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Gender Influences on Return to Work After Mild Traumatic Brain Injury

Published:April 25, 2015DOI:https://doi.org/10.1016/j.apmr.2015.04.008

      Abstract

      Objective

      To examine the influence of gender on the return to work experience of workers who sustained a work-related mild traumatic brain injury (TBI).

      Design

      Qualitative study using in-depth telephone interviews.

      Setting

      Community.

      Participants

      Purposive sampling was used to recruit participants. Participants were adults (N=12; males, n=6, females, n=6) with a diagnosis of mild TBI sustained through a workplace injury.

      Interventions

      Not applicable.

      Main Outcome Measures

      Not applicable.

      Results

      Our findings suggest that gender impacts return to work experiences in multiple ways. Occupational and breadwinner roles were significant for both men and women after work-related mild TBI. Women in this study were more proactive than men in seeking and requesting medical and rehabilitation services; however, the workplace culture may contribute to whether and how health issues are discussed. Among our participants, those who worked in supportive, nurturing (eg, feminine) workplaces reported more positive return to work (RTW) experiences than participants employed in traditionally masculine work environments. For all participants, employer and coworker relations were critical elements in RTW outcomes.

      Conclusions

      The application of a gender analysis in this preliminary exploratory study revealed that gender is implicated in the RTW process on many levels for men and women alike. Further examination of the work reintegration processes that takes gender into account is necessary for the development of successful policy and practice for RTW after work-related MTBI.

      Keywords

      List of abbreviations:

      MTBI (mild traumatic brain injury), RTW (return to work), TBI (traumatic brain injury), WSIB (Workplace Safety and Insurance Board)
      Employment and income status are considered key determinants of individual and community health in western societies

      World Health Organization, Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Available at: http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf. Accessed January 6, 2014.

      • Mikkonen J.
      • Raphael D.
      Social determinants of health: the Canadian facts.
      ; an interruption to the typical employment pattern during the life course, therefore, has significant consequences at individual and societal levels. In addition to being an economic necessity, having paid employment after sustaining a traumatic brain injury (TBI) can have a positive impact on a worker's well-being, and returning to the same workplace can enhance this effect.
      • Hooson J.M.
      • Coetzer R.
      • Stew G.
      • Moore A.
      Patients' experience of return to work rehabilitation following traumatic brain injury: a phenomenological study.
      In Ontario, as in many North American and international jurisdictions, the early and safe return to work (RTW) policies in place are based on the assumption that it is best for the worker's health and recovery, and for the employer, if employment resumes as early as possible after a workplace injury. Employers and employees are legally obligated to report workplace injuries and to develop and comply with a RTW plan outlining suitable and safe work duties that provides employment in the workplace where the injury occurred.

      Workplace Safety and Insurance Board (WSIB). By the numbers: 2012 WSIB statistical report. Schedule 2. Toronto: WSIB; 2013.

      However, although returning to work is a significant goal for most injured workers, the interplay of injury-related factors, one's occupational demands, and supports provided in the workplace can influence work reintegration after TBI.
      • Stergiou-Kita M.
      • Dawson D.
      • Rappolt S.
      An integrated review of the process and factors relevant to vocational evaluation following traumatic brain injury.
      Additionally, returning to a workplace where a TBI occurred can introduce a degree of complexity because, in addition to managing the work itself, the worker must confront adversities (eg, returning to the scene of their injury, renegotiating relations with coworkers and employers without having the option of not disclosing their injury).
      Gender impacts many aspects of work. Industries, workplaces, and occupations are often segregated by gender. Although men and women often have the same job roles, they may be assigned to different tasks and may therefore be exposed to different types of risks and hazards.
      • Messing K.
      • Punnett L.
      • Bond M.
      • et al.
      Be the fairest of them all: challenges and recommendations for the treatment of gender in occupational health research.
      • Armstrong P.
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      Taking gender into account in occupational health research: continuing tensions.
      Both paid and household labor are gendered. Women are more likely to be involved in lower paying, lower status jobs
      • Boudarbat B.
      • Connolly M.
      The gender wage gap among recent post-secondary graduates in Canada: a distributional approach.
      • Misra J.
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      The gender wage gap in the United States and cross nationally.
      ; paid less for the same work
      • Lips H.M.
      The gender pay gap: challenging the rationalizations. Perceived equity, discrimination, and the limits of human capital models.
      ; and employed in casual or temporary positions than men.
      • Menéndez M.
      • Benach J.
      • Muntaner C.
      • Amable M.
      • O'Campo P.
      Is precarious employment more damaging to women's health than men's?.
      Women are also more likely than men to perform domestic and caregiving work, without wages, whether or not they also have paid employment.
      • Mackenzie C.R.
      ‘It is hard for mums to put themselves first’: how mothers diagnosed with breast cancer manage the sociological boundaries between paid work, family and caring for the self.
      Men, on the other hand, are more likely to be employed, and sustain fatal injuries, in high-risk occupations

