Being a co-worker or a manager of a colleague returning to work after stroke: A challenge facilitated by cooperation and flexibility

Abstract

Background: The process of return to work is complex. Knowledge is scarce regarding the experiences from co-workers and employers about this process.

Aim: To explore and describe how co-workers and managers experience the return to work process involving a colleague with stroke who is participating in a person-centred rehabilitation programme focusing on return to work including a work trial.

Material and methods: Seven co-workers and four managers were interviewed during the work trial of a colleague with stroke.

Results: Being a co-worker or manager was related to various challenging experiences; the emotional challenge of being a supportive co-worker or manager, the challenging experience of having too much responsibility, and the challenge of being supportive despite a lack of knowledge.

Conclusions: The participants placed value on having support from the coordinator for handling different challenges, but despite this they experienced difficulties in being a valuable support. The limited time of work trial and occasional lack of support from the employer were aggravating aspects.

Significance: This study highlights the importance of establishing a commitment between the employer and all involved actors in the initial phase in order to create the best possibilities for a fruitful return to work process, including work trial.

Keywords:

• Rehabilitation
• vocational
• stroke
• occupational therapy
• coordinator

Introduction

The proportion of people having a stroke under the age of 65 years is increasing both internationally [1] and in Sweden [2]. After a stroke about half of the people have physical impairments, and dependency in daily activities can be a consequence [3]. For others the symptoms can be more “hidden” as cognitive and emotional changes as well as fatigue [4] and symptoms related to seeing and speech [5]. A major consequence of stroke is work disability [6]. Fewer than half of those who were working at the time of their stroke return to work (RTW) [7], thus approximately 3,000 Swedish workers do not return to work annually due to their stroke [2]. RTW is an essential part of returning to life as it was before the stroke [8], and work has been reported in a study of people below the age of 55 to be an important factor for life satisfaction [9].

The process of RTW for persons with stroke is complex and has numerous challenges, for example, the large number of stakeholders that are involved. The RTW process is described by Loisel et al. [10] in the Sherbrooke-model, which puts the worker in the centre surrounded by four influential systems: the personal system, the health-care system, the workplace system, and the compensation system. This model matches the Swedish system and regulations in which the individual on sick leave absence is at the centre, supported by four stakeholders (the employer, the healthcare team, and representatives from the Swedish Social Insurance Agency and the Swedish Public Employment Office). In Sweden the employer has a responsibility for the employee during sick leave and, in cooperation with the employee, in charge of facilitating RTW through rehabilitation and modifications at the workplace [11]. The RTW process is often supported by someone from the healthcare team and regulated by the Swedish Social Insurance Agency. Commonly a work trial period, generally three months, is included in the RTW process. In the planning of this period, work place and functional assessments are not regularly performed. During the work trial the employee has adjusted work hours and is supernumerary, which gives the possibility to try different work tasks within a limited time financed by the Swedish Social Insurance Agency.

Interventions developed to promote RTW (not stroke specific) generally involve people at the workplace as key stakeholders, and the workplace is seen as an arena for action [12]. The support from employers and co-workers has turned out to be important for RTW [13,14], and the relationship between the injured worker and their supervisor also has an important role in the success of RTW [15]. Furthermore, Ilmarinen et al. [16] emphasised that the work, work organisation, work community, and management are important factors that influence the work ability. This implies that factors beyond the individual with reduced work ability are important in order to promote RTW [17].

Previous research has found that a supportive employer [18] and modifications in the workplace or changed/modified work tasks [18–20] can be the main facilitating factors for RTW after stroke. Although research is limited in this area, employers face complex practical and emotional issues during the process of RTW [21]. Coole et al. [21] found that employers who supported an employee with stroke experienced that being able to provide support was rewarding and enjoyable, while also demanding in terms of feeling sadness and anxiety [21]. Advice and support from health-care professionals were welcome because employers lacked knowledge and experience of assisting people in RTW, and the quality of the support networks they could access varied [21]. This is in line with studies focusing on persons with stroke who expressed a need for information about the consequences of stroke as well as about the RTW process [19,20,22].

