Positive encounters with rehabilitation professionals ... - IOS Press

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Work 22 (2004) 247–254 IOS Press

Positive encounters with rehabilitation professionals reported by persons with experience of sickness absence Ulrika Klangheda,∗, Tommy Svensson a,b and Kristina Alexanderson a,c a

Division of Social Medicine and Public Health, Department of Health and Society, Faculty of Health Sciences, Linköping, Sweden b Department of Behavioral Sciences, Link o¨ ping University, Link o¨ ping, Sweden c Personal Injury Prevention, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

Abstract. More knowledge is needed on different factors that can promote return to work among sick-listed persons. One such factor might be by their interactions with the rehabilitation professionals they encounter. The aim of the present study was to identify and analyze statements about positive encounters with rehabilitation staff, reported by persons who had been absent from work with back, neck, or shoulder diagnoses. A descriptive and explorative qualitative approach was used to analyze data from five focus-group interviews. There were few statements on positive encounters, and they were frequently attributed to sheer luck. Experiences of positive encounters were assigned to two major categories: respectful treatment and supportive treatment. Receiving adequate medical examination or treatment was also mentioned as being positive. Further efforts are needed to study and develop methods for investigating interactions with rehabilitation professionals that laypersons experience as positive and that may contribute to empowerment and influence return to work when sickness absent. Keywords: Sickness absence, sick leave, rehabilitation, encounter, return to work

1. Introduction Sickness absence is increasing in many Western countries, and musculoskeletal disorders, one of our largest public health problems, are the main diagnoses behind both sickness absence and disability pensions [6,18,24]. Nevertheless, the scientific knowledge base on effective treatment and rehabilitation measures regarding these diagnoses is very limited [24], and more information is needed regarding factors that can facilitate return to work among sick-listed persons with these and other diagnoses. Previous investigations ∗ Address for correspondence: Ulrika Klanghed, Division of Social Medicine and Public Health Science, Department of Health and Society, Faculty of Health Sciences, SE-581 85 Linköping, Sweden. Tel.: +46 13 22 42 32; Fax: +46 13 22 18 65; E-mail: [email protected].

of sickness absence have mainly focused on risk factors for sickness absence, such as gender, health status, satisfaction with work, motivation, physical and psychosocial work environment, or the design of insurance systems or rehabilitation programs [1,2,7,13,15,18,21]. By comparison, few studies have dealt with factors that influence return to work among sick listed. One such factor that might be of great importance is the type of treatment sick-listed persons receive from rehabilitation professionals, or, more precisely, the quality of the actual encounter between patient and professional [33]. Patients perceptions, satisfaction, and expectations associated with encounters with caregivers, primarily physicians and nurses, have been studied although definitions and measures of these aspects vary between studies [4,5,9–12,14,20,27,29,33]. However, very few studies have examined the interaction between persons on sick leave and the rehabilitation professionals they encounter.

1051-9815/04/$17.00  2004 – IOS Press and the authors. All rights reserved

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U. Klanghed et al. / Positive encounters with professionals reported by sick-listed persons

Patient experience is an important source of knowledge when attempting to identify factors that can promote return to work [28], therefore the opinions of sickness absentees regarding their encounters with rehabilitation professionals is an area of interest. In a previous study [30], expressions of negative experiences of encounters with rehabilitation professionals were described and analyzed. From a salutogenic perspective [3], it is also necessary to focus on encounters that persons look upon as positive, since such experiences may enhance empowerment and self-confidence, and promote return to work. This type of knowledge might also be highly useful in the training of rehabilitation professionals. To ask sick-listed persons direct questions about positive encounters with professionals would probably result in many accounts on that subject. However, at this stage of this research line we were interested in any emphasis sick listed might place on those encounters in relation to return to work. Therefore, we initially wanted to explore that topic by using a method other than asking direct questions about positive encounters. Hence, in this study analyses were performed on data from interviews that were focused on factors that hinder or promote return to work [25]. The aim of the present study was to identify and analyze statements about positive encounters with rehabilitation professionals made by persons who had been sickness absent with back, neck, or shoulder diagnoses.

