# Teachers returning to work after sick leave for mental disorders

About the authors

# Abstracts

Este estudo analisa os sentidos de retorno ao trabalho atribuídos por professores servidores públicos após afastamentos por transtornos mentais e comportamentais. Tratou-se de pesquisa qualitativa com 20 professores, ativos e em readaptação funcional, do ensino fundamental. A coleta de dados ocorreu entre 2011 e 2012, por meio de entrevistas individuais, grupos focais e questionário socioeconômico e de condições de trabalho. A análise de dados foi realizada por codificação temática para o estabelecimento de uma estrutura de ideias. A maioria dos participantes era de mulheres. A média de idade era 44 anos e de jornada de trabalho de 43,2 horas/semana. Os sentidos de retorno ao trabalho para os professores ativos estavam ancorados nas ideias relacionadas aos motivos do afastamento, à capacidade para o trabalho e à valorização do trabalho. Para os professores readaptados, os sentidos atribuídos refletiram conflitos entre retornar à sala de aula ou manter-se readaptado. Discutir e compreender a identidade profissional foram primordiais no entendimento do processo de retorno dos professores readaptados. Dois temas associados ao retorno foram transversais a ambos os conjuntos de professores: o papel da equipe gestora neste processo e os preconceitos no ambiente de trabalho. Não foi possível abordar o retorno ao trabalho sem considerar o afastamento. A análise sobre os sentidos de retorno ao trabalho, na perspectiva dos próprios professores, disponibilizou uma série de elementos para a compreensão do processo de afastamento e retorno e das condições de vida e trabalho nesta categoria profissional. Observa-se a premência em favorecer ações de retorno ao trabalho no ambiente escolar como determinante da saúde dos professores.

Docentes; Retorno ao Trabalho; Transtornos Mentais; Licença Médica; Preconceito; Saúde do Trabalhador

The present study evaluates the significance of the process of public school teachers returning to work following sick leave for mental and behavioral disorders. It is a qualitative study conducted with 20 elementary school teachers currently active or undergoing retraining. Data was obtained thru individual interviews, focus groups and a questionnaire, which included socioeconomic data and work conditions, during 2011 and 2012. Data was analyzed by means of thematic categorization. Most participants were women, average age of 44 years old, and working 43.2 hours per week. Among those who were active teachers, returning to work was associated with the reasons that led to the sick leave, their ability to accomplish actual work and the possibility of being valued at work. Regarding teachers undergoing retraining, the impacts of returning to work included the conflict of returning to the classroom or being away from it. It was paramount to discuss their professional identity in order to understand the process of returning to work for the teachers undergoing retraining. Two themes were common to both groups of teachers: the role of the school managerial team during the process of returning to work and the prejudice they faced in the work environment. It was not possible to approach returning to work without discussing the sick leave process. The performed analyses, by the point of view of the participants, revealed a number of topics to understand the process of sick leave and returning to work, as well as the living and working conditions of the teachers.

Teachers; Return to Work; Mental Disorders; Sick Leave; Prejudice; Occupational Health

# Introduction

In the early 2000s, the World Health Organization (WHO) and the International Labor Organization (ILO) predicted an increase in the incidence of mental health problems. Together, these two organizations warned of serious consequences that would suffer the working population: decreased productivity, increased burden of disease, accidents, absenteeism, employee turnover, reduced functional capacity at work, social exclusion and stigmatization (WHO; ILO, 2000WHO - WORLD HEALTH ORGANIZATION; ILO - INTERNATIONAL LABOUR ORGANIZATION. Mental health and work: impact, issues and good practices. Geneva: WHO, 2000.). These are consequences that affect both the workers and employers. Currently in Brazil, mental and behavioral disorders (MBD) are responsible for a considerable part of sick leave (Brazil, 2013BRASIL. Ministério da Previdência Social. Acompanhamento mensal dos benefícios auxílios-doença acidentário concedidos, segundo os códigos da CID: 10 janeiro a junho de 2013. Brasília, DF, 2013. Disponível em: <http://www.mpas.gov.br/arquivos/office/1_130724-092419-743.pdf>. Acesso em: 26 ago. 2013.; São Paulo, 2013SÃO PAULO. Prefeitura Municipal. Atlas municipal de gestão de pessoas: edição 2013. São Paulo, 2013. Disponível em: <http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CB0QFjAA&url=http%3A%2F%2Fsindsep-sp.org.br%2Fsistema%2Fck%2Ffiles%2FPPT%2520e%2520PDF%2Fatlas_municipal_de_gestao_de_pessoas_2013_v10_1370270158.pdf&ei=qfA_VavMEorcsAWos4CwCA&usg=AFQjCNGtlc2dRcowlz_4eOMi8VqPX0Sw4g&sig2=-MH8RpjK8kAkb3FyK1Fl5w&bvm=bv.91665533,d.b2w&cad=rja> Acesso em: 21 nov. 2013.
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Among the active municipal public employees of São Paulo, teachers were the third professional category in 2012 that were absent from work due to health problems. MBD represented the second most prevalent diagnosis in this group. In the years 2010-2012, there was a 15% increase in sick leave among teachers in the city of São Paulo (São Paulo, 2013SÃO PAULO. Prefeitura Municipal. Atlas municipal de gestão de pessoas: edição 2013. São Paulo, 2013. Disponível em: <http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CB0QFjAA&url=http%3A%2F%2Fsindsep-sp.org.br%2Fsistema%2Fck%2Ffiles%2FPPT%2520e%2520PDF%2Fatlas_municipal_de_gestao_de_pessoas_2013_v10_1370270158.pdf&ei=qfA_VavMEorcsAWos4CwCA&usg=AFQjCNGtlc2dRcowlz_4eOMi8VqPX0Sw4g&sig2=-MH8RpjK8kAkb3FyK1Fl5w&bvm=bv.91665533,d.b2w&cad=rja> Acesso em: 21 nov. 2013.
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).