A resource person for coordinating among all of the stakeholders involved has been acknowledged as a facilitator in improving vocational rehabilitation [23,24], and the need for such a person has also been emphasised in the RTW process for persons with stroke and acquired brain injuries [22,25,26]. One study taking the perspective of persons with stroke highlighted the importance of having a coordinator with knowledge and experience in the field that could facilitate communication and increase understanding among co-workers and managers at work [22]. However, there is still limited knowledge regarding how co-workers and managers experience the RTW process, especially when a coordinator is involved. The aim of this study was to explore and describe how co-workers and managers experience the RTW process involving a colleague with stroke who participated in a person-centred rehabilitation programme focusing on RTW including a work trial.

Methods

Design

This study draws on a qualitative explorative design inspired by grounded theory [27]. The study was approved by the Regional Ethics Committee in Stockholm, Sweden, reg. no 2012/101-31/1, 2017/530-32.

Study context

This study is part of a larger project evaluating and further developing a person-centred rehabilitation programme targeting RTW among employed people on sick-leave with stroke. The rehabilitation programme was conducted by two coordinators who were experienced occupational therapists working at rehabilitation units for people with brain injuries in two different county councils in Sweden. They had worked with rehabilitation of people with brain injuries for 16 and 25 years, respectively. The officers from the Swedish Social Insurance Agency that collaborated with the person with stroke and the coordinator specialized in brain injury rehabilitation had knowledge in insurance legislations but no specific knowledge/education about brain injuries. The coordinator role demands knowledge of the consequences of stroke and experience with physical rehabilitation and vocational rehabilitation after stroke. The rehabilitation programme includes a preparation phase that can vary in length, in which the prerequisites for the RTW are mapped out, and a work trial phase is initiated. The programme is person-centered, targeting the specific needs of each person with stroke in their work context. The work trial is to commence with at least 10 hours per week and typically be utilized no longer than three months. Actors such as co-workers, managers, and social insurance officers were participating at different time points and to various extents during the RTW process. The coordinator provided information concerning consequences of stroke based on assessments of work ability. Some co-workers/managers had close cooperation and meetings with the coordinator together with their colleague with stroke on several occasions at the workplace for planning and evaluating the work trials. On some occasions, the social insurance officer also joined these meetings. The contact with the colleague with stroke and the coordinator varied among the co-workers/managers according to the specific situation. More details concerning the rehabilitation programme are described in the study by Öst Nilsson and colleagues [22].

Recruitment and participants

Participants eligible for inclusion in this qualitative study were persons who were involved in the work trial phase of a colleague with mild (n = 5) or moderate (n = 2) stroke with a median age of 52 at stroke onset, who participated in the person-centred rehabilitation programme. Further descriptions of the colleagues with stroke are found in Table 1 and in the previous article [22]. Participants in this study were initially recruited in collaboration with the persons participating in the programme. The colleague with stroke chose one person with whom they had a trustful relationship, worked closely with at the workplace, and who had insight into the person’s process of RTW. The coordinator informed the person about the study, both verbally and in writing, and asked about their willingness to participate. All persons who received information about the study agreed to participate, whereupon concrete times and places for meetings were arranged. The sample consisted of 11 persons (7 co-workers and 4 managers). The participants represented various types of work and employment backgrounds such as manufacturing, health care, education, transport, and services, and the participants’ characteristics are presented in Table 1.

Table 1. Characteristics of participants, colleagues with stroke and their workplaces.

