Narratives of burnout and recovery from an agency perspective: A two-year longitudinal study

Con en s lis s a ailable a ScienceDi ec Bu nou Resea ch jou nal homepage: www.else ie .com/loca e/bu n Na a i es o bu nou and eco e y om an agency pe spec i e: A wo-yea longi udinal s udy S ela Salminen a,⁎ , Elena And eou a , Juha Holma a , Mika Pekkonen b , Anne Mäkikangas a,c a Depa men o Psychology, Uni e si y o Jy äskylä, Jy äskylä, Finland b Peu unka Rehabili a ion Cen e, Laukaa, Finland c Facul y o Social Sciences (Psychology), Uni e si y o Tampe e, Finland ARTICLE INFO Keywo ds: In e iew Na a i e analysis Sphe es o meaning Rehabili a ion Occupa ional heal h ABSTRACT Pu pose: To p o ide knowledge abou he eco e y p ocess du ing ehabili a ion and wo yea s la e by ex- plo ing he mani es a ion o agency and sphe es o meaning in he na a i es o pa icipan s in a na ional e- habili a ion cou se. Ma e ial and me hods: The subjec s o he s udy we e ou pa icipan s in a na ional ehabili a ion cou se, whose bu nou le els had dec eased be ween he ini ial and ollow-up pe iods o he cou se. Semi-s uc u ed in e iews on wo occasions and an elec onic ques ionnai e 1.5 yea s pos ehabili a ion comp ised he main ma e ial. In addi ion, he BBI -15 (Be gen Bu nou Indica o ) and DEPS-sc een we e used. Resul s: Thema ic na a i e analysis e ealed highly indi idual and he e ogeneous pa hs o eco e y. The fi s pa s o he na a i es demons a ed a high deg ee o p oxy and collec i e agency. As eco e y p og essed pe sonal agency was s eng hened. The sphe es o meaning pa icipan s a ached o hei s o ies also a ied, wi h he ehabili a ion cou se and he p o essionals in ol ed being iewed as mo ally good. Th ee majo common hemes we e iden ified: 1) he benefi s o he ehabili a ion cou se; 2) supe iso suppo ; and 3) pe sonal ac o s. Conclusions: Bu nou and eco e y a e no he consequence o wo k- ela ed o indi idual- ela ed ac o s alone, bu a he he ou come o a combina ion o hese. Rega dless o common ac o s, he p ocess and he deg ee o eco e y may a y. The mos beneficial pa h was obse ed when pe sonal agency was high and was ein o ced by a suppo i e job en i onmen and a ou able pe sonal ac o s. 1. In oduc ion Bu nou is a wo k- ela ed s ess diso de , which affec s a la ge numbe o people o wo king age in indus ial coun ies. In Finland, in he la es na ional ep esen a i e su ey conduc ed in 2011, 2% o men and 3% o women in he wo k o ce suffe ed om se e e bu nou , while he pe cen age o hose wi h mild bu nou was significan ly highe : 23% and 24% o men and women espec i ely (Duodecim, 2015). In occupa ional heal h psychology, bu nou is ypically desc ibed as a eac ion o long-las ing un ea ed occupa ional s ess, which is cha - ac e ized by h ee symp oms: exhaus ion, cynicism and educed p o- essional efficacy (Maslach, Jackson, & Lei e , 1996). I is no classified as a medical disease, bu ins ead an addi ional code (ICD-10: Z73.0) (Duodecim, 2015), which indica es he p esence o a p oblem ela ed o li e con ol, is added o he diagnosis. The ela i ely high p e alence o bu nou unde lines he need o a be e unde s anding o i s an e- ceden s, de elopmen p ocesses and, abo e all, he pa hs o eco e y. In esponse o his need, his s udy sough o cap u e subjec i e expe i- ences om he onse o bu nou o eco e y. Since bu nou in es iga ion began, a la ge body o esea ch –mainly quan i a i e –has ocused on he causes, symp oms and consequences o bu nou (Schau eli & Enzmann, 1998; Schau eli, 2000). Al hough no single psychological heo y offe s a ull explana ion o bu nou , i is commonly ag eed ha he causes o bu nou can be di ided in o h ee ca ego ies (Schau eli & Enzmann, 1998;Schau eli, Maslach, & Ma ek, 1993): indi idual (bu nou is ega ded as he ou come o in ape sonal ac o s); in e pe sonal (bu nou is seen as he esul o difficul ela ions wi h o he s a wo k); and o ganiza ional (bu nou is iewed as a mis- ma ch be ween he pe son and he job). Consequen ly, bu nou in e - en ions ha e ocused on hese same ca ego ies o causes (Schau eli & Enzmann, 1998). While ehabili a ion in e en ions ha e been ound o exe a posi i e effec on bu nou educ ion (No lund e al., 2011; S enlund, Ahlg en e al., 2009;S enlund, Bi gande , Lindahl, Nilsson, & Ahlg en, 2009;S enlund, No din, & Jä holm, h p://dx.doi.o g/10.1016/j.bu n.2017.08.001 Recei ed 28 Ma ch 2017; Recei ed in e ised o m 9 Augus 2017; Accep ed 10 Augus 2017 ⁎ Co esponding au ho . E-mail add ess: [email p o ec ed].fi(S. Salminen). Bu nou Resea ch 7 (2017) 1–9 2213-0586/ © 2017 The Au ho s. Published by Else ie GmbH. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/BY-NC-ND/4.0/). MARK 2012), pa icula ly in he componen s o exhaus ion (Hä inen e al., 2009;Hä inen, Kinnunen, Pekkonen, & Kalimo, 2007;Hä inen, Mäkikangas, Kinnunen, & Pekkonen, 2013) and cynicism (; Hä inen e al., 2007), he ocus ended o be on in es iga ing co ela ions be- ween a iables a he han indi idual de elopmen al ajec o ies o bu nou and eco e y (Mäkikangas & Kinnunen, 2016). The ew quali a i e s udies on ehabili a ion ha e highligh ed an impo an concep – ha o agency –and a gued ha he s eng hening o agency is one o he p ima y goals in ehabili a ion in e en ions (Jä ikoski, Ma in, Au i-Rämö, & Hä käpää, 2013). Theo e ically, h ee diffe en modes o agency a e dis inguished: pe sonal, p oxy, and collec i e (Bandu a, 2000). Pe sonal agency implies aking con ol o exe cising influence wi h he aim o achie ing o p oducing gi en e - ec s. In many cases, howe e , indi iduals a e unable o di ec ly impac hei social en i onmen . Ins ead hey employ a media ed o m o agency, p oxy agency, in which hey u n o o he s in possession o he app op ia e esou ces, knowledge o means o ac on hei behal o p oduce he ou comes hey desi e. The hi d mode, collec i e agency, emphasizes he ac ha many ou comes a e achie able only h ough join effo . A he co e o i is people’s sha ed belie in hei powe o achie e desi ed ou comes. Al hough o he s udies on bu nou ehabili a ion do no e e spe- cifically o he concep o agency, hey iden i y simila hemes and ca ego ies. In a s udy o an es ablished ehabili a ion in e en ion in Finland, u ilizing he same baseline in e iew da a as in he p esen s udy (Salminen, Mäkikangas, Hä inen, Kinnunen, & Pekkonen, 2015), he impo ance o he accumula ion o suppo , awa eness and app o al led clien s o he e ela ion ha hey a e p ima ily esponsible o hei own well-being. The o e a ching heme o My well-being in my own hands, which eme ged in he analysis, s ongly esembles he concep o agency (Bandu a, 2000). Ano he s udy, conduc ed in Sweden, o pa- ien s’expe iences o ehabili a ion consis ing o wo diffe en in e - en ion g oups –one wi h cogni i ely-o ien ed beha iou al e- habili a ion and QiGong (a p og amme combining ension- elie ing mo emen s, elaxa ion and medi a ion), and he o he wi h QiGong alone –p oduced simila esul s (Fjellman-Wiklund, S enlund, S einhol z, & Ahlg en, 2010). Du ing he eco e y p ocess, pa ien s emphasized he beneficial effec s o affi ma ion and suppo om e- habili a ion p o essionals and g oup membe s, in enabling hem o e- s o e con ol o e hei li es. Despi e hei con ibu ion o he unde - s anding o he mechanisms o change, a common ea u e o hese s udies is he use o a c oss-sec ional design, which does no yield sufficien in o ma ion abou pa icipan s’pos -in e en ion expe i- ences. To ou knowledge, he e a e no published quali a i e s udies which ha e acked he de elopmen o he eco e y p ocess o e ime. To fill his gap, he p esen s udy is a pilo esea ch comp ising ou na a i es, which se s ou o in es iga e he en i e p ocess om he onse o bu nou o eco e y a diffe en ime poin s du ing and a e e- habili a ion. The main ocus was on he con en o he na a i e, i.e., on wha pa icipan s old abou he a ious s ages o he p ocess. As he ein o cemen o agency is an impo an goal in ehabili a ion and i s significance has been demons a ed in p e ious s udies (Jä ikoski e al., 2013; Salminen e al., 2015), a u he aim was o explo e he ole o he h ee modes o agency (pe sonal, p oxy and collec i e) in mo e dep h along wi h hei impac on eco e y wi hin his sample. Na a i e inqui y was chosen as he p ima y me hod o in es iga ion, as eco e y pa hs a e ypically indi idual and he e ogeneous (; Hä inen e al., 2013). 