Return to work among workers recovering from severe COVID-19 in Slovenia: a focus group study

Abstract

Purpose

For working age adults, return to work (RTW) after severe COVID-19 can be an essential component of rehabilitation. We explored the expectations and experiences related to RTW in a group of workers recovering from severe COVID-19 in Slovenia.

Materials and methods

Four focus groups were conducted between May 2021 and August 2021. Fifteen men and three women, aged between 39 and 65 years, participated. We analysed data using reflexive thematic analysis.

Results

Four main themes were developed in the analysis, pertaining to (1) work identity, (2) challenges to work re-entry, (3) personal strengths and support systems, and (4) possible adaptations at work. The disruption of work triggered sentiments about its role in identity. Workers’ personal agency and self-advocacy helped participants cope with various barriers that were beyond their control, such as physical limitations and lack of systematic routines to address RTW. Workers recovering from severe COVID-19 were at risk of developing negative expectations regarding their work re-entry.

Conclusions

RTW after severe COVID-19 involves different personal, organizational and systemic dimensions that need to be considered and carefully aligned. Due to the individuality of the process, the worker should be involved as a key partner in the RTW process.

IMPLICATIONS FOR REHABILITATION

• Lack of clinical pathways can negatively impact return to work (RTW) after severe COVID-19.

• RTW processes should start early but timely and include individual follow up.

• Patients expect the interdisciplinary team of experts to work together and involve them in all phases of decision-making regarding their rehabilitation and RTW process.

• Positive expectations regarding work re-entry are essential for the RTW process.

Keywords:

• Experience
• individuality
• SARS-CoV-2
• vocational rehabilitation
• work re-entry
• qualitative research

Introduction

COVID-19 affects not only people’s health status, but also their ability to participate in the society and work [1,2]. Research exploring return to work (RTW) after severe COVID-19 is only now beginning to emerge [1,3]. This can be explained by an early research focus on the virus, screening, and vaccination; however, today the subsequent rehabilitation needs after having survived severe COVID-19 are becoming more visible and can be prioritized. This is relevant because a sizable number of survivors from severe COVID-19 require support to return to meaningful and productive work, with substantial differences noted between different country contexts [1].

Severe COVID-19 is characterized by requiring oxygen support and persons being more prone to complications such as respiratory failure, acute respiratory distress syndrome (ARDS), sepsis and septic shock, thromboembolism, and/or multi-organ failure, including acute kidney injury and cardiac injury [4,5]. Those who become critically ill (approximately 5%), often need endotracheal intubation and mechanical ventilation [5]. In the recent two years, persons with COVID-19 have been increasingly referred for interdisciplinary rehabilitation, especially those who had severe COVID-19 and were initially treated in the intensive care units (ICUs) due to the critical nature of the condition [6]. Hürlimann and colleagues [3] found that persons hospitalised in ICU departments for COVID-19 took longer to return to work, which is similar to other populations impacted by critical illness that requires ICU treatment [7]. Persisting symptoms of the COVID-19 disease, which may change or relapse, are also common [8]. The findings of an international cohort study showed that seven months after the infection, many persons with COVID-19 did not recover nor return to previous level of work, primarily due to fatigue, post-exertional malaise and cognitive dysfunction [9].

Return to work (RTW)

RTW refers to the process that leads to varying degrees of resumed work participation after a period of work disability due to illness or injury [10]. Along this line the authors place focus on the RTW process in this paper rather than the outcome of work. RTW begins in the initial phases of rehabilitation and concludes when situationally relevant vocational goals are reached, with several work-related and psychosocial factors impacting the process [10,11]. Research on RTW in various groups consistently shows that among psychosocial factors, peoples’ own expectations regarding RTW are a strong predictor of work resumption [11–14]. Young et al. [11] suggested that capturing and addressing peoples’ RTW expectations already in the initial stages of rehabilitation may support optimal RTW outcomes. This has also been reported in other groups of relevance here, with an emphasis on early but timely rehabilitation [15,16]. It can thus be important to study the assessment, management of symptoms, and ability to participate in the society and work related to return to work (RTW) after COVID-19, including both severe and long COVID [1,2,17].

Rehabilitation and RTW

It has previously been discussed that to optimize RTW after interdisciplinary rehabilitation, the vocational issues need to be addressed during and beyond the rehabilitation intervention aimed at functional recovery and consider different stakeholders, including the worker and their employers as well as society as a whole [10,18]. In this dynamic process, the worker generally transitions through four phases: “off work,” “work re-entry,” “retention” and “advancement,” with a strong focus on the reciprocal relationship between health and work [10]. When people are still in the “off work” phase, the RTW actions can commence and include determining the individual’s work abilities and intentions, identifying suitable work options, and establishing readiness for work re-entry as well as exploring expectations regarding RTW [10,11].

