Supervisors managing sickness absence and supporting return to work of employees with burnout: A membership categorization analysis

Abstract Supervisor support alleviates burnout, but little is known about supervisors’ activities in supporting employees with burnout. This study discerned supervisors’ category-bound activities during the absence management and return-to-work (RTW) process of employees with burnout, and activities where the supervisors need support and guidance, from the perspective of occupational physicians and RTW coordinators in Finland. Data from semi-structured interviews and essays were analyzed with membership categorization analysis (MCA). First, occupational physicians and RTW coordinators saw supervisors as key actors in managing sickness absence and supporting RTW of employees with burnout. The large number of supervisors’ category-bound activities was discerned before the prolonged sickness absence, during the sickness absence, at work resumption, and after recovery from burnout. Second, supervisors were seen by occupational physicians and RTW coordinators as requiring support in implementing organizational absence management and RTW policies and procedures and communicating about burnout-related matters. The results of this study challenge occupational health services and employers to develop education for supervisors to improve their management practices as well as education for supervisors and employees to improve mutual communication to prevent and reduce burnout-related absenteeism and disability pensions. Further research of supervisors’ activities is needed from the perspectives of supervisors and the employees with burnout.


PUBLIC INTEREST STATEMENT
Job burnout is a syndrome developing from chronic work-related stress. High levels of burnout have been measured among the workforce worldwide. A significant number of those in the working population experience burnout, indicating that many supervisors have to deal with the burnout problem. Previous studies have shown that supervisor support alleviates burnout, but little is known about supervisors' actual activities in supporting employees with burnout. This ethnomethodological, descriptive study using membership categorization analysis (MCA) discerned supervisors' category-bound activities during the absence management and return-towork (RTW) process of employees with burnout, especially supervisors' need for support and guidance, by interviewing occupational physicians and RTW coordinators and recognizing supervisors' category-bound activities in their descriptions. This study adds our understanding about supervisors' categorybound activities, as well as their need for support and guidance, and contributes in developing supervisor support to prevent and reduce burnout-related absenteeism and the need for disability pensions.
as education for supervisors and employees to improve mutual communication to prevent and reduce burnout-related absenteeism and disability pensions. Further research of supervisors' activities is needed from the perspectives of supervisors and the employees with burnout.

