Introduction

Mental illness, traditionally a taboo topic in the workplace context, has recently become recognized as one of the major drivers for illness-related absenteeism from work [1, 2]. Globally, it is estimated that approximately $1 trillion is lost in productivity every year due to mental illnesses, and this number is projected to double by 2030 [3]. In Canada, lost productivity due to mental illness is estimated to be around $6 billion annually, a metric that likely worsened since the COVID-19 pandemic and the subsequent rise of mental illness [4]. Evidently, mental illness-related absenteeism from work is becoming more prevalent, which is why issues related to returning to the workplace after a leave of absence due to mental illness are emerging as an understudied, yet important topic for research and policy [5, 6].

The research on absence from work due to mental illness is further complicated by considerable global variation in the policies and protections offered to workers due to physical or psychological sickness, with some countries providing more generous sick leave packages than others [7, 8]. In Canada, where employment law is under the purview of provinces and territories, there are notable differences in access to paid or unpaid sick leave among employees [9]. Although far from a universal practice, many Canadian employees—especially those working in large or unionized organizations—have access to paid leave, the duration of which is stipulated in their collective agreements or work contracts [10]. Depending on the institutional arrangements, workers might be assisted during recovery and return-to-work (RTW) by a RTW coordinator (RTWC), an individual whose job is to facilitate sustainable RTW after a leave of absence due to illness [11]. Those involved in RTW management can include licensed health care professionals, such as occupational health nurses or physicians, as well as disability and human resources managers or other individuals with diverse educational backgrounds [5, 11, 12]. As such, individuals involved in RTW processes are often balancing several responsibilities, with the goal of facilitating RTW for injured employees [12, 13]. Research that examined the roles RTWCs play in accelerating RTW for sick employees suggests that coordinators’ face-to-face interactions with the injured workers and their ability to address barriers for returning to work can decrease the duration of workplace absence [13]. These strategies, however, are not equally effective in RTW of employees suffering from mental illness [12]. Overall, there is a notable gap in the literature on how RTWCs navigate RTW for workers who took a leave of absence for mental health-related issues.

In this paper, we address this gap by focusing on how RTWCs manage RTW for individuals with mental illness-related absence employed in high-risk positions defined as “safety-sensitive”, as these types of professions are susceptible to retention issues and pose unique challenges to workers during RTW [13,14,15]. According to the Canadian Human Rights Commission, safety-sensitive positions refer to the type of work that “if not performed in a safe manner, can cause direct and significant damage to property and/or injury to the employee, others around them, the public and/or the immediate environment” [16]. Concerns about employees’ physical wellbeing in safety-sensitive positions have been raised in reference to policies regarding substance use, shift work, and other environmental factors that can compromise employees’ fitness to work, or (to a lesser extent), their mental health [17,18,19,20]. Personal and organizational barriers for reporting mental illnesses have been noted in policing, medicine, nursing, and other safety-sensitive professions [21,22,23,24,25,26]. Strong evidence exists that organizational and professional cultures, workplace conditions, lack of workplace supports, and stigma related to mental illness are key factors influencing mental health of workers in safety-sensitive positions and/or preventing them from disclosing their illness to their employer [22, 27, 28]. RTW after taking a leave of absence due to a mental illness can therefore be a challenging process, but how RTWCs facilitate this process, especially for workers in safety-sensitive positions, has not been addressed in the literature. We explore this gap by examining how RTWCs understand the unique features of working in safety-sensitive positions, what challenges exist in facilitating RTW in these industries, and how they navigate RTW after mental illness-related absences for individuals employed in safety-sensitive positions in Canada.

Methodology

This paper draws on 47 qualitative interviews conducted with RTWCs across Canada for a larger project that started in 2018 and aimed to develop a guide for RTW coordination of individuals absent from work due to mental illness [29]. Upon receiving ethics clearance from the University of Waterloo Office of Research Ethics, participants were recruited using LinkedIn and snowball sampling to take part in semi-structured interviews which explored how RTWCs navigate workplace integration for employees after a leave of absence due to mental illness. A Stakeholder Advisory Committee, composed of RTW stakeholders in Canada, was formed for consultation over the duration of this study and members were approached to disseminate the information about the study to potential participants.