Participant	Colleague with stroke	Stroke severity according to BI^a	Work relationship	Years of working together	Type of work	Number of employees at the workplace	Number of interviews per person
Katrine	1	Mild	Co-worker	15	Education	20	2
Johan	2	Mild	Manager	6	Transport	100	2
Marcus	3	Moderate	Manager	7	Manufacturing	20	2^b
Simon	3	Moderate	Co-worker	8	Manufacturing	20	1^b
Patric	3	Moderate	Co-worker	7	Manufacturing	20	1
Lena	4	Moderate	Co-worker	10	Health care	35	2
Carola	5	Mild	Co-worker	10	Services	6	2
Sofie	6	Mild	Manager	16	Education	12	2
Hans	7	Mild	Manager	0	Manufacturing	50	2
Peter	7	Mild	Co-worker	10	Manufacturing	50	1^b
Tony	7	Mild	Co-worker	8	Manufacturing	50	1^b

^aBI scores (0–100): mild stroke (50–100), moderate stroke (15–49) or severe stroke (<15).

^bInterviewed together.

Data gathering

The participants were interviewed one or two times by the first author (See Table 1). The first author was not involved in conducting the rehabilitation programme. In two cases where it became clear that the participant had not been involved in the RTW process to a great extent, other persons (n = 3) that were more closely involved were asked to participate, and these persons were interviewed in time for the second interview. This resulted in 16 interviews with a total of 11 participants with experiences from the RTW process for seven persons with stroke. This is in line with the use of theoretical sampling [27], where the emerging data guided the process of including more participants.

All co-workers were interviewed at their workplace in order to meet in the natural working environment, but three of the managers had their second interview by telephone. The first interview was conducted 2–3 weeks after the beginning of the work trial, and the second interview was 8–9 weeks later. The second interview was conducted with the purpose of getting information about the process of RTW over time. All interviews but two were conducted individually (See Table 1).

The interviews were semi-structured using an interview guide with open-ended questions about the topic of interest. A pilot interview was conducted to test the interview guide, which was thereafter revised before the beginning of the data collection. Examples of questions in the first interviews: Can you please give examples of work tasks your colleague is doing and how you chose these tasks? Can you please describe your contact with your colleague during the vocational rehabilitation? Can you please tell me something about the contact with the coordinator if you have had any? Participants interviewed twice received individually designed questions in the second interview that were based on the first interview. The interviewer carefully listened to the first interview prior to conducting the second interview.

Memos were written and/or recorded in connection with each interview containing the first author’s own reflections during and after the interview according to content of the interview and the work environment. Discussions were continuously held in the research group about the inclusion of participants connected to the data collection and the richness of the data. The data collection ended when the research group did not see anything new in the shared experiences of the participants. All interviews lasted between 19 and 62 minutes, were digitally recorded, and were transcribed verbatim.

Data analysis

A constant comparative method was used for analysing the data [27]. The analysis process started with successively reading all materials to get an overview. Initial coding was performed line-by-line, and open coding was used. For example, one participant described insecurity about what level of work ability the colleague could achieve: “The rehabilitation is not finished yet, but we have kind of a vision, that he will be able to work 50% and maybe more,” and the initial code was “The future work capacity is uncertain.” This step was performed by the first author in close collaboration with the last author who had thoroughly read all of the interviews and then had in-depth discussions about the coding. In the next step of the analysis, focused coding was used, i.e. an analytical comparison of the initial codes from each interview was conducted, and the codes were compiled into subcategories. The fourth step of the analysis consisted of comparing all of the interviews that were performed with the different participants. Different patterns emerged when working with the codes, and these gradually became more visible during comparisons of the growing material. During the analysis process, memos were written in order to explore ideas about the codes, to elaborate on subcategories, and to identify gaps for further gathering of data. Finally, the subcategories from each interview were compared, and the forming of the final categories was shaped for all categories as mentioned below. Each step in the analysis was discussed with the last author, and the emerging results were discussed with all authors who read all the material and asked probing questions.

