Introduction

Common mental disorders (e.g., depression, adjustment disorder, anxiety disorder) are, in many Western countries, the most commonly cited reasons for sickness absence, and account for more than 35% of disability claims accepted by insurance companies [1] Common mental disorders (CMDs) are considered a major public health problem [2, 3]. Dewa et al. [4] mention that a large proportion of individuals on sick leave following CMD generally progress through a return-to-work (RTW) process, which rarely results in permanent work disability [5]. However, sustainable RTW is not guaranteed, given the high occurrence of symptomatic relapses, from 20 to 30% for CMDs [6], and higher than 50% for depression specifically [2].These CMD relapses are related to the interaction between personal factors [2], work environment factors [7] and the lack of collaboration between RTW stakeholders [8]. A successful RTW process involves the ability to consider the perspective of multiple RTW stakeholders, working together in a collaborative approach [9]. In a recent scoping review, Corbière et al. [8] described the involvement of 11 stakeholders from the organization (e.g., immediate supervisor), health (e.g., general physician), and insurance (e.g., insurer) systems, who have an impact on the RTW for people with CMDs. The authors describe the crucial roles of stakeholders’ actions across the RTW process, from the onset of the sick leave until the sustainable RTW [8].

Workers on sick leave, such as those with CMDs or other types of disability (e.g., breast cancer), often feel vulnerable and seek the support and understanding of the service providers who assist them through their RTW [10, 11]. According to Renger et al. [12], social support and recognition of one’s worth (in the workplace for instance) are related, in the sense that social support is an important aspect of socially experienced recognition. More specifically, the absence of recognition from key stakeholders can lead to demobilization, whereas its active presence is considered essential in the preservation of health [13]. It is also a vector for physical and psychological health [14, 15] thanks to its intersubjective and dialogical components [16]. The notion of recognition at work has been studied in terms of work performance or linked to the prevention of health problems [14, 17], emotional exhaustion [12], or long-term sick leave [18]. However, few studies have considered the importance of recognition of workers in the RTW process, particularly following a CMD [15]. Yet, Dorvil, Kirouac and Dupuis [19] describe that workers are in a status of 'capability discredit', since their skills are usually questioned by co-workers and immediate supervisors, to name a few [15]. When returning to work, workers seek the confirmation or recognition of their skills, particularly team members (e.g., co-workers), with whom they work on a daily basis. The recognition by others of one's own competencies, values and skills can eventually consolidate or revalidate the professional identity of workers who have been absent from the workplace due to a CMD. By a snowball effect, workers increase their chance to maintain their job in better health, enabling them to reconnect with RTW stakeholders, and avoid potential relapses.

The notion of recognition counts no less than 23 meanings [20], which shows its polysemy, at the crossroads of disciplines such as philosophy, psychology, and sociology [21]. Honneth [22], a philosopher and sociologist, attempted to clarify the notion of recognition, in the broad sense, as a moral act anchored in the social world. He relies on four premises: (1) recognition must be understood as the affirmation of positive qualities of human subjects or groups; (2) recognition consists of an action; (3) actions of recognition constitute a phenomenon that should not be understood as a by-product of an action oriented in another direction; they should be sincere and not guided by strategic motives; 4) recognition is a generic concept encompassing different sub-variants or spheres, referring to the value of the worker's skills in his environment [23]. Most of the time, after a long-term sick leave, workers have to establish a new position at work considering their health challenges [24]. As Brun and Dugas [25] mentioned in their ethical perspective of recognition, it is important to facilitate this transition period, for example, from sick leave to RTW, by respecting the workers’ recovery pace. In this vein, Worms [26] specifies that recognition also means recognizing the individual's incapacities, since RTW does not necessarily mean a full recovery in terms of health [27]. Indeed, residual clinical symptoms usually persist during the RTW process, at least during a gradual RTW.

A genuine recognition of their vulnerability as well as their skills seem to be an essential key to ensure that the workers’ RTW is a successful experience [24]. Such recognition will have beneficial effects on the recovery of the workers’ professional identity as well as on their continued employment in good health. The denial of workers’ needs for recognition during RTW, by their immediate supervisor or colleagues, may be experienced as hostile or contemptuous behaviours. It can also be seen as humiliation or a sense of an amputated self, discrimination, disqualification and invisibility [28], which have been linked to burnout [29]. In brief, we make the hypothesis that the recognition needed for workers in a RTW process could be both a recognition of their work skills and of their recovery needs (i.e. considering their limitations).

Based on a review of the literature on the notion of recognition, Brun and Dugas [14, 25] suggested different types of work recognition, which are subdivided into different levels, underlying an interactionist mode: (1) organization, through the implementation of institutional mechanisms aimed at better recognizing the productive contribution of individuals; (2) vertical, a relationship of recognition within the framework of a hierarchical line, both from the top to the bottom and vice versa. It refers in particular to the quality of the relationship between the immediate supervisor and the worker; (3) horizontal, recognition is established between peers or co-workers within the same work group; (4) external, recognition in relation to the provision of services, which also involves specific recognition practices from clients, students, consultants, patients, and partners; and (5) social, referring to the relationship of employees and the organization with the community. This last type of recognition can be illustrated by the community's appreciation of an organization or a profession for its social utility. While these various levels of recognition are relevant in terms of interactions with diverse stakeholders in various systems, including the organizational system (e.g., immediate supervisor, co-workers, HR), little is known regarding which key stakeholders can provide recognition to the worker with CMDs returning to work, and how these stakeholders act out these marks of recognition to the worker. In order to fill these gaps, the main objectives of this study are: (1) to document the meaning of the experience of recognition in the RTW process of work after a sick leave due to a CMD, and (2) to investigate the phenomenon of work recognition for workers in the process of RTW after a sick leave due to a CMD, by evaluating the presence or absence of marks of recognition from salient RTW stakeholders stemming from different systems.

