Employment rates for people with disabilities are just above 40 %, compared with 75 % for people without disabilities. Employment opportunities for people with health problems or disabilities are limited. Only about one in four people who report mental health problems are in employment. Unemployment is twice as high for people with a disability as for those without. In 2007, an average of about 6 % of the Organisation for Economic Co-operation and Development (OECD) working-age population received a disability benefit. In some European countries, as many as 10–12 % of the population have a disability pension; in Sweden, the figure is almost 9 %. Rates of RTW after being granted a disability pension are less than 2 % per annum in the OECD countries [7].

VR, and how it can be reformed and improved, has been the subject of debate in several countries for a number of years. The OECD has also shown an interest in enhancing VR and provided examples of how it can be improved. There are several reasons why VR has been in focus. One of the reasons could be demographic. In order to sustain their welfare systems, many countries are obliged to have enough people working to safeguard the necessary tax revenues [8]. Another reason is the exceptionally high cost of sickness benefit and disability pensions. A third reason is the increasing number of unemployed people. Work has a central place in Western societies and is highly valued in people’s lives. It is described as providing an important meaning to life, as well as providing structure to the various life domains that make up a person’s social context. Having a job is also crucial to social inclusion. Having a job can also promote personal needs, such as enhanced self-efficacy and an ability to move away from a feeling of being lost and hopeless to one of feeling that you are making a contribution to society.

Health problems among unemployed people are common, as shown in many studies [9–12]. Unemployment was associated with an increased mortality risk for those in their early and middle careers. The risk of death was highest during the first 10 years of follow-up [11]. Paid employment improves quality of life and self-rated health. Labour force participation should be considered as an important measure to improve the health of unemployed people and to reduce socioeconomic inequalities in health [12]. Many countries have been affected by high rates of unemployment in the wake of the financial crisis. On the one hand, unemployment affects the young, who find it difficult to gain a foothold on the labour market; on the other, however, even those established on the labour market have been greatly affected by unemployment. Given the negative effects of unemployment on health that the latest research has shown in those in the early or middle stages of their careers, these results emphasise how important it is to offer VR as a way of supporting people in returning to work or obtaining a job before they are affected by ill health. However, more research is needed into why those unemployed when young or in middle age are affected by a higher mortality risk.

VR plays an important role in people’s lives when it comes to returning to work following a period of illness or injury. There is, however, no standard definition of VR. This is probably because so many different professional areas and organisations are involved in VR. In certain cases, it has been easier to describe the components of VR than to define the term [3]. VR forms a significant part of the efforts and measures undertaken to help people with a work disability to RTW. Despite the difficulties in defining the concept, many definitions have been proposed for VR, though it has been difficult to find agreement on a uniform definition that would be acceptable globally at individual, organisational and social levels. The one that seems to be most complete is the one that defines VR as: ‘Medical, psychological, social and occupational activities aiming to re-establish among sick or injured people with previous work history their working capacity and prerequisites for returning to the labour market, i.e. to a job or availability for a job’ [13]. However, this definition omits those who have never worked. Many young people today find it extremely difficult to enter the labour market and those with disabilities find it even harder. The words ‘with previous work history’ should therefore be erased from the definition. The suggestion is that the definition of VR should be: ‘Medical, psychological, social and occupational activities aiming to re-establish among sick or injured people their working capacity and prerequisites for returning or entering the labour market, i.e. to a job or availability for a job’ [6]. In 2011, the ICF devised a broad definition of VR, and this conceptual definition of VR contains the main component of the various definitions given above, e.g. ‘optimising work participation’ [14]. VR is a wide range of vocational and educational services that are offered to people who are working, as well as those out of work or who have never worked. Disabled people participate less in the labour market than do nondisabled people [7].

