba, Ca- views and focus groups representatives, 11 occupational experience, knowledge or perspectives on (25) nada health professionals, 12 workers, importance in work injury RTW issues plus 16 others including regula- field and RTW process in tory agency, government, the workplace workers groups, compensation board, occupational therapists 7 Habeck et Michigan, Part of a larger quantitative 32 site visits, each involving Companies chosen randomly Medium Implementation al, 1998 United study on workplace poli- 14 people from systematic sample of of RTW policies (35) States cies, practices, and work high- and low-performance and practices disability; interviews with companies (based on lost employers and document workdays) in 6 industry and review; some site tours 3 size categories, recruited by letters to companies chosen 8 Innes & Australia Semi-structured interviews 26 providers of work-related Recruited through personal High Therapists be- 2002 (34) and one focus group therapists, 8 physiotherapists) groups, at a national conference liefs about work- Straker, assessments (18 occupational contacts, professional interest place-based and by snowball sample assessments 9 Kenny, New Structured interviews with 12 injured workers (8 women, Referred by representative of Medium Experiences of 1995 (29) South injured workers, involving 4 men, age 2461 years) off the Labour Council of New long-term injured Wales, open-ended questions; work for more than 26 weeks South Wales, who was involved workers Australia mix of qualitative and in injured workers advocacy guantitative methods 10 Larsson & Northern Interviews with employers 10 managers in organizations of Recruited employers who had Medium Employers Gard, 2003 Sweden different rural areas, differed in sent workers with musculo- experiences with (28) age, experience with rehabilita- skeletal problems to a 3-week work rehabilita- tion planning, size of company vocational rehabilitation tion planning program process 11 Nordqvist Southern Part of larger cohort study 18 workers (13 women, 5 men) Participants chosen from res- Medium Laypersons et al, 2003 Sweden of injured workers off work with previous low-back injuries pondents to a 1996 question- views of (33) for at least 28 days; five naire, recruited by letter employer RTW focus groups with workers role 12 Roberts- South Interviews with injured 85 injured workers (37 women, Workers referred from a net- Medium Experiences of Yates, Australia workers 48 men, age 2565) from wide work of employers, advocacy workers with 2003 (32) variety of jobs, different RTW groups, treating medical practi- complex claims experiences tioners and other contacts 13 Shaw et al, North- Semi-structured interviews 30 nonsupervisory employees Participants selected by corpo- High Role of super- 2003 (23) eastern with workers (11 women, 19 men, job tenure rate health & safety managers, visors to prevent United 4 months-19 years) from four companies recruited via busi- workplace States companies in high physical work ness and research ties with disability demand or injury rate industries funder health care systems that hinder workers ability to ne- gotiate a complex path to return to work. For instance, in various Canadian jurisdictions, the system is set up in a way that workers are expected to be self-reliant, to assert their legal rights, and to balance the demands of the workplace, insurers and health professionals during maceache.pmd 8.8.2006, 11:49 262 Scand J Work Environ Health 2006, vol 32, no 4 263 MacEachen et al the process of recovery and return to work (25, 26). However, injured workers are reported as feeling vul- nerable and less than self-reliantthey are unsure about process, procedures, and entitlements, and they may lack guidance or support from their workplace (25, 26, 30, 32). Workers often do not understand the rules about workers compensation or the language used by provid- ers. This lack of knowledge of process and procedures can set the stage for problematic rehabilitation, misun- derstandings between workers and their workplace, and poor strategizing with respect to health care and return to work (2931). Studies have pointed out that, even when injured workers are advised about processes and procedures, the system requirements can be difficult to meet. For in- stance, injured workers can have a difficult time docu- menting events for the compensation board while also trying to get on with their physical rehabilitation, dis- rupted personal lives, and worktasks and relations (27). Workers also have problems cooperating with return- to-work mandates because this cooperation is a ne- gotiated process with no clear guidance on exactly how and when to fulfill this duty (26). Contact with worker between injury and return to work. Early contact with injured workers is a part of many re- turn-to-work programs, and several studies character- ized this contact as a time when future cooperation, flex- ibility, and credibility are at stake. A friendly social phone call from a workplace can be a motivator for workers considering return to work; this kind of con- tact reminds them that they have not been forgotten (33). Two studies reported return-to-work processes that worked well when employers initiated the rehabilitation process right after injury and did not wait for an insur- er, health professional, or worker to make arrangements (25, 28). Some studies showed that there are occasions when neither the worker nor their employer are in the right mind set to be in contact immediately following an in- jury. Early contact was unhelpful when the worker, for example, had performance problems or had pre-injury problems with workplace relations (31). Early contact can also be problematic when the worker senses that the employer is not forthcoming about support and reinte- gration or is unhelpful about worker rights and entitle- ments (29). Because early contact is often a required part of the return-to-work process, it can be perceived by both workers and employers as an unwelcome obli- gation rather than as care-oriented (26). Employer contact with physicians. The studies reviewed found that employers experienced difficulties coordinat- ing with physicians when they attempted to set up phys- ically appropriate return-to-work arrangements for in- jured workers. Several studies describe employers hav- ing difficulty with physicians who are hard to contact and who do not promote or assist with early return to work for workers (31). Recommended practices of re- turning to work prior to complete resolution of an Figure 1. Flow chart of studies in the literature review. maceache.pmd 8.8.2006, 11:49 263 264 Scand J Work Environ Health 2006, vol 32, no 4 Systematic review of qualitative return-to-work literature injury are not always supported by treating physicians, and some arrive at diagnoses that involve prolonged treatments and absence from work (27). Physician con- tact and the timing of return to work is problematic for employers when they need additional physician input about a workers ability in relation to particular work- tasks before they can design an appropriate modified job for an injured worker. Workplace visits that could al- low for a full understanding of an injured workers re- turn-to-work needs are outside the range of normal phy- sician activity, and physicians lack employers financial motivation to promote early return to work (25). This disconnect between employers and physicians can lead to difficulties for workplace parties as they attempt to comply with early return-to-work requirements (26, 29). When employers do not coordinate closely with treating physicians, they can be drawn inappropriately into workers treatment issues. One study showed that employers who have difficulty contacting physicians or who feel that physicians delay worker return to work can end up taking on the role of mediating and coordi- nating medical aspects of the return-to-work process (26). In many jurisdictions, confidentiality rules allow employers to know only the functional abilities of an injured worker, but, with early return requirements, employers can be drawn into taking an interest in work- ers medical progress. In this context, particularly in smaller firms, employers learn details of treatment and make personal judgments about workers abilities and recovery pace. This situation draws employers inappro- priately into practical decisions about workers injuries and recovery. One study of workplace assessments of disability management conducted by therapists found that these workplace evaluations can be sensitive to organization- al and industrial relations issues such as restructuring, changes in staff numbers, and the sociocultural environ- ment. Therapist visits can offer a view of the worker situation, which includes relevant aspects of the job and work environment (34). This synthesis suggests that in- termediary health care professionals may be in a key position to bridge return-to-work planning gaps between employers, busy physicians, and injured workers. Modified worksocial, physical and financial aspects. Once early contact requirements have been fulfilled and workers have been assessed for functional ability, em- ployers begin to consider appropriate modified work for injured workers. The studies reviewed refer to social, physical, and financial components of modified work that need to be considered in order to achieve adequate modified work conditions. Workable modified work ar- rangements were described as flexible, tailored to the workers particular needs (30, 35), and having produc- tion value (24). Social aspects of modified work included relation- ships between injured workers and their co-workers and social dislocation. Co-workers may resent the injured worker if they have to take over some of his or her work- load or if the injured worker gets an easier jobes- pecially when this job has been co-opted from another worker (28). They may also feel that the presence of an injured worker has an adverse effect on the groups pro- duction statistics and production-related bonus oppor- tunities. Co-workers may be suspicious about the extent and duration of an injured workers injury (32) and un- willing to assist an injured worker with tasks (31). Dif- ficult relations between an injured worker and his or her co-workers may be compounded because injured work- ers can have difficulty telling colleagues about their re- strictions and asking for help and because they may al- ienate co-workers when their functional restrictions lead them to refuse another workers request for assistance (27, 32). One study suggested that re-injury is influ- enced by these aspects of co-worker relations during periods of modified work (33). Social