Patients’ experience of a workplace dialogue in physiotherapy practice in primary care: an interview study

Abstract

Purpose

To describe how patients with acute/subacute back pain and/or neck pain experienced a workplace intervention, conducted as a structured workplace dialogue (convergence dialogue meeting, CDM) within physiotherapy practice in primary care.

Materials and methods

Semi-structured interviews were performed with 10 patients who took part in the CDM. Qualitative content analysis was applied to the data.

Results

Three categories emerged from the analysis: physiotherapist (PT) as a facilitator, the employer as a key stakeholder and lack of transparency and concrete changes.

Conclusion

This study describes patients’ experiences of a workplace dialogue in physiotherapy practice. Even though few patients experienced concrete changes at the workplace, they were supportive for the intervention as well as how the PTs conducted the CDM. The patients expressed trust in the PTs who were seen as someone who could facilitate changes at the workplace, being proficient and supportive. The CDM could be a method to facilitate communication between stakeholders and support work ability.

Keywords:

• Musculoskeletal (neck)
• musculoskeletal (back)
• evidence-based physiotherapy/medicine
• EBM
• occupational health/ergonomics
• primary care
• qualitative research

Introduction

Sick leave due to musculoskeletal disorders is common and multi-domain interventions have shown a high level of evidence in reducing sick leave [1], whereas there is limited evidence for interventions focussing only on treatment of the medical condition [2]. A systematic review regarding the effectiveness of workplace interventions showed evidence for a clinical intervention combined with occupational interventions [3]. Other studies have shown that support from the supervisor [4,5] and contact between the healthcare and the workplace facilitate return to work (RTW) [2,6]. In a qualitative study by Dionne et al. [7], employees that had suffered from work-disabling back pain (BP) were asked about obstacles and facilitators of RTW. Almost half of the employees ranked ‘lack of collaboration and understanding from employer’ as an obstacle [7]. There is often a lack of communication between healthcare professionals and employers when an employee is on sick leave or is at risk of sick leave. Commonly, in Sweden, it is the physician who communicates with employers and other stakeholders because they are responsible for writing medical certificates. This communication is often minimal, and it mainly occurs late in the sick leave period [8,9]. In Sweden, physiotherapy is first line treatment for patients with musculoskeletal pain, such as BP or neck pain (NP). The physiotherapist (PT) often spend a substantial amount of time with the patient and are highly familiar with their functional capacity [10]. Earlier studies indicate that PTs can take responsibility for communication with employers [11,12].

Convergence dialogue meeting (CDM) is a method that includes communication in three steps: an interview with the patient, interview with the employer and finally, a meeting between the patient, employer and a health care professional [13].

In this study, we wanted to deepen the understanding of patients’ experiences of a workplace dialogue conducted within a cluster-randomised controlled trial (ClinicalTrials.gov ID: NCT02609750) in primary care; WorkUp [14]. In WorkUp, a new approach in treating patients with acute/sub-acute BP and/or NP was tried where the PTs communicated in a work-oriented way with patients and employers at an early stage, mainly even before sick leave had occurred. The main results from WorkUp showed that a higher proportion of patients in the intervention group had work ability at 12 months follow-up compared to the control group [14]. Before this dialogue method can be implemented in ordinary healthcare, it is important to gain knowledge of the patients’ experiences of the workplace dialogue in WorkUp. The aim of this study was therefore to describe patients’ experiences of a workplace dialogue in physiotherapy practice.

Material and methods

Design

We conducted an interview study with a qualitative content analysis method to analyse the data [15]. We used an inductive approach [16] since there is no previous knowledge of patients’ experience of the CDM.

Setting

WorkUp is a two-armed cluster randomised trial conducted in primary care in Southern Sweden. The trial was conducted at 20 different physiotherapy units, attached to 35 primary health care centres. Inclusion criteria for WorkUp were age between 18 and 67, acute or sub-acute (<12 weeks) BP and/or NP, no sick leave or shorter sick leave (<60 days), working at least 4 consecutive weeks last 12 months, and ≥40 points at the ‘ÖMPSQ-short’ questionnaire, indicating a higher risk for future work disability. A cohort of 352 patients who applied for physiotherapy in primary care were included in the trial during 2013–2014, with 146 patients in the intervention group. The intervention in WorkUp consisted of structured, evidence-based physiotherapy in combination with a workplace dialogue (CDM), whereas the reference group received structured, evidence-based physiotherapy only. All patients in the intervention group were offered CDM, but there were differences in how many steps of CDM the patients participated in. Ninety-one patients (62.3%) participated in at least step 2. Both groups were followed-up at 3, 6 and 12 months. In addition to this, all participants received weekly text messages (SMS) where they answered three questions on the impact of the acute/sub-acute BP and/or NP on work and leisure time. The primary outcome measures in WorkUp were work ability and health-related quality of life [14].

