Introduction

Public safety-Personnel (PSP) include professions such as, but is not limited to, police officers, paramedics, firefighters, correctional officers, and communications officers/dispatchers [1]. Due to the nature of their work, individuals in these professions are often exposed to events that can range from medical emergencies to critical incidents, and that have the potential to be psychologically traumatic [1,2,3,4,5]. Many different factors determine if an event will be traumatic for an individual such as their susceptibility to trauma, the intensity of the event, coping strategies and level of resilience [2, 6].

When an event or multiple events built up over time prove to be traumatic, an individual can develop symptoms of a psychological injury, such as sleep disturbance, difference in mood, increase in alertness as well as an increase in avoidance [1, 7]. The presence of these symptoms can affect an individual’s ability to go to work and perform their work duties, and also impact their personal lives [7].

Many PSP who sustain a work-related psychological injury, resulting in a diagnosis like posttraumatic stress disorder (PTSD), may need to take time off from work to recover, causing them to interact with the worker’s compensation system. The Workplace Safety and Insurance Board (WSIB) of Ontario has processes in place for individuals who need to make a claim due to a psychological injury or traumatic mental stress [8, 9]. In 2016, the Ontario government passed legislation that presumes that PTSD in PSP (referred to in the legislation as first responders) is work-related [10]. Between January 1, 2016 to April 30, 2020, WSIB approved 5691 mental stress injury claims (MSIP) by workers from all PSP career categories covered under this presumptive PTSD legislation [11]. MSIP claims increased from 0.3% of all WSIB lost time claims in 2002 to 3% in 2020 [12]. Alarmingly, studies suggest that the increase in these types of claims underrepresents the prevalence of mental disorders and symptoms among PSP in Canada. A study investigating the prevalence of mental disorder symptoms in the PSP population in Canada found that 44.5% of respondents reported symptoms associated with at least one mental disorder [1], a rate that is far higher than the 10.1% observed within the general Canadian population [13]. It is important to note that not every one of these individuals makes a WSIB claim, thus the WSIB numbers only capture a portion of psychological injuries currently present in the PSP population. Making a workers compensation mental health claim can be complicated by the high degree of stigma surrounding mental health in PSP workplaces, which often manifests itself as a culture of strength and self-reliance [4, 14], making it difficult for many PSP to make a mental health related claim.

Return to work (RTW) is an important step in the WSIB claim process. Many healthcare providers (HCP) are involved in helping PSP RTW after a psychological injury, including but not limited to psychologists, psychiatrists, occupational therapists (OT), social workers and physicians [15]. The process of RTW may be a long one, but certain factors are linked to claim duration and experiences. Recovery is likely to improve by implementing treatment early and keeping in contact with the workplace throughout the claim process [7]. Workers making a claim who have poor support from their employers and a high amount of mental health stigma in their workplace are more likely to have a negative experience [16].

When working with PSP in their RTW journey, it is important for HCP to understand the barriers and facilitators faced by the PSP seeking help. Barriers to seeking help can include mental health stigma in their workplace, fear of confidentiality breaches, or negative experiences with therapists [14]. Facilitators can include the realization that PSP are not alone in what they are feeling, and positive therapeutic experiences with HCP may increase PSP buy in [14]. Training in trauma-informed methods, awareness of PSP culture, and adequate resources for treatment can all be facilitators of recovery [14].

Due to the increasing number of WSIB mental health claims made by PSP and the unique nature of the trauma exposure experienced by PSP, it is important to investigate the RTW experience of PSP, including their experience with different HCP and their employers. To the best of our knowledge, the RTW experiences of PSP working with different HCPs as part of the WSIB claims process in Ontario has not been explored. This study explored the RTW experiences of Ontario PSP who made a WSIB claim for a work-related psychological injury, including their access to and experience of HCPs and the RTW process.

