ArticlePDF Available

The Work Ability Divide: Holistic and Reductionistic Approaches in Swedish Interdisciplinary Rehabilitation Teams

Authors:

Abstract and Figures

Stakeholder cooperation in return to work has been increasingly emphasised in research, while studies on how such cooperation works in practise are scarce. This article investigates the relationship between professionals in Swedish interdisciplinary rehabilitation teams, and the aim of the article is to determine the participants' definitions and uses of the concept of work ability. The methods chosen were individual interviews with primary health care centre managers and focus groups with twelve interdisciplinary teams including social insurance officers, physicians, physiotherapists, occupational therapists, medical social workers and coordinators. The results show that the teams have had problems with reaching a common understanding of their task, due to an inherent tension between the stakeholders. This tension is primarily a result of two factors: divergent perspectives on work ability between the health professionals and the Social Insurance Agency, and different approaches to cooperative work among physicians. Health professionals share a holistic view on work ability, relating it to a variety of factors. Social insurance officers, on the other hand, represent a reductionistic stance, where work ability is reduced to medical status. Assessments of work ability therefore tend to become a negotiation between insurance officers and physicians. A suggestion from the study is that the teams, with proper education, could be used as an arena for planning and coordinating return-to-work, which would strengthen their potential in managing the prevention of work disability.
Content may be subject to copyright.
Linköping University Post Print
The Work Ability Divide: Holistic and
Reductionistic Approaches in Swedish
Interdisciplinary Rehabilitation Teams
Christian Ståhl, Tommy Svensson, Gunilla Petersson and Kerstin Ekberg
N.B.: When citing this work, cite the original article.
The original publication is available at www.springerlink.com:
Christian Ståhl, Tommy Svensson, Gunilla Petersson and Kerstin Ekberg, The Work Ability
Divide: Holistic and Reductionistic Approaches in Swedish Interdisciplinary Rehabilitation
Teams, 2009, Journal of occupational rehabilitation, (19), 3, 264-273.
http://dx.doi.org/10.1007/s10926-009-9183-2
Copyright: Springer Science Business Media
http://www.springerlink.com/
Postprint available at: Linköping University Electronic Press
http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-19739
- 1 -
The work ability divide: Holistic and reductionistic
approaches in Swedish interdisciplinary rehabilitation
teams
Christian Ståhl1, 2*, Tommy Svensson 3, 4, Gunilla Petersson3, Kerstin Ekberg1, 2
1 National Centre for Work and Rehabilitation, Department of Medical and Health
Sciences, Linköping University, Linköping, Sweden
2 HELIX VINN Excellence Centre, Linköping University, Linköping, Sweden
3 Department of Behavioural Sciences and Learning, Division of Sociology,
Linköping University, Linköping, Sweden
4 Nordic School of Public Health, Göteborg, Sweden
* Corresponding author
Email addresses:
CS: christian.stahl@liu.se
TS: tommy.svensson@liu.se
GP: gunilla.e.petersson@liu.se
KE: kerstin.ekberg@liu.se
Running head: The work ability divide
Christian Ståhl
SAM/RAR
Department of medical and health sciences
Linköping University
581 83 Linköping
Sweden
+46 (0) 13 22 14 57
- 2 -
Abstract
Introduction
Stakeholder cooperation in return-to-work has been increasingly emphasised in
research, while studies on how such cooperation works in practice are scarce. This
article investigates the relationship between professionals in Swedish interdisciplinary
rehabilitation teams, and the aim of the article is to determine the participants‟
definitions and uses of the concept of work ability.
Methods
The methods chosen were individual interviews with primary health care centre
managers and focus groups with twelve interdisciplinary teams including social
insurance officers, physicians, physiotherapists, occupational therapists, medical
social workers and coordinators.
Results
The results show that the teams have had problems with reaching a common
understanding of their task, due to an inherent tension between the stakeholders. This
tension is primarily a result of two factors: divergent perspectives on work ability
between the health professionals and the Social Insurance Agency, and different
approaches to cooperative work among physicians.
Health professionals share a holistic view on work ability, relating it to a variety of
factors. Social insurance officers, on the other hand, represent a reductionistic stance,
where work ability is reduced to medical status. Assessments of work ability therefore
tend to become a negotiation between insurance officers and physicians.
- 3 -
Conclusions
A suggestion from the study is that the teams, with proper education, could be used as
an arena for planning and coordinating return-to-work, which would strengthen their
potential in managing the prevention of work disability.
Key words
Work ability; return-to-work; cooperation; team; interdisciplinary
- 4 -
Introduction
A multi-stakeholder or a system approach to return-to-work is supported by an
increasing number of studies [1-3]. Cooperation, though identified as a cornerstone of
successful return-to-work, is challenging due to incompabilities between stakeholders
regarding policies and definitions of concepts [1]. Furthermore, national systems of
social insurance differ, which makes the implementation of research results into
practice difficult.
In the Swedish sickness insurance system, the concept of work ability has become
increasingly important due to a change of policy, where the effect of a disease on the
individual‟s work ability is considered as the principle for eligibility to sickness
insurance rather than the disease itself. This development is in line with the trend of
“activating-welfare-states” in several Western countries during the last decades,
where work oriented labour market policies are commonly promoted [4, 5].
This study focuses on interdisciplinary rehabilitation teams as a cooperative work
form between two central stakeholders within the Swedish sickness insurance system:
the Swedish Social Insurance Agency (SSIA) and primary health care. The latter has a
central role since eligibility to sickness insurance is not dependent on whether the
disability is work-related or whether individuals are employed or not, which makes
occupational health physicians a less central actor compared to insurance systems
where eligibility is more closely tied to employment (cf. Canada or the Netherlands).
The work ability of the individual is assessed by physicians through a medical
certificate. This certificate is a legal document that the SSIA base their decision on
when considering eligibility to sickness insurance and when planning the individual‟s
- 5 -
vocational rehabilitation. Thus, the physician have a central role in the system, which
implies that their interpretation of the concept of work ability have an impact on
eligibility to insurance. This situation makes dialogue between physicians and the
SSIA a central issue.
Aim
The aim of this article is to determine how the relationship between health care
professionals and social insurance officers is expressed in twelve Swedish
interdisciplinary rehabilitation teams, specifically focusing on the definitions and uses
of the concept of work ability.
Research setting
In the county of Östergötland, interdisciplinary rehabilitation teams have been
initiated to facilitate return-to-work for people on sick leave and to reduce the societal
costs of sickness insurance by enhancing cooperation routines between health care
and the SSIA. The reason for choosing Östergötland as the research setting is that the
work form at the time of study was present only in this county. The work form could
be considered an exception from regular Swedish practice in handling sickness
insurance issues within health care, which makes a study of how the relationship
between the participating stakeholders develop relevant.
In the teams, physicians, occupational therapists, physiotherapists, medical social
workers and representatives from the SSIA regularly meet to discuss and plan the
rehabilitation of each individual for whom sick leave has exceeded twenty-eight days.
In some of the teams, representatives from employment services, psychiatric care and
- 6 -
social welfare offices attends team meetings. Team size varies between four and
sixteen participants, where those including many participants include several
physicians who participate when their patients are discussed, while teams with fewer
participants commonly have a permanent consultative physician.
Team meetings take place in health centres. The frequency of meetings varies, but
most commonly teams meet every two weeks. During the meetings, both new and old
cases are discussed regarding the plan for treatment, rehabilitation and return-to-work.
In every team, a coordinator (most commonly a nurse) is responsible for the
administration of the meetings. The task of the coordinator is to administrate and to
initiate team meetings, after which team members update themselves individually on
cases through the journal system at the health care centres. Further, the coordinator is
responsible for contacting the individuals to obtain an informed consent, either by
meeting them or by letter.
The teams are interdisciplinary in the sense that the participants are to jointly plan the
treatment; this can be contrasted with multidisciplinary work, where people from
different disciplines treat patients independently and then share information with each
other [6].