The conditions and organization of the elementary school teacher's job collaborate with this mental illness framework and absence from work, as well as other miscellaneous causes and triggers involved. Teachers are subjected to excessive workload . This has been considered by some authors as the intensification and precariousness of work represented, for example by: long working hours, needing to teach in several places, large classes, overlapping roles/functions, dealing with extracurricular activities that interrupt the main work of the teachers, reorganization of work due to lack of teachers, lack of control at work, the contradictions between educational aims and training group criteria, and the communitiess values of education but not of the teachers (Oliveira, 2007OLIVEIRA, D.A. Política educacional e a re-estruturação do trabalho docente: reflexões sobre o contexto latino-americano. Educação & Sociedade, Campinas, v. 28, n. 99, p. 355-375, 2007.; Garcia; Anadon, 2009GARCIA, M. M. A; ANADON, S. B. Reforma educacional, intensificação e auto-intensificação do trabalho docente. Educação & Sociedade, Campinas, v. 30, n. 106, p. 63-85, 2009.; Assumption; Oliveira, 2009ASSUNÇÃO, A. A.; OLIVEIRA, D. A. Intensificação do trabalho e saúde dos professores. Educação & Sociedade, Campinas, v. 30, n. 107, p. 349-372, 2009.; Souza; Leite, 2011SOUZA, A. N.; LEITE, M. P. Condições de trabalho e repercussões na saúde dos professores da educação básica no Brasil. Educação & Sociedade, Campinas, v. 32, n. 117, p. 1105-1121, 2011.).

Sick leave in this professional group is usually of long duration , over and over for the same reasons (Glina et al., 2001GLINA, D. M. R. et al. Saúde mental e trabalho: uma reflexão sobre o nexo com o trabalho e o diagnóstico com base na prática. Cadernos de Saúde Pública, Rio de Janeiro, v. 17, n. 3, p. 607-616, 2001.; Juracy; Siqueira; Ferreira, 2003JURACY, M.; SIQUEIRA, T.; FERREIRA, E. S. Saúde das professoras das séries iniciais: o que o gênero tem a ver com isso? Psicologia: Ciência e Profissão, Brasília, DF, v. 23, n. 3, p. 76-83, 2003.). Returning to work causes worsening of symptoms, suggesting that the return to work at the school takes place under conditions similar to those that affected the absences, and with the added aggravation of the lack appropriate policies for the time of this return (Glina et al., 2001GLINA, D. M. R. et al. Saúde mental e trabalho: uma reflexão sobre o nexo com o trabalho e o diagnóstico com base na prática. Cadernos de Saúde Pública, Rio de Janeiro, v. 17, n. 3, p. 607-616, 2001.).

A number of authors pointed out that are not enough objective discussions and proposals for actions, aiming to facilitate the process of returning to work after a sick leave due to MBD. This is particularly important when considering teachers to other occupational groups (Souza; Leite, 2011SOUZA, A. N.; LEITE, M. P. Condições de trabalho e repercussões na saúde dos professores da educação básica no Brasil. Educação & Sociedade, Campinas, v. 32, n. 117, p. 1105-1121, 2011.; Oostrom et al., 2009OOSTROM, S. H. V. et al. A participatory workplace intervention for employees with distress and lost time: a feasibility evaluation within a randomized controlled trial. Journal of Occupational Rehabilitation, Dordrecht, v. 19, n. 2, p. 212-222, 2009.; D'Amato; Zijlstra, 2010D'AMATO, A.; ZIJLSTRA, F. Toward a climate for work resumption: the nonmedical determinants of return to work. Journal of Occupational Environmental Medicine, Hagerstown, v. 52, n. 1, p. 67-80, 2010.; Cornelius et al., 2010CORNELIUS, L. R. et al. Prognostic factors of long term disability due to mental disorders: a systematic review. Journal of Occupational Rehabilitation, Dordrecht, v. 21, n. 2, p. 259-274, 2010.; Hoefsmit; Houkes; Nijhuis, 2012HOEFSMIT, F.; HOUKES, I.; NIJHUIS, F. J. N. Intervention characteristics that facilitate return to work after sickness absence: a systematic literature review. Journal of Occupational Rehabilitation, Dordrecht, v. 22, n. 4, p. 462-477, 2012.; Silva; Fischer, 2012SILVA, A. A.; FISCHER, F. M. Teachers' sick leave due to mental and behavioral disorders and return to work. Work, Amsterdam, v. 41, p. 5815-5818, 2012. Supplement 1.).

Besides the absence of appropriate policies, another reason which probably explains this situation is the difficulty of finding equivalent activities to teaching, which makes up this complex process of returning to work even harder (Brown; Gilmour; Macdonald, 2006BROWN, J.; GILMOUR, W. H.; MACDONALD, E. B. Return to work after ill-health retirement in Scottish NHS staff and teachers. Occupational Medicine, London, v. 56, n. 7, p. 480-484, 2006.).