Context of the study

Because working conditions as well as policies relating to COVID-19 vary between countries and sometimes within a country [1], we will situate the experiences and data presented in this paper. All data were gathered in Slovenia. Slovenia is a small Central European country, member of the EU, with a population of about two million people. According to the Slovenian National Institute for Public Health [19], 266 418 cases of COVID-19 were confirmed between 4 March 2020 (when the first case of COVID-19 was confirmed in Slovenia) and 31 August 2021. This is relevant because the data for this study was gathered within this period. The National Institute for Public Health recorded 72 116 cases of COVID-19 in the working population in 2020 or 7.98 cases per 100 workers. The average duration of sick leave was 12.9 days, with a total of 972 919 days of sick leave attributed to COVID-19 in that year [20]. In 2021, there were 178 493 of COVID-19 cases in the working population or 19.19 cases per 100 workers. There were 1 932 525 days of sick leave due to COVID-19 in that year, with an average duration of 10.8 days [21].

Slovenian health insurance system consists of compulsory health insurance and supplementary health insurance. People who have both types of insurance, receive free medical treatment and rehabilitation. Almost everyone in Slovenia (99.9%) has compulsory health insurance and a further 95% has supplementary health insurance [22]. Without supplementary insurance certain medical services are fee-based. The above guidelines also applied to persons with COVID-19, who had access to medical treatment in hospitals, physical and cognitive rehabilitation post discharge from hospital (if applicable), as well as medical rehabilitation in spas and vocational rehabilitation for those returning to work.

As in most EU and OECD countries, workers in Slovenia receive benefits from sickness insurance for the duration of their illness or injury. The first 30-days of sick pay is covered by the employer (pending a medical certificate), and thereafter by the Health Insurance Institute. Insured workers who are on long-term sick leave can be referred to the vocational rehabilitation program by their General Practitioner or other medical specialists and attend the program as inpatients or outpatients. The vocational rehabilitation team consists of a physician, psychologist, occupational therapist, social worker, rehabilitation technologist, and other experts when relevant.

The Slovenian sickness insurance system does not have a maximum benefit payment duration, resulting in relative financial security when it comes to long-term sickness and disability [23]. Although the amount of sickness compensation usually corresponds to 80% of the worker’s full salary, during sick leave due to COVID-19, the amount as well as the source of payment were adjusted. The Act on Intervention Measures to Assist in Mitigating the Consequences of the Second Wave of the COVID-19 Epidemic [24] ensured 100% salary for the duration of sick leave if workers got infected at work (despite using all the protective equipment) as this was considered injury at work or occupational accident. In other cases of absence from work due to COVID-19, 80 − 90% of pay was guaranteed depending on the circumstances. Moreover, from day one, the cost of sick leave was covered directly from the national budget and not by the employer [25].

The aim of this paper is to explore expectations and experiences regarding RTW during the rehabilitation process among a group of workers recovering from severe COVID-19.

Methods

To meet the aim of the study, a qualitative cross-sectional study design with focus groups data gathering technique was used.

Recruitment and participants

Participants were recruited via the University Rehabilitation Institute - URI Soča, which is located in Ljubljana. The inclusion criteria for the study were that the individual (1) had severe COVID-19, (2) required rehabilitation post-covid due to the severity of the disease, (3) was planning to return to work, (4) could understand and communicate effectively in Slovenian language.

According to the internal records of the University Rehabilitation Institute - URI Soča, in the period between October 2020 and August 2021 (which coincided with the second wave of the COVID-19 pandemic in Slovenia), 63 persons under the age of 65 were admitted following severe COVID-19 that included some complications. This group, all spent prolonged periods in ICUs, and were initially immobile and dependent in activities of daily living. At the time of the study, some had already been discharged to their home environments, while others were still hospitalised at the University Rehabilitation Institute - URI Soča. Since data collection was planned in Ljubljana, those who were from Ljubljana or nearby towns and those who were still inpatients were approached by the social worker and the head of occupational therapy regarding their willingness to participate in the study. The aim of the study was presented to them verbally as well as the format of data collection. Those who agreed, were given written information about the study and they signed a consent form. Of the 25 individuals who were contacted, five did not meet the inclusion criteria (they were retired or did not plan to return to work), one declined to participate, and one could not be reached.

In total, 18 individuals participated in four focus groups, each group consisting of four to six participants. Participants were between 39 and 65 years old (mean age 51.2 years). Participant characteristics are presented in Table 1.

Table 1. Participant characteristics.

