Collaboration in work ability assessment for sick-listed persons in primary healthcare.

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.

Quality in sickness certificates in a Swedish social security system perspective.

AIM: In Sweden, the information in the sickness certificate is crucially important for the sick-listed person as well as for the Swedish Social Insurance Agency and the sick-listed person's employer. The certificate is used as the basis for deciding whether a person is entitled to sickness benefits. Further, it communicates information significant for the return-to-work process. The aim of the study was to evaluate the quality of sickness certificates issued in primary health care and examine if the patients' or physicians' gender influences the information in the sickness certificate. METHODS: An insurance specialist at the Swedish Social Insurance Agency assessed the quality of the stated information in a sample of 323 certificates issued by 146 different general practitioners at 29 different primary health care centres in northern Sweden. RESULTS: Thirty-four percent of the certificates did not contain sufficient information requested. The areas of the certificates in need of supplementary information were mainly the descriptions of impairment of body function and activity limitation. More certificates issued for women than certificates issued for men lacked the required information. Full-time sick leave was more often prescribed for male patients than for female. Significant differences between certificates issued for women and certificates issued for men appeared in the group of musculoskeletal diseases. No differences in quality aspects connected to physicians' gender were found. CONCLUSION: Our study indicates a need for increased knowledge about the descriptions of functioning for sick-listed persons; more cooperation between health professionals in primary health care and a better gender awareness in health care encounters.

Healthcare encounters and return to work: a qualitative study on sick-listed patients' experiences.

BACKGROUND: Sickness absence is a complex phenomenon affected by aspects other than disease. One important factor that can affect sick leave is the individual's experience of healthcare encounters. It is therefore essential to consider the quality of the encounter with health professionals and its impact on the patient's rehabilitation and return to work. AIM: The aim was to explore how sick-listed patients in Sweden perceive their contact with healthcare professionals in primary healthcare and to analyse what they view as crucial components for returning to work. METHODS: A qualitative approach was used. Data were collected by semi-structured telephonic interviews with patients who were or had been on sick leave. The transcribed interview text was analysed according to qualitative content analysis. FINDINGS: The analysis revealed two themes that highlight important areas for persons on sick leave in their healthcare encounters. The theme 'Trust in the relationship' contains categories describing the patients' feelings of participation, and of being believed, confirmed, and listened to, and also dedication on the part of healthcare providers. Healthcare encounters that were characterised by professionalism, knowledge, continuity, and a holistic approach seemed to create trust. The theme 'Structure and balance' contains the participants' views on important factors that could support the return-to-work process. All participants stated the importance of follow-up and a plan for rehabilitation. Sick leave itself can make a person passive, and participants in this study asked for support to balance activity, exercise, and work demands, which could facilitate their return to work. CONCLUSION: Healthcare professionals can facilitate sick-listed persons' rehabilitation back to work by providing a clear structure in the process and support in occupational balance. The healthcare encounters must build on a mutual trust.

Work ability as obscure, complex and unique: views of Swedish occupational therapists and physicians.

UNLABELLED: The concept of work ability is not clearly defined although it has a central place in vocational rehabilitation. Several health professions are involved in assessing work ability, physicians and occupational therapists are two of these. OBJECTIVE: The purpose of this study was to explore occupational therapist and physician views about work ability and experiences in assessing work ability. PARTICIPANTS: Fourteen physicians and 23 occupational therapists participated in seven focus group discussions that were audio taped and transcribed verbatim. METHODS: Qualitative content analysis was used. Each author performed an individual preliminary analysis. These analyses were later discussed and refined in the research team and a workshop. The final categorization resulted in one theme, four categories and 13 sub-categories. RESULTS: The overall theme expressed work ability as an obscure, complex and unique concept. The four categories illustrate the affecting factors and confirm the complex structure of work ability: the person, the context of life, the work, and the society. Physicians expressed greater difficulty in assessing work ability than occupational therapists did, because they have fewer instruments to access this concept. CONCLUSIONS: Assessment of work ability requires team cooperation with several different professionals. Cooperation could increase accuracy in issuing sickness certification and strengthens the ability of identifying individual requirements for rehabilitation.

Work related factors and sick leave after rehabilitation in burnout patients: experiences from the REST-project.