Several authors also found that the predictors and consequences of a sick leave for mental health problems are different from those for back pain and voice problems, for which there are more studies and intervention programs (D'Amato; Zijlstra, 2010D'AMATO, A.; ZIJLSTRA, F. Toward a climate for work resumption: the nonmedical determinants of return to work. Journal of Occupational Environmental Medicine, Hagerstown, v. 52, n. 1, p. 67-80, 2010.; Cornelius et al., 2010CORNELIUS, L. R. et al. Prognostic factors of long term disability due to mental disorders: a systematic review. Journal of Occupational Rehabilitation, Dordrecht, v. 21, n. 2, p. 259-274, 2010.; Hoefsmit; Houkes, Nijhuis, 2012HOEFSMIT, F.; HOUKES, I.; NIJHUIS, F. J. N. Intervention characteristics that facilitate return to work after sickness absence: a systematic literature review. Journal of Occupational Rehabilitation, Dordrecht, v. 22, n. 4, p. 462-477, 2012.).

We should take into account the experiences and knowledge of the workers identifying problems and solutions of their daily activities in order to ensure changes will be well-suceeded. These include their work environment and the macrostructures.

The workers are the actors who may be able to engender changes and eventually these will lead to the preservation of their health. This framework helped us to understand that both the work activity as well as the working environment are social determinants of health.

Due to the reasons mentioned above the processes of returning to work in the context of sick leave by MBD are significant to be evaluated and discussed (Oddone et al., 1986ODDONE, I. et al. Ambiente de trabalho: a luta dos trabalhadores pela saúde. São Paulo: Hucitec, 1986.). This study aims to analyse the process of returning to work from the point of view of public school teachers of São Paulo, Capital, after they were on sick leave due to mental and behavioral disorders.

# Methods

This is a qualitative study of exploratory nature. Twenty teachers employed by the government of the city of São Paulo participated in this study. All of them worked in elementary education. They were from 15 schools, representing nine regional boards of education. All participants were on sick leave due to MBD. At the time of their participation they had already returned to work either as teachers (named here as "active teachers") or in another function due to a temporary or permanent decrease of their workability. In this case they were classified as "functional readapted".

This study used a convenience sample. Teachers were invited to participate in the research by: social network, the teachers' labour union of, the researchers visiting the public schools and/or being recommended by other teachers.

Data collection took place between 2011 and 2012. Individual interviews and focus groups were performed totaling 14 documents: 11 interviews, six of active teachers and five readapted; and three focus groups, two with readapted teachers and one active. Participants of the interviews were different from the group participants.

We used distinct methods to validate the results and respective assumptions mentioned by the participants, as the aim of the present study was to allow a comprehensive view of teachers and resolution of issues raised by them. These is in accordance to (Barbour 2009BARBOUR, R. Grupos focais. Porto Alegre: Artmed, 2009.).

Each group had only one meeting of approximately three hours. All participants filled out a questionnaire with socioeconomic and occupational information. Individual interviews took place at the site of choice of the participants and focus groups, in a room granted by the above union.

Individual interviews were centered on the theme "The process of being absent by MBD and the return to work of teachers" in an oral narrative line. This type of interview is the combination of narratives and questions related to the focused opinion of the interviewee in relation to the problem(s) around which the interview is centered (Flick, 2009FLICK, U. Introdução à pesquisa qualitativa. Porto Alegre: Artmed, 2009.). The focus groups followed the guidelines of (Aschidamini and Saupe 2004ASCHIDAMINI, I. M.; SAUPE, R. Grupo focal: estratégia metodológica qualitativa: um ensaio teórico. Cogitar e Enfermagem, Curitiba, v. 9, n. 1, p. 9-14, 2004.) and (Barbour 2009BARBOUR, R. Grupos focais. Porto Alegre: Artmed, 2009.) regarding the understanding of the used technique, composition of the groups, number of participants and number of meetings. Throughout the data collection, open scripts were used; when conducting the interviews and groups, it was possible to dialogue with the participants and test hypotheses that were raised during the field work. The techniques used enabled a rich set of results. In this article we selected the most relevant themes to analyze.

The interviews and groups were recorded and transcribed. Data analysis was carried out according thematic coding following (Gibbs 2009GIBBS, G. Análise de dados qualitativos. Porto Alegre: Artmed, 2009.) and (Flick 2009FLICK, U. Introdução à pesquisa qualitativa. Porto Alegre: Artmed, 2009.), which guided the perspective of grounded theory. This type of coding is a way to index the text and to establish thematic ideas about it, resulting in thematic areas. The steps taken were: open, axial and selective codification, case by case comparison. The present study presents the thematic area referred to as "returning to work".

The study was approved by the School of Public Health Ethics Committee of the University of São Paulo, protocol 179/11, and by the Municipal Secretary of Education of the city of São Paulo City. To preserve anonymity, the names of those interviewed were replaced by Prof, followed by the number corresponding to the order of participation in the research;, the teacher was identified as active or readapted. Other names have been replaced by the function that the person exercised in that context, for example, the director, and the coordinator. Focus groups were identified with the word "group", followed by the order of occurrence in the research and also with the words active or readapted, referring to the participants that composed.