Interviews were conducted by telephone in 2018 by five members of the research team. A semi-structured interview guide was utilized to inquire into participants’ experiences of working with individuals absent from work due to mental illness and the strategies used to facilitate RTW for these injured workers. All interviews were conducted in English, transcribed verbatim, anonymized, and uploaded to NVIVO 11 for analysis [30]. Utilizing an inductive approach, six members of the research team independently coded a subset of data, identifying common themes, and then collaboratively designed a coding scheme that was applied to the rest of the data. Each interview was coded by two team members, and regular team meetings were held to discuss and refine coding. During this analysis, the team was mindful of the role that personal (i.e., gender, ethnicity, immigration status) and professional (i.e., research experience, RTW expertise, mental health expertise) identities may have had in data interpretation. Therefore, each code was discussed at length and refined, if needed. From this initial analysis, the research team identified key themes within the data, including a focus on safety-sensitive work. During the interview, participants were asked to consider how RTW processes for workers with mental illness might differ for those employed in safety-sensitive positions and sometimes they also reflected on their experiences of working in safety-sensitive industries without prompting. Collecting data on participants’ experiences, views, and perceptions about safety-sensitive work under a thematic category of “safety-sensitive” was followed by a further, more in-depth analysis of participants' experiences, which resulted in identifying separate analytical threads within this thematic category pertaining to the (a) understanding of the nature of safety-sensitive positions among the participants; (b) their views on risks associated with RTW in safety-sensitive jobs, and (c) strategies they adopted when working on RTW with employees from safety-sensitive industries.

The 47 RTW coordinators who participated in the study had diverse educational backgrounds, ranging from degrees in nursing or psychology to diplomas in disability management or hospitality. The participants were mostly women (n = 40) and most (n = 36) had 5 + years of experience working in the RTW industry. Most participants (n = 33) were based in Ontario, while the rest (n = 14) worked in other Canadian provinces or territories. All participants were involved in RTW processes and had a range of employment arrangements. Some worked within their organizations as representatives of the human resources department (n = 11) or a union (n = 7). Others were employed by insurance companies (n = 8), workers’ compensation boards (n = 12), or third-party organizations (n = 9) contracted to manage RTW. This diversity was mirrored in how the participants described concerns related to RTW processes in safety-sensitive industries: while a few participants during the time of the interview worked in safety-sensitive industries, others were familiar with safety-sensitive work environment due to prior experience or accumulated knowledge on the topic. Participants’ accounts suggested some ambiguities in how they understood the unique features of safety-sensitive jobs, which impacted how they saw their roles within the RTW process for individuals working in safety-sensitive positions. In what follows, we summarize key findings alongside themes pertaining to RTW processes in safety-sensitive jobs. We first demonstrate how the participants saw the nature of safety-sensitive positions, and then discuss unique challenges and strategies they employed in navigating RTW for individuals working in safety-sensitive industries. Where possible, we add illustrative quotes but use pseudonyms and omit some contextual details to protect participants’ confidentiality.

Findings

Understanding the Nature of Safety-Sensitive Positions

There was considerable diversity in how participants explained the unique features of safety-sensitive occupations. Some RTWCs, especially those who worked in a safety-sensitive environment, had a very specific view of these positions. For example, Amelia, employed by a third-party, described safety-sensitive positions as follows:

[It is] any position where the person has to drive as part of their occupation, or operate machinery […], those kinds of roles… So, for those types of positions […] – law enforcement, anything safety sensitive […] – we have to have doctor’s signature clearing a person to go back […], regardless of what their illness is.

In Amelia’s narrative, the safety-sensitive position is conceptualized as the one that poses a concern for physical safety in general, which is akin to the definition offered by the Canadian Human Rights Commission [17]. Listing examples of occupations in which the physical safety of the public can be threatened by the compromised wellbeing of the worker, Amelia explained that in these cases, the authority to decide about RTW lies with a physician. The necessity to rely on a physician’s clearance was seen as a distinct feature of safety-sensitive positions. In other jobs, RTWCs expressed concerns about the validity of physicians’ assessments, given doctors’ presumed lack of knowledge about the employee’s unique workplace situation. For RTW in safety-sensitive work, on the other hand, the readiness to go back to work was firmly defined as the purview of physicians, attested by a “clearance” and “signature”.