Work ability in theory and practice
Work ability is in the literature commonly seen as determined by both individual and
contextual factors. Illness and disease are examples of individual factors causing work
disability, while contextual factors include the organisation of work and social
relations in private or working life. An example of the latter is presented by Johansson
- 7 -
and Lundberg [7], who suggest that the adjustment latitude and attendance
requirements in workplaces have an impact on whether an individual will be able to
retain their work ability and whether sickness absent will be able to return-to-work.
The assumption that work ability is affected not only by individual factors is
supported by the WHO‟s International Classification of Functioning (ICF). The ICF
considers functioning as dependent on six interrelated components: disease and
disorders; functions and structures; activities, such as performing tasks or applying
knowledge; participation in family and social life or work environment;
environmental factors; and personal factors, such as age, gender and social
background[8]. The ICF model has been used as a point of reference when creating
schemes for assessments of function and work ability (cf. the Norwegian functional
scheme), and is also a reference in the Swedish medical certificate on work ability
issued by physicians. In the Swedish system, the physicians make an initial
assessment of how the disease affects the individual‟s functional capacity, based on
the ICF. Thereafter, in the same certificate, the physicians are to assess whether the
work ability is affected in relation to the individual‟s present occupation, and to what
extent it is reduced (25 %, 50 %, 75 % or 100 %). Hence, the functional capacity
determines the work ability in the assessments. However, the theoretical relationship
between functioning and work ability is not entirely clear.
A study of Dutch insurance physicians suggest that physicians tend to focus on the
“functions and structures” and “participation” components of the ICF model [9].
Previous studies of work ability assessments within the Swedish sickness insurance
system shows that physicians often take non-medical aspects into account when
- 8 -
assessing work ability, e.g. motivation for work [10, 11], indicating that both the
relation between functioning and work ability and the relation between legislation and
practice is unclear.
It is also of importance to note that assessments of work ability have different
purposes in different countries. In most countries, instruments for work ability
assessments are used for deciding upon eligibility to disability pension. Sweden
differs in this respect, since the concept of work ability is equally central to the
decisions on eligibility to temporary sickness benefits. It is also not entirely related to
the individual‟s occupation: after an initial period of six months, work ability should
be assessed in relation to the entire labour market rather than to a specific occupation.
Hereby, the Swedish sickness insurance is related to work rather than occupation,
which is mirrored in it‟s financing: the employer pays for the first two weeks of sick-
leave, after which the financing is taken over by the SSIA.
The present study does not offer a definition of the concept of work ability. Rather,
the purpose of the study is to identify how the different stakeholders in the
interdisciplinary teams interpret this concept and how these interpretations relate to
each other.
Interdisciplinary cooperation: a theoretical framework
In their study on treatment of back pain, Loisel et al. [3] propose a shift from disease
treatment to disability prevention. They introduce a disability prevention management
model that emphasise the involvement of the health care system as well as the
workplace system, the personal system and the compensation system in order to
- 9 -
prevent disability and to attain sustainable return-to-work. In their model, cooperation
between stakeholders is noted as a crucial factor in managing disability prevention,
suggesting that interdisciplinary teams should be set up to work with the patient in
order to function as a consultant towards the insurance system and the employer, and
to secure a coherent message to the individual.
The teams in this study involve two of the systems proposed in the model: the health
care system and the compensation system, which makes them a structure for
interorganisational dialogue between two central stakeholders in return-to-work [3].
However, they remain solely on an interprofessional level by not involving the
individual in team meetings.
Cooperation in public health settings, according to de Rijk et al. [12], is most often
concerned with actors who have some sort of dependency towards one another.
According to the authors, the perceived dependence rather than the objective
dependence is of interest; a conclusion from their study is that one of the requirements
for motivation to cooperate is the perception of interdependence. The authors also
acknowledge different types of interdependence: asymmetric dependence, where
power differences between involved actors are prominent; symbiotic dependence,
where actors need each other to achieve their respective goals and where one goal
does not disadvantage another; and competitive interdependence, where goals are in
opposition to each other [12]. Further, actors generally have multiple goals: some
might be symbiotic, while others are competitive. The authors also point out that
goals that are initially perceived as mutual may on closer inspection prove to be
divergent: the overall aim may be formulated similarly, while interpretations of the
- 10 -
aim may differ. The actors‟ perceptions of each other are also central to how
cooperation will work: the authors conclude that perceptions of the other and
willingness to cooperate are reciprocally interrelated. From an institutional
perspective, the dependence between actors and their ability to cooperate is also
affected by legislation and political decisions.
In this article, the theoretical framework of cooperation will be used in order to
analyse how the stakeholders in the interdisciplinary teams are interrelated and to
understand what factors that may affect cooperation in this example of a cooperative
work form.
Methods
In the study, the participants‟ perceptions, attitudes and experiences regarding team
work were central. In order to make an analysis of such aspects possible, an
interpretative approach was called for, and qualitative methods for data collection
were used [13].
Participants and data collection
The material for this study was collected between October 2006 and February 2007.
At the time of study, there were forty teams in total whereof twelve were selected for
inclusion in the study. The selection was made strategically to attain a suitable
variation regarding the length of time the team had been working in order to make
comparisons possible regarding the development of the teams. The oldest team in the
study was initiated in 2001, while the remaining teams were started between 2004 and
- 11 -
2006. One of the teams in the study included the employment service and the social
welfare office as additional stakeholders, and another team included a representative
from psychiatric care. These two teams were included in order to observe whether
additional stakeholders affect the dynamics of the team.
To capture the dynamics of the teams and to investigate the relationship between the
participants, twelve focus groups were held, one with each team. In the focus group
method, the discussion between participants concerning specific topics is central. In
this method, disagreements within the groups become obvious, and generally the
discussion does not result in any consensus. By using this method, a scope of
perspectives on the subjects discussed is presented through interaction between
participants who do not necessarily share each other‟s views [14, 15].
In the focus groups, teams were to discuss their work and the ways in which the new
work form was put into regular practice. All in all, the focus groups involved sixty-six
professionals, ranging from four to nine participants per group. The focus groups were
semi-structured, meaning that the role of the researcher was to initiate topics for
discussion, but not to act as an interviewer. A highly structured form would have
resulted in a group interview, and a lower level of structure might not have managed
to cover the subjects of interest [15]. Topics introduced by the researcher most
commonly served as starting points for the discussions. These topics were the history
and the implementation of the teams, how the roles of the professionals were
developed, and the practice of the teams. In the end, the focus group discussions
covered a variety of issues.
- 12 -
Four of the focus groups were conducted by one researcher, while two researchers
were present at eight of the interviews. In these cases, the second researcher had an
observing role, and discussions were held between the researchers after every focus
group about what had come up during the interview and how it could be interpreted.
In addition, individual interviews were conducted with the managers of the primary
health care centres where the selected teams were located, i.e. twelve interviews. The
focus for these interviews was a managerial perspective on how the teams have
affected the daily practice of the health care centres in handling sick-listing issues.
The interviews were semi-structured, based on an interview guide. The interviewees
were asked about the aim of the teams, how teams were implemented, about the
efficiency of the teams regarding sick-leave tenure, and how the managers perceived
that the teams have affected the professionals‟ practice.
The focus groups lasted for between one and two hours, and were recorded and
transcribed verbatim by a professional transcriber. The individual interviews lasted
for between fifteen and sixty minutes. By request, one of the individual interviews
was not recorded, but notes were taken during the interview. The remaining eleven
interviews were recorded and transcribed.
Analysis and interpretation
The analysis was performed according to the principles of a qualitative content
analysis [13]. The material was read through several times to get an overall view of
the content. The broad variety of issues raised in the focus groups resulted in several
possible paths for analysis. The first author made a preliminary thematisation of
- 13 -
recurrent issues in the material, covering both pre-established domains of interest
(such as the work tasks and implementation of the teams and how the participants
communicate with each other) and issues that arose from the discussions with the
respondents (such as different understandings of work ability and changes in the
medical professions). Hereby, the analysis can be said to incorporate inductive as well
as deductive elements, where theoretical concepts were applied both before (theories
of cooperation) and after (theories of work ability) the data collection.