Introduction
A burnout syndrome develops at work as a response to chronic work-related stress (Maslach, Schaufeli, & Leiter, 2001). Employees with burnout are at risk for increased absenteeism and the need for disability pensions (Salvagioni et al., 2017). High levels of burnout have been measured among the working population worldwide (Creedy, Sidebotham, Gamble, Pallant, & Fenwick, 2017;Rezaei, Karami Matin, Hajizadeh, Soroush, & Nouri, 2018;Rothenberger, 2017), indicating that burnout is a global occupational hazard. In European countries, there are no burnout-specific estimates for the cost of absence, but 10% of occupational illnesses were related to work-related stress in 2002 and the annual costs reached €20 billion (Hassard et al., 2014). In Finland, a survey in 2011 indicated that one-fourth of workforce had experienced burnout symptoms and the symptoms were severe among 2% of men and 3% of women (Duodecim, 2015).
Burnout is defined by its dimensions of experienced exhaustion, cynicism, and inefficacy. Being emotionally exhausted, employees distance themselves from work and develop negative, cynical attitudes, and feelings towards the work (depersonalization) as well as feelings of incompetence and a lack of personal accomplishment (sense of reduced professional efficacy) (Maslach et al., 2001). Burnout develops from mismatch in workload, job control, reward, community, fairness, values (Maslach et al., 2001), job demands, and resources (Demerouti, Bakker, Nachreiner, & Schaufeli, 2001). Perceptions of workload and management have predicted exhaustion, whereas perceptions of teamwork (level of cooperation), workload, and older age have predicted cynicism. In the same study, perceptions of workload and teamwork have also predicted unit-level exhaustion and cynicism. Selfefficacy strongly predicted both exhaustion and cynicism (Consiglio, Borgogni, Vecchione, & Maslach, 2014). A recent systematic review and meta-analysis by Aronsson et al. (2017) found moderately strong evidence of an association between job control and reduced emotional exhaustion. They found limited evidence for the associations between workplace justice, demands, high workload, low reward, low supervisor support, low co-worker support, job insecurity, and change in emotional exhaustion. Most of the work factors in their analysis were associated with cynicism. Interestingly, only low reward was associated with reduced personal accomplishment (Aronsson et al., 2017).
Studies have shown that supervisor support alleviates the dimensions of burnout (Charoensukmongkol, Moqbel, & Gutierrez-Wirsching, 2016;Gibson, Grey, & Hastings, 2009;Karatepe, 2010;Li, Ruan, & Yuan, 2015;Salahian, Oreizi, Abedi, & Soltani, 2012;Salminen, Andreou, Holma, Pekkonen, & Mäkikangas, 2017;Tayfur & Arslan, 2013;Thomas & Lankau, 2009). Supervisors were considered as the most important external support actors when regaining the ability to work by employees with exhaustion disorder (Norlund, Fjellman-Wiklund, Nordin, Stenlund, & Ahlgren, 2013). Supervisors provided practical and structural support to assist with information needed, arrange for extra personnel, make decisions regarding work modifications, and follow-up. Emotional support from supervisors-a shoulder to lean on and encouraging words-was valued by exhausted employees (Norlund et al., 2013). An understanding, emphatic supervisor was able to alleviate symptoms of exhaustion and facilitate return-to-work (RTW) (Salminen et al., 2017). Kim and Lee (2009) investigated effects of different types of supervisory communication on burnout and turnover intention and found that job-relevant communication (supervisory communication regarding job-related matters) and a positive relationship communication (supervisors interacting with their subordinates in an informal and supportive manner) had a negative correlation with burnout resulting from role stress (role ambiguity and role conflict). Additionally, open upward communication (from lower to higher members in the organizational hierarchy) buffered the effect of role stress on burnout (Kim & Lee, 2009). Supervisors with a high leader-member exchange relationship (high level of mutual trust, respect, liking, interaction, and support) reduced emotional exhaustion through increased socialization and decreased role stress (Thomas & Lankau, 2009). Moreover, workplace interventions, including enhanced communication between the employees and their supervisors, had an effect on sustainable RTW among younger employees with burnout (Karlson, Jönsson, & Österberg, 2014).
Managing absence due to sickness and supporting RTW is complicated in burnout cases, because the supervisor can be perceived as the source of stressors (workload and role ambiguity originating from the supervisor) as well as the source of support (Kickul & Posig, 2001). When employees who experienced role conflict or time pressure received high emotional support from their supervisor, they experienced increased exhaustion because the support from the supervisor caused an additional role conflict (reverse buffering effect) (Kickul & Posig, 2001). Emotional support from the supervisor did not help the employees to cope with demand stressors. The authors discuss that when the supervisor is part of the problem, he/she should not try to provide emotional support, but instrumental support might also be considered (Kickul & Posig, 2001). Jenkins and Elliott (2004) found that higher stressor scores, in terms of lack of adequate staffing and dealing with physically threatening or difficult or demanding patients, were associated with higher levels of depersonalization for nurses who experienced higher levels of social support, but not for nurses who had low levels of support. They suggest that the reverse buffering effect requires social support that minimizes negative communication and promotes the constructive discussion of job-related stressors (Jenkins & Elliott, 2004).
In Finland, occupational physicians and RTW coordinators are involved in the absence management and RTW processes, therefore we considered their perspectives on the supervisors' category-bound activities in this study. Employers are obliged to inform occupational healthcare when the sick leave of an employee exceeds 30 days and after 90 days, the employer, occupational healthcare (occupational physician), and the disabled employee have to collaborate in evaluating possibilities to RTW (Sosiaali-ja terveysministeriö [Ministry of Social Affairs and Health], 2001). Therefore, we assume that occupational physicians and RTW coordinators have knowledge of supervisors' category-bound activities in managing sickness absence and supporting RTW of employees with burnout. Previous studies have shown that supervisor support alleviates burnout, but little is known about supervisors' category-bound activities in managing sickness absence and supporting RTW. Therefore, we aimed to discern supervisors' categorybound activities during the absence management and RTW process of employees with burnout, especially supervisors' need for support and guidance, by interviewing occupational physicians and RTW coordinators and recognizing supervisors' category-bound activities in their descriptions. A significant number of those in the working population experience burnout, indicating that many supervisors have to deal with the burnout problem. Better understanding of the supervisors' category-bound activities, as well as activities in which they need support and guidance, is essential to develop supervisor support to prevent and reduce burnout-related absenteeism and the need for disability pensions.
Our research questions were as follows: (1) How do occupational physicians and RTW coordinators describe supervisors' category-bound activities during the absence management and RTW process of employees with burnout in their accounts?
(2) How do occupational physicians and RTW coordinators describe supervisors' category-bound activities for which they need support and guidance during the absence management and RTW process of employees with burnout in their accounts?
The term "category-bound activities" in this study refers to the activities the supervisors are expected to undertake in their institutional positions according to occupational physicians and RTW coordinators.

