Introduction

Every year, many workers take sick leave for work disability associated with musculoskeletal disorders (MSDs), common mental disorders (CMDs), cancer or other chronic diseases (OCDs) [1, 2]. Various sociodemographic trends in industrial societies also point to a general aging of the population and a low birth rate. Against this backdrop, the current and anticipated shortage of skilled labour, as well as the postponement of retirement to a later age, inevitably means a growing presence of so-called “aging” workers (aged 45 and over) in the future job market [3,4,5,6,7].

While accidents, injuries and occupational diseases do not appear to occur systematically with any greater frequency among aging workers, statistical data reveal the increased severity of their disabilities, reflected in longer sick leaves [8,9,10,11,12,13,14]. These findings, mainly drawn from statistical database analyses and epidemiological cohort studies, remain uninformative about factors that might explain longer sick leaves. Indeed, such research designs consider only a limited number of factors, and mainly individual ones, without examining possible influences of specific contexts (e.g. legislation, workplace, health services) [9, 11, 15,16,17,18]. A more in-depth investigation into factors affecting the return to work of aging workers with a work disability therefore appears necessary if we are to effectively reduce absenteeism among these workers.

More general literature on aging at work could provide a useful starting point for deepening our understanding of such factors and issues. Indeed, aging workers are often described as less productive and efficient, less flexible and versatile, less willing to adapt to changes and technology, and less inclined to take advantage of training, as well as more often absent and less interested and engaged in work than their younger co-workers [19,20,21,22,23,24,25,26]. Such observations could pose greater obstacles for aging workers returning to work after a long sick leave. However, several studies have shown that these social representations, shared by many societal actors, including those involved in the return-to-work process, are far from the reality [27,28,29,30,31]. In fact, the link between older age and performance is not corroborated when tested in real work situations rather than in experimental settings [32,33,34,35,36,37,38,39,40], thus suggesting an influence of the work context on aging workers’ capacity to accomplish their work.

This lack of a demonstrated association between older age and loss of capacity may also be explained by another portion of the aging-at-work literature, which sees aging as a factor that transforms rather than reduces capacities [32, 41, 42]. According to these studies, the effects of the decline of certain capacities on work performance may actually be offset through the use of selection and optimisation strategies in real work contexts [7, 43,44,45]. This proposal seems particularly relevant with regard to the cognitive capacities of aging workers, in whom the documented losses of fluid intelligence (i.e. working memory, abstract reasoning) may be partially compensated for by the gains realised, over time, at the level of crystallised intelligence (i.e. knowledge acquired through education and experience) [33, 34, 43,44,45,46,47]. With cumulative experience in recognizing and managing their emotions, aging workers also tend to adopt more positive coping strategies than younger workers, suggesting that they might react more positively to stressors [48]. These capacity transformations and positive strategies possibly used by aging workers thus suggest some strengths or personal resources that could be capitalised on during the return-to-work process.

To facilitate the enactment of such individual adaptative capacities and strategies, and thus narrow the gap between capacities and work demands, the above-mentioned literature on aging at work recommends adopting an individualised approach providing aging workers with autonomy and flexibility, which could also help increase their work motivation and retention [31, 35, 36, 44, 48,49,50]. Such an individualised and flexible approach could also be applied to aging workers with work disabilities, strengthening their motivation to return to and stay at work despite the difficulties and efforts involved, while making it possible to capitalise on their personal capacities and strengths in the process.

Interesting as they are, these insights from the general literature on aging at work do not deal directly with specific issues that aging workers may encounter when struggling with a work disability. To better understand the situation of aging workers with a work disability, a synthesis of factors and issues specifically impacting their sustainable return-to-work (S-RTW) was prepared in this study. The main causes of absenteeism, namely, MSDs, CMDs, cancer and OCDs, were targeted. This synthesis was part of a broader study that also examined the characteristics of gender and ethnocultural identity in workers.

Methodology

The method used was grounded in an interpretive description approach [51,52,53,54,55]. This so-called “interventionist” approach seeks to develop practical knowledge for use in interventions and to provide contextualised, in-depth understanding of a human phenomenon, its components and how these components fit together and interact [51,52,53,54,55]. This study involves two main steps.

Step 1: First, we conducted a critical review of the literature [55, 56] that identified the knowledge needed to establish a preliminary theoretical framework (scaffolding) for later methodological and analytical decisions [52, 55, 57]. This involved identifying the factors impacting the S-RTW of aging workers, for the four targeted causes of work disability (MSDs, CMDs, cancer and OCDs). The framework generated in this step guided the second step.