dislocation can arise during modified work if the worker is placed temporarily in a new work area and must adjust to a new set of relationships, routines, and sometimes new behavioral requirements (26). For in- stance, a male truck driver may be given light work in a female-dominated office, where he feels socially and physically ill at ease. Such social aspects of modi- fied work may have a strong impact on the success or failure of an arrangement, as modified work that is so- cially awkward can be resisted by the worker (28, 31, 32). A second component of the modified work referred to in the studies reviewed is the physical arrangement of work. One study noted that when modified work is planned, the selection of tasks is usually left to the su- pervisor and is rarely based on ergonomic considera- tions (31). This situation can be a problem because, if work is not tailored to a workers particular needs, it may predispose the worker to re-injury (30). If the job modification requires them to take over some of the in- jured workers duties, the physical arrangement of mod- ified work may also increase co-worker workload and risk of injury (28). A third component of modified work is financial. It includes employer costs associated with keeping a job open, modifying tasks, and paying workers compensa- tion premium surcharges. Employers may be reluctant to incur the costs of changed procedures and individual worker accommodation (28). Where employers find that the provision of appropriate modified work is difficult or expensive, workers may be given meaningless work so that employers can keep workers at work and there- fore avoid workers compensation premium surcharges (24, 26, 27). maceache.pmd 8.8.2006, 11:49 264 Scand J Work Environ Health 2006, vol 32, no 4 265 MacEachen et al Role of unions in return to work. Union organizations and union members in some workplaces support return to work and promote the practice of modified work, es- pecially when the union is a full partner in the develop- ment and implementation of the return-to-work program (27). However, the studies reviewed identified ways that union support for return to work can be side-tracked by practical workplace considerations. Return-to-work leg- islation can set unions at odds with return-to-work plans because the requirement to provide alternative or mod- ified work can conflict with seniority clauses in collec- tive agreements. In addition, jurisdictional issues with multiple unions within a workplace can hinder cooper- ation with respect to temporary reassignments for mod- ified work (24, 27). Unions can also be reluctant to fa- cilitate modified work arrangements if they support the right of workers to stay off work while they cannot do their job and if they (similar to some physicians as not- ed above) have not fully accepted the principle of ear- ly return to work before full recovery (31). Union sup- port for return to work may be tempered by sensitivi- ties to production statistics as an important priority of management, views of return to work as a cost-saving mechanism, and workers obligations to return to mod- ified work without voluntary consent (24). Role of supervisors in the day-to-day social relations of return to work. Several studies pointed to supervisors as important to the success of return to work because of their daily proximity to the worker. The role of the su- pervisor is not usually to make major workplace chang- es that may alter the physical or organizational environ- ment, but within an organizations existing conditions supervisors are uniquely situated to manage the day-to- day social relations and physical conditions in the work environment. The supervisor role in physical aspects of work accommodation involves the implementation and regular monitoring of a safe and appropriate modified work environment for the injured worker. They are in a position to monitor modified work and to ensure that it is meaningful to the injured worker (23). Because pro- duction needs can change and workers can be reluctant to complain about breaches of physical restrictions, su- pervisors who are on location can consider appropriate concurrent changes to modify work (29). Therefore, su- pervisors are an important source of certainty that re- strictions are upheld (27, 29). They can also monitor worker job practices and habits. For example, one study described how workers returned from off-site rehabili- tation and reverted to unsafe work techniques (28). Therefore, supervisors engaged in return-to-work proc- esses may be well situated to ensure the proper adjust- ment of workers to their previous job. The supervisor can also be a well-placed advocate who can lend legitimacy to a workers condition and restrictions, validate the injury, and smooth difficult workplace relations (as described earlier) between the injured worker and his or her co-workers (23, 27, 29, 33). One study suggested that even when the workplace has an on-site nurse who is managing a return-to-work program, the supervisor should still be closely involved because he or she is present every day, has the closest contact with worker, and is aware of social dynamics that may help or hinder the return-to-work process (23). This synthesis found that supervisors can play an im- portant intermediary role in physical and social aspects of work accommodation. However, in order to