1.1. Na a i e analysis Na a i es enable he explo a ion o human expe ience in a holis ic manne by p ese ing i s ich and complex na u e (Bell, 2002) and ecognizing li ed expe ience as a sou ce o knowledge and unde - s anding (Clandinin, 2013). Wi hin he amewo k o na a i e esea ch, a ple ho a o diffe en defini ions, app oaches, and specific me hods exis s (Pinnega & Daynes, 2007). Fo he pu poses o his s udy, hema ic na a i e analysis, as desc ibed by Ca he ine Riessman (2008), was applied. I is one o he mos commonly used ypes o na a i e analysis, and one in which exclusi e emphasis is placed on he con en o he s o y old. While p ese ing he ea u es o he indi idual na a i es, his ype o analysis enables iden ifica ion o common he- ma ic elemen s ac oss he pa icipan s’accoun s (Riessman, 2004). This ype o analysis, wi h i s exclusi e ocus on na a i e con en , was conside ed pa icula ly sui ed o cap u ing bo h pa icipan s’expe i- ences o e ime and he meanings hey a ibu e o he p ocess o e- co e y. A he co e o na a i e inqui y lie ques ions abou wha he s o y e eals abou he pe son and his/he wo ld and wha ligh in e p e a- ion o he s o y can shed on he cul u al and social milieu in which he na a i e is p oduced (Pa on, 2015). In cons uc ing hei s o ies, in- di iduals bo h inco po a e hei unde s anding o he su ounding wo ld in o he ab ic o hei na a i es and engage in a sense-making p ocess. Se e al sphe es o meaning –emo ional, explana o y, mo al and e hical –can be disce ned in na a i es (Hänninen & Koski-Jännes, 1999) and hese a e explo ed in his s udy. Emo ional sphe es o meaning e e o he emo ional unde pinning o a na a i e –whe he he goals o he main cha ac e a e achie ed o hwa ed, whe he he s o y has a posi i e (happy) o nega i e ( agic) ending, wha i s high and low poin s a e (Ge gen, 1988). The explana o y pe spec i e is e- la ed o he manne in which e en s a e linked wi h each o he as causes and consequences. The mo al sphe e o meanings deals wi h he alloca ion o esponsibili y o e en s and whe he he e a e elemen s o accusa ion o excuse in he na a i e (Baumeis e & Newman, 1994). The e hical aspec a icula es he deepe esona ing elemen s o good and bad as well as igh and w ong in li e. Thus, in addi ion o he mani es a ion o agency and he explo a ion o he en i e p ocess o eco e y, hese ou sphe es o meaning a e all disce nible in he pa - icipan s’na a i es. Thei iden ifica ion p o ides a ye deepe le el a which subjec i e expe iences can be cap u ed, while simul aneously e ealing impo an pe cep ions abou he b oade social and cul u al milieu in which he na a i es a e p oduced. 2. Ma e ial and me hods 2.1. S udy design, pa icipan s and da a collec ion This s udy comp ises he na a i es, collec ed on h ee occasions, o ou pa icipan s in a Finnish na ional ehabili a ion cou se. These cou ses we e s a e financed, i.e., he Finnish Social Insu ance Ins i u ion unds ehabili a ion se ices and p o ides income du ing pa icipa ion in he cou se. Pa icipan s ei he apply o a e e e ed by hei occu- pa ional heal h ca e se ice o a bu nou in e en ion. Applican s and e e als a e sc eened by he local b anch o he Social Insu ance Ins i u ion and he final selec ion is made by a physician om he e- habili a ion cen e. These ehabili a ion cou ses s a wi h a 10-day pe iod and end wi h a ollow-up pe iod, which akes place wi hin a mos 7 mon hs a e he fi s pe iod. Rehabili a ion includes an e a- lua ion o an employee’s physical and psychological s a us by a ious p o essionals, including a physician, psychologis , physio he apis , and social wo ke . The ehabili a ion ac i i ies in bu nou in e en ions ocus p ima ily on enhancing indi idual esou ces and suppo ing coping s a egies. This is achie ed h ough a ious indi idual- and g oup-le el ac i i ies. Indi idual-le el ac i i ies, which accoun o 11 h o he 70-h ehabili a ion p og amme, include guidance and counselling wi h a ious ehabili a ion p o essionals, es s and examina ions, and specific asks o be comple ed be ween he ehabili a ion pe iods. G oup-le el ac i i ies, amoun ing o 59 h, comp ise physical exe cise, educa ion on nu i ion, e gonomics and heal h, and pa icipa o y g oup discussions. Pa icipan s o his longi udinal s udy we e selec ed om a ious S. Salminen e al. Bu nou Resea ch 7 (2017) 1–9 2 ehabili a ion cou ses ha ook place in 2012 a a ehabili a ion cen e in Cen al Finland (Salminen e al., 2015). O he h ee ehabili a ion cou ses wi h a ollow-up pe iod be ween Augus and Decembe 2012, 15 eligible employees, whose bu nou le els had dec eased, we e iden ified, and 12 pa icipa ed in he fi s phase o he s udy (Salminen e al., 2015). The psychologis a he ehabili a ion cen e in o med clien s whose bu nou sco e had diminished o he possibili y o pa i- cipa e in he s udy. Thei willingness o pa icipa e in he ollow-up phases o he s udy was also inqui ed. The baseline le els o bu nou and he subsequen change we e measu ed wi h he Be gen Bu nou Indica o (BBI-15) (Nää änen, A o, Ma hiesen, & Salmela-A o, 2003). The BBI-15 comp ises he h ee symp oms o bu nou : exhaus ion, cy- nicism and educed p o essional efficacy. To al sco es a y be ween 15 and 90, o ming ou diffe en classes o bu nou : se e e, mode a e, mild and no bu nou . Eligibili y was de e mined i he bu nou symp- oms had dec eased by a leas one class and in a leas one sub-di- mension. The fi s in e iews, which p o ide accoun s o bu nou de- elopmen and expe iences o he ehabili a ion cou se we e conduc ed a e he end o he cou se ollow-up pe iod in he au umn o 2012 on ehabili a ion cen e p emises (Salminen e al., 2015). Pa icipan s we e app oached 1.5 yea s la e (in Sp ing 2014) ia an elec onic ques ionnai e sen o hei p i a e e-mail add esses. The ollow-up ques ionnai e measu ed pa icipan s’bu nou and dep ession sco e wi h he BBI-15 (Be gen Bu nou Indica o , BBI-15, Nää änen e al., 2003) and wi h he DEPS-sc een (Salokangas, Pou anen, & S enga d, 1995). The ques ionnai e also included open ques ions, in which pa icipan s we e asked o e alua e, e.g., hei manage ’s ac i i ies, changes ha had occu ed a wo k and he impac diffe en ehabili a ion ac o s had had on hei well-being. A eminde o hose who had no answe ed was sen a he end o May 2014. Nine ou o wel e pa icipan s sen back he filled-ou ques ionnai e. O he h ee pa icipan s who did no espond, one was on sick lea e a he ime o da a collec ion and hus did no ecei e in o ma ion abou he ques ionnai e. The o he wo pa icipan s could no be eached. O