Study design and participants
The present research was an ethnomethodological, qualitative, and descriptive study. The Research Ethics Committee of Northern Savo Hospital District approved the research plan for a large study in which RTW practices for employees with burnout were sought from occupational health professionals (physicians, nurses, psychologists, and physiotherapists) (Kärkkäinen, Saaranen, & Räsänen, 2018a) and RTW coordinators (e.g. human resource (HR) managers, occupational safety managers, heads of occupational well-being, work ability coordinators, and senior nursing officers) (Kärkkäinen, Saaranen, & Räsänen, 2018b). In the large study, the responsible managers of the private occupational health medical centers, employer-operated occupational health centers, and municipal health centers all around Finland were contacted and asked for permission to recruit their staff. The RTW coordinators were recruited by contacting the managers of the human resources departments in 15 universities, five university central hospitals, and 16 central hospitals in Finland and asked for permission to participate. The responsible managers appointed the participants to both studies. The analysis of the present study is based on data from all the occupational physicians (n = 7) and RTW coordinators (n = 15) who participated in the larger study.
Six of the occupational physicians were employed in employer-operated occupational health centers and one was employed in a municipal health center. Six of the seven occupational physicians were female. Their age ranged from 46 to 59 years, and they had from 8 to 29 years of working experience as occupational physicians. Seven RTW coordinators from universities and eight from hospitals participated. The RTW coordinators were located within human resource divisions, occupational safety and health teams, occupational well-being units, and nursing management. Totally, 14 of the 15 RTW coordinators were female. The RTW coordinators were aged 35 to 62 years. Their working experience with the absence management and RTW processes varied from 3 to 33 years. An inclusion criterion was that the participants had to be professionals involved in the treatment of employees with burnout (occupational physicians) or involved in the absence management and RTW processes of employees with burnout, at least in a part-time position (RTW coordinators). The demographics of the participants are presented in Table 1. The participants were asked to provide signed consent after they were informed about the purpose of the study, their voluntary participation, confidentiality precautions, and the opportunity to withdraw from the study at any stage.

Data generation
The data were generated through semi-structured interviews and open-ended essays between June 2014 and December 2014 (occupational physicians) and between March and June 2017 (RTW coordinators). Six dyadic interviews with two participants in each, and 10 individual interviews were conducted. The dyadic interviews were conducted when the responsible managers appointed two participants from the work organization to participate and the participants preferred to be interviewed together. The occupational physicians were interviewed at their workplaces. Of the 15 RTW coordinators, two were interviewed over the internet using the software application Skype, others were interviewed at their workplaces. Interviews were carried out by the first author. The interviews lasted approximately 1 h and were recorded. The participants were asked to describe their experiences with the RTW of the employees with burnout and about factors that had facilitated or obstructed RTW. In addition, they were asked to describe their experiences concerning cooperation with the supervisors in the RTW of the employees with burnout. In the essay assignments, participants were asked to describe their experiences of RTW support for employees with burnout. All participants received the essay assignment via an encrypted e-form before the interview. Six of the 22 participants responded to the essay assignments as shown in the Table 1. The essays produced six A4 sheets of data, and they supplemented the interview data. The transcribed interviews and essays produced 340 pages of text.

Analysis
We applied membership categorization analysis (MCA), a form of ethnomethodology, in our analysis. An ethnomethodological approach in the work context investigates how work is organized as a recognizable social accomplishment (Martin & O'Neill, 2011). MCA is used to study practices that members of a given community deploy in the routine accomplishment of everyday social interactions and how they engage in routine common sense reasoning to explain, predict, and describe others' behavior (Housley & Fitzgerald, 2015). Although the interaction under investigation usually occurs naturally (Hester & Eglin, 1997;Lepper, 2000), the method has been applied to different kinds of talk and text (Lepper, 2000). Membership categories are used to categorize people (Hester & Eglin, 1997;Housley & Fitzgerald, 2015), either ourselves or other people. In this study context, we focus on the interaction between the supervisor, the employee with burnout, the occupational physician, and the RTW coordinator as given institutional categories. Categories form collections of categories and can act together as a team (Sacks, 1972a(Sacks, , 1972b, like the supervisor, the employee with burnout, the occupational physician, and the RTW coordinator who are all involved in the absence management and RTW process. The members of the team form standardized relational pairs (Hester & Eglin, 1997;Lepper, 2000;Sacks, 1972b;Stokoe & Attenborough, 2015), such as a supervisor-employee with burnout pair, occupational physicianemployee with burnout pair, and RTW coordinator-employee with burnout pair. Category-bound activities are activities that are expected from each category by the other members of their work team (Sacks, 1972b;Stokoe & Attenborough, 2015), together with predicates, rights, and obligations (Lepper, 2000;Stokoe & Attenborough, 2015). Members have categorically located knowledge, that is, a knowledge they have adopted in their institutional positions, of the expected behavior of each other (Sacks, 1972b). Occupational physicians and RTW coordinators have knowledge about supervisors' category-bound activities in managing sickness-related absence and supporting RTW of employees with burnout.
The analysis process was conducted by the first author and the other three authors reviewed the analysis. There were no discrepancies to be solved. The researcher (the first author) read the data through several times and recognized descriptions of supervisors' category-bound activities, predicates, rights, and obligations (Sacks, 1972a). Occupational physicians' and RTW coordinators' descriptions of the supervisors' category-bound activities were reflexively descriptions of their own category-bound activities in collaboration with the supervisors (Baker, 1997), including support and guidance they provided to the supervisors.