      Bilsker D, Goldenberg L, Davison JA. A roadmap to men's health: current status, research, policy & practice. 2010. Available at: http://www.sfu.ca/carmha/publications.html. Accessed January 6, 2014.

      and reach higher levels of success than women in women-dominated occupations.
      • Hultin M.
      Some take the glass escalator, some hit the glass ceiling? Career consequences of occupational sex segregation.
      Because gender plays such a prominent role in the labor market, it is worth examining whether and how gender might influence RTW after mild traumatic brain injury (MTBI). In this study, we focus on the intersection of gender with RTW processes after a work-related MTBI.
      Sex refers to the biologic features that identify one as male or female, and it is one's sex on which one's gender is assumed.

      Johnson J, Greaves L, Repta R. Better science with sex and gender: a primer for health research. 2007. Available at: http://bccewh.bc.ca/publications-resources/documents/BetterSciencewithSexandGenderPrimerforHealthResearch.pdf. Accessed January 6, 2014.

      • Johnson J.L.
      • Greaves L.
      • Repta R.
      Better science with sex and gender: facilitating the use of a sex and gender-based analysis in health research.
      In contrast, gender is a social construct that signifies the socially appropriate behaviors or roles ascribed to male and female bodies.

      Johnson J, Greaves L, Repta R. Better science with sex and gender: a primer for health research. 2007. Available at: http://bccewh.bc.ca/publications-resources/documents/BetterSciencewithSexandGenderPrimerforHealthResearch.pdf. Accessed January 6, 2014.

      • Johnson J.L.
      • Greaves L.
      • Repta R.
      Better science with sex and gender: facilitating the use of a sex and gender-based analysis in health research.
      Gender shapes how people learn, relate to one another, and express attitudinal or behavioral patterns that are created and maintained through socioeconomic, political, and cultural institutions.

      Johnson J, Greaves L, Repta R. Better science with sex and gender: a primer for health research. 2007. Available at: http://bccewh.bc.ca/publications-resources/documents/BetterSciencewithSexandGenderPrimerforHealthResearch.pdf. Accessed January 6, 2014.

      • Knaak S.
      On the reconceptualizing of gender: implications for research.
      • Schofield T.
      • Connell R.W.
      • Walker L.
      • Wood J.F.
      • Butland D.L.
      Understanding men's health and illness: a gender-relations approach to policy, research, and practice.
      Gender analysis is a theoretical framework that explores the consequences of gender inequities.

      Johnson J, Greaves L, Repta R. Better science with sex and gender: a primer for health research. 2007. Available at: http://bccewh.bc.ca/publications-resources/documents/BetterSciencewithSexandGenderPrimerforHealthResearch.pdf. Accessed January 6, 2014.