# Results

## Data presentation

The general characteristics of the participants

Seventeen of the 20 study participants were women. The average age of teachers was approximately 44 years, the youngest 23 and the oldest 58 years old. The majority (n=13) reported to being the sole provider for financial expenses at home. The approximate average family income was R$4.640,00, with variations between R$ 2.000,00 and R\$ 10.000,00.

Only three teachers reported never been working in the State school system of São Paulo and 12 have never worked in private schools. Nine teachers reported having another job or working at the time of the survey, in addition to their link with the municipal school system. Of these, eight also worked as teachers. The average working week as a teacher was 43.2 hours. The minimum and maximum weekly working hours were 20 and 70 hours respectively.

The average duration of the last sick leave for MBD, prior to this research, was a year ago. The shortest sick leave was 15 days and the longest was five years. Considering the International Classification of Diseases (ICD-10), ten groups of illnesses were reported by teachers with medical diagnoses related to their clearances by MBD. The most prevalent in this group was: depressive episodes (11 citations), other anxiety disorders (seven citations) and reactions to severe stress and adjustment disorders (six citations).

## Returning to work in the context of sick leave by MBD: analysis of the feelings recognized by teachers

The analyses of the interviews and focus groups aimed at looking both at the differences in feelings and meanings of returning to work between active and functional readapted teachers . It also aimed to evaluate, the similarities in the narratives of both groups of teachers. Overlapping themes are presented when analyzing the meanings attributed to returning to work. In spite, there are independent reasons for return to work, it is necessary to understand the feelings expressed by the participants.

Considering those perceptions were different between the two groups , active teachers decided to return to work due to: 1) reasons attributed to absenteeism (examples of the elements that demonstrated these meanings : "when coming back everything will be different," "returning again and nothing good will happen," and feelings of caution and suspicion in this context); 2) appreciation of/at work (elements: "new chances to see this work in a good way... realize what need to continue in this profession"); 3) health or functional capacity to perform the work activities (elements: "Am I going to be okay?", "How am I going to position myself?" Doubts about being in good health or not).

Today? (pause) Today I return to work with caution, suspicious, I am ... talking less, if possible not talking, do not give opinion, not a piece (Prof. 1 - active).

Back to work ... in this context, is ... well, it depends on what the person is feeling. If he is already healthy, okay, you know, the problem is that this is long-term. This type of problem that we have is something that is psychosomatic (Professor 8 - active).

Coming back again. Right? Comes with agitation. The first concern I have is: am I well? [...] How am I going to position myself in front of some of the problems that happened in the classroom [...] (Prof. 9 - active).

Ah, another chance to try to see this work in a good way. I did not think in this sense, until this time... at the same time I thought, tell the truth, still, back then, as soon as I returned, like: come back again and nothing good will happen. You know? But on the other hand I thought, ah, I have several students there that are worth of it. So it's a chance for me to realize what is necessary to continue in this profession, I do not give up for good (Prof. 10 - active).

The identification of the reasons for sick leave, in turn, results from the analyses of the meaning on sickness absences from work among the studied teachers. The narratives indicated "last drop motives" were justified by several other reasons for medical leave. Among them it also mattered ,the school dynamics and/or the overworked life of the teacher. The prominent motives mainly referred to the disease itself or the context of specific social relationships, such as conflictive relationships with the management team at school and/or students. This is illustrated in the quote below:

I think that ... with sickness! With a health problem. In this case, when talking about it, then I think of my sick leave due to stress. I think of two words: sadness and unfairness. Sadness for everything ... the way education is there at that school. And unfariness because of a management team that did not help me (Prof. 10 - active).

The feeling of returning to work mentioned by the " readapted teachers" were based on the ideas of conflict and "going back to what?" which is a referred to as functional readaptation . The state of readaptation was then perceived as feelings of worthlessness, idleness, frustration and despair, but also as a possible life condition beyond the classroom. The following sections present these ideas about what it is like to return to work for the readapted teachers:

At first you feel you became useless! Practically, the re-adaptation is useless. Second there is the discrimination that you will suffer from colleagues. One thing is to be active another thing is to be in school, but away from classroom. And the third thing is, what are you gonna do with your life as readapted? You are a teacher, you know! You have to prove to be correct, correct work, preparing lessons, daily arrangements, right? Evaluate materials... well, you have all of that work. And as a readapted teacher what are you going to do?! Help in the office, help someone in the reading room, with the computer?! You are here, you have a lot of readapting! It has practically no service for you! So...(Prof. 7 - readapted).

Because at the moment the (medical expert) said: No, you will be readapted then I started to cry because it comes with conflict. It gives you a shock really (Group 1 - readapted teachers).

In the case of Prof. 7, it is possible to analyse the relationship between what is a teachers´ work and what you do in school when you return "to work" as a readapted teacher.. The example of Prof. 5 indicates that even being in school as a readapted teacher it is not referred as returning to work:

Interviewer (I): What is the first thing that comes to your mind when you hear sick leave from work?

Prof. 5: Look, in my case this was a solution! I had no other way!

I: Solution. When did you think of returning to work?

Prof. 5: Oh, I do not want to! But part, right? I do not want to! (crying) Not at all! (Prof. 5 - readapted).

The themes here are called transversal topics i.e. common to both active and readapted teachers, and contributed to the understanding of the opinions listed above. They are: the role of the management team at school and prejudices perceived in relation to illness and readaption . In some previous quotes we identified elements that refer to the role of management and prejudices. It follows few examples of these themes.

