Competence and professionalisation among return-to-work coordinators in Sweden: comparisons by original profession

ABSTRACT

Return-to-work coordinators (RTWC) support people on sickness absence and is a new healthcare occupation in Sweden. Its practitioners represent a variety of professions, there is no common undergraduate training and vague role and competence descriptions. The aim was to explore differences in training and competence according to original professions (occupational therapists, physiotherapists, counselling, and other professions) and coordinators’ views on which professions they believe provide the best competence for the role. All RTWCs (82) in one region were invited to answer a questionnaire (89% response rate). Mixed-methods analyses were applied. The results showed that counselling professions were more likely than other professional groups to have further training, particularly in conversation methods, and a lower proportion of them stated needing more knowledge about gender equality, social problems, insurance/benefit and conversation methods. The analysis of free-text answers identified three competence areas of importance: advice and guidance, a holistic view, and personality over profession. Occupational therapists and social workers were seen as having the best competence for the coordinating role. The results outline some common values, norms and important competences for RTWCs that could help develop the RTW coordination training and pave the way for RTWCs professionalisation process.

SAMMANFATTNING

Rehabiliteringskoordinatorer är en ny yrkesroll inom hälso – och sjukvården som stödjer sjukskrivna patienter i rehabiliteringsprocessen. Koordinatorerna saknar dock en tydlig roll – och kompetensbeskrivning, och det faktum att yrkesrollen saknar en gemensam yrkesutbildning och innehas och utvecklas av olika professioner gör den unik. Syftet med studien var att undersöka skillnader i kompetens baserat på rehabiliteringskoordinatorers olika grundprofessioner, samt vilka professioner de menade hade bäst kompetens för att arbeta som rehabiliteringskoordinator. Alla rehabiliteringskoordinatorer i en region bjöds in att svara på en enkät (89% svarsfrekvens). Både kvantitativa och kvalitativa analysmetoder användes. Resultaten visade att kuratorer hade mer vidareutbildning än övriga professioner, särskilt inom samtalsmetoder, och kuratorerna uppgav mindre behov av ytterligare kompetens inom områdena jämställdhet, sociala problem, försäkringar/bidrag och samtalsmetoder. Analysen av fritextsvaren visade att holistisk syn, personlighet framför profession samt rådgivning och vägledning ansågs vara tre viktiga kompetensområden för rehabiliteringskoordinatorer. Arbetsterapeuter och socionomer ansågs ha mest passande kompetens för att arbeta som rehabiliteringskoordinator. Resultaten adresserar några gemensamma grundvärden, normer och viktiga kompetensområden för rehabiliteringskoordinatorer som kan bidra i utvecklingen av utbildning för rehabiliteringskoordinatorer och bana väg för deras professionaliseringsprocess.

KEYWORDS:

• Return to work
• rehabilitation
• sickness absence
• coordination
• collaboration

NYCKELORD:

• Återgång i arbete
• rehabilitering
• sjukskrivning
• koordinering
• samverkan

Introduction

To combat high rates of sickness absence (SA) and insufficient collaboration in the return-to-work (RTW) process, many countries have appointed return-to-work coordinators (RTWC) in recent decades. These are a form of case manager who support people on SA in their RTW process. Since 2020, the Swedish healthcare system is obliged to offer RTW coordination to people on SA. This new role, also called rehabilitation coordinators in Sweden, was implemented rapidly after a decade of pilot interventions. The role description is vague and lacks specific competence description or requirements for any particular vocational training (Holmlund et al., 2020). There is no consensus on what the best training is, although some experts have suggested that social workers’ training would be appropriate, as it covers social law, social work, behaviour science, conversation methods, a person-in-environment approach and a holistic approach to health (Karolinska Institutet, 2018). Coordinators thus have a variety of training, with the most common professional backgrounds being social workers, occupational therapists, physiotherapists, and nurses (Swedish Association of Local Authorities and Regions (SALAR), 2022). There is therefore a need to establish a common knowledge base to guide its practice, to ensure equality in support offered and successful outcomes.

RTWCs may currently not be defined as a profession of its own, as a profession often is defined as associated with years of higher education and/or vocational training (Evetts, 1999). As this is, to the best of our knowledge, not the case for RTWCs in any country yet, they may rather be understood as a new occupation at the beginning of their professionalisation process, generally characterised by internal discussion and differing views about what the best competence is and how the practice should be performed (Abbott, 1988; Evetts, 1999). However, it is unusual for a new occupation to be represented by practitioners with such widely differing vocational training with no common professional qualification. This makes the professionalisation process of RTWCs unique and interesting. Using responses to a questionnaire, the present study aims to explore differences in the level and type of training and competence of the different professions working as RTWCs in one urban region of Sweden. We also explore RTWCs’ views about the most important competence and which professions they believe provide the best competence for the role. We elaborate on the concepts of competence and professionalisation process in the theoretical frame.