Method

The phenomenological method entitled "Relational Caring Inquiry" [30, 31] was used to explore the meaning of recognition during the return-to-work process in a group of workers (purposive sample) who returned to their employment after a sick leave due to a CMD, as well as the marks of recognition (presence of absence) stemming from people considered as significant RTW stakeholders by workers. The duration of the RTW period ranged from three weeks to three months to collect their meaningful RTW experiences in a time frame that was neither too short (i.e., few experiences) nor too long (i.e., affected memory). Following the example of the Relational Caring Inquiry, we adapted the proposed steps: (1) Acknowledging the researcher's worldview (bracketing or epoching; the introduction to this article provides an understanding of the theoretical contributions with which the authors are familiar), (2) Seeking participants, (3) Being present to the participants' stories, (4) Discovering the essence of the participants’ stories, (5) Reciprocating the participants’ stories (sending a summary of the interview to each participant), (6) Relational caring process (second interview), and, (7) Elucidating the essence of the phenomenon by synthesizing the results obtained from all participants [31]. With respect to the bracketing (experiences and perceptions of the phenomenon), the authors experienced firsthand in their team and university departments staff on sick leave due to CMD. The authors noticed the need for recognition from workers on sick leave due to CMD, particularly stemming from co-workers, supervisors and the institution. Even though they experienced this specific need, the authors could not clearly identify the various dimensions of this concept, and from whom (other stakeholders) it was expected. The authors were aware of the importance of this concept without having more details. In other words, their experiences could not unduly influence their analysis other than their knowledge of the literature.

Participants were recruited through a network of collaborators in the health care system and private rehabilitation clinics of the Greater Montreal (Canada) area, as well as through advertisements in social media. These diverse recruitment strategies allowed us to capture different workers’ experiences across various sectors of activities (e.g., education, health services). A sample size of 20 women and men, who returned to work after a sick leave due to a CMD, allowed us to document a variety of recognition experiences with this clientele and reach data saturation. The inclusion criteria were as follows: (1) be 18 years old and over (2) recently returned to work (three weeks to three months) to avoid potential bias of memory (3) experienced a RTW following a medical absence due to a CMD (i.e. depression, anxiety disorder or adjustment disorder).

To obtain an initial understanding of the participant's experience with recognition during their absence and upon their return, as well as the experience of marks of recognition, a first interview was conducted in person and tape-recorded. The interview guide constructed by the research team to support these interviews consisted of open-ended questions such as: What is your personal definition of recognition following a sick leave due to a CMD? In terms of the recognition received, what helped you in your RTW process? What hindered your RTW? All interviews were transcribed. The verbatim from these initial interviews were analyzed in a circular process between the researchers to construct a summary for each participant covering their RTW process, their definition of recognition, marks of recognition or non-recognition by different stakeholders. The N'Vivo software was used to support the analysis. These personal summaries were sent to each participant and their content was validated in a second interview. These phone interviews also allowed participants to clarify their experience and add elements related to recognition that emerged during their RTW process.

For elucidating recognition after a RTW due to a sick leave related to a CMD, beyond the singularity of each participant's experience, the aim was to bring out a universal meaning (essential structures) to this group of individuals [30, 31]. It comprised a definition of the experience of recognition from the workers' perspective and a synthesis of the presence or absence of expressions of recognition. The proposed definition was developed by analyzing the common elements from each personal answer to the specific question asked to each participant (Table 1) as well as a synthesis of the marks of recognition mentioned. A first draft was conceived and an iterative process of several rounds of individual reading and team discussions lead to a definition that kept all the components mentioned by participants (to respect all ideas), but also ensured a structure that was easy to read. This study was conducted from August 2018 to January 2020 and was approved by the research ethics committee of the Integrated University Center in Health and Social Services of the East of the Island of Montreal (Centre intégré universitaire en santé et services sociaux de l'Est-de-l'île-de-Montréal).

Table 1 Description of participants and personal definitions of recognition (N = 20)
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Results

Participants’ Characteristics

The final sample (n = 20) consists of 16 women (89%) and 4 men (11%), ranging from 26 to 53 years old (M = 39). Self-reported diagnoses related to sick leave were: depression (n = 11), adjustment disorder (n = 6), and anxiety disorder (n = 3). Three workers had more than one mental disorder (comorbidity). The length of sick leave varied from 1 week to 2 years and 8 months. In total, 10 participants were on sick leave less than 6 months (Table 1). Regarding the sector of activity, most participants (n = 12) worked in health and social services, or in a private service company (Table 1).

All participants were asked to provide their own definition of recognition in the context of absence and RTW following a CMD (Table 1). Recognition was felt through concrete expressions by key stakeholders in the RTW process. The analysis showed that nine RTW stakeholders were mentioned (e.g., immediate supervisor, colleagues, general physician). For each of these RTW stakeholders, several themes related to expressions of recognition or absence of recognition emerged. They are presented in order of frequency of description, by group of stakeholders: (1) Stakeholders of the work system (immediate supervisor, co-worker, HR, worker as well as clients/patients/students); (2) stakeholders of the health system (general physician, psychologist, rehabilitation professionals); and (3) stakeholders of the insurance system (insurer), as well as by the phase within RTW—during the sick leave and from the RTW (including the gradual RTW)—when these marks of recognition were received. Tables 2 and 3 summarize these expressions of recognition while presenting the number of references for each of them.

Table 2 Expressions of recognition – Stakeholders of the work system
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Table 3 Expressions of recognition—Stakeholders of the health, insurance and social systems
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Stakeholders of the Work System

Immediate Supervisor

All participants discussed in length about the presence or absence of expressions of recognition by the immediate supervisor throughout the RTW process.

During the Sick Leave

Three main marks of recognition were expressed by the immediate supervisor during their sick leave: (1) maintaining contact (n = 17), (2) providing support (n = 15), and (3) respecting their pace of recovery (n = 11).