The workplace-oriented intervention consisted of a dialogue method, CDM. The CDM was originally developed for patients on long term sick leave due to burnout [13]. In WorkUp, the CDM was applied to patients with acute/subacute BP and/or NP at risk for sick leave or on short term sick leave. CDM in WorkUp consisted of a dialogue in three steps. Step 1 was an interview with the patient, step 2 was an interview with the employer and step 3 was a CDM between the PT, the patient and the employer. The focus in the dialogue was the BP and/or NP in relation to work and finding important factors that could support RTW or inhibit sick leave. Possible modifications or already conducted modifications were discussed. The different steps in the dialogue meetings took place either at the primary care centres, at the workplace or over the phone and lasted approximately between 30 and 60 min. The PTs involved in the intervention received education in CDM by researchers experienced in occupational health. The education consisted of a lecture on work-oriented rehabilitation and practical training [14].

Participants and procedure

We used a criterion sampling strategy and included patients who had participated in at least step 2, preferably step 3 in the CDM. We also decided to include only patients who participated in WorkUp during the second half of 2014 in order to reduce recall bias. Patients that met the criteria (n = 14), were identified at four different primary health care centres. They were contacted by the first author by mail and telephone and asked to participate in the study. One patient declined to participate and three patients did not respond. Ten patients agreed to participate and received oral and written information about the study. Patients’ characteristics is presented in Table 1.

Table 1. Patient characteristics.

	Mean age (range)	Patients (n = 10)
Age	52.5 (37–68)
Female		4
Male		6
Occupation
Industry		3
School		1
Service		2
Health care		1
Social service		1
Haulage		1
Official		1
Step 2 of CDM		1
Step 3 of CDM		9

Data collection

We used an interview guide that was developed in collaboration between the three authors. The interview guide was used to give structure to the interviews [17,18] and is provided in Supplementary File 1. All authors were clinically experienced from the field of work disability, and the senior researchers were also experienced in the research field as well as the methodology. The pre-understanding was seen as a strength and a necessity when conducting interviews as well as analysing data [18] and we constantly reflected on it. None of the authors had any relations with the patients. Before the study started, a pilot interview was performed in order to test the interview guide and if necessary, make changes. The patient in the pilot did not meet all inclusion criteria and was therefore not eligible to participate in the study. We made changes in how the questions were formulated and made sure that questions were open-ended and more general in relation to the topic.

The 10 semi-structured individual interviews were conducted, and audio recorded in June and July of 2015 by the first author and lasted for 25–60 min. They were conducted in an undisturbed room at the patient’s physiotherapy units (n = 8), at the patient’s work (n = 1) and in a house that was accessible to the first author (n = 1). Before each interview, information was verbally presented regarding confidentiality, information about the interviewer and purpose of the interview. The questions in the interview guide were not asked in the same sequence since the interview was seen as a conversation where the patient could speak freely [19]. Topics covered in the interviews were for example the patients’ discussion with the PTs concerning work-related pain, the patients’ perception of the PTs’ role when contacting the employer and the patients’ experiences of the CDM. In one of the interviews there was a technical malfunction, which led to the last minutes of that recording being lost.

Analysis of data

This study utilised a qualitative content analysis method with an inductive approach [15] where the research question and the data itself steered the analysis process. The recorded interviews were transcribed verbatim by the first author. The first and third author thereafter read the interviews several times to become familiar with the text. All transcribed text from the interviews was seen as a unit of analysis. From the unit of analysis, the text was divided into meaning units. A meaning unit is several words or sentences that are related to each other. The first and third author divided two of the interviews separately into meaning units and then discussed the results and came to consensus. The remaining eight interviews were divided into meaning units by the first author. These meaning units were condensed, by reducing the number of words without losing content [15]. The meaning units were thereafter labelled with codes.