The suggested themes were discussed with the co-authors, revisions were made, and
new discussions followed until agreement was reached on a thematic structure that is
well grounded in the empirical material and that shows satisfactory internal
homogeneity and external heterogeneity, i.e. that themes are well defined and does
not overlap [13]. For this article, these themes were narrowed down to focus on the
relationship between health care and the SSIA regarding their perspectives on work
ability.
Results
The material that has emerged from this study covers a variety of issues regarding
how interdisciplinary teams are started, how they function and what they can be used
for. This article focuses on the results that concern the relationship between health
professionals and social insurance officers, and how this relationship affects the
cooperation within the teams. This relationship can be illustrated through the
following excerpt from a discussion.
- 14 -
Social insurance officer: Of course, we don‟t look at illness – we look at work ability.
Occupational therapist: You look at work ability and we look at illness.
(Focus group 7)
Divergent perspectives on work ability, health and disease
A recurrent theme in the material is communication problems between social
insurance officers and health professionals, particularly physicians. Over the last
years, the Swedish Social Insurance Agency‟s (SSIA) use and definitions of concepts
have changed, for example the concepts of work ability and disease, where the
importance of the former has been strengthened. Simultaneously, the SSIA has begun
applying their regulations more strictly. In a recent change of regulations, the effect of
a disease on an individual‟s work ability has become the criteria for eligibility to
sickness insurance rather than the disease itself. A social insurance officer comments
on this change.
What has changed a lot is the SSIA‟s assessment of the concept of disease. I mean, what
was considered a disease just a few years ago is not considered a disease today. Then of
course I think of those people […] where something happens in life that affects how the
patient feels, that‟s where nowadays the SSIA often says no to sickness benefit. (Focus
group 9)
What the insurance officer says in the quote is that there has been a change in which
diagnoses that qualifies an individual for sickness benefits, and that some previously
recognised diagnoses have been disregarded. Further, the change of regulations
implies that physicians need to state not only a diagnosis, but also in what way this
disease affects the individual‟s work ability. This change results in increasing
demands on physicians when writing medical certificates, which is a development that
physicians rarely welcome. Also, the physicians often seem to disagree with the SSIA
whether their patients could be considered work disabled or not. In the following
- 15 -
quote, a discussion between a physician and a social insurance officer illustrates such
a disagreement.
Physician: If someone‟s child for example have been run over and they feel really bad,
you can‟t sick-list them […] if you follow the guidelines […]
Social Insurance Officer: Well, of course, what you can do is describe it as temporary
shock, stating that the plan from now on is to … And that‟s what‟s usually missing in the
certificate.
Physician: Well, that helps. But a state of shock? […] You‟ve got to be really strict,
what is it in the illness that reduces the patient‟s work ability? There‟s no disease that
reduces his or her work ability, but there is a family problem that‟s really difficult – and
that means that he or she can‟t work. (Focus group 3)
The key issue to understanding this disagreement lies in how the stakeholders define
the concept of work ability. The insurance officer needs a medical diagnosis that
complies with the regulations about which causes for reduced work ability that makes
an individual eligible for sickness benefits. If there is no medical diagnosis, as in the
example in the quote, the SSIA cannot authorise sickness benefits. Hereby, the
concept of work ability is interpreted in a reductionistic way focusing solely on
medical conditions, with disease as the only valid cause of work disability. On the
other hand, the physician in the quote presents a holistic view on work ability, where
illness or life crises makes an individual just as work disabled as if they would have
had a diagnosable disease.
What the insurance officer tries to accomplish in the quote is to reformulate the
situation described by the physician into a medical state: by medicalising the
situation, the insurance officer complies with the physician‟s wish to offer the
individual a period of sick-leave. Thus, what the quote illustrates is a negotiation
about how to formulate a certain situation to fit into the grid offered by the regulations
for sick-leave. It is therefore possible to look upon the quote as a sympathetic act from
- 16 -
the insurance officer in trying to handle the physician's holistic views on health and
work ability. Another possible interpretation is that work ability assessments are
affected by individual differences in how physicians formulate their certificates,
where a medicalised formulation is more likely to get accepted by the SSIA.
The holistic perspective seems to be prevalent among most health professionals in the
study. Consequently, the health professionals perception of the principal aim of the
teams is rather to improve the individual‟s quality of life, where enhanced work
ability is merely one of the potential outcomes. In the following quote, an
occupational therapist illustrates the holistic perspective toward the individual.
A lot of us, in the health care sector anyway, look at all this with a holistic view that the
authorities can‟t have, because they have a completely different, well, job focus or
whatever it is. Whereas I can see more that …, well I see my role in the team, like when
I meet a patient of course I look just as much at how things work on an everyday basis,
and how that person can have quality of life. (Occupational therapist, focus group 9)
Non-medical factors that affect whether an individual is able to work cannot be
included in the concept of work ability when defining it through the reductionistic
perspective of the SSIA. These differences in how the stakeholders interpret key
concepts imply that the SSIA and the health professionals will have different
perceptions of the goals of working in an interdisciplinary team, and that there is an
inherent tension between them.
Changes in professional roles
The tension between physicians and the SSIA is not only due to a change of insurance
regulations. Another reason is a change in the medical professions toward a more
- 17 -
cooperative stance. Both these changes have resulted in a loss of authority for
physicians, towards the SSIA and towards other health professionals.
It‟s this moving away from the idea of being some kind of almighty person who nobody
questioned, as they do now, so of course people are quite right to question doctors just
like everyone else. (Interview 8)
A reaction to this development is an increased scepticism among physicians, towards
the SSIA as such, but also towards new work forms aiming for a broadened
discussion of their assessments. Some physicians perceive the teams as a control
system, and several respondents express weariness over the increased demands,
illustrated here by a manager.
[…] you think you do a good job, and you would really like, yes, I think you would like
that your judgement as a doctor would be sort of good enough as far as the SSIA was
concerned. Because in some way your judgement is questioned by the SSIA, because
they see other things in the certificate. (Interview 11)
Two subgroups within the physician profession can be identified from the material.
One is the traditionalist physician who expresses sceptical views on development
towards increased cooperation and who seems to grieve the loss of authority. The
other is the cooperative physician who is more positive to a broadened responsibility
for the sick leave process, where other professions are considered necessary in order
to attain better assessments [16]. The following quote from a health centre manager (a
physician) illustrates this cooperative view, emphasising team work as beneficial for
managing long-term sick leave.
Of course, this is a help for us too with those who tend to be on sick leave for a long
time, that we sit down and discuss where we go from here, because in most cases of
long-term sick leave it‟s not the medical part that‟s the difficult bit, but often it‟s
everything else around it and how they are to move on, and then of course it‟s much
better to work as a team. (Interview 3)
- 18 -
Several respondents in the study emphasise that cooperative work through
interdisciplinary teams was something entirely new to them, and that the
implementation of the work form was made with a top-down approach, resulting in
further ambiguities regarding the purpose of the teams.
[…] the directive came from above and then all of us here were supposed to try and
adjust to that […] I remember the first meetings when we didn‟t really understand what
was intended and what the point of it was, and what form it was all going to take, and
then we all had to take it back home with us, and do it in our own way. (Focus group 10)
Moreover, managers had not allocated any economic resources for the teams to create
an arena for dialogue on team work. Adding this to the inherent tension regarding
definitions of concepts and a general lack of introduction, the preconditions for
reaching a common understanding on central concepts were not the best.
Assessing work ability: could team work help?
The quality of work ability assessments is negatively affected by the physicians‟
limited knowledge of working conditions in workplaces. This lack of knowledge
leaves room for subjective interpretations from the physicians on which abilities that
are needed in order to perform a certain kind of work. In such assessments, medical
expertise comes second-hand.
