The close in-depth collaboration and knowledge sharing among CMs and RCs at the primary care centres created added value in the health care services. Good communication was also seen as a guarantee that all tasks were done. Participants in the study emphasised the difficulty in working with some locum tenens GPs, who often switch workplace. RCs expressed that a visit to the patient’s workplace benefited the understanding of the working environment. However, the person-centred dialogue meeting was preferably conducted at the primary care centres. There was an agreement among the participants that the RC was a bridge between the employer and the patient and that an early initiation of the person-centred dialogue meeting was beneficial for the patient. A common source of frustration was that employers generally knew so little about their own responsibilities for the working environment and for rehabilitation. The RCs perceived that the person-centred dialogue meeting sometimes revealed an unknown complex situation.
The importance of collaboration at the primary care centres
CMs and RCs described that close collaboration and knowledge sharing among professionals at the primary care centres created added value in their health care services. The patients were ensured of receiving advice regarding RTW, irrespective of which professional they turned to. Good communication was also seen as a guarantee that all tasks were done, and that nothing fell between the cracks.
It saves an incredible amount of time! Instead of writing a lot and sending it away, I can knock on the door and leave the information directly to whom it concerns. (FG 1)
Sharing different views on how best to treat patients with CMD was said to improve the quality of health care. However, it was stressed that to make this collaboration work, professionals needed to take a personal responsibility and be willing to lose prestige for the good of the patients. Problems with cooperation were lifted as something that could harm the patient’s recovery or even increase their emotional suffering.
Collaboration and division of roles between the rehabilitation coordinator and the care manager
CMs and RCs thought that the Co-Work-Care model had improved and developed the collaboration at the primary care centres. Through this method, the CM and the RC had further developed a common working model for patients with CMD. A goal was to be flexible about patients’ needs, so that patients received help from the most suitable professional at the right time. In most cases the CM took the role to first understand the patient’s situation, and then to thoroughly communicate this information to the RC. The role of the RC was to use the information strategically, in a way that benefitted the patient during the person-centred dialogue meeting with the employer. The main goals in this meeting were to create a common ground concerning the patient’s situation and to support the patient in relation to the employer. The RC also had the main role in practical matters concerning the sick leave.
I can feel that collaboration is like putting an equal sign between collaboration and qualitative-enhancing measures. … .. to get more substantiated decisions. (FG 4)
Collaboration with the GP
According to the participants, the CM and the RC planned the interventions for patients with CMD, while the GPs prescribed medication or were involved in practical matters regarding sick leave. Participants perceived that the GPs often followed their recommendations, since they were expected to have extensive information about the patients’ situation.
The GPs benefit so much from a close cooperation with us. I have spoken many hours with the patient, and then I summarise everything in notes. I have the habit of reminding the GPs to read what I have written. You have to make sure and work a little harder to remind new GPs to read the notes. (FG2)
Participants emphasised the difficulty posed by the fact that many GPs switched positions often, and did not have time to become familiar with the working model for patients with CMD. Participants also perceived that, at a structural level, GPs were not expected to be very aware of the patient’s overall situation. Both these issues were seen as barriers to a more profound collaboration with the GPs in general.
The person-centred dialogue meeting
The main purpose of the person-centred dialogue meeting was to create a basis for collaboration where the patient felt safe to communicate needs and concerns from his/her own perspective. The primary care centres was seen as a neutral place for the meeting, whereas the workplace was considered as potentially intimidating from a patient’s point of view.
Participants agreed that the RC should function as a bridge between the employer and the patient, to lay the basis for a healthy relationship that could contribute to a sustainable RTW. A common experience was that when the employer and the patient tried to solve problems entirely without help from the RC, they often fell into habitual relationship patterns which complicated their ability to find sustainable solutions.
It is generally beneficial to include an external part at the meeting. The employer is higher in the hierarchy, and the patient is in a vulnerable situation. Therefore, the patient may benefit from getting support from someone who is external. (FG 1)
The person-centred dialogue meeting was emphasised as crucial when dealing with an unsustainable work situation. RCs described how they made sure to clarify and confirm perspectives of the patient as well as the employer, in order to create a plan based on a common understanding.