Return-to-work coordination in Sweden

In most countries, RTWCs are located in the workplace or at insurance companies; in Sweden they tend to be found in the healthcare system. Their main assignments are to give individual support to persons on SA and to collaborate with healthcare professionals and other stakeholders, for example, employers, the Employment Services, the Social Insurance Agency, and the social services (SALAR, 2022). The social insurances, social services and healthcare system are tax funded and all stakeholders are expected to collaborate in the RTW process, but there are no national RTW program guiding stakeholders in this process.

Many RTWCs are recruited internally at the work place and have long experience from their original professions (Svärd & Jannas, 2022). Several universities provide a basic course in RTW coordination at advanced level (7.5 credits), and a few offer a supplementary course (2 credits). The course leaders decide the content of the courses, although it is to some extent guided by the Swedish Association of Local Authorities and Regions (SALAR) recommendations about the fields RTWCs should have knowledge about: social insurance, insurance medicine, vocational rehabilitation, medical terminology, assessments made in healthcare and insurance medicine, the labour market, labour law, rehabilitation, and gender equality (SALAR, 2016). SALAR also stresses that RTWCs should understand the diseases and health conditions relevant to the particular clinical setting (e.g. primary or specialist healthcare). A number of qualities are seen as essential for all RTWCs: organisational, administrative, interpersonal relationship, communication, and problem-solving skills (SALAR, 2016).

Previous research into important competence for RTW coordinators

The role and competence requirements for RTW coordination can differ internationally according to the particular welfare or social insurance system, the setting, and the types of people on SA. Previous studies have identified a number of important general skills for RTWCs. These include information gathering (Pransky et al., 2010), assessment (Gardner et al., 2010; Shaw et al., 2008), having organisational, administrative (Bohatko-Naismith et al., 2016; Gardner et al., 2010) and social problem-solving skills (Azad & Svärd, 2021; Gardner et al., 2010; Pransky et al., 2010; Svärd et al., 2021). Other studies have emphasised the importance of a knowledge of diseases, and the relevant legislation (Azad & Svärd, 2021; Bohatko-Naismith et al., 2019; Shaw et al., 2008; Svärd et al., 2021). However, the most commonly identified competences are related to interpersonal relationships. These include interviewing (Shaw et al., 2008), communication (Azad & Svärd, 2021; Berglund et al., 2022; Bohatko-Naismith et al., 2015; Bohatko-Naismith et al., 2019; Shaw et al., 2008; Svärd et al., 2021), being positive, the ability to gain people’s trust (Azad & Svärd, 2021; James et al., 2011), having empathy (Azad & Svärd, 2021; Bohatko-Naismith et al., 2015; Bohatko-Naismith et al., 2019), engagement (Azad & Svärd, 2021; Bohatko-Naismith et al., 2019), advocacy (Azad & Svärd, 2021), conflict resolution (James et al., 2011; Pransky et al., 2010; Shaw et al., 2008) and counselling skills (Azad & Svärd, 2021; Bohatko-Naismith et al., 2016; Svärd et al., 2021). Having professional and life experience (Azad & Svärd, 2021; Bohatko-Naismith et al., 2019) and demonstrating professional credibility (Azad & Svärd, 2021; Pransky et al., 2010) have also been viewed as important.

The effects of RTW coordination are not clear. For example, one review showed no effect (MacEachen et al., 2020) while others have found moderate evidence (Franche et al., 2005) that RTW coordination results in a higher probability of RTW. The association between RTWCs’ trainings and the effects of coordination has not been investigated.

Theoretical frame: professionalisation and competence

As RTW coordination in Sweden is practised by people from different professional backgrounds, negotiation may be needed to establish a common understanding of the role and its knowledge base that will guide its practice. Such negotiations can be competitive and takes place in a system of professions (Abbott, 1988). Abbott (1988) argued that professional groups strive to defend and expand their area of jurisdiction in competition with rival professions. This can involve striving for autonomy and monopoly over certain problems and work tasks, which can be formalised by means of legislation and public regulation or specified in job descriptions. The jurisdictional work can also be informal within workplaces through professions’ constantly ongoing negotiations about defining the problem, assessing, diagnosing, suggesting and deciding on interventions based on the different professions’ knowledge base. Jurisdictional work is influenced both by inter-professional and intra-professional interactions. This process may be double-edged for RTWCs, since they may identify professionally both as RTWC and with their original profession, for example as a nurse or a social worker.