2. The study Data from five focus-group interviews performed in 1998 were analysed. 2.1. Interviewees Interviewees were strategically chosen from a cohort of all the 213 persons in a Swedish city, who, in 1985, were 25–34 years old and had had a new sick-leave spell of at least 28 days with back, neck, or shoulder diagnoses [7,16,25,30]. In 1998, an introductory letter about the project was mailed to 84 persons. Of these, 63 persons could be reached by phone, and 33 agreed to participate and were assigned to one of the five focus groups. The remaining 30 declined to take part, because they had not had a back disorder for many years, they lacked the time, or they had other engagements on the dates of the five interviews. One person refused due to shyness. Fifteen of the persons did not show up

at the actual interview due to acute illness, or because they could not get away from work, or had forgotten the appointment [25]. In all, 18 persons were interviewed (Table 1). 2.2. Focus-group interviews Focus-group interviews are a well established method of data collection in health research [23,32]. All interviews in the present study were conducted in a public school building. The moderator explained the purpose of the interview and aspects of confidentiality, and informed the participants that they could withdraw at any time. The interviewees were encouraged to speak freely, and they agreed not to tell other people what was discussed in their focus group [25]. An interview guide that had previously been tested in a pilot study [26] was used. Focus of the interviews was factors that hinder or promote return to work when sick listed. The task of the moderator was to introduce new topics, to balance the participation of talkative and quiet interviewees, and to continually summarize what was said during the interviews [17]. An observer, sitting outside the group controlled the two tape recorders used for documentation and asked complementary questions at the end of the interview. Neither she, nor the moderator initiated talk about encounters the interviewees had had with professionals. In all five groups the discussions were active, and the atmosphere open and positive, which the interviewees also commented on afterwards. The introduction lasted half an hour, and the focus-group interviews approximately one and a half hours [25]. 2.3. Data analysis The five focus-group interviews were audio taped and transcribed verbatim. In the present study analyses of the data has been performed by using an descriptive and explorative qualitative approach [22]. The analyses were performed at the group level, and little effort was made to identify individuals who made certain statements or to note the frequency or intensity of certain comments [17]. The three authors individually read and analyzed all five transcribed interviews several times [17]. Each author independently identified statements about positive encounters with rehabilitation professionals, in other words, interactions that had led to positive emotions or that were described by the interviewees with positive words or emotions. The chosen quotations were


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Table 1 Participants in the five focus groups Group

1 2 3 4 5

Level of sickness absence Mixed High High Low Low

Agreed to participate Women Men 4 − 4 3 4 3 4 3 4 4

then compared and discussed in the group until agreement was reached on which statements to include. Pronouncements that were not agreed on to be clearly indicating positive encounters were excluded. Thereafter patterns were searched for in the identified quotations, categories were formed, and boundaries for categories were established. During this process several discussions and seminars about the analyses were held. Excerpts from the interview transcripts are presented below to support and illustrate our categorization, “/. . . /” shows that text has been omitted, and “. . . ” indicates a pause or brief silence. The designation after each quotation represents the first letter of the interviewee’s name, “W” for woman or “M” for man, and the letter “G” followed by a number (1–5) to indicate the focus group in question. The study was approved by the Swedish National Data Inspection and by the Local Committee for Research Ethics.

