Empowering self-direction in return to work of employees with low and high levels of education: A qualitative comparative study

1.1Empowering leadership and self-direction of employees in return to work

Following the above, it can be postulated that – in order to act in line with the rationale of the legislation – Dutch employers ought to use a leadership style that involves power sharing with or empowerment of employees. Leadership styles such as transformational [9] or ethical leadership [10] meet this criterion. Empowering leadership as described by Amundsen and Martinsen particularly stands out in this regard though, given that it supports the opportunities, motivation and ability of individual employees to fulfil autonomous activities [11]. Self-direction of employees – i.e. making decisions about work resumption [1, 12] – can be considered an example of such an autonomous activity.

Empowering leadership consists of two dimensions. First, autonomy support concerns “empowering leader behaviors that theoretically influence subordinates’ opportunities and motivation in performing autonomous work-role activities through delegation, coordination and information sharing, encouragement of initiative and goal focus, efficacy support, and inspirational communication” ([11], p.506). Second, development support covers “leader behaviors that influence subordinates’ continuous learning and development through leaders’ role modelling and guidance, which also clearly have implications for their ability to cope with autonomous activities” ([11], p.506). Employers may, for instance, provide autonomy support by sharing the decision latitude regarding the employees’ RTW. Also, employers may support the development of absent employees as directors of RTW by taking an advisory role (adapted from [11]). To illustrate, many items of Amundsen and Martinsen’s scale to measure empowering leadership [11] can be applied to the context of RTW. Table 1 describes several empowering leadership behaviors that may enable absent employees to self-direct their RTW.

To our knowledge, empowering leadership as described by Amundsen and Martinsen [11] has not yet been studied in the field of sickness absence and return to work. Nevertheless, the literature concerning employees who are not on sick leave suggests that employees on sick leave will benefit from empowering leadership. For example, employees may be less dependent on empowering leaders than on transformational, directive or transactional leaders ([14, 15] as cited in [11]).

1.2The role of employees’ educational level

Employees with low levels of education are often employed in low-skilled occupations. These jobs typically provide employees with limited job control [16]. Having a job with limited decision control declines the chance of absent employees to achieve early work resumption [17]. It can be postulated to be more challenging for these employees to self-direct their RTW. Given that all Dutch sick-listed employees are legally required to pursue RTW in cooperation with their employers [3], particularly employees with low levels of education may be in need of empowering leaders. However, findings from our previous qualitative study based on 13 semi-structured interviews with employers of employees with low levels of education show that their employers tend to take the lead in managing their RTW, for example by deciding about the planning and mode of work resumption. Table 2 provides a short overview of the main results of that study [12].

Moreover, based on research findings [1, 12], employers of employees with low levels of education can be postulated to play a more steering, directive role, compared to employers of employees with various educational levels. This assumption suggests a relative inequality in self-direction, where employees with higher levels of education are given more opportunities to self-direct their RTW.

3.1Study design

This qualitative study was based on semi-structured, in-depth interviews. To achieve rigor, we addressed several criteria of the COREQ-checklist for qualitative studies. This concerns, among other things, the methods of sampling and approaching interview participants, the number of interviewees, the topic list, and how themes were obtained from the interviews. The results section covers quotations and clear descriptions of themes that comply with the data [19].

3.2Study context

The interviews were conducted in the Netherlands in 2018 and 2019. The Dutch Gatekeeper Improvement Act (DGIA) stipulates that both absent employees and their employers should work together to achieve the employees’ RTW. This involves composing and monitoring an action plan for RTW. During maximally two years, the employer pays at least 70% of the absent employees’ income [3, 12, 20]. Moreover, employers are obliged to provide absent employees with work that fits with their abilities. This can concern work with the employees’ current or different employers [3, 20].

3.3Population and procedure

Two samples were used. The first sample included representatives of a university [21]. The second sample included representatives of employers for employees with low levels of education [12]. Below, we describe the study population and procedures for both samples.

3.4Data analyses

Study sample 1 [21] was used to analyze how representatives of a university manage RTW (study objective 1). The data were analyzed thematically in NVivo 12 [24], building on a part of/several themes of and simultaneously with the data analyses for the study concerning the RTW management of employees with low levels of education [12]. The following steps – that were inspired by Braun and Clarke’s thematic analysis [25] – were taken: NH read the transcripts to develop preliminary ideas about how representatives of the university manage RTW. Upon that, she performed multiple cycles of coding and reviewing until she created an initial thematic map that was relevant to the study objective, covered a significant part of the dataset, and was meaningfully organized. Then, BP and IH carefully inspected the NVivo file to check the quality of coding. When all researchers agreed on the coding structure, NH described the study results. During the writing process, she kept on refining the coding. BP and IH provided feedback on the written study results.

To compare the RTW management of employees with low levels of education versus that of employees at a university, i.e. an employer for employees with high levels of education (study objective 2), we used the written results regarding study aim 1 on the RTW management at a university. In addition, we used the main themes - that were described in Table 1 and derived from the study results of Hoefsmit and Houkes [12] - on how employers for employees with low levels of education manage RTW. NH compared both collections of themes and made an overview of similarities and differences (see Table 3). BP and IH provided feedback on the written version of the study results.

