Background
Long-term sick leave may lead to negative consequences such as impaired psychological well-being and sleep disturbances [
1], feelings of powerlessness [
2] or inactivity and isolation [
1,
3]. People with long-term sickness absenteeism also have a high risk of a future disability pension [
4]. In Sweden, mental illness and musculoskeletal diseases constitute the most common reasons for long-term sick leave (≥60 days) [
5]. Longer durations of sick leave (≥60 days) increases the need for vocational rehabilitation [
5], which are rehabilitation interventions aimed at facilitating return-to-work (RTW) [
6].
The rehabilitation process for RTW can sometimes be complex and many factors can influence an individual’s work ability [
7]. Factors linked to the individual (including physical, cognitive, affective and social domains) and elements in the environment, such as the workplace system (e.g., environment, organisation, work relations, work load), the healthcare system and the compensation system influence the disability, which must be taken into consideration by the authorities that partake in rehabilitation processes to facilitate RTW [
8].
The Swedish Social Insurance Agency (SSIA) is in charge of coordinating the rehabilitation process and is the responsible actor for the administration of sickness benefits in Sweden. Other authorities involved in vocational rehabilitation with different responsibilities are (1) the health care provider, with responsibility for medical rehabilitation; (2) the Swedish Public Employment Service (SPES), with responsibility for vocational rehabilitation; (3) municipalities, with responsibility for social rehabilitation; and (4) the employers [
9]. The client on sick leave is dependent on how these authorities work and the decisions they make [
10]; and lack of cooperation and communication among them is an obstacle to the RTW process [
11]. Since vocational rehabilitation programs should be planned in cooperation between the authorities and the clients and designed according to the needs of the client to reach a positive outcome [
12], they may have various designs.
The relationship and cooperation between the client on sick leave and the authorities that work with vocational rehabilitation is important for the client’s RTW [
12]. It has been argued that there is a need for more cooperation between various authorities to better meet the needs of clients on sick leave [
13] and provide them with proper support [
7]. However, research shows varying results regarding cooperation in vocational rehabilitation [
14‐
17]. Some studies point to positive effects of collaboration [
18,
19], one study failed to see any significant effects at all [
20] and another study found negative effects of RTW [
17]. Overall, however, the cooperation between authorities seems to be regarded as a positive idea that is being reviewed by both employees [
20,
21] as well as clients [
22,
23].
Furthermore, several researchers seem to agree that co-location of different organisations, or parts of organisations, into a common local area creates good conditions for cross-border cooperation [
24] In a study, co-location of organisations is even described as a “full integration” [
25]. In Sweden, several attempts have been made with co-location of state and municipal authorities in so-called
med-citizen or service offices [
26].
The principles of motivational interviewing (MI) have been used to improve RTW in a number of vocational rehabilitation interventions, including different populations with various conditions or illnesses, which is shown in a recently published review [
27]. MI is a client-centered communication method aimed at facilitating behavioural changes by strengthening an individual’s motivation and commitment to change.
In MI, active collaboration between advisor and client is emphasised, as the client is believed to be the one who best describes his current state of health and the psychosocial situation [
28]. MI is based on the principles of partnership, acceptance, compassion and evocation. The
partnership should be based on cooperation between the professional and client, where clients should be seen as experts on themselves.
Acceptance includes seeing the value of every human, striving to understand the client’s perspective, showing empathy, respecting the client’s autonomy and confirming the client’s strengths.
Compassion is shown by actively trying to help clients feel good, with a focus on their needs.
Evocation is about eliciting the client’s own motivation for change. Furthermore, another important foundation for clinical use of MI is active listening [
28], i.e., the expression of empathy, the development of discrepancy and avoidance of argumentation, as well as the abilities to roll with resistance and support self-efficacy [
29].
Two recently published studies found that RTW was both improved and more sustainable for workers with disabling musculoskeletal disorders when MI was added to a routine work rehabilitation intervention compared with controls who did not receive MI [
30,
31].
The following study is part of an evaluation of a Swedish vocational rehabilitation project, the Dirigo project, targeting individuals on long-term sick leave. The Dirigo project has been described in detail in a previous publication focusing on organisational and professional aspects [
32]. The project took place in two municipalities in the southern part of Stockholm from January 2012 to April 2014. The intervention of the project was directed to three groups: 1) clients on long-term sick leave (>180 days), 2) youth with disability benefits (benefits for long-term reduced working capacity in young adults 19–29 years), or 3) recipients of social allowances. In the present study, only Group 1 is included. The inclusion criteria were a diagnosis corresponding to mental illness (anxiety, mild depression, and stress problems) and pain-related problems. The exclusion criteria were suicidal risk, serious physical illness or injury based on the criteria of the Swedish National Board of Health and Welfare [
33], another ongoing treatment, or participation in another cooperation project. Potential participants in Dirigo were identified by the SPES, SSIA or the municipalities and referred to the project. The Dirigo project developed unique features compared to regular practice and was built on the following three pillars: the direct collaboration between the SSIA, SPES and the municipalities, the individual tailored interventions and the motivational interviewing approach.