Step 2: Focus groups were then held with various types of stakeholders involved in S-RTW to contextualise and improve understanding of the impact of these factors on the return-to-work process of aging workers on sick leave [58]. The data collected were analysed inductively, comparatively and iteratively [51, 52]. This project had received prior approval from the Ethics Committee on Health Research involving Human Subjects of the Centre hospitalier universitaire de Sherbrooke (CHUS).

Data Collection

Literature Review

A critical review was conducted of the literature [56] published between January 2000 and November 2016, which we retrieved using various search engines and databases (CINAHL, ERIC, ProQuest, PsychInfo, Francis, SCOPUS and Sociological Index). The review targeted four causes of work disability in aging workers. For each work disability cause, keywords specifically related to the cause were combined with the keywords for other dimensions under study, i.e. work disability (e.g. disability, return to work) and aging workers (e.g. aging, senior) (“Online Appendix”). The 2000–2016 period was chosen because it corresponded to the years when the view of work disability as a strictly biomedical phenomenon [59] was replaced by a view of work disability as the product of an interaction among four social systems, namely, the personal, healthcare, workplace and compensation systems [60,61,62,63,64]. Three selection criteria were applied. The articles had to:

  1. 1

    Examine work disability in relation to one of the four causes under study, i.e. MSDs, CMDs, cancer and OCDs;

  2. 2

    Present specific results for aging workers, i.e. persons aged 45 and over. This age was retained given the lack of consensus on a specific age for defining an “aging” worker in the current literature [65], but also the emergence of several health problems starting around mid-career (age 45) [66, 67].

  3. 3

    Identify factors that impact the S-RTW of aging workers.

A professional research assistant compiled all the articles identified in EndNote databases specific to each of the four targeted causes of disability, on the basis of the specific keywords combinations (i.e. for each disability cause) that led to their identification. The same member of the research team then performed an initial selection of articles based on their titles, and a second selection based on their abstracts. These articles were classified in three categories: retained, excluded and uncertain. Another member of the team randomly validated the selection at each of these steps (MFC for titles; MJD for abstracts). Next, the articles in the “uncertain” category were discussed by three members of the research team (MJD, MFC, professional research assistant) until consensus was reached. All the articles retained in this step were then read in their entirety by another team member (MAP), resulting in the exclusion of several more articles. For each article retained, one team member (MAP) used a standardised template for extracting data on (1) the characteristics of the study population (criteria for defining an aging worker, cause of the work disability, geographic location where the study was carried out); (2) the study’s aim and objectives; (3) the methodological approaches (study design, data collection and analysis strategies) and theoretical approaches (conceptual or analytical frameworks) used, and (4) the results obtained and their main implications in terms of the actions to be implemented by clinics, workplaces, and insurers, and, more broadly, in terms of policy.

An updated review of the available literature was conducted for the November 2016 to December 2018 period, following all the same procedures as in the initial search.

Focus Groups

As recommended by Carlsen and Glenton, four focus groups were held, specifically, one homogenous group and three heterogenous groups [58]. Their composition was defined by a project steering committee including researchers and social partners. Given health professionals’ central role in the S-RTW process, a first homogenous group composed solely of this type of stakeholder was held to allow the main findings emerging from this group to be integrated into the next phase of data collection. The participants in this group had to be health professionals directly involved in work rehabilitation (e.g. occupational therapist, physiotherapist or physician). The composition of the three other groups was representative of the different work contexts (company size, presence or not of a union) and various stakeholders involved in the S-RTW process. The three targeted work contexts were (1) large unionized entreprises (500 employees or more); (2) large non-unionized enterprises, and (3) small and medium-sized enterprises (10 to 499 employees).

Each of these three groups included representatives of employers, insurers (public and private), health professionals and workers’ rights groups (unions or associations defending their rights), with the exception of the group representing the non-unionized large-enterprise context. Participants were identified and recruited following a non-probabilistic approach, either by snowball sampling, using a research volunteers’ contact list or targeting key informants identified by the various stakeholders (insurers; professional associations; employers; unions; patient associations) within the broader research team [68]. The focus groups were moderated by the two principal investigators (MJD and MFC). The interview guide for this component of the study explored (1) the various factors related to the S-RTW of aging workers and identified in the critical review, and (2) the interactions between these factors and certain sociodemographic characteristics, including gender and ethnocultural identity or immigration status. The discussions were recorded and transcribed with the participants’ consent. Each participant also completed a form compiling his or her personal sociodemographic data. Any identifying information in the data obtained from the focus groups was deleted to preserve the participants’ anonymity.