he nine esponden s, eigh ga e hei consen o be con ac ed o u he inqui y. O hese eigh , ou we e selec ed h ough pu pose ul sampling (Pa on, 2015) o an in-dep h in e iew wi h a iew o col- lec ing diffe ing s o ies o bu nou and eco e y. The sampling was based on he deg ee o eco e y (con inued eco e y o wo sened bu nou ) and on whe he job change had aken place ( wo o he pa - icipan s had changed jobs and wo we e in he same job). They we e app oached by e-mail and hei willingness o pa icipa e in a ollow-up in e iew was elici ed in Oc obe 2014. Sample age a he las da a collec ion poin a ied be ween 41 and 64 yea s (mean 55.8 yea s). Two o he pa icipan s had a oca ional school educa ion, one had comple ed a p o essional poly echnic qualifica ion and one had a uni- e si y deg ee. Time wi h he cu en employe a ied be ween 3 mon hs and 40 yea s. All pa icipan s we e cu en ly wo king, bu one was on pa - ime e i emen . The ou pa icipan s whose eco e y p ocess was explo ed in mo e de ail we e in e iewed by means o a hema ic in e iew by a Mas e ’s s uden o Psychology in No embe - Decembe 2014. The in e iews we e conduc ed in a quie place in he pa icipan ’s home. Each in e iew las ed be ween 1 and 1.5 h. The in e iews we e ansc ibed e ba im; howe e , he p ecise leng h o pauses, s u e s and o he sounds, and non- e bal language we e no w i en down as he main emphasis was on he con en o he s o y old. The o al leng h o he ansc ibed in e iew ma e ial om he fi s and hi d da a collec ion poin s was 138 pages, while he ques ionnai e adminis e ed a he second da a collec ion poin was 12 pages in leng h. 2.2. Da a analysis The accoun s gi en a hese h ee da a collec ion poin s we e e- ga ded as h ee pa s o he same pe son’s na a i e. This app oach was adop ed o honou he longi udinal design o he s udy and, mo e im- po an ly, o allow he acking o change o e ime h ough compa ison o each pa icipan ’s desc ip ions o bu nou and eco e y a he diffe en ime poin s, and o he diffe en social condi ions and places in which he da a had been collec ed. This acco ds wi h he h ee commonplace ea u es o na a i e inqui y posi ed by Connelly and Clandinin (2006): a en ion o empo ali y, sociali y, and place. Tem- po ali y e e s o he con inui y o expe ience and he ac ha people and e en s a e si ua ed in ime and a e desc ibed wi h a pas , p esen and u u e. The sociali y commonplace eflec s he no ion ha pe sonal and social condi ions shape he indi idual’s con ex . The hi d com- monplace d aws a en ion o he ac ha all e en s occu in a conc e e physical place. In line wi h Riessman’s (2008) p esen a ion o hema ic na a i e analysis (p. 54), da a we e in e p e ed in ligh o he agency heme, which se ed as he heo e ical amewo k o he s udy, i.e., he pa icipan s’accoun s we e iewed h ough he lens o agency and how i s diffe en modes we e in e wo en he ein. In he analysis, he ocus was on he con en o he na a i es, i.e., on wha pa icipan s epo ed abou he p ocess, and no on how hey epo ed abou i . Fu he mo e, he choice o na a i e analysis was jus ified as we wan ed o iew he na a i es as whole en i ies ins ead o iden i ying ca ego ies as, o example, is done in o he ypes o quali a i e analysis. The na a i es o each pa icipan om he h ee collec ion poin s we e fi s ead o g asp he gene al meaning and spi i o he s o y. Du ing successi e eadings we ocused on unco e ing he pa icula manne in which he pa icipan econs uc ed he o ma ion o bu nou , how change s a ed o eme ge in he s o y, pa icula ly in he ehabili a ion s age, and how he p ocess had con inued a 1.5 and 2 yea s a e he end o he ehabili a ion cou se. While eading, we a - emp ed o disce n all h ee modes o agency as well as he p esence o weak agency o he absence o agency. Once we had ob ained a be e unde s anding o he s o y, we p oceeded o iden i y i s emo ional, causal, mo al and e hical aspec s. These we e based exclusi ely on he pa icipan s’subjec i e expe iences and hei in e p e a ion o he e en s be o e and du ing he bu nou s age and h oughou he e- co e y pe iod. Finally, we assigned a i le o he na a i e, which e- flec ed i s co e meaning. When he na a i es o all he pa icipan s we e analysed, we isola ed he mos impo an common hemes o close examina ion. The common hemes we e ecu ing opics, e en s o ac o s, ound in all ou na a i es, which we e expe ienced as pa icula ly impac ul in he whole p ocess, and we e hus indica i e o ei he success ul o impeded eco e y. The pa icipan s we e iden ified by a pseudonym o gua an ee hei anonymi y and a oid any isk o hei being ecognized based on he na a i e p esen ed in he s udy. 2.3. C edibili y To inc ease he c edibili y o he s udy, he pa icipan s we e o i- ginally selec ed om h ee diffe en cou ses. The ehabili a ion cou ses comp ise a lo o g oup exe cises, which aim o enhance g oup cohe- si eness. Howe e , his may lead o g oup hink, and inhibi he ex- p ession o indi idual and diffe ing opinions. By s udying pa icipan s om diffe en g oups, we aimed o minimize his effec . To inc ease he c edibili y and in e p e i e po en ial o he s udy, da a iangula ion based on (1) a sel - epo ques ionnai e (BBI-15); (2) a w i en ques- ionnai e a Time 2; and (3) semi-s uc u ed in e iews a Time 1 and 3, was used (Denzin, 1970). 2.4. E hical conside a ions The s udy was app o ed by he E hical Commi ee o he Uni e si y o Jy äskylä, Finland. The s udy was in oduced o he ehabili a ion cen e clien s by he psychologis , who p o ided hem wi h w i en ma e ials. The olun a y na u e o pa icipa ion, anonymi y and con- fiden iali y we e emphasized be o e he s a o he s udy and we e men ioned a each subsequen s age o he da a collec ion. The pa i- cipan s signed a consen o m and we e in o med o he possibili y o discon inue hei pa icipa ion a any ime du ing he s udy wi hou any S. Salminen e al. Bu nou Resea ch 7 (2017) 1–9 3 consequences. A consen o audio eco ding was also eques ed. Rehabili a ion s aff ep esen a i es we e no p esen a any poin du ing he in e iews. 3. Resul s 3.1. Sa a, age 57, kinde ga en eache , di o ced: “Change is he only cons an ” Sa a’s na a i e e eals he s o y o a woman who ound he sel g appling wi h massi e and cons an changes in he wo kplace (Table 1). As hese changes spun ou o he con ol, hey affec ed he well-being and e en ually led o e y se e e bu nou . I is impo an o no e ha she did no pe cei e ha he bu nou was caused by he na u e o he wo k, pe sonal conflic s o eam- ela ed schisms, bu as a esul o he apid accumula ion o changes, which unde mined he eeling o belonging, ole cla i y and p o essional iden i y.