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Developing trust and balancing control : social interactions in work accommodations Kwan, Hanah C. 2013

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     DEVELOPING TRUST AND BALANCING CONTROL:  SOCIAL INTERACTIONS IN WORK ACCOMMODATIONS  by Hanah C. Kwan  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF ARTS in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Counselling Psychology)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  October 2013  ? Hanah C. Kwan, 2013   ii Abstract The return to work (RTW) literature has identified various determinants for successful outcomes for injured workers.  Social interactions due to multiple stakeholders within multiple systems have emerged as an important area in need of further investigation.  Additionally, the increase use of work accommodations to facilitate early return to work has gained increased focus due to the promising direct and indirect benefits to stakeholders.  This study examines the social interactions in the RTW accommodation process from the perspectives of three key stakeholders?the injured worker, the workers? compensation system and employer representatives?with the aim of developing a middle-range theory grounded in these stakeholders? perspectives.  Interview data from 27 participants (17 workers, 5 employers, 5 insurers) were transcribed and analyzed using constructivist grounded theory method.  The resulting theory identified that developing trust and balancing control are interdependent core processes in the RTW accommodation process.  Developing trust and balancing control are dynamic processes with opportunities to repair/increase or falter/decrease these core processes among stakeholders.  These processes impacted the outcomes and goals of returning the worker to productivity, the satisfaction with the accommodation process, the amount of loss reduction, and claim closure.  Study results imply that stakeholders can intervene when trust is not being developed and there is an imbalance of control.   The measurement of trust and control in the RTW accommodation process would support the application of study findings.  The resulting grounded theory provides a framework for the implementation of successful RTW accommodations.      iii Preface  The five employers and five insurer representative interviews utilized for data analysis and development of the final theory were conducted or coordinated by Alison Stewart.  I separately coded these 10 interviews, and I was fully responsible for the development of the grounded theory.   The conceptual introduction to this study, based on the review of the literature on work accommodations was accepted for publication as a chapter.  Kwan, H.C. and Schultz. I.Z. (in press) Work Accommodations in Musculoskeletal Disorders, in Handbook of Musculoskeletal Disorders in the Workplace, by Gatchel, R. & Schultz, I.Z. (Eds.), in the Springer Handbook Series on Health, Work and Disability.  I conducted all of the literature review and wrote most of the manuscript.   Ethical approval for this study was obtained from the UBC Behavioural Research and Ethics Board, certificate number H11-00987.             iv Table of Contents  Abstract .............................................................................................................................. ii Preface ............................................................................................................................... iii List of Tables .................................................................................................................. viii List of Figures ................................................................................................................... ix Acknowledgements ........................................................................................................... x Chapter  1: Introduction .............................................................................................. 1 1.1 Statement of the Problem ................................................................................... 2 1.2 Key Concepts ..................................................................................................... 3 Chapter  2: Literature Review ..................................................................................... 5 2.1 Work Accommodation Research ....................................................................... 5 2.1.1 Injury-related conditions .............................................................................. 6 2.1.2 Key accommodations by type ...................................................................... 6 2.1.3 Temporary accommodations ........................................................................ 7 2.1.4 Economic studies of accommodations ......................................................... 8 2.2 Work Accommodation Process and Implementation ....................................... 10 2.3 Stakeholders and Social Interaction Research ................................................. 11 2.4 Summary and Research Questions ................................................................... 12 Chapter  3: Method ..................................................................................................... 14 3.1 Study Design and Rationale ............................................................................. 14 3.1.1 Epistemological stance and theoretical orientation .................................... 15 3.1.2 Emergent design ......................................................................................... 16   v 3.2 Data Collection and Procedure ........................................................................ 17 3.2.1 Recruitment ................................................................................................ 17 3.2.2 Sampling .................................................................................................... 18 3.2.3 Study participants ....................................................................................... 19 3.3 Data Analysis and Theoretical Sampling ......................................................... 21 3.3.1 Coding the data .......................................................................................... 21 3.3.2 Memo-writing and constant comparison .................................................... 22 3.4 Criteria for Judging Rigour .............................................................................. 22 Chapter  4: Research Study Findings ....................................................................... 25 4.1 A Grounded Theory of Social Interactions in RTW Accommodations ........... 25 4.2 Defining Trust .................................................................................................. 27 4.3 Developing Trust .............................................................................................. 30 4.3.1 Communicating with other stakeholders .................................................... 31 4.3.2 Evaluating trustworthiness ......................................................................... 34 4.3.3 Building relationships ................................................................................ 37 4.3.4 Managing expectations .............................................................................. 40 4.4 Balancing Control ............................................................................................ 44 4.4.1 Establishing guiding principles of interactions .......................................... 48 4.4.2 Managing risks ........................................................................................... 49 4.4.3 Managing needs ......................................................................................... 51 4.4.4 Creating options ......................................................................................... 54 4.5 Consequences of Trust and Control ................................................................. 55 4.5.1 Context of distrust and reduced trust ......................................................... 55 4.5.2 Context of trust .......................................................................................... 57   vi 4.6 Consequences and Goals of Social Interactions in Accommodation Process . 58 4.6.1 Returning worker to productivity ............................................................... 58 4.6.2 Reducing losses .......................................................................................... 59 4.6.3 Claim closure ............................................................................................. 63 4.6.4 Satisfaction with the work accommodation process .................................. 64 4.7 Work Accommodations Received ................................................................... 65 4.8 Context of Social Interactions in Work Accommodations Process ................. 66 Chapter  5: Discussion ................................................................................................ 71 5.1 Meaning, Relevance and Implications of Study Findings ............................... 71 5.2 Comparison to Extant RTW Literature ............................................................ 76 5.2.1 Conceptual models of occupational disability ........................................... 76 5.2.2 Work accommodation studies .................................................................... 78 5.2.3 Accommodation process and implementation ........................................... 80 5.2.4 Expectations of RTW accommodations ..................................................... 82 5.2.5 Stakeholders and social interactions .......................................................... 83 5.3 Trust and Control in the RTW Literature ......................................................... 86 5.4 Application of Research Results ...................................................................... 88 5.5 Methodological Considerations ....................................................................... 90 5.5.1 Study limitations ........................................................................................ 90 5.6 Recommendations For Future Research .......................................................... 92 5.7 Concluding Remarks ........................................................................................ 92 References ........................................................................................................................ 94     vii Appendices ..................................................................................................................... 104  : Introduction Letter to Healthcare Professionals ............................... 104 Appendix A : Worker Recruitment Poster .............................................................. 105 Appendix B : Consent to Contact Worker .............................................................. 106 Appendix C : Interview Protocols .......................................................................... 107 Appendix D :  Demographic Form .......................................................................... 110 Appendix E     viii List of Tables  Table 1: Summary of Participant Details .......................................................................... 20 Table 2: Categories, Properties and Dimensions of Developing Trust and Balancing Control in Social Interactions of RTW Accommodation Process ..................... 28  Table 3: Summary of Three Key Stakeholders Perceived Barriers and Facilitators to the Accommodation Process .....................................................................................71    ix List of Figures  Figure 1: Theory of Social Interactions in RTW Accommodation Process among Three Key Stakeholders ............................................................................................. 26    x Acknowledgements  This thesis was part of a larger research study entitled, ?Towards Effective Work Accommodations of Injured Workers?, that was supported by funds from the Workers? Compensation Board of Nova Scotia and WorkSafeBC through the FOCUS ON TOMORROW program.  Many individuals contributed toward this research study.   Special thanks goes to the participants, who shared their experiences and made these findings possible.  I am indebted to the participating rehabilitation centres and their staff for their support of this study: CBI in Coquitlam and Burnaby, Back In Motion in Richmond and Surrey, and OrionHealth in Vancouver.   I would like to extend my thanks to Dr. Richard Young, my thesis advisor and to committee members, Dr. Izabela Schultz and Dr. Vaughan Marshall for their feedback and extensive knowledge.  I also felt fortunate to have the opportunity to work together with Alison Stewart.   Most of all, I?m grateful to three people who have been with me throughout this process.   I could not have done this work without my brother and sister, Victor and Linda Kwan, whose encouragement and help made all the difference.   Finally, Andrew Nguyen, my husband who has supported me throughout my pursuit of further education and worked tirelessly beside me.    1 Chapter  1: Introduction When workers are injured at work in Canada, they enter a complex network of systems with many stakeholders.  In fact, thousands of workers are injured every year with a large percentage involve musculoskeletal injuries (MSI).  During 2012, in British Columbia alone, 144,865 injuries were reported; 2.9 million days were lost from work for all workplace injury claims; and approximately 57 % of the claims were due to back strain or other strains (WorkSafeBC, 2013).  With little doubt, there are substantial financial, economic, personal and societal costs to these types of injuries?and the reason why the return to work (RTW) process in occupational disability has been extensively researched.   Many stakeholders have vested interests in successful outcomes of injured workers, with great attention paid to factors that improve outcomes and prevent disability, because of the high costs involved.  There has been evidence that workplace interventions reduce the time off work due to an injury (van Oostrom et al., 2009).  As a result, there has been an increase of RTW programs over the past decade, with many of them offered by employers, and some by workers? compensation systems.  One workplace intervention that has gained considerable attention is the offer of work accommodations.  Many workplaces have begun to offer accommodations, as early as the first day after an injury.  The stakes are high for all involved, especially for the injured worker, the employer and the workers? compensation board.  Not surprisingly, injured workers and even trained professionals can find the process complicated and may have difficulty navigating multiple systems.  When the stakes are high and there are stakeholders with differing views and objectives, emotions can run high, making for difficult negotiations and cooperation.  Thus, the social interactions in the RTW process have been identified as crucial to successful outcomes.    2 1.1 Statement of the Problem The use of accommodations to reduce occupational disability, as an early intervention in the workplace, has garnered much attention.  There has been increased use of accommodations over the last decade.  In addition, there has been an increased recognition of the importance of psychosocial factors, and the role of key stakeholders and organizational structures as crucial to RTW outcomes for all injured workers  (Freisen, Yassi & Cooper, 2001; MacEachen et al., 2006).  Despite these important findings, the successful implementation of accommodations remains elusive.  Unfortunately, problems of implementation, communication and cooperation among stakeholders, and disengagement of stakeholders from the RTW process continue to have negative consequences on RTW outcomes.  As such, there is a need for evidence-based practices, strategies and policies to support improved accommodation implementation.  Moreover, other researchers have suggested that social interactions are a key area in need of further investigation.  There is a paucity of research in the social interactions that affect the accommodation process.  In response to this problem I explore how multiple stakeholders perceive social interactions, barriers, facilitators and expectations of the accommodation process in RTW.    A brief summary of key terms and concepts concludes this chapter.  Chapter 2 reviews the relevant research in RTW, accommodations, and social interactions, and concludes with a detailed research question that fits with this identified research gap.  Chapter 3 explains the research approach and method in greater detail.  Chapter 4 describes the findings of this study and Chapter 5 is a discussion of the implications, relevance, application of the findings, and recommendations for future research.       3 1.2 Key Concepts  Research studies vary in the way that concepts related to RTW are defined and measured. According to Schultz and associates, the field of occupational disability has been ?largely hampered by lack of a clear definition of RTW and remains fragmented? (2007, p.329).  As such, key concepts are defined as they are used in this study.   RTW and RTW process.  The term ?return to work? (RTW) is utilized as both a process and outcome measure, such that RTW can be conceptualized as the ?process? of returning an injured worker to work, or the status of working or not working (Schultz et al., 2007).  In this thesis, RTW is used to describe a RTW outcome, whereas RTW process will be utilized to encompass the various stages and phases.  The process begins at the onset of work disability and concludes when a satisfactory long-term outcome has been achieved (Young et al., 2005).   Work accommodations.  Though often used synonymously, the research literature has begun to differentiate between ?work/workplace accommodations?, and ?job accommodations?.  Job accommodations involve modifying physical features of workplace settings, and essential job tasks to maximize productivity and efficiency, whereas work accommodations involve modifying workplace rules and culture to ensure that employees with disabilities enjoy equal benefits and privileges as similarly situated employees without disabilities (Gold, Oire, Fabian & Wewiorski, 2013).  The term work accommodation is used in this report to refer to both types of accommodation, which is defined as an adjustment to a job, the work environment, or the way things are usually done, with the aim of reducing or eliminating workplace barriers to enable a qualified individual with a disability to return to work.   Examples of accommodations include gradual hours, assistive devices, job modifications, and transitional work programs.  Work   4 accommodations in the RTW process are henceforth referred to as ?RTW accommodations? or ?RTW accommodations process?.   Types of work accommodations.  Gradual hours may be defined as the process of gradual reintegration to the workplace through a structured increase in hours of work to improve workday tolerance.  Assistive devices are any materials, devices, or equipment used to eliminate or reduce the restrictions and limitations caused by an injury or illness.  Job modifications are any change in the structure of duties that make up a job; they may involve reorganization or elimination of tasks, physical changes to the work area and/or changes in the equipment used.   Most modified work programs fall under the category of transitional work programs.  In these programs, a temporary accommodation is offered to facilitate an injured or ill employee's safe transition to full employment hours and duties. The transitional work program may complement external treatment programs (e.g. physiotherapy, chiropractor).  Modified work can include various interventions such as light duty, graded work exposure, job modifications, work trial and supported employment (Krause et al., 1998), which are generally offered on a temporary basis.   Social interactions and social processes.  Social processes and social interactions are key concepts in this thesis.  The term social interactions are the acts, actions, or practices of two or more people that are mutually oriented towards each other, that is, any behaviour that tries to affect or take account of each other?s subjective experiences or intentions (Rummel, 1976).  Thus, the term ?social interaction? is used in relation to how, why and with whom individuals interact in the RTW process.  Social process consists of sequence of events, repetition of events, relationships between events, continuity of events and consequences (Charmaz, 2006; Glaser & Strauss, 1967).     5 Chapter  2: Literature Review  Characteristics of the injured worker, components of particular medical and occupational rehabilitation interventions, physical and psychosocial job characteristics, workplace factors, the insurer?s or worker?s compensation scheme, and broader societal factors such as labour market conditions and the prevailing legal framework all have been shown to influence RTW outcomes, independent of the underlying medical condition (Krause et al., 2001; MacEachen et al., 2006; Pransky et al., 2002).  One of the major challenges is that relevant research crosses many disciplines and is even well represented in unpublished reports from various statutory authorities and other stakeholders in the RTW process (Krause et al., 2001). This has resulted in an extremely large body of literature which is difficult to compare and synthesize because of the great variation in the population studied, the study designs, and how variables are defined and measured (Krause et al., 2001).  This literature review concentrates on factors affecting RTW for workplace-injured workers with physical injuries.  The recent research on RTW includes accommodations, social interactions, and the role of various stakeholders.  2.1 Work Accommodation Research  The terms ?workplace interventions?, ?modified work?, ?job modifications? and ?accommodations? are overlapping, entangled concepts in the literature.  Current RTW research on work accommodations can be classified into two broad categories: (1) an inclusion strategy for employees with long-term disabilities, often from non-work related injuries, into a new organization and position (Gates & Akabas, 2011), and (2) an early intervention to facilitate return to work of injured workers.  This body of research is multidisciplinary, involving disability studies, human resource and management, occupational disability, and physical and occupational therapy.  In the first category, inclusion strategy accommodations may be   6 extensive, involving transportation access and assistive technology.  Short-term disabilities due to non-work related injuries are often grouped together within the second category in the literature, which may confound findings.  The objective of both accommodation types is to promote full participation for all.  While some of the research reviewed does not distinguish between accommodations for work or non-work related injuries, there may be different social processes involved in accommodations that have different rationales and goals (Cleveland, Barnes-Farrell and Ratz, 1997).   2.1.1 Injury-related conditions  Injury-related conditions studied have varied in the literature (Burton et al., 2009; Waddell et al., 2008).  Many of the conceptual models of RTW are derived from research on musculoskeletal disorders (MSD) and have been applied to RTW processes for all types of work disability (vanOostrom et al., 2009).  