Some of the definitions that exist either build around some accreditation or qualifications, skills or legislative framework or around the main activity, which means helping people back to work. At an organisational level, some definitions emphasise the word ‘facilitation’, while those that start out from the main activity define VR as activities that help someone with health problems to obtain employment or to return to and remain at work. It is an idea and an approach as much as an intervention or a service [15]. The word ‘facilitate’ usually originates from case management activities. The definition by Wadell et al. [15] is more in line with the clinician’s point of view and could refer to almost any activity that supports a person in returning to employment. This is a very broad definition and is not solely confined to measures to facilitate an RTW, such as medical treatment and medical rehabilitation alongside VR. It also includes efforts to prevent sickness absence and even covers measures to promote a sustainable working capacity. According to Langman [3], these two definitions can be regarded as two main threads in terms of understanding ‘vocational rehabilitation’. The first definition may be regarded as a case management process, where the aim is to facilitate the client through a series of various rehabilitation activities that promote RTW [16].

There is also the debate as to what medical rehabilitation is and what VR is. Ekberg [17] takes the view that medical rehabilitation primarily aims to restore functional capacity, while VR is about the relationship between an individual’s capacity for working and the requirements of the job. The measures taken need to focus on creating the right conditions to allow individuals to support themselves through employment. It can be difficult or impossible to distinguish between medical rehabilitation and VR, and one simple way of making the distinction depends on what is being focused on in terms of the individuals and their goals. If the aim is for the person to regain their working capacity and create the conditions whereby they can support themselves through employment, then this may be regarded as VR. This is entirely in line with the definition given and is based on that of the ICF [14]: ‘Vocational Rehabilitation is a multi-professional, evidence-based approach that is provided in different settings, services and activities to working-age individuals with health-related impairments, limitations or restrictions with work functioning, and whose primary aim is to optimise work participation’. Looking at this definition, it seems to cover a broad spectrum of services and set of clients. One of the key expressions is ‘optimising work participation’. Understanding this expression is not a problem; it can be shared and is an accepted view among different countries, settings, practitioners and clients as to what constitutes VR. If this definition can be accepted worldwide, then the obstacles relating to what constitutes medical rehabilitation and what constitutes VR can be avoided. We can then always have in mind that the objective of VR is work participation for the individual, regardless of whether we operate in a clinical setting or in various environmental settings in society at large – for example, Social Insurance Agencies, employment agencies or various kinds of private agencies. In the United States, VR is generally looked upon more as a social services intervention, whereas in Sweden and pretty much the rest of Europe, it is considered to be more a form of medical treatment [1]. With the definition proposed by the ICF, we can move more towards interventions that can be embedded in social services, where the individual will be the key person in the rehabilitation process. This would not only help cooperation among stakeholders and minimise the debate as to what are medical and what are vocational activities, it would also certainly help the worker-centred rehabilitation process. VR will then move away from being mostly rehabilitation for the organisations to being rehabilitation for the clients. Germundsson and Danermark conclude in their study [18] that the recognition of other people’s knowledge and respectfulness towards other professions facilitates the process of VR and the collaboration process. The agencies’ lack of flexibility increased the risk of conflicts as attempts were made to integrate the new working methods. The authors identified a number of obstacles, such as lack of collaborative competence, ignorance about collaborative partners, lack of support from management and lack of resources.

The process of VR is discussed in the literature as a process in its own right but is also discussed as a process under the overarching disability management or as identical with the RTW process. Some also put forward the argument that disability management has to be looked upon as a broad term that encompasses all sorts of disabilities, including work disability [14]. However, there is no consensus among the stakeholders as to what is included in the VR process. VR can be seen both from an organisational level and from the level of the client involved in a rehabilitation activity aimed at facilitating an RTW. When describing the process of VR, we usually think of the term ‘RTW’ and all the necessary activities and efforts required to achieve the ultimate aim of gainful employment. How extensive the process will be depends on the definition of VR among the various stakeholders and in the different settings within the field of VR. Which activities or interventions are included in the VR process depends on the stakeholders involved and the rehabilitation programme offered.