Results
In their accounts, occupational physicians and RTW coordinators constructed two categorizations: supervisors as key actors and supervisors as recipients of support in managing sickness absence and supporting RTW of employees with burnout. An absence management and RTW process became apparent in occupational physicians' and RTW coordinators' descriptions. Supervisors were expected to be involved before the prolonged sickness absence, during the sickness absence, at work resumption, and after recovery from burnout.
4.1. Supervisors as key actors in managing sickness absence and supporting RTW of employees with burnout 4.1.1. Supervisors' category-bound activities before the prolonged sickness absence 4.1.1.1. Control employees' work capacity through development discussions. RTW coordinators mentioned that they expected supervisors to conduct development discussions with the employees regularly. The development discussion was a tool for the supervisor to gain better understanding of an employee's capacity to work. The supervisor and the employee discussed whether the employee needed to update his/her professional knowledge and competence. The supervisors needed to control employees' participation in additional training because according to the RTW coordinators, the employees were not always proactive in maintaining their professional skills despite continuous changes in their working life. Lack of a professional knowledge and competence was seen as a risk factor for developing burnout.
That is the reason why the work ability has been lost, when the competence and knowhow no longer are what they should be it leads to exhaustion and cynicism and further to work disability…The employees think that they cannot admit that there is something they cannot do…and they try to hide it from the supervisor and use excuses so that they do not need to be participated in training…(RTW coordinator 9b).
4.1.1.2. Monitor sickness absence. Supervisors were categorized as having obligations to monitor sickness absence and to intervene before prolonged sickness absence, as guided by the organizational absence management and RTW policies and procedures. Participants described the obligation to monitor as follows.
We have an early intervention procedure…and according to it the supervisors have responsibility to intervene in a certain number of sickness absences…(occupational physician 4a).
4.1.1.3. Observe work performance; broach a concern of an employee's ability to work. Participants saw that supervisors were obliged to observe work performance and broach their concern regarding employees' work ability with the employees. Standardized forms could be used for that purpose.
The supervisor recognizes that everything is not well, even if the supervisor does not know what it is but recognizes that the employee does not cope with the work, or the employee is somehow more tense or changed somehow. Then the "broach the concern" forms are brought into use…(occupational physician 2a).
Participants also described that, besides the supervisor, co-workers also might notice that the employee does not cope with his/her work and intervene.
4.1.1.4. Provide support to manage stressors at work. According to participants, in cases where the chronic work-related stress had not yet escalated to burnout, support from the supervisor alone might be enough for the employee to cope with his/her work. Supervisors had managerial rights and obligations to modify the workload. It depends on how severe the situation is, it can be that the managerial activities of the supervisor are sufficient and joint meetings or assessments in the occupational health services are not needed…If it [burnout] is in the initial phase the supervisor should modify the job description and the work tasks…to lighten the workload…(RTW coordinator 8).
4.1.1.5. Guide the employee to seek occupational health services for work ability assessment. An obligation of supervisors was to recommend the employees to seek help from occupational health services as described by participants. Also, supervisors' right to request occupational health services to assess the work ability of the employee was expressed.
The supervisor can make an appointment [for the employee] to the occupational nurse and he/she [the employee] goes to the occupational nurse's office…And the supervisor can also request work ability assessment…(RTW coordinator 2a).
4.1.1.6. Initiate a joint meeting on the employee's work ability and work modifications. A shared activity among the employee, supervisor, and occupational physician is illustrated in the following extract, as each of the parties might initiate a joint meeting. Joint meetings are the arena in which to discuss the employee's work ability and possible work modifications among the employee, the supervisor, the occupational physician, and the RTW coordinator. Joint meetings can be initiated by the client or the supervisor or us…(occupational physician 1b).