Both study samples [12, 21] were used to analyze the degree to which the roles of employers for employees with low levels of education versus that of the representatives of the university resemble empowering leadership (study objective 3). Elements of pattern matching [26] were applied in a similar manner as reported in an earlier study [27]. Regarding employers for employees with low levels of education, the expected degree of empowering leadership (both the dimensions of autonomy support and development support) was estimated as low. A moderate degree of empowering leadership was expected among the representatives of the university ([26] as cited in [27]). These estimations were based on the background of this study (particularly studies [1, 12]). Upon that, the interview transcripts were read in order to rate the actual degrees of autonomy support and development support for each individual interview participant. Afterwards, all ratings were taken into account into an overall average score (low, moderate or high) for autonomy support and development support among employers for employees with low levels of education and representatives of the university separately. Finally and for each sample separately, a comparison was made between the expected and actual degrees of autonomy support and development support ([26] as cited in [27]). NH conducted the pattern matching procedure. To support peer validity, BP and IH reviewed the results of this procedure.

4.1RTW management of employees at a university (study objective 1)

Interview participants with the university, i.e. representatives of an employer for employees with high levels of education (EH) generally appeared to trust their absent employees. One interviewee noted: “ ⋯  the boss makes a phone call ⋯   not to monitor. We know our people too well for that ⋯   everybody is committed  ⋯   we contact [absent employees] by phone to show interest.” (EH5)

EH generally considered their employees capable of self-directing their RTW and career paths. “Employees are responsible for their jobs, employability, careers, sickness absence ⋯  ” (EH1) Another interviewee mentioned: “you are to self-direct your own career development ⋯   it fits with the spirit of our times.” (EH5) The EH generally respected their employees as quite independent and motivated professionals. Please note that employees’ responsibility for their own career development is part of a new HR policy at the university (HR Manager university, personal communication, September 2019).

All EH reported to take an activating stance on absent employees. “[despite a health injury] You may still want to return to work ⋯  ” (EH3). These interviewees aimed to identify and utilize the employees’ work abilities. To enhance their employability, if needed, professionals such as “ ⋯  an employability coach ⋯  ” (EH3) were asked to support absent employees.

EH appear to use conversation as a means to identify what employees need to return to work. “I think the solution can be obtained from the employee. He knows best what has to be done first.” (EH5) Another interviewee reported to aim for sustainable RTW: “I don’t want someone to return to work after a month and call in sick two weeks later. That doesn’t seem like a good plan to me.” (EH8) Many EH seemed to accommodate the needs and preferences of their employees as much as possible. “As employer, you particularly need to facilitate [your employees].” (EH4) Another interviewee mentioned: “Not everybody returns to their own jobs, not everybody wants that.” (EH8) Some EH reported difficulty for employees to return to work at another department. “ ⋯  the employee has to apply for this job ⋯  ” (EH4)

Moreover, supervisors differ in their ability to manage RTW. For example, an interviewee mentioned: “It depends on mutual trust [employee-supervisor]. You need to show warm and business-like behavior ⋯   You must show empathy, yet it shouldn’t prevail. This [quality] is partly inherent in a person.” (EH2)

According to multiple EH, employers should prepare their supervisors to carry out RTW management tasks. Most interviewees wished to use tools for and training of supervisors to get a grip on the basics of RTW management and to achieve efficiency as a RTW manager. For example, an interviewee noted: “I am going to help them [supervisors]. As an organization, you have to facilitate. You need to give a lot ⋯   I think they [supervisors] would like to have [an administrative ICT system to support RTW management] and [a guideline for the supervisors’ responsibilities]. They are busy, busy, busy.” (EH3) Please note that most tools were still in development at the time of the interviews, and there also was disagreement among interviewees about the specific tools they preferred to use. Also, training on RTW management was implemented. A part of the EH had already received training.

With respect to legislation, EH appeared to consider it self-evident to abide by requirements on RTW management. For example, most interviewees mentioned to ensure regular contact with absent employees, over and above legal requirements: “Someone shouldn’t be at home for three weeks without any contact [with the employer]. Work sort of drifts away.” (EH1) Some interviewees mentioned to consult the OP when they were legally obliged to do so, and/or when they needed advice. “The supervisor and the employee are to self-direct as much as possible. The OP is your remote medical advisor.” (EH4) Please note that the new RTW policy at the university emphasizes the primary responsibility of employees, and secondarily that of supervisors (HR Manager university, personal communication, September 2019).

In sum, our results describe that EH focus on meeting legal requirements on RTW management, and on identifying, enhancing and utilizing the absent employees’ work abilities. Even more apparently, EH usually seem to play a facilitating role in the absent employees’ RTW processes. Yet, these findings should be interpreted with caution. It appears from the data that some interviewees had experience of deciding how the employees’ sickness absence or return to work should unfold. To illustrate: “At first, we arranged temporary replacement. But the employee interpreted it as an attack ⋯   The employee hadn’t mentioned to want any rest.” (EH5) The end of this quote suggests that this interviewee has learnt from this experience, now knowing not to decide for employees to stay at home.