Results

A common theme for the results was the challenge of being a co-worker or a manager to a colleague with stroke during the RTW process, which were experienced in various ways, and described in the following three categories: the emotional challenge of being a supportive co-worker or manager, the challenging experience of having too much responsibility, and the challenge of being supportive despite a lack of knowledge. The first category reflects the co-workers’ and managers’ own emotions and their relationship with the colleague, while the second category reflects on different aspects of responsibility connected to organisational factors. The third category describes how limited knowledge and experience about stroke among the co-workers and managers causes difficulties in being supportive in the RTW process.

The emotional challenge of being a supportiveco-worker or manager

During the RTW process, it was a challenge to handle one’s own emotions while being a supportive co-worker or manager. Having the colleague with stroke back at work initially filled the participants with a certain happiness that the colleague had survived and recovered. However, the participants described a challenging emotional process of renegotiating the relationship with their colleague during the RTW process. This was illustrated in repeated situations of being challenged because some aspects in the relationship were changed compared to before the stroke. One participant said:

“He isn’t the same person, and he even says that himself. He has parts that, he is not the same person that I got to know, except…. Then there are a number of things about Sven that I now like very much, but also things that are, that are not there.” (Katrine, co-worker)

Having an established relationship was seen as both a strength and a challenge. Participants described themselves as being well grounded in how the colleague had performed their work before and had many years of shared experiences at work.

“It is better if you can come back to the workmates you have, who know what you have been through.” (Tony, co-worker)

The past relationship with the colleague was of significance during the RTW process because a positive working relation and knowledge about the person’s previous work ability entailed a large commitment to being supportive during the process.

“That is, of course, why it is so easy and to be a mentor, because we have such an open relationship. I dare say, there isn’t much that I avoid telling him.” (Carola, co-worker)

Still, the findings also indicate that participants and their colleagues with stroke underwent parallel processes in RTW, but these processes were inherently not synced. For example, some participants described uncertainties about the colleagues’ work ability, which could sometimes differ from how the colleague with stroke perceived their work ability. Moreover, for the co-workers it also entailed a challenge with respect to sometimes needing to shoulder the burden of work. Participants described an increased workload for themselves when their view was incongruent with the colleague’s own view of their work ability. This led to frustration and anxiety among the participants, and such pressure was a challenge to handle, especially when there were obvious difficulties for the colleague to perform tasks at work.

“She isn’t really part of the work force, not really. She has a really hard time to start something and to know what she should be doing and then to get the job finished…. So it is extremely difficult for us, because we have to like, check her and see if she has done what she is supposed to do.” (Lena, co-worker)

The participants expressed empathy and concerns about their colleague during the RTW process, while at the same time they struggled with worries about the future as the view of the possibility for RTW changed as time went by. Some participants expressed greater hope and felt confident, while others became more aware of the remaining difficulties at work and their anxiety about the future increased. For many of the participants, the coordinator was essential.

One is totally left alone to oneself, like, if you didn’t have someone like the coordinator who can help and give support. So, I think that is, like, mandatory.” (Marcus, manager)

The challenging experience of having too much responsibility

Having too much responsibility during the RTW process was a pressuring experience. The participants described a demanding situation and a challenge to be a supportive co-worker when there was only vague support from the organisation. Some participants that had the role as co-worker (not managers) experienced that unclear leadership and an absence of defining roles between managers and co-workers led to confusion about the mandate and guidelines. Without having the formal mandate to make decisions regarding the RTW process, the participants felt pressured to carry out duties for which they did not have the competence or formal authority to make decisions. This became particularly challenging as the work trial came to an end.

The participants experienced a state of readiness during the process of RTW with demands for making adjustments and handling various situations depending on how the work trial proceeded. The role as a supportive co-worker involved being flexible and trying new strategies if the ones being used did not work out well.

“We can see that Sven will get this far, but then maybe he won’t get any further and then we have to help him with different things.” (Katrine, co-worker)

Some of the participants were well aware of the limited time of three months for the work trial. This was not always easy to handle, and a reappearing thought was whether the colleague would be able to return to work or not and, if so, to what extent and with which work tasks. While working with handling today’s and tomorrow’s challenges, the “thoughts” were also about the future.