As such, there is a large body of research on musculoskeletal disorders (Arnetz et al., 2003; Bultman et al., 2009; Franche et al., 2007; McCluskey et al., 2006) and a specific focus on back pain (Loisel et al., 1997; Karjalainen et al., 2003; Soeker, Wegner & Pretorius, 2008; Steenstra, Verbeek, Heymans & Bongers, 2005; Yassi et al., 1995).  The question of the cross validity and application of these studies for differing conditions has emerged in the research literature.  For example, vanOostrom and her associates? review of workplace interventions found an insufficient number of studies to determine whether intervention outcomes differ by condition type (vanOostrom et al., 2009).  2.1.2 Key accommodations by type Descriptive studies of the prevalence of various types of accommodations, and outcome studies of the efficacy and effectiveness of accommodations for specific populations, are generally lacking (Sanford & Milchus, 2006).  Though the importance of work accommodation   7 in RTW is recognized, little is known about the impact of specific ergonomic, work organization and schedule components on outcomes (Franche et al, 2005, p.538).  Butterfield and Ramseur (2004) also reviewed the types of assistive technologies used in the workplace for work-related or non-work related and broadly classified disabilities.  The authors also reported that computer technologies were the most prevalent workplace accommodation in the literature.  They found that short term accommodations were commonly implemented such as adjusting work schedules, adopting flexible leave policies, and restructuring jobs which they referred to as supported employment and adaptive strategies.  Other modified work studies have also found that the most common type of modified work or accommodations were light duty, followed by flexible schedule and reduced hours (Brooker, Cole, Hogg-Johnson, Smith & Frank, 2001; Krause et al, 1998).  2.1.3 Temporary accommodations Krause and associates (1998) found that temporary modifications or accommodations were better than no accommodations.  They found employees with temporarily modified work were twice as likely to RTW as employees without access to any form of modified work.  Moreover, it was estimated that on average, a fifty percent reduction in days lost from work could be expected for those employees with modified job activities (Krause et al., 1998).  Overall, modified work programs facilitate return to work for temporarily and permanently disabled workers (Schultz, Crook & Winter, 2005) and reduce work absence duration (Crook, Milner, Schultz & Stringer, 2002; Franche, Frank & Krause, 2005; Krause et al., 1998; Turner, Sheppard & Gluck, 2008).  Often ?modified work? is broadly defined, including all forms of modified work and combined with other interventions (Krause et al., 1998).  Work programs executed in a rehabilitation clinic outside the workplace were often excluded from reviews.  A   8 key review by Krause and colleagues focused only on workplace-based modified work programs and did not include accommodations offered through compensation/insurer systems (Krause, Dasinger & Neuhauser, 1998).  However, many jurisdictions within Canada have work programs external to workplaces.   In current theories of RTW, timing is of particular importance.  Interventions should be early but also appropriate (Franche et al., 2005; Pransky, Shaw & McLellan, 2001).  There has been some criticism of the indiscriminate use of early return to work, especially with workplace interventions.  Some studies have found an increase in re-injuries (Pransky, Benjamin, Hill-Fotouhi, Fletcher et al., 2002) further supporting this criticism.  Key determinants of a safe and sustained RTW are appropriate timing, and properly structured accommodations to decrease ergonomic risks (Pransky et al., 2002).  Providing adequate accommodations can be challenging.  It is generally perceived to be more difficult in small workplaces where there may be fewer modified work options.  Larger companies often have more established policies and procedures, and may have more flexibility in implementing accommodations (Schultz, Milner, Hanson & Winter, 2011).  2.1.4 Economic studies of accommodations  Legislative frameworks vary with respect to employer efforts to deal with disabling medical conditions and provide reasonable accommodations.  Financial incentives for employers to reduce sickness absence also vary by country and by insurance system.  Economic studies have examined the effects of economic incentives for employers, differences on compensation type during time off work, and cost-benefit analysis for insurance/compensation systems and employers.  These studies have provided mixed evidence about the economic benefits of RTW interventions and programs (Anema et al, 2007; Arnetz et al, 2003; Loisel et al, 1997).  Overall,   9 there is moderate strength evidence to support the financial merits of interventions with work accommodation offers (Franche, Baril, Shaw, Nicholas & Loisel, 2005a; Franche et al, 2005b; Tompa, Oliveira, Dolinschi & Irvin, 2008; vanOostrom et al, 2009).   Costs of accommodations are often considered prohibitive despite the lack of empirical support for this view in economic studies.  Employers are most likely to respond positively where financial implications are favorable to productivity and profitability and where workplace roles are clear and not burdening (Franche et al, 2005a).  Baldridge and Veiga (2006) found that monetary costs and impositions on others negatively influenced the likelihood of requesting recurring accommodations for employees with hearing-impairments.  The assessment methods utilized to determine costs have been criticized for not including direct and indirect benefits, and for not distinguishing disability related accommodation costs from generic employee costs unrelated to disability (Schartz, Hendricks & Blanck, 2006).  Blanck (2004) reported that most accommodations had no direct costs.  Indirect costs of supervision and coworker time were reported in accommodations for individuals with mental health disabilities (MacDonald-Wilson, Rogers, Massaro, Lyass & Crean, 2002).  Utilizing a model of direct and indirect costs, Schartz and associates suggests that accommodation costs may be even less than previously reported when disability related costs are differentiated from general employee costs (2006).  There has been an increase over the last decade in workplace accommodation offers from employers (Brooker, Cole, Hogg-Johnson, Smith & Frank, 2001) due to strong evidence that work accommodation offers reduce work disability (Franche et al., 2005b).  Direct benefits of work accommodation include decreased worker anxiety (Pransky, Shaw & McLellan, 2001), reduced re-injury rates (Yassi et al., 1995), retaining valued employees, increasing employee productivity, and eliminating costs associated with training new employees (Hernandez et al.,   10 2009; Job Accommodation Network [JAN], 2012).  Indirect benefits include improving colleague interaction, increasing overall company morale, and increasing overall company productivity (JAN, 2012).  However, a disconnection exists between the effectiveness of accommodations and perceptions of workplace costs (Schartz, 2006).  Though there is evidence that workplace interventions reduce sickness absence (van Oostrom et al., 2009; see also Franche et al., 2007), others suggest that workplace interventions need to account for the social context and provide opportunities for communication and interaction to ensure success of the accommodations and other workplace interventions (Gates, 2000; Gates & Akabas, 2011; Franche et al., 2005b).  2.2 Work Accommodation Process and Implementation According to Gates (2000), the traditional view of accommodation as technical changes to job tasks, job routines or the physical environment is missing a key component of the social impact of accommodations in successful RTW outcomes.  The RTW accommodation process often requires the cooperation and support of others in the workgroup (Colella, 2001; Tjulin, MacEachen, Stiwne & Ekberg, 2011).  Accommodation requests and implementation are negotiated processes requiring a balance of worker, employer and workplace needs (Gates & Akabas, 2011).  When accommodation is recognized as a social process, there is the ongoing need to evaluate whether or not the accommodation best meets the needs of stakeholders (Gates & Akabas, 2011).  Under-accommodation or over-accommodation can also have adverse implications for involved parties (Gates & Akabas, 2011).  Cleveland and colleagues (1997) assert that accommodations are not limited to responses to disabled individuals, and that organizations routinely use accommodations to compete for qualified individuals by adjusting work activities or the work environment.  Organization justice literature indicates that the   11 worker?s satisfaction with the accommodation process is not based purely on the accommodation outcome (Balser & Harris, 2008). 2.3 Stakeholders and Social Interaction Research RTW researchers have begun to enlarge their focus from workers and the physical nature of their injury and recovery, to include the key roles of other stakeholders and psychosocial factors to reduce work disability. There is an emerging body of research on how key stakeholders influence the RTW process.  Long-term work disability is seen as a result of interactions between the worker and three systems: the healthcare system, the work environment, and the financial compensation system (Franche & Krause, 2002; Loisel et al., 2001; vanOostrom et al., 2009).  Some researchers have explored the varying perspectives of the stakeholders in the RTW process.  Friesen, Yassi and Cooper (2001) conducted a qualitative study looking at the facilitators and barriers to RTW from the perspective of various stakeholders and developed a conceptual model of system levels.  In the study, all stakeholders groups agreed that ?positive relationships?, good communication and working together were important to success in the RTW process.  Structures which promote communication among all stakeholders are most effective if the individuals involved exercise trust and establish credibility by following through with the formal plans and programs (Friesen et al., 2001).   However, Franche and associates (2005) challenge the assumption that all stakeholders need to be involved for optimal RTW outcomes.  They postulate that modulating the level of involvement of stakeholders may lead to a reduction in conflict and improve RTW outcomes.  MacEachen and associates (2006) also found that RTW involves complexities related to beliefs, roles, and perceptions of many stakeholders.  Good will and trust are overarching conditions that are central to successful RTW arrangements. The authors provide that the condition for goodwill   12 exists largely in the social environment of the firm.  Goodwill was related to occupational bonding or job attachment with employers and co-workers or in the ?moral economy? of the company (MacEachen et al., 2006).  The absence of goodwill can undermine efforts by all parties in the RTW process and can lead to an environment characterized by suspicion.   Not surprisingly, the worker?s active participation has been found to be instrumental in successful modified work programs (Loisel et al., 1997).  A concept closely linked to the social climate of work and the worker?s role in RTW is ?legitimacy?, that is, the degree to which an injured worker feels believed by others regarding authenticity of their injury and symptoms (Franche et al., 2009).  According to Friesen and associates (2005), human interactions and structures which allow for and encourage worker participation and empowerment in the RTW process, are vital to the well-being of the worker and his/ her ultimate RTW.  2.4 Summary and Research Questions  Overall, a wide range of determinants have been identified that influence RTW outcomes (Krause, Dasinger, Deegan, Rudolph & Brand, 2001; MacEachen, Clarke, Franche & Irvin, 2006; Pransky et al., 2002). As interest in factors associated with disability management versus pain management has increased, so has the number of clinical and workplace interventions intended to facilitate a safe return to work or prevent lengthy work absences (Shaw, Linton & Pransky, 2006).  Few of these interventions, however, have been designed to target specific risk factors in social interactions, particularly with the increased practice of early RTW practices where the individual re-enters the workplace before a full medical recovery.  Gaps exist between known accommodation interventions and how to implement them.  Existing accommodation research has mainly looked at the effectiveness of modified work programs and factors that impact RTW outcomes.  Due to its multi-interactional and dynamic nature, the RTW process is   13 laden with potential for miscommunication and misunderstanding with regard to important social aspects of work accommodations.  This grounded theory study from the perspectives of three key stakeholders: (1) the injured worker, (2) the workers? compensation system, and (3) the workplace system, asks the following overarching question and sub-questions:  1. How do injured workers, workers? compensation representatives and employer representatives construct social and interactional aspects of RTW accommodations? a. How do the three key stakeholders construct their expectations and perceptions of the RTW accommodation process? b. What are the barriers and facilitators of RTW accommodation as perceived by these three stakeholders?  For simplicity, the workers? compensation representative and employer representatives will henceforth be referred to as the insurer and employer respectively.  As well, this thesis was conducted as part of a larger research study entitled, ?Towards Effective Return to Work for Injured Workers:  Accommodation as Social Interaction?.  There were four members to the research team - Izabela Schultz with expertise in RTW, Richard Young with expertise in grounded theory, and Alison Stewart who undertook the insurer and employer portion of the study.  I was responsible for the worker portion of the study and the integration of data for the study results.     14 Chapter  3: Method  In order to advance knowledge in social interactions specific to the RTW accommodations process, a qualitative research design was deemed appropriate.   The flexibility of qualitative research permits the researcher to follow leads as they emerge and be ?discovery-oriented? as the concepts pertaining to the given process are not adequately understood or conceptualized (Charmaz, 2006; Creswell, 2013).   3.1 Study Design and Rationale  The aim of this study was to develop a theory of social interactions grounded in the RTW experiences of three key stakeholders?the injured worker, the insurer, and the employer.  Given that there are considerable gaps that exist in our understanding of what social processes facilitate or hinder an effective RTW accommodation, a grounded theory qualitative study is a preferred starting point to further understand this process (Charmaz, 2006; Corbin, & Strauss, 2008; Creswell, 2013).  Grounded theory (GT) method provides guidelines for conducting inductive quality inquiry such that issues of importance to participants emerge from the stories they tell (Bryant & Charmaz, 2007).  This method enables researchers to study the development, maintenance and change of individual and interpersonal processes to generate an emergent explanation of a process, action or interaction from empirical data (Charmaz, 2003).  Grounded theory has been described as an approach with various methods.  Despite the variations in grounded theory, engaging in any form of grounded theory requires the researcher to address a set of common characteristics and common epistemological underpinnings from the founding fathers, Glaser and Strauss: treatment of the literature, theoretical sampling, constant comparative methods, coding, memo-writing and the measure of rigour (Charmaz, 2006; Corbin & Strauss, 2008; Glaser & Strauss, 1967).  A constructivist grounded theory method as described   15 initially by Charmaz (2000; 2006) and Bryant was utilized to develop categories from the data (Bryant & Charmaz, 2007).  This form of the grounded theory method attends to issues such as reflexivity, the research context, and the inescapable effect of prior knowledge and existing literature (Bryant & Charmaz, 2007).  3.1.1 Epistemological stance and theoretical orientation This research study considers the topic from a social constructivist paradigm with the stance that individuals develop subjective meanings of their experiences that are varied and multiple. Constructivist grounded theory assumes that the researcher plays an active and vital role in the research process in developing dialogue from which data and categories eventually develop (Bryant & Charmaz, 2007).  The constructivist grounded theory is also in line with my subjectivist epistemological stance and relativist ontology.  Within this stance, the data reflects the researcher and participant?s constructions.  In line with constructivist view, participant?s subjective meanings are formed through interactions with others and through historical or cultural norms that operate in individuals? lives (Charmaz, 2006; Creswell, 2013).  As a researcher, I am part of the research and my positions, perspectives and interactions affect the research, as do my prior knowledge and experience in the rehabilitation field.  Theoretically, I take a biopsychosocial perspective on disability and this is the approach of this study.  Schultz and associates (2007), provide that there is no one unifying biopsychosocial theory, but suggest a unified and specific model that has inclusion of the key elements.  My biopsychosocial perspective of occupational disability considers the following components to be interrelated as described by Schultz and associates: 1) personal characteristics of the injured worker and environment/social system; 2) reciprocal interactions among multiple key macro-, and meso-system factors involved in RTW; 3) microsystem inter-relationships among individual   16 microsystem factors: medical/physical, demographic, and psychosocial interacting with work demands; 4) expectation factors; 5) environmental variables; and 6) time factors (Schultz et al., 2007).   Professionally, I work as a Vocational Rehabilitation Counsellor in the capacity of helping individuals with persistent and severe mental illnesses and physical illnesses to return to work.  I have worked using supported employment models with clients who have been off work for many years and may require accommodations.  I believe this work informs and influences my understanding of the impact of extended disability on individuals and systems.  As a researcher, I bring my personal experience with physical injuries, rehabilitation, and accommodation requirements to this research project.  I also recognize that my gender, age, ethnicity, professional status and differences with research participants may affect the content and direction of interviews.  Relevant to this study is the other interviewer, Alison Stewart who also works as a Vocational Rehabilitation Counsellor with previous experience with grounded theory research.   3.1.2 Emergent design Grounded theory has an emergent rather than fixed design.  In grounded theory, researchers begin their studies with certain guiding empirical interests and general concepts that give a loose frame to these interests (Charmaz, 2006). The research question in a grounded theory study is not a statement of the phenomenon being studied, but rather the problem emerges and questions regarding the problem emerge to guide theoretical sampling.  The flexibility of a qualitative grounded theory permits the research to follow leads as they arise.  Semi-structured interviews, with an initial protocol (Appendix A) were used to explore the research question.  The interview protocol served as a tentative tool to develop ideas about processes from the data.  When sensitizing concepts proved to be irrelevant, they were dispensed (Charmaz, 2006).     17 Another unique feature to the grounded theory method is the delayed literature review.  However, a researcher needs to have sufficient knowledge of the research literature to sensitize the herself/himself to the core themes, categories and ideas that recur in the literature (Charmaz, 2006).   Therefore, I conducted a preliminary literature review to become sensitized to the relevant themes and categories.  A second literature review was conducted of the core processes that emerged for the data analysis and the earlier literature review was reviewed in light of the developed grounded theory.   3.2 Data Collection and Procedure  The workers? compensation system with jurisdiction in this study is called WorkSafeBC.  In the province of British Columbia (B.C.) where this study was conducted, there is no requirement under the Workers? Compensation Act for employers to rehire injured workers, though there are incentives for employers related to insurance premiums.  This is a no-fault system whereby workers also relinquish rights to litigation for the injuries.  However, it is important to note that several provinces and territories in Canada under workers? compensation legislation impose a legal obligation on certain or all employers to take all reasonable steps to return injured and ill employees to their pre-injury job as quickly as possible. For this obligation to apply, the illness and injury has to be work-related, although all employers have a general duty to accommodate to the point of undue hardship under the Canadian Human Rights Act (CHRA).   3.2.1 Recruitment Returning to work injured workers were recruited through local rehabilitation clinics with programs providing services to the workers? compensation board.  Worker participant interviews took place from October 2011 to November 2012.  Insurer representative and employer recruitment and interviews were conducted by phone from 2010 to 2012.  Worker and employer   18 interviews were audio recorded and professionally transcribed verbatim.  Insurer representative interviews were hand recorded by trained Research Assistants.  Self-reported injury and RTW dates were considered sufficient for this study to determine the duration of disability.  Specification of work sites, other concurrent interventions and contextual information were collected to help differentiate the emerging research literature (Krause, Frank, Dasinger, Sullivan & Sinclair, 2001b; Cleveland et al., 1997), for transferability of findings, and constant comparison.  Recurrence of work disability was also noted for each worker interviewed, since a first RTW does not necessarily mark the end of the disability period (Young et al., 2005; van Oostrom et al., 2009). As well, Young and associates (Young et al., 2005) found that the work re-entry stage includes concerns about job performance, disability recurrence, and coworker and supervisor interactions, which also guided exploration of the research questions.   3.2.2 Sampling   Approaching rehabilitation organizations working with injured workers in the RTW process, I initially used purposive and intensive sampling.  A sample of individuals with workplace injuries returning to work with an accommodation were selected and interviewed.  Individuals from varying occupations, industries, age ranges, ethnicity and a mix of genders were sought initially.  Next, theoretical sampling was used as themes emerged in the data analysis (Charmaz, 2006).  Discriminant sampling was used in order to determine when categories were saturated or when the theory was sufficiently detailed (Charmaz, 2006; Creswell, 2013).    Demographic information and RTW data on worker participants was collected such as age, job title and industry, length of sick leave, RTW date, type of accommodation(s) received and duration of accommodation(s) in a form (Appendix E).  