Maintaining contact Close to 90% of participants raised the importance of having contacts with the immediate supervisor during their sick leave. More specifically, workers who received calls, letters or cards from their immediate supervisor felt that their immediate supervisor was concerned about their health and well-being.

When I was absent, I would say maybe once every 2 weeks, she would send me a little text to ask me how I was doing or if I had any questions. She was always there to see if I was okay. (Part. #18)

In other cases, workers had no contact with their immediate supervisor. For some, this was seen positively, as it allowed them to step back from work, while for others it was seen as a lack of recognition, as something that should have been done.

No supervisor of either my replacement department or my former department has called me...I feel this is a big lack of communication and it should have been done. (Part. #1)

Providing support For three quarters of the participants, the support of the immediate supervisor was important. This support was illustrated by emotional support, with the immediate supervisor showing understanding and sensitivity to the employee's situation.

She [my immediate supervisor] really encouraged me during my absence. She was very supportive, she called me a lot. (Part. #18)

Some participants also reported informational support from their immediate supervisor who referred them to resources that could support them in relation to their sick leave or recovery (e.g., employee assistance program (EAP), psychologist).

I had a psychological follow-up with the EAP, initially it was my supervisor who encouraged me to apply to the EAP to help me through all this. She was very supportive... (Part. #5)

Respecting the pace of recovery Just over half of the participants also raised the importance of the immediate supervisor respecting their pace of recovery and their need to take a distance from work during their sick leave.

When she called me, it was to check in, she told me to take my time. I didn't feel any pressure. (Part. #20)

However, a few participants felt pressure to return quickly and that their needs were not being respected.

I announced that I was going to be away and it's like, well, no, you can't and when are you going to be back ... it's like all the pressure ... it's like your needs aren't important anymore ... it's like "you have to be there, we need you". It was like just guilt, making me feel guilty, trying to get me back faster. (Part. #10)

Upon the RTW

In the participants' discourse, the immediate supervisor can impact the feeling of recognition during the RTW through his attitudes and behaviours. Eleven types of expressions of recognition were described in Table 2 (e.g., providing support, respecting their pace of work and limitations, the accommodation measures).

Providing support The support received or expected but not given by the immediate supervisor was discussed by almost all participants. This support could take many forms. Emotional support was most frequently discussed by three quarters of participants. Although 12 participants reported receiving emotional support from their immediate supervisor, three were disappointed by the lack of presence, availability, and listening from their immediate supervisor.

What she sends as a message…I would like to feel that there is someone if there is something and that I should not hesitate to go to her. (Part. #2)

The second type of support explained by participants was instrumental support. Specifically, they raised the importance of having access to training after their RTW or of being supported to accomplish their work tasks during their RTW. Regarding support for their tasks, some employees felt lucky to receive support from a few days to several months, while others felt that the lack of support made it more difficult to RTW.

My replacement stayed with me full time until today, so she was with me for 3 months. So, for three months I was accompanied. [...] For me, the fact of paying two full-time workers for the same workload is really a lot. (Part. #4)

I would have liked to have had a real two-day meeting with my replacement so that we could go over the files. Let her show me how it changed in the system. (Part. #13)

The last form of support mentioned was informational support. While one participant claimed to have been well informed by his immediate supervisor of the procedures and tasks to be done upon his return, five participants reported feeling that the information was absent or unclear.

I feel like I wasn't made aware of the procedures for my return in a clear way. When you're new, you have a super clear training program. But coming back from a sick leave, there's not really any structure. (Part. #8)

Respecting their pace of work and limitations Many participants stressed the importance of their immediate supervisor respecting their abilities, their functional limitations and their pace in resuming all of their usual tasks. While a majority felt that their pace was respected, others felt that they were rushed to return to their usual pace and workload too quickly.

Usually, they are strict about the number of calls that they have to make, but when I returned, they were not. I didn't feel any pressure to get back to work quickly. That's why I'm more comfortable in my job now. (Part. #5)

I had the impression that the management wanted me to do 5 days in 2-3 days. (Part. #13)

Respecting the accommodation measures Of the participants who raised the importance of the immediate supervisor respecting the agreed upon accommodation measures to facilitate the RTW, about half participants reported that these measures were not applied as planned.

He [my immediate supervisor] was really accommodating and he tried to make my return as easy as possible. It was the accommodations that made a difference in my return. (Part #3)

When I came back, I was supposed to cut all my activities in half, but it was not possible because of my immediate supervisor who was not open to negotiation. She was only open to what is written in the collective agreement (convention). (Part. #7)

Acknowledging their competencies It was important for many participants to have their immediate supervisor reflect to them that they valued their competencies regardless of their sick leave. While half received this recognition, the other half felt that their overall level of competence was being questioned.

Now that I'm back, if there are extra days or hours to give out, he's going to give them to me because he finds me effective. (Part. #3)

I don't feel that I am taken seriously, that they take into consideration what I can bring... (Part. #7)

Stigmatizing (as a lack of recognition) While some workers were relieved to feel that their immediate supervisor maintained a positive image of them, other participants felt pushed aside or perceived as a person that could no longer be counted on.

I liked the fact that she told me on several occasions that it [my absence for a mental disorder] didn't change her view of me, because that worried me. (Part. #17)

My principal put me in a small office in the extension of the school. He put me away from him, as far away from the principal's office as possible. He didn't ask me too much about what I was doing, he wasn't too interested in me. (Part. #14)

Giving positive or constructive feedback The importance of receiving positive or at least constructive feedback on their work from the immediate supervisor was raised by several participants, and while many of them reported that they got this mark of recognition, some stated that it was mainly their mistakes that were highlighted.