enable and encourage supervisors to manage social and physi- cal aspects of return to work, workplaces may need to remove disincentives for the supervisor to engage with the process. Several studies mentioned obstacles to the supervisors role in return to work. They may lack skills for managing complex psychosocial workplace dynam- ics. They may also lack training about ergonomic prin- ciples and how to keep work within the injured work- ers restrictions (31). There can be a lack of managerial consensus about return-to-work processes (24), and the return-to-work role may be an unwanted burden, espe- cially when conflicting priorities orient the supervisor to see return to work as an obstacle to production (24, 31). In addition, supervisors may not have enough time to manage nonproduction needs such as the extra social and physical needs of return to work (33). Return to work and organizational environments. This review identified two aspects of organizational environ- ments that can affect return to work, economic context and internal dynamics. The economic context of the work organization can affect internal practices related to return to work, as growing companies will acquire personnel and expertise and will have greater flexibili- ty to arrange modified positions. However, if an organ- ization is downsizing, reduced jobs for everyone means that organizations will have difficulty finding modified work for injured workers (24, 25). With financial con- straints, there may be increased emphasis on the man- agement of claims, with health aspects of return to work outweighed by financial concerns (27). Even when an organization is in good fiscal condi- tion, workplace parties may not always accept the re- turn-to-work mandate. At least, in the short term, return to work can be expensive, with increased personnel ef- fort and time (27). In some cases, this situation may override the financial incentives of workers compen- sation premiums to initiate return to work. Distractions and disincentives to return to work can multiply when organizations do not explicitly endorse the return-to- work process and, thereby, give it credibility among managers, union leaders, and supervisors (25, 27). In addition, managerial consensus about how to achieve maceache.pmd 8.8.2006, 11:49 265 266 Scand J Work Environ Health 2006, vol 32, no 4 Systematic review of qualitative return-to-work literature return to work in the organization is needed, together with methods for tracking and disseminating informa- tion about workplace injury (33, 35). Discussion An analysis of the eight key concepts yields three main findings from this synthesis of qualitative literature on workplace-based return to work. The first finding relates to the scope and complexity of workplace-based return- to-work processes. We found that return to work in- volves more players and dimensions than were identi- fied in any one study. Our findings about the role of workers, co-workers, employers, health professionals, unions, organizational environments, and the workers compensation and health care systems as they interact with each other to support or undermine the possibility of appropriate modified or return-to-work conditions provide a comprehensive and detailed picture of return to work that extends beyond the current literature. Re- turn to work therefore extends well beyond local con- cerns about managing injured worker physical function to broader complexities related to work organization and the beliefs and roles of a myriad of players. Successful outcomes will require active planning and sensitivity to the complexity of the process. Our second synthesis finding relates to the role of goodwill and trust as overarching conditions that are central to return-to-work arrangements. While the term goodwill was not directly mentioned in any of the studies reviewed, almost all of the studies reviewed pointed implicitly to this intangible, but influential as- pect of social environments. In this synthesis, good- will and trust was a key concept and also a cross-cut- ting theme. For instance, other key concepts that focused on the role of early contact, unions, supervisors, and modified work conditions each pointed to the potential for conflict and the importance of considerate under- standing of mutual needs. Our finding of the relevance of goodwill highlights the need for creativity and good teamwork in return to work. Because every workplace is different, employers and other players must be moti- vated and also aware of opportunities for viable modi- fied work (28). Our third synthesis result builds on the two findings already presented. Our findings about the scope and complexity of the return-to-work process and the im- portance of social conditions of goodwill and trust pro- vide insight into particular social and communication barriers and needs in the return-to-work process. Be- cause of the differing players in the return-to-work proc- ess, there is a built-in challenge for communication and coordination, and so we found that intermediary play- ers have the potential to play a key role in facilitating the return-to-work process. More specifically, we iden- tified two key intermediary players, rehabilitation or occupational health care providers and workplace su- pervisors. Because employers experience difficulty co- ordinating details of return-to-work