Dropped out Women Men 2 − 1 2 2

− 2 3 2 1

Interviewed Women Men 2 4 3 2 2

− 1 − 1 3

therapists, nurses, employment agency staff and, social welfare staff. The interviewees mentioned two types of positive encounters with professionals: verbal interactions and actions. It was also possible to assign the positive encounters to two major categories, namely: a) respectful treatment and b) supportive treatment (Table 2). Furthermore, it should be noted that the material also included another dimension of positive statements, in which the interviewees expressed satisfaction with having been given proper and adequate medical examination or treatment, for example X-rays or surgical procedures. However, these types of statements are not within the scope of our analysis, which instead focused on the interactions between rehabilitation professionals and interviewees, not on the type of medical treatment prescribed. 3.1. Respectful treatment

3. Findings A general observation from the analyses is that interviewees frequently attributed experiences of positive encounters with rehabilitation professionals to sheer luck. More precisely, some participants stated that they had gone through periods of interactions with various rehabilitation professionals that had not been helpful in solving their problems, and then, “purely by chance”, they just “happened” to meet a professional who they experienced as providing a positive encounter. Some interviewees related that they themselves had preserved and actively navigated through the care system to come in contact with rehabilitation professionals that they felt really improved their situation Expressions of experiences of positive encounters with professionals were found in the material from all five focus-group interviews, and were made by all interviewees, except by two males. The following professionals were mentioned: physicians, social insurance staff, physiotherapists, naprapaths, occupational

In this category of encounters, three subcategories were identified in which the interviewees experienced the following: that they were believed in and/or taken seriously; that they were acknowledged as being in the right; or that the professionals listened to them. The subcategory “being believed in” comprised encounters in which an interviewee stated that the professionals showed respect and did not question his or her story or disorders, and that she or he had confidence in the professional: Because now I’ve found a physician that I can trust. Who can see me, and I don’t have to explain what I need. (A. W. G 4) “Being taken seriously” by a physician was also described as essential and implied that the professional really paid attention to the patient. Another aspect was the great importance of eventually having been acknowledged as being in the right after first having been met with skepticism or treated badly. Both these aspects are illustrated by the following quote:

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U. Klanghed et al. / Positive encounters with professionals reported by sick-listed persons Table 2 Categorization of positive encounters with rehabilitation professionals expressed by individuals with experiences of sickness absence Respectful treatment – Being believed in/taken seriously – Being acknowledged to be in the right – Being listened to

Supportive treatment – Being supported/ encouraged – Personal involvement by professional – Individual’s abilities believed in by the professional – Professional acting as the patients “advocate” – Easy access to professionals

A fantastic physician. He was good because he took me seriously. My first impression of him wasn’t very positive, because we had a dispute/. . . /he told me “Kristina, you just have to live with this”/. . . /And I got so angry that I told him that he could just go to . . . yes, that’s right. Said that I would never accept this, just so you’re aware of that, I told him. /. . . / So he admitted his mistake and after that we had a good contact. (K. W. G 1) One interviewee said that it was like “a blessing in disguise” to end up at the emergency ward, where her disorders were finally acknowledged. This incident indicates the importance of being taken seriously, even though it was attributed to luck by the interviewee: It was like a blessing in disguise ending up at the hospital emergency ward. And it was somehow, yes, I think that was what saved me. Because then they began to understand that it was, that it was for real. Yes, somehow I felt that now, now they understand that I’m in this much pain. (B. W. G 4) 3.2. Supportive treatment Supportive treatment includes five subcategories in which interviewees experienced the following in their contacts with rehabilitation professions: being supported and/or encouraged; some degree of personal involvement; belief in their ability to work; willingness to be an advocate or spokesman; or easy to access. Several interviewees expressed the significance of being treated in a supportive manner, which seemed to imply being strengthened and encouraged by professionals. One interviewee said the following about staff at the rehabilitation clinic and the value of their encouragement: You kind of needed a little help to get started. And I must say, that I got that at the rehabilitation clinic at the hospital. I felt like I sort of managed one thing after another. . . . you need help to get on with your life. (K. W. G 4)

