Integration of the work-related online aftercare intervention ‘GSA-online plus’ (healthy and without stress at the workplace) into clinical practice: study protocol for an implementation study

In Germany, inpatient medical rehabilitation has been implemented for patients with chronic mental and somatic complaints in order to restore and maintain work ability [1]. Approximately one third of the German population has reported significant work-related stress [2]. As we found previously, inpatients of psychosomatic rehabilitation clinics reported not only higher work-related stress, but also fewer coping resources when compared to the general German population [3]. Therefore, various work-related interventions have been adopted during inpatient medical rehabilitation treatment in order to deal with work-related stress [4]. In a previous clinical trial we could show that vocational training during inpatient psychosomatic rehabilitation improved return to work in the long run [5]. A recent meta-analysis of randomised trials for work-related medical rehabilitation interventions in patients with musculoskeletal disorders showed better return to work outcomes compared to usual medical rehabilitation [6].

Applying psychological and practical strategies acquired in rehabilitation into daily work remains a critical obstacle for many patients with chronic mental or physical disorders, particularly if they have already had long periods of sick leaves. Aftercare interventions have therefore been implemented in order to support return to work and participation in social life [7, 8]. However, few patients take part in outpatient treatments following inpatient rehabilitation because of incompatibility with their duties at work or within their families, or poor access to the outpatient rehabilitation facility [9, 10].

Internet-based interventions appear to be promising, as the great majority of the German population (84% in 2016) is online, and the internet is increasingly used for health- related issues [11, 12]. Under the heading of occupational e-mental health, internet-based interventions have been applied to deliver education, health risk assessment, work-place health promotion, preventive interventions, treatment, relapse prevention, and return-to-work assistance [13]. But online interventions focusing directly on workplace reintegration after inpatient rehabilitation are still missing. Furthermore, acceptance and uptake of online interventions is generally still limited [14] and dropout rates for psychological online interventions are often elevated [15, 16].

In order to promote successful vocational reintegration after inpatient medical rehabilitation we devised a transdiagnostic psychodynamic online aftercare programme for patients with chronic diseases (psychosomatic, cardiological, orthopaedic) [17]. This is one of the few examples of online interventions, based on a psychodynamic model [18‐21]. As we could show recently, hassles with colleagues or superiors play a major role for work-related stress, fatigue and depression [22]. Another study, analysing expectations of patients toward case management after psychosomatic rehabilitation, found that most patients required support concerning conflicts at the workplace [23]. Therefore we chose a psychodynamic concept focusing on interpersonal conflicts at the workplace in our prior study [17]. In weekly writing tasks, participants were instructed to describe interpersonal situations at the workplace according to their wish, reactions of the other and their own reactions. Following the concept of the ‘Core Conflict Relationship Theme (CCRT)’ [24], the online therapist identified maladaptive relationship patterns and provided written feedback. In a randomised controlled trial (RCT) with a total of 664 participants (vs. an information only control group), we could show that the online intervention was reasonably accepted (78% of log-ins, 66% writing blogs).The majority of participants did not use the online intervention continuously, but rather six times (M = 6.00; SD = 4.21) during the possible 12 weeks [25]. Overall, psychodynamic online aftercare was effective to enhance subjective prognosis of future employment and improved psychological complaints (anxiety, depression, somatisation) as well as quality of life across a variety of chronic physical and psychological conditions, albeit with small effect sizes [25]. While most previous trials recruited over the internet, one of the strengths of our previous RCT was that we recruited patients from the rehabilitation clinics. As usual in RCTs, enrolment of participants was done by research staff based on screening criteria assessed by questionnaire. Recruitment also included a brief group intervention in each clinic by trained clinicians in order to familiarize participants with the programme and its rationale and to motivate them for participation.

While internet-based interventions have been demonstrated to be efficacious, drawbacks refer to participation and implementation into clinical practice. In clinical practice, participation rates and compliance have been found to be less than satisfactory [42]. Thus, most programmes have not found a place in usual care. Dissemination and implementation of efficacious, evidence-based treatments into medical practice has become a growing issue for mental health care [43]. Therefore it is important to investigate how interventions evaluated in RCTs with selected participants, usually recruited over the internet, can be transferred into routine clinical care, and whether the health care system benefits from such developments. Thus, we implemented a transdiagnostic programme found efficacious in a previous RCT [25] into clinical practice. However, in order to be successfully implemented in routine clinical care, an online intervention needs to be self-explanatory, i.e. easy to handle by busy and changing staff members. Therefore, we augmented the programme by additional exploratory and motivational videos on the study web application to familiarize potential participants and medical professionals with the internet-based aftercare programme. Based on our previous experience with a considerable number of drop-outs from the programme we also took care to motivate them to follow through with it [26]. As other aftercare interventions, referrals to ‘GSA-Online plus’ are made by the physicians in charge. The focus of evaluation is on acceptance of the programme, both by the physicians in charge and the patients. The lack of a control group may be seen as a limitation. However, we take care to specify who gets referred, respectively accepts the recommendation compared to those who do not get the recommendation, respectively refuse to participate. Additionally, we assess the frequency and subjective evaluation of participation in order to model treatment gains based on regular participation. If our implementation study proves to be successful, a next step will be to resolve legal requirements and financial resources necessary to implement ‘GSA-Online plus’ as a regular aftercare programme for vocationally stressed inpatients of medical rehabilitation.