The literature review also suggests that the type of accommodation received or nature of accommodation, rationale for   19 accommodation and who instigated the accommodation are relevant; therefore evidence related to those were gathered from the interviews (Cleveland et al, 1997).  3.2.3 Study participants Twenty-seven participants were interviewed for the study, which included 17 worker participants with accepted workplace injury claims, 5 workers? compensation insurer representatives and 5 employer representatives.  All workers returned to the pre-injury employer and many workers had long work histories with the same employer prior to the injury, an average of 10 years.  Workers had a range of diverse musculoskeletal conditions, including upper extremity and back pain and other physical conditions, in all phases of disability as defined by the number of days off work (Franche & Krause, 2002).  Workers with both temporary and permanent work accommodations were included in the study.  Injured workers with severe brain and spinal cord injuries were excluded, as were those with concurrent severe mental illness diagnoses, due to probable additional social factors in the work accommodation process.  Workers were interviewed between 1 to 8 weeks after returning to work with an accommodation.  Insurer and employer representatives were required to have prior experience with RTW accommodations.  All employer participants were from medium to large organizations, often with extensive RTW programs. (See Table 1 for Participant Details)     20 Table 1: Summary of Participant Details  Worker Sex Age Industry/Sector Education Level Employment (Pre-injury) Time Off (Weeks) 1 Male 43 Service Bachelors 1.5 years 21 2 Male 41 Transportation College 4 years 16  3 Male 41 Landscaping High School 6 years 2 days 4 Female 60 Service Bachelors 5 years 11  5 Male 59 Healthcare  College 3 years 10  6 * Male 47 Trades University 1 year  8  7 Female 50 Service Bachelors 20 years  20  8 Male 29 Manufacturing High School 3 years 12  9 Female 64 Administration  University 12 years 32 10 Male 49 Construction  High School 1.5 years 20  11 * Female 50 Healthcare College 22 years 36  12 Male 31 Service High School 1.5 years 4 13 Female 54 Public Services University 27 years 20 14 Female 54 Administration College 12 years 12 15 * Male 47  Service College 31 years 72 16 Male 28 Trades College 3.5 years 32 17 Female 52 Public Services College 18 years 7 Averages  47   10 years 19.6 weeks * Workers with previous work injury claim and RTW experience  Employer Sex Position Industry RTW Program Union 1 F HR Manager Construction Yes Yes 2 M Regional Manager Food Industry Yes Yes 3 F Regional Manager Provincial Public Sector Yes Yes 4 M Regional Manager Food Industry Yes Yes 5 F Regional Manager Hardware Industry Yes No  Insurer Sex Position 1 F Nurse Advisor 2 F Vocational Rehab Consultant 3 M Case Manager 4 M Vocational Rehab Consultant 5 F Nurse Advisor    21 3.3 Data Analysis and Theoretical Sampling The data analysis process was guided by the grounded theory methodology.  In accordance with this method, simultaneous data collection and analysis occurred (Charmaz, 2008).   3.3.1 Coding the data The first step in data analysis was open coding, where elements of the data were classified into themes or categories and relationships between categories such as commonality, association and implied causality were identified.  The creation of analytic codes and categories were developed from data, not preconceived hypotheses (Charmaz, 2006)?another distinguishing feature of the grounded theory method.  The initial literature reading generated initial codes with a topic guide to direct initial coding of actions and processes.  Line by line coding was conducted with a focus on actions.  In vivo codes were initially used to ?stay close? to the data.  Codes were kept simple and precise and I moved quickly through the data as suggested by Charmaz (2006).   Next, focused coding was conducted, where the initial codes were used to review the data.  Focused coding allowed me, as the researcher, to create and try out categories, which developed an analytic framework to make comparisons among data, incidents, contexts and concepts (Charmaz, 2006).  Overall, the data was broken up into their component parts or properties and defined by the actions on which they rested.  I looked for tacit assumptions, explicating implicit actions and meanings, crystallizing the significance of the points, and identifying gaps in the data (Charmaz, 2006).   Throughout the process, the following questions guided the analysis: What process(es) is at issue here?  How can I define it?  How does this process develop? How does the research participant act while involved in this process? What does the research participant   22 profess to think and feel while involved in this process? What might his or her observed behavior indicate?  (Charmaz, 2006)   3.3.2 Memo-writing and constant comparison  The crucial intermediate step between coding data and writing first drafts of papers is writing analytic notes through memo-writing that explicate and fill out categories (Charmaz, 2006).  Memo writing elaborates processes, assumptions and actions that are subsumed under the initial code(s) and analyzes them from every angle, in order to take the categories apart by breaking them into their components.  Memos included using constant comparison, which is another feature of the grounded theory analysis.   In particular, memoing was used in the analysis to compare and consider: 1) stakeholders to similar stakeholders, e.g. worker to worker, insurer to insurer, employer to employer; 2) one stakeholder to another?e.g. worker to insurer, insurer to employer; 3) same participant at different times.  The constant comparison in memo writing led directly to theoretical sampling as I returned to the sample population to further develop the emerging theory (Charmaz, 2006).  In other words, this simultaneous data analysis led to theoretical sampling, which delineated the properties of categories and clarified relationships among emerging categories (Charmaz, 2006).  Advanced memos were used to take the focused codes and raise codes into conceptual categories.  Data saturation and raising conceptual codes to categories was achieved through ongoing discussion with other investigators in the research project.  3.4 Criteria for Judging Rigour  Ensuring quality in qualitative research is a contentious issue with diverse opinions.  Charmaz (2006) offers a number of criteria for grounded theory research studies including credibility, originality, resonance, and usefulness.  Within the qualitative research community   23 there is discussion about whether there should be a generic quality criteria for all qualitative research.  In this study, various strategies were used to improve credibility including respondent validation, clear exposition of methods of data collection and analysis, and reflexivity (Mays & Pope, 2000).  Reflexivity was used to guard against forcing interview data or failing to elicit participants? experiences in their own language.  Scrutinizing how I gathered data and which areas I sought further questioning improved the quality of the data (Mays & Pope, 2000).  For example, my review of the interview transcripts in accordance with simultaneous data collection and analysis assisted to identify which topics I explored with participants and guided future interviews.  In other words, my review of interviews allowed me to identify topics that participants described but I may have selected another aspect for questioning or commenting.  Furthermore, workers may have perceived my vocational rehabilitation background to reflect a worker bias and been more inclined to share their experiences as a result.    Scrutiny of my adherence to the GT method and field notes was utilized to further improve the quality of the data and to support the emerging analysis in its social context (Mays & Pope, 2000).  Verbatim transcription of interviews was also used to ensure trustworthiness of the data.  Particular attention was given to ensure my notions of what was most significant were not imposed and to ?stay close? to the data (Charmaz, 2006).  Credibility was assured by a process of collaboration and peer debriefing with the research team in ongoing data analysis.  Dependability of the findings and ?confirmability? of the data were enhanced by review by members of the research study team.  Two of us on the team, analyzed and coded initial interviews independently until there was agreement on coding, development of focused codes, and initial conceptual categories for theoretical sampling.     24  Finally, theoretical saturation is what grounded theorists aim for, though disagreements exist about its meaning (Charmaz, 2006).  Charmaz argues that saturation requires conjectures that properties of a category are saturated (Dey, 1999) because one cannot produce evidence to support this conjecture but suggests a preferred term of ?theoretical sufficiency?.  Therefore, I made judgments of theoretical sufficiency when no new categories emerged in my data analysis and there was repetition of properties of categories.  In addition, sampling issues have been clearly articulated in the methods section in support of establishing theoretical sufficiency and transferability of the findings (Kuper, Reeves & Levinson, 2008).   25 Chapter  4: Research Study Findings Data from the perspectives of three key stakeholders were analyzed to develop a theory to explain social interactions in the RTW accommodation process.  Application of Constructivist Grounded Theory produced a middle range theory, which emphasizes practices and actions, rather than explain ?reality? (Charmaz, 2006).  Participant quotes illustrate aspects of the theory and participant perceptions.  To improve ease of reading, fillers such as ?um? and ?ah? have been removed from verbatim transcriptions and additions have been included within brackets, while preserving the original intent and meaning.  4.1 A Grounded Theory of Social Interactions in RTW Accommodations The findings of this study indicate that stakeholders construct perceptions of social interactions of workplace accommodation based on core processes of ?developing trust? and ?balancing control? (Figure 1).  These two social processes are distinct, yet interdependent and fundamental to social interactions in the RTW accommodation process.  Developing trust subsumes: (1) communicating with other stakeholders, (2) evaluating trustworthiness, (3) building relationships, and (4) managing expectations. Balancing control is attained through: (1) establishing guiding principles of interactions, (2) managing risk, (3) managing needs and, (4) creating options.    26  22222   Figure 1: Theory of Social Interactions in RTW Accommodation Process among Three Key StakeholdersWork Accommodations Received Consequences & Goals ? Returning worker to productivity ? Satisfaction with work accommodations ? Reducing losses ? Claim closure I n s u r e r  E m p l o y e r  Developing Trust ? Communicating with other stakeholders ? Evaluating trustworthiness ? Building relationships ? Managing expectations  Balancing Control ? Establishing guiding principles of interactions ? Managing risk ? Managing needs ? Creating options  W o r k e r  Doctors Rehab Staff Supervisor/Manager Coworkers Unions   27 The focus of developing trust and balancing control in the accommodation process served to: (a) support successful RTW outcomes, (b) ensure a positive experience for all stakeholders, (c) reduce potential losses or litigation, and (d) ultimately attain satisfactory claim closure.  These two core processes are embedded within the context of: (1) the worker?s circumstances, (2) workplace factors, (3) economic labour market and (4) societal views of illness. These contextual conditions, along with the social interactions among stakeholders, influence the quality of the accommodation process in duration, level of satisfaction, perceived control, and complexity.  Although the core processes are explored in sub-categories for theoretical description, they are interconnected and dynamic.  The proposed core processes in this grounded theory are applicable for all stakeholders but how each stakeholder conceptualizes the processes varies.  Table 2 further explains categories, properties, dimensions, and consequences of balancing control and developing trust. 4.2 Defining Trust Trust is defined by the Merriam Webster Dictionary (2013) as, (a) assured reliance on the character, ability, strength or truth of someone or something; (b) one in which confidence is placed.  Similarly, in this theory, stakeholders defined trust as honesty in communication, consistency in follow-through, belief in others? integrity, and consideration of others? needs/perspectives.   I expect the employee to commit within the best of their abilities to the process, to trust that they?re being carefully guided within our professionalism and ability to provide assistance to help them get back to a job safely... that he?s truthful in terms of what?s going on for him, that he compartmentalizes what my role is versus other people he?s upset with in the system.  (Insurer 3)   28  Stakeholders described varying levels on a continuum, high trust, neutral trust, low trust, and distrust.  In this theory, most stakeholders enter the accommodation process with a general sense of distrust, based on the perception that individuals may manipulate the situation for a preferred outcome. This sense of distrust is also possibly due to the proliferation of negative stories/perceptions in society.  Due to the precarious nature of trust, a distrusting dynamic could be established relatively quickly if the perceived magnitude and dimension of a violation of trust were significant, even if there were no previous violations.  Perceived trust violations will be discussed further in the section ?Evaluating trustworthiness?.   Table 2: Categories, Properties and Dimensions of Developing Trust and Balancing Control in Social Interactions of RTW Accommodation Process  Category Properties Dimensions Consequences Core Category:  Developing trust  Disposition toward distrusting Honesty/clarity in communications  Integrity of others / Following through by stakeholders in systems History-based trust Trusting to distrusting environments/interactions Perceived honest to dishonest communication Perceived high integrity to low integrity Consistent to inconsistent follow through Positive to negative past interactions Enables stakeholders to work collaboratively Balancing of control through more formal processes/policies Assists to return worker to productivity Sub-category: Communicating with other stakeholders Quality of contact Sharing information Awareness of communication between other stakeholders Direct vs. indirect modes of communication Negative vs. positive communication experiences  High disclosure vs. low disclosure Highly aware to no awareness of other stakeholders Efficiency of interactions Effectiveness of communication  Sub-category: Evaluating trustworthiness Examining trustworthiness and integrity of stakeholders Dealing with perceived trust violations  Stakeholders considering your interests vs. out for themselves Small to large violations of trust Perceived high social capital to low social capital  Collaborative to cautious to guarded environment Increase, maintain or decrease motivation to build relationship Change in expectation of cooperation     29 Category Properties Dimensions Consequences Sub-category: Building relationships Establishing common goals Managing reputation  Types of exchanges Modes of communication Clarity vs. ambiguity  Mutual respect vs. frustration Potential increase or decline in developing trust Perceptions of actions Expectations of trust vs. distrust Sub-category:  Managing expectations Clarifying expectations Time expectations of recovery   Maintaining vs. reducing expectations  Supportive of early RTW practices vs. 100% before RTW mentality Accepting the situation Reducing expectations as negative emotions are draining Major category: Balancing control Perceived imbalances in control Perceived biases in laws, systems and policies  Perceived losses in accommodation process Navigating a complex, interdependent process Regaining sense of control vs. increased frustration and negative emotions Stop additional losses vs. recouping losses Forced cooperation vs. voluntary cooperation Confidence vs. distrust in system Familiarity vs. unfamiliarity with the system Incentive to cooperate  Empowerment  Sub-category: Establishing guiding principles of interactions Collaboration for closure of claims Cooperation for efficiency Active participation in RTW efforts Collaborative to disconnected Inactive to active participation Reinforcing RTW efforts to decreasing motivation to cooperate Improves outcomes and reduces potential losses for all stakeholders Sub-category: Managing risks Recognition of worker limitations Workplace readiness to handle RTW Worker concerns for re-injury Impact of accommodation on many others  Awareness of workplace policies and legal obligations Dealing with 100% before RTW mentality High vs. low recognition Clarity of accommodations to all stakeholders Prepared vs. unprepared for re-entering worker Worker determined readiness vs. RTW pressure to do more before ready  Education and awareness of workplace   Reduced fear of injury Dealing with potential losses Sub-category: Managing needs Returning worker to productivity  Differing priorities Helping company / meeting business needs Partial to full meeting of needs Validating concerns to disregarding  Desire to return to full duties vs. other agendas  Being valued as a stakeholder Increased or decreased productivity at the workplace Sub-category: Creating options Availability of options Desirability of options  Authoritative involvement Desiring meaningful work Determining reasonable accommodations Many options to no options Highly desirable duties vs. undesirable duties Perceived reasonable vs. unreasonable accommodations  Regaining control for all stakeholders Creative solutions   30 4.3 Developing Trust  ?Developing trust? ranged on a continuum from pre-existing trust to distrust, which was influenced by earlier contact, prior to the RTW accommodation process.  Workers often perceived a high level of trust in the relationship with the employer based on perceived strong workplace reputation prior to injury.  However, the worker was often new to the insurer and employer representatives, even if the worker had been with an employer for multiple years.  Workers often expected that previous work history would be known to other stakeholders, and considered as a starting point for developing trust.   And I work really hard. And you know I would skip breaks. I would start early, stay late. And I wouldn?t put in for all my overtime. But it?s pretty common I think that it doesn?t matter how valuable, how hard, or how great of a worker you think you thought you were or you were. That when you?ve been away for a while you?re of no use to a company, basically. (Worker 15)  Supportive and caring environments were often conducive for developing trust.   I think just to have it being supportive?supportive rehab, supportive workplace workers? compensation board?you know all the different components. If you have everybody being really supportive I think it makes for a successful return to work.  That really helps.  (Worker 11)  All stakeholders expressed apprehension about fully trusting other stakeholders.  Moreover, trusting or distrusting was neither linear nor static, but a process with opportunities for repairing/increasing and wavering/decreasing.     31 But, I think what happened was the overall relationship between me and my company that I work for has really, markedly improved.  You know, it?s just gone up and up and up.  Also, I think because when I was able to do more tasks, I always just continuously kept going to take more tasks.  They realized, you know, I wasn?t just sitting there just old poor me, look at me.  (Worker 3) 4.3.1 Communicating with other stakeholders Developing trust involved communication with other stakeholders, which allowed individuals to gather information about the other stakeholders and determine how to proceed.   It helped to have open, clear communication where something as simple as returning a phone call the same day, putting things in writing that we are agreeing to, that we can get whatever professionals appropriate to assist this client.  (Insurer 4)  Workers and insurers preferred direct in-person contact versus indirect contact by phone or by email but insurers described a lack of organizational support for direct contact due to organizational constraints.  There was more understanding of delays or other problems if trust was increasing in the relationships.  Timely communication was important to maintain trust, especially with significant delays.  The key stakeholders all noted the impact of delays in communication.  Insurers and employers perceived the worker to have the onus of keeping contact and being forthcoming with information.  I expected that the employee would tell me when she was physically ready to RTW and that she would RTW.  Also the employee would contact me at least weekly or if there was an issue.  (Insurer 2)    32 Indirect, infrequent or negative communication was often linked to perceived imbalance of control and lack of cooperation/consideration.  For example, some workers reported being upset with one-sided contact?insurers in contact with the worker when they needed something but not returning calls when the worker had questions.  Overall, negative communication experiences were more salient among stakeholders and were damaging to developing trust within the accommodation process.   They had said something quite negative to him after the second injury, called him a baby and I thought that that was unrealistic and unfair.  (Insurer 3)  Negative communications involved questions concerning: lack of integrity; RTW pressure; lack of consideration for concerns/fears; dishonesty; angry or disrespectful responses; no communication; and exaggeration of injuries.  As well, employers valued insurer?s understanding of the workplace environment, which was facilitated by having a single contact person and previous prior dealings with each other.  As well, insurers valued having an experienced RTW coordinator provided by the employer.  Overall, the frequency and mode of communication impacted the quality of communication.  The quality of the communication affected whether trust was developed or decreased.   In addition to communicating with others, becoming aware of the interactions among other stakeholders was another component of developing trust, and often an indication of collaboration, which was reassuring to the stakeholders.  Being aware of the communication of the other stakeholders was particularly important to workers because they had less experience with the systems and needed to learn how to navigate the complex, interdependent accommodation process.  Workers talked about learning to deal with four systems in the accommodation process: the workers? compensation system, the rehabilitation   33 system, the medical system and the workplace system.  Workers? awareness of communication between other stakeholders assisted them to understand other stakeholders? roles, the working relationship of these stakeholders to each other, and who might be active or inactive in supporting their goals.  Workers often described a need for better integration among systems for improved communication.   I think they are very independent of each other, occupational rehabilitation program, workers? compensation board and the employer.  