What they‟re supposed to do is to decide whether it‟s medical or not and how does the
work ability look as far as they can decide. It‟s impossible to know what they‟re doing in
a workplace, you can only, it‟s more about what knowledge I have as a human being and
a doctor, not what my profession says or my competence as a doctor, right? This isn‟t
about medical competence anymore. (Interview 2)
- 19 -
As a result, physicians tend to account for non-medical factors when assessing work
ability, such as the patient‟s motivation for work and the social context. An
implication of this is that work ability assessments may become subjectively biased.
These assessments are made in the initial state of the sick leave, and they affect the
further handling of the individual through the sickness insurance system as well as the
health care system.
In the teams, there are professionals with more detailed insights into individuals‟
working conditions, e.g. occupational therapists and physiotherapists. Still, there is an
ambiguity in the teams whether they are supposed to work with assessments and
reassessments of work ability. Several managers view the teams as an arena where a
discussion of such assessments can and should take place. On the other hand, one
manager who actually participates in a team states that the issue is not discussed at all.
No, I can‟t say that, because it‟s usually like this, to assess work ability, you need, you
need occupational therapy and physiotherapy and maybe other factors, and there‟s still a
lack there. So I can say it like this, I miss the possibilities of fully assessing the patient.
Because I can‟t assess this when the patient sits with me, then I can only go on the details
that the patient gives me. […]
But you meet an occupational therapist and a physiotherapist during the team meetings?
Don’t you discuss these things?
No, it hasn‟t, no. No. (Interview 5)
Several respondents in the teams are open to using the resource of an interdisciplinary
group to facilitate the assessments of work ability; particularly occupational therapists
and physiotherapists mention this as one of the areas where the teamwork could be
developed further. A physiotherapist notes how the cooperation with physicians in
work ability assessments is generally increasing, and that physicians have started to
use other professionals when assessing or reassessing patients‟ work ability.
- 20 -
Yes, we notice that the physicians […] like to talk to us physiotherapists, like, what
work ability does this patient have?”. They‟ll maybe meet them for five minutes or on
the phone and are supposed to prolong the sick-leave on those grounds, while we meet
them once or twice a week for a long time, so to speak. (Physiotherapist, focus group 11)
Time is a central factor in whether the physicians are able to make proper assessments
of work ability: while physicians seldom meet their patients, other professionals meet
them regularly.
So, could team work help? Many of the respondents claim that a more elaborated use
of the competences represented by physiotherapists and occupational therapists are
called for, and that the teams could function as an arena for such work. Thus, the
results of this study identify a wish among the health professionals to improve the
teams‟ possibilities in facilitating work ability assessments.
Summing up
As a summary, the results may be presented in a figure, describing different
approaches to two factors: work ability and cooperative work (figure 1). As becomes
visible in the figure, both of these factors represent barriers between team members
that need to be overcome in order to attain a common understanding of the work tasks
of the team. There is a barrier between health professionals and the SSIA regarding
the interpretation of work ability, and there is a barrier within health care between
traditional and cooperative physicians regarding teams as a work form.
- 21 -
Perspectives on work ability
Holistic Reductionistic
Positive to
cooperative work
Negative to
cooperative work
Figure 1: Divergent perspectives in the teams
Discussion
The teams in this study have had problems with reaching a common understanding of
their task, due to an inherent tension between the stakeholders regarding their
perspectives on work ability, and of different approaches to cooperative work among
physicians. This section focuses on the causes for this tension and on how it may be
resolved.
Understanding the tension
In order to understand the tension between the stakeholders in the teams, the theory of
cooperation introduced by de Rijk et al. [12] is useful as an analytical tool. The
authors emphasises stakeholders‟ goals, focusing on whether they are mutual or
divergent. According to the authors, goals may often seem mutual at first, while
proving to be quite divergent when going into depth. This situation can be recognised
Cooperative
physicians
Other health
professionals
SSIA
Traditional
physicians
- 22 -
also in this study, where the goals of physicians and social insurance officers are both
mutual and divergent. The mutual goal is a fair rehabilitation process for the
individual, but the interpretation of this goal differs. Hereby, the interdependence
between physicians and social insurance officers is symbiotic at the surface, while
being competitive concerning means and values. In practice this means that when
discussing sickness benefit issues, the stakeholders articulates the same goal, but since
they mean different things when using concepts such as work ability, health or
disease, they will not be able to find a common ground.
After the change of sick listing regulations, the medical certificate that physicians
issue has changed so that physicians need to state in what way the disease decreases
the work ability of the individual, which implies a more demanding assessment.
Through this change, it has also become possible for the SSIA to question the
physicians‟ holistic view on work ability. However, in the medical certificate the
physicians are to assess how the disease limits the abilities of the individual according
to the WHO‟s definition in the ICF model. Since the ICF‟s definition of functioning is
broader than the reductionistic definition of the SSIA, physicians are to choose from
taking either a broad or a narrow perspective on work ability. As shown in this study,
physicians tend to take the broader one. Thus, this reference to the ICF in the medical
certificate may work as a factor in creating the tension between the stakeholders.
As a result of the changes in regulations, the interdependence between physicians and
the SSIA has gone from asymmetric to symmetric: none of the stakeholders can at the
present time be considered having higher authority than the other. Although the
decrease of physician authority in the sickness insurance system has resulted in a
- 23 -
more equal relationship between the stakeholders, the tension between the
stakeholders has increased, due to physicians‟ discontent with the change. Neither has
the change made the goals of the stakeholders more symbiotic: rather, the differences
have sharpened as an effect of the equalisation of authority. Thus, the physicians‟ loss
of authority has resulted in a power struggle over sick-listing decisions.
The interdependence between physicians and other medical professions in the teams
is more asymmetric, placing the physician on a higher hierarchical level than the rest.
Previous research on the hierarchy of interdisciplinary teams in health care
strengthens the assumption that physicians takes and receives a higher position than
other professions when working together; physicians are often dominant, thereby
limiting the participation of other professionals [17]. In the present study, it was
obvious that teams with a strong traditionalist physician had more difficulties in
attaining a constructive dialogue and to find a common ground on central concepts
and issues compared to teams with cooperative physicians. Thus, the hierarchy within
health care is more obvious in teams where physicians predominantly represent a
traditional perspective on cooperation in sickness insurance issues. Where physicians
represent a more cooperative perspective, the interdependence between physicians
and other health professionals is more symmetric.
One interpretation of the asymmetric interdependence prevalent in the teams is that
medical education, for both physicians and other health professions, is focused
exclusively on their own profession, disregarding the fact that interdisciplinary work
is an increasingly common feature in medical practice [18]. Teamwork as such is
therefore contrary to medical single-mindedness and traditional medical socialisation
- 24 -
[6, 16, 19]. Since the socialisation in health professions is strong, cooperation is
dependent on changing attitudes, where a cooperative approach would imply a more
clear emphasis on patient outcomes through dialogue and joint decisions [6, 16].
As noted by de Rijk et al. [12], perception of the other and willingness to cooperate is
reciprocally interrelated. In the teams of this study, the prevalence of this reciprocity
is indicated by the differences between teams regarding how the physicians‟ attitudes
influence the possibility of cooperation: in teams where the relationship between
physicians and social insurance officers is tense, the willingness to cooperate is
negatively affected. A conclusion to be made from the focus groups is that a tense
relation between the stakeholders is more prevalent in teams where the physicians
represent a more traditional view of professional identity, placing less emphasis on
joint learning and responsibility.
Overcoming the divide
Despite their divergent approaches to work ability, physicians and insurance officers
work together. They do so because they are required to, and they do so by negotiating
how cases should be formulated to fit into the regulations, making the holistic and the
reductionistic approach meet at the middle: the holistic view is expressed in a
reductionistic way by formulating non-medical aspects of work disability in terms of
disease. The question is often therefore not whether an individual is eligible to
sickness benefit, but how the certificate could be formulated to secure that benefits
will be granted. As reported elsewhere, physicians actual work has not changed, but
what they write in their reports have [20].