We strived to keep codes short and descriptive. Meaning units from different interviews that shared content were given the same code. See the coding tree (Supplementary File 2). The first and third author coded one interview together, two of the interviews were coded by the third author alone and seven interviews were coded by the first author alone. One interview at a time was coded and similar statements were given the same code. All codes were discussed between the first and third author and if needed changed. This process went back and forth until we were confident of the labelled codes. The codes were sorted and categories derived from the data were settled, which represented the manifest content. Both the first and third author were involved during this process in order to confirm the categorisation. The categories were reviewed and altered until consensus was reached between the first and third author. The final categorisation was approved by all three authors.

Ethical considerations

This study was approved by the regional ethical committee in Lund in context with approval for WorkUp (Dnr:2012/497). Participation in the study was voluntary and the patients were inquired by a written informative letter. A written consent was obtained from each patient before the interview. Confidentiality was emphasised.

Results

The patients’ experiences of the CMD emerged as three categories. The physiotherapist as a facilitator, The employer as a key stakeholder and Lack of transparency and concrete changes. The categories are illustrated with quotes from the interviews. Each quote has a number, illustrating the interview where it was obtained.

The PT as a facilitator

The PTs played a major role in this dialogue, being responsible, facilitating all steps in the process and taking an active part in the subsequent mutual meeting. They were also regarded as proficient, professional and supportive by the patients in this study who believed that the PT could influence employers regarding job assignments or work environment and thereby facilitate workplace modifications. PTs approach was perceived as professional in contact with the employer. They were knowledgeable concerning the patients’ problems and how it should be treated. This gave them authority when in contact with an employer and the employers could be more willing to listen to the PT than the employees. Talking to the PT about work felt natural and easy. To be supportive was seen as an important feature of the PT, as well as understanding problems described by patients. Support was particularly important when the patients took contact with the employer, especially when they were in pain and in an inferior position to the employer. Patients believed that involvement and support from the PT could lead to greater possibilities for changes at the workplace.

‘Well, I thought it was good. Hopefully, it carries more weight if she (PT) says it rather than if we’re whining about it.’#2

‘I think it carries additional weight since a lot of people could be experiencing difficulties with having that dialogue with your employer and then it can be a great relief that the physiotherapist is taking that contact.’#10

The patients experienced that the PT acted as a chairperson during the convergence meetings. They steered the meeting and ensured that necessary exchange of information took place and any action proposals was discussed. The PTs also made suggestions or demands.

‘- Yes, she made demands. I thought she did. It wasn’t a long conversation, so to speak. But I perceived that she tried to make demands. We have to try this and see, she said.’ #3

The employer as a key stakeholder

During the interviews, there were a number of opinions expressed about the importance and benefits of involving the employer. The employer’s attitude was seen as significant in order to conduct changes concerning the work environment or work assignments as well as enabling a dialogue. The response from the employer was considered decisive because a reluctant employer could be difficult to affect. Patients expressed that the employers did not take complaints seriously and that they had pointed out the need for different workplace modifications and aids but nothing had been addressed. They believed that employers might take more responsibility if they are involved in their employee’s rehabilitation.

‘I feel that from my perspective it is good that the employer knows a lot because it forces him to be active, inquire about 'Do you think this will work?' and so on, it is not me who need to slow down all the time, but he also needs to slow down a bit sometimes and feel that 'I also have a certain responsibility because I'm part of the process'.’ #8

A poor relationship between the employee and the employer was described as an important factor that could affect the patients’ willingness to disclosure possible sensitive information in the last step of the CDM. Addressing problems at work or to inform the employer about your own problems was believed to possibly lead to the risk of receiving a negative role at the workplace. The patients expressed a fear to be seen as someone who complains a lot and becomes an encumbrance for the employer or the colleagues. On the other hand, they believed that a good relationship with the employer can make an employee feel safe when it comes to disclosure of pain.

‘ To talk with my boss and things like that, that is. no. Maybe I’m a bit stupid but I can’t talk to him about this, because it… It has gone to the point where I go detours just to avoid talking to him.’ #6

‘… everything depends on what kind of employer you have. If it is an employer that is interested in doing the best for the employees, then I see it as a huge advantage. However, is it the other way around, I think it can create more problems if you address it.’ #9

Lack of transparency and concrete changes

Several of the patients described a lack of transparency concerning the PT’s initial contact with the employer, step 2 of the CDM. They also described an uncertainty of what the PT and the employer had talked about since the feedback afterwards sometimes was scarce. In some cases, they were not even aware that the employer and PT had been in contact. Their primary focus during the intervention was to recover from their pain and regain work ability. Work was often seen as the main cause of the pain.