Variable	Categories	N	Average (range)
Total N		18
Gender	Female	3
	Male	15
Hospitalization and rehabilitation	Time in acute hospital (in days)	–	58 (16 − 156)
	Time in ICU (in days)	–	31 (8 − 85)
	Duration of rehabilitation (in days)	–	32 (17 − 58)
Sick leave	Duration of sick leave (in days)	–	219 (96 − 328)
Current employment status	Working full time	1
	On sick leave	15
	Unemployed	1
	Partially retired	1
Area of work prior COVID-19 infection	Health care and education	4
	Food industry and catering	2
	Maintenance and security	3
	Manual work	3
	Engineering and technology	2
	Self-employed	2
	Other	2
Work ability index (WAI) score (N = 16)	poor	6
	moderate	5
	good	3
	excellent	2

Data collection

Qualitative data were collected using focus group interviews. This method has been recognized as appropriate when trying to engage participants or service users who are often not considered when gathering data in disability research [26]. Focus groups were conducted at the University Rehabilitation Institute - URI Soča between May 2021 and August 2021. Two moderators were present at each focus group. They both have a background in occupational therapy and experience with conducting focus groups interviews and qualitative research. One, who previously worked in vocational rehabilitation and now works in chronic pain management, acted as the main moderator (AŠ) and guided the discussion. The other (UB), who works in academia, was in the assistant role, taking notes on who was speaking and occasionally asking clarifying questions. The same pair of moderators was present for all focus groups. The participants were also asked to complete the Work Ability Index (WAI). The WAI is an instrument intended as a self-assessment of work abilities from the workers’ perspective. It includes a series of questions about estimated work abilities, work demands and health status. The index score ranges from 7 to 49 points, a higher rating suggesting better work ability [27].

Each focus group started with a short introduction of the moderators and the participants, followed by the main focus group interview. An interview guide was used to help guide the discussion through different stages of the rehabilitation and RTW process. The interview guide was developed based on the research of Asaba et al. [28] who conducted a similar study in the Swedish context and with whom we collaborated when designing the present study. Topics that were covered in the focus group discussions included, for example, experiences with the rehabilitation process, home discharge, expectations and experiences of work re-entry, first contact with the employer, and relationships at work. The complete interview guide is available as a supplementary file. Focus group interviews lasted between 67 and 89 min and were audio recorded with the participants’ permission. Recordings were transcribed near verbatim.

Data analysis

The material was analysed using reflexive thematic analysis [29]. To ensure the trustworthiness of the results, the following procedures were carried out. Importantly, triangulation of researchers was employed. Three authors (UB, BD, MK), who were all experienced in qualitative analysis, first independently coded the interviews with the help of computer software Atlas.ti. Codes were collated into preliminary themes and subthemes. During this process, the researchers met three times to critically discuss their respective findings and compare as well as contrast the directions that they were taking in the coding process. In this way, the analysis was iterative and through discussions around the analysis, consistency in use of codes was strengthened between researchers. There was a notable congruity between the researchers, although the themes and subthemes were occasionally named differently by each researcher. The ongoing discussion was used to review and refine the themes and decide which ones to explore more in-depth for the purpose of this study. Additionally, the selected themes were checked for internal coherency and citations with unique identifiers from the focus group interviews were included to support the analysis. Since the researchers come from different professional backgrounds, the analysis benefited from an interdisciplinary approach. It was conducted in Slovenian language and later translated to English by one of the authors (BD) who holds an English language degree. The accuracy of the translations was double checked and compared with the Slovenian original by one of the other authors (UB) who is also fluent in both languages.

Ethics

The medical ethics committee at the University Rehabilitation Institute - URI Soča approved the study (no. 035-1/2021-3/3-7). All participants gave written informed consent for participation. Participation was voluntary and did not include any incentives for the participants. Participants could withdraw from the study at any time without consequence. To de-identify participants, pseudonyms were used throughout the study and in the representation of the findings

Findings

Four main themes and five subthemes were developed in the analysis (Table 2). The findings describe the experiences and expectations regarding RTW as well as the meaning attributed to work, which was subtly detected throughout the analysis. Themes are substantiated with citations from the participants, including the focus group number next to the representative quote.

Table 2. Themes and subthemes with descriptions.

Theme	Subtheme	Description
My work, my identity	–	The importance of work in a person’s narrative and a strong wish for work re-entry. Also, a sense of loss if work re-entry is not possible yet or in doubt.
Challenges to work re-entry	Not a linear recovery	The recovery process has ups and downs and is generally unpredictable, which makes work re-entry more difficult to plan for and contributes to feelings of uncertainty.
	One-size-fits all system	Health and social care systems do not consider the individuality of patients’ recovery process; therefore, specific needs are left unmet. Absence of follow-up noted.
	Lack of collaboration	Decisions are not taken collaboratively in terms of interprofessional and cross-sectoral input. Patients’ perspective and active involvement are not considered in the process of RTW.
Personal strengths and support systems	Personal agency and self-advocacy	The individual’s level of motivation and engagement plays a significant role in the process of RTW and recuperation. Participants take responsibility and are motivated to do additional work that could help their recovery process. They act as self-advocates when required to make their voices heard.
	Supportive relationships	The importance of relationships, including family, friends, co-workers and managers. If support is not in place, recovery experience and RTW are more difficult.
Possible adaptations at work	–	Different strategies that could help with work re-entry, such as gradual return to work, reduced work hours, job reassignment. For some jobs, the existing options are not sufficient to enable work re-entry, which can prompt thoughts about retirement or career change.