Supervisors' category-bound activities during the sickness absence
4.1.2.1. Delegate the work/arrange a substitute. RTW coordinators expressed that when the employee with burnout stayed on sick leave, the supervisor delegated the work tasks to the employee's co-workers. Unless it was known that the employee would stay on sick leave for a longer time, a substitute could be hired. The supervisor has a very big role…when someone is absent from work for a long time it causes a great deal of extra work for the supervisor because the work has to be arranged and it burdens the others in the work community because they [co-workers] have to take on the work tasks of the person…(RTW coordinator 5).
4.1.2.2. Maintain contact with the employee; provide emotional support. Supervisors were expected to keep in contact with the employees during the sickness absence. This activity was considered important so that the employees would know that they are welcome back to work. According to participants, supervisors need to communicate with empathy and courage employees to focus on their recovery without pressure to RTW. I have seen it in many RTW processes of the burned-out employees that the ability of the supervisor to be emphatic is very important…The supervisor keeps contact with the employee who is at home and does not pressure to come back to work…but says: "You come when you are feeling well!" (occupational physician 2a).
Empathic support from supervisors was considered important by participants at each phase of the absence management and RTW process.
4.1.2.3. Plan RTW. Both occupational physicians and RTW coordinators mentioned their shared activity with supervisors in planning RTW in the joint meeting. It was important that the supervisor was involved in this activity because without the supervisor it was not possible to discuss the work modifications. Participants emphasized the importance of designing a good RTW plan to make sure that the employee had a chance to succeed in RTW. To succeed in RTW was considered especially important to the employees with burnout who, in principal, had a sense of reduced professional efficacy.
In the joint meetings…we can discuss the situation also with the supervisor and give support to design such a job description that makes it possible for the person to succeed in the RTW… Often the burned-out person has a low sense of professional efficacy and that is why the experience to succeed in RTW can be very important…(RTW coordinator 2a).
Participants expressed that when discussing the work modifications with supervisors it was important to keep in mind that the work modifications should not burden the co-workers.
4.1.3. Supervisors' category-bound activities at work resumption 4.1.3.1. Inform co-workers on RTW. Participants expected supervisors to inform co-workers on RTW status of an employee and supported the supervisor and the employee in the joint meeting to make an agreement on how the supervisor should inform co-workers on RTW status of a co-worker and the planned work modifications. It belongs to the supervisor, and we have started to bring it up in the joint meetings and remind the supervisor that his/her responsibility is to come to an agreement with the employee about how to inform [the co-workers] and what the supervisor can tell them… (occupational physician 1b).
Participants explained that co-workers should be informed so that they would understand the situation and provide empathy and support for the employee who RTW.
…sure, the co-workers are often very empathetic and want to help when they know that someone has it difficult but if it is not talked about and it is not known what is the reason for the work absence it may lead to wrong interpretations and negativity…which does not help the situation when the person RTW…(RTW coordinator 2a).
4.1.3.2. Implement work modifications. The following extract illustrates how the supervisor is a key actor in implementing work modifications was described. Participants explained supervisors' overriding rights and obligations to implement work modifications as follows.
It is the attitude of the supervisor that the supervisor understands what it is about. And often the RTW happens part-time, so the supervisor really modifies the work…I think that the supervisor is the key actor in it (occupational physician 3a).

4.1.3.3.
Re-orientate the employee. RTW coordinators had expectations of supervisors to take care of the re-orientation of employees returning from a prolonged sickness absence. According to the RTW coordinators, working environment, especially technology, can change rapidly and the employees need to be familiarized with it again when RTW. …takes care of the orientation because if the employee has been absent from work for a long period of time the information systems may have been changed meanwhile for example… (RTW coordinator 1).
Moreover, RTW coordinators emphasized that supervisors needed to arrange the reorientation for employees returning to their previous work or some other work tasks so employees would recognize their capacity to perform the work and that the work would be tailored further at this point in time. RTW coordinators mentioned that the supervisor might designate a support person among the co-workers to carry out the re-orientation.

4.1.3.4.
Monitor coping at work. Supervisors were expected to monitor employees' coping at work and observe that the employees did not stay late and overwork. According to participants, supervisors made an agreement with employees on how to monitor and give feedback to the employee. In other words, supervisors involved the employees with burnout in the decision-making regarding employees' absence management and RTW support. An agreement is made with the supervisor that the supervisor, for example, in the beginning of the week quickly goes through how the week has gone, is the workload under control, and all that. The supervisor in a way looks after the person a bit…that the person does not work overtime but goes home in time…(occupational physician 4a).

4.1.3.5.
Remind the employee of deadlines. RTW coordinators expected supervisors to remind employees of deadlines related to applying the sickness benefits to ensure progress in the RTW process.
Regarding sickness benefits and insurance claims…to ensure that the person does not lose his/her benefits due to the illness…due to less initiative so that the deadlines would not be exceeded…we have tried to make a routine so that supervisors remind the exhausted person on certain dates… (RTW coordinator 4a).
4.1.4. Supervisors' category-bound activities after recovery from burnout 4.1.4.1. Focus on preventing the recurrence of burnout. An expected activity of supervisors was to focus on preventing the recurrence of burnout after recovery. As described in the following statement, supervisors should continue with the open communication that had been enhanced between the supervisor and the employee during the absence management and RTW process. I would hope that the dialog between the supervisor and the employee would continue after the recovery to prevent new burnout…I would hope that the support that had been built into the situation where it was needed would not be left off, but that the honest interaction between the employee and the supervisor would continue…(occupational physician 2a).
In the following extract, participants describe the importance of the working atmosphere and workload to sustainable RTW. Both the supervisor and the co-workers were mentioned as influencing the work atmosphere. They also emphasize the importance of an equitable workload.
RTW coordinator 1: A good working atmosphere that the person experiences that he/she is RTW coordinator 2: The co-workers RTW coordinator 1: The co-workers and…a good supervisor with whom things are going well RTW coordinator 2: And the work is evenly distributed…the fairness so that the exhausted person gets work evenly and does not always take the work of others…(RTW coordinators 4a and b).
Participants also expressed that the workload should not be increased to the previous exhausting level after the employee had recovered from burnout.
Supervisors' category-bound activities during the absence management and RTW process of employees with burnout that were mentioned by the occupational physicians and/or the RTW coordinators are presented in Table 2. 4.2. Supervisors as recipients of support in managing sickness absence and supporting RTW of employees with burnout 4.2.1. Supervisors' category-bound activities for which they need support and guidance before the prolonged sickness absence 4.2.1.1. Conduct development discussions. The following extract illustrates a supervisor category as one requiring support. An RTW coordinator mentioned that the organizational absence management and RTW policies and procedures were not fully implemented and not all supervisors followed the procedure to regularly arrange development discussions with employees. It was, therefore, more difficult for supervisors to control employees' need for updating professional knowledge and competence to maintain work capacity.
The attitude towards the development discussions can be that the physicians, for example, [as superiors for the nurses] can say that they do not have development discussions for the nurses…the policies and procedures of the organization should be followed better…(RTW coordinator 9b).