Several RCs wanted the person-centred dialogue meeting also to function as a platform for making a rehabilitation plan. They considered it ineffective to first gather a lot of information about the patient, and then not be able to use this in a purposeful way during the meeting. Others felt that it was better to keep the person-centred dialogue meeting as an initial “ice-breaker” discussion, to create a solid ground upon which to build further work.
In some cases, participants received information of a personal nature from the patients that could have been meaningful for understanding the development of CMD and for the caring process. Thus, RCs needed to know which information they could share during the person-centred dialogue meeting. Nevertheless, it was mentioned that even when patients experienced problems outside of work, their overall situation could be improved by creating a healthier work situation.
… so that the contact with the workplace becomes a health factor, so that the patient can get better, and not get into isolation or social exclusion. To create this, I don’t see the underlying problem as especially important … what exactly the problem is, so to speak. (FG 3)
Initiating the person-centred dialogue meeting
Having a meeting early in the sick leave period to create a plan with the patient and the employer was considered beneficial for the patient. A shared experience was that when the RC scheduled the person-centred dialogue meeting at a later stage, it became more difficult for the patient and the employer to reach a shared view of the problems.
RCs experienced that patients often interpreted employer’s unwillingness to reach out as indifference, while the employer could be concerned about not putting a pressure on the patient. To avoid such misunderstandings, an early meeting could serve as an icebreaker, sparing both parties some distress, and making it easier for the patient to focus on getting well.
It is also easier when the patients still have their work identity. If you wait for too long, they will more and more identify themselves as being sick. (FG 3)
Scheduling a first talk with the employer early on also meant practical advantages concerning sick leave. The RC could then form a time plan together with the patient and the employer, so that all parties knew what to expect and how to act, well before the sick leave ended.
Some changes that need to be done cannot be fixed within a day. Sometimes the employer needs to start up a process at the workplace, and therefore we need to start this communication early on. (FG 4)
Having a collaborative talk with the employer prior to the person-centred dialogue meeting was done to prepare oneself for how the situation was perceived by the employer and thus facilitated the development of a return to work plan. However, participants explained that if the patient’s condition was too poor, they had to wait with the person-centred dialogue meeting, to avoid the risk of not being able to establish a functioning collaboration between the employer and the patient.
Person-centred dialogue meeting to improve collaboration with the employer
RCs perceived employers as being generally humble about their lack of knowledge of mental health disorders, and they seemed grateful about receiving practical help and valuable advice from the primary care centres. RCs communicated a frustration about the fact that employers generally knew so little about their own responsibilities for working environments and rehabilitation. Some participants even thought that patients would not have become ill in the first place if employers had known more about these issues.
As a starting point, I usually ask the employer if they have easier, uncomplicated tasks that we can offer the patient. It is often difficult for the patients to concentrate on several tasks simultaneously. (FG 3)
Participants agreed that having full cooperation with the employer was crucial in order to help them change possibly harmful working conditions. It was also agreed that if nothing changed, the risk for the employee to end up on sick leave again was high.
Person-centred dialogue meeting to teach about the return to work process
Collaboration was also considered important to resolve misunderstandings about how to think about the RTW process. Participants emphasised that returning to work had to be seen as an ongoing, one-step-at-a-time process.
Some people think that you need to feel completely well before you can return to work. It’s more about that you get well by gradually increasing the workload.
(FG 3)
The way to a better working situation was said to go through creating a healthier and sustainable working situation. However, it was mentioned that at the beginning of a collaboration, both employers and patients could share the idea that resting at home was the best way to recover one’s working capacity. Finding ways to collaborate with the employer, creating solutions for better working conditions, and planning for a gradual return to work were therefore considered incredibly important.
During the person-centred dialogue meeting, employers often understand things that they haven’t seen before or understood the extent of. The conversations can work as an eye-opener for the patient’s situation and for the working environment. (FG 2)
According to participants, the person-centred dialogue meeting sometimes revealed a complex situation, for example that the patient had been bullied at work or had an overly complicated relationship with the employer. In some cases, participants decided that problems were so difficult to resolve, that it would be in the patient’s best interest to change workplace.