My boss will often give me verbal praise when he appreciates the work I do. (Part. #3)

At work, it's mostly mistakes that are highlighted in the feedback or you don't get any feedback... when you come back you feel a bit lost, so if the supervisor points out our good deeds, it makes us want to invest ourselves more than if he just points out our mistakes... (Part. #1)

Showing trust Of the ten participants who discussed trust, almost all felt that their immediate supervisor still had confidence in their ability to get the job done and actively contribute to the team, while one participant felt that she had lost his trust after her illness.

My director trusts me, she lets me do my thing. I appreciate the autonomy my director gives me by telling me that she trusts my judgment. (Part. #12)

There's a lack of trust. You know, even when I was doing work from home it was like "oh well, she probably did her laundry”. (Part. #10)

Taking time to welcome About half participants noted the importance of being formally welcomed by their immediate supervisor on their first day, but also that the immediate supervisor had notified their colleagues of their RTW. Unfortunately, most of them said that they did not receive this mark of recognition. Moreover, it is not enough to get a formal welcome from the immediate supervisor, it is also necessary that this welcome is warm and truly felt, which was not the case for two of the participants.

I arrived and it was business as usual. No meeting. No one greeted me except my colleagues. (Part. #14)

Demonstrating appreciation About half of the participants discussed the importance of feeling appreciated by their immediate supervisor, feeling that he or she is happy with their RTW. About two thirds reported receiving this recognition while two others felt that their immediate supervisor was disgruntled by their RTW, that their presence was not appreciated.

What helped me in my return was knowing that I was expected and wanted to come back. [...] When you have supervisors or superiors who are able to make you feel like something other than a number, to tell us that we are making a difference in the organization... (Part. #15)

Providing flexibility The theme of flexibility granted by the immediate supervisor was addressed by over a quarter of the participants. Most of them said that their immediate supervisor allowed them a certain amount of flexibility in their schedules, to facilitate personal life or medical commitments. Only one participant complained about the lack of flexibility in her schedule.

My immediate supervisor is flexible and accepts that I leave work early when I have an appointment with my psychologist. (Part. #8)

He [my immediate supervisor] asks me to take my medical appointments on my days off but on my days off, when he has an emergency meeting, I have to accommodate him. I found it really ordinary, it just goes one way and not both. (Part. #13)

Recognizing work overload and its impact Three participants commented that they wished their immediate supervisor had recognized their heavy workload and the difficulties of their work and the contribution of these factors to their sick leave.

I would have appreciated it if he didn't necessarily just see my ... my speed and my efficiency, but if he could also see that efficiency is good, but I’m also running out of steam. To be like, "you've been giving so much for so long, look I'm going to hire another employee, you'll be able to separate the workload, it'll do you both good.” (Part. #12)

Co-workers

The contribution of colleagues to the feeling of recognition seems important and was raised by all participants.

During the Sick Leave

Three main marks of recognition were demonstrated by colleagues during the sick leave and were appreciated by the participants; (1) maintaining contact (n = 14); (2) receiving support (n = 10), and (3) respecting their pace of recovery (n = 8).

Maintaining contact The first mark of recognition by colleagues, addressed by nearly three quarters of the participants, was keeping in touch by calling or writing to the employee or including him or her in social events.

What helped me the most was my colleagues, I was really looking forward to meeting them and the fact that they didn't let me down, they were asking around, sending me messages, inviting me to dinner. (Part. #7)

Providing support The second mark of recognition described by half of the participants was when their colleagues provided social support. This support could take three forms: (1) emotional support by providing a listening ear or encouraging the worker to take care of him or herself, (2) practical support like offering financial help or preparing meals for the worker, or (3) informational support, such as informing the worker about the resources and services that could help him or her.

I had people writing to me after a month when they realized I was gone. They offered if I needed something, needed to talk. It’s not everyone [who wrote to me], but some people did. (Part. #18)

Respecting their pace of recovery The third mark of recognition received from colleagues during this period and raised by slightly less than half of the participants was to respect the worker's pace of recovery.

What helped me was my colleague telling me that she missed me as a colleague and that she enjoyed being around me but wanted me to take all the time I needed. (Part. #17)

However, a small number of participants raised the fact that they felt pressure from some colleagues to return quickly or difficulty in respecting their need to not talk about work while recovering.

Sometimes I felt pressure from my assistant when she asked me if I was coming back soon. It wasn't intentional, but sometimes it was indelicate. (Part. #19)

Upon RTW

Regarding the RTW, eight types of expression of recognition were identified (e.g., demonstrating appreciation, taking time to welcome, recognizing their efforts).

Demonstrating appreciation An important proportion of participants mentioned that they felt appreciated when colleagues expressed they were happy to see them and missed them.

Most of my colleagues gave me a hug and told me they were glad I was back. After all this, it feels good to be appreciated. (Part. #1)

Only one participant noted that her colleagues seemed unhappy or indifferent to her RTW and that she felt surprised and disappointed by their attitude.

It seemed like we had nothing to talk about. It seemed like nobody wanted to be there. It was weird, it was my first day in 14 months and they're not any happier... (Part. #13)

Taking time to welcome The second mark of recognition named by the participants is that their colleagues took the time to welcome them back thus raising the importance of their presence in the team.

I was just happy to be there and to see that I was welcomed like that without making a big deal out of it. (Part. #11)

Three participants reported that they were not formally welcomed back and that this lack of recognition was disappointing and hurtful.

So I came back to work for the daily meeting and my colleagues were saying "hello" to me as if they had seen me last week, as if I had not left. No one said "welcome back" to me. I was mostly angry and disappointed that I didn't get a welcome from them. (Part. #6)

Providing support The third theme is related to the support received from colleagues, either when they took time to inform them of the changes that had taken place at work during their absence or by agreeing to modify their tasks or their schedules to help them upon their RTW.