In the Dirigo project, the professionals shared workplaces in two dedicated offices, worked together in pairs, and shared responsibility for a case. This close cooperation between the authorities differs from regular practice where the professionals generally work alone and only collaborate with other authorities at specific time points [
34].
The professionals also worked closely with the clients to support their individual vocational rehabilitation process. The professionals had relatively few cases; the caseload was about 30–40 per professional compared with over 100 in regular practice. This allowed the professional to spend more time with the clients and offered more flexibility in terms of where and when meetings with clients could be held. For example, professionals carried out several meetings in locations other than the office, such as on walks, and could accompany clients to various meetings within the framework of the vocational rehabilitation process.
All professionals working in Dirigo received MI-training at the beginning of the project and the principles of MI [
28] were used as a guideline for meetings with clients. MI was used as a tool to improve both cooperation between clients and professionals, i.e., the principle of partnership, and to improve client and professional communication and alliance, i.e., the principles of acceptance and compassion. MI was also used as a means to strengthen clients’ motivation for transition to work, i.e., the principle of evocation.
The aim of this study was to investigate clients’ experiences with an individually tailored vocational rehabilitation, the Dirigo project, and encounters with professionals working in it.
Discussion
The main result of the qualitative analysis was the consensus that the clients had overall positive experiences with the rehabilitation project and encounters with the professionals working in it. The positive experiences were based on the following key factors: the intervention provided opportunities for receiving various dimensions of support, good overall treatment by the professionals, satisfaction with the working methods of the project, and opportunities for personal development.
The clients felt that they received support, that they were cared for and treated with respect by the intervention professionals. Moreover, the clients experienced that the intervention, especially the cooperation between the authorities, allowed the professionals to spend more time with each individual compared with regular practice. The professionals were also perceived as having high availability and continuity in their contacts with project clients, which facilitated an appropriately individualised rehabilitation plan.
The clients’ experiences of their contacts and interactions with the authorities and the professionals working in the project are in line with previous research indicating that a cooperative approach resulting in a coordinated and tailored rehabilitation plan is considered positive and helpful by the individual [
23]. This was described in our study in strong contrast to past experiences of the regular treatment by authorities. Although cooperative approaches vary in terms of intervention design, participating actors, target group, and expected outcome, there is a common understanding that a coordinated rehabilitation process is perceived to be helpful for the individual [
34]; our results reinforce this.
Comparing results from studies involving cooperation in individually tailored rehabilitation is difficult because the context, design, and sample usually differ. It is also difficult to accurately measure the effects of cooperation, because it is often not possible to determine whether the observed effects depend on the cooperation itself, on other aspects of the intervention, or on a combination of all of these factors [
37]. In our study, the cooperation between professionals was a central aspect of the intervention, but this was combined with the use of MI [
29] as a tool for meeting the participants.
Opportunities for receiving various dimensions of support
The clients felt that they received both emotional and instrumental support in terms of having someone on their side, helping them set goals, and receiving coaching and guidance. The clients in Dirigo claimed that the intervention had strengthened their beliefs in their abilities, which may be related to previous findings that support from professionals and family during vocational rehabilitation facilitated RTW for patients with musculoskeletal and/or psychological disorder [
38]. Emotional support from professionals that is perceived as having someone to stand up for them is considered an essential part of a positive encounter between sick-listed persons and rehabilitation professionals [
39]. There may also be a need for support from professionals to move forward in the rehabilitation process. This support may include e.g., assistance with making contacts, job training arrangements and follow-up meetings [
40]. In the Dirigo project, the clients received help with contacting employers and support during job training from professionals. This may be seen as a stepwise transition to work in parallel with consultations with professionals that may have helped clients to overcome various barriers in transition to work.
Good overall treatment by the professionals
The clients expressed how their encounters with the professionals were perceived as empowering and respectful, and that the good treatment brought them a sense of confidence in contacts with the professionals. This may be related to previous studies on the importance of fair treatment, and that the quality of encounters has an important influence on the self-perception of the clients, including their expectations of being able to work [
41,
42]. Previous research has shown that the clients’ sense of confidence during vocational rehabilitation is important when communicating important information to the professionals so that they can correctly assess the client’s work ability and appreciate their difficulties and resources [
43]. The manner in which the clients describe the overall treatment by the professionals reflects the fundamentals of MI, i.e., cooperation and partnership, showing respect toward the client, confirming the right to self-determination (autonomy) and active listening [
28].