If they could work together and accommodate the person?injured person back to work, to previous injury, it would improve the return to work.  (Worker 6)  Employers were concerned about communication with other stakeholders that might hinder the RTW accommodation process, especially with doctors. For example, employers perceived some doctors as having inaccurate or inadequate understanding of the job environment and of the role of modified duties.  Employers may also believe some doctors have a bias toward worker?s preferences and lacked objective information for recommendations.   Well, doctors I would say, ?Be more than just a paper pusher and look at the benefits of having employees staying at work.? As far as just as the speed of recovery, instead of just blanket saying, ?Take whatever it is, four days or four weeks off.?  (Employer 1)  Insurers valued communication between employer representatives and the workplace (unions, supervisors/managers and coworkers) that involved an assessment of the social and operational readiness to accommodate the returning worker.    34 4.3.2 Evaluating trustworthiness    Developing trust involved evaluating trustworthiness, in particular examining the motives and integrity of the actions of other stakeholders.  In essence, before deciding to develop trust or distrust in the RTW accommodation process, stakeholders evaluated the demonstrated character of the other stakeholders.  Prior to this point, stakeholders remained open to the possibility of developing trust.    Oh yeah, it just got to the point where I knew that you know that there was no point in me even...you know, I could tell that we weren?t going to get along. You know like that something had changed. And so even though he was very superficial and then sort of nice, but you know I just knew that the whole dynamic had changed.  (Worker 15)  Earlier interactions were relevant in evaluating the stakeholders? characters, especially the quality of the early contact during the injury phase.    So when they (Insurer) call you they treat you like you?re lying. I?I can?t explain it?I?ve never been treated like that?just the demeanour and just their attitude over the phone.  I couldn?t even?I couldn?t wrap my head around it.  Like it wasn?t very nice at all.  (Worker 9)  They didn?t really look after me.  I mean they didn?t really call me once about how you doing, how you feeling and stuff.  Except just telling me when are you coming back to work.  Basically I don?t think they?re more worried about me.  They?re worried about the cost and replacing me with someone else.  (Worker 8)   35 Thus, violations of trust in the early injury phase could be especially damaging to developing trust because trust violations influence evaluation of integrity and trustworthiness.   Well because of what happened with my company waiting for so long to fill out the forms I didn?t trust nobody you know.  I just didn?t.  (Worker 3)  Consequently, stakeholders examined previous violations, additional trust violations specific to the accommodation process, the perceived magnitude of the offenses, and the type of violations.   Specific to the RTW accommodation process, two main violations impacted evaluating trustworthiness and ultimately the development of trust for the key stakeholders?significant delays in communication and lip service to accommodation process. First, significant delays in processing or responding to inquiries were often perceived as trust violations.  Though delays were often expected, significant delays, consistent untimely responses or no communication were perceived as lack of consideration or cooperation, which reduced trust in the stakeholder.  Thus, decrease of trust occurred when stakeholders were evaluated as uncooperative or lacked concern for other stakeholders.   What it felt like is, if it is not their problem, who cares?  They (Insurer) would only contact you when something is wrong.  Like you fill out the wrong paperwork you forgot a form or it?s just whatever.  Is covering their side of the business.  Their need but whatever you need?forget what you need.  Forget your concern, forget your questions?you know just go with the flow.  (Worker 12)  Okay we need you to get somebody?to get somebody on the Board because?you know because he keeps calling this claims adjudicator and they?re not responding to   36 emails.  We can?t even leave messages any longer because their voice boxes are full.  (Employer 5)  Second, lip service to work accommodations was a second trust violation that was a concern for all stakeholders.  For workers, lip service was perceived when workplace practices differed from the company?s stated policies.  Specifically, it could include violations of the accommodation plans, that is when the workplace was not prepared for the accommodation and the worker had to bear the brunt of the consequences.  Workers wanted policies that reflected available resources rather than promises that could not be upheld.   So, they say exactly what they?re supposed to say. But they?re not doing it.  And maybe they try.  I don't know.  I don?t want to be like unfair.  It?s?maybe they try. Maybe it?s difficult to do all these things.  First of all, if the companies, in general, if they could find a way to do whatever they say.  (Worker 2)  But it surprised me that right on the first day that the manager would think that I could go and push a client up a ramp, when it (restriction details) said no.  You know.  So, that left a little bug behind my ear.  (Worker 5)  Another way lip service was described by workers was work practices that put business needs before the worker; for example, when there were insufficient work accommodations because they were not deemed cost effective or when employers were not truly committed to the accommodation process.   They pay lip service to this. We have a union and it?s often?the company just kind of leaves it to the union to figure it out, but they can be really difficult.  The company   37 can be really difficult.  They can make your life hell.  And that?s not their policy.  So they have great policies but they don?t always abide by them.  (Worker 17)  For the employer or insurer, lip service to accommodations entailed the worker saying he/she wanted to return to work but denying every accommodation or modified duty offer.   Well, it doesn?t matter what we offer them, they claim they can?t do it?total lack of participation.  (Employer 5) 4.3.3 Building relationships  Regardless of whether evaluating trustworthiness resulted in an evaluation of distrust, neutral trust, low trust or high trust, stakeholders attempted to work in this context.  Even in distrusting situations, the relationship was built on establishing common goals and managing reputation with the other stakeholders.  Establishing common accommodation goals was prominent in this category for employers and insurers.   The ability of stakeholders to achieve mutual understanding and clarity about the meaning and intent of goals assisted in building better working relationships.  Getting ?on the same page? involved recognizing that all stakeholders benefited from an appropriate and timely RTW.  So, it?s actually, you know, for employers they?re bottom?line motivated.  It?s a cost thing.  If nothing else, if you?re not concerned about your workers? welfare, then think about your wallet.  Yeah, and I mean it?s good for the employee.  There?s certainly a lot of statistics out there about that.  So if you care about your employees, then you?re going to want to do the right thing by them.  Yeah, and you?re going to get them back to work sooner, which is going to save you money.  You?re not having to sit out there paying them benefits.  (Employer 3)    38 In addition, stakeholders wanted to validate the concerns of the other stakeholders in order to create an alliance, which allowed easier identification of barriers to the RTW accommodation process.  The section titled, ?Consequences/Goals of Social Interactions in Work Accommodation Process?, examines the common goals among the stakeholders.   Managing reputation was an important property to all stakeholders in building a working relationship with the other stakeholders.  Workers perceived rehabilitation professionals as having a key role in advocating and confirming their rehabilitation efforts to the insurer and employer.  For workers, building relationship involved communicating to others their commitment to RTW.  You?re showing him (employer) that you have his company?s best interest.  Of course he?s going to take it in consideration that since you have my company?s best interest in your heart?I?m going to have you at my best.  So whatever I can do for you, ask.  Tell me and I?ll help you out.  (Worker 10)  If despite the worker?s best efforts to communicate his/her commitment to RTW, there were ongoing questions of legitimacy, the worker often experienced frustration.   I got the impression from my company that they thought that I was faking my injury. You know, they didn?t come out and say that, but because I?d been on for so long and they expected me to come back... I just didn?t like how I was treated. You know and I thought that it would definitely have a lot of weight because I took a lot of pride and I worked very hard for the company. So, for them to sort of question my integrity is pretty insulting.  (Worker 15)   39 When workers felt mutual respect from other stakeholders, workers described increased ability to focus on recovery efforts rather than dividing energy to manage the relationships with other stakeholders.   For insurers, managing their reputations meant being perceived as objective rather than taking sides, and being perceived as competent and having expertise in order to influence and motivate the other stakeholders.  Some insurers attempted to achieve objectivity by creating an environment of non-judgment that allowed stakeholders to voice concerns honestly and constructively.   I guess the main expectation is for me that I am objective in what I am doing.  I am empathetic because I am a nurse but I need to be objective and see the needs of the employer and the worker and try to not take one side over the other. I also need to be seen as objective and non-judgmental.  (Insurer 1)  Insurers also often considered it their role to manage the reputations of both of the worker and employer with each other.  For example, the insurer may help the worker see that the workplace valued his/her contribution in order to create motivation for recovery and RTW, and vice versa. The employer was open to meet, that we can meet at their office because when my client sees his co-workers, a lot have missed him and are keen to meet/greet him and that?s a very powerful underlying aspect in his own recovery?for him to know that he?s missed and accepted at work.  (Insurer 3)  Managing reputation for employers involved establishing that the workers? limitations were known and that the organization was willing to cooperate and accommodate   40 the worker.  Employers had to manage their reputations on multiple fronts, not only with the insurer and worker but also with other stakeholders in the workplace.  For example, employer representatives had to cooperate and work together with other staff who might be dealing with business needs, operational requirements and staff personality differences. I think that communication is probably the key, and the involvement of the Voc. Rehab, and the employee being aware of the fact that myself, that I did have a good working rapport with the Voc. Rehab.  And the fact that, also with the case manager and the employee knowing that the store was fully aware of his limitations, and was willing to accommodate him.  A lot of times if there is friction between the department manager and the employee that could always hinder that.  But in this case there wasn?t.  It was as good working rapport all over.  (Employer 2)  A lot of it is just educating the manager on the duty to accommodate to start with?why we have to do what we have to do.  And you know basically that it?s their job to educate the rest of the staff then.  (Employer 3)  That they would be open to this RTW and the other employees would also be supportive of it.  Hoping to have a supportive work environment. That I always find starts at the top and works its way down. So if the management is not supportive of it then the employees will not be.  (Insurer 2) 4.3.4 Managing expectations   All stakeholders need to manage expectations.  For insurers and employers, managing expectations meant providing clarity about recovery expectations and roles.  In particular, insurers and employers described challenges with many individuals have a ?100% before   41 RTW? mentality, where full medical recovery is deemed necessary before RTW.   Providing education and awareness about RTW as a recovery strategy was part of managing expectations.  Insurers and employers described the need to ?get people on board with RTW? and convince workers, workplaces and other stakeholders that early RTW is considered best practice in rehabilitation.  Rehabilitation professionals were perceived as having important roles in assisting workers with these RTW best practices and pain management.    And I think in the employee?s case it really impacted I think if they?re psychologically actually ready and to try to return to work.  Because a lot of times I notice with the back injuries or mostly any physical injuries, the employees are always in the fear of re-injuring themselves.  In this case I think also having a physiotherapist or any therapist that?s working that helps them in coaching them with pain management, especially.  (Employer 2)  Employers and Insurers perceived that when medical doctors recognized the value of getting back to work, they were less likely to advocate for inactive time off work as a recovery strategy for workers.   A lot of the time a worker will go to the doctor with pain and the doctor will ask how long they want to be off and the worker will say 3 weeks.  That is not based on evidence but on patient-physician relationship.  This can be an impediment to the employer to the point where they will no longer be interested in having the employee, instead of looking into a graduated return to work option.  (Insurer 1)    42 There are a lot of physicians out there that are of the mentality that if an employee is injured, they should completely remain off work. And shouldn?t work until they?re 100% better. And I think that always definitely hinders it.  (Employer 2)  Employers and insurers might construe a worker?s denial of first accommodation offers negatively, as a ?red flag? or a possible indicator that the worker may have ?another agenda? other than RTW.  You know you have to accommodate people and you have to take them at face value and everyone?s you know, I look at it?if they say they?re injured, they?re injured.  There?s nothing I can do about it.  I can offer them appropriate duties to get back.  And how they respond to that kind of determines how I feel about them.  But everyone starts off the same.  (Employer 1)  At the end of the meeting, I said, ?You?ll notice that he was really wanting to focus on what he couldn?t do and not on what he could do.?  And that was a red flag for us. When someone is hung up on what they can?t do, it?s a lot harder to get them engaged in their return to work I find.  (Employer 3)  Employers and insurers expressed concern about workers attempting to manipulate the situation to create a preferred outcome to their prior workplace situation.  Managing expectations in these cases meant that employers required workers to provide full justification for accommodation requests and that employers would need to have a thorough investigation process for special requests.  Furthermore, some employers expressed that the investigation process is not meant to reflect on the individual?s integrity but a process of   43 sorting through ?legitimate needs? versus wants or desires due to the large number of requests.   So, the fact that we have a fairly formalized process of medical investigation before we grant accommodations, etc. it kind of helps because at least you know that we?re not granting accommodations willy-nilly based on the employee?s say so.  (Employer 3)  However, a number of workers with perceived successful RTW outcomes described declining earlier modified duty offers, as the modified positions were not desirable and they wanted to return to their prior position.  Workers? perceived focus on limitations in the negotiation process may be due to perceived lack of acknowledgement of their difficulties by other stakeholders. Thus, managing expectations often includes working with differing priorities and perspectives among stakeholders, such as RTW in unrewarding work to meaningful work; dealing with differing views on early RTW strategies and other interventions such as designated modified duty positions.  These so called ?designated modified duty positions? were positions carved out for the purposes of accommodations.  For example, these positions were often perceived to be unrewarding work by workers, whereas employers considered them ?favoured positions?.   ?Managing expectations? for workers was often used to handle emotional responses to questions of legitimacy and other emotions, which ranged from anger, anxiety, uncertainty, fear of re-injury, to positive emotions of excitement about returning to work.  As well, some workers reduced expectations of the accommodation process and what assistance might be realistically offered at the workplace, rather than getting upset.     44 They do their job, you know.  So, basically, I knew they don?t care. They are just doing their job.  I didn?t call her (OR Staff). She called me and said, ?How are things going?? And I said this thing happened.  She said, ?Oh, my God. How come this happened?? I said, ?I knew. I told you.? [laughing] This is going to happen. I mean it?s a big company. And to be honest with you, it is not easy for them, you know, to manage all these things.  (Worker 2)  Managing expectations was often used to maintain a positive attitude despite negative circumstances and to stay motivated in the recovery and rehabilitation process.  It was more like, ?When can we start putting you back on the schedule because coverage is low??  I?m just a number.  It is something that I in a way expected.  It?s just a culture right?  If you?re trying to be close with everybody if you?re trying to be close with everybody, emotion gets involved.  Business has got to be tough.  So this is something I can understand but on the receiving end always sucks.  (Worker 12) 4.4 Balancing Control The Merriam-Webster dictionary (2013) defines control as, (1) to exercise restraining or directing influence over, (2) to have power over, (3) to reduce the incidence or severity of (something) especially to innocuous levels.  In this theory, the major conceptual category of balancing control involves: (a) establishing guiding principles of interactions, (b) managing risks, (c) managing needs and (d) creating options.  Stakeholders described varying levels of control on a continuum, from high control to no control.  I felt that by coming back to work, I didn?t have to worry about what I had to do ?cause I knew that my body was going to say what it couldn?t do in a way.   So, I   45 knew that they would cater to me anyways, but if anything got?was going to be tough, I knew I could say no.  (Worker 16)  If I could have talked to somebody about changing something, I think it would have been easier but there wasn?t.  I didn?t know who to talk to.  (Worker 9)  Social interactions in the accommodation process are affected by perceived imbalances of control by the stakeholders.  For example, a worker may perceive that the insurer and employer have all the decision-making authority to grant work accommodations, while employers may perceive a bias in laws and the insurance system toward workers; and still the insurer may perceive that the other stakeholders have the ability to road block the process if they are not willing to accommodate or return to work.  We do get frustrated with the workers? compensation board.  The other thing that?s frustrating about them is, upfront the inconsistency in case management because you have some very employee biased case managers there, some are more employer biased.  Some are more unbiased.  But you kind of don?t know what kind of reaction you?re going to get from the manager that is managing the case.  (Employer 3)  In addition, employers and insurers may have authoritative power such as developing policy or cutting payments, while workers may hold control with their willingness and capacity to participate in the process.  Thus, perceived imbalances of control impact the ability of other stakeholders to do their part and impede reaching goals.   But recently when I tell whatever I tell them that I needed to go.  They say, ?Yeah it?s too busy.  We can?t, you can?t.  Can you wait??  They would kind of deliver the message as yeah you can go, but they kind of sugarcoat it that you can?t go.  Yeah if   46 you don?t have to don?t, but if I don?t need it I wouldn?t be asking for it.  So it?s not how you feel, it?s what they think. It?s what they think you need. And?it?s the need of the business that we can accommodate and because of manpower that we can?t accommodate.  So in a way too bad.  (Worker 12)  If they think that you?re capable of modified duties, they can suspend any loss-time payment, if you?re refusing to show up on site.  So that was very helpful.  Yeah, well, it was very helpful because then the worker didn?t have a pay cheque coming in. (Employer 1)  Furthermore, control imbalances may expose stakeholders to vulnerabilities in exploitation or manipulation, which are related to perceived losses in the accommodation process.  When a stakeholder perceives an existing loss, there is often a fear of additional losses and a sense of reduced control.  Gaining additional control might result in recouping some losses, whereas being able to trust the other stakeholders might reduce fear and anxiety.   I was afraid that I wouldn?t be valued as much because I wasn?t able to do what they asked me.  So I was afraid that you know I might it might give me some setback on advancement, but area my supervisor actually told me, ?No you don?t have to worry.  We?ll keep you.  Your job is safe.  You don?t have to be worried.  Your injury is not going to affect you in any way.?  This is what they tell me, and you know it depends on how it goes.  I guess time will tell.  (Worker 12)  Okay, what made it good?what made it better was their (Insurer) consistency.  By making sure that everybody was following the rules.  That really helped me?from   47 management, the head office, all the way to the supervisors?that every step of the way, they [Insurer] were watching it [workplace].  That encouraged me.  (Worker 3)  Perceptions of forced cooperation, when stakeholders could not exit the relationship, often created feelings of frustration.  The ability to balance control or the willingness of others to relinquish some control, often increased a stakeholder?s motivation to cooperate.  Familiarity or unfamiliarity with the systems also impacted perceived control.  Overall, the complex and interdependent nature of the RTW and accommodation process influenced stakeholders? ability to balance control.  For workers, the perception of control was related to worker-determined RTW readiness versus perceived pressure to RTW.   There was never any, ?You better be able to do your work.?  You know, not ultimatums.  There was nothing of that nature at all. All I saw was?and experienced?was concern and just let us know if there?s any help you need and anything you need, just let us know.  (Worker 3)  Some workers indicated that they had no input into the accommodation process but still had positive outcomes, while others had no input and had negative outcomes.  Workers? perceptions of control or the ability to influence the accommodation process may have mediated the outcomes.  The worker?s ability to determine readiness and appropriateness of accommodations may have facilitated a smooth accommodation process.   They were actually really, really, really supportive and they basically let me write my own program.  Of course they had to oversee it and make sure it was okay, but they basically put me in charge of writing my own return to work program.  I appreciated that because I?ve had experience with this before like returning to work.  (Worker 11)   48 4.4.1 Establishing guiding principles of interactions   The expectation of using the guiding principles of interactions involving collaboration, co-operation and active participation or engagement in RTW accommodation efforts was consistent with all the key stakeholders.   I think everyone is invested in this and that?s a good thing.  Like I think the company and even the workers? compensation board?that they all seem to really recognize that this is better than just throwing somebody in and seeing if they can swim.  (Worker 17)  Because I think they?re doing their best?Occupational Rehabilitation program, workers? compensation board, and the employer?they?re doing what they can.  And I?m doing my part.  (Worker 6)  The properties of this category have some overlap with other categories.  For example, establishing the guiding principles is related to role clarification, which is a property of managing expectations.  However, knowing the roles of other stakeholders did not necessarily create collaboration.  Having common goals also did not guarantee that stakeholders would work together.  There was variation in how well these guiding principles were established.  Some ?triads? were very collaborative and everyone was on the ?same page? while others were more disconnected with only some stakeholders on the ?same page?. The level of cooperation and participation among stakeholders varied and impacted the success of the accommodation process and reduced losses.     49 Having the union involved was helpful.  The client feels that they?re a sense of support?an ?us? versus ?you/I?.  We?re working together in this process to help you versus just the Board.  (Insurer 4)  Whatever I?m now facing?that program I think is somewhere, something is wrong. You?ve got to design properly, followed by the employer or followed by the rehab program team or followed by the case manager.  (Worker 1) 4.4.2 Managing risks   Risk management was important for all stakeholders, and perceived risk was based on potential losses and exposure to vulnerabilities.  The risk of re-injury and subsequent recovery and rehabilitation costs were a main concern for the key stakeholders.  For workers, managing risks was related to finding a balance between following rehabilitation best practices and fear of further injury resulting in chronic or permanent limitations.  Insufficient accommodations in type or duration were concerns for workers, which were often related to workplace safety practices, especially for positions with heavy physical demands and limited accommodation options.  Workers wanted to know that they were returning to a safe workplace but did not wish to be perceived as ?milking the system? nor to lose their job.   I talk to my supervisor and they?re like you know we don?t want you to hurt yourself again and stuff.  So they kind of understand you know but still, for them, customers are the money.  So if you cannot do something they?re not going to keep saying it?s okay, it?s okay, it?s okay.  One day they come up to you, they be like you know it doesn?t work out this way ?cause they want the job?they want me to get it done.  (Worker 8)    50 Most stakeholders understood that the RTW accommodations provided, whether formal or informal, were temporary.    For a few months, or 4 or 5 months, maybe they?re still thinking I?m an injured person.  I came back from injury.  After that oh I think he can do it.  He?s 100%, so we don?t have to help him anymore.  I still need help for a period of time but gradually they (are) going to wean me off the milk.  (Worker 6)  Nevertheless, a discrepancy in the perceived length of time required to return to full duties and duration of RTW accommodations, has potential to break down trust and to influence perceived risks in balancing control.  The type of injury and differences in workplace cultures also influenced definitions of recovery and recovery timeline expectations.  In other words, recovery meant different things to different stakeholders and there could be disagreement about how long it should take the worker to recover.  I think they were concerned that I was probably not?almost wasn?t taking it seriously.  In a way because I was told that initially I was only going to be like a month?maybe two months.  And then like later on I was under the understanding that since I was still hurting that they didn?t really want to be part with me. They wanted me to get going through it but I was just not advancing or not getting healthy. Not fast.  I was a little frustrated about it.  (Worker 16)  Employers, insurers and workers may have had different perspectives on what is meant by ?active worker participation?, which is another area for potential distrust to develop and influence the balance of control.  For employers, managing risks due to over-eager   51 dedicated returning workers not keeping within their physical limitations and risking re-injury was a major concern.   And we have other associates that despite being put on a modified duty plan and they are back at work but don?t respect their modified duties.  And quite consistently like to step outside of them because it causes their re-injury and then they get more time off.  (Employer 5) 4.4.3 Managing needs   Stakeholders noted that validation of other stakeholders? concerns and their needs was important in balancing control.  In line with the interdependent nature of developing trust and control, managing expectations and managing needs were connected.  As well, the needs of the stakeholders were directly connected to the goals of the RTW accommodation process.  The main needs of the key stakeholders were to return the worker to productivity, to achieve a satisfactory accommodation experience, to reduce losses, and to have satisfactory claim closure.  Specific to the RTW accommodation process, most workers wanted to be valued as an employee, and to return to productivity and/or to a position of being an asset to the company.  The need for modified duties was often in conflict with workplace demands or needs.   I was thinking that actually I have to go back to the full duty as soon as possible. Because like I said, either you?re either at this job, you?re either 100% working or you?re not. There?s no in-between.  So, that was my concern was to push myself to finish the gradual return to work and be 100%.  And the employer was?the concern was the same thing.  His concern was well if I can actually return 100% to work after the gradual return.  (Worker 6)   52 Return to productivity for most workers meant returning to their former position and being assisted to return to full duties gradually.   As much as I stubbornly did not want it, people stepping in and giving a hand helped.  Just to ease back in when I?I mean it was probably to prevent me from hurting myself again. Or taking unnecessary risk away.  (Worker 16)  Similarly, while employers wanted to return the worker to productivity, fulfilling the business needs of the position and managing the implications for the workplace were also priorities.  All stakeholders described investment in returning the worker to productivity, with variations in priority and definitions of productivity.  Nevertheless, workers and employers could differ substantially in their understanding of returning a worker to productivity.  Worker concerns with position status or dislike of certain duties were problematic from some employers? perspectives.  For insurers, returning the worker to productivity was defined by the acceptability and appropriateness of accommodations.  Insurers described the importance of a mutual understanding that RTW benefits all stakeholders and to identify the role of accommodations.   Workers should understand that RTW is not the goal of recovery.   RTW is a strategy to reach the goal of full recovery.  That is RTW is part of treatment and is not the overall goal.  The overall goal is full recovery.  (Insurer 2)  In particular, insurers and employers were concerned about determining the objective or ?actual needs? of the worker to RTW.  As mentioned in ?Managing expectations?, perceived resistance to RTW goals from medical professionals or ?100% recovered before RTW mentality? were prevalent barriers to accommodations for both the insurer and   53 employer.   Stakeholders often described a desire and/or need for objective evidence and information, including some workers. A lot of the time a worker will go to the doctor with pain and the doctor will ask how long they want to be off and the worker will say 3 weeks.  That is not based on evidence but on patient-physician relationship. This can be an impediment to the employer to the point where they will no longer be interested in having the employee, instead of looking into a graduated return to work option.  (Insurer 2)  Though returning the worker to productivity was a common need, many stakeholders described other differing priorities and difficulties to ?get on the same page?, including managing organizational constraints and working within different systems.   There is, yes, because there are conflicting priorities in lots of cases. So like sometimes the length of time it takes and that?s partly?particularly when we?re working with workers? compensation board.  (Employer 3)  Not how to recover, not how to or what help I was going to get, or what process to go through. It was just?every call I got was how much they would be paying to me; to compensate me while I was off, which I couldn?t have cared less.  I want my injury fixed.  Different than their priorities their priorities are all dollar signs in my eyes, not the welfare of the person that?s injured.  (Worker 9)  So, we?re getting to that point where managers are like, ?Well, I already have two workers on modified duties and I can?t take on another one.?  So, that?s just something that we're just coming to see now. Yeah, a lot of it is just you know we talk to the managers. I feel badly for our store managers. They?re hit by information   54 from every department at head office all the time. So, I?ve always, you know, kind of talked to staff that you need to acknowledge that the manager?s really busy.  (Employer 3) 4.4.4 Creating options   Stakeholders were aware that creating options was dependent on the workplace and the availability and feasibility of accommodations.  The desirability of the options was important especially for the worker, since he/she would be carrying out the work duties.  Determining a reasonable and acceptable accommodation offer could be difficult, depending on workplace and stakeholders involved.  Hence, considering flexible, creative and evidence-based options were not always part of the accommodation process.  When employer is willing and employee is willing, the process is greatly facilitated.  They?re going to look creatively and be proactive rather than reactive.? (Insurer 2) ?I think the expectation of myself as the rehabilitation expert was to be prepared for the long haul because it was not going to be a quick and dirty RTW, it was going to require encouragement, listen to her suggestions and find some objective unbiased feedback.  (Insurer 5) Sometimes the authoritative involvement of another stakeholder was required to facilitate cooperation in the negotiation process.   I didn?t see it really happening, but then you know when they were saying, ?Okay, look, we?re about to make our own decision about this.?  So, I knew something was going to happen... It was pretty obvious there was a road that the (Rehabilitation Professional) wanted to go down. Yeah she was pretty strict.  (Worker 3)    55 Despite best efforts to create options, people make their own choices and stakeholders are limited in what they can do.    As a Case Manager, I can?t make a worker do anything, but I can only provide them with options and consequences.  I believe that people are allowed to make bad decisions.  (Insurer 2) 4.5 Consequences of Trust and Control  The development of a distrusting or trusting context has numerous consequences that impact on the stakeholders.  In particular, on the stakeholders? need to balance control.  4.5.1 Context of distrust and reduced trust A distrusting context often resulted in an increased need for structure and balancing control through more formal processes, policies and laws in the accommodation process, and in less flexibility from all stakeholders.  Within this context, stakeholders reduced expectations that individuals would follow guiding principles of interaction, especially cooperation and active participation.   It [accommodation position] was something that was forced on me.  And that it was done probably the whole process, in the way that my company went about it was wrong.  I mean I should have been in my previous workplace.  I shouldn?t have been sent out to another site and doing what I?m doing.  And it?s almost like they did it on purpose, so they don?t have to pay me as much.  That?s how I interpret it.  (Worker 15) Hence, as would be expected, perceived satisfaction with the accommodation process was reduced with increased perceived losses to stakeholders.  When workers were distrusting, they were more hesitant to open up and share information with the individual/system whom   56 they distrusted.  Restriction in the flow of information impeded collaboration and cooperation in the accommodation process.  Distrusting created conflict between what the worker was ?supposed to do? and fear of information being used against the worker.  This conflict was noticeable, for example, when workers indicated that they would rather not have gone through the insurer if the option had been available because it created a lot of pressure and a sense of being controlled or monitored.   I just think that the experience is something that I wouldn?t want to go through again.  I would rather not get hurt working you know. Deal with it on my own than rather than dealing with it? seemed like a lot of pressure from workers? compensation and?it wasn?t a good experience.  (Worker 9)  In addition, some workers stated that the compensation given was not worth the stress and trouble of going through ?the system?.   In the end, when workers could not rely on the workplace to adequately accommodate them, they often needed to work differently?taking into account their injury?while balancing personal work ethics.   Before, so, whenever I saw someone I thought this guy?s lazy, he won?t work. You know what I mean?  So, now for second time maybe this?those guys?they?re not lazy.  Or maybe at the beginning they were like me.  But, then, after a while they find out okay, this is like they cannot do it like this forever... Like I?m a hardworking guy. I don't know if it?s good or bad. Whatever. It?s my nature. It?s not easy for me to just take it easy. Ah, so here they tell me now you have to learn to work smart, not hard. (Worker 2)  With distrust, workers were less committed to the organization and often began to consider retraining or other types of work and/or litigation.     57 Well, I still take a lot of pride in what I do.  I mean that?ll never change. I mean I go on and even now I?m working hard but that?s cause I take pride in what I do. But as far as respect for a lot of people in my office, probably not.  (Worker 14)  I have to go back to work. Even though I know I mean I?m in pain. Like I said I want to go back and do my job. But keep looking for a different position if I can.  (Worker 2) 4.5.2 Context of trust   When a trusting environment was created with any of the stakeholders, there was increased collaboration and a reduced requirement for structure in the accommodation process.  Workers considered that the other stakeholder ?had their back?, understood the workers? desire to return to work, and would assist them with a successful return to work without risk of further injury.  In essence, there was a high expectation for consideration and cooperation.  Some workers stated that they had had no input in the accommodation process in these trusting environments.  When questioned further, workers explained that they did not deem it necessary to be highly involved in the negotiations since they had a high level of confidence in the other stakeholders.  However in these cases, the workers also perceived a high level of influence and/or control in the accommodation planning. Well they just had their plan and I just followed it along.  Then, well, actually he showed it to me and asked me if I thought it was okay. Does that make sense? So, I mean I could have had?if I found a problem with it, he would have you know made adjustments I guess, but basically it was based on their program. It all seemed to work out very, very well.  (Worker 13)   58 When trust was developed and maintained with key stakeholders, there was an increased likelihood of perceived successful outcomes and perceived satisfaction in the accommodation process for all stakeholders.  Balancing control supported creating mutually beneficial outcomes and increased incentives for cooperation and collaboration. Letting me write my own program like my return to work program was great.  That?s huge, yeah, that bit of control I guess.  You know so that, and I guess them having trust in me to be able to do that.  I mean obviously they would make their recommendations also and you know I was happy with that too.  (Worker 11) 4.6 Consequences and Goals of Social Interactions in Accommodation Process Just as RTW is both a process and an outcome, so too is accommodation similarly both a process and an outcome.  Hence, four goals and consequences were related to the theoretical categories and were common for the three key stakeholders: (a) returning the worker to productivity, (b) satisfaction with the accommodation process, (c) reducing losses and (d) claim closure.  In this grounded theory analysis, these goals were elements in the definition of a ?successful outcome? for the three key stakeholders.  4.6.1 Returning worker to productivity   The RTW accommodation process had potential to create positive outcomes and even ?new gains? for the worker and the workplace as a part of the accommodations process.   Physically I was getting into shape top-notch shape.  Really which I had only I think been in that kind of shape for 10 years or more for sure.  Yeah it tremendously helped me improve my physical appearance, abilities, and my overall.  Combined with the weight loss, big improvement in my overall appearance and mentally it was very good as well.  (Worker 14)   59 For example, workers who felt empowered in the RTW accommodation process described experiencing improvements in physical health and improved safety practices in the workplace.   Since my injury, our company has put into place a real emphasis on keeping the weight with tarps and all lifting type objects to a certain weight per individual.  They would rather that you wait for the help; there are so many different tasks that we can do in a day. We can get two people to come back to it. And no one gets hurt.  (Worker 3) In addition, the rehabilitation process allowed some workers to gain a new appreciation for their physical capacities.  Workers described a recommitment to their jobs and plans for training and upgrading to advance in their position.  On the other hand, there was also potential for negative outcomes on the worker?s sense of empowerment and reduced self-efficacy.  Workers described experiencing stress due to a distrusting environment and taking a ?guarding/protective? stance.  Increased anxiety and stress due to concerns of dislocation or demotion also affected worker emotional well-being.  If you bring me a lower position, then put me in situation where I fight to survive?I fight for income on the same position.  It?s not possible for me.  They?re not aware we have 3 problems?whatever I was pre-injury, afterward I have another problem to fight?with pain, with clinical diagnosis and psychological recovery and then confidence level.  (Worker 1) 4.6.2 Reducing losses   The accommodation process resulted in different levels of perceived loss.  All stakeholders aimed to reduce their losses.  Often, when one stakeholder did not consider the   60 losses of the other stakeholders, there was more overall loss.  For example, employers offered modified duties involving dislocation and demotions in pay grade or positions that were very contentious and quickly created a distrusting dynamic from the worker?s perspective.   Well I think with the changes in the job perspective I should have had I felt that I should have been included in meetings for the planning process of what was going to change in my job.  I should have been told or, you know, not coming back with all these changes and expecting me to just jump right in and do it.  They weren?t interested in my input?wasn?t of any value to them whatsoever.  So I would say that?s a lot of stress right there.  (Worker 14)  As noted earlier, workers often managed risks through changing the way that they work, but they also used it as a strategy to reduce losses.   You know I do what I can. Before my injury I was doing everything.  Basically they ask me to do this. I was doing it.  I was doing sometimes two different jobs, two different jobs at the same time.  (Worker 8)  Employers also described potential losses in the RTW accommodation process.  There was the initial loss of a productive employee and the necessity to fill in the worker gap.  Specific to the accommodation process, employers described the implementation of one accommodation as having a ripple effect on many others.  Employers with multiple unions were particularly concerned with the legitimacy of accommodation requests as these had the potential to create a ?domino effect?, overriding seniority and moving employees into classifications for which they were otherwise ineligible.    61 So, we?ll offer the junior worker the opportunity to become a general clerk in the store.  But, if they?re junior that means they probably have to work twelve to midnights.  Whereas the day general clerk ah would fall to more senior general clerks to take over that day shift.  So, there are those kinds of things that take place.  So there?s somebody impacted by that.  (Employer 4)  Modified duty and accommodated positions at some workplaces were considered ?favoured? positions with preferred hours or locations.   So, you know there?s some skepticism around those duties ?cause they also have favourable times of day.  So, there are a number of factors for why people like those duties but they also fit people who have damaged backs.  (Employer 4)  Reducing losses for employers meant minimizing the impact of the accommodation.  Employers described the involvement of lawyers, legal aspects of accommodations, and due diligence to investigate accommodation requests as costly.  Larger employers were concerned that though there was not undue hardship for the organization to accommodate workers, often there were significant challenges for departments or units to accommodate workers and manage economic pressure and the ability to serve customers or business needs.   