The support was really there. There was one time where I feel really bad when I went back to work and I started crying just like that and my co-workers told me to sit down and they did the service for me. It was more supportive than I thought it was going to be. (Part. #18)

Stigmatizing (as a lack of recognition) The fourth theme represents a lack of recognition felt due to stigmatizing attitudes and behaviours from colleagues. Some report feeling some discomfort or awkwardness from their colleagues, while others report overtly negative behaviours, such as being ignored, overhearing negative comments about them or their absence or feeling that their colleagues were envious of their accommodations.

She walks by me and ignores me. It's pretty insulting and I really don't feel good. (Part. #7)

And the accommodations I asked for, the employer was fine with it but the other assistants [her colleagues] were not. They were like "I'm tired too, I'd like to have my Friday morning too.” (Part. #10)

Acknowledging their competencies A little less than half of the participants discussed about their colleagues' perceptions of their skills. Some participants were pleased to feel that their colleagues still had confidence in their professional skills, while others felt that their skills were being questioned.

No, I was afraid that I had lost my role, that people didn't trust me anymore... but not at all. (Part. #7)

It was during the beginning or the middle of my gradual RTW [...] she didn't want to let me be in this file. She told me that she didn't feel I was right, or back to 100%. She really passed me comments like that. It was unpleasant, infantilizing. (Part. #17)

Respecting their privacy Another theme is the respect of privacy. While some participants said they appreciated that their colleagues did not question them about the reasons for their sick leave, a few others said they did not appreciate the questioning or gossip and perceived it as an invasion of their privacy.

I was fine with people not asking or talking about why I stopped. I know that some people like to talk about it more, but not me. They were like "if she wants to talk about it she's going to talk about it.” They respected me in that. (Part. #8)

When I learned that my colleagues had told others about my depression, I felt sad. It means there's a lack of confidentiality. (Part. #9)

Respecting their pace of work Three participants said they appreciated that their colleagues respected their work pace and that they did not feel pressured to perform quickly.

I was told: "Don't go too fast, take it easy and go slowly, don't stress.” I've had a few of my colleagues telling me that. (Part. #4)

Recognizing their efforts Finally, a small number of participants said they appreciated that their colleagues recognized their efforts at work as well as acknowledging the work overload that may have contributed to their sick leave.

I felt that he [my colleague] was able to recognize that I work hard. That really made me happy... (Part. #1)

They told me that now they understood what I was going through because they saw how my group was. (Part. #14)

Human Resources

This important stakeholder in the RTW process also influenced the experience of recognition as seen by the marks of recognition mentioned by participants.

Providing Support

Emotional, practical or informational support, offered by human resources (HR), was a mark of recognition that was discussed by a substantial number of participants.

There was the HR clerk who was very nice, she told me she hoped there was nothing wrong, she was very nice. (Part. #2)

Unfortunately, in many cases, the participants were confronted with a coldness, a lack of understanding of their needs, which caused them to be more stressed and feeling judged.

In HR, I felt like a number, with the message: we're not here to chat with you, we follow the rules and that's it. There wasn't much empathy, it wasn't warm. (Part. #7)

Respecting Their Pace of Recovery

This expression of recognition, or lack thereof was raised by about half of the participants. Some participants felt that their pace was respected in the process, and especially in the progression established for the RTW.

They [the HR people] really went at my pace. They waited for me to call them when I felt solid enough. (Part. #20)

Providing flexibility in the application of the rules Another recognition mark reported by some participants and specifically related to HR is that they provide flexibility in the application of rules. In most cases, it was inflexibility that was reported by participants.

She [the HR manager] told me she had to check, that it wasn't 12 weeks, that usually 12 weeks is when you do the gradual returns ... it was 11 weeks. So I was like “I'm ready to come back and I would have to wait another week to come back?” It doesn't make sense, but anyway. (Part. #12)

Clients/Patients/Students

For some participants, who were less numerous, clients, patients or even students also allowed them to feel recognized and were integrated into this section considering the similarity of the themes raised by these two types of stakeholders.

Demonstrating Appreciation

Similarly, nearly three quarters of participants said they felt appreciated when clients, patients, or students showed them that they were happy to see them again.

When I came back, my students were very happy to see me: "where were you, I'm happy that you came back before the end of the year". So nice words like that from my students were really nice. (Part. #12)

The patients I visit and who tell me that they are happy to see me again, it is really this recognition that I got. (Part. #2)

Taking Time to Welcome

Some participants also noted that they had received this recognition mark from their clients, patients or students.

There is a small group of 3–4 students who wrote me a welcome card. (Part. #14)

Worker Himself

Finally, although participants did not address their own role when asked to define recognition, two marks of recognition present during the sick leave and upon the RTW were extracted from the interviews; (1) self-stigmatization (as an absence of recognition, n = 10) and (2) respecting their pace of work and limitations (n = 7).

Self-stigmatization

Half of the participants shared that they had difficulty accepting that they had reached their personal limits and had to go on a sick leave. Many reported feelings of shame or guilt.

I went there on my own free will, but basically to be convinced. Because I didn't want to be out of work, because to me that's kind of like giving up, being a coward. I'm not weak (Part. #16)

Respecting Their Pace of Work and Limitations

Upon return, some workers were afraid they would not perform as well as before.

I was anticipating being [less] efficient, I didn't want to be the worst employee. I was putting pressure on myself to perform, pressure that I didn't need. (Part. #8)

However, a small majority of them mentioned a certain acceptance of their reduced performance or even changes in attitude and behaviour to respect their capacities.

I'm happy to be back at work. Am I performing at the level I would like? No, you definitely leave something behind when you've been sick. It seems like there's stuff that I don't know if it's ever going to come back, I have to grieve for it. It's definitely different. (Part. #15)

Instead of saying to myself: "what does my boss think of me" "what didn't I do enough of this week,’ I am able to leave my computer at work instead of taking it home. (Part. #8)

Stakeholders of the Health, Insurance and Social Systems

General Physician (GP), Mental Health Professionals (MHP), Insurer (Ins), and Significant Others (SO)

Although the role of these RTW stakeholders appears to be less central to the recognition experience of people who have experienced a sick leave due to a CMD compared to that of the immediate supervisors or co-workers, several participants raised important signs of recognition from these stakeholders, both during their sick leave and the RTW. These marks are: (1) providing support (GP = 10, Ins = 3, MHP = 2, SO = 3), (2) Respecting their pace of recovery (GP = 11, Ins = 1), and (3) Sharing the decision-making (GP = 10, MHP = 2).

