Background
Sickness absence regulations in Sweden
Methods
Design
Setting and participants
Characteristic | Number |
---|---|
Health care settinga | |
Occupational health care | 6 |
Primary health care | 13 |
Psychiatric outpatient clinic | 5 |
Geographic setting | |
Big city | 8 |
Smaller town/rural area | 16 |
Gender | |
Male | 12 |
Female | 12 |
Age (years) | |
Range | 42–69 |
Mean | 55 |
Specializationb | |
Primary health | 15 |
Psychiatry | 6 |
Occupational health | 3 |
Rehabilitation medicine | 2 |
Other | 3 |
Years since medical degree | |
Range | 9–40 |
Mean | 26 |
Years since specializationc | |
Range | 1.5–37 |
Mean | 18 |
Data collection
Analysis
Results
Category | |||||
---|---|---|---|---|---|
1 | 2 | 3 | 4 | 5 | |
Identifying, understanding, creating and fitting the pieces together in the work capacity jigsaw puzzle | The significance of the disorder while assessing work capacity and sickness absence | Identifying work-place-related pieces of information | Identifying capacity in everyday life; contextual pieces of information | Assessing the need for sickness absence | |
Sub-categories | a. Using previously acquired personal experiences | a. Identifying work setting, work tasks and work demands | a. Issuing sickness absence in cases of decreased work capacity | ||
b. Sharpening the prime source of information: the patient | b. Identifying potential risk situations at work | b. Using sickness absence as a tool | |||
c. Understanding the patient at work |
Category 1: Identifying, understanding, creating and fitting the pieces together in a work capacity jigsaw puzzle
The finalized jigsaw puzzle was considered to be a comprehensive picture and required for adequate assessment of work capacity and need for sickness absence; however, minor assessments were constantly performed while identifying, creating and fitting the pieces together. They stressed that the jigsaw puzzle was highly individualized, which was the reason why patients who appeared to be alike (e.g. same disorder) were assessed differently. An essential prerequisite was time because identifying, understanding, creating and fitting the pieces together were time consuming. Although the participants described work capacity assessment, they also closely linked it to clinical reasoning. Jigsaw puzzling relied on two distinctive features, identified as two subcategories: “Using previously acquired personal experiences” and “sharpening the prime source of information – the patient”.It’s like doing a jigsaw puzzle, sometimes is it easy and sometimes quite difficult. You make the assessment based on their difficulties, [trying to understand] what kind of limitations do they really have? (Interview 5)
Sub-category 1a: Using previously acquired personal experiences
… then I could ask, as I did yesterday to a patient, she is a geologist and she explained to me that she install flowmeters in wells and bring numbers back to the office for modelling where they need to take care of the rainwater in order avoid flooding elsewhere. Since I have built a house myself, I can understand such things as drainage and flows and water levels and so on. So I let her describe a project for me, and then I realized that she was having a hard time concentrating and getting tired very easily, making it difficult to perform because she could not think clearly. (Interview 16)
Sub-category 1b: Sharpening the prime source of information: The patient
I try to get them [the patients] to verbalize, and that is the hardest part for the patient because they have perceived they cannot manage the work, but it is very difficult for them to describe in what way. (Interview 15)
I ask the patient to tell me more, to be more specific, to tell from your [the patient’s] point of view so I don’t place pictures of my own pre-understanding about what they [patients] do. I do not ask [precise questions] rather I say; tell me more, what are your work tasks? Open questions so that I get a picture of how it looks. (Interview 2)
I always ask the patient, how long should we state [the sickness absence duration]? Just that, by asking the patient, do you have any suggestion, he discloses for me his own views. That have helped me many times, because sometimes they are too narrow in their time conception and reckon they will return to work sooner. It could also be the opposite, if the patient says, I need to be sick-listed for three months, well then I know that the motivation to return to work is very low. (Interview 24)
Category 2: The significance of the disorder when assessing work capacity and sickness absence
There is a disorder we call generalized anxiety disorder, I mean GAD, which naturally could be very troubling for some and there you simply need to consider the depth of the sickness. In a serious case of GAD, well, then the patient might not work at all because that would be at the cost of being stoned [due to medication] and that on the other hand is unfit with doing work. (Interview 13)
Medical dimensions: | |
---|---|
– | if the patient recognizes him/herself as the kind of person they used to be |
– | if the patient recognizes their work performance as it used to be |
– | sleeping problems |
– | alcohol and/or other addictions (affects both disorders and functions) |
– | suicidality |
– | any triggers at work or home maintaining disorders |
– | how symptoms affect functioning |
– | variation in circadian rhythm |
Category 3: Identifying work place-related pieces of information
Subcategory 3a: Identifying the work setting, work tasks and work demands