The professionalisation process is characterised by the striving to strengthen the professional identity by shaping common values, norms and knowledge bases (Evetts, 2013). This is not always a linear process based on knowledge and expertise (Saks, 2012), but standardisation of training and qualifications is usually established early in the formation of an emerging occupation (Evetts, 1999). When there is no established common vocational training or knowledge base, as in the case of RTW coordination, the latter must emerge from the negotiations and interactions that take place in practice. This gives rise to a relational understanding of competence, as what is conveyed and used by professionals in their interactions with others. Professional competence is described to include knowledge, values and skills, but in his comprehensive theory on professional action competence, Nygren (2004) also stresses the importance of developing an occupationally and situationally relevant readiness for action. He points to how values form basic conditions for and guide professional actions, and argues that there is a false divide made between personal and professional competence, and that they are rather integrated with each other. Personal competence is a necessary tool for all relation-based professions – hard to define, but suggested to involve qualities such as conveying empathy, accountability and enthusiasm (Nygren, 2004).

Materials and methods

A cross-sectional study was conducted of RTWCs in one large urban Swedish region. The study is a part of a larger project about barriers and prerequisites for RTW coordination that was developed in collaboration between researchers, experts in insurance medicine, and representatives from this region. Several representatives in the collaboration raised the issue of important competence for a RTWC to possess, which we explored from different stakeholder’s perspectives (see e.g. the patients perspective in Azad and Svärd 2021). This study focuses on the coordinators’ perspective.

Participants and data collection

All 82 RTWCs working in primary healthcare and psychiatric and orthopaedic clinics in one urban region in Sweden received a questionnaire in February 2020 by post. Three reminders were emailed to non-responders in March, April and May. Of the 82 coordinators, 73 completed and returned the questionnaire (89% response rate).

The questionnaire

The questionnaire consisted of 41 questions plus partial and open-ended questions. The questions covered sociodemographic information; the coordinators’ work with the RTW process; collaboration with stakeholders; vocational/undergraduate training; further training; acquired competence; needed knowledge in a variety of areas; and which professions they believed had the best competence for the role. The questions were developed from previous questionnaires about the work of physicians (Alexandersson et al., 2020) and coordinators (Svärd et al., 2019) with people on SA, and literature about RTWC. The questionnaire was tested and discussed in a reference group of RTWC and physicians. A pilot study was conducted with ten coordinators from other Swedish regions in order to test the reliability and validity of the questionnaire items, after which minor adjustments were made. The present study uses free-text answers and the answers to questions about trainings and skills.

Analyses

The analyses combine qualitative and quantitative methods. The different approaches offer opportunities to evaluate the research questions with different measures, thus adding knowledge and depth to one and another (Caruth, 2013). Descriptive statistics, including frequencies and percentage or mean and standard deviations, were calculated for the different variables according to original profession (i.e. occupational therapists, physiotherapists, counsellors, and others). Kruskal–Wallis tests were used to test differences in mean ranks and non-parametric correlations; Spearman’s rank was used to test the relation between variables. All tests were two-sided, with a significant level of p < 0.05. The statistical analyses were performed using IBM SPSS statistics, version 27.

The free-text answers were analysed by content analysis following the six steps recommended by Krippendorff (2018). After selecting the units of analysis, all free-text answers were read through twice by both authors to gain an overall understanding of the data. Descriptions of all aspects of the content were then generated using free notes. After this, the content was condensed and grouped under higher order headings. For example, texts (‘I think that personal features are more relevant for a coordinator than what kind of education one has’) relating to which profession had the best competence was condensed (‘personal characteristics more important than vocational education’) under the higher order heading ‘best competence’. Next, the condensed texts were classified in different categories. This involved finding a pattern in the content that reflected similarities or relations across individuals. The purpose of creating categories is to provide a means to describe the phenomena of interest, thus increasing understanding and generating knowledge about the particular subject (Krippendorff, 2018). Lastly, each category was named (e.g. personality over profession). The authors discussed coding and suggested categories during the analysis process in order to reach dialogic intersubjectivity and consensus about the most important categories and to strengthen reliability and validity (Castleberry & Nolen, 2018).

Ethical considerations

Steps were taken to ensure the anonymity and confidentially of the participants in a small sample. Accordingly, attribute-disclosure information such as less common vocational training and original professions were not given, nor were some subgroup analyses of, for example, gender, age, or clinical setting reported in numbers. The study was approved by the Swedish Ethical Review Authority (No. 2020–00403). Respondents gave informed consent to participate by sending in the filled questionnaire.