When one of the clients was dissatisfied with a contact and complained to the project management, the complaints were resolved immediately by appointing a new contact. This measure may be in line with the project’s readiness to show participants respect and trust.
Satisfaction with the working methods of the project
The participants expressed positive attitudes toward the project and the working methods, which were considered helpful. The professionals were perceived as highly available and as having continuous contact with participants, which was seen as helpful to the development of an appropriate and individualised rehabilitation plan. Previous research has shown that a cooperative approach resulting in a coordinated and tailored rehabilitation plan is considered positive and helpful by individuals on sick leave or who are out of work due to common mental disorders [
22]. Participating in decisions regarding one’s own vocational rehabilitation has also been shown to be an important factor for the individual’s RTW [
39]. In our study, the close cooperation between the participants and professionals involved the participants in the rehabilitation process. If there is a structured plan for the vocational rehabilitation process and the individual on sick leave understands what will happen, what steps will be taken and who is doing what, this could support the RTW process [
40].
In the Dirigo project, professionals used the principles of MI when communicating with clients. MI has been considered to be a key to successful RTW in studies in other countries [
30,
31]. One of the components in MI is to support self-efficacy [
29], which has been shown to be important in promoting health and the return to work [
42]. A previous study showed that when professionals worked according to MI, it increased self-efficacy in individuals by supporting their belief that they could accomplish the actions needed to reach their goals [
44]. The association between MI and increased self-efficacy has been shown in previous studies in areas such as physical activity and self-management strategies [
45,
46]. Using MI may be considered to be a step in offering relevant social support (e.g., through regular contact with the professionals and group activities), and has also been associated with higher self-efficacy [
47‐
49]. The clients in the Dirigo project expressed that they had increased their self-awareness during the intervention, which may have had an impact on their future opportunities to return to work. Hence, the results of this study are likely to have been influenced by a combination of the use of MI, the close cooperation between professionals, and the organisational conditions allowing the professionals to have continuous and close contact with the clients.
Opportunities for personal development
The clients experienced, on a personal level, increased self-awareness and belief in their own ability, i.e., increased self-efficacy, and that they had gained new social contacts through participation in the intervention.
They expressed that their encounters with the professionals strengthened their self-awareness, self-worth and belief in their ability to start working or studying. In a previous study, self-awareness, such as identity, resources, will and values were found to be facilitators of returning to work after sick leave [
38]. The interactions that may occur between the professionals and individuals involved in vocational rehabilitation have also been found to have an important influence on the individuals’ perceived abilities, including their expectations about or belief in being able to work [
41].
The result in this study shows that the interactions between professionals and clients induce most positive outcomes, depending on the competence of professionals and how clients experience the encounters. The answers in the interview with the clients indicate that their interactions with the different professionals may affected their self-efficacy, and thus, possibly the outcome of the received intervention and the transition to work. Whether or not our study participants began to work is not the focus of the present study. However, these approaches were primarily individual and for a successful transition to work, vocational rehabilitation interventions need a further societal approach to actually be able to offer clients opportunities for job training and real jobs.
Methodological considerations
Since the aim of this study was to capture client’s experiences, a qualitative design with content analysis was chosen. Content analysis is a method that has been used for a long time in qualitative studies, for example in the area of public health. This data analysis method was considered appropriate since it can be used to analyse verbal and written communication [
36]. A purposive sampling method was used to reach both women and men of various ages to capture different experiences with the research questions. The sample size was judged to be sufficient when saturation in the collected data was considered to be reached. To strengthen credibility, the first steps of the analysis were performed independently by the three researchers, followed by discussions in the research group, until the codes and categories were consistent [
50]. Dependability was strengthened by transparently describing the steps of the research process [
50]. To achieve confirmability, authentic citations were presented, illustrating the data from which the categories were formulated [
51].
There are also limitations worth noting. The participants in the interviews were recruited by professionals with whom they already had a relationship. The professionals were asked to include clients who were willing to talk about their experiences of the project, both women and men and of various ages. However, our sample was older (mean age 47.2) and included fewer women (57%) than the Dirigo project (mean age 42.5 years, 64% women). The interviews were performed at the project site, which could have affected the outcome. Furthermore, it is unclear how many individuals declined to participate in our study and how they experienced the project and encounters with the professionals. With this in mind and the fact that this is a qualitative study which does not claim generalisability, the results should be interpreted with caution and is primarily valid for these clients.