“Wha hen s a ed inc easing my eelings o bu nou was he cons an , incessan change and he ac ha he e was no s abili y o cla i y. I mysel had he eeling some imes ha I don’ know who I am anymo e, le alone a he ime when I was my colleague’s supe iso o a yea –a yea and a hal , and hen all o a sudden I was an o dina y line wo ke alongside ellow wo ke s.” He pe sonal agency was p esen in he bu nou s age in he effo s o call he managemen ’s a en ion o he de imen al effec s o he cons an o ganiza ional changes, bu his mode o agency seemed o lack efficacy and ailed o make an impac on he o e all si ua ion. “When we hen s a ed alling ill and aking sick lea e absences and subs i u es came in, and hey s a ed alling ill, hen occupa ional heal hca e s a ed o ake an in e es in ou p oblem, he hing is ha we ied e y ha d o communica e his and sp ead he wo d ha hings a e no all igh he e, bu simply no hing happened.” The ques ion o he accumula ion o s ess becomes pa icula ly e iden he e: as Sa a’s bu nou co-occu ed wi h physical ailmen s and amily p oblems (di o ce), she a ibu ed he symp oms o exhaus ion, loss o p o essional p ide and cynicism o hese p oblems and hus ailed o ecognize he p ima y cause o he bu nou . “You a e as bu n ou as you could possibly be…you eally need a b eak...I mysel hough in a way ha … ha I ha e o demand mo e and mo e om mysel , I ha e o jus manage and cope wi h i , and so...I jus didn’ ealize how deep I was in my own bu nou .” The high poin in Sa a’s na a i e was a he end o ehabili a ion, which she saw as good, use ul and affi ma i e. She also p aised he ole o he daugh e and pe dog, who ga e he he gen le push she needed o eco e y. He pe sonal agency emained somewha in he back- g ound, whe eas p oxy agency (help om ehabili a ion p o essionals as well as amily membe s) and collec i e agency (help om he e- habili a ion g oup) we e boos ed. A e he fi s change o job, Sa a con inued on he oad o eco e y, bu soon he same p oblems as in he p e ious wo kplace s a ed o eme ge. She had h ee diffe en manage s du ing he wo yea s she spen in he second wo kplace. Thus, he accoun o he e en s du ing he 1.5 yea s a e ehabili a ion, was inged wi h disappoin men : e- plica ion o he same p oblems a e he change o job ollowing he ehabili a ion cou se led o se e e bu nou , as also iden ified by he sco e on he bu nou scale (BBI-15). E en ually, a e his fi s job change she mo ed o he hi d wo kplace, sho ly be o e he in e iew wo yea s a e he ehabili a ion cou se. The hi d sub-na a i e was e alua i e and e aced he ull spec- um o e en s and emo ions accompanying he bu nou , ehabili a ion and p esen s a e o well-being. Sa a also discussed he effec s o pe - sonnel u no e and he lack o s abili y in he wo kplace, hus a - aching a mo ally nega i e meaning o he la e . I is no ewo hy ha despi e he disappoin men caused by he fi s job change he na a ion o e en s was in o med by a ce ain deg ee o awa eness and se eni y. She was able o offse he ull de elopmen o bu nou by demons a ing p oac i i y, exe cising pe sonal agency and changing jobs again. The emo ional one in he hi d sub-na a i e was cau iously op imis ic and p onouncedly ealis ic, and Sa a was no esigned o helplessness o hopelessness. Pe sonal agency was mani es ed in he in en ions o keep looking o a sa is ying job: “I hasn’ a any poin en e ed my mind, oh, wha did I do, I mean I ha en’ hough , did I make he igh decision o any hing like ha ...I ha en’ eally…and I saw ha my coming o X. (he new wo kplace) happened jus a he igh poin , i was good…[…]. My ea lie wo k- places we e somehow...I always had o s a om sc a ch and again om sc a ch and c ea e ou ines…and I would ha e liked o c ea e some hing, o d i e some hing o wa d, bu he eali y o wo k somehow de ou ed so much. […] Now I eel I wan o look a all he possibili ies…’cos you know his job can be done in so many diffe en ways…and especially he e in [ his] a ea he e a e so many ways…and i ’s an expe ience o me.” The ac ha Sa a had mo ed o a new wo kplace p io o he in- e iew explained why he na a i e emained open-ended. She e- cognized ha he eco e y was a long p ocess and was awa e ha she was no ye ully eco e ed. She hoped o a be e ou come his ime, and allowed he sel o explo e u he oppo uni ies, should he igh momen a ise. Sa a’s pe sonal agency, al hough exis en , was ende ed ineffec i e and u ile by poo managemen o p oblems in he wo kplace. P oxy and collec i e agency we e he mos ac i ely exe cised du ing e- habili a ion, which in u n boos ed he pe sonal agency. The main cause o de eloping bu nou we e he cons an o gani- za ional changes, which unde mined Sa a’s eeling o s abili y, blu ed he ole cla i y and obbed he o he sense o belonging and con ol. The na a i e blamed he mul i ude o , in he iew, poin less changes in he wo kplace which we e no handled adequa ely by he managemen . C edi was gi en o amily membe s (daugh e and dog), who p o ided suppo wi hou passing judgemen . On a deepe , alue-d i en le el, Sa a saw he a i ude o dis espec and dis ega d o he suffe ing as e hically bad e en when hese we e openly aised. Wha Sa a empha- sized as e hically good was he suppo , despi e all he suffe ing, p o- ided by occupa ional heal h ca e, he ehabili a ion p o essionals and amily membe s. 3.2. Diana, age 61, ecep ion nu se, ma ied: “Eyes se on e i emen ” Diana’sna a i e ep esen s he pa h o an employee who suffe ed om se e e bu nou , which could no be comple ely ea ed, and who expec s e i emen o esol e he p oblem (Table 2). Fo Diana, he accumula ion o s esso s leading o exhaus ion was some hing ha s a ed a long ime ago, when he numbe o ecep ion nu ses emained unchanged while he amoun o wo k s eadily in- c eased. Be o e he onse o he bu nou Diana desc ibed he wo king condi ions as inadequa e and he o ganiza ional clima e as Table 1 Open-ended na a i e “Change is he only cons an ”. Massi e cons an changes −> e y se e e bu nou −> ehabili a ion 1s pe iod −> change o job −> ehabili a ion ollow-up pe iod −> imp o ed well-being −> exace ba ion o he wo k si ua ion −> change o job −> mixed eelings/cau ious op imism −> con empla ion o change −> open-ended na a i e Emo ional one: mix u e o op imism and disappoin men Explana o y: cons an changes, no fi m g ound Mo ally blamed: he lack o s abili y unde mines one’s ounda ions; p oblems a e no aken se iously by managemen Mo ally p aised: daugh e and dog E hically good: p esence o suppo E hically bad: being ea ed wi hou espec ; being obbed o p o essional digni y S. Salminen e al. Bu nou Resea ch 7 (2017) 1–9 4 unsuppo i e. Employees’needs we e dis ega ded and he managemen ailed o eac o inequali ies. He hopes o imp o emen we e sha e ed when, con a y o p omises, an ex a pe son was no hi ed, which led he o see he sel as a ic im o se e e injus ice. I was a his poin ha Diana el she could no longe cope, and she s a ed complaining o s omach aches and sleeplessness, which in u n led o inc eased ex- haus ion and sensi i i y. “And hen he momen came… ha I couldn’ cope anymo e. I had somehow managed up o when hey p omised again and again ex a help, bu hen in he win e i jus came o he poin whe e I couldn’ cope anymo e. I had come up agains a wall.” An addi ional bu dening ac o men ioned by Diana was he sick mo he who equi ed daily ca e and axed he esou ces. Th ough ex- e cising p oxy agency, wi h he help o occupa ional heal h ca e p o- essionals and he ehabili a ion cou se, Diana was able o mode a e he bu nou symp oms and achie e an imp o emen in he well-being. This was ansla ed in o inc eased ene gy le els and he mo i a ion o en- gage in mo e physical exe cise. Howe e , Diana’s ocus ega ding he means o eco e y lay mainly in educing he wo kload and being g an ed pa - ime e i emen . She ecognized he impac o he physical ailmen s on he well-being, and hus he effo s we e di ec ed owa ds minimizing s ain a he han achie ing ull eco e y in o de o e u n o he p e-bu nou wo k capabili y. This sligh ly passi e app oach o eco e y p esumably led o an in e es ing disc epancy be ween he measu ed le els o bu nou and he bu nou she epo ed a he second ime poin . Al hough Diana’s o e all bu nou sco e diminished be ween he fi s and second da a collec ion