My work, my identity

Prior to COVID-19, the participants were generally satisfied with their work/job and reported a sense of competence pertaining to work. Participants described a work ethic of personal meaning and commitment to work, work representing an important part of their identity. The participants reported a wish to commence work again. Since most had a long history at their workplace (and in the profession) they were hoping to return to their previous jobs, if possible, as described by Izidor who works as a chef:

I have always been interested in cooking, already as a child. Right now, I have 21 years of employment and I am happy to do my job. I want to learn, I want to make progress, but right now, I’m unable/…/I was already at the workplace a couple of times, just to see it and I want to go back and I also want to prove to myself that I will come back. (Izidor, FG3)

Work could be a source of purpose in life, a vocation, something the participants were proud of. Therefore, not being able to work was a heavy disappointment for some of the participants. At the same time, the loss of work made work itself more valuable; the participants realized how much work meant to them when they could not engage in it anymore. Simona, who works in a nursing home, gave an account of the meaning work has for her:

I finished school for caregivers at the age of 33. It means that I was, so to say, mature, that I knew what I wanted. And when I started my practical training, I realised, well, some do it at the age of 16, but I discovered the meaning of life at 33. This work is right up my street. I live for older people. I adore this job. But I don’t know if I will ever set my foot across that doorstep again/…/COVID took that away from me … My purpose in life was basically taken away from me by COVID, right … (Simona, FG3)

Klara, who works with adolescents, also saw an additional value of her work in the new situation:

Now that I was ill, I know how much I love my work … Because I saw, how the young people reacted, what … Basically, I really do something for them and they for me. And no one can imagine that, what I do, impossible. (Klara, FG2)

Work was a vital force for the participants, a solid and stable component of their identity. Being able to return to work thus meant more than resuming their duties. It symbolized regaining inner consistency and place in the world, returning to the life path they knew before it was abruptly interrupted by COVID-19. Consequently, the process of returning to work was experienced as complex and rather fragile in a multitude of ways.

Challenges to work re-entry

Not a linear recovery

What made the RTW process particularly challenging was the uncertainty and unpredictability of the participants’ current health status and its trajectory. The main health issues limiting the participants’ ability to RTW as reported by them were mainly physical, but also cognitive and behavioural. Participants complained of loss of strength and fatigue, e.g., feeling completely exhausted during tasks or after work. Participants in this study also had trouble walking longer distances, climbing stairs, lifting heavier burdens, lacked the strength in legs for kneeling and squatting, and some even struggled to stay on their feet for a longer period. Thus, physical work presented a big problem for most. Moreover, they experienced various aches and pains, mainly muscle and joint pains, e.g., in the arms, shoulders, hand joints and legs. Some also reported painful vocal cords and throat, resulting in difficulties with speaking or singing. Some suffered from sensitivity problems, e.g., numbness and tingling in the feet and hands resulting in limping and stumbling, difficulties driving a car and handwriting. Among cognitive and behavioural difficulties reported by the participants were lapses in memory, attention and concentration problems, so that finding the right words or multitasking was difficult at times, and increased irritability. The recovery process was not linear and featured both improvements and exacerbations of the condition that affected everyday life activities as described by one of the participants:

For two months, that is in February, March and the beginning of April, I had very strong pain in my joints, so it was a problem to get up in the morning or, I don’t know, put on the socks and also a T-shirt, go round the flat, so that I had a sort of a huge exacerbation.… Whatever, consequently, from being up and about, for example I took walks, with hiking poles of course, it came to the point that I couldn’t even go for a walk, it was a problem for me to walk already around the flat. (Ana, FG1)

“Bad days” were not uncommon and made planning less reliable. For one of the participants this was something he overcame but remembered it as a feature of the recovery process:

But there was a problem from time to time, at the beginning each week, then every 14 days, every three weeks, there were days, when I was totally exhausted. The moment appeared that crashed me totally, I could only lie down. When I slept over it, took rest, the next day I was like new. But now, this also doesn’t happen anymore. (Miha, FG1)

In addition, because of the limited knowledge of illnesses like COVID-19, the participants were not able to receive guidance and reassurance from the health professionals regarding the timeline of their recovery and work re-entry:

The other thing now is that it is moving on very slowly. You can’t do anything to speed it up. And that is very difficult for the psyche … You also don’t know exactly, there is no protocol … And now, I don’t know, with knee, with hip, you know it means approximately two to three months of sick leave and then you come back to work. You can’t tell [with COVID]. And that is the most what actually … it affects me the most. (Jani, FG4)

The participants sometimes doubted if they would be able to continue working and they recognized the temporality factor that was often outside of their control. The unpredictability of the condition could represent a considerable psychological burden, especially when considered in opposition to the anticipated black-and-white expectations at the workplace:

Yes, and the moment you think you would work, right then you go on sick leave. That is the problem. They all expect from you, now you came back to work and you will be able to work the same as if you haven’t been at home. That is the problem. They all expect you to be healthy, when you come. Either you are or you aren’t, right. (Roman, FG2).

To cope with the uncertainty on the one hand and the expectations on the other hand, the participants often suggested that the most reliable indication of work re-entry would be the actual performance in situ: “It is getting better. But how much it will improve at the end… When we try, we will see, best then. You will not know it until you start working.” (Roman, FG2)

One-size-fits-all system

Participants encountered various difficulties in the process of rehabilitation and RTW. They recognized that the system in place did not meet their unique needs and expectations because it was based on a one-size-fits-all approach as explained by Branko (FG3): “It is like those socks that one can stretch from size 36 to 47. But unfortunately, people are different, or luckily…”

While the participants generally praised the medical treatment that they received, they were critical of the lack of follow-up post discharge. Participants felt that the rehabilitation approach should be more individualized throughout the process, including the transition to home environment. It was also expressed that the rehabilitation after COVID-19 should be longer and more intense in order to achieve better progress and reach individual goals:

After you are discharged from the system, it is really like being cut-off. And here maybe, in my opinion, it would nevertheless be reasonable to keep a sort of contact with us, because you actually don’t know, what is going on. Because each one has its specifics. Someone is all right after half a year, so they say, and someone else is not yet even after a year and a half. (Jani, FG4)

Lack of collaboration

The participants came across several systemic barriers around organizing their sick leave and disability status, which often left them feeling frustrated and angry. They did not feel involved in the decision making and felt misunderstood or let down as described by one of the participants who had to start working earlier than he felt ready:

I was told, [name of the person] told me till summer maximum [I will be on sick leave], but it didn’t turn out that way. It was decided by the Commission [to start working earlier], and I can’t do anything about it. I went to the doctor to get some kind of a disability supplement. I was told it will take another year. (Janez, FG1)

As pointed out by other participants, various experts playing important parts in the process of rehabilitation and RTW were perceived as acting in a rather uncoordinated manner or were even missing at certain crucial stages as explained by Ana who is a music teacher:

We have already been thinking about returning to work with [the name of the social worker] here. Well, so somehow, I should say, I was without worries, because I knew I was supposed to be on sick leave until the check-up. I said, this means I will take time for rehabilitation. And then it turned out the check-up was set only in the end of June. And the Commission informed me I had to return to work for two hours [a day]. Well, but I can’t do anything with the voice like I have now. I also had a check-up at the Clinical department of Otorhinolaryngology. Although the vocal cords aren’t hurt, I allegedly suffered the paresis of those nerves. Well then, I must say, I was totally shocked. I also called my employer. Well, the principal said: "I don’t know what to do with you, I need a musician that can sing, that can talk in the classroom", she said: "I need that kind of a teacher", she said:" I can’t place you anywhere else", right … (Ana, FG1).

Participants were expecting for all involved to participate in the discussions, including the person recovering from severe COVID-19 who should be considered an expert when assessing their work arrangements and requirements. However, this rarely happened, and decisions were often taken separately and out of context:

I have diabetes, a very mild form, it is not, I mean, it’s manageable. But, he [the doctor at the Commission] said I shouldn’t do night shifts … But I prefer night shifts … And no one can imagine what I do, impossible. And it is not OK to be told I shouldn’t do night shifts. (Klara, FG2).

A variety of different aspects and characteristics found in the participants’ narratives made it clear that their rehabilitation trajectories were unpredictable and extremely varied. What contributed most to their health or was accepted by participants as a temporary solution was very specific to the individual and sometimes even contradicted expert opinion. These findings support a more individualized therapeutic approach, collaborative team decision making, and active participation in this by those affected. Despite the severe impairment of their health and functionality, participants showed a high degree of personal determination and acknowledged the strengthening powers of their social support networks.