Analyses

The data obtained from the literature and focus groups were analysed sequentially using methods recommended by Miles et al. [69]. To this end, the articles were first analysed separately according to the specific disability cause with which they were previously associated. Next, for each work disability cause, they were grouped by design type (e.g. epidemiological, quantitative or qualitative study) in order to extract and analyse factors and issues impacting S-RTW. For each cause, a crosscutting analysis was performed across the different types of design to identify the converging, diverging and complementary points. This analytical process was repeated, this time comparing the articles by study concept (disability, RTW, sustainability, retirement, absenteeism). A comparative analysis was then conducted of factors and issues impacting the S-RTW of aging workers across disability causes. Analysis of the focus group verbatims was then based on the factors and issues that emerged from the critical review. Data reduction was performed through coding by two coders (MFC, MAP) and supported through the development of matrices [69]. The results of the focus groups underwent individual analysis and then crosscutting analysis.

Next, the results of these analyses were compared to those found in the literature review to highlight the common, complementary and diverging points. The data were thus synthesised, conceptualised and recontextualised [51, 52, 54, 70]. This part of the analytical process highlighted two main themes around which factors and issues revolved: (1) the capacities of aging workers to meet job demands, and (2) their mobilisation toward S-RTW. In order to provide a comprehensive and meaningful professional narrative applicable to the practice of stakeholders involved in the S-RTW process of aging workers, results from the literature review and the focus groups concerning the impact of older age on S-RTW are thus presented here as an integrated whole, structured according to these two main themes.

Results

Characteristics of the Studies and Participants

Characteristics of the Studies Documented

A total of 7664 titles were identified, of which nearly a third (n = 2359) concerned CMDs (Fig. 1). The first selection, based on the titles, substantially reduced the number of abstracts to be read (n = 597). A reading of the abstracts further reduced the number of articles to evaluate to 58. Ultimately, 30 articles were included, nearly half of which (14) concerned OCDs.

Fig. 1
figure 1

Flowchart of the literature review. (1) See Appendix for the detailed combinations of the keywords used. (2) CMD common mental disorder, OCD other chronic disease, MSD musculoskeletal disorder. (3) Articles that dealt with two work absence causes counted as .5 of an article for each of the targeted causes.

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As reported in Table 1, the articles identified during the initial search—the vast majority of which came from western Europe and North America—examined the aging worker phenomenon from two perspectives: half regarded older age as one of several factors influencing S-RTW, while the other half focussed on populations of aging workers (aged 45 or over) to identify the impacting factors. Only one article explicitly compared aging workers to workers in other age groups [71]. This virtual absence of comparative data between age groups limited the possibility of identifying factors and issues specific to aging workers. In addition, the literature focussed mainly on workers and their work environment with regard to S-RTW. The impacts of other systems, such as the healthcare and compensation systems, have received little attention to date, with only one study investigating the impact of the healthcare system on the S-RTW of aging workers [72].

Table 1 Characteristics of the articles included in the literature review
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Apart from three literature reviews [73,74,75] and one mixed method study [76], the designs were mostly epidemiological (n = 26), and were only rarely grounded in a conceptual or analytical framework. When such models were present, they essentially treated the role of age as one of a set of factors impacting S-RTW, and did not seek a specific understanding of the particular effect of aging on S-RTW [77, 78]. They therefore proved to be of little help for organising and integrating all factors and issues identified in our study. As such, these are not referred to in subsequent steps of the research.

The search conducted to update the literature initially provided 3097 references (OCD = 1323; CMD = 1063; MSD = 408; cancer = 303). Screening the titles and suppressing duplicates then reduced this number to 217 (OCD = 79; CMD = 83; MSD = 34; cancer = 21). Reading the abstracts for these articles ultimately yielded 25 new articles to read and analyse (OCD = 10; CMD = 9; MSD = 5; cancer = 1). Of this number, 20 were epidemiological studies and two were qualitative studies [79, 80]. The remaining three were literature reviews.

Four studies explicitly compared aging workers to workers in other age groups [79, 81,82,83].