ime poin s, she ne e heless epo ed an inc ease in bu nou symp- oms. Such a misma ch could pe haps be accoun ed o by he ap- p oaching ull e i emen age as well as he a ious physical ailmen s she suffe ed om. P esumably, she in es ed less effo in eco e y, i.e., she exe cised pe sonal agency on a smalle scale, and ins ead ocused he a en ion on e i emen . The las pa o he na a i e a wo yea s pos - ehabili a ion was mo e con empla i e and o ien ed owa ds he amily. Bo h sides o he bu nou and eco e y p ocess we e oiced. The o e all one became mo e philosophical as ealisa ion o one’s age and fini eness g ew. In ela ing he expec a ions o he u u e, Diana exp essed a wish o be heal hy and able o spend ime wi h he child en and g andchild en. Hence, he pe sonal agency was mo e di ec ed owa ds eaching and main aining good physical heal h so as o be fi o se e he amily membe s. “I’m wai ing o e i emen and hen I hope I’ll be heal hy again, so ha we can a el and ha e hobbies, and hen o cou se ha I’ll ha e he ene gy o ake ca e o my g andchild en and play wi h hem… his is a wonde ul ime ha I’m looking o wa d o.” In Diana’s na a i e, p oxy agency is he mos p ominen mode o agency and he mode exe cised mos ac i ely ac oss he s udy pe iod. Diana holds expe s’ ips and ecommenda ions in high ega d and e- lies s ongly on hei knowledge and encou agemen . Occupa ional heal h ca e and ehabili a ion p o essionals along wi h he ehabili a ion g oup played a significan ole in he p ocess o eco e y and hey emained ins umen al in main aining i . Pe sonal agency was also iden ifiable in he accoun , al hough o a lesse deg ee. I was e- ac i a ed du ing and a e he ehabili a ion cou se, and was p ima ily isible in Diana’s a emp o main ain a heal hie li es yle h ough spo s and balanced nu i ion. The o e all emo ional one was o sligh esigna ion and a igue, al hough in he las pa hope and expec a ions o he u u e we e also oiced. The na a i e did no incline owa ds a posi i e o a nega i e end, bu could a he be ca ego ized as suspended. The cause o bu nou was pe cei ed as wo k o e load and he lack o an adequa e o gani- za ional esponse he e o, combined wi h pe sonal ailmen s. F om a mo al pe spec i e, he ehabili a ion p og amme and he pee suppo we e p aised whe eas he dis ega d o employees’suffe ing and he injus ice inexpe ienced we e ha shly blamed. On a deepe le el o a- lues, Diana iewed he wo k e hic and he connec ion o he amily membe s as good and he injus ice pe pe a ed owa d a pa icula employee g oup as e hically e il. 3.3. Paula, age 41, managemen sec e a y, ma ied: “The success ul job change ” Paula’s na a i e desc ibes he bu nou and eco e y p ocess, s a ing om b eakdown o he egaining o joy and cla i y by means o a men al shi (Table 3). She depic s he accumula ion o an excessi e wo kload, o which she esponded wi h habi ual conscien iousness, and he implemen a ion o manage ial changes. Paula ealised ha he amoun o wo k was becoming in ole able, bu despi e he a emp s o b ing he p oblems o unde s affing o he managemen ’s a en ion, he conce ns we e no adequa ely esponded o and no hing changed o ligh en he bu den. Simul aneously, she had heal h p oblems which caused a igue and p e en ed he om ecognizing ha she had symp oms o bu nou . She also s a ed suffe ing om sleeplessness and anxie y o e unfinished wo k un il he b eakdown, which happened “o e nigh ”. Wi h egula help om occupa ional heal h ca e p o es- sionals (a physician, a heal h nu se and a psychologis ), in o he wo ds, h ough exe cising p oxy agency, she was able o a icula e he p o- blems and become awa e o he bu nou . The iden ifica ion o he p oblem igge ed an ini ial eac ion o ea : “I was aw ully sca y…you know, all o a sudden I can’ manage any- mo e. Bu he sca y hing was ha I had been walking wi h my eyelids shu , in a unnel. And i (bu nou ) had been he e o a long ime, bu I hadn’ ealized i mysel . So… ea was he bigges hing, I guess.” Paula demons a ed ini ia i e and sough he se ices o a p i a e he apis o gain an ou side pe spec i e on he s a e. She also spoke abou he eno mous g a i ude she el owa ds he dog, who was by he side, non-judgemen al and suppo i e, h oughou he en i e p ocess. A e se e al s in s o sick lea e, she e u ned o wo k pa - ime, bu con inued on pa ial sick lea e. Specific changes ega ding he di ision o labou we e in oduced and ag eed upon in w i ing, and an addi- ional pe son was hi ed o ligh en he wo kload. Table 2 Na a i e “Eyes se on e i emen ”. Inadequa e wo k condi ions and ch onic o e load −> se e e bu nou −> ehabili a ion −> Ha nessing bu nou −> Subjec i ely pe cei ed exhaus ion −> pa - ime e i emen −> looking o wa d owa ds ull e i emen Emo ional one: esigna ion and a igue Explana o y: wo k o e load and lack o adequa e esponse he e o; physical ailmen s Mo ally blamed: injus ice Mo ally p aised: ehabili a ion p o essionals and pa - ime e i emen E hically good: own wo k e hic E hically bad: pe cei ed injus ice Table 3 Na a i e “The success ul job change ”. Excessi e wo kload −> Unawa eness o he symp oms −> U e exhaus ion and b eaking down o e nigh −> Occupa ional heal h ca e suppo −> S in s o sick lea e and commencemen o eco e y −> Re u n o wo k −> Rehabili a ion −> P ocessing −> Job change −> Re i al −> Main enance o balance Emo ional one: e i al Explana o y: excessi e wo kload combined wi h ex eme conscien iousness Mo ally blamed: wo k e hic in he childhood amily Mo ally p aised: ehabili a ion E hically good: men al ma u a ion E hically bad/e il: pe cei ed injus ice S. Salminen e al. Bu nou Resea ch 7 (2017) 1–9 5 Fo Paula, ehabili a ion came a e he acu e s age o bu nou had been o e come and he ini ial phases o eco e y had commenced. She belie ed his enabled he o benefi om i he mos and she desc ibed he expe ience hus: “[Wha did ehabili a ion mean o you?] P: Pausing…and comple e and ho ough p ocessing o hese hings. I has been…le ’s see how I am, how I eel. Pe haps I had always pushed mysel in o he backg ound be o e, o make oom o o he hings. So [in ehab] I could be mysel , o mysel . ” Paula had o go h ough a p o ound and ho ough p ocess o e- p io i izing he alues: coming om a amily wi h en ep eneu -mo- he , Paula belie ed ha wo k had o be done and was op p io i y. Posi ioning he own well-being highe in he hie a chy equi ed con- scious effo and pe sonal agency, bu he ou come, al eady a he fi s ime poin , was imp o ed wo k-li e balance. O e all, despi e he posi- i e changes, Paula was awa e ha he p ocess o eco e y was slow and ime-consuming, and she admi ed he possibili y o a enewal o bu nou . As a p e en i e measu e, Paula b ough up “ alking ea lie ” and “s ongly desi ing change”. Fac o s hinde ing eco e y we e ela ed o he managemen , who ins iga ed he subsequen changes. P oblems wi h he indi ec supe - iso led o an inc ease in bu nou symp oms. Wi h he help o he di ec line manage , who was suppo i e and help ul, she was ans- e ed o ano he uni wi hin he same o ganiza ion be ween he fi s and second da a collec ion poin s. A he second ime poin , Paula expe ienced a lo o posi i e changes. She el accep ed and welcome in he new eam, enjoyed g ea e esponsibili y and was able o c a he job mo e eely. Despi e he long dis ance be ween he home and he wo kplace, Paula el ha she was in cha ge o he li e again, which in u n had a posi i e effec on he ela ionship wi h he husband and child en. The