Personal strengths and support systems

Personal agency and self-advocacy

The participants’ own engagement and motivation were essential for rehabilitation and RTW as well as for their performance and independence in the activities of daily living. They agreed how important it was that they did the work themselves. Some actively searched for additional rehabilitation options to further their recuperation and paid out of pocket for private services. Participants agreed that in-patient rehabilitation provided only the foundation as demonstrated in the discussion between three participants during focus group 2:

Nace: But I think it is extremely important to know that the physiotherapy that we receive here at URI Soča alone doesn’t help anyone. If I am at home, I can see that if I didn’t do it every day at least for an hour and a half, I am lucky in this respect that my wife can help me with the exercising, stiffness comes back again in two days. If it happens that I can’t stretch my arm well, every finger, every joint, it takes a lot of effort and if you don’t do it at home on your own, even Soča with all its professional competency and dedication…

Marjan: They teach us here to exercise also at home, because it is not that they could make you now, that you would be healthy when you come out. They teach you to do it yourself.

Roman: They only show you, you have to do it yourself, because if you don’t, it doesn’t help you a bit, not you not them basically.

Although the participants expressed a strong wish and will to return to work, they also placed their health and family first as advocated by one of the participants who previously worked as a baker:

First thing I said was that I would like to leave the bakery, to go to the warehouse. Lungs were most important to me, to avoid the problems with lungs … Yes, I said I was not willing to go, I said it straight away. Even if adapted, I don’t know, I would not go I said. Even if they sack me, I will not go back there again. Lungs are more important. (Janez, FG1)

Supportive relationships

The role of positive, supportive relationships was often mentioned. The participants described the support they received from their families that enabled normal functioning post discharge:

Now, I tried as much as I maximally could to do everything on my own. But, for example, when I got out of the hospital, I couldn’t take a shower on my own. I showered myself all right, but I couldn’t dry myself. Not at all. And I … Thank God my wife helped with all this. (Tadej, FG4).

Some also experienced support in their workplace, from employers and co-workers. However, the support at work was sometimes conditional and participants were aware that it might cease if they were unable to perform their work obligations as before: “Currently, I can say the employer or rather my supervisor truly supports me. We shall see what happens when I start working. How all of this will turn out.” (Janko, FG2)

In contrast, sometimes attitudes of the employers or superiors towards some of the participants were perceived as lacking empathy or encouragement:

I would say, in the first place, the attitude towards workers should be sorted out, because at our workplace, truly, we are treated like a piece of garbage/…/I, for example, was the first patient in the bakery, the first to get sick with COVID, to go to hospital. All the rest had milder symptoms, were in quarantine for 14 days or 2 weeks on sick leave, could go normally to work straight away. Only I have these severe consequences. So, they will not stress out for one person, so to say. (Janez, FG1).

Lastly, the participants emphasized the importance of support exchanged among themselves, among people recovering from severe COVID-19 as well as other with serious health problems:

It was on the ward, where you could listen to others, but not all were COVID patients, also some other [diagnosis], but it was actually some sort of a therapy through such conversations. It happened also outside, in the courtyard and so on. For example, if you only stand nearby and just listen … Because, when you are all alone at home, thinking, oh, you are alone in your head…If we got together like this, even with different, maybe, once every 14 days for example, or once a week, or whatever, it would be also good for us … maybe to support socializing a little bit. (Jani, FG4)

With such radical life upheavals, preserving one’s autonomy, the highest possible degree of self- management, care and decision making became prominent. In achieving this, support from others proved invaluable, whether at home, from other survivors of severe COVID-19 and also in the workplace, where various adaptations or solutions could be considered.

Possible adaptations at work

The participants had limited experience of the actual work re-entry. Some visited their workplaces already or were in communication with the employer. Based on the expectations of their workplace and current functional status, several possible adaptations were suggested, including gradual return to work and reduced work hours: “Above all, to start gradually, I don’t know, 4 h, 6 h, only then 8 h [a day]. Gradual returning. (Marjan, FG2).

Job transfer or reassignment within the same organization was also considered:

The work is physical, so I don’t know how I will go about it. I can’t bend, nothing, lifting heavy burden, sometimes a palette of 60 kilos. They only suggested different kind of work, because I can do other things also. Work, where you sit, that would still be acceptable, right. (Stane, FG4).

At some workplaces, adaptations were not possible for various reasons, some related to the nature of work or its specific context, others to personal characteristics:

At my work, 4 hours isn’t possible. Even if it is prescribed 4 hours, I will get a call, for example, 2 hours after I need to stop working. Even if I don’t answer, I will hesitate whether it is important or if I can do anything. It is really like that, mentally I am really very uneasy, irritable … (Jani, FG4)

If the participants felt that no existing adaptations and systemic options could enable their work re-entry, they sometimes started considering retiring or changing career:

I am lucky in this respect to have very few years till retirement … Basically 20 months to fulfill the first condition, approximately. Otherwise, I would like to return very much, but at this moment there is no chance for that. (Vlado, FG4)

New career could also be embarked on by continuing and finishing education as described by Peter (FG1) who was hoping for a new job:

I started attending school again before I got ill, to conclude my studies. So, I am in this process now. I have an exam next week. Now, concerning the future…They [companies] search a lot lately, so I think, I will finish my studies and apply for a post in plastic programming. So basically, my expectations are for a better future, like with all the rest. But we will see what turns out.