4.2.1.2.
Monitor and react to the increased sickness absence. Participants expressed distrust towards supervisors' monitoring and reacting to an increased sickness absence. The following extract contains information on the need to check whether supervisors had been active in monitoring sickness absence and had acted in compliance with the organizational absence management and RTW policies and procedures.
We follow up whether the supervisors have reacted to the alarm messages [from the electronic software program] and we intervene and guide the supervisors…(RTW coordinator 8).
4.2.1.3. Recognize burnout. According to participants, supervisors did not always notice that some employees were developing burnout and thus delayed support. Sometimes supervisors first understood the situation in the joint meeting during which the employee's work ability was discussed.
In the joint meeting it appeared that the supervisor had not understood that the person could by any means be developing burnout because the person had always been effective and taken care of everything so that it had been always possible to give him/her all the tasks and he/she took care of them…(occupational physician 4a). 4.2.1.4. Broach a concern of an employee's ability to work without hesitation. According to participants, unexperienced supervisors could struggle with how to broach their concern regarding an employee's work ability with the employee and, therefore, ask for advice. Young supervisors may call for help "I should broach this with the employee. What can I say?…" (occupational physician 4a).
4.2.1.5. Provide the employee support to manage stressors at work without causing additional role conflict. RTW coordinators described that it was difficult for supervisors to act to buffer the effect of stress on burnout. Despite supervisors' attempts to verbally support employees to limit their work, employees did not change their behavior at work. Even though the supervisor says that now you must go home and all that but the person does not. The person cannot manage the situation themselves and it just keeps going on and on… and it goes to the end and the sickness absence is needed before the situation stops…(RTW coordinator 5).
RTW coordinators also expressed that some other external support actors, such as occupational health professionals, were needed to provide the support for the employee who was developing burnout, because the supervisor's activities did not help.

4.2.2.
Supervisors' category-bound activities for which they need support and guidance during the sickness absence 4.2.2.1. Communicate with the employee on sick leave. Participants explained that the supervisors might not always have the courage to contact employees during the sickness absence. Supervisors' lack of courage to perform that category-bound activity reflects that they do not feel competent and confident in their role.
The supervisor does not necessarily dare to call…(occupational physician 1a).
A participant described that supervisors' contacts during the sick leave, which were meant to be supportive, may produce reverse negative reactions in the employees as follows.
Can't I be left alone on sick leave! Must the supervisor keep calling home…(RTW coordinator 9b).

4.2.2.2.
Communicate with the employee on burnout and stressors at work to plan RTW. In the experiences of the participants, employees did not always want their supervisors to know that they were burned out. According to the participants, if the employee did not want burnout to be mentioned in the joint meeting, it made planning RTW challenging. In the following extract, participants describe their own activity in facilitating communication about burnout-related matters between the supervisor and the employee.
Physician 1: It can make it more difficult, because if the employee does not want to tell the supervisor what it is all about, then we will have the kind of meeting I have been in sometimes where there has not been really anything told about what it is about except that it has been a long sickness absence and now we should somehow look at this, and then they are very difficult Physician 2: We do not talk about the right things then Physician 1: Yeah nothing about the right things…they are seldom, usually you can persuade the person…(occupational physician 4a and b).
In the participants' experiences, the difficulty in communication between the supervisor and the employee on burnout-related matters may arise from the employee's experience of the supervisor being part of the cause of his/her problems, that is, simultaneously a source of stressors and support.
It can be that the person [employee with burnout] experiences that the work community [coworkers] or the supervisor are part of the reason why he/she has become sick, then, of course, the RTW is pretty difficult…(RTW coordinator 3).

Manage administrative tasks in RTW. The supervisors needed guidance from the RTW coordinators regarding administrative tasks and payment terms in RTW.
It is often the first time for the supervisor to be in such a situation and he/she thinks "What can I do? How can I do the work modifications? What does this mean regarding payment terms?" There are a lot of administrative tasks…the supervisors need support in those prac-tices…(RTW coordinator 2b).