Providing Support

Support, whether emotional, practical or informational, is a mark of recognition that appears to be important to a very large number of participants and can come from all of these stakeholders (GP, MHP and Ins). Although reported less frequently, family members and friends also have a role to play in recognition during absence and RTW related to a CMD.

I was lucky because my children's father paid for my children's school during that time. My spouse also covered the mortgage. I had the support of my relatives during that time. (Part. #17)

Emotional support can be an understanding and warm attitude, a feeling of being listened to and considered.

What was most helpful, I would say, was my doctor […]My trusting relationship with my doctor was so there and he is so human. (Part. #12)

My social network [my parents, my friends] is really important to me. I would say that it was really the two groups most important in my mind, they didn't judge me, they helped me to get up, they followed my own pace, while pushing me in the balance. (Part. #12)

Many participants also discussed the importance of being supported by their GP, their MHP and their Insurer, through the process, being taken care of (practical support) and getting accurate and useful information (informational support).

I have professionals, psychologists and occupational therapists who share the right information with me. (Part. #19)

However, several participants said they felt left on their own and had difficulty getting the support and information they needed making it more difficult to focus on their recovery.

Everything [the steps related to the stop and return] is complicated, you have to do everything yourself, you have to protest to everyone, you have to do your follow-ups. (Part. #15)

No one [at the insurer] tells me why they won't pay me my money because they are missing parts of my medical file. If you had told me that there were missing pieces, I would have followed up. But now no one tells me why I'm not getting paid. (Part. #15)

Respecting Their Pace of Recovery

This sign of recognition, or lack thereof, from the GP and insurance companies were raised by about half of the participants. Some participants felt that their pace was respected in the process, and especially in the progression established for the RTW.

My doctor put in 2 half days the first week, increasing by a half day a week. I'm up to 5 half-days this week. So it's really a very smooth return. (Part. #19)

Others had the impression of being rushed, pushed to RTW too quickly or not progressively enough.

It was my doctor [who decided I was going back to work]. I wasn't ready. I didn't feel ready. (Part. #13)

The gradual return [proposed by the insurer] was super fast, over a period of 4 weeks. I couldn't absorb it, I told them it couldn't work like that. I told my supervisor that I couldn't do that. (Part. #19)

Sharing the Decision-Making

In addition to respecting their own pace, almost half of the participants stressed the importance of having their opinions considered in decisions about their health and recovery by their GP, MHP or occupational therapist.

He [my GP] listened to my point of view and I really appreciated that, because he could have said no he's the doctor and he decides. (Part #12)

It was the GP and the occupational therapist who asked me what I wanted, so I asked for something progressive, gradual. They put it on me even more progressive than I thought. (Part #15)

Definition of the Concept of Recognition During the Return-to-Work Process

The rich individual definitions as well as the descriptive marks of recognition made it possible to develop a more complete definition allowing us to grasp the essence of recognition during the RTW process, among people who have experienced a CMD.

The definition proposed is as follows:

For employees who have been absent due to a CMD, signs of recognition are related to the actions of the organization, the behaviours and attitudes of various stakeholders, stemming from the work, health, insurance and social systems (e.g., immediate supervisor, general physician, family members) that allow them to feel appreciated, valued and respected. Workers who have been absent due to a CMD feel recognized when:

  • they are informed about the changes that have taken place in the environment to make their RTW easier;

  • all stakeholders are concerned about their well-being and provide support;

  • their pace of recovery is respected;

  • they feel support from their co-workers if overwhelmed;

  • they are offered flexibility in the execution of their tasks and work schedule.

  • they are offered the tools to bring themselves up to date;

  • their own qualities, skills and contribution to the work team and the organization are highlighted;

  • it is made clear that they are wanted as employees in the company, in particular by mentioning possible professional promotions in the organization.

Discussion

The main objectives of this study were to better understand the notion of recognition for workers who experienced the transition from sick leave (due to CMDs) to return to work, using a phenomenological design. Furthermore, we asked workers on how recognition was expressed by RTW stakeholders stemming from different systems. To summarize our results, first, the definition of recognition that emerged from workers in the RTW process involved several components, encompassing different sub-variants or spheres as suggested by Honneth [22] and Worms [26], illustrated here by the recognition of workers’ recovery and their work contribution. In our study, marks of recognition were more often described as demonstrating appreciation, respect (of pace, of recovery), trust, and in offering positive or constructive feedback. Beyond the workers’ competencies, skills and other characteristics, Worms [26] specified that recognition means respecting the individuals' difficulties and their limitations. An important element of recognition for workers returning to work was consequently to consider their residual symptoms. Many health professionals in our study perceived the RTW as a key recovery element for workers. Not surprisingly, respecting the work accommodations measures agreed upon, was also perceived as a mark of recognition by most workers in the present study. This further shows the coherence between these two expressions of recognition—skills and vulnerability—while also reinforcing the notion of recovery during the RTW. In fact, Brun and Dugas [25] describe a humanistic and existential view of recognition, closely related to recognize people, their being, their unique and distinctive character, which could be illustrated here by offering personalized arrangements and flexible work schedules. Buys [32], to echo the recovery process, argued that the workplace should be the “therapeutic environment of choice”, enabling all stakeholders from the work system (e.g., supervisors, co-workers) to contribute to the sustainable RTW of the worker. Consequently, the notion of recognition is larger than the context of work, since it is also related to the recognition of workers’ vulnerability in returning to work, as illustrated with themes such as acknowledging their competencies and respecting their pace of work and limitations as well as their pace of recovery. Yet, the notions of vulnerability and recovery are also mentioned by other workers living with other types of disability, particularly amongst women with breast cancer.