Methods

Survey Design

A 31-question anonymous self-report survey inspired by the theoretical integrative quality framework model [17] was created. The survey began with 11 demographic questions and the remainder of the questions were evenly divided between two types of experience-oriented questions: quantitative questions that included frequency-oriented checklists and Likert scale questions, and qualitative questions with open text responses. Given that interpretations of what satisfaction means can be very subjective to participants without a set definition of the concept [18], a 5-point Likert scale ranging in response options from very poor to excellent was utilized [18, 19]. Open ended questions were used to provide respondents with an opportunity to share their RTW experiences in more detail [18].

The survey questions focused on participants’ work history, their experiences with HCPs, facilitators and barriers that play a role in accessing HCP and RTW resources, and their overall RTW experience, including WSIB and employer support.

The survey received ethical review and approval from the Health Sciences Research Ethics Board (HSREB) at Queen’s University and participants consented to participate before beginning the survey. The consent form contained information on how participant responses would be used, which included appearing in research publications.

Recruitment and Study Procedure

The survey was distributed using an online platform as web-based surveys have been found to be more consistent than other methods of surveying [20]. Using an anonymous web-based survey may capture more honest opinions as opposed to in person interviews where participants may be inclined to provide socially acceptable answers [18]. Links to the survey were sent to PSP employers, unions, and associations throughout Ontario via email and shared over social media platforms between November 1st, 2021 and June 1st, 2022. Since the link was accessible over multiple platforms, there is no way to accurately estimate the number of individuals who were invited to participate in this survey.

Data Analysis

Frequency counts and descriptive analyses were used for quantitative data, and qualitative framework analysis was conducted to identify the major themes emerging from open text participant responses. Employing an interpretive/constructivist approach for open text data, framework analysis provided a systematic and comprehensive analytic method to analyze qualitative data [21]. Ritchie and Spencer’s [21] five key stages were used, which include: familiarizing, identifying a thematic framework, indexing, charting, mapping, and interpreting. MAXQDA, a qualitative data analysis software program, supported the team’s analysis.

Results

Study Population

One hundred forty-five survey participants (N = 145) met inclusion criteria, which were: (i) must live in Ontario, (ii) must have an approved WSIB claim for a work-related psychological injury, and (iii) must have worked with an HCP during the claim duration. Eighty-seven participants were excluded from the survey for not meeting the inclusion criteria. An additional 90 participants were excluded because they did not respond past the demographics stage of the survey and thus did not provide any experience-related data for analysis.

Demographics

Table 1 outlines the demographic information for the respondents who met the inclusion criteria (N = 145). The most frequent age range reported was 40–44 years (21%, n = 30), followed by 35–39 and 50–54 years, which both contained 16% of respondents (n = 23). 68% of respondents (n = 100) identified their gender identity as a man, while 30% (n = 44) identified as a woman. One participant identified as transgender. The majority of the sample (95%, n = 138) identified as white. One participant identified as Hispanic/Latin(a/o/x), 1 as Indigenous, 1 as Asian Caribbean, 1 as Eurasian, and 1 person preferred not to answer. The most frequent range of years of service was 20–24 years of experience working in their career (18%, n = 27). In addition to working as a PSP, 3% (n = 5) of participants previously served in the Military Regular Force and 4% served in the Military Reserve Force.

Table 1 Demographics
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The sample included a variety of PSP occupations: paramedics (42%, n = 61), career firefighters (29%, n = 43), police officers (12%, n = 18), correctional officers (8%, n = 12), communications officer/dispatcher (3%, n = 5), a volunteer firefighter (0.6%, n = 1), and 2% (n = 3) selected the “other” category.

