Background
Although work participation is an important determinant of public health, many people are confronted with a work disability [
1‐
3]. People with a work disability face unemployment twice as much as people without a disability [
4,
5]. Unemployment leads to a decrease in health for these individuals, since work provides structure, social contacts, a sense of belonging and the feeling of being part of society [
6‐
8]. In addition, unemployment greatly reduces the labour supply, which limits economic growth for society as a whole [
9].
In the Netherlands, people with a work disability can apply for disability benefits. The work disability policy is decentralised and delegated to the municipalities in order to provide individuals, referred to as ‘clients’, with customised support [
10]. In recent years, most municipalities have shifted towards a more support-oriented policy instead of a more control-oriented policy, because it proved to be more effective in supporting individuals to return to work (RTW) [
11,
12]. To support clients, that is people who receive a disability benefit and being supported towards RTW, many municipalities have pre-purchased re-integration interventions executed by a re-integration organisation, such as schooling or training (e.g., learning Dutch language), empowerment interventions, work placements to ‘learn’ the client to work etc., which are deployed depending on a client’s situation [
13].
After the application for a disability benefit has been received, reintegration professionals in the work and income domain check and approve the issuance of this disability benefit (‘legal aspect’) and primarily support the client toward RTW (‘goal-oriented’), adapted to his or her abilities [
14]. Depending on the municipality, these functions are either executed by one reintegration professional so that he/she has the complete overview of a client’s situation, or intentionally distributed among two reintegration professionals as some municipalities strongly believe that dividing the goal-oriented and the legal aspect is more effective in building an alliance with a client [
15].
The decisions and actions in order for a client to RTW, like promoting an individual’s employability, greatly impact a client’s life. Therefore, it is important to include the client’s preferences in the decision-making process [
15‐
17]. A method to stimulate inclusion of the perspectives of both the professional and the client, is shared decision making (SDM) [
15]. SDM originates from the medical sector and focuses on the three-talk model that contains three phases: ‘team talk’, ‘option talk’ and ‘decision talk’ [
18]. Firstly, in team talk a professional and the patient must cooperate as a team, after which the patient needs to be informed that he or she can be part of the decision-making process, and the professional and the patient need to discuss the shared goal they want to achieve [
18]. Secondly, the patient is informed about all the available options to reach the shared goal and all the possible pros and cons of these options are discussed, that is option talk [
18]. Finally, in decision talk, the preferences for the various options are discussed and a shared decision is made, which could also entail delegating the decision to the professional [
18].
The premise of SDM is that both the physician and the patient have unique and valuable information relevant to the decision; the physician provides evidence- and experience-based knowledge, while the patient contributes his or her preferences and personal experiences [
18,
19]. The use of SDM in doctor-patient relationships results in greater satisfaction with the alliance between physician and patient, higher levels of self-management and autonomy, and greater compliance with the plan of action [
16]; outcomes which could highly facilitate the process of RTW. Therefore, in this article we want to explore the research question whether reintegration professionals already use one or more of the SDM steps in their interaction with clients and to what extent, and whether they would like to use one or more of these steps in their ideal interaction with clients in the future.
Methods
We performed semi-structured interviews with reintegration professionals working for municipalities. Before the start of the interviews, we developed an interview guide to answer the research question of this study (see
Supplementary Material), based on the three-talk model explaining SDM [
18] and multiple work sessions with the research team to formulate and structure the questions. Features of the consolidated criteria for reported qualitative research (COREQ) [
20] were used to improve the design and quality of reporting the present qualitative research and are addressed in this methods section (see
Supplementary Material). The Medical Ethics Committee of the Netherlands Organisation for Applied Scientific Research TNO determined that no ethical approval was required for this study.