While some participants echoed the view of safety-sensitive work provided by Amelia and connected it to designated industries such as policing or health care, there were some who offered a different understanding of this type of employment. For instance, Nancy, employed by a third-party, shared the following view when asked about safety-sensitive jobs:

Well, I guess, you know […] I feel that you could get injured in any job. Like, you know, like, I worked, and I have worked in all of them, factories, yes, we have more injuries, more slip or falls […] and we have you know, we’ve got conveyor belts, you’ve got, you know, major […] equipment that people are […] working with, but I have also had some really major injuries […] well, well I have had one person that actually had his leg amputated in a factory […]. I’ve had you know, […] … employees at [name of the organization] where it’s mostly office work […] fall, and they have been off just as long, you know what I mean?

According to Nancy, physical safety concerns can also be applied to the risks and dangers of the work that is performed by an employee, a view that was shared by a few other participants as well. For these participants, therefore, the meaning of “safety-sensitive work” was related to the wellbeing of the worker, even if it did not impact the safety of the public. These views impacted how RTWCs navigated RTW processes for injured workers and assessed their readiness to get back to work. Unlike the participants who saw safety of the public as a primary feature of safety-sensitive jobs, Nancy and some of her fellow RTWCs challenged the premise that the safety of the worker is less important than the safety of the public, linking “work” with the notion of “risk”. Overall, the RTWCs indicated that their approach to facilitating RTW for employees in safety-sensitive jobs was different than for those who worked in other industries, a topic we further discuss in the next section.

Being a Risk and Being at Risk

Discussing their work with employees who are not employed in safety-sensitive industries, many RTWCs described the challenges of managing “non-compliant” workers, who were generally defined as those unwilling to return to work and needed to be “pushed” by RTWCs to get back to regular employment. These workers were often seen as intentionally or unintentionally manipulating the system using their illness to delay the RTW process. In the case of safety-sensitive jobs, however, most workers emerged in the narratives of RTWCs as being too eager to return to work, sometimes deliberately concealing their health condition or their vulnerable state. In these scenarios, assisting with RTW for individuals absent due to mental health issues presented a unique challenge.

One of the key frustrations RTWCs described in reference to their work was the navigation of diagnostic disclosure. Since medical information is confidential, RTWCs did not always have knowledge about the medical condition of the worker, and some participants believed that it compromised their ability to do their work well and identify suitable accommodations. However, in the context of safety-sensitive positions, participants felt they understood the desire of the worker to conceal their mental illness, as it often posed a threat to the image of the professional. For instance, Emily, who worked as a RTWC in the aviation industry, said pilots may be reluctant to disclose their medical diagnosis because “if it goes on [their employment] record that they have a depression, it can impact their license or their ability to hold a license”. Several other participants echoed Emily, linking a formal diagnosis of a mental illness to the possibility of a loss of professional license or stigmatization in the workplace. As a result, the diagnosis of mental illness was seen by participants as having a dual impact within the safety-sensitive work environment: if not well, the worker may pose a risk to the safety of others, and, simultaneously, the worker may be at risk of losing their own job and/or experiencing stigma or discrimination. Navigating these challenges, however, most study participants prioritized the management of risk posed by the injured worker to the public. Kelsey, another RTWC from the aviation industry, explained how this approach informed the assistance she could provide to the injured worker:

So, we want to reduce the stress […], so we figure that [there] might be a way to help […], but as far as the tasks, again, they have to be able to, in an emergency situation… handle that pressure. So, if they’re not ready to do that, then they would have to, unfortunately, stay off work, continue their therapy with their counsellor or their psychologist, you know, continue their pharmacological treatment until they’re ready, and then we can at least accommodate them with reduced hours. So, we want to make sure that they’re safe when they come back to work […], right.

While working in other industries, RTWCs sometimes suggested that gradual RTW is possible even if the worker is not completely well. Kelsey’s expectations for readiness was quite high when assisting injured pilots, claiming that the worker should be able to navigate stressful workplace conditions, which might be particularly challenging for someone recovering from a mental illness. Moreover, despite her own desire to accelerate RTW, Kelsey said she needed to ensure that the worker is “safe when they come back to work”. In this case, however, Kelsey’s concerns about safety were focused on the public, not the worker. Hence, while in other industries participants saw their job as facilitating the RTW process for (sometimes unwilling) employees, workers in the safety-sensitive industry, according to Kelsey, were “motivated to come back […] but there is really nothing we can do”.