      Although gender analysis is increasingly used in health scholarship,
      • Sharman Z.
      • Johnson J.
      Towards the inclusion of gender and sex in health research and funding: an institutional perspective.
      the examination of gender in workplace health and safety research remains limited.
      • Armstrong P.
      • Messing K.
      Taking gender into account in occupational health research: continuing tensions.
      • Jensen S.Q.
      • Kyed M.
      • Christensen A.D.
      • Bloksgaard L.
      • Hansen C.D.
      • Nielsen K.J.
      A gender perspective on work-related accidents.
      Moreover, although RTW barriers and facilitators after MTBI have been investigated qualitatively,
      • Hooson J.M.
      • Coetzer R.
      • Stew G.
      • Moore A.
      Patients' experience of return to work rehabilitation following traumatic brain injury: a phenomenological study.
      • Levack W.
      • McPherson K.
      • McNaughton H.
      Success in the workplace following traumatic brain injury: are we evaluating what is most important?.
      • Soeker M.S.
      Occupational adaptation: a return to work perspective of persons with mild to moderate brain injury in South Africa.
      the construct of gender and how it intersects with work reintegration processes has not been examined. Therefore, in this study, we explored the relation between gender and RTW after TBI to address this gap.

      Methods

      An exploratory qualitative approach using in-depth telephone interviews was used. Telephone interviews were used to enhance feasibility (workers may have returned to full-time work) and decrease costs (workers resided throughout Ontario). Ethics approval was provided by the research ethics board at a major rehabilitation hospital in Ontario, Canada.

      Participant recruitment and inclusion criteria

      Participants were purposively sampled from a participant pool of an outpatient unit at a major hospital in Ontario, Canada, that provides service to individuals with workplace injuries. Purposive sampling aims to identify participants who have specific knowledge relevant to the area under investigation,
      • Silva S.
      • Fraga S.
      Qualitative research in epidemiology.
      • Miles M.B.
      • Huberman A.M.
      • Saldaña J.
      Qualitative data analysis: a methods sourcebook.
      • Francis J.
      • Johnston M.
      • Robertson C.
      • et al.
      What is an adequate sample size? Operationalising data saturation for theory-based interview studies.
      in this case, RTW experiences after work-related TBI. The outpatient unit provides assessment services to people with work-related TBI who have experienced delayed recovery and persistent symptoms after mild to moderate TBI and who are referred by the province's workers' compensation board, the Ontario Workplace Safety and Insurance Board (WSIB).
      In this study, individuals were eligible to participate if they had been assessed as having a mild to moderate TBI that was sustained at the workplace. Assessment initially occurred at the time of injury and was corroborated through an extensive multidisciplinary assessment (eg, neurology, physiatry, neuropsychology, occupational therapy, physical therapy) at the outpatient clinic. An initial Glasgow Coma Scale score may have also been available to the assessment team if it was collected at time of injury. Patients of this rehabilitation hospital are routinely asked if they would like to participate in future research. To recruit participants for this pilot study, we drew on a consecutive series of 37 patients from a prior study using the same population
      • Colantonio A.
      • Comper P.
      Post injury symptoms after work related traumatic brain injury in Canadian population.
      who had expressed interest in participating in future studies. The staff sent an introductory letter and consent form to these participants to inquire about their interest to participate in the present study. We were able to contact and/or received positive responses from 12 of 37 potential participants. Of the 37 potential participants, we do not know how many were eligible; however, many declined because they had not returned to work and therefore did not see the relevance of participating in the study. Interviews were completed at a convenient time to accommodate participants' schedules.