Participants
We recruited reintegration professionals. In the Netherlands, there is no specific training required to become a reintegration professional working at a municipality. Most reintegration professionals have a background (i.e., study and/or work experience) in social work. The professionals were recruited using two strategies. In the first strategy we approached managers of the municipalities with whom we have already cooperated in projects to optimise the support of professionals. We asked the managers if we could interview their professionals. After receiving the managers’ consent, we asked the managers to distribute information leaflets explaining the aim and content of the study among the professionals. Professionals who indicated an interest in participating, were invited to send an email to the primary researcher (MV), providing their name, contact information and the municipality they work. In the second strategy we informed professionals at a national conference, to which professionals of all municipalities were invited, of the possibility of participating in the study. They too could apply by providing their name, contact information and the municipality they work for in an e-mail to the primary researcher (MV), after which they were sent an information leaflet. We selected professionals using consecutive- and voluntary sampling [
21], including professionals who are Dutch-speaking, had over 5 years of experience and provided current and frequent support to clients to facilitate their RTW. We also selected professionals from four different municipalities, since each municipality has its own approach to work participation. In two municipalities, the execution of the legal aspect and support to RTW was performed by two separate professionals, in which we spoke to the person facilitating the support to RTW. In the other two municipalities, these functions were performed by one professional. Municipalities subdivide clients (i.e. people who receive a disability benefit and are supported towards RTW) into client profiles, categorised according to the estimated time to RTW or how ‘work fit’ a client is. We took care to select professionals supporting clients of all client groups; people who were not ‘work fit’ and had an estimated time to RTW of over two years, ranging to people who were work fit and were estimated that they could RTW right away.
Data collection
The semi-structured interviews with professionals were conducted by telephone in November 2018 and had a duration of an hour on average. The interviews with the professionals were conducted by an experienced female researcher (MV, PhD) working in the occupational health field. Participants were informed that all information obtained prior or during the study would be handled confidentially and that an audio recording would be made. Prior to the interview, all participants were asked to provide a verbal consent which was audio recorded. During the semi-structured interviews with the professionals, we zoomed in on the different steps supporting SDM in both their current interaction with their clients and their ideal interaction with their clients, specifically team talk (having a safe relationship and the professional and client collaborating as a team, informing clients that they can be part of the decision-making process and discussing shared goals), option talk (informing clients of all available options, and the pros and cons of these options), and decision talk (discussing the preferences of both the professional and the client of the available options and making a shared decision). We also focused on the execution and evaluation of the decisions and preconditions of the use of SDM. We interviewed participants until data saturation was reached.
Data analysis
The audio recordings of the interviews were transcribed verbatim. The transcripts were coded according to content analysis, applying open and axial coding [
22], using the Atlas.ti software program. Themes were derived from the interview guide, following the three-talk model of Elwyn et al. [
18]. The researchers MV and MaVi coded one of the transcripts independently using open coding, after which they discussed the codes until they reached a consensus. MaVi then coded the remaining transcripts. Afterwards the retrieved open codes were categorised into subjects and themes. The themes are described in the results section. During the process, the list of open, axial and selective codes was repeatedly checked by the primary researcher (MV) and discussed with the entire team to check the codes and reach a consensus.
Discussion
In this article we explored whether and to what extent reintegration professionals used SDM steps in their interaction with clients and if they would like to use one or more steps in their ideal interaction with their clients. Results show that reintegration professionals found it very important to have a good relationship with clients, to trust each other, and to work together as a team. They did not inform their clients that they could be part of the decision-making process or discussed a shared goal. Although professionals did emphasise the importance of aligning their approach with the preferences of the client and they tried to discuss some choice options, they did not discuss all available options or the pros and cons of these options, or evaluated decisions with their clients. They also did not mention these aspects in their ideal interaction with clients. Preconditions mentioned are either connected to the client, such as having motivation and self-management, or to the organisation, such as having choice options, having a reasonable caseload to apply SDM and reflecting on having to perform both goal-oriented and legal aspect of the job.
Trust, collaborating as a team, and having an alliance are expressed by professionals as essential elements of supporting a client toward RTW in this study. These are important steps, as emphasised in SDM literature [
18], and also in literature focusing on supporting clients toward RTW in general [
12,
15]. Although found to be essential, de Winter et al. [
23] stated that most of the municipalities in the Netherlands focus on checking entitlement to benefits, and fraud. This puts a damper on trust, collaborating as a team and having an alliance, and as a result it limits SDM and the support of clients toward RTW in general. This is emphasised by research stating that control decreases intrinsic motivation, because it fails to satisfy the basic needs of clients [
24]. This means that although professionals clearly mention the necessity of building trust and collaborating together, the policy of municipalities may counteract clients’ autonomy and intrinsic motivation. Municipalities should therefore consider the effect of the legal aspect of the job, and consider whether focusing on trust and collaboration (i.e., goal-oriented activities) is more effective in achieving both SDM and the support of a client toward RTW in general.