As an organization and we?re part of government quite frankly, and economically we?re never going to get to undue hardship.  Well, really, there?s always clearly the expectation that we?re going to accommodate. We?re going to?you know we?re going to set the bar.  But on an individual, store basis it can be very much undue hardship. So, yeah, we?re going to have to really explore that.  (Employer 3)   62 Accommodation implementation might result in complaints from other staff to unions, an onslaught of new accommodation requests and/or perceived unfairness of the accommodation.   If I go back to the person in charge?like this guy said, ?If anything over your limit, don?t do it.  Don?t worry about anything.? He said, ?Just come back to me.?  But the thing is I want to work with all these people for a long time.  And you know what? I know I can go and complain.  But if you do that, they?ll call you a rat.  You rat me out, so you don?t want to do that because you are here for two weeks on light duty and then you have to go back work with all these people.  So I just work as much as I can.  I felt actually lots of pain, especially the first day.  (Worker 2)  Employers often saw the benefit of reducing losses to both the worker and the workplace, in particular by helping workers to recover and avoid re-injury.   I expect that we care for our employees and make sure that they don?t get injured, or if they are injured to help them with a speedy recovery and to ensure that they don?t become re-injured.  (Employer 1) Employers were also concerned about reducing losses related to presenteeism, whereby workers were concerned about not being productive in the workplace, leading to job insecurity.   It?s not something that they communicated or that I felt from them.  It was only in my own mind. Oh, gosh, I better be able to do this or you know if I, if I can?t, they?ll have to let me go because you have to do your job. You know you have to do what you have to do.  (Worker 4)   63 For insurer representatives, ongoing payment of claims and costs associated with escalating claims were identified, in particular when employers opt out of the RTW accommodation process.  However, the challenges and time required in creating viable options and getting collaboration from other stakeholders were also associated with potential losses.  Relevant to all stakeholders were workers who did not RTW and implications for individual and societal losses in potential, ability and long term disability.    4.6.3 Claim closure   The ultimate goal for the insurer and employer was to close the claim in a timely manner.  A lengthy RTW process could result in increased losses and prolonged vulnerability to other risks.  Workers also often wanted claim closure but sometimes perceived claim closure to be premature if it was considered equivalent to medical recovery or successful RTW.   They just say I?m going to close your file?now you?re on own.  That is the way.  First I have fight three months for my injury.  Now I?m fighting for my pain. Now fighting for my job.  Fighting for my financial. That?s the way.  (Worker 1) Some workers viewed claim closure as a means to leave behind the challenges of dealing with the insurer.  Perceived high levels of satisfaction with the accommodation process were associated with positive reactions to claim closure, whereas perceptions of ?under-accommodation? were considered equivalent to premature claim closure for workers.  One insurer representative stated that his role was often to help stakeholders with closure so that they could move forward with their lives, describing the need for motivation from all stakeholders to be cooperative and collaborative and to recognize that closing a claim could be beneficial for all stakeholders.     64 4.6.4 Satisfaction with the work accommodation process   Overall, the level of satisfaction in the accommodation process was closely connected to the perceived development of trust and balance of control with the other stakeholders.  Workers were most satisfied with the RTW accommodation process if there was respect, related to trust and control in the interactions.   Well, I?ve had nothing but you know, positive experience with it, so, very supportive from the supervisor?s standpoint.  Well, just very positive.  Like there was nothing negative from them.  I didn?t feel like I was being pushed at all or anything else. It was like very respectful of my limitations and you know wanting to know what they were, and then you know basically we?ll work around whatever you need to work around.  (Worker 13)   Evaluations of satisfaction with the RTW accommodation could be very high to very low for workers.  Workers described, ?being fully accommodated? to having little sense of being accommodated.  Workers were often discontent with designated modified duty positions versus returning to the same job and location with flexibility in gradually returning to full duties.   If you?re going to be designing a rehab program for me, why not place on same position to me?  Give me a chance to perform?is the right way.   (Worker 1) Workers felt they could draw on established relationships and social capital when returning to their pre-injury position and work team, whereas dislocation had additional stressors in an already stressful situation. And usually so I have my own shift and I work with my own colleagues.  I know the guys. We work with everything together.  So, we know each other.  It?s easier to work   65 in order to do the job.  But when I go back they cannot put me with my own crew...So, I at first I don?t feel comfortable in those situation. (Worker 2) For employers and insurers, satisfaction with the RTW accommodation process was closely aligned with the perceived legitimacy of the workers? accommodation requests and the ability to offer what was needed while balancing the needs of the other stakeholders.  4.7 Work Accommodations Received  Being accommodated by the workplace communicated care and concern to the worker.    Anything that you need, just you know make sure you ask for it.  I felt really accommodated.  I felt valued.  I felt that I mattered.  I didn?t feel that I was left hanging.  (Worker 4)  It is sometimes assumed that workers who receive ?ideal? accommodations would be more satisfied with the accommodation process.  However, not all workers in this study wanted full modifications or the full time available for accommodations.  They gave me light duties.  I look at them and said, ?What the heck is going on here?? I said, ?(If) I wanted light duties, I would have accepted light duties.  They said, ?Okay ?what you need to do.?  And I did what I needed to do.  I came in halfway.  I didn?t want to come in ?pitter patter?.  I came in halfway and then worked my way up.  (Worker 10) In this exploratory theory, perceived consideration and cooperation from the workplace and other systems impacted on established trust, based on accommodations requested and alignment to these requests.     66 On paper, it?s?I knew on paper it?s?they could do anything.  But it?when you?re actually there it?s a different thing (than) on paper.  They gave me exactly what I asked for.  (Worker 7)  Further, the accommodation received was not the only deciding factor in the worker?s evaluation of social interactions in the RTW accommodation process.  Stakeholder interactions with the worker were evaluated on an individual basis and often compared to the other stakeholders.  A worker might be satisfied with the accommodation process while at the same time be dissatisfied with social interactions with one or more stakeholders or vice versa.   Yeah, the person who?s looking after my file has been awesome, at workers? compensation board.  And that?s huge because I?ve worked with people there that are absolutely terrible.  If it weren?t for her I would have (been further injured).  So, just knowing that she?s only the one person that I really trust in this whole thing?is my case manager.  And there?s actually a couple of people, here (OR Program), have been really good too. So, I mean if would have had an awful case manager, this would have been horrendous.  (Worker 15) 4.8 Context of Social Interactions in Work Accommodations Process The actual work accommodations received mediated the consequences and goals of the accommodation process.  I utilized Bronfenbrenner?s (1992) ecological systems theory, which is also consistent with the biopsychosocial perspective of disability (Schultz, Stowell, Feuerstein, & Gatchel, 2007), when coding the influences to stakeholders from various levels.  The microsystem (micro), mesosystem (meso), and macrosystem (macro) level factors identified in the data as relevant to the social interactions of the RTW accommodation   67 process were: 1) the worker?s situation at the micro level, 2) the workplace factors at the meso level, and 3) the economic labour market and societal views of illness at the macro level.   At the micro level, worker circumstances were prominent contextual factors in the social interactions of the accommodation process.  Data in interviews from key stakeholders identified individual worker differences in: emotional responses, personality, re-injury concerns and fears, previous experience with injury (whether work or non-work related), worker expectations of recovery time, actual recovery progress, workplace history and relationships with coworkers.  And you know if there are of course problems in the workplace.  We?ve had people work in the same small stores sometimes for years and you know you might have animosities sort of develop over the years.  And they never go away and that can impact.  But I find more it?s the?their personal attitude.  Now, their personal attitude may be affected by how they feel about the workplace as well.  (Employer 3)  Meso level factors, such as the workplace environment interact with individual differences to create a specific accommodation context for each worker.  The nature of the job affected available accommodations, with some positions more difficult to modify or accommodate than others.   So they?re pretty good at trying to accommodate because it is unionized.  Right? And the job is such that there is a lot of variety in the functions that they can accommodate more...They have flexibility in moving people around to make something work for you. It?s just the nature of the job allows for it. And they?re pretty good with it. (Worker 7)   68  In all honesty, I worked in heavy industry and it was kind of old school. It was like well they?re better off not here, so, no follow up.  It was from one extreme to another kind of thing. It?s like well we don?t really have limited duties. We don?t really want them here.  (Employer 3)  Workers were also aware that workplaces needed to cover the vacant employment position during their recovery period.    Other stakeholders not included in our study but identified by the three key stakeholders were coworkers, supervisors or direct managers, unions, and family doctors.  Especially prominent with workers were rehabilitation professionals, including kinesiologists and physiotherapists.  Yeah they (Occupational Rehabilitation program staff) just made you, they made you feel better and they helped you to do things you couldn?t do.  ?Cause nobody?s ever helped the whole 9 months, no one helped; no one.  (Worker 9) You know I was really impressed with it.  Because like I said, I had no idea what the rehab thing was. And that was really important. It was a big big big big piece of the puzzle.  Also, I think the rehab ?psychologically too... but that physically that process was?mentally and physically that process was really, really good.  (Worker 7)  Economic labour market factors at the macro level were connected to job security for workers.  Workers in smaller organizations were aware that the employer would need to replace the injured worker to manage workload.  Pressure from the workplace to RTW was also connected to economic labour market factors.  Employers described economic factors in the accommodation process in relationship to managing business needs.     69 And you know we?re they?re (Supervisors) getting a fair amount of pressure especially because of economic times haven?t been so great and reduced labour costs.  So, they?re really in a bind.  (Employer 3)  Societal views of illness were also part of the macro level.  Many stakeholders indicated that they thought it was human nature to think that someone might be taking advantage of the system and ?taking a holiday?.    Thus, there were questions of the legitimacy of the recovery and accommodation requirements, and of grouping individuals into those ?milking the system? and those with genuine chronic injuries.  One worker said,  But I think over a period of time, you can kind of sort of see what type of person?if somebody gets hurt and they?re really trying to milk it and they really don?t want to go back to work and they?re not doing the work, you know should they be treated differently?  Possibly. If somebody comes in, really wants to get better, and is putting in all the work, you know, should they be treated a little different?  Yeah, I think so. You know because those people don?t even have injuries.  So what it does, it probably taints?people that are probably in this program that there?s nothing wrong with them.  And there?s people that are?that really have serious problems and so now?you know people become jaded. It?s human nature.  (Worker 15)  Due to the multifactorial nature of RTW and the RTW accommodation process, two sub-questions were used in this study to focus on the social processes that were relevant to the RTW accommodation process.  These sub-questions also yielded interesting results, in particular the perceived barriers and facilitators in the RTW accommodation process.    70 Though these were incorporated into the grounded theory, it seemed worthwhile to summarize the main barriers and facilitators described by key stakeholders in Table 3. Table 3: Summary of Three Key Stakeholders? Perceived Barriers and Facilitators to the Accommodation Process  Facilitators / Barriers Worker Insurer Employer Facilitators Explanation of processes and how to navigate systems Preferably an unbiased person familiar with the system   Follow up with agreed plans Everyone doing his/her part Occupational rehabilitation programs Working with an employer who is experienced with the accommodations process Conducting a job-site visit In-person meetings with worker and employer Having an existing, established RTW policy & structure to guide the process Early contact with worker Cooperative doctor Previous positive relationship/history with Insurer Barriers Questioning worker integrity/legitimacy Contentious interactions Designated RTW positions that involved dislocation and unrelated duties to previous position One sided communication or untimely responses/no responses to concerns Heavy case load makes it challenging to allow for in-person meetings Uncooperative worker and/or employer Lack of communication from worker and/or employer Lack of concrete medical evidence or clarity from doctor regarding worker limitations Already having multiple accommodated workers at job-site Lack of control in decision-making process regarding accommodations   71 Chapter  5: Discussion The RTW research literature was reviewed in light of the study results and a literature search was conducted of additional research relevant to the developed theory.  My intention was to generate a theory that fits the empirical situation and is understandable to researchers, front-line rehabilitation professionals, and the layperson alike (Glaser & Strauss, 1967).  In this chapter, the 6 major propositions of this grounded theory are reviewed, with discussions of the meaning, relevance and implications of the study findings.  Comparison to the extant literature, methodological considerations, and recommendations for future research are suggested.   5.1 Meaning, Relevance and Implications of Study Findings The first proposition of this grounded theory is that the core processes of developing trust and balancing control guide every social interaction in the RTW accommodation process.  This means that these processes should be considered.  As such, it implies that considering developing trust and balancing control in the RTW accommodation process will increase the likelihood of successful outcomes.  Conversely, it implies that overlooking or ignoring these processes will likely result in less successful outcomes.  The relationship between these two processes has not been previously conceptualized in the RTW research literature.  However, trust and control have been researched in the organization sciences literature and is incorporated into the discussion of the concepts of trust and control.  This body of research could potentially be transferred to broaden the understanding of these concepts in the RTW accommodation process.     Measurement of trust and control.  Considerations of trust and control in the RTW accommodation, would require the measurement of trust and control.  Thus, measurement of   72 trust and control can support the application of these research findings.  Trust is particularly amendable to measurement as various trust measures are currently available within the organization sciences literature (Dietz & Hartog, 2006; Mayer, Davis & Schoorman, 1995).  Development of instruments to measure trust and control for RTW professionals would allow for monitoring trust levels.  For example, a short survey or questionnaire may quickly provide an assessment of trust levels.  However, the measurement of perceived trust, as it applies to the RTW and accommodation process, is in need of further investigation.   Trust and control as interdependent processes.  The second proposition of this theory is that developing trust and balancing control are interdependent core processes.  If there is a lack of trust or an imbalance of control, stakeholders can intervene.  For example, when trust problems occur in the RTW accommodation process, stakeholders can balance control as a strategy to increase trust and vice versa.  In the organization sciences, relinquishing control by stakeholders with high control has been shown to support the development of sufficient levels of trust for collaboration and cooperation (Davis, Schoorman & Donaldson, 1997).  Conversely, excessive utilization of control strategies can reduce relationships to distrust levels (Mayer et al., 1995; Schoorman, Mayer & Davis, 2007).  Distrust has been shown to be counter-productive within organizations, affecting organizational commitment and citizenship behaviours (Colquitt, Scott, & LePine, 2007; Dietz & Hartog, 2006; Kramer, 1999).   Rousseau and associates describe trust as a critical resource between individuals and systems reliant on each other in complex negotiations (Rousseau, Sitkin, Burt & Camerer, 1998).  In essence, developing trust can be considered a strategy in complex negotiations.  The data in this study further imply that high levels of trust were not necessary to achieve   73 successful RTW accommodation outcomes.  The dedicated trust literature indicates that the development of trust in complex negotiations requires an examination of whether trusting is in the best interest of the trustor (Das & Teng, 1998; Skinner, Dietz & Weibel, 2013).  While investment in developing trust has many potential benefits in RTW, it may be difficult due to limited resources and/or conflicting perspectives of various stakeholders.  Trusting also includes vulnerability, risk-taking, uncertainty and opportunities for others to misuse the trust bestowed (Colquitt et al., 2007; Mayer et al., 1995; Bigley & Pearce, 1998; McEvily, Perrone & Zaheer, 2003).  Skinner and colleagues (2013) postulate that trusting excessively or in light of evidence that the trust is inappropriate, links the experience to poor judgment.  Control systems can also be viewed as a strategy to reduce the amount of risk taking required (McEvily et al., 2003).      In this study, building positive working relationships was also possible with stakeholders despite the perceived adversarial nature of the systems or after negative initial contact.  These study findings imply that trust can be restored, repaired and increased, consistent with the literature in the field (Schoorman et al., 2007; Lewicki & Bunker, 1996).  It is generally believed that there is a preference for trust rather than distrust in relationships, as distrust is associated with anxiety and uncertainty, and requiring more scrutiny and monitoring (Rousseau & Tijoriwala, 1999).  In addition, whether the RTW accommodation results in trusting or distrusting has potential long-term consequences for all stakeholders, such as perceived justice (Aryee et al., 2002; Colquitt & Rodell, 2011; Holtz, 2013), and perceptions of leaders (Dirks & Ferrin, 2002; Kramer, 2009).  For example, the trust process involves the principle of reciprocity to sustain it; social patterns of obligation and exchange are created (Skinner et al., 2013) which can improve productivity in organizations (Aryee,   74 Budhwar & Chen, 2002).   Categories of developing trust and balancing control.  The third proposition of this theory is that developing trust subsumes: (1) communicating with other stakeholders, (2) evaluating trustworthiness, (3) building relationships, and (4) managing expectations.  The fourth proposition is that balancing control is attained through: (1) establishing guiding principles of interactions, (2) managing risk, (3) managing needs, and (4) creating options.  Within the RTW field, there is a lack of research on social interactions and there are no theories on the social interactions.  Therefore, an important contribution of this study is the generation of a substantive theory (Glaser & Strauss, 1967) that further delineates the conditions of developing trust and balancing control, which may be used to facilitate successful RTW accommodations.  Even though RTW accommodations have been proven to be successful, gaps exist in formalization and implementation.  I put forth that this theory fills in some existing gaps.  This theory can thus be used to develop specific strategies and remediation plans to formalize specific processes to be customized so that the RTW accommodations are more successful.   These study findings mean that we can further use the framework in the theory to identify policies to develop trust and balance control.  A lack of framework for RTW accommodations often means there are inefficiencies in the implementation of RTW accommodations.  There are redundancies and wastage when ad hoc, trial and error approaches are used.  Additionally, despite improved RTW outcomes, stakeholders may have ?overspent? to achieve the desired outcomes.  Valuable money and time may have been exhausted to get the positive result, which may be used elsewhere.  We hope that the findings of this study will reduce the potential losses by identifying what is working and what is not working.    75 Consequences and goals. The fifth proposition of this theory is that the goals and consequences common to the three key stakeholders in developing trust and balancing control in the accommodation process served to: (a) return worker to productivity, (b) ensure satisfaction in the accommodation process for all stakeholders, (c) reduce potential losses or litigation, and (d) ultimately attain satisfactory claim closure.  These findings mean that all stakeholders considered these 4 criteria to be present in successful outcomes.  The success of the accommodation process in this study was conceptualized on a continuum by absence of any of these criteria.  The more criteria were present, the more successful the process as viewed by all stakeholders.   