      Data collection

      Demographic and injury severity data were obtained from medical records of patients who consented to participate. Qualitative data were collected using semistructured telephone interviews that focused on gaining an understanding of participants' experiences with returning to work and the workplace accommodation process. A semistructured interview guide was developed, allowing the researchers to guide discussions while still being open to additional personal insights that participants felt to be most relevant. Within the interviews, participants were first asked to describe how their injuries occurred, their resulting impairments, and their experiences of the rehabilitation processes. This was followed by in-depth discussions about their experiences with returning to work. All interviews were conducted by one of the authors who had 15 years of experience performing qualitative interviews related to health and the workplace. The interviews ranged from 45 to 90 minutes; the average duration was 1 hour. We considered the data as being saturated when no new themes emerged.
      • Francis J.
      • Johnston M.
      • Robertson C.
      • et al.
      What is an adequate sample size? Operationalising data saturation for theory-based interview studies.
      • Morse J.
      Determining sample size.
      If additional data were required to reach saturation, participants could be drawn from a large pool of eligible patients seen at the clinic annually.

      Data analysis

      Interviews were audio recorded and then transcribed verbatim by a professional transcriptionist. An inductive thematic analysis approach was used to analyze and identify themes related to gender within the interview data. Thematic analysis is a multistep approach that has been used extensively in health, sociologic, and psychological studies
      • Harkins C.
      • Shaw R.
      • Gillies M.
      • Sloan H.
      • et al.
      Overcoming barriers to engaging socio-economically disadvantaged populations in CHD primary prevention: a qualitative study.
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      The impact of organisational and individual factors on team communication in surgery: a qualitative study.
      • Stewart B.J.
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      Help-seeking and coping with the psychosocial burden of chronic hepatitis C: a qualitative study of patient, hepatologist, and counsellor perspectives.
      to identify thematized meaning across a data set.
      • Braun V.
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      Using thematic analysis in psychology.
      In step 1, 2 researchers (M.S.-K. and E.M.) and 1 research assistant read each interview several times to become familiar with the data. In step 2, these 3 individuals independently coded each interview using a line-by-line coding method. They discussed the codes and reached consensus on a set of codes applicable across the interviews. Codes were also reviewed by a fourth researcher (A.C.) to ensure consistency and comprehensiveness. In step 3, a qualitative data management software programa was used to organize the coded data and generate code summaries. In step 4, code summaries, which included data from across all interviews, were analyzed to identify key themes reflecting gendered experiences in the RTW process.

      Results

      Participant characteristics

      Twelve workers who were diagnosed with a work-related MTBI were interviewed. Six of the 12 participants were women, and 10 participants were married. Nine of the 12 participants were middle-aged (age range, 40–69y). Four participants had completed high school, and the remaining participants completed some level of postsecondary education. All participants in our sample had returned to work in the public sector, trades, or protective services jobs of varying company size (<20 to >50 employees). Three participants reported having returned to full-time work initially, and the remaining 9 participants returned on a gradual basis. Table 1 summarizes participants' demographic characteristics. Participants reported on their RTW experiences after work-related MTBI that had taken place 2 to 6 years prior to the time of the interview.
      Table 1Demographic and occupational characteristics (N=12)
      CategoryGroupingn
      SexMale6
      Female6
      Age range (y)20–393
      40–659
      Marital statusSingle2
      Married10
      Educational backgroundHigh school4
      Community college4
      University4
      Industry sectorTrades4
      Health, education, public works4
      Protective services4
      Company size
      A small company is <20 employees; a medium company is 20 to 50 employees; and a large company is ≥50 employees.
      Small2
      Medium3
      Large7
      Time since injury (at interview date)3–4y10
      5–6y2
      Employment status at time of injuryFull-time12
      A small company is <20 employees; a medium company is 20 to 50 employees; and a large company is ≥50 employees.
      Similar impairments after a work-related MTBI were reported by all participants: headaches, chronic pain, extreme fatigue, and sleep disorders; psychosocial impairments (eg, depression, mood swings); and cognitive impairments affecting memory, focused attention, and information processing. Most participants reported having numerous physical, cognitive, and mental health problems at the time they returned to their preinjury job.
      The following themes related to issues of gender identity, gender relations, and gendered workplace cultures were identified: the importance of paid work and occupational roles; help-seeking behavior and RTW processes; and supportive and nonsupportive workplace cultures. Each theme is subsequently discussed with supporting quotes from the interviews.