Results

Of the 73 coordinators who answered the questionnaire, 16% were 20–39 years old, 41% were 40–54 years old and 43% were 55 or older. The majority (63%) had worked 1–3 years as coordinators and 45% worked 60% or more of full-time as RTW coordinators (most spent the remainder of their working hours in their original profession). Twenty-two (30%) were occupational therapists, 34 (47%) were physiotherapists, and nine (12%) were social workers or had similar vocational trainings relevant for counsellors, such as psychotherapy, behavioural science or social pedagogue training (these are here categorised as counsellors). Eight (11%) were categorised as ‘other’. This included nurses, other healthcare professions, or those with a mixture of trainings, such as in human resources. The majority of respondents worked in primary healthcare clinics (71%), followed by psychiatric (including addiction) (19%) and orthopaedic clinics (10%). Most common mental disorders are dealt with in primary healthcare, thus constituting the major part of the RTWCs cases in primary healthcare (Svärd & Jannas, 2022). A higher proportion of physiotherapists worked in orthopaedics and a higher proportion of counsellors in psychiatry.

Further training

All respondents answered that they had some form of further training. The majority (92%) had taken a basic course for RTWC (7.5 credits) followed by occasional seminars/lectures in insurance medicine/the rehabilitation process for people on SA (89%) and a course in motivational interviewing (83%) (Table 1). Compared to the other groups, a larger proportion of physiotherapists had a master’s degree, while a larger proportion of counsellors had basic training in psychotherapy. A Kruskal–Wallis test showed that the sum of further training differed significantly between the professions H(3) = 9.491, p = 0.023, n = 71, with counsellors having more further training than the other groups.

Table 1. Proportion (and number) of respondents in each profession and in total who answered that they had completed a certain type of further training.

Training	Profession
	Occupational therapists	Physio-therapists	Counsellors	Others	Total
Basic course for RTW coordinators	96% (21)	88% (29)	89% (8)	100% (7)	92% (65)
Supplementary course for RTW coordinators	14% (3)	7% (2)	38% (3)	0% (0)	12% (8)
Occasional lectures/seminars	91% (20)	85% (28)	89% (8)	100% (7)	89% (63)
Course in motivational interviewing	81% (17)	88% (29)	78% (7)	71% (5)	83% (58)
Course in problem-solving conversation	5% (1)	3% (1)	57% (4)	29% (2)	12% (8)
Basic psychotherapy training	9% (2)	6% (2)	78% (7)	0% (0)	16% (11)
Specialist training	18% (4)	21% (7)	29% (2)	29% (2)	22% (15)
Master’s degree	10% (2)	38% (12)	33% (2)	17% (1)	26% (17)
Sum of additional training (0–24)
m (sd)	9.8 (2.9)	10.6 (4.3)	15.1 (4.6)	9.6 (5.2)	10.8 (4.3)
n	22	33	9	7	71

RTW = return-to-work.

The coordinators’ view of their role

In order to understand what competence a RTWC might need, it is important to understand how respondents viewed their role. Forty-six answered the open-ended question: ‘In your opinion, what should the main task of the RTW coordinator be?’. Our analysis of the responses generated three categories. According to the first, coordination and collaboration, RTWCs should support healthcare teams in the RTW process, especially sick-listing physicians. It also included informing stakeholders of their legal rights and responsibilities, improving communication, and being, as one respondent wrote, the ‘spider in the web’, linking external and internal stakeholders. In the second category, patient work, respondents described the RTWC as chiefly supporting, coaching and motivating patients, as opposed to having a nurturing or therapeutic role. Having good communicative skills was important as the coordinator should motivate patients. Other important competences were advising and guiding, for example about adjusted or alternative work tasks or new employment. Patient work also includes informing patients about their legal rights and responsibilities regarding SA benefits, and using measures to prevent SA exceeding 180 days, by helping patients to identify obstacles in the RTW-process, finding forward-looking solutions, and maintaining a rehabilitation plan. For these reasons it was important to involve coordinators early in the SA process. In the final category, maintaining SA policy and routines, the coordinators described their role as, for example, ‘supporting sick-listing physicians and other healthcare colleagues in SA and rehabilitation issues’, and facilitating investigation, rehabilitation and routines. They underlined the importance of having access to clinics’ SA statistics in order to be able to evaluate routines.

Making use of their competence – a driving motivation

Sixty-six respondents wrote free-text answers to the question ‘Why did you take the position as a coordinator?’. Our analysis resulted in two categories. In the first, personal benefits, respondents mentioned variation in the work and further development. Variation included taking a break from clinical work or taking on work of a more administrative nature or new groups of patients. There were also differences between professions. Occupational therapists and physiotherapists described the coordinating function as taking on new tasks. One wrote: ‘Exciting to learn something new’. Social workers, on the other hand, did not describe coordinating as something new, with one writing: ‘Nice to deepen your knowledge’. Further development meant having the opportunity to put previous experience and knowledge into a new context. For others, the personal benefits of the RTW coordinating role were fun, educational, exciting, meaningful and interesting. A second category, the potential of the role of RTWC, included the opportunity to focus on the ‘health’ aspects of recovery, helping patients in the RTW process, and being able to influence patients’ health and life in a positive direction. One social worker wrote ‘Have always preferred working to strengthen people’s health and their ability to utilise their rights.’ Respondents also replied that they saw a need for RTW coordination and that taking on this role was a way of bringing about positive change in healthcare.