“I really don’t believe in stressing through something … If he expands (his working hours) too fast, he will fail.” (Patric, co-worker)

The work trial very much consisted of trial and error in order to form a suitable plan for the future. This was a challenging process of balancing different aspects with commonly defined goals and the colleague sometimes felt stressed as time passed and their employer did not handle the issue.

“Now is the time for the employer to start thinking of the possibility of employing at 25%…//Now it is for real because the Swedish Social Insurance Agency might say no.” (Carola, co-worker)

Having the possibility to exchange ideas with the coordinator and to receive reassurance was mentioned as important, even if it was time-consuming, because several participants felt unsure about how to find the “right track” during the work trial, especially when the co-worker/manager and the colleague had different views on how the work trial progressed. Creative discussions were held in order to find a decent match between tasks and the potential of each individual. Possible solutions and adjustments were ventilated and then tested to overcome difficulties in performing work tasks. When progress was not satisfactory, participants stressed the difficulty of discussing it directly with their colleague. When difficult questions came up, the participants described how cooperation with the coordinator was needed to reach suitable solutions. At certain times, participants were affected emotionally with a sense of discomfort.

“It’s now that I am starting to feel that it is a little, almost, uncomfortable. I don’t know how much he is with it, how much that he is actually catching when he gets information about different things.” (Carola, co-worker)

The participants experienced a challenge in being honest without creating a stressful situation, and having the coordinator as a neutral partner in such discussions was expressed as valuable by the participants.

The challenge of being supportive despite a lack of knowledge

Limited knowledge and experience about stroke and RTW entailed difficulties for all participants in being supportive of their colleague, and this led to doubts about how to plan and carry out the work trial. Feelings of hesitation were described when the participants did not know how to handle the consequences the stroke had had for their colleague. They expressed a fear of pressuring the colleague too hard and thereby causing a setback. Understanding the consequences of a stroke was seen as important to be highlighted at work.

“I mean, he doesn’t have this, that you see him limping. When you meet Paul and don’t know him, it is clearly a handicap for him that everyone believes that he is totally healthy, but he is not totally healthy.” (Sophie, manager)

Participants described close contact with the colleague at work as vitally important. For instance, “hidden problems” like fatigue and vision deficits demanded more insight about how work tasks were performed in order to understand these challenges. The participants described how they tried to use previous experiences from both work and private life in order to handle the challenges with which they were confronted. They emphasised the usefulness of having other experiences like supporting persons with other diagnoses and other difficulties in returning to work as well as one’s own experience of long-term sick leave. These insights contributed to increased awareness about the complexity in the process of RTW and the importance of having sufficient time. Still, these experiences were not stroke specific and the participants valued the cooperation with the coordinator, which offered the possibility to ask questions and to ask for advice.

Furthermore, the participants expressed how the coordinator complemented and contributed with knowledge in medicine, experience of stroke, and RTW, which were valuable for the workplace.

“So it felt safe for us to have some sort of expert present so that we didn’t have to decide such things by ourselves.” (Johan, manager)

Support from the coordinator entailed an improved structure and understanding of the RTW process including the work trial, and created a solid foundation for making decisions for the future. The cooperation also resulted in better preparation before meetings with the employer and the Swedish Social Insurance Agency at the workplace.

“It is, of course, just priceless….just this support and explanation of the social welfare system, the Swedish Social Insurance Agency and rehabilitation, what it can look like, the time restrictions one has, and things like that. She has a total grip on things, for sure.” (Carola, co-worker)

Discussion

The findings in this study contribute with new knowledge regarding the intricate challenges of being a co-worker or manager to a colleague with stroke who participated in a person-centred rehabilitation programme for RTW during the work trial phase. That data were gathered during an on-going process of RTW is something that is rare, especially in combination with incorporating the co-workers’ or managers’ experiences. Previous studies have explored experiences retrospectively [21]. Also, in previous studies the importance of the co-workers’ perspective and their involvement in the RTW process has been underlined when exploring RTW for workers on sickness absence due to a variety of diagnoses [15,28–30]. However, to the best of our knowledge, this is the first study to explore the experiences of co-workers supporting a colleague with stroke during the RTW process.