      Importance of paid work and occupational roles

      Participants from varied social class, educational, and industry backgrounds discussed the importance of work in relation to their breadwinner role and as a financial necessity. A participant discussed how his injury affected his feelings of self-worth and sense of male identity: “I felt like my manhood was taken away. I couldn't go to work. I couldn't go and do what I went back to school to do. I quit a factory job making good money to go back to school to do this [trades job] to make life even better.”
      Another participant described how important work was to her sense of professional identity: “I really had a hard time with not being productive, because if I'm not an [educator], who am I, you know. And I think women [in general]…[and] in particular for professional women, we link our self-identity with you know, what we do and how we serve.”
      The impact of a work-related MTBI on personal finances was discussed by participants as a significant factor in their RTW decision-making process. A participant discussed how she returned to work too soon after her TBI because she was fearful of losing her job in a depressed local labor market: “But to find that kind of work [locally] is limited. You get into a spot where you can support your children on your own income without having to have the stress of worrying about that second income coming in—it's nearly impossible in rural areas. So, you know, you deal with it [issues at the workplace] because you really don't have any other option.”

      Help-seeking behavior and RTW processes

      Some gender differences were evident in how workers sought and requested assistance with the RTW process. Gendered behaviors influenced participants' understanding and awareness of their impairments and their abilities to self-advocate and navigate formal support systems. Women participants tended to be more proactive in seeking health care and requesting multiple medical opinions. For example, a participant was skeptical of relying on medical specialists assigned to her case by workers' compensation representatives. She was concerned that WSIB-appointed physicians might be motivated to reduce the costs of an insurance claim and, as a result, would not provide a thorough diagnosis and prescribe necessary medical treatment. In addition to seeing the WSIB doctor, this participant sought medical specialists who eventually diagnosed her with atypical neuralgia:So I think it was about two weeks later I had an appointment with my neurologist … and I say my neurologist because when WSIB send me to somebody, like a professional, they will say one thing. However, when my doctor schedules me with somebody that she hears is really, really good [then] I will finally get some answers … So I had gone to see a neurologist through my doctor, not WSIB. Anyhow, he's the one who ultimately said that I had atypical neuralgia and at that time, that's when he wrote, “She's in chronic pain, this pain is disabling.”
      In contrast, men reported being less involved in seeking health care support. A participant described how he experienced debilitating symptoms but did not challenge the WSIB medical specialist's recommendation that he was ready to RTW. Another participant received minimal health care support after his TBI and did not follow-up when test results were not communicated to him:Since then I haven't been back to a doctor. My doctor that I had all my life, he retired, so I had this other doctor for about a year and a half maybe and I've never ever seen him. All I've seen is the nurse practitioner for, you know, flu and stuff like that. I'm just tired. I went through all this crap for four years and I'm waiting for something good … for somebody to say okay here's a solution.

      Supportive and nonsupportive workplace cultures

      In addition to personal impairments that affected the RTW process, participants described the significant role that workplace cultures and social relations in the workplace played in shaping their postinjury work experiences. Social relations could include relations with employers and coworkers.
      Participants reported both supportive and unsupportive workplace settings and discussed how this shaped their RTW and postinjury experiences. For example, a participant described how his supervisor and coworkers worked together to support him. He described a nurturing workplace setting where he was comfortable communicating his needs for support to coworkers:So just generally speaking, my office was a pretty nurturing [place]. Everyone was being very careful of everyone, and deadlines and productivity were not the watchwords of the day; it was just about making sure that everybody was okay … Like it took a fair bit of time for me to train some of my co-workers and my summer staff, that you know, the old [me] you could kind of pass in the hallway and say you know, I need this [item] set up for tomorrow afternoon by one o'clock, and I would nod and smile and say yeah, no problem, and it would get done. The new [me], it would be better if you sent me an e-mail.
      Another participant described retuning to work in a supportive workplace setting where her employer advocated for her with both the administration and WSIB. The employer restructured the participant's job so she could continue to have meaningful work: “So what she [the employer] did was [hire] another full time employee, so that one does a ton of paperwork, and all I do is work with [students].”
      In contrast, other participants reported that returning to work at the preinjury job was a stressful, sometimes punitive experience. Some participants—both men and women—who worked in traditionally male-dominated workplaces (eg, protective services) described workplace environments where requests for work modifications and supports after TBI were often denied. A participant reported feeling marginalized by his coworkers: when he returned to work, his managers and coworkers behaved as if the injury had never taken place. Similarly, another participant perceived her TBI as damaging her occupational identity and opportunities for advancement in a predominantly male workplace: “I still have this injury kind of attached to my name. As far as promotions, I haven't had any…You know, it's probably oh ‘She's a girl, she can't hack it, she can't—she couldn't take it.’ We're [women employees] yeah, treated differently and then after an injury, yeah. Even though no one would say it to me, I kind of knew it.”