The dialogue was experienced as meaningful by a majority and lead to some viable suggestions. At some meetings there were many suggestions and in others there were none. One reason was that it was not possible to implement any changes in the work environment or the work tasks. Another possible reason was that there wasn´t need for work place adjustments.

‘If we had had worse working environment and we could have bought new seats or any kind of aid then this could have helped.’#8

Patients stated various reasons for that: the nature of the work, directives from a higher authority that was not possible to alter or that changes had already been made. Alternating working tasks could be theoretically possible but practically impossible due to lack of employees with necessary skills at the workplace. In cases where modifications had been made at an earlier stage, occupational healthcare had been involved. Some patients believed that the dialogue might have been more effective if they had had a worse working environment and others expressed that the intervention did not lead to concrete suggestions on their behalf but could still be beneficial in the future or for others at the workplace.

‘… when we discussed, we realized that there wasn’t anything we could do to further improve. So no, I can’t see anything that could solve it, there is nothing at work. Then you would have to do something completely different. Completely change the environment as I see it.’ #9

Several patients had work-related pain but felt that it was impossible to change their work assignments or working environment. They felt that the only way to improve the situation was to change job.

Discussion

This study describes how patients with acute/subacute BP and NP with no sick leave or a short period of sick leave experienced a workplace dialogue conducted in physiotherapy practice. To the best of our knowledge, this is the first time that CDM was tried in a PT setting for patients with acute/subacute BP and/or NP. The patients in this study were supportive towards the communication between the PTs and their employers. The PTs were seen as a facilitator, being professional, proficient and supportive. The employers were seen as having a key role in the dialogue. A lack of transparency regarding the communication between the PT and the employer as well as a lack of concrete changes at the workplace were also expressed by the patients in this study.

Previous studies have shown that encouraging and supportive attitudes from healthcare professionals is a significant and facilitating factor for patients on sick leave in a RTW process [20]. Müssener et al. [20] also revealed that patients had an experience of lacking communication between different stakeholders with the patient being caught in the middle. Several other studies also highlight the importance of support and professionalism [10,21] from different rehabilitation professionals where the supportive relationship with the professional was sometimes more important than the treatment itself [22]. The PTs in this study were seen as supportive professionals that could have an influence on the employers in order to implement modifications at the workplace. The PTs working in primary care in Sweden are often first-line treatment for patients seeking care through open access for musculoskeletal disorders. They often have contact with the patient during a period of time and have therefore adequate knowledge concerning the patient and what is causing the pain which is an advantage in assessing work ability [12,23].

In this study, the patients perceived talking to the PTs about their work as convenient and they experienced the PTs as knowledgeable about their problems and how it would be dealt with. Some studies have also identified PTs as skilled and well suited in assessing work ability and RTW recommendations [10,11,24,25] which the results in this study also indicate from the patients’ point of view.

The CDM as a method for preventing sick leave and facilitating RTW has previously been tried with patients on sick leave for clinical burnout and common mental disorders [13,26]. The theoretical base for the CDM used in the original study was the mismatch perspective, which focuses on the fit between the job and the person [13]. As far as we know, the CDM has not previously been tried with patients suffering from acute/subacute BP and/or NP. However, there is extensive research about other workplace interventions. Some of them consist mainly or partly by communication between different stakeholders, similar to the CDM [2,27–29]. One of the similar studies compared an early workplace intervention for employees with musculoskeletal disorders and showed a higher RTW rate and fewer days on sick leave in the intervention group [27]. The CDM is intended to support the patient, the PT and the employer where communication between stakeholders can lead to concrete suggestions in order to promote work ability [13]. With that in mind and the patients’ perception of the CDM, a presumption is that the method could be successful in preventing sick leave and promoting RTW in patients with acute/sub-acute BP and/or NP particularly if the dialogue takes place at an early stage.

In a qualitative study by Dionne et al. [7], workers with BP were interviewed about obstacles and facilitators in their RTW. One of the most significant obstacles was a lack of collaboration and understanding from the employer, an opinion which also emerged in this study. Some employees concern themselves with the disclosure of their problems could lead to them being viewed as a problem at the workplace [30]. An early intervention facilitates RTW [2,29], sometimes implicating that the employee still has some physical challenges which might require workplace modifications [21] when RTW. In this study, some of the patients expressed a fear that they could become a burden for the colleagues and employers at the workplace. Another study has made similar findings and describes that the affected employee saw reduced working hours by relinquishing work assignments as a failure [31]. For that reason, it is essential for the employee to be supported by the employer and co-workers at the workplace. Some of the patients in this study expressed that they received support from their employers and that different modifications at work had been tried, indicating communication between the employer and employee. However, there can be difficulties in the cooperation between employers and employees and a solution could be that professionals support the process in order to establish an effective RTW [32]. This study supports the notion of the PT being that professional. If the employee deducts from having a necessary discussion with the employer, support from the PT might facilitate an early discussion and dialogue at the workplace.