All in all, the findings showed that work was an enormously important segment of quality of life for the participants. They expressed a strong will to work, but the process of returning to previous workplaces proved rather challenging and often seemed out of their control. In such situations, the importance of a person’s dignity, autonomy, and social inclusion may have been prioritized over full recovery of health and functionality. In their narratives, participants appeared as human beings who were primarily striving to regain control over their lives. As articulated by Branko (FG3), “Basically you have to stand by yourself, that’s it. You will find the thread you lost, there is no other.” In order to return to their path, they expected to be supported and actively involved in decision-making regarding their individual rehabilitation and return to work.

Discussion

This was the first study that explored the experiences and expectations of workers in Slovenia who had survived severe COVID-19 and were going through the process of RTW. The findings included four main themes. The theme My work, my identity described the importance of work and work re-entry for participants who had survived severe COVID-19. Challenges to work re-entry illustrated participants’ difficulties navigating a very unpredictable landscape where their individual needs were rarely considered, and they were not involved in the decision-making process. Their expectations were marked by feelings of uncertainty. Primarily, uncertainties stemmed from ongoing physical and/or cognitive limitations that made the participants doubt their current and future work abilities. This ambiguity regarding the future appeared to be intensified by the experience of a nonlinear recovery. Despite the obstacles, participants demonstrated a high level of motivation and advocated for their rights, which, along with supportive personal relationships, formed the Personal strength and support systems theme. Finally, participants suggested some possible strategies that could facilitate their work re-entry. These were described in the Possible adaptations at work theme and acknowledged that for some, work re-entry may not be possible despite the adaptations.

The meaning of work

It has previously been shown that work has an extremely important meaning for many people, which surpasses the financial benefits. Work includes dimensions of identity, personal development, a sense of belonging and achievement [30–33]. It is, therefore, not surprising that the participants were eager to continue working despite the difficulties that they were experiencing. This finding is somewhat contradictory to a previous study that included a sample of Slovenian working-age persons in which the authors reported that they wanted to cease work and retire already at the age 57.4 years, significantly earlier than most of their European counterparts [34]. In contrast, participants in this study were very motivated to work for as long as possible. One explanation for this discrepancy can be that people assess their working life differently when they are healthy and have the choice to work compared to when choices are limited. On the other hand, it has previously been found that perceived health had weaker association to RTW than work beliefs and attitudes [35]. In this group, work was generally perceived as positive, and workers had a positive attitude toward work already before the onset of COVID-19 as described in the interviews. For participants, the onset of the illness was sudden and unexpected and affected their lives dramatically, sometimes interrupting a meaningful and self-realising career. For some, not being able to return to work left them with a sense of loss. Similar experiences after an illness with a sudden onset were described by Salzwedel et al. [36] in a study of persons after an acute cardiac event. The authors found that the occupational expectations during the three-week cardiac rehabilitation process predicted work capacity at discharge, which was also strongly associated with depression and limited physical capacity. The authors emphasised that the persons with reduced physical performance and co-morbid psychosocial burden should be identified early in the rehabilitation process to plan individualised recovery and RTW interventions.

Challenges to work re-entry

Several findings of the present study can be discussed in relation to existing knowledge about the factors affecting the RTW process. Some challenges described by the participants were related to the specifics of their recovery after COVID-19 and others to the way in which the RTW process was (not) supported by existing health and social systems.

Due to extremely complex clinical picture, treatment/rehabilitation paths and effects of COVID-19, there is no uniform trajectory of regaining health and functional capacity. There is therefore no single disciplinary method to holistically support a person recovering from COVID-19. Rather, the need for an interdisciplinary approach with active engagement of the person has been well recognized [6,37–39]. The participants in this study expressed appreciation of interdisciplinary care they received as inpatients. However, when evaluating services that were outside the scope of medical and rehabilitation interventions, it was noted that synchronous collaboration among various agents was critically lacking. This became prominently evident in cross sectoral issues such as organizing sick leave, disability status and work re-entry. Decisions were often made separately and out of context. This finding illustrates that a biomedical view was taken, rather than the work disability paradigm, which proposes a view that goes beyond the work-disabled worker and considers other determinants that affect work, such as workplace and societal factors [40]. The work disability paradigm is well established in some fields, however, when newer health problems lead to work disability, the shift to the work disability paradigm is often not yet complete and work reintegration remains limited [41,42].