Findings in the present study indicate that the participants experienced an emotional challenge with insecurity, anxiety, and frustration when acting as a support person to a colleague with stroke. They struggled to deal with their own feelings about the colleague who was not always acting like she/he did before. Furthermore, they described how there were no clear policies for their role in the RTW process. This led to feelings of insecurity and stress at times when they experienced difficulties in the work situation for their colleague. They felt anxious if there were doubts about how to proceed and if they lacked support from the employer. This concern has previously been reported by Dunstan & MacEachen [28], where co-workers pointed out a need for more support from the employer, indicating that the role of the co-worker in the RTW process needs to be formalised.

In the present study, the participants described how the communication among actors involved was facilitated by the coordinator assisting in raising more “sensitive” questions about actual resources and limitations in the work situation after stroke. A lack of communication between co-workers and returning workers has been raised as a significant barrier to RTW [29]. This study also confirmed the importance of discussing and expressing one’s own questions and feelings among co-workers and managers during the RTW process in order to move forward and find suitable solutions to problems that arise [15,31,32].

Even though the participants’ role was sometimes experienced as vague, the co-workers took on the challenging responsibility of adjusting the work tasks in order to fit the colleague with stroke and of giving support in the performance of these if needed. It was, however, experienced as demanding to identify which work tasks the colleague with stroke was able to perform especially when the employer was not so supportive in this process. Such adjustments of work tasks by the co-worker have previously been highlighted by Tjulin et al. [30]. They underlined the co-workers’ contribution to a successful RTW by providing practical assistance and daily adjustments to work duties, but with a focus on assuring that work responsibilities were completed.

In the present study, it became evident that the participant was drawn between the adjustments on the one hand and the completion of work assignments on the other. This conflict created feelings of stress, which had an impact on their work environment. The pressure during the RTW process for those who worked closely with the colleague with stroke has not been described before. Further, the participants experienced it as stressful to decide whether RTW worked out or not for the colleague during the limited time of three months for the work trial. In these cases the support from and collaboration with the coordinator was valuable to discuss the unique situation and sometimes the need for an extended work trial. This is another example showing the importance of having support from the employer in order to feel comfortable in the role of supportive colleague.

Limited knowledge on stroke and lack of experience of RTW after stroke were also expressed by the co-workers and managers in the present study, and support from the coordinator was therefore appreciated. Advice concerning how to deal with “hidden” consequences of stroke at the workplace and how these could be handled in relation to work assignments, working hours, etc., was very useful according to the co-workers and managers. However, despite the involvement of an experienced and knowledgeable coordinator in the RTW process the participants still experienced difficulties. This suggests the complexity of the RTW process and highlights factors that might be hard for the coordinator to influence, such as organisational factors and legislative requirements. Earlier research has also argued for the usefulness of support and cooperation in the RTW process. The need for guidelines has been highlighted for a successful RTW [18–20], and Coole et al. [21] called for support from healthcare staff who are knowledgeable in stroke to be integrated into the RTW process. The county councils in Sweden have introduced coordinators to facilitate the RTW process for people on sickness absence by providing support and structure for work trials. The present study underlines the need for expertise in specified target groups, for example, expertise in how the consequences of stroke can impact RTW. Further, communication with the Swedish Social Insurance Agency was smooth and allowed for more concrete strategies to be developed to handle work demands and to identify appropriate work tasks in relation to the individuals’ actual resources. The collaboration between the systems that influence the process of RTW, according to the Sherbrooke model [10], was thus facilitated by the contributions from the coordinator. Still, the recommendations concerning the 3-month period for the work trial that is applied by the Swedish Social Insurance Agency was seen as a real challenge. The legislation for RTW and the by the Swedish Social Insurance Agency applied norm of proposing a time-constrained work trial in Sweden have been criticised by different stakeholders [25] as being too limited to be able to provide a fair opportunity for the returning worker to find a suitable new work situation. The RTW after stroke has recently been found to occur up to over 3 years post stroke, indicating the need for a prolonged time frame for vocational rehabilitation [33,34].