emo ional one o he na a i e was ela ed and hope ul. The amoun o pe sonal agency she exe cised had g own and was isible in he mo i a ion o engage in spo s, ea heal hily and main ain he well-being. She also ac i ely e- isi ed he lessons lea n du ing ehabili a ion and could now see he bu nou in a posi i e ligh : “Bu nou can affec anyone. I am happy I wen h ough ha hell, because I was able o g ow as a pe son.” Paula’s s a e wo yea s a e ehabili a ion (a T3) was good, al- hough a he ime o he in e iew she was on a sick lea e due o physical ailmen s. She was able o eflec mo e ex ensi ely on he change o job and he app ehension she had el a ha ime. He mo- i a ion o a oid bu nou o be able o de ec i in ime was isible in he conscious moni o ing o he s a e, in he effo s o keep he wo k- load wi hin manageable p opo ions and in he abili y o lis en o he body’s signals, all o which a e mani es a ions o enhanced pe sonal agency. P oxy agency was exe cised h ough he supe ision p o ided by he wo kplace, which se ed as a o um o sel - eflec ion and ad- di ional moni o ing o he well-being. Paula had adop ed a new mindse h ough a men al shi : “I’ e ealised I’m no omnipo en […] a kind o anquilli y has se led in…being me ci ul o onesel […]I’ e done so much… ha I find joy in hings in a new way o in a bigge way han ea lie . Ea lie I would ha e s a ed a he unfinished wo k…oh, he e a e s ill so many hings o do, and I’ e only done his…now i ’s he o he way a ound: I ha e finished so much, and well, he e a e s ill unfinished asks…bu hey don’ s ess me...I’ll ge down o hem nex .” A ac o axing he esou ces was he mo he , who was eco e ing om cance , bu his was coun e balanced by an inc eased pool o physical, men al and in e pe sonal esou ces. Howe e , she epo ed an enhanced ma u i y and p udence in accep ing addi ional asks. In summing up he main easons o he eco e y Paula ga e c edi o he ehabili a ion p og amme o p o iding he wi h aluable knowledge abou bu nou and helping he adop a mind ul a i ude and an abili y o be p esen . She exp essed g a i ude o he husband, who had been a sou ce o suppo du ing he bu nou pe iod, and was hank ul o he oppo uni y o ha e a new ewa ding job. He ision o he u u e was posi i e and mo e amily-o ien ed. Paula demons a ed a lo o pe sonal and p oxy agency, bo h a he beginning, p io o he de elopmen o bu nou , du ing he sick lea e and a e ehabili a ion. I is no ewo hy, howe e , ha pe sonal agency, e en when p esen , ailed o lead o he desi ed esul s a he wo kplace. The es o a ion o balance was a slow p ocess in which pe sonal agency was suppo ed h ough he deploymen o p oxy and collec i e agency. He ex ensi e use o occupa ional heal h ca e was essen ial no only in aising awa eness and ini ia ing a men al shi , bu also in building obus pe sonal agency in he o m o asse i eness and sel -me cy. Paula held he accumula ion o excessi e wo kload and he mindse o being in cha ge accoun able o he de elopmen o he bu nou . This combina ion gene a ed a icious ci cle o inc easing ex a du ies and an inabili y o pu a s op o i . B eaking poin was eached “o e nigh ”. She ound aul wi h he wo k mo ali y adop ed in he childhood amily, whe eas she p aised he ehabili a ion p og amme. On a deepe le el o alues, “e il”was seen in he injus ice p esen in he wo kplace, in which employees we e no ea ed equally. The e hical i ue in u n can be seen in Paula’s men al ma u a ion. He men al awakening and s eng hening o pe sonal agency, which occu ed h ough he ecep- ion o ex e nal help, ans o med he om being a ic im in o being an ac i e agen . 3.4. As id, age 64, di ec o , ma ied: “Tu ning being ma ied o he job in o a happy ma iage” As id’s na a i e is an example o success ul eco e y (Table 4). I demons a es well he eco e y o pe sonal agency in a balanced manne , al hough i should be bo ne in mind ha he ini ial bu nou le el was no high. As id el he onse o bu nou wo yea s be o e he ehabili a ion cou se, when he pace a wo k in ensified and she s a ed ha ing p oblems sleeping. As id’s exhaus ion was he main eason she sough help and pa icipa ed in ehabili a ion. The p essu e caused by wo k was in ensified by pe sonal ac o s (he husband’s disease and agg a a ed poo heal h) and accele a ed by he own heal h p oblems, which axed he physical and men al esou ces. The onse o bu nou also caused As id o e hink wha wo k mean o he : al hough she was close o e i emen she did no wan o lea e he li e’s wo k unfinished. He esponse o bu nou was p oac i e and pe sonal agency was disce nible in se e al aspec s: she sough means o alle ia e he si ua- ion by lea ning o delega e, by accep ing social suppo om iends and colleagues, and by lis ening o music. The p og amme ga e As id many ake-home messages and led he o make significan shi s in he hinking and in he pe cep ion o he own bounda ies. She became awa e o he endency owa ds pe ec ionism and adop ed a mo e me ci ul and sel -app o ing a i ude. He well-being e en s a ed Table 4 Na a i e “Tu ning being ma ied o he job in o a happy ma iage”. P essu e a wo k and conce ns abou husband’s heal h −> exhaus ion −> unawa eness o he own s a e −> ecommenda ion by a doc o −> ehabili a ion p og amme −> aised awa eness −> inc eased sel -me cy and asse i eness −> men al shi −> e-o de ing o p io i ies −> ull eco e y Emo ional one: happy and elie ed Explana o y: own pe ec ionism Mo ally blamed: eeling o insufficiency Mo ally p aised: ehabili a ion and husband’s eco e y E hically good: e-o de ing o p io i ies in li e and being econnec ed o he amily E hically bad: – S. Salminen e al. Bu nou Resea ch 7 (2017) 1–9 6 imp o ing be ween he wo pe iods o he p og amme h ough an ac- cumula ion o posi i e e en s (imp o emen in husband’s heal h, no - maliza ion o wo king hou s, ime spen wi h g andchild en) and pe - sonal agency (spo s, con e sa ions a home abou he spouse’s disease, changes in nu i ion). The wo k en i onmen and he hi ing o an ex a pe son allowed o a mo e long- e m planning and o ecas ing, which in u n exe ed a beneficial effec on As id’s well-being. She also a ib- u ed he commencemen o eco e y o he pee suppo ecei ed om he ehabili a ion g oup, which ein o ced he p oxy agency. A sig- nifican men al shi was disce nible in he accoun : “When I came he e i el like being in a unnel, wi h no ligh a he end o i . The walls we e alling in. Bu now I see so many o he possibili ies, ha wo k is no always he only igh hing o do, ha he e a e o he hings you can spend you ime on. I don’ know, I don’ unde s and i I was eally so bu n ou ha I didn’ see any hing else. Bu now my mind has begun o clea in a o ally diffe en way” As id’s well-being was main ained a e he ehabili a ion p o- g amme and was de ec able al eady a he second ime-poin . This was also confi med by he BBI-15 measu emen sco e, which showed no p esence o bu nou . The hi d sub-na a i e was asse i e, imbued wi h posi i e emo ion, sel -confidence, dedica ion and commi men o wo k. Wo k was pe cei ed as manageable and enjoyable, and As id’s lea- de ship was isible in decision-making, conflic esolu ion and he handling o mino p oblems in he wo kplace. As id pe cei ed he sel as ully eco e ed. The e is also a sense o elie , as he husband’s suspec ed disease u ned ou no o be se ious. As he eco e y ad- anced, As id pu enewed effo in o he hobbies, which u he ac- cele a ed eco e y. As id’s pe sonal agency was high, and