Lastly, four studies referred to conceptual or analytical frameworks [79, 83,84,85]. As was the case for the above-mentioned studies, one of these frameworks was not designed for the purpose of understanding the particular effect of aging on S-RTW, and therefore, was not explicitly used in our study [83]. Among the three other frameworks, the “socio-ecological risk and resilience model for workforce transition” hypothesizes that the resilience of these workers modulates in different ways the potentially negative impact of certain event-related factors (e.g. discriminatory events), contextual factors (e.g. financial precariousness) and individual factors (e.g. state of health, limitations, education) on aging workers’ work participation [84]. The second framework, proposed by Gignac et al., deepens our understanding of the impacts of accommodations (required, available and used) on different work outcomes (limitations, interruptions, losses of productivity, absenteeism) [85]. Lastly, Jetha et al. propose using Edler’s life course theory to try to understand how some changes in three interrelated areas of life (i.e. health status, career progression, and roles and responsibilities outside work) may be differently experienced by individual workers as they age, and therefore affect their work participation [79]. Interesting as they are, these last three frameworks do not provide an overarching view of the S-RTW of aging workers with a work disability that could properly structure data analysis. Consequently, the factors and issues raised were integrated into the two themes that emerged from the data: aging workers’ capacities to meet job demands and factors affecting their mobilisation.

Characteristics of the Participants in the Focus Groups

The four focus groups brought together 35 participants, including 11 health professionals (n = 8 in the homogenous group; n = 3 in the heterogeneous groups), 10 employer representatives, 8 insurer representatives and 6 union representatives. The groups lasted an average of 134 min, ranging between 108 and 151 min. The first group (3 men; 5 women) of health professionals included occupational therapists (n = 4), physiotherapists (n = 2), an ergonomist (n = 1) and a physician (n = 1), each with between 6 and 40 years of professional experience. Table 2 details the characteristics of participants in the three other, heterogeneous groups.

Table 2 Description of the participants in the three heterogeneous focus groups
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The results obtained from the focus groups revealed closely converging discourse from one group to the other, regardless of the work context they represented. Consistent with the gaps identified previously in the literature, the groups confirmed or clarified certain impacts concerning workers or their workplaces, notably by identifying aging worker-specific factors and issues in detail. Focus groups were also the main source of data for identifying and detailing factors and issues related to the healthcare and compensation systems, as these matters were virtually absent from the literature.

Impact of Older Age (Aged 45 or Over) on S-RTW

As mentioned earlier in “Methodology” section, this complementarity between the results of the literature review and those of the focus groups led us to present them simultaneously to provide the most comprehensive synthesis possible. Given that neither the comparative analysis of the literature nor the thematic analysis of the focus groups participants’ statements about aging workers in particular allowed us to identify specific factors or issues in terms of disability causes, the results are also integrated for all the causes examined. The results are presented here under two main themes: the capacities of aging workers to meet job demands and factors affecting their mobilisation.

The Capacities of Aging Workers to Meet Job Demands

This theme is articulated around eight factors and their issues. Table 3 summarizes the findings.

Table 3 The capacities of aging workers to meet job demands: main associated factors and issues
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First, aging (age 45 and over) is known to have a direct impact on workers’ capacities. In fact, it is generally acknowledged that this tends to translate into a deterioration in their health, often characterised by several comorbidities, occurring even prior to an injury or occupational disease [15, 18, 71, 73,74,75, 80, 85,86,87,88,89,90,91]. This finding of a deterioration in capacities with advancing age was also reported in the focus groups:

On average, at age 55, one Quebecer in four has a chronic disease. At age 60, (. . .) two in four, half [of them] have two chronic diseases. (HP 107 :119)

Moreover, participants in all focus group reported observing diminished psychological capacities (e.g. tolerance of stress) and physical capacities in several aging workers, resulting in a poorer recovery, adaptation and performance capacity than observed in younger workers:

So I see more and more people over 50 who are less able to resist stress (. . .). And it’s no secret that it’s not just capacities that diminish, but that recovery is also longer and slower. (HP 107 :137)

I have the impression that for injured workers between the ages of 55 and 60, the functional gain you can try to obtain is often limited. (LE-NU 140 :148)

According to some participants, certain biological interactions specific to women (e.g. effects of menopause on sleep, energy and recovery) appear to further reduce these capacities in aging female workers:

So even menopause affects sleep. It’s not a good mix with musculoskeletal problems when women don’t get restorative sleep (. . .), these women have a really hard time managing their energy. (HP 159)