      Discussion

      The findings from this preliminary exploratory study are based on interviews with 12 participants who experienced a work-related MTBI. The findings highlight the role that gender plays in RTW after work-related MTBI and areas where men's and women's RTW experiences can converge and diverge. To our knowledge, this is the first qualitative study that applies a gender lens to investigate RTW processes after a work-related MTBI. First, in contrast with studies reporting differences in men's and women's identification with occupational roles,
      • Côté D.
      • Coutu M.
      A critical review of gender issues in understanding prolonged disability related to musculoskeletal pain: how are they relevant to rehabilitation?.
      • Dolan A.
      ‘You can't ask for a Dubonnet and lemonade!’: working class masculinity and men's health practices.
      our findings revealed similarities in the importance of work for both men and women. For example, Côté and Coutu
      • Côté D.
      • Coutu M.
      A critical review of gender issues in understanding prolonged disability related to musculoskeletal pain: how are they relevant to rehabilitation?.
      reported that men typically identify more strongly with worker roles, whereas women identify with multiple roles (eg, mother, worker, spouse). Similarly, in a study examining how working class men constructed their masculine identities, Dolan
      • Dolan A.
      ‘You can't ask for a Dubonnet and lemonade!’: working class masculinity and men's health practices.
      reveals that all men in the sample, regardless of whether they adhered to other male stereotypes, strongly believed in their role as financial providers (breadwinner) for their families. However, in our study, men and women each discussed adversities associated with loss of an occupational role and how closely occupational roles were related to both their self-identities and the need to financially support themselves and their families. The similarities in perceived importance of occupational and breadwinner roles could reflect changing gender dynamics based on changing social, political, and economic conditions. Whereas identification as the breadwinner has historically been considered a uniquely masculine role,
      • Côté D.
      • Coutu M.
      A critical review of gender issues in understanding prolonged disability related to musculoskeletal pain: how are they relevant to rehabilitation?.
      • Dolan A.
      ‘You can't ask for a Dubonnet and lemonade!’: working class masculinity and men's health practices.
      changes in household composition (eg, single income families led by women) or changing labor markets could also influence views on occupational roles.
      Second, gender norms were evident in the way participants sought help. Women were more likely to engage in self-advocacy and to report following up with health and insurance providers when they required assistance. Although gender differences in help-seeking behaviors are well-documented in the health literature,
      • Dolan A.
      ‘You can't ask for a Dubonnet and lemonade!’: working class masculinity and men's health practices.
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      • Peerson A.
      • Saunders M.
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      they have not been qualitatively examined in studies of RTW processes. Men were also often reticent to discuss injury-related work limitations with employers and coworkers and to request rehabilitation services. This is consistent with studies of occupational health and safety in high-risk workplaces.
      • Breslin F.C.
      • Polzer J.
      • MacEachen E.
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      Workplace injury or “part of the job”?: Towards a gendered understanding of injuries and complaints among young workers.
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      Predisposing factors leading to depression in the British Army.
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      Keep going: perspectives on ageing and masculinity of self-employed tradesmen in Australia.
      Reticence to discuss health and occupational safety needs may be re-enforced by gendered workplace cultures and the gendered nature of discourses about health.
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      • Walters V.
      ‘Men are the leavers alone and women are the worriers’: gender differences in discourses of health.
      Further inquiry into the role that gender relations play within an occupational health and safety context is therefore also warranted.
      Finally, we noted that injured workers could experience a workplace environment as being supportive or unsupportive. Gender relations shaped RTW experiences most notably in traditionally male workplaces where workers reported feeling pressured to tough out the postinjury experience.
      • Desmond M.
      Becoming a firefighter.
      • O'Brien R.
      • Hunt K.
      • Hart G.
      ‘It's caveman stuff, but that is to a certain extent how guys still operate’: men's accounts of masculinity and help seeking.
      What appeared to make a difference was whether the workplace culture was considered nurturing (or what may be traditionally considered a feminized workplace) versus a masculinized workplace culture that valued risk, competition, and profits over social justice principles and individual workers' needs.
      • Hilgert J.
      Building a human rights framework for workers' compensation in the United States: opening the debate on first principles.
      • O'Brien R.
      Other voices at the workplace: gender, disability, and an alternative ethic of care.
      In this study, participants returning to traditionally male-dominated, masculinized workplace cultures (ie, protective services, construction, transportation) often reported an unsupportive work environment after work-related MTBI. Health care professionals, employers, and workers' compensation representatives might need to consider how gender plays out in different workplace settings and potentially influences RTW and rehabilitation processes. This could include understanding what gender norms exist within a specific workplace and how gender norms are re-enforced within workplace settings to support safe workplaces and successful rehabilitation and RTW processes.