she a gued ha eco e y s a s om onesel , bu she also exe cised p oxy agency by elying on he occupa ional nu se’s ecommenda ions: “Reco e y s a s om onesel ...I’ e lea n wo k he ha d way and also I use he wo d le ing go and I ha e delega ed o he o he s...I ha e jus lea n i and come o he ealisa ion ha i I don’ le go hen I won’ be able o manage…and hen he e’s he occupa ional heal h nu se […] who always eminds me o my well-being…so his is also a means o help” She concluded he na a i e in a sligh ly humo ous way, which condensed he meaning o he ans o ma ion she had unde gone: “When I u ned 60 I said in my hank you speech ha he hea e has been my second home and my husband co ec ed me saying ha i was he fi s (laugh e )…and hen I ponde ed o he fi s ime whe he e - e y hing is in he igh o de (laugh e ), ha indeed i has been like ha ...I don’ know i i ’s inhe i ed om home, bu wo k has always been numbe one…and i has been ex emely difficul o change his, bu I hink I ha e succeeded in i .” As id’s na a i e demons a es he powe o p oxy agency e- p esen ed by he doc o , who sugges ed aking a dis ance om wo k, and he occupa ional heal h nu se, who suppo ed he a a la e s age. As id was able o a ail he sel ully o he lessons lea n in e- habili a ion. He na a i e, desc ibing he aised awa eness, men al shi and a changed a i ude owa ds he sel and wo k also shows he s eng hening o he al eady exis ing pe sonal agency. He mo i a ion o manage a wo k un il e i emen was high, bu his was handled in a balanced way, allowing o he inco po a ion o o he meaning ul and impo an aspec s o li e such as he amily, social engagemen s and spo s ac i i ies. The na a i e is comple e, and i s emo ional one is one o happiness and elie . He eco e y, commenced wo yea s ea lie , con inued on a s able pa h, along wi h a ealignmen o he alues and p io i ies in li e. The explana ion o bu nou was ound in onesel : As id’s pe ec- ionism and inabili y o delega e du ies is pe cei ed as he main eason o he bu nou . She blames he own eeling o inadequacy and he desi e o main ain con ol o e e e y hing, whe eas she exp esses he g a i ude o he ehabili a ion p o essionals and o he posi i e e en s ela ed o a amily membe ’s heal h. On he e hical le el, As id did no iden i y any hing as “e il”, bu ins ead celeb a ed he e-o de ing o he p io i ies in li e and he e-eme gence o connec edness wi h he amily. 3.5. Common hemes Acco ding o Riessman (2004, 2008), hema ic na a i e analysis enables common hema ic elemen s o be acked ac oss pa icipan s’ accoun s while a he same ime p ese ing he s o y as an en i y. Following Riessman’s guidelines (2008), we iden ified h ee common hemes ha we e encoun e ed ac oss he na a i es and which we e pa icula ly meaning ul o all ou pa icipan s. 3.5.1. The benefi s o he ehabili a ion cou se The e was common ag eemen ha he ehabili a ion cou se was c ucial o he eco e y p ocess. The cou se was ega ded by all pa i- cipan s as highly beneficial and awa eness- aising. The suppo and affi ma ion gi en by he ehabili a ion g oup alida ed he expe iences each pa icipan had indi idually gone h ough. The knowledge and p ac ical ad ice p o ided by he ehabili a ion p o essionals, along wi h hei non-judgmen al a i ude, helped pa icipan s a icula e and com- p ehend hei bu nou si ua ion and achie e bodily and men al awa eness. Th ough ehabili a ion and he exe cise o p oxy ( ia he p o essionals) and collec i e ( ia he g oup) agency, he pa icipan s’ pe sonal agency was e-ac i a ed and s eng hened, wi h i s effec s ex ending well beyond he du a ion o he cou se. Rehabili a ion was also an objec o he pa icipan s’sense-making p ocess and came in o mo al p aise. 3.5.2. Supe iso suppo Supe iso suppo was o immense impo ance o eco e y. An unde s anding, empa hic supe iso was able o alle ia e he symp oms o exhaus ion and acili a e he e-adap a ion o wo k by ensu ing adequa e wo king condi ions and p o iding emo ional suppo . An unsuppo i e o neglec ul supe iso , on he o he hand, ende ed one’s pe sonal agency comple ely ineffec i e (in Diana and Sa a’s cases), led o an inc ease in bu nou symp oms and he expe ience o injus ice. Fu he mo e, such a supe iso could p ecipi a e a change o job (as in Paula and Sa a’s na a i es). 3.5.3. Pe sonal ac o s Pe sonal ac o s such as di o ce, he sickness o a close amily membe o o onesel had a subs an ial impac on bo h he onse o bu nou subsequen eco e y om bu nou . The simul aneous p esence o a disease p e en ed o obs uc ed he pa icipan s om egis e ing o dis inguishing he onse o bu nou . The ea and anxie y as well as physical ailmen s caused by he disease in ques ion led in gene al o a dec ease in pe sonal esou ces and an inc ease in epo ed symp oms o exhaus ion and impai ed wo k capaci y, as seen in Paula’s and Diana’s s o ies. C ises such as di o ce slowed down ecupe a ion, as demon- s a ed in Sa a’s na a i e. The suspicion o a majo disease in he pa icipan ’s pa ne , as in As id’s case, had a simila effec , causing he pa icipan o expe ience an eno mous emo ional bu den on while he emo al o ha h ea had an immedia e posi i e impac on he pa i- cipan ’s well-being. 4. Discussion The p esen s udy in es iga ed he na a i es o ou pa icipan s co e ing he onse o bu nou and eco e y he e om o e he cou se o wo yea s. The esul s demons a ed ha eco e y om bu nou is a slow and indi idual p ocess, which does no ollow a uni o m pa h. The mos c ucial ac o s o eco e y in his pa icula sample we e agency, pa icipa ion in he ehabili a ion cou se and he supe iso suppo . Agency bea s a esemblance o aking con ol o one’s li e, S. Salminen e al. Bu nou Resea ch 7 (2017) 1–9 7 being in cha ge and assuming esponsibili y, and s udies ha e shown ha i plays a significan ole in ehabili a ion (Jä ikoski e al., 2013; Salminen e al., 2015). Agency is a obus p edic o o well-being and adap i e psychological unc ioning ac oss ime (Gallaghe , 2012), which emphasizes u he he long- e m effec s o a s eng hened sense o agency. Cong uen wi h his finding, ehabili a ion was ins umen al in ein o cing pe sonal agency h ough p oxy and collec i e agency wi h a ela i ely long- e m impac . Con e sely, he phase o bu nou was associa ed wi h ineffec i e pe sonal agency and he absence o o he modes o agency. I is no ewo hy ha e en in he na a i es o in e up ed eco e y and inc eased bu nou pe sonal agency emained p esen , al hough o a lesse deg ee han in he na a i es o s able eco e y. The combina ion o high pe sonal agency wi h a suppo i e job en i onmen and conduci e pe sonal ac o s p o ided he mos a ou able p e equisi es o beneficial eco e y. The ehabili a ion cou se was pe cei ed by all pa icipan s as ha ing had an eno mous posi i e effec on hei eco e y. I p o ided nu- me ous healing expe iences, affi ma ion and aluable knowledge in- s umen al o he ea ly ecogni ion o bu nou symp oms. Rehabili a ion in e en ions ha e been ecognized as means o he alida ion and affi ma ion one’s expe iences o bu nou in p e ious esea ch, al hough he o e all benefi has a ied depending on he s uc u e and con en o he in e en ion (Salminen e al., 2015; Fjellman-Wiklund e al., 2010;Söde be g, Jumisko, & Ga d, 2004). Supe iso suppo o he lack he eo had a huge impac on he ease o making he e u n o wo k and was an essen ial ac o influencing pa icipan s’pe cep ion o s ess. A suppo i e manage had a posi i e impac on well-being by alle ia ing