Even though timely access to the health services required by a worker’s condition can potentially improve his or her capacities, our data indicate that certain attitudes on the part of workers or health professionals, as well as certain compensation rules, may well hinder it. Two studies in fact point out that some aging workers tend to consult health professionals either rarely or late, which can have negative impacts on their S-RTW [71, 91]. For example, some aging workers with a CMD who confuse depressive symptoms with a “normal” response to the grieving associated with a reduction in their capacities, may be late in seeking a medical opinion. Certain perceptions that health professionals have of aging workers also hinder the workers’ access to the health services that their condition nonetheless requires. Indeed, both the lack of knowledge and unfamiliarity of many professionals regarding the medical and psychosocial aspects of disability in aging workers could be associated with less sensitivity to certain symptoms when managing such workers [91]. An Australian study underscores the fact that some professionals have negative prejudices about aging workers’ real capacities and possibilities for S-RTW, which would partly explain the higher rates of “unfit for work” certification (vs. alternative/modified duties) among these workers [72]. Moreover, the intergenerational distance between caregiving staff (usually younger) and aging workers may pose challenges in terms of establishing the therapeutic relationship, according to some focus group participants:

The same thing goes for an older person. I belong to a health cooperative at work. It’s also responsible for the occupational health of these workers. So there was a nurse clinician who’d just arrived. Everyone was super happy. She was 23 years old, this nurse. The average age of people in our workplace is 61 to 62. Well, for a toothless old man or someone who has health problems, or for the lady who sees this young 23-year-old nurse, it just doesn’t work. (HP 629)

By applying certain rules regarding reimbursement for services and rehabilitation programs, the compensation system (insurer) can also play a role in limiting access to health services. During the focus groups, health professionals raised the point that a context in which the third-party payer provides the rehabilitation care is often associated with strict, generic regulations. The application of these rules, by not allowing aging workers with disabilities to benefit from services adapted to their needs, could hinder their attainment of the rehabilitation objectives:

If you look at the rehabilitation program and the functional capacities, when you have the possibility of developing a person’s capacities, (. . .), you realize that often, for aging workers, they [the programs] will last a little longer than for most people. And then the programs, most of the time, whether they’re offered through public or private insurance, are not adapted to their needs. Everybody’s supposed to fit into the mould of so many weeks or so many days, when in reality the needs are different for this aging worker clientele. (SME 98 :102)

Aging workers in disability situations thus seem to face several challenges when it comes to regaining a capacity level that would allow them to meet their job demands. According to several authors, the high psychological demands (job strain) and/or physical demands associated with certain jobs may pose additional challenges for aging workers with reduced capacities, and hence hinder their S-RTW [75, 76, 86, 92,93,94,95]. In fact, according to some focus group participants, the current context of work intensification is characterised by organisational and technological changes requiring employees to have additional performance and adaptation capacities:

It’s probably like that in all workplaces, especially the private sector, (. . .) You’re always asked to do more with less, increasingly so (. . .) So for sure, for an aging worker, who is injured on top of it, that can be problematic. (LE-U 35 :39)

By raising the level of job demands, such an intensification context therefore seems likely to increase the gap between job demands and aging workers’ “naturally” declining capacities. This gap could prove to be particularly large in sectors employing predominantly women (e.g. education, health, and daycare), where performance and adaptation demands are perceived as being increasingly higher [95]:

Take jobs in the teaching sector (…) they’re becoming more and more demanding, and aging workers are having a harder and harder time keeping up. (LE-U 089 :091)

This gap could be narrowed by adapting the job demands and working conditions. From this perspective, several studies indicate that it would be well worthwhile for workplaces to allow aging workers to adapt their own work pace and working methods as needed, notably by offering them a sufficient degree of autonomy and control to do so [76, 79,80,81, 85, 87, 93, 94, 96, 97]. Despite the lack of empirical consensus regarding the efficacy of these interventions in promoting S-RTW, accommodation efforts by the employer are also part of the preferred means for reducing the gap between aging workers’ reduced capacities and high workplace demands [75, 85, 86, 91, 92, 98,99,100]. However, such accommodations may be more difficult to provide in some activity sectors [85]. Jobs involving mainly “physical” work are a good example, according to the focus group participants:

Well, that’s for more sedentary jobs, but for jobs that are physical, what we also realize is that there are few possibilities for modifying the tasks as we age. You have a job that is very physical [by nature]: over time, the employee will lose some physical capacities, that’s clear. But there’s no replacement option. (SME 66 :72)