Not all steps of SDM are performed. For a start, professionals generally do not inform their clients that they can be part of the decision-making process or provide the client information about the various choices and their pros and cons. This lack of raising awareness and providing information, limits a client’s self-management [
16] and their intrinsic motivation as well [
24]. Although professionals indicate self-management in clients as a precondition for the use of SDM in this study, clients are denied the opportunity to do so due to lack of information [
16]; a vicious circle. Informing a client could be a crucial first step to break that circle. The medical sector offers various tools, such as decision aids, informational websites and campaigns [
25] that provide clients with the necessary knowledge and skills, facilitating the self-management in clients and the opportunity to discuss options, and SDM, applicable to both professionals and clients in this sector.
With regard to making a shared decision, professionals clearly indicated the importance of aligning the approach of the professionals with the preferences of clients. Therefore, most professionals strive to ask the client for his or her preferences before making a decision. They do so because they find that essential to motivate the client to take steps toward RTW. Research underlines this by explaining that a client’s intrinsic motivation can be an important facilitator to RTW [
12], which can be increased by clients experiencing autonomy and feeling connected to the process [
24], and is achieved by collaborating with a client during the process. Although professionals state the importance of including a client’s preference in the decision, they do not go so far as to actually make shared decisions; they express that they have the final say in the decision-making process. We believe that by not only including a client’s preference in the decision, but actually making shared decisions, intrinsic motivation of a client will increase even more because of the increased autonomy of a client in being part of the process [
24]. This is also the crucial difference with other available methods to facilitate support to RTW, such as supported employment or motivational interviewing [
25,
26]. These methods strive to involve the clients in the process, but differ in that they do not explicitly offer choice and that the client is not actually part of the decision making process and facilitated to make a decision.
Several professionals explained that they feel limited in their choice and decision options due to the pre-purchased interventions of municipalities, and the municipalities’ focus on professionals supporting RTW. In addition, a lack of evidence of the effectiveness of these pre-purchased interventions [
12,
27] limits the discussion about the pros and cons of the options. In fact, in the medical sector [
28] the pros and cons are discussed based on scientific evidence, which facilitates choosing the appropriate option. To increase choice and decision options, municipalities can explore whether these interventions are effective and for whom and when. This enables professionals to explain evidence-based pros and cons per intervention and per step toward RTW, and be able to meet the needs of the individual client instead of applying a supply-driven approach.
Although professionals are willing and strive to implement SDM, professionals clearly state that SDM is not suitable for all clients; they state that SDM is only for clients who are responsive and motivated, show initiative and follow-up on plans, in other words: self-management. However, as discussed, professionals do not provide the information to build the knowledge and skills needed for self-management and motivation. This can lead to a self-fulfilling prophecy [
16]. It implies that municipalities demand self-management in clients, but do not provide sufficient resources to achieve this. It could mean that there might be more clients who could be self-reliant and motivated if given sufficient information and opportunity [
16]. Finally, SDM would actually increase motivation, since the client has more autonomy in the decision-making process. Both of these reasons are underlined by de Winter et al. [
23]; they explain that how you treat the client determines how the clients will behave [
29]. In addition, as some professionals indicated that SDM is possible when adapted to the level of self-management of the client, professionals could explore whether SDM or steps of SDM could be performed adapted to the level of self-management of clients.
A limitation of this study is that we performed the interviews by telephone, which minimised the information from non-verbal behaviour. However, we elected this method to make it possible for more professionals to participate in the study, considering their large caseload and limited amount of time. Another limitation is that we approached professionals in municipalities that we already facilitated to optimise support for clients in their RTW. In addition to voluntary sampling, this means that these professionals were most likely to be more motivated to provide optimal guidance, and subsequently SDM, but that they were also more likely to provide us with more information on the ideal and current use of SDM. Another limitation is that we did not include the perspectives of clients into this study, to reflect on the steps used in SDM. Future research is needed on these perspectives and if clients recognize and prefer steps of the SDM in the received support towards RTW. Future research is also needed to explore and acquire insight into the experiences of both professionals and clients in the use of SDM, to see which elements of the approach add value to both clients and professionals. Finally, although professionals state that they are willing and motivated to use SDM, increasing the knowledge and skills of professionals seems needed [
30‐
34] to raise their awareness so they can reflect on the value of using SDM and the steps of SDM toward RTW. Also, providing clients with information seems necessary to facilitate self-management as a first step in increasing the applicability of SDM. Future research should focus on how and what knowledge and skills are needed for the use of SDM by professionals and clients.
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