Interprofessional Healthcare Practitioners

Of the 145 PSPs in the sample, 61% (n = 89) has seen a psychologist, 60% (n = 88) an occupational therapist, 44% (n = 64) a general practitioner, 29% (n = 43) a psychiatrist, 23% (n = 34) a psychotherapist, 13% (n = 19) an Employee and Family Assistance Plan (EFAP) counsellor, 12% (n = 18) a social worker, 8% (n = 12) a physiotherapist, and 6% (n = 9) a nurse practitioner (Table 2). 8% (n = 12) listed another healthcare provider, including: neurofeedback provider, massage therapist, osteopath, homeopath, mental health worker, trauma counsellor, family health team, and a vision therapist (for a concussion).

Table 2 Health Care Professionals (HCPs) Accessed
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Open text responses related to medical HCPs showed that psychiatrists, general practitioners, and nurse practitioners were often involved with the paperwork associated with a WSIB claim, and primarily prescribed medications as a treatment modality. Physical therapists were noted to provide support for physical function, including managing chronic pain and improving strength and mobility. Other professionals, including psychologists, psychotherapists, social workers and EFAP counsellors were more focused on psychological symptom management and psychotherapeutic approaches, including talk therapy, cognitive behavioural therapy, and exposure therapy. It was most common to see a psychologist, followed by a psychotherapist, and less common to see a social worker or EFAP counsellor. EFAP counsellors are part of a confidential short-term mental wellness service that many employers provide to employees at no cost for the employee. EFAPs can be accessed through self-referral, and the services provided are often general in nature rather than targeted to specific professions or mental health conditions. Despite their small representation in the sample, open text responses related to EFAP providers were more frequently negative in comparison to other counseling professions. For example, one participant responded “[he] did not understand my field, felt it was a waste of time, spent more time explaining about my profession than him helping me.”

This survey took place during the COVID-19 pandemic, and many respondents noted that services they received from HCPs were virtual or phone based, and that they would have preferred access to face to face treatment. One profession that appeared to have more home and community-based contact with participants was occupational therapy, with respondents noting the value of treatment that took place in person and was linked to coping skills and tangible return to work aspects. One participant noted “they helped me manage my coping skills and setting me up for a successful return to work” and another wrote about the importance of “getting back out into the community, addressing triggers and how to manage.” Another shared the value of an applied therapeutic approach, with their occupational therapist “helping me be able to be back in public, around groups of people, working on fear of being in a car, and being able to handle situations with noise that may be unpredictable.”

Often, respondents noted that their health providers lacked the specific knowledge required to treat PSP who have a work-related psychological injury, be it general mental health knowledge, knowledge of mental health conditions in PSP, and knowledge about the work and challenges associated with being a PSP. Many of the respondents who provided open text comments about HCP experiences were unhappy with the quality of care received from their HCP. With respect to the specific knowledge and skills required to treat PSP, one respondent wrote: “First responders have different stress than the gen pop… we see death all the time - traumatic like suicide”, while another stressed that “the provider should have experience with other patients; specifically, work-related health-trauma, understand moral workplace injury, including complex PTSD.” A police officer noted:

Health care providers must understand the realities of the real world which first responders live within. They must understand the sheer volume of constant negativity and traumatic experiences that police deal with. The health care providers must understand the culture of policing to understand how that impacts those that are struggling.

Respondents pointed out that due to the inherent differences in PSP careers, it is important for HCP to be informed of the different roles and traumatic events that various PSP experience. One noted that:

Each role is unique and dynamic in being exposed to trauma. There’s a difference between direct and vicarious trauma, but still harms the same way. The five senses are super important to focus on, as first responders on scene might have a smell and sight issue whereas 911 communicators might have an auditory issue.

Possessing this level of nuanced knowledge about the various PSP professions and trauma was raised by respondents as a way to save time in treatment and also assist in building rapport and trust with a PSP client. For instance, one PSP reported that “…not having to explain what it was like to be a paramedic allowed me the space to focus on what was troubling and begin to work through that very early on.”

Time Off Work and Frequency of Return-To-Work Amongst PSP

Table 3 details the amount of time PSP took off from work and whether they returned to work with full-time or accommodated duties, or not at all. 15% of respondents (n = 22) returned to work with accommodated duties while 30% (n = 44) returned to work with full-time duties. The remaining 54% (n = 79) either had not returned to work (30%, n = 44), or did not respond to the question (24%, n = 35).