Providing treatment beyond what could be expected was another aspect identified and expressed in positive terms by the interviewees. A display of some degree of personal involvement by the professional, more than could be expected, was described as an appreciated quality. One interviewee talked about how her physiotherapists always say a few words when she runs into them down town: I still run into them nowadays, and, when I do, they say hello, how are you, and how are things going and so on/. . . /how fantastic they are. (K. W. G 1) The same individual gave another example, about a physician telephoning her at home to enquire about how she was doing: He could phone me and ask “How are you Karin, how are things going?” /. . . /When we run into each other in town, he comes up to me and talks to me. Same thing if he happens to see me at the hospital. (K. W. G 1) The interviewees who felt that the rehabilitation professionals believed in their abilities were in turn positive about the encounter with those experts. It seemed to be appreciated when the professionals recognized that, although the interviewees were on sick leave, they were still capable of doing some kinds of work. An interviewee said the following about how she perceived that a counselor at the employment office appeared to believe in her ability to work by suggesting that she should begin vocational rehabilitation, which provided new opportunities and eventually led to employment: Then we took a field trip to Samhall [a sheltered workshop] and then she told me “that might be a good job for you, you could at least try it”. So, it was actually just a test, but it worked out well, and I’ve been there since 1985, that’s how it happened. (A. W. G 2) One interviewee had experienced that her physiotherapists showed belief in her capacity by demanding some real effort from her when doing physical exercises, while at the same time, encouraging and coaching her:


And they were really hard on me, they brought me coffee when I was in the pool/. . . / I’d take a sip and then continue for a while and then take another sip and then they’d push me to the limits. In that way it was kind of like a pep talk, and they’d say that “when you’re done, you’ll get a massage and today you can go to the solarium, and do other things and we’ll help.” So, they’re just wonderful. (K. W. G 1) A positive experience described by some interviewees was that some professionals acted like their patient’s “advocate” or “spokesman” in problematic situations, and actually stood up for and supported them in a very direct way, for instance regarding private matters such as personal finances and family interactions. One of the interviewees recounted that when having difficulties in her relationship with her mother, her physician had phoned the mother to explain the situation: I talked to my physician a lot, because he knew about my problems with my mother. And he even phoned her and talked to her/. . . /“if you want to stop Kerstin’s progress now that she has had surgery and is supposed to get back on her feet, you had better not see each other any more. We can’t allow anything to interfere with her progress, and that means that YOU have to make a decision”. He was very hard on her. (K. W. G 1) Another example of this is that one interviewee felt that a woman at the employment agency had encouraged her to make her voice heard at a meeting with other rehabilitation experts, which seemed to increase the participation of the interviewee in the decision making: A lady at the employment agency encouraged me a lot. Several times we talked about the things I should bring up. And we had several meetings – just the two of us, so that she could pep me up. She told me to “take a lot of notes”, and then at the next rehabilitation meeting she began by saying “yes, this meeting, now A can take over, you can start now A”. So it was in no way a question of whether the others would be in charge, instead I was the one who was supposed to begin. (A. W. G 3) Interviewees talked about difficulties they had had in making contact with professionals, and they were consistently positive about professionals who were easy to access. A female interviewee who said that her naprapath had urged her to call immediately whenever she needed help illustrates this: And he told me “don’t wait, come as soon as . . . or call me immediately”. And I have always done so ever since. (I. W. G 1)

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Another interviewee mentioned a visit to a physiotherapist who introduced herself in a way that made the interviewee feel that they had established a good relationship and that the professional was available when needed: We were also in touch with physiotherapists who helped us with such things and also with exercises. “You need to do these exercises, you can come here, I am here for you.” The manner she introduced herself made it possible to establish contact in a different way. (A. W. G 3)