Again according to the participants, the possibilities of accommodations tend to be more limited for workers with few skills or a narrow range of skills, thus limiting their capacity to meet the demands of other types of jobs. These employability issues appear to be further exacerbated for some aging workers from ethnocultural communities, who, for example, do not master either official language:

An example comes to mind of a little lady [from an ethnocultural community]. She didn’t want to stop working. She was injured, she had a hernia, but she didn’t report it. It took four months, and then she was no longer able to work (. . .), there wasn’t much that could be done in the workplace. And outside [the workplace] it was even harder because of her age, given that she spoke little English and no French [no language that’s commonly spoken in Quebec], and that on top of that, she had a pretty severe musculoskeletal condition (. . .) All of that made it really really hard. (SME 801 :804)

Access to accommodations in the workplace also depends on the support offered by supervisors and co-workers, support that aging workers recognize as a facilitating condition for their S-RTW [76, 80, 91, 93, 94, 98]. Yet it may prove especially difficult for aging workers to obtain such support [89], particularly when the extent of their limitations and the accommodations needed to address them require a major transfer of the workload to co-workers:

We have to really scramble to try to see what we can deconstruct, I mean, the work, without affecting our operations too much in terms of breaks, performance criteria (. . .) And sometimes, the operators [supervisors] just don’t want to take them (. . .) because they’re not able to keep up with the pace. (LE-U 177 :181)

Moreover, support from supervisors and co-workers generally appears to be contingent on recognition of the value and contribution of aging workers in the workplace. According to our participants, gender can affect this recognition, particularly for women:

So apart from a person who doesn’t want to return [to work] because she sees her retirement ahead and all that, I also wonder up to what point the know-how and strategies developed by aging workers are valued in a company that allows individuals, for example, to create their own niches in the company. (HP 75 :77)

Some employers have a terrible attitude. Beyond age 50, a woman has fewer chances, far fewer chances than a man at age 50 (…) of an easy reintegration. (HP 229 :235)

Even when accommodations involving adjustment of the work demands and conditions to the aging workers’ capacities are present, the cumulative workload of some aging workers continues to exceed their “naturally” reduced capacities. More specifically, the accumulation of domestic and family (caring) responsibilities increases a person’s total responsibility burden. The impact of aging on the evolution of these responsibilities, which traditionally befall women, is therefore expected to translate into particular issues for aging workers. For example, one study suggests that aging, which generally goes hand-in-hand with the departure of children from the family home, would help reduce these responsibilities and have a favourable impact on the S-RTW of aging workers [88]. However, some participants, who see the growing phenomenon of being caregivers to aging parents as maintaining or even increasing the burden if the workers assume the roles of both parent and caregiver, nuanced this assertion:

For us, this is a new phenomenon, but we see it increasing every year: family responsibilities. At first glance, it may seem paradoxical: aging people should have fewer family responsibilities, but as their own parents are now aging and living longer, at some point they also have to take care of them (. . .) And that means it takes longer for these workers to return to work because people are no longer able, they don’t want to abandon their family (. . .) We see this more in women, but we also see it a bit in men. (LE-U 201 :209)

Factors Affecting the Mobilisation of Aging Workers

Several factors affect aging workers’ mobilisation toward S-RTW either positively or negatively. This section will present five factors and related issues, as presented in Table 4.

Table 4 Mobilisation of aging workers toward S-RTW: main associated factors and issues
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In fact, the results of a study by Jason et al. indicate that the great resilience capacity (i.e. “the ability to navigate adversity and maintain emotional stability,” p. 270) of some aging workers helps mitigate the potentially negative impacts of various causes of disability on their engagement in work [84]. The intrinsic value of work also appears closely related to this engagement, and thereby to the S-RTW outcomes in aging workers with a work-related disability. In fact, aging workers who regard remunerated work as a source of personal accomplishment tend to be mobilised more easily in the S-RTW process than workers who sees work as a burden and the main cause of their health problem [71, 80]. This notion of the value placed on work also came up in the focus groups.