Second, several RTW stakeholders were identified as key people that can give marks of recognition, whether affiliated to the work system (immediate supervisor, co-workers, HR, client/students/patients), or the health, social and insurance systems (general physician, mental health professionals, insurer, and significant others)—referring to the large array of stakeholders involved in the RTW [8]. Consequently, actions and significant marks of recognition from diverse RTW stakeholders could be further clarified given they are considered essential in the RTW process for workers with CMDs. Regarding the work system, our results show that recognition from the immediate supervisor and co-workers are essential, across the whole RTW process of workers on sick leave due to CMD (i.e. from sick leave to RTW). These results put emphasis on the role of these stakeholders from the workplace who offer two levels of recognition: vertical (from immediate supervisors) and horizontal (from co-workers), not only for preventing health problems [25], but also for insuring sustainable RTW. We also identified other stakeholders on the periphery of the work system, such as clients/patients/students (or those receiving a work service from the worker). These are also Brun and Dugas’ model [25] as the ‘external level’, where actions on the part of the clients can also demonstrate appreciation of the worker’s skills.

Third, in regard to the health system, these stakeholders (e.g. medical doctors) also play an important role in terms of recognition, especially related to the workers’ recovery pace. As such, several workers mentioned shared decision-making as a form of recognition. Studies on workers’ sick-leave underline the importance of considering the workers’ perspective in terms of their health in order to facilitate a sustainable RTW and avoid potential relapses. In our study, this was mentioned as shared decision-making between doctor and patient, which included the workers’ preferences, as suggested by Coutu et al. [33]. Beyond this recognition of workers’ perspective, several studies have demonstrated that shared decision-making can improve treatment adherence, health knowledge, and overall well-being while creating a strong working alliance between the health professionals and their patients [34, 35]. Finally, although not found in Corbière et al.’s [8] scoping review on salient RTW stakeholders for workers on sick leave due to CMDs, ‘non-work-related social networks’ such as friends and family members were mentioned as important sources of recognition by workers in the present study. Others, namely Armaou et al. [36], also found that wider support systems (e.g., family) were key stakeholders in the RTW of workers on sick leave due to cancer.

Fourth, regardless of all stakeholders’ ability to offer several types of recognition, recurrent themes suggest that some types are more frequent, such as providing support (e.g., emotional support), and respecting their recovery pace. Our results are in line with Renger et al.’s study [12] that found a narrow conceptual relation between the notions of social support and recognition. Renger et al. [12] even merged both concepts, suggesting three forms of social recognition: (1) achievement-based social esteem, which refers to the recognition of a person’s achievements and contributions; (2) equality-based respect, which refers to the recognition of a person’s equal basic rights and dignity; and (3) need-based care, which refers to the fulfilment of, and care for, a person’s emotional needs. Similarly, Pfister et al. [37] showed in their study that appreciation or marks of recognition, were especially close to the emotional component of social support of “caring, empathy, and esteem”. In fact, recipients of social and emotional support frequently perceive appreciation-related aspects as the most helpful element for well-being [37] and RTW [38]. All together, this leads us to suggest that social support and recognition are intertwined, since social support, particularly emotional support, can only be perceived as useful by workers if it is offered by someone who already recognizes them.

Fifth, most of the marks of recognition received were experienced by the worker throughout the whole RTW process. As mentioned above, the marks of recognition given by immediate supervisors and co-workers were, for some, present during the sick leave phase as well as during the sustainable RTW of workers. Several studies support that communication and frequent contacts during sick leave are important for the success of the RTW process [7, 38]. In Negrini et al.’s study [7], maintaining contact during the sick leave was found to help employees RTW after a depression because they felt appreciated. This is reflected in our study as actions or marks of recognition offered by immediate supervisors and co-workers, such as maintaining contact and respecting their recovery pace during the sick leave. This type of appreciation can be also present for people with breast cancer.

According to Buys et al.’s results [32], immediate supervisors should not hesitate to contact employees on sick leave as they appreciate this support. However, workers on sick leave could feel these actions are intrusive or inappropriate. Keeping contact with the worker during the sick leave is certainly important to convey a message of belonging to the team and workplace. It is implicitly recommended that these contacts with the immediate supervisor, co-workers or other stakeholders from the workplace, should be implemented with the worker’s agreement. Ideally, workers should inform the workplace regarding who might initiate these contacts, as well as the type and frequency of contacts (e.g., emails, telephone, videoconference). In our study, these contacts were considered marks of recognition after the sick leave, and expanded to, for example, taking time to welcome back worker returning to work. In a study on unions' perception of RTW of workers who experienced depression, the ‘welcome-back’ reception was identified as a key factor in RTW [39]. As underlined by Geue et al. [40], trust is the glue of relationships and it promotes a better collaboration between stakeholders from the workplace, particularly the worker and his team (i.e. co-workers, immediate supervisor); it is perceived as a vector of energy. In their study on workers on sick leave due to cancer, Yagil et al. [41] showed that mutual trust and respect were an important resource, enhancing RTW and productive joint work. The opposite is also true, where immediate supervisors or co-workers adopt stigmatized behaviours (e.g., shaming, ignorance of workers’ needs), long term disability and workers’s self-stigma (e.g., shame) develop.