4. Discussion The aim of the present study was to identify and analyze statements made by individuals who had been on sick leave with back, neck, or shoulder diagnoses concerning positively experienced encounters with rehabilitation professionals. Compared to the number of negative encounters found in a previous study [30] using the same material there were few accounts of positive encounters with rehabilitation experts, and the interviewees attributed many of those to sheer luck. The positive encounters could be divided into two prominent, comprehensive categories, referred to as respectful treatment and supportive treatment, respectively. Positive encounters appeared as an important factor when people who have been on sick leave are asked to identify factors that promote return to work. 4.1. Methodological considerations In this pilot study we used a tentative and explorative approach to identify and analyze statements about positive encounters with rehabilitation professionals made by persons with experience of long-term sickness absence. It should be noted that our data are based on a relatively small sample and a specific diagnostic group, and the results cannot be generalized to other groups. Nonetheless, we contend that it has provided sufficiently interesting results to motivate further investigations with a more direct and focused design. The individuals who took part in the present focus groups had all been, and some still were, on sick leave with back diagnoses, and the interviews were arranged so that the participants would discuss their experiences of factors that hinder or promote return to work. The focus-group interviews proved to be successful for the purposes of the study. The group interaction encouraged the interviewees to share and discuss their own

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experiences, and to remember also events that had occurred many years ago. The number of persons not coming to the interview was large, which is often the case with focus groups, partly due to that the time for the interview cannot be altered for individual needs. The moderator and the observer did not base the interviews on theories about encounters with rehabilitation professionals. The fact that the moderator neither introduced nor asked questions about the topic of experiences of such encounters obviously implies methodological advantages as well as disadvantages. Emotional aspects of interactions can be a sensitive issue to discuss for a group of individuals who have not previously met [23], nevertheless, such discussion occurred spontaneously in all the focus groups. In fact, the interviewees frequently seemed to recognize each other’s experiences and to associate with similar encounters, which also lead to a willingness to share personal experiences. We might have obtained more explicit data if we had used more direct questions focused on the topic here under investigation. However, the interviewees talked about positive encounters with professionals even though they were not asked specific questions on that subject, which indicates that they perceived those experiences as being of importance in the context of factors that hinder or promote return to work. Experiences of laypersons who have previously had, or still suffer from, musculoskeletal disorders need to be studied, as such conditions represent a large public health problem and are the most common cause of sickness absence and disability pension. In the focus groups both individuals with none or little sickness absence, as well as persons with high sickness absence or on disability pension were included. This was done to ensure that there would be contrast and variation in regard to experiences related to being on sick leave and factors effecting return to work. Several steps have been taken to ensure the validity of the results [17]. The interview guide was previously tested in a pilot study [26] to confirm that questions were correctly understood, and, at the conclusion of every focus group, the respondents were asked to verify a summary of the comments [25]. The moderator was a trained group leader and had long experience of working with both individuals and groups of persons suffering from pain disorders. In the present analyses, the three authors read the interview transcripts independently many times. Quotations were first selected separately, and then compared and discussed in the group. Statements not agreed on by all authors to indicate positive encounters were excluded. The authors were of different ages, sexes and educational backgrounds.

4.2. Result discussion This study focused on expressions of positive encounters in general, and there were relatively few such statements compared to the number of negative encounters found in the same material in a previous study [30]. This might suggest that there was a real and substantial lack of positive experiences of interactions with rehabilitation professionals among the interviewed individuals. However, other possible reasons could be a misunderstanding; that the interviewees did not believe that positive encounters were of interest for the study and therefore did not mention them, or due to cultural circumstances; it might be considered inappropriate to talk about being respected, supported, or receiving adequate and good treatment. Furthermore, group norms may have affected the discussions, so that positive experiences did not seem meaningful or relevant and were therefore largely ignored. However, we do not consider these alternative explanations to be very probable. When the interviewees did mention positive experiences, those were described as being important, and there was no indication that they were regarded as irrelevant or inappropriate in the discussions. Respectful treatment appeared as one of the main categories of positive encounters. Interviewees described the importance of relational aspects of the encounters and of interpersonal competence displayed by rehabilitation professionals. “Being believed in”, “being taken seriously”, “being acknowledged as being in the right”, and “being listened to” were pointed out by the interviewees as essential elements of high-quality encounters with a positive emotional content. Moreover, the participants emphasized that it is important that a professional believes in and shows respect for the patient’s problem, and also believes in her or his capacity to solve or handle the problems at hand. The fact that several interviewees had consulted one physician after the other might reflect a desire to be listened to and to be understood. The results regarding respectful and supportive treatment are in accordance with previous research on interactions between clients and caregivers, mainly patientsphysicians [4,5,8–12,14,19,20,29,33,34]. However, studies on such interactions cannot always be compared with studies on encounters between individuals on sick leave and rehabilitation professionals. The importance of social interaction in care is often stressed, although in most cases interest has been focused on encounters between physicians and patients or nurses and patients. It has been suggested that the out-