The concerns about public safety were not unique to the aviation industry. Similar sentiments were raised by participants employed as RTWCs in health care settings and industries operating heavy machinery. In both cases, participants described the workplace as volatile and dangerous, which required ensuring that the injured worker is completely well and ready to get back to work. Describing the high stakes, Rebecca, in-house RTWC, said, “someone’s life could be in jeopardy” if the worker in this type of industry comes back while not fully recovered.

Although most participants prioritized public safety concerns, some, including those who had more encompassing views on safety-sensitive positions, also saw their role as protecting workers, especially in the cases where mental illness or poor performance in the workplace could result in the loss of a professional license. RTWCs who participated in this study were aware of the stigma attached to mental illness, which was especially prominent in safety-sensitive jobs. Licensure and professional regulations associated with certain safety-sensitive work imposed additional constraints on both injured workers and RTWCs. While most participants sincerely believed that early RTW was highly beneficial for workers, they needed to balance their desire to integrate the employee back to work with concerns about the worker's performance. Sandy, working in the HR department in a hospital, explained this struggle when she said:

You think it’s good for her to get here, but from a safety perspective and a licensable perspective [...], you need to be careful on that.’

Describing one such case, Sandy recalled how she had to reverse her decision and remove the worker from their position to protect them from potentially jeopardizing their own professional status:

[The worker has] some cognitive issues related to their underlying disorder, and that it wasn’t safe for him. It was licensable {laughs} […]. You know, the person was a social worker, and [...] you know, he was not meeting the minimum college standards […]. He was putting the hospital at risk; he was putting himself at risk, so we shut it down […].

Working in a hospital as a full-time employee herself, Sandy commented that she developed long-term relationships with workers, explaining why she could intervene to protect the worker from potential harm. Such intervention would not be possible if Sandy was employed by an insurer who only dealt with workers while they were off work.

Managing the People in Safety-Sensitive Jobs

Most participants in this study felt strong determination to facilitate RTW for ill or injured workers and ensure that they are back at work as soon as possible. In some cases, the desire to accelerate the process was imposed by administrative pressures related to costs associated with illness-related absence from work. In other cases, however, participants sincerely believed there were strong benefits for workers to get back to employment as soon as possible. Moreover, some RTWCs said that prolonged absence from work was detrimental to the worker’s wellbeing and made RTW process more challenging.

While participants discussed these challenges as always embedded in RTW processes, they felt they were more pronounced in safety-sensitive jobs. Shannon called the management of RTW for individuals in safety-sensitive industries, “fine balancing between the company’s needs, the employee’s needs, the business area’s needs, and the expectations of WCB [Worker Compensation Board].”

To achieve this goal in the context of high-risk jobs, RTWCs employed multiple strategies. Some participants felt that the safety-sensitive industry required a more hands-on approach in RTW, which was described by Teresa, a third-party coordinator, in the following way:

I would say I kind of approach everything kind of the same, but I just make sure that, you know, I may check in with them a little bit more often, or I may make sure that I am setting aside enough time for the onsite observation… Yeah, and just kind of making sure – you know, like, checking on things like medication intake, and […] using symptom management strategies that don’t involve taking medication […].

In Teresa’s description, her ongoing involvement with the worker resulted in better knowledge of the worker’s unique situation, which also helped her determine when the worker was ready to go back to work. Simultaneously, it implied a closer monitoring of the worker, which potentially could feel more invasive by the injured employee.

While this interfering strategy was commonly utilized by RTWCs working with individuals who were away from work due to mental illness, the unique feature of RTW in safety-sensitive work was the reluctance to rely on the practice of short-timing. Short-timing–or reducing the time off-work recommended by a health care professional–was commonly utilized by participants assisting injured employees with RTW in other industries. In safety-sensitive jobs, however, the mounting concerns about liability issues outweighed the financial benefits of faster RTW, which often drove short-timing practices. Describing gradual RTW in the aviation industry, Kelsey raised the following issue:

We do our due diligence, but… I’m just giving an example… due to weather, they’re stuck somewhere, then it goes against the medical restrictions of the physician, so we can’t take that risk […] – we can’t, right, it’s not safe […]...