The patients in this study expressed that the CDM led to few concrete changes at their workplace due to various reasons. A recent study conducted in a Swedish municipality showed that employees on sick leave experienced higher support from supervisors if they had discussed workplace adjustments to support RTW [33]. Employees with a university education also reported higher levels of support than employees without a university education [33]. In this study, patients had discussed workplace adjustments with their employer but did not describe so many concrete changes at work. Compared to the study by Buys et al. [33], most patients in this study did not have a work that required a degree from a university and this might have affected their perception of support from employer and possible workplace adjustments. Another explanation for the patients’ perception that CDM led to few concrete changes at the workplace could be due to the limited possibilities in changing work assignments. For example, at a small industrial company, there are, for obvious reasons, limited possibilities for alternative work assignments. However, the previously published RCT [14] showed that the CDM improved work ability and suggests that a productive communication between patient, PT and workplace might be beneficial for work ability despite that some patients experienced negligible concrete changes. Another aspect that emerged during the interviews were a few patients lack of knowledge regarding the communication that took place between the PT and the employer. This lack of transparency risks excluding the patients from their ongoing treatment and impairs the open communication between patient and PT. A previous review showed that a good, open communication and patient participation in health care was extremely important for patients with BP [34] which should be emphasised as a natural part of patient-centered healthcare.

Methodological considerations and limitations

This study presents original data on patients’ experiences of a workplace dialogue in physiotherapy practice in primary care. In this study, we collected data almost 1 year after the patient had taken part in the intervention. This may have led to recall bias. The patients had varying experiences of the dialogue and some had a vague recollection. This might have had some limitation in the data and therefore also in the sequent analysis. A limitation in the study is also the selection of sample and possibly the size of the sample. The criteria that only the patients in WorkUp who had completed steps 2 or 3 of the CDM was chosen in order to capture comprehensive experiences of the dialogue. The patients who only had completed step 1 was considered as not having enough experiences of the dialogue. However, this could also mean that the patients included in this study were generally more positive towards the dialogue and whether the findings can be transferred to similar contexts should be interpreted with caution.

Since this is a qualitative study, measures to achieve trustworthiness has been considered [35]. We have thoroughly described the analysis process and used authentic citations in order to provide trustworthiness [16]. Furthermore, credibility is considered by securing that the categories cover the data [15,19]. Two researchers were involved in the analysis process, which can secure confirmability [19]. All authors reflected on the possibility for the preunderstanding to steer the research process. We reflected and talked about it throughout the research process, when creating the questions, conducting the interviews, analysing and interpreting the data. The preunderstanding was also seen as a strength because it enabled a depth during the interviews. The third dimension of trustworthiness is dependability [15,19] which was strengthened by using an interview guide and thereby asking the same questions to all patients. The concept of transferability refers to the generalisation of the findings from the study [19] and we have thoroughly described the setting, the patients and the process of analysis. We think that the key findings from this study could be generalised to other contexts where PTs are communicating with employers and facilitating stay at work or RTW. We imply this because of the consistency in the material regarding these key points.

Recommendations

Results from a clinical trial support the use of CMD in PT practice in order to improve work ability and health related quality of life. This qualitative study adds valuable knowledge on patients’ experiences of the CDM. A structured dialogue method such as the CDM could be an applicable method to support patients and facilitate communication between healthcare and workplace.

Conclusions

This qualitative study describes how patients with acute/subacute back and/or NP experienced a workplace dialogue in physiotherapy practice. The aim of the dialogue was to discuss BP and NP in relation to work, and to find important factors that could support RTW or inhibit sick leave. The workplace dialogue has been reported to have a positive impact on work ability as well as health related quality of life in long-term follow-up. In this study, we found that the patients in this workplace dialogue experienced the PT as supportive and facilitating, the employer as a key stakeholder although there were some lack of transparency and concrete changes at the workplace.

Acknowledgements

The authors are grateful to all the participants in this study.

Disclosure statement

No potential conflict of interest was reported by the authors.