- 25 -
The SSIA‟s emphasis on medical diagnoses places a close link between work
disability and the original disorder, which implies a risk that psycho-social or work
related factors of work disability are neglected in the assessments. As shown in the
study, physicians‟ approach to work disability generally include such factors, which
suggests that the noted negotiations about how to formulate certificates are more
concerned with attaining a “politically correct” description of the patient than with
reaching an appropriate assessment.
The teams in this study are primarily used to plan the medical treatment of the
individual, using the SSIA representative mostly as a source of information on the
insurance regulations. However, the results of this study suggest that an arena for
interorganisational dialogue on the concept and the assessments of work ability is of
need, and that the teams possibly could function as such. In order to make the teams
more efficient in facilitating return-to-work, the assessment of work ability could be
given a more central position in the teams‟ work in order to make better use of
physiotherapists and occupational therapists in assessing work ability.
Creating a functional team is dependent on bridging the work ability divide between
health care and the SSIA in order to achieve a common understanding on the purpose
of the teams. Without a proper implementation process, this is likely to take a long
time. Additionally, teams need to overcome hierarchical tensions in which the
physicians‟ attitudes play an important role.
Previous studies of cooperation in health care show that a discrepancy of values is
common [21]. However, a study of Loisel et al. [22] suggests that a targeted
- 26 -
educational effort can result in a more coherent team where the values of the
participants are more centred on the team‟s objectives and on team unity. This
strengthens the assumption that the teams in this study could have been more coherent
if the implementation process would have been done more carefully. It is possible that
the teams, with proper education, could function like a return-to-work coordinator
instead of being occupied with planning medical treatment.
Relating to the Disability Prevention Management Model presented by Loisel et al.
[3], the teams in this study comprises two of the systems proposed as central: the
health care system and the insurance system. In order to create a work form that
efficiently manages return-to-work and disability prevention, the other two systems
would also need to be included, i.e. the personal system and the workplace system.
There are also studies that suggests that the individual him-/herself are likely to make
a good prediction of his/her return-to-work [23].
If the teams in this study would embrace the ideas of Loisel et al. [3], they should
consider inviting the individual and his/her employer to the team meetings. Though,
involving these stakeholders would imply a radical change of the team structure
towards a larger team whose meetings could hardly manage more than one or a few
cases per meeting. Therefore there is a risk that the teams would become too time
consuming and difficult to administrate. It should be noted that some of the teams has
included the Public Employment Services as an additional stakeholder, which adds
some knowledge on the workplace system into the discussions. However, this was at
the time of study uncommon.
- 27 -
Methodological considerations
The design of this study was made to assure a fair representation of the experiences
and perspectives of the respondents and their views on the topics in focus. The
selection of respondents was made with regard to possible cases for bias, such as how
long teams had been working together, and which stakeholders that participated in the
teams. However, the study was not able to identify any of these factors as central to
the teams‟ functioning. Instead, the results show that teams differ substantially more
regarding what attitudes that are most common among physicians than regarding the
time the teams has been working. Further, no major differences could be identified in
teams with additional stakeholders regarding the work ability divide or perspectives
on cooperative work. Though, it should be noted that these conclusions could be the
result of the limited number of teams included in the study.
The credibility of the study is strengthened by the co-authors‟ examinations of the
analytic process, and the results and manuscripts have been discussed thoroughly, in
order to attain trustworthiness in Lincoln‟s and Guba‟s sense of the word [24]. The
results have also been validated through reporting back to the respondents and the
managers responsible.
In the focus groups, topics were both initiated by the researchers and the participants;
though, it is possible that the results would have been different if the researcher had
raised other topics for discussion. The analysis was primarily carried out by using
empirically grounded themes, which was related to a theoretical structure. The
approach therefore had both inductive and deductive traits.
- 28 -
Qualitative studies generally lack the possibility of generalisation to a broader
population in a statistical sense. However, there is no reason to assume that the teams
in this study are unique. The conclusions from this study may serve as a foundation
for future comparisons and hypotheses.
Conclusions
The results of this study show that the teams have had problems with reaching a
common understanding of their task, due to an inherent tension between the
stakeholders. This tension is primarily a result of two factors:
1. Divergent perspectives on work ability between the health professionals and
the SSIA, where the former represent a holistic approach, considering a
variety of factors as contributing to an individual‟s work ability, while the
latter represent a reductionistic approach, considering only disease as a valid
cause for work disability.
2. Different approaches to cooperative work among physicians, where
“traditional” physicians‟ dissatisfaction with changes in sickness insurance
regulations negatively affects the possibilities of cooperation.
A suggestion from the study is that the teams, with proper education, could be used as
an arena for planning and coordinating return-to-work, which would strengthen their
potential in managing the prevention of work disability.
- 29 -
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
CS: study design, fieldwork, first drafts of the analysis and writing the text.
KE: study design, examining and commenting on the analysis and the manuscript.
TS and GP: examining and commenting on the analysis and the manuscript.
Acknowledgements
The authors wish to thank Linda Schultz for assisting with the data collection, Peter
Johansson and Grace Hagberg for help with the selection of participants, Lars-
Christer Hydén for comments on the design, and Åsa Tjulin for valuable support
during the revision of the text.
References
[1] Brunarski D, Shaw L, Doupe L. Moving toward virtual interdisciplinary teams
and a multi-stakeholder approach in community-based return-to-work care. Work.
2008;30(3):329-336.
[2] Franche R-L, Baril R, Shaw W, Nicholas M, Loisel P. Workplace-Based
Return-to-Work Interventions: Optimizing the Role of Stakeholders in
Implementation and Research. Journal of Occupational Rehabilitation.
2005;15(4):525-542.
[3] Loisel P, Durand M-J, Berthelette D, Vézina N, Baril R, Gagnon D, et al.
Disability Prevention: New Paradigm for the Managemeng of Occupational Back
Pain. Disease Management and Health Outcomes. 2001;9(7):351-360.
[4] Esping-Andersen G. Why we need a New Welfare State. Oxford: Oxford
University Press 2002.
- 30 -
[5] Wilthagen T, Tros F. The concept of „flexicurity‟: a new approach to
regulating employment and labour markets. Transfer: European Review of labour and
research. 2004;10(2):166-186.
[6] McCallin A. Interdisciplinary practice a matter of teamwork: an integrated
literature review. Journal of Clinical Nursing. 2001;10:419-428.
[7] Johansson G, Lundberg I. Adjustment latitude and attendance requirements as
determinants of sickness absence or attendance. Empirical tests of the illness
flexibility model. Social Science & Medicine. 2004;58(10):1857-1868.
[8] World Health Organization. International Classification of Functioning,
Disability and Health. Geneva: World Health Organization; 2001.
[9] Slebus FG, Sluiter JK, Kuijer PPFM, Willems JHHBM, Frings-Dresen MHW.
Work-ability evaluation: A piece of cake or a hard nut to crack? Disability and
Rehabilitation. 2007;29(16):1295-1300.
[10] Sjukförsäkring, Kulturer och Attityder: Fyra aktörers perspektiv (Sickness
Insurance, Cultures and Attitudes: Four Actors' Perspectives) Stockholm:
Försäkringskassan (SSIA); 2006.
[11] Alexanderson K, Brommels M, Ekenvall L, Karlsryd E, Löfgren A, Sundberg
L, et al. Problem inom hälso- och sjukvården kring handläggning av patienters
sjukskrivning (Problems in health care in handling patients' sicklisting). Stockholm:
Karolinska Institutet; 2005.
[12] de Rijk A, van Raak A, van der Made J. A New Theoretical Model for
Cooperation in Public Health Settings: The RDIC Model. Qualitative Health
Research. 2007;17(8):1103-1116.
[13] Patton MQ. Qualitative research and evaluation methods. 3 ed. London: Sage
2002.
[14] Krueger RA. Focus groups: A Practical Guide for Applied Research. 2 ed.
London: Sage 1994.
[15] Wibeck V. Fokusgrupper (Focus groups). Lund: Studentlitteratur 2000.