INTRODUCTION: The aim of this study was to investigate the impact of psychosocial working conditions and coping strategies at work on change in sick leave level for patients on long-term sick leave due to burnout. METHODS: A cohort sample of patients (n = 117) on long-term sick leave due to burnout was analyzed. The patients answered a questionnaire at baseline and sick leave information was collected from the Swedish Social Insurance Agency at baseline and at follow-up 2 years later. Two groups were formed depending on whether the patients had "improved" and reduced their sick leave level (56%) or if the sick leave level was "unchanged" (44%) at follow-up. The association between change in sick leave and predictors measuring psychosocial working conditions and coping strategies at work were analyzed using logistic regression. RESULTS: The predictor, low control at work, was associated with unchanged sick leave at follow-up. When background characteristics were taken into account, usage of covert coping towards supervisors and covert coping towards workmates, respectively, also predicted unchanged sick leave level. High overcommitment was of borderline significance and associated with a reduced sick leave level at follow-up. CONCLUSIONS: Patients with burnout who have experienced low control at work and used covert coping towards supervisors and/or workmates have a higher risk of not reducing their sick leave after rehabilitation. The workplace may contribute to a reduction of sick leave lengths with a more flexible work environment and improvement in communication strategies for employees and supervisors.

Cognitively oriented behavioral rehabilitation in combination with Qigong for patients on long-term sick leave because of burnout: REST--a randomized clinical trial.

BACKGROUND: Despite an increase in the occurrence of burnout, there is no agreement on what kind of rehabilitation these patients should be offered. PURPOSE: Primary aim of this study was to evaluate effects on psychological variables and sick leave rates by two different group rehabilitation programs for patients on long-term sick leave because of burnout. Rehabilitation program A (Cognitively oriented Behavioral Rehabilitation (CBR) and Qigong) was compared with rehabilitation program B (Qigong only). METHOD: In a randomized clinical trial, 96 women and 40 men with a mean age of 41.6 +/- 7.4 years were allocated to one of the two rehabilitation programs. RESULTS: A per-protocol analysis showed no significant difference in treatment efficacy between the groups. Both groups improved significantly over time with reduced levels of burnout, self-rated stress behavior, fatigue, depression, anxiety, obsessive-compulsive symptoms, and sick leave rates. In an intention-to-treat analysis, patients in program A had fewer obsessive-compulsive symptoms and larger effect sizes in self-rated stress behavior and obsessive-compulsive symptoms compared to patients in program B. CONCLUSION: This study showed no differences in effect between CBR and Qigong compared with Qigong only in a per-protocol analysis. Both rehabilitation programs showed positive effect for patients with burnout.

Effort-reward imbalance, "locked in" at work, and long-term sick leave.

OBJECTIVES: The objective was to study the relationship between a situation characterized as being in a "locked-in" position (LIP) in occupation and/or place of work, Effort-reward imbalance (ERI), and long-term sick leave. METHODS: The study population derived from one section of a cross-sectional study SKA (sick-leave, culture and attitudes), and comprised all employees at the Swedish Social Insurance Agency responsible for management and compensation of illness in the working population. The analyses were performed for 2,951 women and 534 men who had complete data. Logistic regression was used to calculate odds ratio (OR) for ERI and sick-leave, the latter only for women. RESULTS: The results showed a strong association between LIP within the place of work and ERI (for women OR = 3.28 95% CI 2.65-4.07, and for men 2.74 1.75-4.30). Also LIP within occupation resulted in high ERI (for women OR = 1.96 1.57-2.41, and for men 1.92 1.22-3.03). In women, ERI (OR = 1.40 1.15-1.70) as well as LIP within place of work (1.88 1.50-2.36) and within occupation (1.48 1.12-1.86) were associated with sick leave. ERI showed a significant mediating effect between LIP and sick leave, within place of work and within occupation (Z value 2.20 and 2.88, respectively). CONCLUSIONS: High ERI is associated with a situation characterized by being locked-in within an occupation or/and within a place of work. The results thereby support the theoretical model of Effort-reward imbalance. The results show that high ERI and being locked in are associated with long-term sick leave. ERI is a potential mediator of the association between being locked in and sick leave.

Experiences within the process of sick leave.

The aim of this study was to explore what individuals who have been on sick leave experienced as important in the process of returning to work, moving to long-term sick leave, or receiving a disability pension. Grounded Theory was used for interpreting interviews with 15 people who had been on sick leave four years previously. In the results four ideal types were crystallized which are presented in the form of vignettes. The ideal types were discussed focusing on occupational life using the Model of Human Occupation and the theories of Sense of Coherence and Status Passage. The study provided a deeper understanding of people's experiences during the process of their sick leave. Valuable predictors for re-entry into work or disability retirement were: individual mental resources; clear or unclear diagnosis; how long had been spent in the sick-leave process; and personal belief in an ability to work in the future. The interventions and support given by professionals and the social environment, the balance and sense of coherence in life, and participation in the sick leave process were also important. The idealtypes found could be helpful to professionals working in this field in deepening their understanding of the clients.