A simple illustration (Fig. 5.1) can be used to demonstrate the VR process. The figure illustrates how a person affected by a work disability first arrives in the health care service, which treats the acute phase of the illness. If the illness subsides following conventional treatment, the individual returns to their job. If the illness process should become more prolonged and a number of measures are required, such as social rehabilitation in the form of various social measures, these can be initiated at an early stage in the course of the illness, in parallel with the medical treatment. During the person’s medical treatment, the doctor may perhaps consider that the person needs to be examined and that they should contact the stakeholders in the field of VR or medical rehabilitation for a comprehensive assessment of any actions necessary for RTW. All of these measures can take place in parallel to avoid unnecessary waiting times. Once an individual has become the subject of various measures from different stakeholders, the RTW process ends with an outcome that results either in an RTW or a disability pension (see Fig. 5.1).

The assessment stage of the process is vital. It provides the foundation on which to establish goals and to develop and implement appropriate strategies to assist the individual in realising those goals. Reviews of the literature have found a huge number of assessment tools, none of which could be used to measure a worker’s ability to perform real and relevant work tasks [19]. Across different disciplines and rehabilitation settings, assessment of functions for work has different meanings and a large number of definitions exist. Assessment is more than just assessing the individual’s problems or limitations. It also involves identifying the strengths of the individual, and identifying the strengths within the environment in which the individual operates, which can be done if VR is based on the biopsychosocial model of the ICF. This is in accordance with the strengths perspective of social work [16].

In a multimodal cohort study, Anema et al. [26] found cross-country differences in RTW rates following chronic occupational back pain. The study population was recruited from Denmark, Germany, Israel, the Netherlands, Sweden and the United States. The Netherlands had the highest reported RTW rate (62 %), while Germany had the lowest rate (22 %) after 2 years of follow-up. These differences could not be explained by differences in individual treatments between the countries. In the Netherlands, where there are strong incentives to RTW, modifications of work were significantly more common. The results show, among other things, that differences in the countries’ social insurance systems and employer responsibilities may explain part of the difference in RTW rates reported in some studies. The study highlights the problems of studying the effects of various activities, such as rehabilitation counselling, RTW plans and job retention in the field of VR.

RTW is seen both as a process and an outcome, although according to some researchers, it is poorly defined and lacks a standardised definition [27–29]. The study by Leyshon and Shaw [29] focused on the stakeholder’s perspective on concepts that need to be considered when understanding successful RTW and future research towards the development of outcome measurement. The stakeholders identified six new concepts, and these were, firstly, the concept of worker performance, worker job satisfaction and worker well-being. These three concepts focus on workers’ ability to engage in activities related to work and life outside work and are also in line with the activities and participation dimension of the ICF. The other three concepts reflect the RTW process, and those are: human rights, seamless RTW through collaborative communication and the satisfaction of stakeholders. The authors concluded that the findings of the study indicate a definite need for a change in RTW outcome measurement.

Here, the RTW process will be described and discussed as both a process and an outcome. Among medical assessors, the view is sometimes taken that the diagnosis and diagnosis-related variables are of decisive importance in determining whether or not a person can RTW. However, not all share this view. Hunt et al. [30] concluded in their study that workers’ subjective interpretation and appraisal might be more powerful predictors of the course of post-injury recovery than medical assessment alone. It is likely that the doctor, when seeing a patient with no objective signs of disease, will share the patient’s negative views of the working capacity and sickness absence [31].

Laisne et al. [32] conclude that psychosocial variables were the most significant ones in predicting involvement in the RTW process. Hilborg et al. [33] stated that a holistic view that included both social and psychological aspects of individuals was considered crucial in the VR process. Hees et al. [34] conclude that successful RTW is not necessarily disease specific. They stress that consensus between supervisor and worker about important subjective criteria is more important for successful RTW.

Tjulin et al. [35] found in an RTW programme that key stakeholders in the programme expressed a more biomedical individual view of working capacity, while the programme was based on a more holistic and biopsychosocial view. Applied to the system in Sweden, the employment service can be taken as an example. They tend to focus on people who are already considered employable [36]. It appears that the biomechanical perspective remains deeply rooted among key stakeholders in the VR field. This may be due to the fact that many countries have enhanced the possibilities of obtaining sickness benefit or a disability pension, which favours the biomedical approach. The Core Sets developed by the ICF for assessment in VR have an important role to play in changing the perspective among some of the key stakeholders towards a more holistic view that includes all aspects of the RTW process.