[16] McCallin AM. Interprofessional practice: Learning how to collaborate.
Contemporary Nurse. 2005;20(1):28-37.
[17] Shaw A, Lusignan S, Rowlands G. Do primary care professionals work as a
team: A qualitative study. Journal of Interprofessional Care. 2005;19(4):396-405.
[18] Catto SG. Professionalism pompous, pretentious and outmoded? Journal of
Interprofessional Care 2005;19(4):313-314.
[19] Berwick DM. Ideas for medical education. Academic medicine.
1996;71(9):972.
[20] Berg M, Horstman K, Plass S, Heusden Mv. Guidelines, professionals and the
production of objectivity: standardisation and the professionalism of insurance
medicine. Sociology of Health & Illness. 2000;22(6):765-791.
[21] Wilmot S. Professional values and interprofessional dialogue. Journal of
Interprofessional Care. 1995;9(3):257-266.
[22] Loisel P, Falardeau M, Baril R, José-Durand M, Langley A, Sauvé S, et al.
The values underlying team decision-making in work rehabilitation for
musculoskeletal disorders. Disability and Rehabilitation. 2005;27(10):561-569.
[23] Storheim K, Brox JI, Holm I, Bø K. Predictors of return-to-work in patients
sick listed for sub-acute low back pain: a 12-month follow-up study. Journal of
Rehabilitation Medicine. 2005;37(6):365-371.
[24] Lincoln Y, Guba E. Naturalistic inquiry. Newbury Park: Sage 1985.
... Physicians are the most important source of information about the sick-listed's health. However, cooperation was found to be difficult due to the actors' different understandings of workability and the rules, regulations, and guidelines that the actors must follow (Lindqvist & Lundälv, 2018;Martin et al., 2012;Söderberg & Mussener, 2008;Ståhl et al., 2009;Thorstensson et al., 2008). Their study further highlighted that many physicians' lacked knowledge about the sick-listed's occupation, which leaves room for subjectivity in workability assessments and makes it more challenging to validate the existence of relevant disease or injury (Söderberg et al., 2010;Söderberg & Mussener, 2008;Ståhl et al., 2011). ...
... We also found that the sick-listed responded that they have perceived the presence of positive and negative experiences in these encounters as having an impact on their self-assessed ability to RTW (Landstad et al., 2009;Lynöe et al., 2013;Nordgren & Söderlund, 2016a;Nordgren & Söderlund, 2016b;Olsson et al., 2016). Articles addressing the SIO perspective more often addressed factors related to the encounter, such as SIOs' cooperation with stakeholders (Eriksson et al., 2008;Söderberg et al., 2010;Ståhl et al., 2009;Thorstensson et al., 2008), policy change (Lindqvist & Lundälv, 2018;Ståhl et al., 2011;Ståhl & Andersson, 2018), and the subsequent impact on SIOs' working conditions. One of the studies included aimed to shed light on SIOs' experience of facilitating the RTW of sick-listed workers (Løchting et al., 2020). ...
... However, despite efforts to progress the handling of workability assessments, such as by implementing training, guidelines, and standardised methods, research literature still reports that the process and cooperation between physicians and SIOs are beset with tension (Aamland & Maeland, 2016;Leoni, 2021). Differing understandings of workability are problematised by the sick-listed (Andersén et al., 2017;Eriksson et al., 2008;Holmgren et al., 2016;Lannerstrom et al., 2013), by SIOs in respect of their interactions with healthcare personnel (Lindqvist & Lundälv, 2018;Løchting et al., 2020;Martin et al., 2012;Söderberg & Mussener, 2008;Ståhl et al., 2009;Thorstensson et al., 2008), and the Employment Service (Ahlgren et al., 2008;Eriksson et al., 2008;Lindqvist & Lundälv, 2018;Söderberg et al., 2010). The stakeholders' different aims, motivations, and specialisations have been found to create gaps in how the parties understand workability. ...
Article
In the Scandinavian countries, social insurance officers (SIOs) hold key positions with regard to coordinating the return‐to‐work (RTW) process of workers on long‐term sick‐leave. This article aimed to systematically explore the experience of encounters between the sick‐listed and SIOs and set out the current scientific knowledge base on factors related to the encounter that are perceived as having an impact on the sick‐listed's RTW. A scoping review was conducted that included peer‐reviewed articles published in the English language in the period January 2000 to February 2021. Of the 435 articles reviewed to determine eligibility, 38 were included. Most of the articles included were qualitative (68%) and focused on the sick‐listed's experience of encounters with RTW professionals. The main finding of this review is that the majority of the sick‐listed perceived the encounters with SIOs as positive. The perspective of SIOs was less subject to study, and the research focus was more often concerned with practical aspects of the encounter, such as stakeholder cooperation and the impact of policy on SIOs' working conditions. Furthermore, we found that SIOs experience challenges in stakeholder cooperation and in performing workability assessments, especially where objective medical information is scarce. The findings of this review suggest that future studies should pay more attention to the SIO perspective in encounters between sick‐listed and SIOs.
... Further, as described by Stahl et al.; 'health professionals share a holistic view on work ability, relating it to a variety of factors. Social insurance, on the other hand, represent a reductionist stance, where work ability is reduced to medical status' [30]. These findings are therefore in line with the present study's findings, describing both the same difficulties and pointing out the same suggestion, namely that the teams need to cooperate more closely [30]. ...
... Social insurance, on the other hand, represent a reductionist stance, where work ability is reduced to medical status' [30]. These findings are therefore in line with the present study's findings, describing both the same difficulties and pointing out the same suggestion, namely that the teams need to cooperate more closely [30]. ...
... The OTs experienced that their assessments of the citizens' work ability were highly requested by the rehabilitation teams in order to help the teams make decisions regarding the next step in the citizen's rehabilitation process. Despite similarities in Swedish studies, it is difficult to say if the requests for OTs' interventions and competencies are similar in other countries, as this is the first study within vocational rehabilitation, to our knowledge, which has examined how OTs perceive that other professions request their competencies [29,30]. ...
Article
Full-text available
Background Twenty-nine out of 94 Danish job centres employ occupational therapists (OTs) and numbers are increasing. Occupational therapy (OT) vocational rehabilitations are diverse, and a more specific description of OT practice within this field is lacking. Aims To explore how OTs employed at Danish job centres describe their own competencies and what they perceive that their colleagues from other professions request from them. Material and Methods Firstly, working diaries were obtained from 16 OTs working in job centres and analysed using content analysis. Secondly, semi-structured interviews were performed and analysed using systematic text condensation. Results The 16 OTs described four areas of competencies to their profession’s practice within job centres; client-centeredness; a holistic approach; work ability assessments and ergonomics and adaptation. The OTs perceived that their colleagues requested their work ability assessment skills and their competencies as health professionals. Conclusion The OTs had a client-centered and holistic focus on the citizens’ whole life situation and used their health professional education and knowledge of ergonomics and adaptation to strengthen their work ability assessments. Significance The OTs perceived that they had competencies that supplemented the competencies of the interdisciplinary team. The results therefore support the inclusion of OTs within job centres.
... Twelve studies [25][26][27][28][29][30][31][32][33][34][35][36] were included in the analysis. All papers met the CASP quality criteria. ...
... A recurrent finding was the importance of having a holistic approach. Medical and non-medical factors were seen as inseparable and equally important as they interact and affect each other; therefore, understanding both the patient and her context was considered vital to assess the patient's work capacity [26,27,32,33,35]. Family situation, conflicts in relationships, social life, financial worries, addiction and lack of social support were all considered important factors for work ability [25,27,28,32,35]. ...
... So was the uniqueness of every patient, calling for individualized assessments [35]. Furthermore, we found uncertainties among physicians as to which non-medical factors could actually be included in the assessment [27,[33][34][35]. Understanding the patient's work place ...