All together, our results have significant clinical implications. As Gilbert and Kelloway [42] mentioned in their study on managers’ transformational, genuine and trustworthy leadership, workers feel they can believe the recognition provided by their immediate supervisors. The most renown behaviours/attitudes characterizing this kind of leadership are: 1) idealized influence; 2) inspirational motivation; 3) individualized consideration; and 4) intellectual stimulation [42]. In the context of RTW after a sick leave due to CMD, these behaviours/attitudes could be implemented by the immediate supervisor by doing what is recommended, such as planning and respecting the implementation of work accommodations, respecting the workers’ recovery process, and adjusting the workload of the worker and other members of the team, trying to meet the unique needs of each other, and finally being innovative to view RTW as a team approach. Yagil et al. [41] recommended to share the responsibility and efforts among the team members, using a sense of interdependence, open communication, and shared decision-making (also with health professionals). These immediate supervisory competencies and adoption of behaviours can not only reduce the length of the absence, the risk of relapse, but can also help improve workers’ health and overthrow the costs associated with CMD.

In addition to these marks of recognition of salient stakeholders from the workplace, Montani et al. [43] mentioned the role of other organizational sources in the recognition process, such as human resources, illustrated in our study as providing flexibility in the application of the rules in the RTW process. Unfortunately, these marks of recognition for the worker returning to work are not often present in the workplace. Pfister et al. [37] investigated why these marks of recognition, particularly from the immediate supervisor, were not implemented and found that immediate supervisors felt uncomfortable giving feedback, doubted the value of positive feedback, or never said much (e.g., infrequent praise is an indicator of high standards). Training supervisors in how to give marks of recognition and constructive feedback during the RTW, while respecting their own values, is necessary [12]. This training could be supported and guided by the employer or HR of the organization. Practical guidelines, including positive behaviours to adopt (e.g., marks of recognition) made available for each RTW skakeholder, would help develop a culture that makes returning workers with CMDs feel valued and respected, without blaming their work absence. In having such guidelines, there could be benefits for facilitating the transition from sick leave to RTW, such as reducing relapses and ensuring a sustainable RTW [12, 44, 45]. According to Gilbert and Kelloway [42], the message in the organisation could be: taking time to provide recognition is not a frivolous management activity, but rather an essential activity that may promote employee’s health and sustainable RTW. Finally, Tiedtke et al. [24] pointed out that employers need to be aware that vulnerability is not a sign of inability, but simply a factor to consider when offering workplace support and marks of recognition.

Some authors working in cancer disability mention that women with breast cancer, who experienced social support in the workplace, felt adequately supported if the support addressed their specific health vulnerability [11]. Several authors, in the context of RTW, stipulated that the nature of the support at work can take different forms: (1) Informational (e.g., colleagues’ advices), (2) Emotional (e.g., trust, caring from the supervisor), (3) Instrumental (e.g., help for doing tasks), and (4) Appraisal (e.g., feedback regarding performance) [11, 46]. In our study, recognition of one’s vulnerability probably represents a specific subtype of social support, most likely a form of emotional support, and consequently should be considered as an essential component of this type of support within the RTW context. A feeling of lacking support could be a consequence of a partial or biased understanding by employers and co-workers of the workers’ health conditions (e.g., cancer, common mental disorder, musculoskeletal) and/or of a gap between expectations and what is offered in terms of work adjustments and support [47]. To facilitate the RTW, recognition of the vulnerability of people with disabilities, expressed in adequate support from the workplace was recommended [11]. Having a supportive workplace including a genuine recognition of vulnerability is probably an important source of motivation for sustainable RTW.

This study has limitations. First, our study focused on marks of recognition given by diverse stakeholders, but we did not ask workers about the meaning of their work during the RTW process. For paraphrasing Bernoux [48], Deslandes and Bouilloud [49], workers are involved in their work, because this work has a meaning, and the recognition of this meaning, not only for oneself but also by others, is essential. To recognize oneself is already part of the requirement of recognition, since the one who asks for recognition has beforehand an idea of what he wants or what he is worth. In fact, without this self-recognition in their work, any request for recognition would not be possible. This is an important limitation, which is also related to the length of sick leave of participants (from 1 week to more than 2 years). A prolonged duration of the sick leave could change the meaning of work in these workers. Second, we did not ask workers about the disclosure of their mental health condition to stakeholders in the workplace. In the eventual disclosure during the RTW, workers could receive more support from co-workers and the supervisor and could also experience stigmatization from these stakeholders. Both positive and negative consequences of disclosure in the workplace are well known in the specialized mental and physical disability literature [50, 51]. In the case of stigmatization and discrimination by some stakeholders, these results could tint the perception of received marks of recognition by workers in the workplace. In this study, we did not specifically expand on these concepts, even if some workers mentioned facing stigmatization from their immediate supervisor and co-workers (see Table 2). In future studies, we recommend evaluating these concepts when asking about perception from others, particularly for perceived recognition. Furthermore, this is a small sample qualitative study from a convenience sample—it is possible that we could have obtained different results with a different sample.

To conclude, our qualitative study was the first, to our knowledge, to evaluate from the workers’ perspective, the presence or absence of marks of recognition during the RTW process following a sick leave due to a CMD. In the work system, taking time to welcome, acknowledge workers’ competencies, demonstrate appreciation, recognize their efforts or their pace of work and limitations, and offer trust vis-à-vis the worker in the RTW are highlighted as important marks of recognition from the different concerned stakeholders. When there is a lack of recognition, workers can experience shame and stigmatization, even self-stigmatization toward themselves. RTW stakeholders from the health, insurance and social systems are also important in the worker’s eyes, even if the marks of recognition are not specifically related to their own professional skills or competencies. According to workers’ perspective, providing support, respecting their recovery pace and limitations, as well shared decision-making, are marks of recognition, facilitating their sustainable RTW. These marks of recognition, centered on health and vulnerability as well as recognition for the contribution to work by stakeholders from the workplace, are valuable for workers. All together, these elements are included in the definition of recognition (see Results). We also highlighted the need to provide specific guidelines in organizations, particularly to immediate supervisors, regarding the RTW process, and particularly roles and actions that different stakeholders could adopt in the workplace to stimulate expressions of meaningful recognition. Such training could reinforce a culture of a collective responsibility in the field of sickness absence and sustainable RTW.