Table 3 Return to Work Outcomes
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Of those responding, 30% (n = 43) reported being on leave from work for one year or less at the time of the survey. A minority (3%, n = 5) had been off work for 79 + months (approximately 6 years); while only 2% (n = 3) had been off work for less than 1 month. Overall, 32% of respondents had been off work for 2 years or longer (n = 46). A quarter (24%, n = 35) of the participants did not respond to this question while 3% (n = 5) provided qualitative responses.

The issue of time, including time required to recover, and time required to transition back to work, featured frequently in participants’ qualitative responses. Many noted the importance of employers and WSIB being patient and respecting individual RTW timelines.

Employees who take a leave from their profession due to PTSD or other traumatic incidents need time. They need support and need to feel like genuine help is being provided on their timeline. It can’t be on a timeline that is being pushed by the employer, or WSIB, it has to be on the affected individual’s timeline. Ideally progress will be made and that can be represented or shared to the employer through the support services or professionals they are working with show that progress is happening. I feel I have made large progressive steps in my personal experience and a return to full working duties will happen. But it has to happen when I feel it is right. I want to return to work, that is why I have actively sought out help for myself to have a successful outcome through this process.

Return to Work Goals

The three most frequently mentioned types of RTW goals included work-related goals, lifestyle goals and goals concerning mental health. For many respondents, work-related goals included gradually returning to “full responsibilities” and “gradually increase hours to full time” revealing that it was important “to be able to complete basic tasks, not to be overworked, properly pace myself, realistic goals between employer and me, consistency in SOG’s applications, implement a training program for persons in my current role.”

Many respondents expressed a desire to RTW but in a different setting or environment (e.g., returning to firefighting but at a different station). For some, however, RTW meant leaving the public sector: “[I] wanted to return to work was not allowed and was not given a job to return to right away and WSIB my cut my wages so had to take a job in private sector.”

Respondents’ lifestyle goals focused mostly on finding joy in their work and life, as well as a desire to manage stress. For instance, one paramedic wrote that his/her goal was to “enjoy my job again, and not let it ruin my life.” A firefighter expressed the careful balancing act required to return-to-work after a psychological injury: “start slow. Do one thing at a time and do it well. Focus on taking care of yourself and filing your own bucket before you decide your able to help others with their problems.” However, most of these goals were also marred with concerns about RTW and its impact on “work life balance” and concerns about work culture. For instance, “the culture of policing doesn’t fit with my current views. I am happy to be in a positive environment and happy to be away from constant negativity.”

Respondents’ mental health goals spoke of the struggles and difficulties faced by PSP returning to work after a psychological injury. For instance, one paramedic stated that his/her goal was to “to go back and not have another breakdown that led me to being put off work. To simply feel happy and smile while doing my job,” while another paramedic wrote of a desire to “once again be in control of anxiety, sleep and invasive thoughts. I need to be healthy or I’m no good to patients.” Some respondents indicated ongoing challenges with their mental health, with one police officer expressed that his/her RTW goal “was not to kill myself.”

Return to Work Accommodations

Table 4 describes the accommodations that PSP believe would be helpful versus those that would realistically be granted in their RTW process. PSP respondents reported that reduced hours (n = 58, 40%), flexible shifts (n = 57, 39%), and reduced number of night shifts (n = 47, 32%) were the most common accommodations they thought would be helpful when creating a plan for RTW. When asked about what accommodation would realistically come to fruition during the RTW process, the numbers decreased, but again, reduced hours (n = 40, 28%) were chosen as the most common accommodation to be granted. Other realistic options included a reduced number of night shifts (n = 24, 17%), and flexible shifts (n = 22, 15%).