Article
Full-text available
Background: Although a main task in the sickness certification process, physicians' clinical practice when assessing work capacity has not been thoroughly described. Increased knowledge on the matter is needed to better understand and support the certification process. In this review, we aimed to synthesise existing qualitative evidence to provide a clearer description of the assessment of work capacity as practiced by physicians. Method: Seven electronic databases were searched systematically for qualitative studies examining what and how physicians do when they assess work capacity. Data was analysed and integrated using thematic synthesis. Results: Twelve articles were included. Results show that physicians seek to form a knowledge base including understanding the condition, the patient and the patient's workplace. They consider both medical and non-medical aspects to affect work capacity. To acquire and process the information they use various skills, methods and resources. Medical competence is an important basis, but not enough. Time, trust, intuition and reasoning are also used to assess the patient's claims and to translate the findings into a final assessment. The depth and focus of the information seeking and processing vary depending on several factors. Conclusion: The assessment of work capacity is a complex task where physicians rely on their non-medical skills to a higher degree than in ordinary clinical work. These skills are highly relevant but need to be complemented with access to appropriate resources such as understanding of the associations between health, work and social security, enough time in daily work for the assessment and ways to better understand the patient's work place. Also, the notion of an "objective" evaluation is questioned, calling for a greater appreciation of the complexity of the assessment and the role of professional judgement.
... Qualitative studies have identified different barriers to collaboration between GPs and patient's employers: organizational factors such as lack of time and channels for communication [19][20][21], ethical/ legal aspects such as confidentiality [2,19,21], stakeholders' attitudes towards collaboration [19,22], and different perspectives and goals regarding RTW [20,21]. However, there is a lack of quantitative studies and results based on larger samples. ...
... Here, cooperation was defined as a physician characteristic, referring to a collaborative behavior. Ståhl et al. [22] showed that GPs' attitudes to collaboration can vary and influence whether collaboration takes place or not. In line with this, we found that GPs who found stakeholder meetings or other employer contacts valuable were more likely to have such contacts. ...
Article
Full-text available
Background: General practitioners’ (GP) contacts with sick-listed patients’ employers have been shown to be of importance for return to work. This study aimed to explore GPs’ contacts with sick-listed patients’ employers and factors associated with such contacts. Methods: In this cross-sectional study, 4228 GPs responded to a nationwide questionnaire about sickness certification (SC) practices. Outcomes of interest were participation in stakeholder meetings, having other contacts with employers, and satisfaction with employer contacts. Logistic regression models were used to investigate associations with factors related to the GP and the GP’s workplace. Results: Among GPs, 34.8% participated in stakeholder meetings and 15.1% had other employer contacts; 39.4% had any or both of these contacts. Of GPs who had contacts with patients’ employers, 65.8% were satisfied with the contacts. GPs regularly collaborating with rehabilitation coordinators had the strongest adjusted odds ratio (OR) for participating in stakeholder meetings, OR 2.72 (95% confidence interval (CI) 2.24–3.31), and having other contacts with employers, OR 3.85 (95% CI 2.85–5.21). Other factors positively associated with employer contacts were being a specialist, collaborating with other health professionals, finding employer contacts valuable, and having a joint SC routine/policy at the clinic. GPs who did not find SC problematic, had managerial support, or had enough resources for SC tasks were more likely to be satisfied with their employer contacts. Conclusions: Both physician characteristics and organizational factors had importance for GPs’ contacts with sick-listed patients’ employers. The findings imply that GPs’ collaboration with patients’ employers may be improved by interventions targeting both individual and organizational factors.
... Table 2, the dimension 'acceptability' is affected by an extensive number of factors, some of which limit the acceptability of work ability evaluations, for instance that the consequences clients suffer after the tests are not taken into consideration in the evaluation but only the results on the tests. In another study [21] physicians stressed the need for several hours of rest or sleep after a work day as a very strong reason for certifying sickness absence, which is in line with the holistic view upon work ability in terms of sustainability as opposed to what the SIA's work ability evaluation includes [22]. The SIA assesses a reductionistic version of work ability [22] using a biomedical perspective focusing rather on function compared to other more holistic approaches in assessing work ability from a biopsychosocial or ecological perspective [23] which may be used by other stakeholders in the welfare system. ...
... In another study [21] physicians stressed the need for several hours of rest or sleep after a work day as a very strong reason for certifying sickness absence, which is in line with the holistic view upon work ability in terms of sustainability as opposed to what the SIA's work ability evaluation includes [22]. The SIA assesses a reductionistic version of work ability [22] using a biomedical perspective focusing rather on function compared to other more holistic approaches in assessing work ability from a biopsychosocial or ecological perspective [23] which may be used by other stakeholders in the welfare system. The clients described how this reductionistic view upon their abilities and difficulties made them question the legitimacy and acceptability of the evaluation. ...
Article
Full-text available
Background: Studies of the social validity of work ability evaluations are rare, although the concept can provide valuable information about the acceptability, comprehensibility and importance of procedures. Objective: The aim of this study was to explore clients' perceptions of social validity of work ability evaluations and the following official decisions concerning sickness benefits within the Swedish sickness insurance system. Methods: This was a longitudinal qualitative study based on interviews with 30 clients on sick leave, analyzed through deductive content analysis. Results: Clients' understanding of the evaluation was dependent on whether the specific tests were perceived as clearly related to the clients' situation and what information they received. For a fair description of their work ability, clients state that the strict structure in the evaluation is not relevant to everyone. Conclusion: The work ability evaluations indicate low acceptability due to lack of individual adaptation, the comprehensibility varied depending on the applicability of the evaluation and information provided, while the dimension 'importance' indicated as higher degree of social validity. The official decision about sickness benefits however was considered unrelated to the evaluation results, lacking solid arguments and sometimes contradictory to other stakeholders' recommendations indicating poor social validity.
... Therefore, the report was found to strengthen the decision making of the jobcentres, where specific follow up interventions were suggested for each patient. The content of the report was also synchronized with the aims of rehabilitation, namely, the focus on person-centered functioning such as coping, work-related self-efficacy, RTW expectations, experiences and resources (27)(28)(29). The development and application of the ICFbased tools seem to have resulted in an extended understanding of functioning and work ability, thus having the focus on salutogenic factors in the personal and activities and participation domains. ...
Article
Full-text available
Background The ICF model is applied as a conceptual framework in occupational rehabilitation in Norway.Objective To systematically apply the ICF model in rehabilitation this study had the following aims: (1) apply an ICF subset by merging an ICF core set and an ICF set to assess functioning in rehabilitation patients related to work; (2) develop a patient-reported ICF questionnaire and a clinician-friendly ICF report complementing the clinician-rated ICF subset and (3) evaluate whether ICF-based tools (subset, questionnaire, report) support the communication between a clinical team, patient and jobcentre contacts during return to work (RTW) follow up.Methods Forty-one patients completing four weeks rehabilitation were recruited. The patients were referred from general practitioners and jobcentres. The ICF subset was a combination of the EUMASS core set for disability evaluation and suggested ICF categories by experts in vocational rehabilitation from Iceland. A clinical rehabilitation team interviewed the patients using the ICF subset and problems were quantified on a generic qualifier scale for body functions, activities and participation and environmental factors. The research team and clinical team developed an ICF questionnaire, by cross-culturally adapting the Work Rehabilitation Questionnaire to Norwegian. The same teams also developed an ICF report. The rehabilitation clinic forwarded the report and questionnaire to the patients' jobcentre contact, which was responsible for the RTW follow up. To evaluate the benefits of ICF-based tools, the clinical team, user representative and jobcentre contacts together participated in four workshops. They were asked the degree to which and in what way the tools supported the communication between them.ResultsThe ICF subset captured RTW challenges but was found to be time consuming. The jobcentres experienced the ICF report and questionnaire beneficial in the follow up as it strengthened their RTW decision-making basis and communication with the rehabilitation clinic and the patients about follow-up interventions.Conclusion The development and implementation of ICF-based tools for clinical practice was a preliminary success in supporting the communication between three stakeholders during RTW follow up. Future applications of ICF-based tools ought to integrate personal factors to capture both facilitators and barriers related to functioning and work, thus, getting closer to a holistic assessment.