In Kelsey’s description, the “risk” of bringing a recovering worker back to work is associated with the responsibility for a potential safety issue. Given the nature of safety-sensitive jobs, Kelsey, as most of her colleagues working in safety-sensitive environments, opted to delegate this risk to a physician. Explaining her concern with taking a more active role, Kelsey noted during the interview: “God forbid something would happen at the workplace. We’re responsible.” Her concern was echoed by Shannon, who managed RTW processes in the western Canada heavy industry, and who noted that safety-sensitive positions are more complicated for RTW facilitation because short-timing is challenging to do for injured workers in this industry.

Working in this unique position, some participants, such as Erin, noted that while the RTW work itself is “basically the same for both safety-sensitive and non-safety-sensitive positions,” it is more time-consuming in safety-sensitive jobs for both the worker and the RTWC. Explaining her position, Erin said:

In a safety-sensitive position, often the length of absence can be longer […] because it’s harder… I mean, you can’t avoid the safety requirements […] in some places. They’re there for a reason, so yeah, I can see how, in the safety-sensitive positions we have, the absences are often longer. They often have to wait ‘til they’re closer to, really, full recovery […].

Thus, while in some industries the participants felt that they had more control over the situation and could accelerate the process of RTW, safety-sensitive industries required careful navigation of organizational legal safeguards established to ensure public safety.

Concerns about costs associated with workers’ absence and workplace regulations were not the only challenges faced by RTWCs assisting employees absent from work due to mental illness. Sometimes, they struggled with uncooperative management who was concerned with the worker’s ability to perform in their job. Describing how she navigated this challenge in the first responders’ population, Rachelle shared the following approach:

…when you are thinking about the first responders and their ability to react to certain situations, that really can’t be tested until they are actually in the situation. […] The question always comes up, are they going to be ready for it, and, and you know, are they going to be safe and are other people going to be safe? […] So, I, I think this is where job shadowing or working as an extra person on the team is really important to put into the return-to-work plan... For example, for a paramedic … to recommend that, that for a period of time … they’re working as a third person and initially starting just observation and then taking on more intense or more traumatic calls… and the psychologist likes that because…what if we return them back and they are an extra so they can walk out if they need to and that would be okay…So, then the, the employer’s receptive too … because they are like, well, wait a second, how are we going to know if they are going to be safe for this and it’s, sometimes you have to explain to them the cost effectiveness of it, that this person is riding out as a third person and they are paying that person to be a third person, as opposed to being a full active person but in the long run they tend to understand.

As Rachelle points out, the RTW process in this case is of concern to everyone–the worker (e.g. can they do the job?), the psychologist (e.g. can they clear the worker?) and the employer (e.g. can they trust the worker?). Trying to navigate this challenge, Rachelle also needed to consider how her proposal would impact the employer financially. Rachelle believed that offering an institutional arrangement that tested the readiness of the first responder benefitted all involved parties. However, implicit in such an arrangement (e.g. if co-workers are involved) is the assumption that the worker recovering from illness ought to be seen by their fellow co-workers as “in recovery”, which may violate the worker’s privacy or be perceived by the worker as a lack of trust in their ability to do the work.

Discussion

In this paper, we explored how RTWCs navigate the RTW process for workers recovering from mental illness who are employed in the safety-sensitive industry. We showed that the participants in this study sometimes broadened their approach to safety-sensitive jobs, to not only include concerns about public safety, but also the safety of the workers doing any type of job. We also showed that the participants saw their work in safety-sensitive industries as requiring unique approaches to RTW processes. Contributing to the literature on this topic, our analysis revealed that the workers in safety-sensitive jobs are often perceived as posing a “risk” to the public, a risk further exacerbated by the stigma attached to mental illness [24, 25, 31,32,33,34]. Consequently, RTWCs identified some tensions between the mandate to protect the public and the workplace from potential liability, and protecting the worker. Notably, the very disclosure of a mental illness exposed workers in safety-sensitive industries to a multitude of personal risks, including the danger of stigmatization, loss of trust from colleagues and management, a potential restriction of duties, and even revocation of professional license in regulated work [35]. Despite the fact that mental illness has become more recognized in the workplace, and more recognized in first response work, healthcare industry, and other safety-sensitive jobs, the participants in this study indicated that RTW after a leave of absence for mental illness in these industries might be slower and more challenging than in other types of workplaces [33,34,34, 36].