Competence

Stated competence

The majority of the respondents agreed fully or largely that they were competent in all the listed areas. The exception was for social problems, where a small proportion (15%) of physiotherapists and less than half (41%) of occupational therapists answered that they were fully or largely competent, compared to a majority of counsellors (75%) and ‘other professions’ (72%) (Table 2). However, a Kruskal–Wallis test demonstrated no significant differences in the total sum of competence between professions (H(3) = 3.837, p = 0.28, n = 72).

Table 2. Proportion (and number) of respondents in each profession and in total who fully or largely agreed that they were competent in the listed areas.

Competence	Profession
	Occupational therapists	Physio-therapists	Counsellors	Others	Total
Have sufficient competence in insurance medicine	77% (17)	74% (25)	50% (4)	88% (7)	74% (53)
Can provide qualified advice about insurance medicine	64% (14)	71% (24)	88% (7)	88% (7)	72% (52)
Can provide qualified advice about SA regulations	73% (16)	79% (27)	88% (7)	88% (7)	79% (57)
Can provide qualified advice about stakeholders’ responsibilities	86% (19)	79% (27)	75% (6)	100% (8)	83% (60)
Can easily define their own and others’ responsibilities	68% (15)	77% (26)	100% (8)	75% (6)	76% (55)
Can motivate patients	100% (22)	88% (30)	88% (7)	75% (6)	90% (65)
Can collaborate efficiently with authorities/employers	86% (19)	74% (25)	88% (7)	100% (8)	82% (59)
Can help to solve/reduce social problems which obstruct RTW	41% (9)	15% (5)	75% (6)	72% (5)	35% (25)
Sum of competence (0–24)
m (sd)	15.4 (3.5)
22	14.6 (4.0)	16.4 (3.5)	17.0 (3.5)	15.3 (3.8)
n	22	34	8	8	72

RTW = return-to-work.

SA = sickness absence.

Useful competence for RTW coordination

The majority (87%) agreed fully or largely that they had acquired useful competence for their RTWC role through clinical experience (87%), their vocational/undergraduate training (73%), the basic course for RTWCs (78%) or from occasional lectures/seminars (76%) (Table 3). However, these proportions were smaller in the group ‘others’.

Table 3. Proportion (and number) of respondents in each profession and in total who fully or largely agreed that they had acquired useful competence for the role of RTW coordinator through the listed areas.

Acquired competence through	Profession
	Occupational therapists	Physio-therapists	Counsellors	Others	Total
Clinical experience	91% (20)	91% (30)	100% (9)	43% (3)	87% (62)
Vocational/undergraduate training	82% (18)	70% (23)	78% (7)	57% (4)	73% (52)
Basic course for RTW coordinators	82% (18)	76% (25)	89% (8)	57% (4)	78% (55)
Supplementary course for RTW coordinators	0% (0)	3% (1)	13% (1)	0% (0)	3% (2)
Occasional lectures/seminars	86% (19)	72% (24)	89% (8)	57% (4)	76% (55)
Course in motivational interviewing	57% (12)	70% (23)	56% (5)	43% (3)	61% (43)
Course in problem-solving conversation	0% (0)	3% (1)	43% (3)	14% (1)	7% (5)
Basic psychotherapy training	5% (1)	6% (2)	67% (6)	0% (0)	13% (9)
Specialist training	9% (2)	9% (3)	29% (2)	29% (2)	13% (9)
Master’s degree	10% (2)	22% (7)	17% (1)	17% (1)	17% (11)

RTW = return-to-work.

Previous experience gives practical competence

Twenty-four respondents answered an open-ended question which asked them to expand on how they had acquired useful competence for the role of RTWC. One distinctive category was found, namely that previous experience gives practical competence. This included both work – and life-related experience and covered experience of issues such as sickness benefits, rehabilitation and work-ability as well as working for the Employment Services, the Social Insurance Agency, or in social services.

Stated need for additional knowledge

Approximately half of the respondents agreed fully or largely that they needed more knowledge in all the listed areas, with a lower proportion of counsellors than other professions answering that they needed more knowledge of other insurances and benefits besides SA (33%), how to promote a gender equal SA process (22%), how to handle social problems (11%), and in conversation methods (11%) (Table 4). However, there was no significant statistical difference between the professions regarding the total sum of stated need of additional knowledge (H(3) = 6.345, p = 0.096, n = 71).