Factors relevant to a return to work: a multivariate approach.

This paper contributes to the understanding of the factors that are significant for returning to work, and identifies factors that might be used early on in a period of sick leave to discern whether people are likely to work again. In the design, the multivariate Partial Least Squares (PLS) of Latent Structures method was used to analyse information from a questionnaire containing socio-demographic items, and information on symptoms, consequences on daily life, expectations and psychosocial factors. Data about the incidence of sickness over a four-year period was included. 121 adults aged 18-64 years on sick leave participated, irrespective of their diagnoses. A reliable prediction of a return to work required the combination of many factors: individual psychosocial instruments are not useful when considered in isolation. The strongest predictive factors for a return to work concern the individuals' expectations, the number of days of sick leave taken in the past, somatic disorders, and a high level of life satisfaction and sense of coherence. Many factors influence the outcome for people on sick leave: PLS analysis demonstrated that a multivariate approach using this method could predict the long-term outcome early on in a period of sick leave.

Significant resources needed for return to work after sick leave.

There are increasing numbers of people on long-term sick leave, especially with stress-related ill health and musculoskeletal disorders. The main purpose of this study is to, early on in the sick leave, find predictors of individual resources for a return to work. The study group consists of women and men on sick leave compared with reference groups of healthy persons. A questionnaire was used regarding diagnosis given on the doctor's certificate, self-reported symptoms, residential area, education, and kind of work. It also contained open questions about consequences in daily life and beliefs about future. Checklists concerning life satisfaction, sense of coherence, locus of control, coping resources and sick leave information over a four-year period have been used. Significant differences between the study group and the reference groups were found, relating to sense of coherence, locus of control, life satisfaction and coping resources. More than half of the study group were still on sick leave at a two-year follow-up. Important predictive factors turned out to be: previous sick leave, own belief about future and self-reported symptoms.

Socioeconomic prognosis after a newly diagnosed unprovoked epileptic seizure in adults: a population-based case-control study.

PURPOSE: To investigate the socioeconomic prognosis after a newly diagnosed unprovoked epileptic seizure in adults. METHODS: Sixty-three patients 17 years or older with a newly diagnosed unprovoked epileptic seizure from 1985 through 1987 and 107 sex- and age- matched controls were followed up for 10 years to 1996. Studied variables were income, source of income, sickness periods, incapacity rate, diagnosis-specific incapacity rate, vocational status, and education. RESULTS: Relative growth of income was similar between patients and controls during follow-up. Patients had lower income than did controls 2 years before seizure onset and during the entire follow-up. This was related to higher morbidity among patients, as measured by sickness periods and incapacity rate. Employment rates did not evolve negatively among patients after seizure onset and were close to employment rates of controls during follow-up time. There was no difference between patients and controls regarding education. CONCLUSIONS: After a newly diagnosed unprovoked epileptic seizure in adults, no negative development regarding employment and education occurs. Income development is positive unless refractory seizures evolve. However, income is lower among patients with epilepsy than among controls, and this difference can be related to overall morbidity.

The physician's role in the vocational rehabilitation process.

PURPOSE: To describe and analyse physicians' experiences of working with sick-listing and vocational rehabilitation, their perceptions of their co-actors and the interaction they participate in. METHOD: Thematic interviews with 14 physicians in Västerbotten County, northern Sweden. The physicians were active in primary or occupational health care, or as hospital doctors. The interviews were conducted during the autumn of 1996. The interviews were tape recorded and analysed according to Grounded theory. RESULTS: Feelings of isolation and diminished control, lack of time and increased demands are all seen as obstacles for doing an optimal job with sick-listing and rehabilitation. Other obstacles are insufficient knowledge regarding the labour market and the social insurance legislation. Interaction between primary and in-patient care does not function satisfactorily. The doctors believe in their patients and a majority of the doctors feel that the patients' own understanding of/need for sick-listing guides the doctor in his or her position regarding sick-listing. To facilitate return to work, the doctors encourage part-time sick-listing. CONCLUSIONS: The interviews show that the physicians experience a growing discrepancy between ideal and reality. They want to be able to act as "team players", but experience increasing demands due to the increased number of patients who are sicker than before. The doctors experience that decision latitude has diminished and this has been followed by less time for patients.