(…) if the person loves his work and finds fulfilment in it, for sure it’s easier. (LE-U 756 :780)

(…) a big proportion of the people I’ve had sitting in front of me attribute their sick leave situation to aspects of their work. And so, they quickly say to themselves, "I’m returning to the environment that put me in this situation in the first place.” (HP 125 :137)

The participants also reported that sometimes the employee benefits associated with certain jobs play a role in the value attributed to the work and the person’s determination to return to work following a disability. To continue benefitting from advantageous employment conditions, some work-disabled aging workers return to work despite the persistence of circumstances or health conditions that are not conducive to S-RTW (e.g. persistent symptoms, presence of working conditions that precipitated the health problem). The return to work may therefore be motivated by reasons other than recovery. Often related to the desire to retain employee benefits and to the insurer-imposed limitations regarding the maximum duration of benefits, such reasons could actually increase the risks of relapse. These considerations concern aging workers in particular, who, given their long employment history, are more likely to have accumulated substantial employee benefits:

One of the specific challenges is people who are afraid of losing all their seniority, their working conditions related to their seniority (. . .) They go back [to work] too fast for the wrong reasons. Often you see relapses in these cases (. . .) First-rate working conditions, I mean, we see them a little more often for aging workers than for young workers. (SME 88 :94)

(. . .) people who’ve been at the same place for years, who are very, very, very well paid, go on sick leave, and then after a while, there are some employers who say, ‘After two years, I’ll cut your contract if you don’t come back to work.’ So what do people do? They’re afraid, so they go back to work, but they’re not really fit to go back. (SME 190 :216)

Apart from losing job-related employee benefits, for many work-disabled aging workers the prospect of losing the initial employment relationship may mean being deprived of income in the medium and long terms. In fact, the perception of reduced capacities with aging, which is held not only by employers, but sometimes by workers themselves, fuels a perception of low employability on the job market [79, 83, 98, 101, 102]. Yet, according to some participants, this perception of low employability might make aging workers more determined than ever to return to and stay at work as they might be convinced that the job they held when their disability occurred is the only one they will be able to obtain:

But once they reach age 55 or 58 (. . .), you can’t say to patients, ‘It might be a good idea for you to change jobs.’ Because that’s just not done: [you can’t tell them that] no one else is going to hire them. So patients go back to work and say ‘I’ll go put my time in until my retirement.’ (HP 141 :143)

The potentially mobilising effect of perceived low employability may, however, be attenuated in aging workers who are able to count on other possible sources of income. As some participants noted, access to advantageous retirement pensions sometimes demotivates work-disabled aging workers, who thus tend to deprioritise work (i.e. attribute less intrinsic value to it) as retirement approaches [75, 103]. In this sense, the late entry of many women into the labour force, by pushing back the time when they will have access to retirement benefits, could result in greater mobilisation of aging female workers in their RTW than of their male counterparts [71].

Some aging workers could also interpret certain indemnities offered by insurers, which (partially) compensate for the loss of income associated with the non-RTW, as an incentive to leave the job market. For example, several focus group participants raised the potentially undesirable effects of one insurance clause aimed specifically at workers nearing retirement age and considered unable to return to their pre-injury job due to an injury or occupational disease. According to these participants, this particular arrangement, initially proposed to support and better protect these workers by allowing them not to use the planned rehabilitation services but to benefit from financial compensation until their retirement, could constitute a potentially major demobilising factor for aging workers for whom work is no longer a priority or a motivational factor:

Someone [One worker] said, ‘No, no, I don’t want to stay at home. On the contrary, I want to be able to go back [to work]. You know, I’d like to get trained in something else.’ For sure, you know, we’re going to explore this [possibility], but if the person isn’t interested or doesn’t want to, then this [insurance clause] becomes a way out [of the job market]. (LE-U 109 :131)

Discussion

The aim of this article was to present a synthesis of the factors and issues affecting the S-RTW of aging workers with a work disability, for the main causes of absenteeism. Our results suggest that an aging worker (over age 45) with a work disability is generally perceived as having poor work capacities and low recovery potential, as well as being more fragile [15, 18, 71, 73,74,75, 80, 85,86,87,88,89,90,91]. They thus converge with those from the aging-at-work literature, suggesting that aging workers’capacities are generally seen to be declining, despite the lack of scientific evidence to support this. In such circumstances, the presence of a disability at work is primarily regarded as an additional burden accentuating the presumed decline in capacities.

Shared by different actors (health professionals, entreprise, insurance) involved in the S-RTW process, such representations of aging workers’ capacities could influence how these actors address their specific needs and situations in the return-to-work process. As such, our results show that employers’ general perception of aging workers as having diminished capacities could interfere with their readiness to support these workers, and, consequently, to provide them with work demands and working conditions adapted to their capacities [89]. However, our results also show that such accommodations may be particularly important in narrowing the gap between the declining capacities of aging workers with a work disability and the heavy work demands associated with the work intensification context [75, 85, 86, 91, 92, 98,99,100] and that make these workers particularly vulnerable in terms of their health or their jobs [104].