Given the roles RTWCs play in RTW, it is conceivable to see them as valuable sources of support for employees in safety-sensitive occupations coming back to work after experiencing mental illness. Navigating the RTW process, RTWCs could advocate on behalf of the worker and facilitate creating an environment in which employees can feel safe to return to work [13, 18]. Our analysis revealed, however, that this approach was not always adopted by the participants of this study. Most participants had heightened concerns about public safety and the image of their organization, and while RTWCs who were employed by the organizations sometimes developed good, continuous relationships with injured workers, concern about the injured worker often came secondary to public safety. Moreover, while some participants included in their view of safety-sensitive jobs considerations for the safety of the worker, in practice RTW processes in safety-sensitive industry were mostly characterized by the reluctance to utilize short-timing and the reliance on physicians’ clearance for work readiness, both of which were seen as precautions for the protection of public safety.

Managing workers in the safety-sensitive industry, RTWCs developed some unique strategies, including a more hands-on approach with individuals away from work due to mental illness. While literature suggests that such an approach is generally beneficial for the RTW facilitation, it does not always work in the cases where workers are recovering from mental illnesses [13, 37,38,39,40,41,42]. Moreover, such an approach can be interpreted as increased surveillance of the worker by the RTWC, leaving workers feeling that they have less autonomy over the management of their own condition [12, 42].

In the past few decades, considerable strides have been made towards normalizing mental illness, but in some industries, especially those that relate to public safety, mental illness continues to be stigmatized [21, 22, 31, 35, 43,44,45,46,47]. While these roadblocks exist to protect public safety, they inadvertently harm workers suffering from a mental illness. In addition to managing the condition itself, workers must manage stigma associated with the condition, carefully considering how much to disclose and to whom about the illness [22, 48]. Many safety-sensitive jobs (e.g., health care professionals, aviation, first response work) are inherently linked to psychosocial workplace hazards, so while gradual RTW has been successfully employed in other industries, it may not offer identical benefits to workers in safety-sensitive positions as their job stress is rooted in the position itself and not (only) the volume of work [26]. The RTWCs interviewed for this study recognized this challenge and tried to find alternative solutions. One solution was to have an injured worker added (as a third member) to a team. While such an approach can reduce the risk to the public and prove to the employer that the worker is ready to return to their position, it also casts doubts about the worker’s professional competence and compromises their privacy by exposing their recovery process to their colleagues [44].

This work has some limitations. Since the focus of the study was on RTWCs’ management of workers suffering from mental illnesses and the sample of RTWCs in this study was rather diverse, we were unable to examine the differences and similarities of RTW in safety-sensitive and non-safety-sensitive positions, as well as compare their experiences in various safety-sensitive jobs. Future studies could explore such differences in professions such as first responders, healthcare professionals, miners, pilots, and other workers employed in safety-sensitive positions. Moreover, our analysis focused solely on RTWCs’ accounts and thus cannot assume the workers’ perspective. Finally, while our sample was robust, the results of this study cannot be generalized to the overall population of RTWCs in Canada or elsewhere.

Notwithstanding these limitations, this paper offers insights about the challenges of managing RTW in safety-sensitive industries for workers taking a leave of absence due to mental illness. In particular, the paper sheds light on the ambiguity of perceived risks, which consider issues of public safety, organizations, and workers’ wellbeing. Evidently, concerns about workers’ wellbeing were often secondary to concerns about public safety and liability, even when RTWCs genuinely wanted to help the injured workers. It seems that protecting injured workers and ensuring their integration back into the workplace cannot occur without destigmatizing mental illness in safety-sensitive industries. This research and future studies may contribute to improving the RTW process and protecting workers in safety-sensitive occupations during the RTW process after absence due to a mental illness.