he symp oms o exhaus ion and helping he eco e ing employee e-adap o wo k. This ela ionship has been demons a ed in o he s udies as well: Aas and colleagues (Aas, Ellingsen, Lindøe, & Mölle , 2008) showed ha ce ain leade ship quali ies, e.g., he abili y o make con ac , being unde s anding, being empa hic, acili a e he e u n o wo k a e sick lea e whe eas lack o suppo leads o an inc ease in he equency o sick lea e (Vaananen e al., 2003). The na a i es p esen ed he e we e highly indi idual and he e o- geneous, which bea s es imony o he ac ha bu nou is a mul iplex phenomenon as confi med by o he s udies (Ru he o d & Oda, 2014). Pa icipan s we e able o oice hei unde s anding o he pa h hey had walked and a ibu e pa icula meanings o he e en s and expe iences encoun e ed. As expec ed, he e we e also ce ain simila i ies and common ea u es, pa icula ly in he phase p eceding he onse o bu nou , e.g., hea y esponsibili ies, bodily mani es a ions, a igue and ul ima ely b eakdown, which ha e been epo ed in o he s udies as well (Eks ed & Fage be g, 2005). The eco e y phase mani es ed mo e a ia ion as he pa icipan s adop ed pa ially di e gen s a egies (e.g., change o job s. no change; agen ic e sus passi e/ ecep i e app oach) and we e affec ed by ac o s beyond hei con ol, e.g., ad e se changes in he wo kplace and a i ude o supe iso . The na a i es p esen ed he e demons a e ha a change o wo kplace pe se was no a decisi e ac o ei he con ibu ing o o impeding healing, as ound in p e ious esea ch (Be nie , 1998). A significan ac o was he amoun o change in impo an a eas such as supe iso suppo , and he possibili y o influence one’s wo kload and implemen changes aimed a diminishing wo k s ess. Pe sonal ac o s such as de e io a ion in one’s own o pa ne ’s heal h, o dis up ion in he amily (di o ce o dea h o a close ela i e) also played a majo ole in he exace ba ion o bu nou and impeded he pa h o eco e y. This demons a es ha bu nou does no occu in isola ion om o he li e e en s, bu in pa allel wi h hem, which in u n p esen s he isk o bu nou emaining un ecognized. Fu he mo e, eco e y may be slowed by hese pe sonal ac o s e en when he necessa y changes a e implemen ed in he wo kplace. 4.1. Me hodological conside a ions To inc ease he alidi y and eliabili y o he findings, we applied diffe en ypes o iangula ion. T iangula ion be ween me hods was implemen ed by collec ing da a om semi-s uc u ed in e iews and sel - epo da a (i.e., BBI-15, Nää änen, 2003) a he fi s and second da a collec ion poin s). Resea che iangula ion was also employed. The fi s in e iews in 2012 we e conduc ed by h ee independen in- e iewe s who we e no in ol ed in he ehabili a ion cou se and hus p o ided a neu al pe spec i e. The in e iews a wo yea s pos e- habili a ion we e conduc ed and ansc ibed by he second au ho . The hi d au ho , who is a clinical psychology esea che , p o ided knowledge o and p ac ical guidance on he applica ion o quali a i e me hods. The ou h au ho , who is a physician and an expe in bu nou , p o ided access o he ehabili a ion cou se and pa icipan s and ensu ed a smoo h da a collec ion. The las au ho and he p ojec leade , who is an expe ienced wo k and o ganiza ional psychologis as well as an occupa ional heal h esea che , p o ided expe ise on he heo e ical backg ound and da a analysis. All he in e iews we e audio aped and ansc ibed e ba im o ensu e maximum da a comple eness. The filled-ou ques ionnai es we e s o ed in acco dance wi h he e hical guidelines o a chi ing in Finland, and he BBI-15 sco es we e calcula ed by he fi s au ho o de e mine pa icipan s’bu nou ca ego y a he second collec ion poin . Pu pose ul sampling (Pa on, 2015) was applied in he s udy as we wan ed o explo e he effec o job change on subsequen eco e y. Semi-s uc u ed in e iews we e ega ded as a sui able me hod o cap u ing he expe iences o pa icipan s, and he use o a ques ionnai e con aining bo h s uc u ed and open ques ions was seen as an ap ool o epo ing in e im s a us. The use o na a i e me hods o analysis was jus ified due o he size o he sample and he longi udinal na u e o he da a. The use o na a i es allowed a mo e in eg a ed in e p e a ion o he expe iences epo ed by he pa icipan s (Bell, 2002) and a ocus on he o e all oad om bu nou o eco e y o epea ed bu nou . T acking he p ocess o eco e y o e ime offe ed a unique oppo uni y o unco e indi idual pa hs and sense-making p ocesses. The p esen s udy has na u ally ce ain limi a ions. Fi s , as i was he ou come o pu pose ul sampling, he size o he sample was e y small (Pa on, 2015). A la ge numbe o s udied pa icipan s could e eal u he common hemes and demons a e in g ea e dep h he impac on eco e y o changing s. no changing one’s job. Ad- di ionally, all he pa icipan s we e emale and hus u he s udies wi h mixed samples a e needed o alida e he esul s ac oss gende . How- e e , he s udy pa icipan s we e ep esen a i e o he popula ion y- pically a ending such cou ses (Hä inen e al., 2009, 2007, 2013). The esul s canno be gene alized beyond he s udy pa icipan s owing o he size o he sample and he ac ha pa icipan selec ion was based on a dec ease in bu nou symp oms. On he o he hand, such gene al- iza ions a e also beyond he scope and pu pose o quali a i e s udies. As his is he fi s s udy in es iga ing long- e m eco e y om bu nou by applying a na a i e app oach, i should be emphasized ha he ou - comes o he analysis may eflec cha ac e is ics o he bu nou and eco e y p ocesses specific only o hese ou pa icipan s. 4.2. Conclusions In all, he na a i es demons a ed ha he p ocess and he deg ee o eco e y om bu nou a y, as a mul i ude o ac o s –indi idual effo , ehabili a ion, change o wo kplace, and supe iso suppo – shape and modi y he pa h each indi idual akes. The mos a ou able pa h o eco e y appea ed o be ac i a ed when pe sonal agency was s ong and o he li e a eas –job en i onmen , supe iso , and amily membe s –we e conduci e o eco e y. I should be ecognised, how- e e , ha he ele ance o agency may be o e emphasized as he s udy pa icipan s we e ini ially selec ed on he basis o success ul eco e y, e en i pu pose ul sampling, using he c i e ia o deg ee o eco e y and job change, was applied a he las da a collec ion poin . Al hough he aim o he s udy was no o e alua e he effec i eness o he e- habili a ion cou se, i is no ewo hy ha he cou se was essen ial bo h S. Salminen e al. Bu nou Resea ch 7 (2017) 1–9 8 in equipping he s udy pa icipan s wi h he ools o ecognize and deal wi h bu nou and in s eng hening all h ee modes o agency, and hus i s inclusion in bu nou ea men should be conside ed. Fu u e s udies should aim a deepening he exis ing knowledge on he ela ionships be ween agency, job en i onmen and long- e m eco e y in a la ge and mo e di e se da ase , p e e ably including amily membe s’sub- jec i e expe iences o he en i e p ocess. Conflic o in e es The au ho s decla e ha he e a e no conflic s o in e es . Acknowledgmen The s udy was unded by a g an o S ela Salminen om he Uni e si y o Jy äskylä. Re e ences Aas, R. W., Ellingsen, K. L., Lindøe, P., & Mölle , P. (2008). Leade ship quali ies in he e u n o wo k p ocess: A con en analysis. Jou nal o Occupa ional Rehabili a ion, 18, 335–346. h p://dx.doi.o g/10.1007/s10926-008-9147-y. Bandu a, A. (2000). Exe cise o human agency h ough collec i e efficacy. 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