Table 4 Return to Work Accommodations
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As revealed above, many PSP spoke of struggling upon RTW and the importance of doing so gradually with reduced hours. For instance, a police officer was concerned about:

Symptoms coming back and affecting my cognitive ability or creating a feeling of fear or significant uncomfortableness that I would have to work through with time. I believe slowly returning to work and being exposed to stresses, and working through those stresses over time will be key to successfully returning to full time hours.

However, not all felt that their work could or would be accommodated by their employer. For instance, one police officer stated that his “work doesn’t follow accommodations and penalize those who do.” Many others also spoke of feeling that their employer would not and did not offer accommodations. A paramedic stated that he/she ‘would much prefer flexible / part-time hours or split role between clinical and other duties, not offered by current employer.” One paramedic wrote at length about the struggle he/she faced when trying to return-to-work and especially his/her employer’s lack of support for accommodations:

The role is inflexible and my concerns re: accommodations were not taken seriously. I was subsequently harassed in my workplace after returning. I no longer feel it’s a psychologically safe environment. I miss interacting with patients one on one in my community paramedic role but I could not handle the multiple sources of sensory input from telephones, radios and patients. I requested to have a lighter patient load and organizational changes to alleviate the cognitive demands temporarily. My requests were not met... I do not feel psychologically safe because the energy required to engage in my workplace significantly takes away from my ability to achieve a work-life balance. I am grieving what I feel is a loss but I am continuing with treatment because I have no permanent restrictions.

PSP Experiences with WSIB and Employers

Table 5 outlines PSP experiences working with their employers and with WSIB Ontario. The majority of PSPs who completed the survey attempted RTW once (n = 81, 56%) while 26 (18%) had multiple attempts, and 38 (26%) did not respond to this question. PSPs’ experience with WSIB and the support they received from their employers had an impact on their RTW timeline and experience. The average experience rating out of 5 (1 = very poor and 5 = excellent) for PSPs who had one attempt to RTW was poor (average = 2.93). Additionally, those who had multiple RTW attempts also rated their experience poorly (average = 2.76). Similarly, when asked about the support they received from their employers, PSPs on their first RTW attempt rated their satisfaction with the support received from their employer poorly (average = 2.46). Those who have had more than one RTW attempt also rated their experience of the support they received from their employer as poor (average = 2.12).

Table 5 PSP Experience with WSIB and Employers
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The most frequently expressed issues with WSIB included struggles navigating the system, communication issues and more specific problems with how psychological injury is handled within WSIB. With respect to navigating the WSIB claims system participants felt that: “There is no road map for dealing with WSIB or with mental health”, and “your head is probably not in a good place to be finding, reading and comprehending policy”. Some respondents also expressed issues regarding communication delays between WSIB and their employer: “The timelines for which different agencies communicate is a huge barrier, it takes 9 months for my employer to get a letter from WSIB, which causes stress and perpetuates the cycle.” Another respondent spoke of the impact that these types of failures in communication had on his/her well-being:

There needs to be better communication with the employee and employer/WSIB. And there needs to be a valid reason provided by the employer for taking an employee off work. I had no slip ups in my job performance and they still put me on a leave of absence, which caused me greater distress.

In addition, to issues with timely communication, some respondents also mentioned problems with how WSIB handled their illness. One PSP reported that:

It was jarring to have to walk the WSIB specialist through exact details of the call that made me take time off work, as I thought it would just be generics. WSIB case manager needed specifics like sounds heard, outcomes, how I felt etc..

Another PSP was concerned about how WSIB classified his illness and the impact that it had on his/her wellbeing:

The sudden, unexpected and poorly explained decision by WSIB to reverse their approval 19 weeks after approving the Recurrence [with no new clinical reporting] has been devastating to my otherwise great progress. I am thankful that when they cut off my Loss of Earnings, they kept my OT so I at least have clinical support.

Respondent RTW experiences with their employers and workplaces are explored further in the following section.