First I ask about the history; have you experienced any difficulties in your work earlier? It could be a person working for 10, 20 years [in health care] saying, ‘I have never had any troubles encountering patients but now I don’t dare do that any longer.’ Then I [the physician] can establish that this person has a fundamental capability to encounter patients in crisis. (Interview 12)
Sub-category 3a: work setting, work tasks and work demands:
| |
Type of occupation | |
Form of employment (permanent, limited, other) | |
Any recent work changes (reorganization, new duties/routines/responsibilities, new manager/colleague) | |
Amount of influence and decision making in own work situation | |
Timely issues: | |
– | working time (hours/week, hours/day, shift work, overtime) |
– | work day breaks, possibilities to take breaks, avoiding breaks (why) |
– | adherence to times, work speed demands, keeping up the pace of the work |
Type of work tasks and inherent demands: | |
– | simple or complex tasks |
– | physical demands |
– | mental demands (concentration, memory, endure stress, planning, multitasking, understanding information, communication, expressing oneself) |
– | emotional demands (being alert, interactions and cooperation with other people, handle other peoples’ emotional reactions such as customers, pupils, clients) |
Work environment: | |
– | amount of surrounding stimuli and sounds |
– | working alone or in group settings |
– | often interrupted or disturbed |
– | amount of support from colleagues/manager |
Earlier work capacity (present work, earlier work) | |
Any work accommodations: what kind of adjustments | |
Sub-category 3c: the patient him/herself:
| |
– | formal and informal roles (e.g. being the most experienced/longest employed and therefore often asked questions) |
– | likes his/her job and work tasks |
– | work motivation in both actual and earlier jobs |
– | earlier work experiences (including reasons for leaving/changing jobs) |
– | having education/qualification for the job, feeling comfortable with work tasks |
– | relationship with colleagues, manager (supportive, reliance, unfriendly, conflicts) |
– | bullying |
– | sexual harassment or assault at work |
– | what has the patient told the manager/colleagues about his/her work problems and responses to that |
– | in the patient’s opinion, what does manager/colleagues think of the patient’s work performance (trust/complaints) |
Sub-category 3b: Identifying potential risk situations at work
The ability to react is often decreased; so if the patient drives a car as a work task, you need to consider that, because that could imply that they not are fit to drive a lorry or taxi or another kind of commercial vehicle as long as they experience decreased ability to react. That could be fatal, not just for the person him/herself. (Interview 18)
Sub-category 3c: Understanding the patient at work
Category 4: Identifying capacity in everyday life: Contextual pieces of information
Factors and support/stressors in private life: | |
– | family situation (single, married, divorced, children) |
– | relatives in need of support (sick, old-aged) |
– | anyone else in the family sick-listed or unemployed |
– | support or not from husband/wife, relatives, others |
– | financial issues |
– | childhood and adolescence |
Capacity to plan and manage home duties: | |
– | taking care of family and children |
– | shopping, cleaning, cooking, paying bills |
– | reading and understanding newspapers, keeping up with news |
– | watching and understanding television programmes |
– | driving a car |
Capacity to plan and carry out activities outside the home: | |
– | exercising |
– | hobbies |
– | socializing with friends |
Category 5: Assessing the need for sickness absence
Sub-category 5a: Issuing sickness absence certification in cases of decreased work capacity
In addition to decreased work capacity, the participants also took into account their perception of the patient’s work place in the assessment of the need for sickness absence. In well-managed work places, the participants’ reasoned that patients were able to work despite decreased work capacity. However, when they perceived the work place as dysfunctional, the participants were more likely to see the need for sickness absence. In cases of work place conflicts, the participants believed such things needed to be dealt with at the work place and sickness absence should be avoided.She [the patient in the vignette] is quite ill and she might lose face by exposing her at work. She has a hard time holding herself together and she has to perform in a working team. She is quite exposed as a teacher in front of the students. The issue is also about protecting people while they suffer from the mental illness so they don’t get hurt and can manage to return to their work again; well she has that kind of a work. However, it could also be persons in managerial positions where employees absolutely should not see them while they are sick. Because then they cannot return to a position with authority. (Interview 2)
Sub-category 5b: Using sickness absence as a tool
At the first visit, I try to find out as much as possible about the work and the network and so on. The next time, I go deeper trying to figure out what has happened. I try to get further information and also to see the patient in another stage, how is she functioning at this time, if she is still as closed off, or whatever it might be [as the first visit]. (Interview 18)