arrangements with busy or disinterested physicians, a rehabilitation or oc- cupational health care provider can play an important role in the facilitation and moderation of return-to-work communication. This intermediary health care profes- sional can visit the workplace, gain a close understand- ing of the needs of the injured worker, and liaise be- tween the physician and the employer. Workplace su- pervisors can also play an important intermediary role in return to work by sustaining positive day-to-day so- cial relations between the injured worker and his or her co-workers and by maintaining the accommodation of the physical environment amidst changing production conditions. In addition, supervisors provide a regular link between the worker and upper management. In summary, we have described how concepts in the papers reviewed lead to eight key concepts that are rel- evant to the return-to-work process. An analysis of the key concepts resulted in three overall synthesis conclu- sions about the complexity of the process, overarching social conditions related to goodwill and trust, and the relevance of two key intermediary players in the return- to-work process. Meta-ethnographic synthesis process Britten et al (21) noted that meta-ethnographic synthe- ses cannot be reduced to a set of mechanistic tasks but that a synthesis will generally consist of series of steps, or building blocks, geared to the derivation of interpre- tations relevant to the synthesis question or topic. In our systematic review, our research questions about dimen- sions, processes, and practices in return to work guided our inquiry of the papers reviewed. We found that the compilation of findings in key concepts provided a broad and detailed picture of the return-to-work proc- ess. The key concepts then provided a platform for anal- ysis leading to conceptual development about the return- to-work process that extends beyond that in any one empirical study. Overall, we were able to gain new ex- planations not articulated in the literature from the syn- thesis findings, as well as observations that, in some cases, were peripheral to the authors original research question, but which were central to our own research question. We placed our findings in a broad realist perspec- tive (13) that takes an explanatory focus and unpacks mechanisms of how complex programs work. Our find- ings acknowledge meaningful and intentional behavior of actors and also recognize that behavior is limited and shaped by social structure. For instance, we acknowledge maceache.pmd 8.8.2006, 11:49 266 Scand J Work Environ Health 2006, vol 32, no 4 267 MacEachen et al the potential worker advocacy role for workplace su- pervisors in return to work, but we also highlight broader conditions of the possibility for supervisor be- havior, such as a lack of managerial consensus about return-to-work processes and conflicting priorities that orient the supervisor to see return to work as an unwant- ed obstacle to their own goals. Future research This review identifies several directions for future re- search and systematic reviews. Many of the reviewed studies focused on return to work at one point in time. A trajectory approach to both workers and workplaces is required for a better picture of the sustainability of return-to-work initiatives and organizational change during this process. The importance of following work- ers over time has been highlighted in quantitative re- search (36); a qualitative study that followed the course of the return-to-work process over an extended period could greatly enhance our understanding of the evolu- tion of the return-to-work process over time. Other re- search may be directed towards the sustainability of re- turn-to-work interventions from an organizational per- spectivehow can employers maintain a worker in a modified position over time, especially when there are economic constraints or organizational changes or when the worker requires long-term accommodation due to permanent disability? The reviewed studies focused on return to work fol- lowing a physical disability. Future research may also include a focus on the mental health of injured work- ersfor instance, what is the relationship between de- pression and unsuccessful return to work? How do re- turn-to-work programs for physically injured workers differ from those of people with other health conditions, including mental health issues? Research may focus on the areas of promise identified in this review, for in- stance, the role of intermediary health care providers and supervisors, each of which requires identification models for practice. Finally, future systematic reviews of qualitative studies can further explore the role of theory in synthe- sis. High-level qualitative studies achieve their ratings of quality precisely because of theoretical frameworks that guide the research question, data gathering proc- ess, and analysis. Given this prominent role of theory in qualitative research, future synthesis of qualitative studies can provide theoretical underpinnings of the studies reviewed and also of the final synthesis. Strengths and limitations A strength of this synthesis was that we reviewed avail- able tools for the evaluation of the quality of qualita- tive studies before choosing the tool used in this review (14). The quality assessment tool we used avoids con- straints