Barriers and Facilitators of Return to Work

Table 6 organizes the most noted facilitators, barriers, or both within PSP organizations. Factors that were commonly seen as both facilitators and barriers included: communication among members involved in the individual’s care (n = 23, 16%), support from peers/family members (n = 21, 14%), general knowledge about services (n = 20, 14%), and expertise of WSIB case manager (n = 20, 14%). The most common facilitators for PSPs to RTW included support from peers/family members (n = 37, 26%), confidentiality (n = 36, 25%), experience of healthcare providers (n = 32, 22%), and elimination of stigma (n = 31, 21%). In the words of one respondent, RTW after a psychological injury requires “resilience training, support from my medical team, support for my union, society’s gradual shift in understanding and acceptance of mental health.”

Table 6 Barriers and Facilitators to Return to Work
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The most frequently cited barriers concerning PSP returning to work include stigma (n = 52, 36%), system navigation (n = 43, 30%), support from leadership/employer (n = 39, 27%), timing/scheduling (n = 31, 21%). These observations were echoed in the participants’ open responses especially with respect to the stigma and lack of support surrounding mental health within PSP organizations:

Fire service workplaces have a long way to go in terms of improving mental health awareness and treatment. It’s one thing to provide access to EAP programs and yearly awareness training, but a completely separate issue of being compassionate, personable, understanding and respectful, while maintaining the upmost privacy and confidentiality. It’s great to have services available and meet government mandates and requirements, but unless employers and managers are prepared to be non-bias and supportive then the system falls apart.

Another respondent wrote of the impact that feeling unsupported by his/her employer had on him/her:

They said they would pay my salary and my treatment and then fell through on both promises, won’t reply to my emails and I feel extremely isolated from the job I love. No one from my workplace has reached out asking how I am, it is as if I never even worked there which in turn hurts my mental health more- I feel disposable.

Stigma surrounding mental health within the workplace featured heavily in PSP responses. One PSP wrote of the impact that the stigma his supervisor expressed toward him had on seeking treatment: “My employer’s immediate supervisor told me prior to going off that he felt people with PTSD were faking. It made me delay seeking treatment”. One firefighter wrote that within his workplace there “is a strong propensity for a divisive and bullying workplace when some individuals see a person on a long term leave of absence, getting paid by WSIB as “milking the system” and taking advantage. Barriers exist from this toxic bullying culture.”

Many of the respondents also mentioned ongoing struggles and concerns with their mental health as a major barrier on their journey back to work. For instance, one wrote of the “anxieties, stressors, constant memories and images, ruminations”, while another of the “dread of seeing staff member involved in the incident.” Another respondent wrote of struggling and worrying about:

Symptoms coming back and affecting my cognitive ability or creating a feeling of fear or significant uncomfortableness that I would have to work through with time. I believe slowly returning to work and being exposed to stresses and working through those stresses over time will be key to successfully returning to full time hours.

Discussion

The goal of the current study was to gain a better understanding of the RTW experiences of PSP navigating the WSIB claims and RTW process including their experiences with HCPs. The results of the survey indicate that the RTW process is fraught with complexities and difficulties for many PSP. PSPs expressed a desire for changes to the WSIB RTW process and to larger systemic issues surrounding how work-related psychological injuries are handled by PSP employers. The study findings revealed shortcomings in the amount and quality of support offered to PSP engaged in the RTW process from WSIB, their employers, and from their HCP.