The participants experienced many barriers and inconsistencies in the system, which often left them frustrated. In their opinion such issues could benefit immensely from a well-coordinated, joint decision-making that would involve medical experts, various (rehabilitation) therapists, social workers, The Pension and Disability Insurance officials and employers as well as themselves. The need for and the potential benefits of a coordinated dialogue and collaboration between stakeholders has been identified in several studies [43–45]. By expressing tendencies to implement patient co-production [46], the participants in our study pointed out patient empowerment and active engagement to be considered a vital quality factor in the process of their RTW. Instead, they often described that the path to recovery and work re-entry was a personal fight that sometimes involved other family members and support systems. The overall conclusion was that the process could have been a lot more efficient and user-friendly if the workers were more involved in the decision-making and their voices were heard. Furthermore, Because COVID-19 is a new illness for all involved (patients and health professionals), participants were uncertain whether the services they received were sufficiently supporting their recovery and work re-entry.

Expectations regarding return to work

The participants’ expectations of RTW depended on their individual recovery trajectory, which they experienced as unpredictable, fluctuating and characterized by persisting physical performance limitations. They seemed to show the vulnerability for developing negative RTW expectations based not only on the possibly persisting physical performance limitations, but also on the feeling of insufficient system and workplace support and on overall sense of loss. A substantial proportion of participants with the lowest WAI score could also be indicative of such a risk. Furthermore, the participants sometimes perceived a discord between the employers’ needs – wanting them to come back quickly and engage in work as before the illness – and their current work ability. This sentiment mirrors the difficulty in how work is understood, something that has been observed as a challenge in studies internationally [30]. In a qualitative study, Young and Choi [47] explored how RTW expectations can be improved through addressing work-related factors and supporting people on sick leave in the RTW process. Their findings suggest that talking to people about the reasons for their current RTW expectations provides the opportunity for identifying crucial work-related concerns that need to be part of a safe and timely RTW plan. Especially addressing the workplace relationships shows a potential to improve the RTW expectations of persons on sick leave. Optimistic expectations of recovery and RTW were also identified as factors affecting RTW after injury or illness in a synthesis of systematic reviews conducted by Cancelliere et al. [48]. Other common factors affecting RTW across conditions include pain and disability level, depression, workplace factors and access to multidisciplinary resources. Several of them were also described by the participants in this study and could be modified through different stages of the RTW process, already in the “off work” stage [10]. Different strategies could be applied to support the RTW process such as consulting and collaborating with a vocational rehabilitation team and other stakeholders in the early stages of recovery, considering health and work-related factors in individual planning of a graded and coordinated RTW in a realistic timeframe [47,49]. Durand and colleagues [50] previously discussed the margin of maneuver concept that considers the interaction between health status and work demands. It includes the possibility that a worker can develop different ways of working that enable them to achieve production goals without negative health effects. The presence of the margin of maneuver can be a prerequisite for a sustainable work re-entry and should be considered throughout the RTW process.

Study limitations

Not all the participants included in the study were in the same stage of the RTW process. While one of them was already back at work, most of the others were still on long-term sick leave and were either undergoing rehabilitation as inpatients or were continuing their recovery at home. The sample was therefore not homogenous in their functional status and the stage of the recovery process. Nonetheless, the WAI score demonstrated that most of the participants (n = 11) assessed their work abilities as either poor or moderate, suggesting some mutuality between them. A follow-up study is being considered, which could enable us to explore the experiences of work re-entry as the final phase of the RTW process. Perhaps a broader range of participant experiences could be captured, and additional themes developed if a larger or more diverse sample or a more specific research focus were applied in future research. Finally, in line with the aim of the study, we have gathered and analysed only the views of the workers. However, to gain a more holistic assessment of the RTW process, the views of health care professionals and employers could also be considered in future research. Similarly, a participatory research approach involving patients and/or their families could better inform the study design and improve the real-world impact for study participants.

Conclusion

This study explored experiences among working age adults after severe COVID-19. It highlighted several factors that should be considered when organizing and developing services related to RTW processes, including the need to coordinate and involve different stakeholders, provide support with negative work re-entry expectations, and consider new workplace adjustments that could meet the complex and highly individual needs of this group of workers. Working-age adults who had severe COVID-19 are a non-homogenous group and the existing approaches within vocational rehabilitation may not be sufficient to meet their needs and adequately involve them in the RTW process.

Acknowledgements

We would like to thank the participants for sharing their experiences. We also thank Dr. Lea Šuc and Ms. Katja Ronchi for their help in applying to the Ethics Board and recruiting participants.

Disclosure statement

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