Context of Social Interactions:  The sixth proposition of this theory is that developing trust and balancing control are embedded within the context of: (1) the worker?s circumstances, (2) workplace factors, (3) economic labour market and (4) societal views of illness.  Developing trust and balancing control may be different based on worker?s situations, workplace factors, industry specific economic indicators and experiences with societal views of illness.  More research can be added that are focused on the contextual factors. For example, there may be cultural and gender differences associated with developing trust and balancing control.  Additionally, these processes might also differ in specific industries and require customized applications.   Overall, risk factors for work disability that have been identified in the RTW literature, include workplace and job-related factors and individual factors (Schultz, 2005).  The issue of motivation, particularly measurement of suboptimal motivation, is implicated in evaluation of both impairment and disability (Schultz, 2005).  Frank and associates (Frank et   76 al., 1998) postulate that the coordination of the main stakeholders is of critical importance to achieve optimal RTW and to decrease risk of chronicity.   5.2 Comparison to Extant RTW Literature A final task in the grounded theory method is to compare the developed theory with existing theories and research (Charmaz, 2006).    Similarities and differences are identified for discussion, in light of the results of this study.   5.2.1 Conceptual models of occupational disability Relevant to the findings of this study are the conceptual models of occupational disability.   Numerous authors have attempted to summarize and provide clarity to researchers and frontline rehabilitation professionals on models, factors and outcomes of RTW (See Franche, Frank & Krause, 2008).  Overall, much of the current RTW research and practice directions have emphasized disability prediction and early intervention (Schultz, 2005).  Likewise, Franche and associates (2008) provided an overview of the operative conceptual models of occupational disability, as they apply to predictive factors of occupational disability.  They describe these models as structural descriptions of occupational disability that also cover temporal aspects of occupation disability (phase-specificity model (Krause et al., 1994).  Similarly, Franche and Krause (2002) state that extant general models of disability tend to focus on risk factors with less emphasis on processes and interventions that sustain RTW and participation in the workforce.   Franche and Krause (2002) put forth two theoretical models, the Phase Model of Occupational Disability and the Readiness for Change Model as a conceptual framework to understand injured workers decision-making and behaviour change processes. They propose that the model captures both the primary agency of the injured worker and the impact of   77 interactions with other systems? stakeholders (Franche & Krause, 2002).  These models often focus on modifiable determinant factors in the development of work disability.  According to Franche and associates, ?When considering the specific nature of the factors, it becomes apparent that an array of strategies are necessary to fully address the problem of work disability? (Franche et al., 2008, p.109).  In current conceptual models, work disability is consistent with a social construction theory, the biopsychosocial model that integrates clinical impairments into a system-based approach, and the ecological conceptual model (Schultz, 2005; See also Waddell & Burton, 2001; Loisel et al., 2002).  Schultz (2005) suggests that the existing research-based models of work disability prediction are not easily transferable to practice, perhaps due in part to difficulties integrating the research data collected from diverse clinical conditions.   As such, the transfer of knowledgeable of the relationship between impairment and occupational disability to practice is limited to specific conditions, stage of disability, context, region or socio-demographic profile of individuals, and specific applications (Schultz, 2005).  Furthermore, despite the apparent agreement on the need for a biopsychosocial model, stakeholders face challenges in the application (Gatchel & Schultz, 2005).  In particular, ?the importance of capturing psychosocial predictors of disability, implicated in most predictive models is one of the challenges? (Gatchel & Schultz, 2005, p.536).  The authors further suggest that, ?An interdisciplinary, biopsychosocial approach will need to be utilized to take into account individual factors, the work environment, social/cultural variables, health care system issues and the economy in general in order to overcome the current epidemic of biopsychosocial disabilities we are facing today? (Gatchel & Schultz, 2005, p.536).  Additionally, there are some excellent general theories of disablement (See   78 Coutu, Baril, Durand, Cote & Rouleau, 2007), which emphasize the importance of the social environment, these only make passing reference to work disability and specifically to the various stakeholders in the RTW process (Franche & Krause, 2002).   Given the vast amount of research, this theory attempted to narrow the focus to direct the research toward developing policies to further develop these concepts.  The theory identified specific processes to help develop policies that will positively affect RTW.  Based on prior research (Franche et al., 2005a; Friesen et al., 2000; MacEachen et al., 2006), this study focused on social interactions, assuming that the accommodation process is complex and multidimensional, not simply about the physical arrangements. Though addressing different processes, this theory also attempts to provide a conceptual framework to better understand social interactions in the RTW process.  However, the framework is amenable to intervention and transferable to practice.  Nevertheless, similar to the other conceptual models, this grounded theory requires further research of the proposed components in the social interactions in RTW accommodations process.  Generally, this grounded theory is also compatible with and complements other conceptual models due to the different focuses of the models.   5.2.2 Work accommodation studies The term ?work accommodation? was used in this study in order to distinguish different types of accommodations such as education accommodations.  Earlier research of RTW accommodations often used the term ?modified work? (Krause, Dasinger & Neuhauser, 1998).  In the last decade, there has been an increased use of ?accommodations? for injured workers.  Previously, accommodations were generally associated with inclusion strategies for individuals with disabilities.  Some studies do not distinguish these two broad   79 categories of accommodations and consistency of terms has not been clearly established.  In attempting to compare the research literature and follow recommended directions for RTW research (Pransky, Gatchel, Linton & Loisel, 2005), it became apparent that the increase use of accommodations has also resulted in a range of how terms are used, resulting in a need to distinguish and clarify terms.  As more and more researchers study this important topic, it is likely that more terms will be introduced.  As noted earlier, the lack of consistent definitions in concepts and terms has hampered the field of RTW (Schultz et al., 2007), and as a result there are additional challenges to determine the relevance of studies and how to translate these research studies to general practice.  This study used specific definitions and provided explicit definitions whereas other studies may have used similar terms differently.   In order to advance the discussion on distinguishing various types of accommodations, I propose the terms ?RTW accommodations? to distinguish work-injury related accommodations.  As noted earlier, the goal of the two broad categories of accommodations is inclusion in the workforce; the term may be somewhat of a misnomer. Furthermore, early intervention has been consistently identified as a predictor of reducing work disability.  However, early interventions are at times used synonymously with the terms modified duties and work accommodations.  There is a need for accommodation researchers to dialogue about terms and to use consistent terms.  In distinguishing accommodation terms, the question arises whether general interventions (targeted at all employees on sick leave) are sufficient to improve RTW outcomes, requires further investigation.  Preliminary findings suggest general interventions are not effective (Hoesfmit, Houkes & Nijhuis, 2012).       80 5.2.3 Accommodation process and implementation Accommodation research has recently focused on individuals with mental illnesses (Schultz & Gatchel, eds, 2012).  Within this body of research Gates (2000) and Gates and Akabas (2011) re-conceptualized that the accommodation process must be considered a social process.   In their words ?This recasts ?accommodation? as a process that cannot occur in isolation, but one that must take into account the mutual and interactive impact of any workplace change? (Gates & Akabas, 2011, p.379).  This view prompted my interest in studying the social processes in RTW accommodations for individuals with physical injuries.  In this view of the accommodation process, barriers to employment are a function of workplace responsiveness, as well as individual characteristics (Gates & Akabas, 2011). To date, the RTW accommodation process for individuals with physical disabilities has not been ?recast?.   The findings of this study suggest that this re-conceptualization would also improve RTW outcomes for individuals with physical disabilities.   A consistent theme in the RTW literature is the importance of constructing a social environment that facilitates an individual?s employment success.  Gates (1998, 2000) suggests that the social network within the workplace requires careful consideration, particularly in light of the potential impact of reasonable accommodations.  In addition, reasonable accommodations can provoke opposition among co-workers when their own job activities are affected, or when accommodation is perceived as a privilege.  Gates (1998) suggests a psychoeducational intervention with a systematic method of collaboration to identify and elicit potential sources of support among co-workers, and counselling focused on inherent qualities of supportive relationships, such as social reciprocity.  In this study,   81 participants indicated that the implementation of accommodations was inconsistent and many experienced the RTW accommodation process merely about physical arrangements.  Evidence-informed practice in accommodations is still lacking for individuals with physical disabilities and all disabilities in general (Sanford & Milchus, 2006).  Despite the extensive body of research on work related injuries, the RTW accommodation process has not resulted in any published large-scale research studies that have distinguished the nuances and variations in the type or user group, rationale and duration of accommodations (Sanford & Milchus, 2006).  The recent emphasis on accommodations for mental health conditions sheds some light in the move toward informed practice with RTW accommodations.  Further research, including a literature synthesis in mental health (Schultz, Winter, et al., 2010), expert interviews (Schultz, Duplassie, et al., 2010), and an employer survey (Schultz, Milner, et al., 2010) point to best practices in work accommodation for non-visible disabilities.  In particular, the following components of the accommodation process have been identified in the RTW research for individuals with disabilities:  1. Assessment of accommodation needs and the workplace environment?s readiness; such as mutual impact of accommodation on individual and work group, ability to support effective communication, and flexibility to accommodate the individual (Gates & Akabas, 2011). 2. Additional training, education, and awareness of accommodations may be needed for the workplace (Schultz, Milner, Hanson & Winter, 2011). 3. Importance of social factors; multi-system collaboration, workplace social support, and relationships (Schultz, Duplassie, Hanson & Winter, 2011).  4. Need to monitor effectiveness of accommodation and relationships at work (Gates &   82 Akabas, 2011), as accommodation may not be a static process due to changing symptoms of the condition, or changes to the job, or relationships at work.   In addition, Schultz, Winter and Wald (2011) put forth that there is a need to determine the effectiveness of a wider range of accommodations; the processes involved; and to match individual strengths, needs and limitations to the right accommodations (Schultz et al, 2011).  These and other facilitators and barriers were similarly identified in this study.  However, this theory suggests that these strategies are often successful due to the link to developing trust or balancing control.   5.2.4 Expectations of RTW accommodations Expectations have emerged in the extant literature as a potential modifiable factor (Schultz, Stowell, Feurestein & Gatchel, 2007).  Few studies have examined expectancy in RTW and little is known about the expectations of accommodations in RTW.   Shaw, Robertson, Pransky, and McLellan (2003) found that workers perceived that interpersonal aspects of supervision were as important as physical work accommodation to facilitate return to work after injury.  Additionally, Shaw and associated found that injured workers expected that employers would provide appropriate accommodations, follow-up to ensure that accommodations were helpful, use ergonomic principles to modify work, and maximize all available resources to accommodate them (Shaw et al., 2003).  Also, Stewart and associates found that concerns about workplace accommodations involved perceived uncertainty about the availability of accommodations and the willingness of employers to accommodate an injured worker (Stewart, Polak, Young & Schultz, 2012).    In this study, participants were asked a sub-question about their expectations. This was to further access their perceptions of social interactions in the RTW accommodation   83 process.  Managing expectations is conceptualized in this theory as a sub-category of developing trust, which encompassed what the stakeholders expected of others, as well as their perceptions of others? expectations of them.  In this study, similar to other research findings, workers had expectations for collaboration, cooperation and active participation from the workplace and employer; especially when the worker perceived strong work history and long-term commitment to the workplace.  In this theory, managing expectations were important to developing trust and balancing control.  Further research on the impact of expectations on developing trust and balancing control in the RTW accommodation process is needed for more conclusive findings.   5.2.5 Stakeholders and social interactions  According to Franche and her associates, identifying the primary stakeholders is considered a critical step in designing and implementing interventions (Franche et al., 2005a).  Different sets of assumptions or paradigms of some key stakeholders that can result in different interpretations and actions in response to RTW issues (Franche et al., 2005a). Optimal level of involvement of stakeholders in the workplace appears to be highly dependent on the phase of the work disability (Franche et al., 2005a).  Franche and her associates (2005a) suggest a need for tolerance of paradigm dissonance and engagement in collaborative problem solving to meet common goals.  In other words, increasing stakeholder tolerance to dissonance involves: (a) establishing clear parameters for optimal stakeholder involvement, (b) increasing communication among stakeholders, (c) decreasing sources of miscommunication and misinformation, and (d) increasing awareness of other stakeholder?s paradigms (Franche et al., 2005a).  Standardization, systematization and formalization of processes of RTW interventions is suggested to facilitate communication and decrease   84 misinformation among stakeholder groups with the need for mechanisms to increase stakeholder engagement with other stakeholders.  In this study, stakeholders also described differences in the goals and outcomes in the RTW accommodation process.  This study further elaborates on common goals and consequences if social interactions are contentious.  Returning the worker to productivity, satisfaction with the accommodation process, reducing losses, and claim closure were the identified goals and outcomes common to the key stakeholders.  However, the key stakeholders differed in their definitions of these goals, which is similar to other research studies.  The identification of paradigm dissonance and the key role of windows of opportunity to participate are important observations in the stakeholder research.  This theory further suggests that disengagement is the observable behaviour and the root cause is the inability to develop trust and balance of control among the stakeholders.  In this theory, meetings among stakeholders provide opportunities to balance the control and develop trust when there is disengagement.  Disengagement in this study was associated with distrust.  Face to face meetings were also suggested and preferred by participants in this study.   5.2.5.1 Workplace stakeholders Relevant to the findings of this study are a number of RTW research studies that have focused specifically on the workplace and investigated interactions specific to the workplace, with so called ?workplace actors? (Tjulin, 2011).  Franche, Baril, Shaw, Nicholas and Loisel (2005b) examined the workplace-based RTW interventions and related stakeholder interactions.  Using the explanatory model developed by Baril and Berthelette, they developed a theoretical framework that illustrates the context of stakeholder interactions for the implementation of early RTW measures.  Similarly, Tjulin (2011) looked at the   85 workplace social interactions among workplace actors.  These studies have identified that supervisors and coworkers have key roles in the workplace.  In addition, human resource or legal departments, and/or unions may need to be part of the RTW accommodation process since many accommodations require the cooperation and support of others in the workgroup (Tjulin, MacEachen, Stiwne & Ekberg, 2011b; Colella, 2001).  Coworker responses may be a factor supervisors consider when deciding whether to grant an accommodation (Cleveland et al., 1997).  Baldridge and Veiga (2001) suggest that past responses to accommodation of group members will influence the likelihood of future requests being made.  Except employer representatives, this study did not include other workplace actors.  Supervisors/managers, coworkers and RTW personnel were also prominent in participant interviews.  Coworker support was particularly important in worker descriptions where there were successful RTW accommodations.   In the extant RTW literature, the role of coworkers in the accommodation process was previously underestimated.  The injured worker may have to deal with co-workers who resent having to take over some of his or her workload or who may feel that the worker has managed to get an ?easier? job (Colella, 2001; Franche et al., 2005; MacEachen et al., 2006).  Tjulin and associates? (2011) also found that co-workers had an active role, but there was often uncertainty and invisibility of their efforts to assist during the RTW process.  For example, RTW accommodations were made informally or in an ad hoc manner by co-workers to re-entered workers, which were generally not visible in the accounts of the supervisors interviewed.  Low or inadequate social support from supervisors and colleagues has been associated with RTW outcomes (Gates, 1993; Shaw, Robertson, Pransky & McLellan, 2003).  In this study, according to injured workers, coworker support was often   86 connected with the ability to balance control, as was ?doing the job differently?.  Knowing that others would help if asked provided a sense of safety for injured workers.  Especially, if the management was unresponsive to accommodation needs.   5.3 Trust and Control in the RTW Literature Unique to this study, are the influence of trust and control in the social interactions of RTW accommodations process.  Although, trust and control have been implied and referenced in other research studies, these concepts have not been extensively explored in the RTW literature.  In their study of human interactions and organizational structures, MacEachen and associates (2006) found good will and trust were overarching conditions central to successful RTW arrangements. The authors provided that the condition for goodwill exists largely in the social environment of the firm.  Goodwill was related to occupational bonding or job attachment with employers and co-workers or in the ?moral economy? of the company (MacEachen et al., 2006).  In MacEachen?s conceptualization, the absence of goodwill could undermine efforts by all parties in the RTW process and can lead to a suspicious environment (MacEachen et al., 2006), which is similar to this study.  However, in their study, the terms ?good will? and ?trust? were connected and mainly related to the organizational culture.  The implication of their study is that the organizational culture cannot be ignored in RTW.  Similarly, Lysaght and Larmour-Trode (2008), found that support of a personal or empathetic nature seemed more important to workers, and respondents identified trust, communication and knowledge of disability as key precursors to a successful RTW process.  Williams-Whitt and Taras (2010) report in their study that failing to adhere to established organizational and cultural norms was a precursor to negative perceptions of performance and the social capital or goodwill available to the person.  These   87 studies have described the importance of trust in organizations and higher levels of trust, which differs from this study.  Their findings are not in conflict with this theory and could be an extension consistent with the findings in this study, but this study discusses trust at the individual level between stakeholders.   Friesen, Yassi and Cooper (2001) have also referenced trust and credibility within meso-system themes, in particular the workplace organization.  Trust and credibility was described within the workplace as well as between micro- and meso-system stakeholders (Friesen et al., 2001).  The authors indicated that the themes of trust and credibility suggest the importance of good communication and positive relationships (Friesen et al., 2001).  Credibility was linked to perceived fairness of RTW programs among all employees (Friesen et al., 2001).  These study findings indicate that the overall RTW process may have many similarities to the RTW accommodation process.  As such, it could reasonably be assumed that both the RTW process and RTW accommodation process have overarching processes of trust.  However, this study focused specifically on the RTW accommodation process.  In the RTW literature, control has also been referenced in relationship to power and empowerment (Krause et al., 2001a).  RTW processes may be perceived as adversarial due to procedures such as claim forms inviting employers to contest claims, or the availability of fraud reporting and ?snitch lines? (Lippel, 2012).  The perceived adversarial nature of the workers? compensation systems may exacerbate imbalances of control (Beardwood, Kirsh & Clark, 2005; Lippel, 2012).  Lippel (2007) identified imbalance of power as one of three primary issues related to negative health consequences reported by workers.  These psychosocial factors tend to serve to perpetuate disability and impede RTW.  