Table 4. Proportion (and number) of respondents in each profession and in total who fully or largely agreed that they needed more knowledge in the listed areas.

Need more knowledge in	Profession
	Occupational therapists	Physio-therapists	Counsellors	Others	Total
Insurance medicine	55% (12)	58% (19)	67% (6)	57% (4)	58% (41)
Other stakeholders’ possibilities/obligations	55% (12)	64% (21)	56% (5)	71% (5)	61% (43)
Multimorbidity	50% (11)	46% (15)	44% (4)	100% (7)	52% (37)
Gender equal SA process	50% (11)	42% (14)	22% (2)	71% (5)	45% (32)
Domestic violence	41% (9)	38% (12)	11% (1)	86% (6)	40% (28)
Social problems	64% (14)	55% (18)	11% (1)	71% (5)	54% (38)
Other insurances/benefits	46% (10)	79% (26)	33% (3)	57% (4)	61% (43)
Conversation methods	32% (7)	49% (16)	11% (1)	57% (4)	39% (28)
Sum of needed additional knowledge (0–24)
m (sd)	13.0 (4.8)	13.5 (4.8)	9.7 (3.1)	15.1 (4.5)	13.0 (4.7)
n	22	33	9	7	71

SA = sickness absence.

Seven respondents also provided free-text answers to the question about the type of knowledge they needed more of. These answers were too few to provide a robust content analysis, but they indicate two broad categories: need for additional training (e.g. in MI, insurance medicine and relevant rules and regulations), and need for supervision in RTW coordination.

The relation between acquired further training, stated competence and need of knowledge

Non-parametric correlations (Spearman’s rank) showed a negative relationship between the sum of stated competence and the sum of needed knowledge: the more competence the respondents stated that they had, the less knowledge they stated needing (r(68) = -.28, p = .018). The relationship between acquired further training and stated competence was not significant (r(68) = .10, p = .0.42), nor was the relationship between acquired further training and needed knowledge (r(68) = -.18, p = .13).

Which profession provides the best competence for the role of RTWC and why

More than half (55%) of all respondents answered that occupational therapists was the profession with the best competence for the role of RTWC, followed by social workers (47%), physiotherapists (41%), psychologists (26%) and lastly nurses (13%) (Table 5). For all professions except for group of ‘others’ (which regarded social workers and psychologists as the best professions), the majority considered their own profession to have the best competence for the role of RTWC. Occupational therapists and counsellors regarded each other as the second-best profession, while physiotherapists regarded occupational therapists as the second-best.

Table 5. Proportion (and number) of respondents in each profession and in total who answered the question about which profession they regarded as providing the best competence for the role of RTW coordinator.

Who provides the best competence	Profession
	Occupational therapists	Physio-therapists	Counsellors	Others	Total
Occupational therapist
Fully agree	77% (17)	53% (16)	29% (2)	17% (1)	55% (36)
Largely agree	23% (5)	37% (11)	57% (4)	17% (1)	32% (21)
Hardly agree	0% (0)	10% (3)	14% (1)	43% (3)	11% (7)
Do not agree at all	0% (0)	0% (0)	0% (0)	17% (1)	2% (1)
Physiotherapists
Fully agree	29% (6)	63% (19)	0% (0)	17% (1)	41% (26)
Largely agree	43% (9)	30% (9)	57% (4)	17% (1)	36% (23)
Hardly agree	24% (5)	7% (2)	29% (2)	33% (2)	17% (11)
Do not agree at all	5% (1)	0% (0)	25% (1)	33% (2)	6% (4)
Social workers
Fully agree	45% (9)	38% (11)	88% (7)	50% (3)	47% (30)
Largely agree	40% (8)	40% (12)	13% (1)	17% (1)	34% (22)
Hardly agree	15% (3)	17% (5)	0% (0)	33% (2)	16% (10)
Do not agree at all	0% (0)	7% (2)	0% (0)	0% (0)	3% (2)
Psychologists
Fully agree	21% (4)	30% (9)	0% (0)	50% (3)	26% (16)
Largely agree	42% (8)	37% (11)	43% (3)	17% (1)	37% (23)
Hardly agree	32% (6)	27% (8)	43% (3)	17% (1)	29% (18)
Do not agree at all	5% (1)	7% (2)	14% (1)	17% (1)	8% (5)
Nurses
Fully agree	17% (3)	7% (2)	14% (1)	33% (2)	13% (8)
Largely agree	39% (7)	50% (15)	14% (1)	33% (2)	41% (25)
Hardly agree	22% (4)	33% (10)	57% (4)	17% (1)	31% (19)
Do not agree at all	17% (3)	10% (3)	14% (1)	17% (1)	13% (8)

RTW = return-to-work.