Return to Work Experiences

Most of the respondents reported negative experiences on their RTW journey with few reporting positive RTW experiences. The major themes in the responses consisted of problems with workplace culture, lack of support from PSP employers, and difficulties navigating the WSIB claim process. Notably, although respondents in our survey rated their experiences with both WSIB and their employer as poor, employers were rated more poorly than WSIB by people making both a first and subsequent attempt to RTW. A previous study revealed that 33% of PSP endorse experiencing stigma related to mental health in their workplace [22]; this finding was consistent with our study, and stigma surrounding mental health not only presents a substantial barrier on PSPs RTW journeys, but it can also have a negative impact on PSP desire to RTW. The PSP workplace culture reported in this study predominately consisted of a “don’t show weakness” attitude where emotional support seeking was looked down upon [2, 23]. Respondents described concerns about how their employers and co-workers would perceive them and whether they would be perceived as “milking the system”. Toxic workplace culture and stigma is an area that must be addressed by organizations to help promote the RTW of employees. These findings are consistent with a recent policing study that focused on RTW in Ontario, also showing that workplace stigma, stoicism and distrust were frequently identified as challenges to RTW [24].

Given that supervisors and employers play a crucial part in maintaining the well-being of their staff and helping them navigate the unique pressures of PSP work [23], social support is one thing that a supervisor can provide that positively impacts PSP well-being, especially after experiencing trauma [25,26,27,28]. One strategy that employers can adopt to help facilitate PSP’s RTW journeys is to work with the PSP’s HCPs to implement a specific RTW plan, tailored to the individual returning to work. Many individuals returning to work do so gradually with reduced hours and responsibilities, easing into re-entering the workforce. This helps ensure success on the first RTW attempt and decreases the need for multiple attempts; a coordinated and person-centred approach has been shown to be effective for other populations making RTW attempts, including those with chronic conditions and mental health conditions [29, 30]. Many of the respondents in our study felt that their employer did not support these types of accommodations. A lack of support from employers can impact the ability of PSP to serve their communities competently and confidently [26, 27]. While support is important for employees when they have returned to work and are working on modified duties, the support from employers can be beneficial while off work. Studies have found that RTW outcomes were likely to improve if the individual on leave was still in contact with the employers [7, 24]. Additionally, the findings of a recent police RTW study recommended a focus on accommodations and trust building, as well as communication [24].

WSIB has implemented policies around psychological injury claims and RTW procedures [8, 9]. However, every individual may experience trauma differently and the way someone responds to trauma may vary depending on their personal characteristics, coping strategies, and family situation [2]. Some participants expressed a desire for WSIB to “customize RTW with employee input, not just blindly follow template”. Ensuring RTW plans are person centered will help increase the likelihood of a successful RTW on the first attempt after a psychological injury claim. Other areas of concern for WSIB were the way case managers go about learning about the claim-related injury. Since walking through a traumatic event with someone can be difficult, it would be beneficial to make the process clearer about what type of details the individual making the claim will need to provide. This way they can prepare themselves for the appointment rather than being surprised or triggered.

Barriers and Facilitators to RTW

While barriers and facilitators of RTW was a specific section of the survey, these concepts showed up throughout the survey responses. While a lack of PSP specific knowledge about their work and culture can be a barrier for HCP when treating a PSP with a psychological injury, there are other barriers that can often stand in the way of PSP seeking help. The most common barriers impacting PSP’s RTW were workplace stigma, system navigation, support from leadership/employer, and timing/scheduling difficulties. The difficulties of navigating the WSIB claims process and the mental health system featured heavily in PSP’s responses. The system can be hard to navigate and as one participant wrote, that can be “crushing at times”. Another barrier for PSP embarking on the RTW process was workplace policies regarding work-related psychological injuries. With different policies in the workplace, it can be difficult to keep track of and comprehend the nuances of each policy. These comprehension difficulties can be further compounded by the cognitive impacts of a work-related psychological injury. It is important that policies are clear and expressed in simple to understand terms and employers and worker’s compensation boards might even include a user or “how to” guide to their claim and RTW processes.

Previous work has revealed that one of the biggest facilitators of recovery from a work-related psychological injury involves rapid identification of an injury by the employer [23]. PSP who have experienced trauma and have been identified by their employer as being at risk for a psychological injury have been found to have a more positive outlook on their organization. Being offered help early demonstrates support from a PSP’s immediate supervisor impacts the well-being of department staff [23]. Findings from our study corroborate the literature. Unfortunately, many PSP delay reaching out for help for their psychological injuries until they are “barely hanging on”, which combined with system delays, can exacerbate the problem. Providing proactive access to HCPs and creating system capacity to try to reduce wait times is important.