Methodological considerations

One strength of this study was that the co-workers and managers were interviewed during the early process of RTW while the colleague with stroke was participating in the rehabilitation programme. The findings might therefore add to the understanding of the early process of RTW and the challenges included in this phase, which have not been described before.

Another strength in this study was that the persons with stroke chose which co-workers and managers to invite [35]. However, the pre-existing relationship can have influenced the results. Having had a prior working relationship can have contributed to being more committed and supportive. Another aspect which could have influenced the responses was that two interviews were not conducted individually. However, it was important to include these interviews because the person with stroke and the participants in the study made this preference. The analysis of all the interviews showed that these interviews have not changed the findings, rather it contributed with richness in terms of situating participants experiences.

During the data gathering it became evident that all participants did not have so much insight into the work trial. In these cases, other persons who worked closer to the person with stroke were recruited. Including both managers and co-workers in the study contributed to a broader perspective and an understanding of the RTW process when being in the phase of work trial. However, carrying out separate studies of co-workers and managers might secure a more in-depth knowledge of their unique experiences from the RTW process since they have different roles and responsibilities.

The credibility of the study was enhanced through validation of the findings by continuously working back and forth in the material. Furthermore, all authors were involved in the different steps of the analysis process, and discussions about the growing material were regularly held within the group [36]. The trustworthiness of the findings was examined in a discussion with experienced members from a specialised brain injury rehabilitation team in a peer debriefing [37]. Quotations have been used to describe the findings and to give the participants a voice. A goal when conducting the interviews was to achieve an atmosphere characterised by safety in order to facilitate sharing of feelings and experiences and to decrease the power imbalance between the informant and the researcher [37]. The interviews took place at the participants’ workplaces in their familiar environment, which also contributed to a deeper understanding of the context of the work trials. A limitation was that the process of the RTW only captured the first three months, even though it has been shown that the RTW process can continue for years until the situation becomes stable and a suitable level of working hours has been reached [33]. Future studies are warranted to deepen the understanding of the whole RTW process for managers and co-workers of a colleague with stroke.

Conclusion

The co-workers and managers experienced a variety of challenges when being involved in the RTW process of a colleague with stroke. They clearly expressed the value of having support from a coordinator, but they still experienced difficulties in being a valuable form of support for their colleague. The limited time of the work trial and the occasional lack of support from the employer were aggravating factors. These results highlight the importance of establishing a commitment with the employer in order to create the best possibilities for a fruitful RTW process, including the work trial. Such arrangements need to be made in the initial phase of RTW in collaboration with the coordinator, the person with stroke, and the involved co-workers and managers. Further, it is important to ensure that the involved co-workers and managers are aware of the rules that regulate the period of the work trial. Also, their different roles during the RTW process needs to be discussed and clarified in respect of expectations, responsibilities and possible contributions. This should preferably be done by a coordinator specialized in brain injury rehabilitation.

Acknowledgements

The authors gratefully acknowledge all the co-workers and managers who took part in the interviews. Without their contribution, it would not have been possible to conduct this study.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This study was financially supported by the Swedish Stroke Association; the Centre for Research and Development, Uppsala University/Region Gävleborg, Sweden; the Doctoral School in Health Care Sciences at Karolinska Institutet, Sweden; and the Norrbacka Eugenia Foundation, Sweden. The regional agreement on medical training and clinical research between Uppsala County Council and the Uppsala University hospital (ALF).