And then, when it was now the end of the year, [...] a new director came to school, she's a young girl, she is 28 years old. And she came up with some ideas ... so much changed at school! Did it not? [...] She had said to us: "You will not be there anymore! You are readapted, but I want you working here with me!" Then she chose the people for the board! [...] And then she called us and asked us to write what we could do to help, what I could do. Then each of us, readapted teachers, wrote there, she held a meeting with all of us and said, "Look, I'll assign roles to you. You are responsible for that, you are responsible for that, you are that ..." Got it? Then I felt good! [...] So, I was never called last year. I participate this year. The new director gave us freedom to participate in all school meetings (Prof. 2 - readapted).

You get labeled . You get labeled , the crazy. [...] Like, the people who leave for physical problems: "Oh, poor of you!? Are you better"? And then we go away: "Oh, hi." And they keep on walking. To me it is like this. It is, not having colleagues that are supportive, many people look the other way for us. So, "you cannot take the work in this area, well do something else." That's it (Group 3 - active teachers).

# Discussion

Returning to work refers to a variety of elements and circumstances of the worker's life, including disability and sick leave from work, not just the specific time the teacher returns to develop some work activity. It can be understood according to a number of perspectives (Krause et al., 2001KRAUSE, N. et al. Determinants of duration of disability and return-to-work after work-related injury and illness: challenges for future research. American Journal of Industrial Medicine, New York, v. 40, n. 4, p. 464-484, 2001.; Young et al., 2005WHO - WORLD HEALTH ORGANIZATION; ILO - INTERNATIONAL LABOUR ORGANIZATION. Mental health and work: impact, issues and good practices. Geneva: WHO, 2000.) and, in this study, teachers defined it from their previous experiences of MBD and returning to school. Some authors theorize and or make proposals of interventions on returning to work to adopt quantitative measures such as, the duration of the absence from work, and the time to return to the usual work activities prior to the sick leave, or the time spent for the adoption of effective strategies to remain at work (Krause et al., 2001KRAUSE, N. et al. Determinants of duration of disability and return-to-work after work-related injury and illness: challenges for future research. American Journal of Industrial Medicine, New York, v. 40, n. 4, p. 464-484, 2001.; Oostrom et al., 2009OOSTROM, S. H. V. et al. A participatory workplace intervention for employees with distress and lost time: a feasibility evaluation within a randomized controlled trial. Journal of Occupational Rehabilitation, Dordrecht, v. 19, n. 2, p. 212-222, 2009.; Brouwer et al., 2010BROUWER, S. et al. A prospective study of return to work across health conditions: perceived work attitude, self-efficacy and perceived social support. Journal of Occupational Rehabilitation, Dordrecht, v. 20, n. 1, p.104-112, 2010.). Other authors studied the social organization as an intervening aspect in the return to work process (Brown; Gilmour; Macdonald, 2006BROWN, J.; GILMOUR, W. H.; MACDONALD, E. B. Return to work after ill-health retirement in Scottish NHS staff and teachers. Occupational Medicine, London, v. 56, n. 7, p. 480-484, 2006.; Stahl et al., 2010STAHL, C. et al. A matter of trust?: a study of coordination of Swedish stakeholders in return-to-work. Journal of Occupational Rehabilitation, Dordrecht, v. 20, n. 3, p. 299-310, 2010.).

In the previous section we exemplified some excerpts of discourses from active teachers, participants of this study, consistent with the meanings of returning to work. We discuss below the various quotes presented by the participants.

When the feelings are anchored in the reasons for sick leave it is necessary to evaluate the process of returning to work and the respective reasons, since the first depends on the second. In order to avoid further medical leaves it is required research and intervention on the dynamics of work, school and being overworked. (Arbex; Souza; Mendonça, 2013ARBEX, A. P. S.; SOUZA, K. S.; MENDONÇA A. L. O. Trabalho docente, readaptação e saúde: a experiência dos professores de uma universidade pública. Physis Revista de Saúde Coletiva, Rio de Janeiro, v. 23, n. 1, p. 263-284, 2013.; Toldrá et al., 2010TOLDRÁ, R. C. et al. Facilitadores e barreiras para o retorno ao trabalho: a experiência de trabalhadores atendidos em um Centro de Referência em Saúde do Trabalhador-SP, Brasil. Revista Brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 121, p. 10-22, 2010.; Lancman; Ghirardi, 2004LANCMAN, S.; GHIRARDI, M. I. G. Introdução. In: ______. Saúde, trabalho e terapia ocupacional. São Paulo: Rocca, 2004. p. IX-XIII.). This dynamic presents itself as a network of causes and therefore will not necessarily be just one reason that illnesses sick leave occurred.