posed by a rigid checklist approach to quali- ty; it offers frameworks sensitive to variance among qualitative studies and with sufficient strength for a con- sistency of judgment and process. An additional strength of this synthesis was that, although the meta-ethno- graphic approach does not explicitly consider the theo- retical dimension of this synthesis, its procedures allow the researcher to consider the original theoretical per- spective of the studies and to synthesize findings into a common theoretical perspective. A limitation of this review was the paucity of high- quality qualitative research relevant to the topic of work- place-based return to work. So that a sufficient body of literature would be included in this review, our criteria for quality assessment excluded only 2 of the 15 stud- ies that had been screened for methodological and topi- cal relevance. These final studies included seven which were of medium quality and which contained a rela- tively thin picture of return-to-work conditions. Un- der optimal conditions, we would only have included studies with a stronger level of analysis that included theory and took into consideration complexities of the local and broader environment. However, on the whole, we found that the medium level studies made a worth- while contribution to the process of constant compari- son and negative case analysis and to an aggregate pic- ture of the process of return to work after injury. In summary, this synthesis has brought together re- search findings from a range of qualitative studies on the theme of workplace-based return to work and has identified key mechanisms of workplace practice, proc- ess, and environment that can affect the success of re- turn to work. The strength of this systematic review is that it has shown the contribution that qualitative litera- ture can make to important aspects of process, social relations, and implementation in relation to return to work. In addition, the findings of this synthesis of qual- itative literature have identified key elements in return to work that are relevant to practitioners and stakehold- ers and have pointed to areas of conceptual promise that may direct researchers to further study. Acknowledgments This study was supported by the Workplace Safety & Insurance Board and the Institute for Work & Health. We also acknowledge the Workplace-based Return to Work Literature Review Group for their overall sup- port and their feedback on iterations of these findings, and Lori Chambers for her editorial assistance. We maceache.pmd 8.8.2006, 11:49 267 268 Scand J Work Environ Health 2006, vol 32, no 4 Systematic review of qualitative return-to-work literature thank the anonymous reviewers for their helpful com- ments on the presentation of the synthesis analysis. References 1. Krause N, Dasinger LK, Neuhauser F. Modified work and return to work: a review of the literature. J Occup Rehabil. 1998;8(2):11339. 2. Saroki FJ, Welch EM. Return to workproof that it works. On Work Compens. 1997;7(2):910. 3. Galvin DE, Schwartz G. Employer-based disability manage- ment and rehabilitation initiatives. Washington (DC): D:ATA Institute; 1986. 4. Shrey DE. Disability management in industry: the new para- digm in injured worker rehabilitation. Disabil Rehabil. 1996; 18(8):40814. 5. Franche R-L, Cullen K, Clarke J, MacEachen E, Frank J, Sinclair S, et al. Workplace-based return-to-work interven- tions: a systematic review of the quantitative and qualitative literature [report]. Toronto (ON): Institute for Work & Health; 2004. 6. MacEachen E, Clarke J, Franche R-L, Cullen K, Sinclair S, Frank J, et al. What systematic reviews gain when they in- clude qualitative research: a systematic review of qualitative work on workplace-based return-to-work practices. [Abstract available at http://www.cochrane.org/colloquia/abstracts/otta- wa/O-087.htm]. 7. Franche R-L, Cullen K, Clarke J, Irvin E, Sinclair S, Frank J, et al. Workplace-based return-to-work interventions: a sys- tematic review of the literature. J Occup Rehabil. 2005; 15(4):60731. 8. Thomas J, Harden A, Oakley A, Oliver S, Sutcliffe K, Rees R, et al. Integrating qualitative research with trials in systematic reviews. Br Med J. 2004;328:10103. 9. Popay J, Roen K. Using evidence from diverse research de- signs [report]. London: Social Care Institute for Excellence; 2003. 10. Harden A, Garcia J, Oliver S, Rees R, Shepherd J, Brunton G, et al. Applying systematic review methods to studies of peo- ples views: an example from public health research. J Epide- miol Community Health. 2004;58:794800. 11. Dixon-Woods M, Fitzpatrick R. Qualitative research in sys- tematic reviews. Br Med J. 2001;323:7656. 12. Hawker S, Payne S, Kerr C, Hardey M, Powell J. Appraising the evidence: reviewing disparate data systematically. Qual Health Res. 2002;12(9):128499. 13. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist re- viewa new method of systematic review designed for com- plex policy interventions. J Health Serv Res Policy. 2005;10(3 Suppl 1):2134. 14. Spencer L, Ritchie J, Lewis J, Dillon L. Quality in qualitative evaluation: a framework for assessing research evidence [oc- casional paper]. London: Government Chief Social Research- ers Office; 2003. No 2 (i98). 15. Eakin JE, Mykhalovskiy E. Reframing the evaluation of qual- itative health research: reflections on a review of appraisal guidelines in the health sciences. J Eval Clin Pract. 