      Study limitations

      This preliminary exploratory study has some limitations. We examined the perspectives of a small and select group of women and men with work-related MTBI; therefore, some sample bias is present. Although we sought participants with mild to moderate work-related TBI, the response from those only with a mild injury also suggests sample bias. However, given that we interviewed individuals with a specific set of experiences, the topic was well-defined, and the participants provided articulate and detailed data, we considered a sample size of 10 to 15 participants as sufficient to achieve thematic saturation.
      • Morse J.
      Determining sample size.
      Although the insights are important, future studies with a larger sample with varied degrees of injury severity and from more diverse backgrounds are required to further investigate the themes identified in this study. Our study included participants who were English-speaking and had relatively high levels of education compared with the broader work-related MTBI population being studied, as identified in a study on the same population.
      • Colantonio A.
      • Comper P.
      Post injury symptoms after work related traumatic brain injury in Canadian population.
      Future studies should also be designed to include participants whose language is other than English. Participants in our sample were insured by the WSIB in Ontario, Canada, in addition to having access to universal health care through provincial health care plans; as such, their experiences may not reflect experiences of workers with different insurance and health care plans. Finally, we applied a gender analysis in this study to afford a unique perspective on the RTW process. A more comprehensive analytical framework (eg, intersectionality) could provide greater insight into how additional variables (eg, race/ethnicity, social status) contribute to and complicate this process.
      • Armstrong P.
      • Messing K.
      Taking gender into account in occupational health research: continuing tensions.
      • Bauer G.R.
      Incorporating intersectionality theory into population health research methodology: challenges and the potential to advance health equity.

      Conclusions

      Returning to work after a work-related MTBI is a difficult and complex process. Gender roles, relations, and the implicitly gendered nature of workplace cultures contribute to the complexity of the RTW processes for men and women alike. These exploratory findings suggest the need for further research to investigate the gendered nature of work reintegration experiences and for knowledge transfer activities that enable health care and workers' compensation providers, employers, and employees to create appropriate policies and workplace supports for satisfactory RTW after work-related MTBI.

      Supplier

      • a.
        ATLAS.ti5; Scientific Software Development.

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