... Workplace interventions specifically target the problem as it affects the person's ability to function in the workplace and involve the active involvement of the employee. However, such a process is likely to be challenging as the employee and employer may have different perspectives and aims [10]. Nevertheless, there is some, although mixed, evidence that work-based interventions can reduce sick leave due to CMD [11,12]. ...
Article
Full-text available
Background: Common mental disorders are the leading cause of workplace absences. While the reasons for this are multifarious, there is little doubt that stigma related to common mental disorder plays a large role in sickness absence and in poor help-seeking. Frequently both managers and staff are unsure of how to approach and intervene with mental health related problems. We have therefore devised a mental health intervention programme (Prevail) that aims to reduce stigma and to educate staff about evidence-based low intensity psychological interventions. These can be used by the individual, as well as in collaboration with managers via co-production of problem-focussed solutions, with the aim of improving mental health, reducing sickness absence, and increasing workplace productivity. Methods: This two-armed cluster randomised control trial (RCT) will evaluate the effectiveness of Prevail. Eighty managers at a large UK government institution (the DVLA) and their teams (approximately 960 employees) will be randomised into the active intervention group or control (employment as usual) arms of the study. All participants will be invited to complete a series of questionnaires related to mental health stigma, their current and past mental health, and their recent workplace productivity (absenteeism and presenteeism). All employees in the active arm will receive the Prevail Staff intervention, which covers stigma reduction and includes psychoeducation about evidence-based low intensity psychological interventions for common mental disorder. The managers in the active arm will also receive the Prevail Managers programme which covers communication skills, problem formulation, and problem-solving skills. The questionnaire battery will then be given to both groups again 4 weeks post training, and 12 months post-training. Official records of absenteeism from Human Resources will also be gathered from both active and control groups at 12 months post-training. Discussion: The treatment trial aims to evaluate if Prevail reduces mental health related stigma (of a number of forms), increases help-seeking behaviours, and increases workplace productivity (via decreased absenteeism and presenteeism). Trial registration: ISRCTN12040087. Retrospectively registered 04/05/2020.
... As all RTW stakeholders (i.e. employers, workers, health care providers) operate from distinct economic, social and legislative contexts, RTW coordinators may facilitate communication between parties that, at times, have conflicting goals and objectives [7,8]. ...
Article
Full-text available
Purpose This scoping review was completed to explore the role and impact of having a return-to-work (RTW) coordinator when dealing with individuals with common mental ill-health conditions. Methods Peer reviewed articles published in English between 2000 and 2018 were considered. Our research team reviewed all articles to determine if an analytic focus on RTW coordinator and mental ill-health was present; consensus on inclusion was reached for all articles. Data were extracted for all relevant articles and synthesized for outcomes of interest. Results Our search of six databases yielded 1798 unique articles; 5 articles were found to be relevant. The searched yielded only quantitative studies. Of those, we found that studies grouped mental ill-health conditions together, did not consider quality of life, and used different titles to describe RTW coordinators. Included articles described roles of RTW coordinators but did not include information on their strategies and actions. Included articles suggest that RTW interventions for mental ill-health that utilize a RTW coordinator may result in delayed time to RTW. Conclusions Our limited findings suggest that interventions for mental ill-health that employ RTW coordinators may be more time consuming than conventional approaches and may not increase RTW rate or worker’s self-efficacy for RTW. Research on this topic with long-term outcomes and varied research designs (including qualitative) is needed, as well as studies that clearly define RTW coordinator roles and strategies, delineate results by mental health condition, and address the impact of RTW coordinators on workers’ quality of life.
Article
Full-text available
Purpose: Identify ethical issues that arise in the coordination of return-to-work (RTW) among employees on sick leave due to common mental disorders (CMDs). Material and methods: 41 semi-structured individual interviews and one focus group interview with stakeholders (n = 46) involved in RTW: employees on sick leave due to CMDs, coordinators and physicians at primary health care centres, managers, representatives of the Swedish social insurance agency and occupational health services. A six-step thematic analysis focused on the ethical values and norms related to autonomy, privacy, resources and organization, and professional values. Results: Five themes were identified: (1) autonomous decision-making versus the risk of taking over, (2) employee rights versus restrictions to self-determination, (3) respect for employee privacy versus stakeholders' interests, (4) risk of unequal inclusion due to insufficient organizational structure and resources, (5) risk of unequal support due to unclear professional roles and responsibilities. Conclusion: The main ethical issues are the risks of unequal access to and unequal support for the coordination of RTW. For the fair and equal provision of coordination, it is necessary to be transparent on how to prioritize the coordination of RTW for different patient groups, provide clarity about the coordinator's professional role, and facilitate ongoing boundary work between stakeholders. IMPLICATIONS FOR REHABILITATIONUnfair and arbitrary criteria for inclusion to the coordination of RTW implicate risks of unequal access for the employee on sick leave due to CMDs.Unclear professional roles and responsibilities among stakeholders in the coordination of RTW implicate risks of unequal support for the employee on sick leave due to CMDs.Coordination of RTW should be transparently prioritized on policy and organisational levels to secure fair and equal inclusion.The coordinator's professional role should be clearly defined to facilitate boundary work between stakeholders and improve the competence around the coordination of RTW.
Article
Background: General practitioners (GPs) have expressed difficulties in issuing sickness certificates and problems may arise if this work is not performed in an adequate manner. There is scant knowledge about how collaboration with other professions could be organized to enhance this work. Objective: Evaluate the feasibility of occupational therapists (OTs) performing supplementary assessments for persons on sick leave. Methods: Four healthcare centres (HCs) tested a working approach intervention where sick-listed patients were offered a complementary occupational therapy assessment. The OT assessments were intended to provide useful information for GP issued extended sickness certificates. Data on sick leave, sickness certificates and patient questionnaires were collected at different HCs. Interviews were conducted with GPs and OTs and the Consolidated Framework for Implementation Research was used to analyse the intervention's implementation. Results: No major differences in the sickness certificate quality was found. Available data on sick leave increased for all HCs during the project. Not all GPs used the OT assessments, which indicates that the implementation of the intervention was insufficient. Conclusion: Testing a new working approach in primary healthcare requires an implementation strategy. To improve sickness certification quality, this work needs to be prioritized as an important healthcare task.
Article
Although professional values present problems of definition and evidence, differences and similarities can nonetheless be identified in relation to nursing and social work. There are good arguments for accepting the differences as being unavoidable, and perhaps desirable; and for concentrating on optimising the quality of interprofessional dialogue around values, rather than for seeking to remove those differences. A conceptual framework for evaluating that dialogue is considered. © 1995 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.
Article
Does the increasing importance of guidelines in health care threaten the professional status of health care professions by reducing their professional autonomy? Or does it increase their position through enhancing their scientific status? In this paper, we focus on this apparent contradiction by studying how Dutch insurance physicians created and used guidelines for the evaluation of labour disability claims. Drawing upon the theoretical repertoire of science and technology studies, we studied the role of the notion of ‘objectivity’ in these developments. A specific redefinition of objectivity played a core role in the active alignment, by the insurance physicians’ profession, of the processes of guideline development and professionalisation. Simultaneously, it is argued, a specific conceptualisation of the position of the client was put to the fore. Guidelines, it seems, can be drawn upon creatively so that rather than embodying a potential constant threat to professional autonomy, they actually enforce it.
Article
• The aim of this literature review is to explore the development of interdisciplinary practice.• The terms interdisciplinary, multidisciplinary, and inter-professional are problematic. Definitions must be viewed carefully, as interpretations tend to reflect historical socialization patterns that are now out of kilter with contemporary understandings.• Changing inter-professional interactions, teams and teamwork are examined; findings indicate that explanations of interdisciplinary teamwork should be all-inclusive of the particular cultural conditions and contextual determinants that affect team practice.• Findings need to be viewed with caution because what is applicable in one country may not be automatically transferable to another, where particular socio-political contexts shape interdisciplinary practice.