Thirty-five respondents elaborated their answer to the question about which profession they thought had the best competence for RTW coordination. Our analysis resulted in three categories highlighting different types of important competence of which they argued that some professions possess more or less. One category, holistic view, included descriptions of how professions with a broad range of competence were best qualified, because RTW coordination required having an overview of a person’s whole life situation. Holistic view also entailed being knowledgeable about a range of symptoms and diseases, rules and regulations, and having experience of rehabilitation. One occupational therapist wrote ‘Occupational therapists and physiotherapists have a ‘built-in’ rehabilitation mindset that I believe is valuable. We see the whole person’. One social worker wrote:

A social worker has knowledge both of conversational methods and society and an understanding of psychosocial problems. Great/important significance. Several physiotherapist/occupational therapist colleagues working as RTWC find patient conversations ‘heavy’, as they find it difficult to cope with people's psychosocial life situations, compared to counsellors’ patient conversations which I find considerably ‘heavier’.

In the second category, personality over profession, personality and experience were described as most important, with one physiotherapist writing: ‘Experience provides more competence than vocational training. Therefore, I don’t think the focus should be on training and/or profession’. Being good at building relationships and having a good attitude towards patients and stakeholders involved in the RTW process also came into this category.

The third category, advisory and guidance, included statements about how the best professions for RTW coordination were those which provided the best competence in supporting, coaching and motivating patients, as opposed to treating them. One respondent in the group of other professions wrote: ‘As a RTWC, you shouldn’t work as a therapist but as a coach’. Nurses were therefore seen to have less adequate competence because they were described as more nurturing than the other professions.

Discussion

In the present study we explored the level and types of training and competence of different professions working as RTWCs within Swedish healthcare. The results indicated that counsellors had more training than the other professions, including conversation methods, communication and counselling – areas previously identified as the most important for RTW coordination (e.g. communication, counselling; Bohatko-Naismith et al., 2019; Gardner et al., 2010; Shaw et al., 2008; Svärd et al., 2021, and communicative and therapeutic skills; Azad & Svärd, 2021). Also, a majority of counsellors rated themselves as fully or largely competent at dealing with social problems obstructing RTW, and only a few said they needed more knowledge in areas relating to social problems, gender equality, other insurances and benefits than SA, and conversation methods. This probably reflects differences in vocational/undergraduate training, where social workers’ professionalisation process has involved the building of a knowledge base and vocational training including law, social insurance, social policy, health, system theory, social psychology and social and psychosocial problems (e.g. Aschcroft et al., 2017; Nygren, 2004; Sandström, 2007). The finding that fewer counsellors stated needing knowledge in promoting a gender equal SA process can be explained by gender equality and domestic violence having been topics included in social work training programs for many decades, whereas they have not until recently been clear topics, compulsory by the Swedish Higher Education Ordinance (1993:952) since 2018, on several vocational trainings (e.g. in physiotherapy, nursing, psychology, medicine).

Most in the group of ‘others’ stated being fully or largely competent in areas such as insurance medicine, advising, collaborating and handling social problems, competences that only about a half seemed to have acquired through their vocational trainings or clinical experiences in healthcare. Most had, however, previously worked in fields such as vocational rehabilitation, human resources, and labour market issues, which could have provided them with practice-based competence. However, as all in the group of ‘others’ answered that they needed more knowledge about multimorbidity, compared with only half in the other professional groups, their experiences or training does not always seem to include knowledge in diseases and symptoms.

About half of the respondents said they needed more knowledge in all listed areas, which indicates that RWTCs in general feel that they need further training. However, our study indicates less of a need for further training (39-61%) than SALAR’s (2022) who reported that 85% of RTWCs who had worked less than a year as RTWCs and 75% of those who had worked more than five years stated a need of further training. One explanation can be that 92% of our respondents had completed the basic course for RTW coordination, compared to 47% in SALAR’s nation-wide study. However, 88% had undergone some kind of course in RTW coordination (SALAR, 2022). Another possible explanation can be differences in the set of original profession and vocational training, with higher proportions of nurses (19%) and social workers/counsellors (18%) in the national sample. The different findings highlight the need for more large-scale studies about what kind of training RTWCs would benefit the most from. Our findings could not establish any relationship between the sum of further training, acquired competence or needed knowledge. It seems thus not to be the amount of training that is related to how much knowledge the coordinators feel that they do or do not need, rather it seems to be related to the types of competence that are seen as important for RTW coordination, or what Nygren (2004) describes as an occupationally and situationally relevant readiness for action.