The teachers' perception of "returning to work" is valued for what it does and produces, reflecting deteriorating social conditions and the elementary school teacher's work in the classroom. This context is part of the current educational conditions with the intensification of work education, anchored in market policies (Oliveira, 2004OLIVEIRA, D. A. A reestruturação do trabalho docente: precarização e flexibilização. Educação & Sociedade, Campinas, v. 25, n. 89, p. 1127-1144, 2004.; 2007OLIVEIRA, D.A. Política educacional e a re-estruturação do trabalho docente: reflexões sobre o contexto latino-americano. Educação & Sociedade, Campinas, v. 28, n. 99, p. 355-375, 2007.). Social and job insecurity, and violence at work came in the wake of the deteriorating work conditions and as consequences, a devaluation of education. It seems does not matter, within the productive logic of the market, that work in education is achieved by the development of dignity, solidarity and potential of the human being. Thus, the loss of these values at work reverberates in the loss of meaning of the work for teachers and other occupations. (Souza, 2008SOUZA, M. C. C. C. Depressão em professores e violência escolar. Notandum, Madrid, v. 11, n. 16, p. 19-28, 2008.; Franco; Druck; Seligmann-Silva, 2010FRANCO, T.; DRUCK, G.; SELIGMANN-SILVA, E. As novas relações de trabalho, o desgaste mental do trabalhador e os transtornos mentais no trabalho precarizado. Revista Brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 122, p. 229-248, 2010.). Under the microschool system, there is a disruption of the educational ties associated with this loss. The return to work after sick leave by MBD has, for some teachers, the resumption of the meaning of work.

The concern of the teacher with regards to their functional capacity and work showed at least two aspects of the resumption of activities of those who return to the classroom: the importance of health care action restoring their ability to work even at the time of removal, i.e. prior to their return (Brouwer et al., 2010BROUWER, S. et al. A prospective study of return to work across health conditions: perceived work attitude, self-efficacy and perceived social support. Journal of Occupational Rehabilitation, Dordrecht, v. 20, n. 1, p.104-112, 2010.), and the support of the management team in the return to work.

The improvement, maintenance or loss of functional capacity or ability to work is not disconnected from the conditions and organization of work, which should be targeted for adjustments or changes to suit the abilities and skills of teachers, and not the other way around (Martinez; Latorre; Fischer, 2010MARTINEZ, M. C.; LATORRE, M. R. D. O.; FISCHER, F. M. Capacidade para o trabalho: revisão da literatura. Ciência & Saúde Coletiva, Rio de Janeiro, v. 15, p. 1553-1561, 2010. Suplemento 1.; Simonelli et al., 2010SIMONELLI, A. P. et al. Proposta de articulação entre abordagens metodológicas para melhorias do processo de reabilitação profissional. Revista brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 121, p. 64-73, 2010.). Returning to work for a classroom consider this relationship could result in greater effectiveness. In this case, as some reports from participants showed, perhaps returned teachers did not manifest worries they would realize the work demands return to action. Both for active and readapted teachers participating in this study, preparation for returning to work in the course of sick leave occurred during individual health treatment spaces, usually with a psychiatrist and/or psychologist, away from the school, where they should be evaluated for the real return to functional capabilities as a teacher (OMS, 2003OMS - ORGANIZAÇÃO MUNDIAL DA SAÚDE. CIF: classificação internacional de funcionalidade, incapacidade e saúde. São Paulo: EdUSP, 2003.).

Although there are few studies of absenteeism due to MBD, there is an agreement among their results that the preparation for returning to work would be a moment of participation of various actors, which would be, in this case, the management team of the school, who are responsible for the return to work; the school manager, should also act as a mediator between the medical licensing department and the teacher, who is the central subject in the process (Hoefsmit; Houkes; Nijhuis, 2012HOEFSMIT, F.; HOUKES, I.; NIJHUIS, F. J. N. Intervention characteristics that facilitate return to work after sickness absence: a systematic literature review. Journal of Occupational Rehabilitation, Dordrecht, v. 22, n. 4, p. 462-477, 2012.; Cornelius et al., 2010CORNELIUS, L. R. et al. Prognostic factors of long term disability due to mental disorders: a systematic review. Journal of Occupational Rehabilitation, Dordrecht, v. 21, n. 2, p. 259-274, 2010.; Brouwer et al., 2010BROUWER, S. et al. A prospective study of return to work across health conditions: perceived work attitude, self-efficacy and perceived social support. Journal of Occupational Rehabilitation, Dordrecht, v. 20, n. 1, p.104-112, 2010.).

As for the meanings ascribed by readapted teachers, the analysis indicated the existence of a conflict between wanting and not wanting to go back to the activities in the classroom and an alternative to returning to work, that is, functional readaptation. The latter, at first, was not understood by readapted teachers as "work." Analysis of the narratives and examples from the previous section, work is understood as activities with students or directed to the classroom; readapted teachers do not initially identify these as having returned to work, even though they returned to school. The activities developed during functional adaptation are not perceived as "work," because the teachers do not recognize themselves in these new situations. Based on (Clot 2010CLOT, Y. Trabalho e poder de agir. Belo Horizonte: Fabrefactum, 2010.), the teacher when readapted cannot be used in the professional genre, i.e. the ability of being and acting in the group with his/hers peers, in particular professional situations. Without this contribution to the professional field, he/she no longer feels like they belong to the group, the collective dimension of work. Consequently, there was a conflict observed that is associated with the professional identity of the teacher (Simplicio; Andrade, 2011SIMPLÍCIO, S. D.; ANDRADE, M. S. Compreendendo a questão da saúde dos professores da rede pública municipal de São Paulo. Psico, Itatiba, v. 42, n. 2, p. 159-167, 2011.; Clot, 2010CLOT, Y. Trabalho e poder de agir. Belo Horizonte: Fabrefactum, 2010.) and the management about returning to work in a functional re-adaptation.

