health providers

Who really has all the pieces of the puzzle?

I’ve worked in pain management for quite a while now, and longer in work rehabilitation, and seen the process from almost all sides.  For ages I thought that, as the health provider working with the person in the workplace itself, I had most of the pieces of the return to work puzzle.  I mean, I did have access to the medical information, progress reports from other health providers, I spoke with and met with the employer, the compensation agent or funder, and worked with the person…but I’ve revised my ideas since my own rehabilitation.

I’ve realised that the only person who has all the pieces of the puzzle is the person who is returning to work. This person is the only one who has been at every health care meeting, treatment session, and progress report.  This person is also the only one who has met with the employer, been a the at-work rehabilitation meetings, and been in ongoing contact with the compensation agent or funder.

I think the importance of this fact may not be made clear to the person very often – it certainly wasn’t made clear to me during my rehabilitation. Although I should have known, I didn’t – even with all my experience! (more…)

“I thought if I held out long enough, someone would find a cure”

I’ve written about acceptance before (here) , (here) oh and (here) – it’s one of those topics that seems to come up again and again (or is that ‘cos I’m looking for it?!).

I have been reading about self efficacy beliefs especially relating to beliefs about returning to work, and the thought crossed my mind that people can hold contradictory beliefs about their condition and their confidence to do things despite pain, but that it probably has some sort of emotional cost. Not sure that I’ve found any specific literature to support that, but hold the thought in your mind!

Anyway, today I was reading an article by Busch, Goransson & Melin (2007) about self-efficacy beliefs predicting sustained long-term sick absenteeism in individuals with chronic musculoskeletal pain. In it they describe the results of a survey of 233 people with chronic pain, aged under 60, who had jobs to return to and had not taken early retirement – the long-term sick leave people. The group were divided into those who had been considered ‘work capable’ (they had been removed from the sick leave register in Sweden in the previous 6 months), or currently sick listed. All participants were given an initial questionnaire which included questions on:
(1) demographics
(2) perceived physical and psychological health
(3) working conditions
(4) involvement in rehabilitation
(5) individual factors including beliefs and mastery
(6) perceived consequences of long-term sick leave

The specific questions and questionnaires used are described in the actual article, so I’ll cut to the chase and get on with the results…
After this initial survey, four follow-up surveys were conducted 6 – 12 months after the initial one. The outcome measures of interest at these follow-ups were sick leave days.

Using regression analyses, five significant predictors were found:

  • psychological health,
  • mastery,
  • mental demands at work,
  • recovery beliefs, and
  • sick absenteeism earlier in life.

The strongest predictor was beliefs about recovery, and the next strongest was a sense of mastery.

Once again, it seems that the physical characteristics of work and the physical capacities of individuals are less useful for predicting return to work than whether the person thinks they will recover. The actual question used was ‘A year from now, do you think your health will be better or worse?’

I’m not entirely sure that this is a question of self-efficacy, however that aside, it seems that the person’s own opinion of whether they are ‘well’ or not has an incredibly powerful effect on whether an individual will or won’t meet the challenge of the workplace.

As the authors in this paper say ‘beliefs about one’s recovery can be interpreted in different ways. They can reflect medical ‘facts’ about one’s disorder, communicated by medical staff or others.’

The person I quoted in the headline today said to me, ‘I thought I shouldn’t go back to work because then they wouldn’t think I needed to have my hand fixed, and if I held out long enough, someone would find a cure’.

He had been told that he shouldn’t risk his hand in a work situation because ‘it might make your recovery slower’.

If only someone had said to him that staying off work would likely mean he would lose his job and make eventual return to work much more difficult!

How does this fit with acceptance? The man I’m working with is slowly moving to a place where he accepts that his hand doesn’t perform exactly the way it used to – and that this doesn’t mean an absolute disaster for him.  Neither does it mean he needs to give up hope that things will be different in the future.  Or that someone might find a ‘cure’.

In the meantime he has a life to live, and he is gaining confidence (self-efficacy) that if he starts to take steps to regain control in his life, he’ll begin to ‘live’ a fuller, more ‘normal’ life.

Self efficacy is about being confident that one can achieve success in a given situation. Acceptance is about giving up a resentful struggle against things being the way they are, and getting on with life – I think they may be linked. It’s very hard to feel confident if you are struggling against the reality of life being different from the way you want it to be.

As for our role as health providers? Well it seems to me, if we instill in people the belief that they shouldn’t return to work in case they delay their recovery, or that we don’t believe they can cope with hearing that their problem may be chronic, we’re undoubtedly contributing to the negative effects of low self-efficacy. If instead we work hard to instill in our patients that we believe they have the ability to do ‘normal’ things in life, like return to work, and that recovery is more than pain reduction, we may contribute to their confidence. I hope we do this!

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Busch, H., Göransson, S., Melin, B. (2007). Self-Efficacy Beliefs Predict Sustained Long-Term Sick Absenteeism in Individuals With Chronic Musculoskeletal Pain. Pain Practice, 7(3), 234-240. DOI: 10.1111/j.1533-2500.2007.00134.x