Although the strategies of an RTW process may differ, there is usually some consensus as to which core factors are to be included in the process. The initial step in the RTW process often starts with an interview, followed by a needs assessment, the development of the rehabilitation plan including the activities to be carried out and the implementation of the plan. Although the strategies of the RTW process may differ, the process then has to be monitored and finally evaluated. By dividing the RTW process into these steps, it is also possible to gain an overall view of which stakeholders are involved in the process and which measures need to be initiated. How successful the RTW will be in terms of resulting in an RTW outcome will depend on how successful each component of the process is (Fig. 5.2).

Irrespective of where the assessment takes place, whether performed in a clinical setting, an outpatient vocational setting with various competences involved or in a single case management environment or facility, the assessment must be carried out thoroughly and the focus must be on enabling the individual to RTW. The professionals involved in the assessment must be skilled in different areas of promoting the RTW process. During the assessment stage, the professionals must have the skills to carry out a comprehensive interview covering all aspects of the individual, medical, social and work-based issues. Comprehensive interview instruments have been developed for use in clinical settings and can be helpful in the medical assessment phase [37]. Mcfadden et al. [38] suggest that other assessment tools should be used in combination with other tools when testing functions such as those that assess psychosocial, behavioural and environmental factors; this was also stressed by Sandqvist and Henriksson [39]. They have developed a comprehensive conceptual framework for the assessment of working capacity, focusing on the social perspective in work assessment. They also point out the importance of seeking out the clients’ opinion. However, the conceptual framework proposed has to be validated in randomised control trials in order to test its evidence.

Some studies have identified communication as a key factor influencing outcomes in the RTW process. Effective communication is seen as an effective facilitator for an RTW [40]. Open, honest communication is one of the best ways to build a successful relationship between VR professionals and the client [41]. The level of caring or concern demonstrated by the counsellor has the greatest effect on participant satisfaction with the entire VR process [42].

Four prevailing models of disability management are described in the literature as emphasising different aspects of important factors that influence the outcome of the RTW process. The models are: ‘medical model’, ‘physical rehabilitation model’, ‘job-match model’ and ‘managed care model’. Pransky et al. [43] stated that communication is often authoritative and unidirectional in these models, with workers and employers in a passive role. They suggest more communication-based interventions, which have been associated with improved satisfaction and outcomes among stakeholders. The common opinion that disability outcomes are unaffected by individual and contextual factors has to be changed. This can be done if all stakeholders involved around the person in need of rehabilitation activities duly inform all involved parties about the actions they have taken.

There is a shift towards greater self-direction in the RTW process, which is manifested in workers taking a leading role in making decisions, setting goals and managing the steps in the services process [44]. Encouraging the individual’s participation in the establishment of goals is important as it enables them to be in the centre of the process. This will encourage their commitment and motivation towards attaining the goals. Playford et al. [45] state that the goal setting in rehabilitation is a core component of the rehabilitation process, and it should be specific, ambitious, relevant and time limited. Involvement of the individual in goal setting, goal planning and self-management in the rehabilitation process is emphasised in several studies [45–47]. Intervention plans may vary in content but there is general agreement that the structure of the plan should determine who does what and when and that the individual has to be in the centre.

The implementation stage and monitoring of the RTW process are crucial for understanding how well the components fit the outcome for RTW. Van Beurden et al. [48] conclude that it is essential to pay more attention to the implementation of the RTW process among other stakeholders involved in the process. Implementation is seen as a key stage in the design and evaluation of complex interventions. Martin et al. [49] state that thoroughly investigating the target population characteristics, contextual constraints and the needs and expectations of stakeholders will help the implementation of the RTW interventions. Egan et al. [50] included four systematic reviews in their study and looked at how well the implementation was described in the studies included in the various reviews. Many of the studies referred to implementation, but the reporting of factors important for the study design – such as intervention settings, resources, planning and collaboration – was generally poor and anecdotal in nature. They conclude that the evaluation of complex interventions should include more detailed reporting of the implementation and consider how to measure the quality of implementation. Finger et al. [25] conclude that research is needed to study the outcomes of VR.