The role of school management was an essential element for the return to work processes and readapted teachers. For the latter, these interfered with satisfaction and maintenance of post-return to school because are associated directly with the activities performed by these teachers. Recognizing the activity performed, the teachers perceived satisfaction when returning to work, and those functional readapted were more effective. The situation when recognition occurred, the activities/work functions were negotiated and agreed upon by the management team. This negotiation must consider the school's requirements with the wishes, skills and capabilities of the readapted teacher. The management team's characteristics are paramount to allow the possibility of these negotiations. For example, directors, assistants and coordinators who have acted more closely advocating for a social model of disability, as in the narrative of Prof. 2, enabled further negotiation of activities to be developed during the return to school. In this model, the inability or activity state of restriction is dependent on a number of conditions resulting from both the teacher and their working environment (OMS, 2003OMS - ORGANIZAÇÃO MUNDIAL DA SAÚDE. CIF: classificação internacional de funcionalidade, incapacidade e saúde. São Paulo: EdUSP, 2003.; Simonelli et al., 2010SIMONELLI, A. P. et al. Proposta de articulação entre abordagens metodológicas para melhorias do processo de reabilitação profissional. Revista brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 121, p. 64-73, 2010.).

The functional readaptation, however, was not necessarily a successful return to the classroom or adapting to a new activity of work, most appropriate and compatible with the capabilities and skills of the teacher, as the results showed. The readaptation may favor an adaptive situation at work without allowing changes in the environment (Toldrá et al., 2010TOLDRÁ, R. C. et al. Facilitadores e barreiras para o retorno ao trabalho: a experiência de trabalhadores atendidos em um Centro de Referência em Saúde do Trabalhador-SP, Brasil. Revista Brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 121, p. 10-22, 2010.; Arbex; Souza; Mendonça, 2013ARBEX, A. P. S.; SOUZA, K. S.; MENDONÇA A. L. O. Trabalho docente, readaptação e saúde: a experiência dos professores de uma universidade pública. Physis Revista de Saúde Coletiva, Rio de Janeiro, v. 23, n. 1, p. 263-284, 2013.). In this sense, returning to work during functional readaptation is by itself it's a purpose, i.e., it does not intend to make the teacher return to the main activity or to prevent further sick leave.

In addition to the role of management, prejudices experienced by active and readapted teachers are related to the return to work process. This study showed it is possible to consider that: a) discriminatory attitudes supporting the "invisibility" of mental disorders compared with other sickness which are more clearly expressed in the body, such as a lack of voice, and b) there is disbelief that the MBD are problems that require sick leave, although there was a consensus among teachers that the current educational context is related to mental illness. For readapted teachers, prejudice is directed to the image functional readaptation. The discrimination and stigma suffered by these teachers affect their everyday work and can generate insecurity and helplessness at work (Arbex; Souza; Mendonça, 2013ARBEX, A. P. S.; SOUZA, K. S.; MENDONÇA A. L. O. Trabalho docente, readaptação e saúde: a experiência dos professores de uma universidade pública. Physis Revista de Saúde Coletiva, Rio de Janeiro, v. 23, n. 1, p. 263-284, 2013.). Prejudices can be minimized if there is a return to work policy, to consider at least the involvement of teachers, their co-workers, managers and coordinators, in order to discuss the possible work activities in school for those teachers who had a sick leave due to MBD.

As for the socio-economic data and aspects of the work of the participating teachers, they were used as a backdrop for the analysis of returning to work after sick leave by MBD. Observing these aspects, it was possible to launch the hypothesis that will support a more comprehensive analysis of the life context and work of teachers. Some of the study's findings fall into the issues related to gender differences, since this is a profession that historical has female characteristics related to care, dual activities at and off-home , the ability to be patient, among others, in addition to the specificity of their social and professional integration (UNESCO, 2004UNESCO - ORGANIZAÇÃO DAS NAÇÕES UNIDAS PARA A EDUCAÇÃO, A CIÊNCIA E A CULTURA. O perfil dos professores: o que fazem, o que pensam, o que almejam. São Paulo: Moderna, 2004.; Araújo et al., 2006ARAÚJO, T. M. et al. Diferenciais de gênero no trabalho docente e repercussões sobre a saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 11, n. 4, p. 1117-1129, 2006.). There are also aspects of relevance about the teaching profession, for example, the observation that the highest prevalence of MBD among women may occur partly as a result of cultural barriers that associate mental illness with weakness. In this case, it is expected that men will complain less and seek medical help later, compared to women (Stansfeld; Fuhrer; Head, 2011STANSFELD, S. A.; FUHRER, R.; HEAD, J. Impact of common mental disorders on sickness in an occupational cohort study. Occupational and Environmental Medicine, London, v. 68, n. 6, p. 408-413, 2011.).