4.2.
3. Supervisors' category-bound activities for which they need support and guidance at work resumption 4.2.3.1. Inform the co-workers on RTW without fear of breaking privacy rules. Participants saw supervisors as needing support in informing co-workers on the RTW status of a co-worker. Participants explained that supervisors may sometimes be afraid of breaking privacy rules and do not dare to inform the co-workers. Supervisors have the fear to step into [person's] private area that they rather do nothing than take that risk, so the tools and the readiness for the supervisors are needed to get further… (occupational physician 1b).

4.2.3.2.
Welcome the employee. According to participants, it was important that the supervisor and the co-workers welcomed the employee at work resumption. It was not, however, always the case; if the co-workers were not properly informed by the supervisors about RTW of an employee, they might ask indiscreet questions about the absence from the employee. Also, it was considered important that the supervisor made the employee feel that his/her work ability was not questioned.
If the supervisor acts at the work resumption phase so that the person understands that he/she is welcome to take over his/her work tasks again it has great importance…(RTW coordinator 3).

Implement work modifications within the economical boundaries.
Participants expressed that supervisors were not always willing to implement work modifications because of the economic profit and loss responsibility. My opinion is that it is a challenge to get the work unit and the supervisor, who possibly struggles with a strict economy, to understand their responsibility to support the employee and think over the work tasks…(RTW coordinator 6).
4.2.4. Supervisors' category-bound activities for which they need support and guidance after recovery from burnout 4.2.4.1. Resolve conflicts to maintain a good working atmosphere. Participants saw supervisors as requiring support in preventing recurrence of burnout in cases where burnout had arisen from conflicts and bullying in the work community. To maintain a good working atmosphere, the work community was provided with mediation and conflict resolution. If burnout is caused by conflicts in a work community, then the conflicts have to be solved…if the burned-out person returns to the same situation it is not good…the challenging situation within the work community has to be helped and we are also providing the tools for it…(RTW coordinator 2b). Supervisors' category-bound activities for which they need support and guidance during the absence management and RTW process of employees with burnout, that were mentioned by the occupational physicians and/or the RTW coordinators, are presented in Table 3.

Discussion
The aim of this study was to discern supervisors' category-bound activities during the absence management and RTW process of employees with burnout, from the perspective of occupational physicians and RTW coordinators. The occupational physicians and RTW coordinators saw supervisors as key actors in managing sickness absence and supporting RTW of employees with burnout, which is in line with previous studies showing that supervisor support alleviates burnout (Charoensukmongkol et al., 2016;Gibson et al., 2009;Karatepe, 2010;Li et al., 2015;Salahian et al., 2012;Salminen et al., 2017;Tayfur & Arslan, 2013;Thomas & Lankau, 2009). Supervisors' category-bound activities were discerned before the prolonged sickness absence, during the sickness absence, at work resumption, and after recovery from burnout. Supervisors' category- bound activities included controlling employees' work capacity through development discussions, monitoring sickness absence, observing work performance, broaching a concern of an employee's ability to work, providing support to manage stressors at work, guiding the employee to seek occupational health services for work ability assessment, initiating a joint meeting on the employee's work ability and work modifications, delegating the work/arranging a substitute, maintaining contact with the employee, providing emotional support, planning RTW, informing co-workers on RTW, implementing work modifications, re-orienting the employee, monitoring coping at work, reminding the employee of deadlines, and focusing on preventing the recurrence of burnout.
Furthermore, occupational physicians and RTW coordinators saw supervisors as needing support during the absence management and RTW process of employees with burnout. According to the occupational physicians and RTW coordinators in this study, supervisors were expected to communicate with empathy-an activity which is recommended by previous research (Norlund et al., 2013;Salminen et al., 2017); however, it is important to consider that communication meant to be supportive may aggravate burnout symptoms due to the reverse buffering effect (Jenkins & Elliott, 2004;Kickul & Posig, 2001). In this study, the occupational physicians and RTW coordinators described several occasions where the reverse buffering effect may be provoked during the absence management and RTW process. First, the employees who were developing burnout may lack motivation to update their professional knowledge and competence and may try to hide their incompetence from their supervisors. In those cases, the supervisor providing the possibility to the employee to take additional training can be experienced as a source of stressors and support simultaneously. Second, the efforts of the supervisor to verbally support the employee to manage stressors at work did not give desired results and it can be discussed whether the employee felt additional role conflict due to the supervisor support. Third, the negative reactions of the employees towards contact from their supervisors during the sick leave can refer to reverse buffering effect due to experiencing pressure to RTW. Fourth, occupational physicians or RTW coordinators were needed to facilitate open communication between the supervisor and the employee with burnout on burnout-related matters.
Solutions to mediate the reverse buffering effect are discussed based on the findings of this study. A primary solution would be that the supervisors provide employees with the type of support they need and expect, that is, emotional support or instrumental support, as suggested previously (Kickul & Posig, 2001). Putting instrumental support in practice might be limited by the economical boundaries. Furthermore, the employees might be involved in the decision-making related to their absence management and RTW support, as in this study, the supervisors made an agreement with the employees on how to monitor their coping at work and give feedback. The supervisors should be educated in job-related communication and positive relationship communication (Kim & Lee, 2009) to recognize employees at risk for burnout and subsequent absenteeism and disability pensions (Salvagioni et al., 2017). Providing employees with the possibility to discuss their role stress with their supervisors in development discussions may be important because it may prevent stress from developing into burnout as shown in a previous study (Kim & Lee, 2009).
Supervisors also should be provided education in burnout-related communication to be able to broach a concern of an employee's ability to work without hesitation, communicate with the employee on burnout and stressors at work to plan RTW, and inform co-workers on RTW status of an employee without fear of breaking privacy rules. Informing co-workers was emphasized in this study because it facilitates co-worker support, which in turn may change individual-level burnout (Aronsson et al., 2017). Also, informing co-workers may contribute to perceptions of workload and teamwork that have prevented unit-level burnout (Consiglio et al., 2014). Furthermore, employees with burnout and their co-workers should be educated in positive open upward communication (Kim & Lee, 2009) to enhance the high leader-member exchange relationship (Thomas & Lankau, 2009) and a good working atmosphere. Supervisors might benefit from education to improve their management practices, as according to the results of this study, supervisors needed support and guidance in performing their category-bound activities in every phase of the absence management and RTW process. A strong practical, structural/instrumental, and emotional support can be important as perceptions of the management (Consiglio et al., 2014) and level of supervisor support (Aronsson et al., 2017) influence employee burnout.