What PSP Would like HCP to Know

For many of the PSP in our study, the RTW process involved treatment from numerous HCPs with the vast majority being treated by a psychologist and/or an occupational therapist [OT]. The PSP in our study also saw a variety of other HCP including psychotherapists and psychiatrists, general practitioners, EFAP counsellors, social workers, physiotherapists, and nurse practitioners. Our study revealed that in general, the vast majority of PSP who took part in this study felt that their HCPs lacked knowledge essential to treat their psychological injury. The PSP who took part in this study expressed a need for their HCPs to:

  • Be informed about mental health;

  • Be informed about “PTSD in first responders”;

  • Be informed and “knowledgeable about the work we do”; and.

  • “Be prepared to hear some of the horrible things we’ve seen.”

Critically, PSP revealed that their HCPs did not understand the nuances of PSP work and culture. Given that many PSPs reported feeling apprehensive about sharing their experiences of trauma due to a fear of confidentiality breeches, past negative experiences associated with sharing such personal experience, and a fear of being perceived as a burden on their families, it is especially important that HCPs make PSP feel safe and understood. Previous research suggests that PSPs dealing with a psychological injury are more likely to relate best to HCPs with a similar background because they feel that that common background is necessary for a deeper understanding of their problems and experiences [31]. For any HCPs working with a PSP who has sustained a psychological injury, it is important to be well-informed of the PSP’s workplace culture [14]. An understanding of the workplace culture can also help develop HCPs plan appropriate accommodations/modifications that have a higher likelihood of being implemented by the employers.

Additionally, in our study, PSP appreciated healthcare services that were practical and linked to their communities and workplaces, helping them develop coping skills to deal with the regular challenges of work, such as those provided by occupational therapists [OTs]. This is consistent with other literature related to RTW for common mental disorders like depression and anxiety, where work-focused therapies have the highest efficacy [32, 33].

Limitations

This study sample included a variety of PSP roles across Ontario, making the findings generalizable to several PSP roles. However, there are a few limitations with this study, one being the way responses were gathered, meaning that only respondents with access to the internet and an electronic device could have responded. Because the web-based survey was sent out to PSP employers, unions, and associations and shared on social media platforms, the research team was unable to quantify how many participants were invited to the survey. It is possible that some groups who agreed to share the survey did a better job of dissemination and promotion than others, for example, firefighters and paramedics comprise a larger portion of this sample than other professions. As well, the sample identified mainly as white men, meaning that a diversity of PSP experiences may not have been captured. Additionally, there were a number of people that started the survey but did not complete all of it. This could be due to the way the survey was built or the nature and difficulty of the questions. Finally, the survey took place during the COVID-19 pandemic, and it is possible that experiences gathered during this time were influenced by pandemic-related systemic issues within bureaucratic and healthcare systems.

Conclusions

The information gathered in this study indicated that PSP would like to RTW after making a work-related psychological injury claim with WSIB. However, PSP face many barriers in successfully executing this, such as lack of support from employers, workplace stigma, HCP not having the systematic knowledge required for treatment, and difficulties with system navigation and getting access to health services and workplace accommodations. Person-centred approaches to workers compensation processes and RTW planning are indicated, along with supportive work environments that enable necessary accommodations and consider the barriers that mental health stigma can create. Access to HCPs with competence in work-related psychological injuries, as well as an understanding of the specific nature of PSP work, is critical. Additionally, access to work-focused therapies, like occupational therapy, is indicated in the RTW process. Future research should focus on ways to overcome RTW barriers and how to support PSP mental health within workplaces, to reduce the number of worker’s compensation claims and their duration.