4.2Similarities and differences (study objective 2)

Our comparative analysis reveals multiple similarities that employers for employees with low levels of education (EL) and EH show in their RTW management. These are: pursuing to meet legal requirements on RTW management, establishing connectedness with absent employees, taking an activating stance on absent employees and making use of the services of healthcare or RTW professionals. Among both EL and EH, supervisors differ in their ability to manage RTW, and employers would need to provide support to them [12].

Our analysis also reveals a fundamental-yet-nuanced difference. EL considered that employees with low levels of education would have limited work ability and there would be few tasks or jobs at their companies that can be done by these employees. They decided individually about the employees’ RTW. Correspondingly, EL instructed, monitored and tried to control the behavior of employees in the direction of RTW [12]. In contrast, EH generally considered their employees capable of self-directing their RTW and career paths. EH seemed to use conversation as a means to identify what employees need to return to work, and many EH appeared to facilitate employees as much as possible.

Table 3 gives a complete overview of all similarities and differences that EL and EH show.

Yet, these results should be interpreted with caution (see Table 1 and paragraph 4.1).

4.3Empowering leadership (study objective 3)

Table 4 shows the expected and observed degrees of empowering leadership.

Almost all EL scored ‘low’ on autonomy and development support. These observed scores match with our expectations. Only one EL scored ‘moderate’ on both dimensions.

Further, one EH scored ‘moderate’ on both dimensions of empowering leadership. This case fits with our expectations. However, multiple EH scored ‘high’ on both dimensions– which exceeds our expectation –, and only some scored ‘low’ on one or both dimensions of empowering leadership.

5.1Discussion of content

It appears that both EL [12] and EH consider it to be their task to activate and enable absent employees to return to work. This task would require them to communicate in an empathic, yet expedient manner. Further, they stressed the importance of ‘strategic RTW know-how’, for example with respect to when and how to make use of professional RTW or healthcare services (see also [12]). Such social norms about an employer’s role suit their own financial interests to limit the costs of sickness absence, and appear to coincide with many of the standards set by the DGIA [3, 20].

Our findings also show clear differences between EL and EH. As mentioned in [12], EL appear to have a tendency to use their power over absent employees. EH tend to engage in dialogue more often. Empowering leadership seems to be more common among EH. This suggests that compared to employees with low levels of education, those with high levels of education may be granted more opportunity to self-direct their RTW. This, in turn, raises the question of why EL and EH differ in terms of the degrees of empowering leadership that they show. Our results point at three possible reasons, which comprise the roles of goals (1), power distance (2), organization policy and training (3). Below, we discuss each of these factors.

5.2Methodological reflections

Strengths of this study include the use of semi-structured interviews to collect in-depth information about the perspectives of employers [12, 21]. In addition, we analyzed the data in a structured manner. For example, we used pattern matching to grade the degrees of empowering leadership among EL and EH separately. Multiple researchers worked on all aspects of this study. Nevertheless, a number of study limitations must be mentioned as well.

First and as mentioned by Hoefsmit and Houkes [12], we only interviewed employers [12, 21], and therefore lack information about the perspectives of employees. As such, we do not know if and how they have experienced their employers to show any valuable empowering leadership behavior during their RTW trajectories.

Second, we used interviews with mostly HR and RTW professionals and only few supervisors [12, 21]. These professionals may have relatively negative views on employees’ motivation and ability to return to work, as they might have – more than supervisors – experience of stagnant RTW trajectories [12].

Third, many EH elaborated on RTW practices that seem to be part of the university’s new HR policy. It is not always clear, though, exactly whether EH always behaved in line with this policy.

Fourth, only one employer for employees with high levels of education, i.e., a university participated in this study. We do not know whether our results are representative of other employers for employees with high levels of education as well.

Despite these shortcomings, our study results appear to be the first to provide a comparison of the RTW management and empowering leadership at EL versus at a university.

5.3Implications for research

Further qualitative research should focus on gathering an in-depth understanding of the perspectives of employees [12] on empowering leadership in RTW management. These insights will help to understand whether and how empowering leadership may be valuable to support employees’ self-direction in RTW. In case employees indeed attach value to empowering leadership, a measurement scale – for empowering RTW management to support absent employees’ self-direction – can be developed and studied. Upon that, quantitative and longitudinal studies should focus on the possible effects of such leadership on employees’ self-direction in RTW, and their actual RTW status. These studies can be conducted among groups of employees with both low and high levels of education who are employed at several different types of organizations. In case empowering leadership is effective, interventions to support the use of this style in RTW management can be developed and evaluated.

5.4Implications for practice

The study results provide some starting points that might help employers who want to enable employees’ self-direction in RTW, and who wish to develop more empowering leadership styles. More specifically, our study results suggest that these employers need to invest in finding shared RTW objectives together with their absent employees. Also, employers may include empowering leadership in their RTW management policies (see also [12]) and training of supervisors.