Strengths and limitations
The occupational physicians and RTW coordinators in this study showed an abundant knowledge of supervisors' category-bound activities in managing sickness absence and supporting RTW of employees with burnout. The RTW coordinators generated slightly more detailed knowledge on that issue than the occupational physicians. The reliability of the analysis is strengthened by the accurate presentation of the data collection and the transparent presentation of the results using extracts, which allow reproducibility. Also, three co-authors reviewed the results and agreed with the first author about how to locate utterances and assign categories (Baker, 1997). Furthermore, the analytic saturation was achieved as we included all the text of supervisors' category-bound activities in the analysis from 22 participants (Baker, 1997). A qualitative, descriptive study like this does not aim to produce generalizable findings to population, therefore, the number of the participants can be considered sufficient.
However, the results of this study must be interpreted cautiously with certain limitations in mind. First, although we consider the application of MCA appropriate for such a descriptive study, a limitation is that we did not analyze naturally occurring interactions (Hester & Eglin, 1997;Lepper, 2000) but the researcher asked questions and made probes to encourage participants to supply the information. Also, we need to exercise caution when applying the results of this study to another context, because we cannot make claims about supervisors' category-bound activities that exist beyond occupational physicians and RTW coordinators' descriptions of supervisor support for employees with burnout. Other actors, such as supervisors and employees with burnout, were not represented in this study although their perspectives would also be important to consider. Furthermore, the majority of the occupational physicians were employed in employeroperated occupational health centers, where the relationship between the occupational physicians and the supervisors may be much closer than, for example, in private occupational health medical centers, where no occupational physicians participated. The RTW coordinators were employed in universities and central hospitals. Therefore, the results might not be entirely transferable to other types of work organizations. Also, the study was conducted in Finland and a successful replication of the results in other countries is doubtful. The category-bound activities proposed in this study might vary in other countries due to either legal restrictions, as a consequence of different absence management and RTW processes, or simply due to cultural differences in how employees and supervisors may react to the activities proposed.

Conclusions
In this study, we discerned supervisors' category-bound activities during the absence management and RTW process of employees with burnout, from the unique perspective of occupational physicians and RTW coordinators. Moreover, we discerned the category-bound activities for which supervisors need support and guidance. Supervisors appeared to be key actors in managing sickness absence and supporting RTW of employees with burnout and, simultaneously, require support in implementing organizational absence management and RTW policies and procedures and in communicating about burnout-related matters with employees with burnout and their coworkers. The results of this study have implications for occupational health services and employers to develop education for supervisors to improve management practices and provide education for supervisors and the employees regarding open communication about the job-and burnout-related matters to prevent sickness absence and the need for disability pensions. Further research is needed to study supervisors' category-bound activities in managing sickness absence and supporting RTW of employees with burnout from the perspectives of supervisors and employees with burnout. Also, research is needed to evaluate the feasibility, importance and potential impact of the activities presented in this study on sickness absence and RTW, and to increase our understanding about the reverse buffering effect on burnout related to supervisor support.

Funding
This study was supported by the Finnish Work Environment Fund;the Finnish Work Environment Fund [118011].