Such a perception of declining capacities, and its influence on employers’ attitudes and behaviour, may have been exacerbated by the absence of explicit recognition, according to our results, of capacity transformation and greater adaptability with advancing age, as identified in the aging worker literature [19,20,21,22,23,24,25,26, 48]. This lack of explicit recognition could be partially explained by the fact that no specific questions were asked in the focus groups about the strengths of aging workers with a disability. However, a useful strategy might be to consider the transformation of capacity with aging in order to determine new compatibility between capacity and work demands for disabled workers. In fact, taking stock of workers' personal resources, acquired through specific occupational and personal trajectories and experiences, would facilitate reflection on the possible options that could be implemented in the workplace to facilitate the S-RTW of aging workers with work disabilities.

This proposal thus aligns well with the previously mentioned recommendations of using an individualised approach in order to increase work motivation and retention among aging worker [44, 50]. It is also fully convergent with the findings of an earlier study by Durand et al., which showed that the presence of a sufficient margin of manoeuvre at work—that is, the possibility or freedom a worker has to continually adapt his or her work activities to demands and capacities that vary over time—would facilitate a S-RTW following a long-term absence [105]. An approach such as this, which takes into account aging workers’ characteristics and their motivation to stay at work, may offer an avenue for developing promising interventions. In addition, it could mobilise various worker empowerment strategies [44, 106].

As summarized here, our results revolve primarily around the workers (capacities, mobilisation) and their work environment, thereby confirming the previously presumed influence of the work context on the performance capacities of aging workers. However, some results, mainly from the focus groups, also reveal that factors from the health and compensation systems could influence S-RTW of aging workers. The contribution of those systems is just beginning to emerge and needs to be explored in depth. For example, the influence of health professionals’ representations of disabled workers undergoing treatment could be documented. Also, the effects of compensation system rules need to be described longitudinally in order to better understand how they affect health care and service delivery, S-RTW and workers’ health. Our results thereby highlight that involvement from different sectors influences the sustainable return to work (S-RTW) of aging workers with a work disability. Possible solutions could come from harmonizing the efforts of all sectors to reduce long-term absences, as recommended in work rehabilitation. Indeed, many authors point out that a key component of S-RTW, when a work disability is present, is coordination between the sectors (health, entreprise, insurance) for the shared goal of returning workers to work [107, 108].

In the current context of labour scarcity, studies on the costs and benefits of the support and adaptation measures offered to aging workers are thus essential in order to allow all the actors involved in the S-RTW process to base their decisions on more objective knowledge of these workers’ capacities and potential contributions in the workplace. In addition to advancing age, we must also consider the influence of other charateristics (gender, enthocultural diversity) which can pose additional challenges and constraints [109].

Limitations

That said, this study has some limitations. First, the search strategies targeted only articles in the field of tertiary prevention. This choice eliminated articles in the fields of primary or secondary prevention that might have been enlightening for aging workers. Second, by encouraging the participants to talk initially about the challenges and issues encountered with aging workers, they may have been less inclined to reveal situations that are usually less problematic. Recruitment strategies may also have introduced some participant selection bias, resulting in voluntary participation. The composition of the focus groups, particularly the absence of aging workers who could testify directly from their experience, may also have influenced the results. Likewise, the choice of a critical review of the literature, while logical in terms of the study objectives, has its own limitations. Generally speaking, this approach has minimal structure and imposes no formal quality-related criteria for study inclusion [56]. Hence, some poorer quality studies may have been included. That said, this limitation was partly curtailed by the interpretive description approach, which further substantiated the problem under study through focus groups.

Conclusion

The aim of this article was to provide a synthesis of the factors and issues specifically impacting the S-RTW of aging workers on sick leave for the four main causes of absenteeism, namely, musculoskeletal disorders, common mental disorders, cancer and chronic diseases. Returning to work and staying at work indeed appear to pose particular issues for aging workers, notably with regard to their ability to meet work demands, as well as their mobilisation and engagement in these processes. This study points to the need for a more personalised approach to supporting sustainable work. Such efforts need to be made by the various stakeholders, and studies should be conducted to help better define the approaches that will enable aging workers to stay at work on a sustainable basis.