comes of medical problems such as low back pain can be improved by engendering better understanding and communication between physicians and patients [8], and it has also been claimed that the personal relationships between these two groups represent one of the most important aspects of health care [19]. This is sup¨ ported by a study by Ostlund et al. [33], who found that persons on sick leave emphasized the quality of the personal treatment rather than the type of rehabilitation programs they had attended for return to work. Showing warmth, understanding, and respect for patients has been found to increase patient satisfaction with medical consultation [14] and also to influence the feelings of being helped and being improved [11]. Being taken seriously, being respected, and being believed in are important relational factors that indicate good care [20] and are the principal components of patient satisfaction [4]. Physicians who listen and take the concerns of patients seriously can provide more effective treatment and increase satisfaction [9], self-disclosure, and trust [29] among their patients. However, in the present study we focused upon encounters promoting return to work, not on patient satisfaction nor on compliance, two often used outcome measures in such studies. Supportive treatment, the second major category of positive experiences of encounters with rehabilitation professionals, involves the importance of being strengthened and encouraged by the professionals. This included showing personal interest, that is, when the professional provided treatment beyond expectations. This aspect has been shown to be important also in a study of Topor [31], including patients with mental disorders, and in a study by Fosbinder [10], including patients at an hospital. That the professionals showed that they believed in the patients’ abilities, for instance, by demanding that the individual made real efforts to benefit from implemented rehabilitation measures, was another important aspect. A third aspect was that rehabilitation staff took an advocate or a spokesman role in conflicts with other professionals or with relatives, as well as being easy to get an appointment with. The mentioned results agree well with the findings of Chewning et al. [5], who suggest that physicians who adopt a friendly and reassuring manner seem to be appreciated by patients to a greater extent than those who maintain a formal attitude during consultations and do not offer encouragement. Interviews of laypersons with long-term sickness absence have indicated that supportive treatment combined with individually chosen measures and goals are important for the rehabilitation process, and, together with adequate treatment, these

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aspects seem to represent the most prominent expectations of a patient consulting a physician [12,33,34]. Nevertheless, little is known about whether personal interactions and positive encounters with professionals actually promote health or return to work. Clearly, more attention and research should be focused on these issues. That experiences of positive encounters with rehabilitation professionals were often attributed to luck also indicates the need for substantial research efforts in this area. It seems reasonable to suggest that interactions between rehabilitation professionals and clients induce either positive or negative emotions, depending on the interpersonal competence of the professionals and how the clients experience the encounters. The interviewees’ comments indicate that their interactions with rehabilitation staff affected their self confidence, and thus, possibly the outcome of the received treatments, and the return to work.

5. Conclusions Positive experiences of encounters with rehabilitation professionals may facilitate return to work by individuals on sick leave. Further work is needed to determine what aspects of such interactions that are of importance and how they can be promoted. To obtain such knowledge patients’ experiences are probably highly significant, especially in the context of improving our understanding of the mechanisms of self-esteem or empowerment. Knowledge in this area is essential for the training of rehabilitation agents.

Acknowledgements Financial support was provided by the Swedish Council for Working Life and Social Research and by the Swedish National Social Insurance Board.

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