In this study, the perceived questioning of legitimacy was prevalent in worker interviews and was   88 conceptualized as perceived violations of trust during early contact.  These impacted on developing trust and perhaps on the ability to balance control.   In summary, the RTW process has been extensively researched and due to the complex nature of social interactions, this study focused on the negotiation and implementation of RTW accommodations as a starting point to ?discover? the social processes that may be involved with multiple stakeholders.  The experiences of the participants interviewed in this study for the development of this grounded theory appear to be consistent with the findings of other studies of accommodation, stakeholder and interaction research.   These study findings can contribute to best practice guidelines regarding the effective process of developing and implementing work accommodations.   5.4 Application of Research Results The results of this study suggest that a change in conceptualization of RTW accommodations is needed for workplace, human resource, and health and wellness policies.  The findings of this study imply that workplace accommodations policies that consider the interdependent processes of developing trust and balancing control are likely to achieve more successful outcomes than viewing them as separate processes or ignoring these processes in RTW accommodations.  Hence, RTW accommodations policies should seek to integrate opportunities to develop trust and balance control among the stakeholders.  The study findings suggest there is ambiguity about whether to trust other stakeholders and how to utilize control strategies to achieve successful outcomes.  Furthermore, the findings indicate that insufficient levels of trust and control among stakeholders impede cooperation and collaboration, thus requiring stakeholders to make difficult decisions based on emotions or intuition.  This issue may be a contributing factor to unnecessary ?re-inventing? (Sanford   89 & Milchus, 2006) and significantly different experiences for injured workers dependent on other stakeholders? propensities to focus on trust or control, potentially resulting in losses for all stakeholders.  Other studies have found that the ability to communicate effectively is connected to trust and control processes (Das & Teng, 1998), especially, stakeholders? use of validation of all stakeholder concerns.  The ability to validate others? concerns is often referred to as empathy and has been identified by other research (Shaw, Robertson, Pransky & McLellan, 2003) and also referred to as an aspect of social support (Akabas & Gates, 1998; Lysaght & Larmour-Trode, 2008).  In addition, the interpersonal skills of RTW coordinators (James et al., 2011) and leaders (Aas, Ellingsen, Lind?e & M?ller, 2008) are considered vital.  Furthermore, training for managers and leaders in communication skills, including empathy have already been shown to be beneficial for improved outcomes (Fossli Jensen et al., 2011; Stein, Frankel & Krupat, 2005).   Hence, an application of the study findings is to incorporate skills training in building trust and effective use of control strategies for rehabilitation and other involved professionals (human resource staff, case managers, return to work coordinators, vocational rehabilitation, etc.).  In particular training or resources materials to recognize signs of trust to distrust, and skillfully modify control if not reaching desired/sufficient levels.   Finally, occupational health and vocational rehabilitation professionals and safety prevention officers affiliated with employers, health and workers? compensation systems, should be equipped with specific practice guidelines for assessments and interventions targeting development of trust and imbalances of control in the RTW processes.  Importantly, our study suggests that trust and control, once quantitatively measured   90 by newly developed instruments, should be explored as potential predictors of injured workers? disability and return to work.  Although many psychosocial predictors of occupational disability were studied, trust and control factors, of potential major significance, have been missed.  Moreover, once they are evaluated, intervention strategies to improve the interactional balance between trust and control could be developed.  Notably, our study uniquely highlights the importance of capturing and measuring social interactional factors related to the RTW, which have not received sufficient attention in the field, likely due to the methodological complexities of this endeavour.      5.5 Methodological Considerations Alternative explanations of the data were also explored in generating the grounded theory. There are a number of possible relationships between the identified core processes.  The most viable alternative explanation, is that developing trust is the overarching process and developing control is a sub-category of trust; meaning that developing trust is more important than balancing control.  Thus, there needs to be at least more than ?50% trust? in the social interactions.   Though this captured a significant number of experiences, the data from the 27 interviews did not fully support that alternative explanation.  Other alternative explanations were considered before the development of the final grounded theory, but did fit the data for all the stakeholders.  The relationship between the core processes was established through constant comparison and theoretical sampling (Charmaz, 2013, 2006; Glaser & Strauss, 1967).  5.5.1 Study limitations The contributions of this research should be viewed in light of several limitations.  The data was retrospective and in particular workers were interviewed at one particular point   91 in time, within 2 months of gradual RTW.  Additionally, insurer and employer interviews were based on retrospective cases.  Thus, no inferences of causality can be established and this study cannot confirm particular success factors.   While theoretical sufficiency was attained with the sample of 27 participants, a larger group may have strengthened the findings, in particular with more employer and workers? compensation representatives.  There was only one source of information; access to other resources such as organizational files and insurer files may have provided useful information.  As well, both the interviewers were female, with one Caucasian and one Chinese Canadian.  In accordance to constructivist grounded theory, different information may have been elicited from participants with different interviewers.  Finally, using multilevel trust nomenclature, which has emerged in the trust literature, trust can be studied at the referent level and at levels of analysis (Fulmer, & Gelfand, 2013).  This means that this study identified trust at the individual referent level, i.e. the individual stakeholder?s degree of trust with an interpersonal, team or organization.  The impact of higher levels of analysis and levels of trust in different referents was not examined and would likely influence the trust process - meaning the study of the trust in organizations, among teams and across organizations.  Antecedents of trust and stakeholders? inclination to trust or distrust (trust propensity) were not considered in this study (Colquitt et al., 2007).   Further verification of this study is needed, as the primary purpose was to generate a theory of the social interactions in the RTW accommodation process.  Consequently, it is the hope that the findings of this thesis offer a starting point for further quantitative research questions and further exploration of this topic.      92 5.6 Recommendations For Future Research Future research would benefit from examining the social interactions in the accommodation process by considering other stakeholders? perspectives, such as rehabilitation professionals, healthcare providers and other workplace stakeholders, especially rehabilitation professionals.  Second, further research in accommodations interventions is needed to explore the implications of designated modified duty positions.  The use of designated modified duties positions, or a different position rather than modified duties within the same position, appeared to be the most contentious accommodation based on worker and employer data.  Third, the impact of trusting or distrusting in the accommodation process on overall organization commitment is a research question that requires further investigation.  Further research in social interactions would need to consider the influence of biopsychosocial context (i.e. culture, race, gender, etc.) on the development of trust and balancing control.  5.7 Concluding Remarks The resulting grounded theory explains that the core issues in RTW accommodations are: developing trust and balancing control among stakeholders.  This method allowed participants to use their own concepts when explaining experiences, which has resulted in a better understanding of the problems associated with the RTW accommodation process.   The resulting theory also contributes to improvements in implementing RTW accommodations.  The social processes in RTW accommodations are in need of further research and are not yet encompassed by existing theories and models of RTW.  Therefore, the focus of this study was on work-related injuries within one injury group?musculoskeletal conditions?so as not to assume that all processes are the same, irrespective of where the injury occurred and the   93 type of injury.  As we have seen, RTW accommodation processes are complex by nature, involving multiple viewpoints and needs. The middle range theory discussed in this research has the potential to assist in conceptualizing critical aspects of RTW accommodations?planning, implementation, and sustainability.  More importantly this theory is intended to offer a framework for the development of practical solutions to front line stakeholders.  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A., Hendricks, D., & Blanck, P. (2006). Workplace accommodations: Evidence based outcomes. Work: A Journal of Prevention, Assessment and Rehabilitation, 27(4), 345-354. Schoorman, F. D., Mayer, R. C., & Davis, J. H. (2007). An integrative model of organizational trust: Past, present, and future. Academy of Management Review, 32(2), 344-354. Schultz, I. Z., Stowell, A. W., Feuerstein, M., & Gatchel, R. J. (2007). Models of return to work for musculoskeletal disorders. Journal of Occupational Rehabilitation, 17(2), 327-352. Shaw, W. S., & Feuerstein, M. (2004). Generating workplace accommodations: Lessons learned from the integrated case management study. Journal of Occupational Rehabilitation, 14(3), 207-216. Shaw, W. S., Linton, S. J., & Pransky, G. (2006). Reducing sickness absence from work due to low back pain: How well do intervention strategies match modifiable risk factors? Journal of Occupational Rehabilitation, 16(4), 591-605.   102 Shaw, W. S., Robertson, M. M., Pransky, G., & McLellan, R. K. (2003). Employee perspectives on the role of supervisors to prevent workplace disability after injuries. Journal of Occupational Rehabilitation, 13(3), 129-142. Skinner, D., Dietz, G., & Weibel, A. (2013). The dark side of trust: when trust becomes a 'poisoned chalice'. Organization. Stein, T., Frankel, R. M., & Krupat, E. (2005). Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study. Patient Education and Counseling, 58(1), 4-12. Tjulin, ?., MacEachen, E., Stiwne, E. E., & Ekberg, K. (2011). The social interaction of return to work explored from co-workers experiences. Disability and Rehabilitation, 33(21-22), 1979-1989. van Oostrom, S. H., Driessen, M. T., de Vet, H. C., Franche, R. L., Schonstein, E., Loisel, P., . . . Anema, J. R. (2009). Workplace interventions for preventing work disability. Cochrane Database of Systematic Reviews, 2009(2). doi:10.1002/14651858.CD006955.pub2 Williams?Whitt, K., & Taras, D. (2010). Disability and the Performance Paradox: Can Social Capital Bridge the Divide? British Journal of Industrial Relations, 48(3), 534-559. WorkSafeBC (2013).  Statistics 2012.  Retrieved October 2013 from http://www.worksafebc.com/publications/reports/statistics_reports/default.asp Yassi, A., Khokhar, J., Tate, R., Cooper, J., Snow, C., & Vallentype, S. (1995). The epidemiology of back injuries in nurses at a large Canadian tertiary care hospital: Implications for prevention. Occupational Medicine, 45(4), 215-220.   103 Young, A. E., Roessler, R. T., Wasiak, R., McPherson, K. M., van Poppel, M. N. M., & Anema, J. R. (2005). A developmental conceptualization of return to work. Journal of Occupational Rehabilitation, 15(4), 557-568.   104 Appendices : Introduction Letter to Healthcare Professionals Appendix A   Research Participants Needed  Dear Healthcare Professional:    We are writing you to let you know about our research study, Towards Effective Work Accommodation of Injured Workers: Accommodation as Social Interaction.   The study is sponsored by WorkSafe BC. This study is expected to contribute scientific evidence to the Return to Work field in the poorly understood area of workplace accommodation and thereby facilitate practical solutions for sustained return to work. We are contacting you because you may have knowledge of individuals who may be interested in participating in the study.    We are currently looking for people who want to take part in this research study and who fall under one of the two categories:   1. Injured workers with accepted back claims returning to work at all stages of injury. 2. Employers or employer representatives actively involved in the return to work of injured workers requiring an accommodation.  The three key research questions of the study are: 1. How do injured workers with workplace injury claims construct their expectations and perceptions of accommodations in the RTW process? 2. What are the barriers and facilitators of accommodations in the RTW process as perceived by injured workers and employers? 3. How do injured workers and the multi-system players involved in RTW construct social and interactional aspects of accommodations?  What is involved?  Participants will be asked to participate in an in person or telephone interview that will take up to 90 minutes. The interviews will involve a number of semi-structured questions about their experience of the various social interactions that facilitate, or hinder, the RTW accommodations process for individuals who are off work due to workplace injury. Trained Research Assistants will conduct these interviews.  All participants will receive a contribution of $30 for participation.    On behalf of the research team, we thank you for your time.  Sincerely, Accommodation Research Team    105 : Worker Recruitment Poster Appendix B    INJURED WORKERS NEEDED FOR RESEARCH STUDY	Are you returning or returned to work after an accepted workplace injury claim from 2011 to 2012?  Does your return to work involve a workplace accommodation (a modification to the job such as reduced hours, light duties, changes to the job, equipment)? Are you 19 or older, willing to be interviewed for up to 1 hour, audio recorded and sign a consent form? Project Title:  Towards Effective Work Accommodation of Injured Workers: Accommodation as Social InteractionPrinciple Investigator:  Dr. Izabela Schultz, University of British ColumbiaCo-Investigator:  Dr. Richard Young, University of British Columbia  106 : Consent to Contact Worker Appendix C   Towards Effective Work Accommodations of Injured Workers: Accommodation as Social Interaction  You are eligible to participate if: ? You are an injured worker with an accepted injury claim; ? You have returned to work; ? Your return to work involves an accommodation (a special arrangement employers sometimes make to help workers with return to work) e.g., shorter hours, flexible scheduling, special or changed equipment; ? You are able to speak English fluently and are 19 years of age or older.  How can I participate?   For research purposes only: Consent to release contact information  ? ACCEPT   I am willing to be contacted about the research study ?Towards Effective Work Accommodation of Injured Workers: Accommodation as Social Interaction?. I understand that by signing this form, I agree to allow my rehabilitation centre to provide my contact details (name and phone number) to the researchers from the University of British Columbia. I can then expect to hear from one of the team Research Assistants.   Name: ____________________________________Date: ________________________ Anticipated RTW date: ____________________________________________________ Phone Number: ____________________________Best time to call: ________________ Email Address: _________________________________________________________ Signature: _______________________________________________________________  I may also choose to contact the Research Assistants myself.       107 : Interview Protocols Appendix D   D.1 Worker Interview Protocol  Health / Wellbeing & Injury ? Tell me about how you came to be injured at work?  ? How are you recovering from your injuries?  ? Current general physical health (Pain, illness, status of injury, sleep...)   Employment  All in all, how satisfied were you with your job?  Do you have any concerns about your work?  (Job security, perceived pain level)  What do you hope will happen with your work?  OR what are your plans with work?    What are the company policies for your RTW?    Expectations  ? What did you think would happen or how did you think things would be with.............................(Insurer, Employer, Rehab Staff, others) when you had your ...........................(each accommodation)?    Work accommodations: ? How was your ________________(accommodations) arranged?  o Type of accommodation received or nature of accommodation; rationale for accommodation and who instigated the accommodation o Did you receive a workplace site visit?  Is there a designated person who is coordinating your RTW?   o What helped or made things worse when you were arranging ______________(accommodations)?   o Did you try to RTW before?    ? What happened once you were actually back at work?   ? As you look back on _________________(accommodations received), are there any events that stand out to your mind?  Could you describe it?  How did the event affect what happened?  How did you respond to that?   ? How satisfied are you with the accommodations you received or are receiving at work?   ? Was _____________ (accommodation) sufficient for your needs?   ? Was there support or help offered by others that wasn?t arranged?   o Who has been the most helpful to you during this time?  How has he/she been helpful?     Interactions  ? What has it been like with ....... (Insurer, Employer, Rehab Staff, others) when you returned to work?  At the beginning?  Has it changed now?      108  Observations in general ? How, if at all has your view of your relationships at work changed since you?ve been back?  ? What things did people say or do that helped you?   ? What things did people say or do that hindered or made it harder?  ? Did you do anything that made things better or worse?     Suggestions & Evaluation of Process ? How satisfied were you with your ___________(Insurer, Employer, Rehab Staff, Others) in the entire process - claim handling and rehabilitation process?   ? What worked in the accommodation process? ? Suggestions for improvement:  After having these experiences, what advice would you give to someone who is returning to work with ____________ (accommodations)?   ? Is there anything else you think I should know to understand about RTW with accommodations at work better?   ? Is there anything you would like to ask me?    D.2 Insurer/Employer Interview Protocol 1) Consider one SUCCESSFUL return to work accommodation employee situation. ? General description (nothing identifying?) of employee and their injury, pre and post injury ? General description / perceptions of employer ? Expectations of employee, Case Mgr / Voc Rehab, work organization (HR, mgmt.), health professionals, self ? In general- did you think it would be successful or unsuccessful, and why? ? Interactions with employee that helped / hindered ? Interactions with WorkSafe staff that helped / hindered ? Interactions with other employees, administration, co-workers of injured employee that helped / hindered  ? Other stakeholders  A.  Personal Experience o Previous RTW accommodation experiences? (Successful or unsuccessful) o Feelings about employee (positive, negative, compassion, judgment) o Feelings about Case worker/ Voc Rehab staff o Any personal or family/ friend experience with sub-acute low back pain?  o Observations of the process   B. What worked? Suggestions for improvement?      109 2) Consider one UNSUCCESSFUL return to work accommodation situation. ? General description (nothing identifying?) of employee and their injury, pre and post injury ? General description / perceptions of employer ? Expectations of employee, Case Mgr / Voc Rehab, work organization (HR, mgmt.), health professionals, self ? In general- did you think it would be successful or unsuccessful, and why? ? Interactions with employee that helped / hindered ? Interactions with WorkSafe staff that helped / hindered ? Interactions with other employees, administration, co-workers of injured employee that helped / hindered  ? Other stakeholders  A. Personal Experience o Previous RTW accommodation experiences? (Successful or unsuccessful) o Feelings about employee (positive, negative, compassion, judgment) o Feelings about Case worker/ Voc Rehab staff o Any personal or family/ friend experience with sub-acute low back pain?  o Observations of the process   B. What worked? Suggestions for improvement?     110 :  Demographic Form Appendix E  FOR RESEARCH PURPOSES ONLY Social Interactions in RTW Accommodation Process   Participant #__________  Date of Interview:  _____________________________ Date of Birth: _________________________________ OR Age _________________________ (month/day/year) Ethnicity:  _____________________________________________________________________ Marital Status:   single   common-law    married     separated  divorced   widowed Number in Household: ___________________________________________________________ Relationships to you: ____________________________________________________________                           (Spouse, children, parents, siblings, etc.)  Your Highest Level of Education:                Some High School   Journeyman / Red Seal   Bachelor?s Degree   Completed High School  Some College/Univ.   Some Graduate School  Vocational School   Completed College  Graduate Degree Other (Specify):  Pre-injury Job Title: _____________________________________________________________ Business or Industry: ____________________________________________________________ Size of company:  __________________________________ Union:  (Yes or No)____________ Length of employment at this job: __________________________________________________ Pre-injury work hours: (Hours per week)_____________________________________________ Date of Injury: (Month, Day, Year) _________________________________________________ Type of Injury or Injuries: ________________________________________________________ Length of Time Off Work Due to Injury:  ____________________________________________ Date of Return to Work: (Month, Day, Year)__________________________________________ Is it with the same employer? (Please specify)___________________________________ Is it the same position?  ___________________________________________________    How many hours per week? _________________________________________________ Accommodation(s) received: ______________________________________________________  

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