In this study, the majority of the studied teachers are females. This was also showed in other studies that address basic education in Brazil (UNESCO, 2004UNESCO - ORGANIZAÇÃO DAS NAÇÕES UNIDAS PARA A EDUCAÇÃO, A CIÊNCIA E A CULTURA. O perfil dos professores: o que fazem, o que pensam, o que almejam. São Paulo: Moderna, 2004.; Ferreira et al., 2009FERREIRA, L. L. et al. O Trabalho de professores na educação básica em São Paulo. São Paulo: Fundacentro. 2009.). In this professional category, the highest prevalence of mental illness among women, compared to men, has been recorded in studies of populations in the northeastern region (Araujo; Carvalho, 2009ARAÚJO, T. M.; CARVALHO, F. M. Condições de trabalho docente e saúde na Bahia: estudos epidemiológicos. Educação & Sociedade, Campinas, v. 20, n. 107, p. 427-449, 2009.). The MBD diagnosis's, mood disorders and stress-related were most often cited by teachers as a reason for sick leave, similar to those recorded in (São Paulo 2013SÃO PAULO. Prefeitura Municipal. Atlas municipal de gestão de pessoas: edição 2013. São Paulo, 2013. Disponível em: <http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CB0QFjAA&url=http%3A%2F%2Fsindsep-sp.org.br%2Fsistema%2Fck%2Ffiles%2FPPT%2520e%2520PDF%2Fatlas_municipal_de_gestao_de_pessoas_2013_v10_1370270158.pdf&ei=qfA_VavMEorcsAWos4CwCA&usg=AFQjCNGtlc2dRcowlz_4eOMi8VqPX0Sw4g&sig2=-MH8RpjK8kAkb3FyK1Fl5w&bvm=bv.91665533,d.b2w&cad=rja> Acesso em: 21 nov. 2013.
http://www.google.com/url?sa=t&rct=j&q=&...
).

Another aspect of relevance in this field was the observation that women are also the main family income provider. This responsibility may have been one of the initial conditions for the occurrence of long working hours among the teachers of this study, which has already been verified by other authors who sought to identify determinants and mediators of long working hours (Silva; Rotenberg; Fischer, 2011SILVA, A. A.; ROTENBERG, L.; FISCHER, F. M. Jornadas de trabalho na enfermagem: entre necessidades individuais e condições de trabalho. Revista de Saúde Pública, São Paulo, v. 45, n. 6, p. 1117-1126, 2011.; Caruso et al., 2006CARUSO, C. C. et al. Long working hours, safety, and health: toward a National Research Agenda. American Journal of Industrial Medicine, New York, v. 49, n. 11, p. 930-942, 2006.). The present study and other publications showed that long workdays are closely related to sick leave leave due to MBD. This is one of the consequences of the precarious work in current elementary school education (Souza; Leite, 2011SOUZA, A. N.; LEITE, M. P. Condições de trabalho e repercussões na saúde dos professores da educação básica no Brasil. Educação & Sociedade, Campinas, v. 32, n. 117, p. 1105-1121, 2011.; Oliveira, 2007OLIVEIRA, D.A. Política educacional e a re-estruturação do trabalho docente: reflexões sobre o contexto latino-americano. Educação & Sociedade, Campinas, v. 28, n. 99, p. 355-375, 2007.; Garcia; Anadon, 2009GARCIA, M. M. A; ANADON, S. B. Reforma educacional, intensificação e auto-intensificação do trabalho docente. Educação & Sociedade, Campinas, v. 30, n. 106, p. 63-85, 2009.; Assumption; Oliveira, 2009ASSUNÇÃO, A. A.; OLIVEIRA, D. A. Intensificação do trabalho e saúde dos professores. Educação & Sociedade, Campinas, v. 30, n. 107, p. 349-372, 2009.).

# Final remarks

The analysis of returning to work after sick leave for mental and behavioral disorders, from the own experience among teachers working in public schools of São Paulo, unveiled a number of elements as the process of returning to work among the study's participants, including the reasons of sick leave and conditions of life and work in this profession.

One such element concerns the relationship between the return to work process and the reasons for the absences. It was understood that, to address returning to work, it is necessary to examine the network of causes related to absenteeism. In spite this statement seems obvious, it just rests on the assumption that workers and teachers of this study return to work under conditions similar to those that influenced the disease and the withdrawal. If improvement measures were taken of the conditions and organization of work at school, for example, in relation to psychosocial aspects, these would benefit the entire school community, not just the active and readapted teachers.

The significances attributed to return to work indicated that most teachers returned to school in unwanted and unfavorable health conditions. Readaptation for teachers, reframed as functional readaptation adequate work conditions are essential for job satisfaction, health and effectiveness of the return process. The school management team also interferes with the return to work process, especially in the relationships with principals, educational assistants, coordinators and co-workers. Therefore, it is suggested that teachers returning to work will also be perceived from the perspective of these actors.

On the other hand, schools are not isolated in society and are influenced by macro-structures and of the various bodies of the educational system. Similarly, the significance of returning to work anchored in the health status and functional capacity also suggests this process includes health care and medical expertise, it also relates to the health system. It is necessary, therefore, that the actions of returning to work also refer to this macro-social context.

Finally, the results of this study revealed that, for the studied teachers, the process of returning to work was not aimed to prevent further diseases and new medical absences or promote health. As being an active work is a major meaning there is the urgent need to encourage return to work actions in the school environment, comprising this entire context as a social determinant of health of teachers.

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# Publication Dates

• Publication in this collection
Sept 2015

# History

• Received
13 Feb 2014
• Reviewed
10 July 2014
• Accepted
07 Aug 2014
Faculdade de Saúde Pública, Universidade de São Paulo. Associação Paulista de Saúde Pública. Av. dr. Arnaldo, 715, Prédio da Biblioteca, 2º andar sala 2, 01246-904 São Paulo - SP - Brasil, Tel./Fax: +55 11 3061-7880 - São Paulo - SP - Brazil
E-mail: saudesoc@usp.br