2003;9(2):18794. 16. Seale C. Quality in qualitative research. In: Lincoln YS, Den- zin NK, editors. Turning points in qualitative research: tying knots in a handkerchief. London: AltaMira; 2003. p 16984. 17. Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. Br Med J. 2000;320:502. 18. Barbour RS, Barbour M. Evaluating and synthesizing qualita- tive research: the need to develop a distinctive approach. J Eval Clin Pract. 2003;9(2):17986. 19. Seale C. The quality of qualitative research. Thousand Oaks (CA): Sage; 1999. 20. Noblit GW, Hare RD. Meta-ethnography: synthesizing quali- tative studies. London: Sage; 1988. 21. Britten N, Campbell R, Pope C, Donovan J, Morgan M, Pill R. Using meta ethnography to synthesise qualitative research: a worked example. J Health Serv Res Policy. 2002;7(4):209 15. 22. Campbell R, Pound P, Pope C, Britten N, Pill R, Morgan M, et al. Evaluating meta-ethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care. Soc Sci Med. 2003;56:67184. 23. Shaw WS, Robertson MM, Pransky G, McLellan RK. Em- ployee perspectives on the role of supervisors to prevent work- place disability after injuries. J Occup Rehabil. 2003;13(3):12942. 24. Baril R, Berthelette D. Components and organizational deter- minants of workplace interventions designed to facilitate ear- ly return to work [report]. Montreal (QC): Institut de Recher- che Robert-Sauv en Sant et en Scurit du Travail (IRSST); 2000. Etudes et recherches, no R263(i53). 25. Friesen MN, Yassi A, Cooper J. Return-to-work: the impor- tance of human interactions and organizational structures. Work. 2001;17(1):1122. 26. Eakin JM, MacEachen E, Clarke J. Playing it smart with return to work: small workplace experience under Ontarios policy of self-reliance and early return. Policy Pract Health Saf. 2004;1(2):1941. 27. Clarke J, Cole D, Ferrier S. Return to work after a soft tissue injury: a qualitative exploration [working paper]. Toronto (ON): Institute for Work & Health; 2002. No 127. 28. Larsson A, Gard G. How can the rehabilitation planning proc- ess at the workplace be improved? a qualitative study from employers perspective. J Occup Rehabil. 2003;13(3):169 81. 29. Kenny D. Barriers to occupational rehabilitation: an explora- tory study of long-term injured workers. J Occup Health Saf Aust N Z. 1995;11(3):24956. 30. Baril R, Martin J-C, Lapointe C, Massicotte P. Etude explora- toire des processus de reinsertion sociale et professionnelle des travailleurs en readaptation [Exploratory study of the so- cial and professional reintegration process of workers under- going rehabilitation]. Montreal (QC): Institut de Recherche Robert-Sauv en Sant et en Scurit du Travail (IRSST); 1994. No, RR082. p 117. 31. Baril R, Clarke J, Friesen M, Stock S, Cole D, Bombardier C, et al. Management of return-to-work programs for workers with musculoskeletal disorders: a qualitative study in three Canadian provinces. Soc Sci Med. 2003;57(11):210114. 32. Roberts-Yates C. The concerns and issues of injured workers in relation to claims/injury management and rehabilitation: the need for new operational frameworks. Disabil Rehabil. 2003;25(16):898907. 33. Nordqvist C, Holmqvist C, Alexanderson K. Views of layper- sons on the role employers play in return to work when sick- listed. J Occup Rehabil. 2003;13(1):1120. 34. Innes E, Straker L. Workplace assessments and functional capacity evaluations: current practices of therapists in Aus- tralia. Work. 2002;18(1):5166. maceache.pmd 8.8.2006, 11:49 268 Scand J Work Environ Health 2006, vol 32, no 4 269 MacEachen et al Appendix Questions used in the quality assessment 1. How credible are the findings? 2. How has knowledge/understanding been extended by the research?/ 3. How well does the study address the original aims and purpose? 4. Scope for drawing wider inferencehow well is this explained? 5. How defensible is the research design? 6. How well defended is the sample design/target selection of cases? 7. Sample composition/case inclusionhow well is coverage described? 8. How well was the data collection carried out? 9. How well was the approach to/formulation of the analysis conveyed? 10. Contexts of data sourceshow well are they retained/portrayed? 11. How well has diversity of perspective and content been explored? 12. How well has detail, depth and richness of data been conveyed? 13. How clear are the links between data, interpretation and conclusions? 14. How clear and coherent is the reporting? 15. How clear are the assumptions/theoretical perspectives/values that shaped form and output of the study? 16. What evidence is there of attention to ethical issues? 17. How adequately has the research process been documented? 35. Habeck RV, Scully SM, VanTol B, Hunt HA. Successful employer strategies for preventing and managing disability. Rehabil Couns Bull. 1998;42(2):14461. 36. Krause N, Frank JW, Dasinger LK, Sullivan TJ, Sinclair SJ. Determinants of duration of disability and return-to-work af- ter work-related injury and illness: challenges for future re- search. Am J Ind Med. 2001;40:46484. Received for publication: 12 December 2005 maceache.pmd 8.8.2006, 11:49 269
The Impact of High Performance Work Systems in The Health-Care Industry, Employee Reactions, Service Quality, Customer Satisfaction, and Customer Loyalty
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