Our analysis of the free-text answers to the question about which profession that had the best competence for RTW coordination identified three categories of important competence for RTWCs: having a holistic view, personality over profession, and advice and guidance. Having a holistic view was described as having a broad range of competence, where occupational therapists and physiotherapists were described to focus on the whole person in the rehabilitation process, while social workers were described to focus on people’s whole psychosocial life situation, which was claimed to be ‘too heavy’ for the former professions – a finding similar to another study were RTWCs suggest that health social workers should take on more complex cases (Svärd & Jannas, 2022). Both examples address, however, a person-in-environment approach relevant for RTWCs, but where the social work approach understands environment differently; stemming from a holistic paradigm of health, incorporating micro-meso-macro levels and the knowledge bases of social psychology, social determinants of health and system theory (Aschcroft el al., 2017). The other two categories of competence, advice and guidance and personality over profession, addresses relational aspects of competence, where the professional uses personal competence. Personality over profession should not be understood as vocational training is irrelevant, rather that it might be more important for RTWCs to develop the personal aspects of competence than to define which original profession is best suited for the job. This relates to Nygren’s (2004) reasoning that personal competence may not be learnt through vocational training. He describes such competence as hard to define, but as something that develops over time depending on how previous life and work experiences are processed. Experiences of coaching, supervision or psychotherapeutic training (or treatment) are helpful in developing personal competence, but may not depend on it.

The three categories of competence can be understood as shaping common values and norms for RTWCs in their professionalisation process (cf. Evetts, 2013). These values and norms should be taken into consideration when discussing desirable competence for the job. As an emerging occupation with a poorly defined role and competence description, there is, however, a great need to further explore and discuss the desirable competence, training and qualifications for practice.

All professions regarded their own as providing the best competence for the role of RTWC, a finding in line with Abbott’s (1988) theory that professional groups strive to defend and expand their own area of jurisdiction in competition with rival professions, including the striving for monopoly over problems and work tasks. Overall, social workers and especially occupational therapists were regarded as having the best competence for working as RTWC. All professions thus seem to value occupational therapists’ professional competence in for example activity science, and their skills in analysing demands of work tasks and planning a paced RTW schedule for people with work disabilities. Occupational therapists and social workers also regarded each other as the second-best profession. This indicates that there is a higher degree of inter-professional understanding of desirable competence between these professions, and a lower degree of rivalry between them (Abbott, 1988). The findings indicate negotiations about how to assess and define problems (Abbott, 1988). However, there also seem to be shared views on desirable professional values and knowledge bases that might guide the development and possible standardisation of RTW coordination training (Evetts, 1999) and RTWCs professionalisation process (Evetts, 2013).

Strengths and limitations

Due to small sample size and to ensure anonymity, we could not conduct subgroup analyses in regards to healthcare settings. Therefore, we do not know if there were different views on important competence in primary healthcare, psychiatric and orthopaedic clinics. Some of our results should be interpreted with caution because of the small numbers and uneven representation of respondents from the different professions. Some differences could go undetected due to low power. A larger sample, or another set of professions, might have resulted in somewhat different results. We believe some results would turn out to be similar in other countries, but one should nevertheless be careful in extrapolating the results to RTWCs in other countries, especially those working for example for insurance companies or at workplaces.

One strength of the study is its high response rate (89%), which means that the results can be generalised for the specific region and time period. Another strength is the mixed method design using both qualitative and quantitative analysis which complement each other; this gives a broader and deeper understanding to the results.

Conclusions

This study outlines differences between RTWCs with different professional backgrounds with regard to their acquired competence and needs for more knowledge. These differences could make it hard to establish a common understanding of the role and adequate competence of the RTWC. The free-text answers, however, indicate that a holistic view, personality over profession, and advice and guidance are viewed as important areas of competence for RTWCs. Further, occupational therapists and social workers were deemed as being the two professions with the best competence for the role of RTWC. These findings suggest some implications for practice as they may be understood as outlining common values, norms and important competences for RTWCs that could help develop the RTW coordination training and pave the way for RTWCs professionalisation process.

Acknowledgments

The authors wish to thank the respondents for their participation.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Region Stockholm: [Grant Number FoUI-954268, FoUI-936413]; the Kamprad Family Foundation for Research: [Grant Number 20190271].

Notes on contributors

Azadé Azad

Azadé Azad has a PhD in Psychology, and is also a certified teacher. She is currently a PI at the Department of Psychology at Stockholm university and research leader at The National Board of Institutional Care. Her main research fields include developmental psychology with focus on adolescence and forensic psychology with focus on children’s testimony.

Veronica Svärd

Veronica Svärd has a PhD in Social Work and is currently an associate professor at the Department of Social Work at Södertörn University, and PI at Karolinska Institute. She is also working on research projects for the National Public Health Agency and the Karolinska University Hospital.