Does feeling respected influence return to work? Cross-sectional study on sick-listed patients’ experiences of encounters with social insurance office staff

Ways of promoting return to work among sickness absentees is an ongoing clinical as well as political theme in many western countries, facilitating return to work among long-term sickness absentees being a special topic of concern. Several different interventions and programs have been introduced to this end, at different structural levels and among different stakeholders, e.g. worksites, healthcare, and insurance offices [1–12].

The long-term sick-listed constitute a vulnerable group in different ways: apart from their morbidity/health condition, they often have a lower educational level compared to others, are more often immigrants, and have a lower disposable income compared to their previous work income [13]. Moreover, to a large degree they are in the hands of both healthcare staff and social insurance office staff, whose judgments and decisions have a major impact on their access to rehabilitation measures, work adjustments, and their economic situation. Long-term sickness absentees have themselves stated that their treatment by professionals from healthcare and social insurance was as important as the different rehabilitation measures [14, 15]. For instance, respectful meetings have been reported to be of relevance for returning to work [9].

In previously conducted studies regarding long-term sickness absentees’ encounters with healthcare staff, based on data from the same questionnaire as the present study uses, we found that both negative and positive encounters influence patients’ self-estimated ability to return to work [16]. We also found that when patients feel respected in addition to experiencing their encounters as positive, their self-estimated ability to return to work is significantly facilitated, whereas patients feeling wronged in addition to experiencing their encounters as negative, estimated that their ability to return to work was significantly impeded [17]. Even though self-estimated ability to return to work is not the same as actually returning to work, long-term sick-listed patients’ own beliefs on this matter is arguably an important predictor for return to work, in a similar vein as self-estimated health has been reported as the most valid predictor of a long life [9, 18].

Since it is social insurance office staffs who decide whether patients fulfil the criteria for sickness benefits, it is also of interest to investigate patients’ perceptions of encounters with these actors. The aim of the present study was to explore long-term sick-listed patients’ encounters with social insurance office staff and the impact of these encounters on their self-estimated ability to return to work. To further illuminate these patients’ experiences of encounters with social insurance office staff, those experiences were compared with their experiences of encounters with healthcare staff.

In this cross-sectional study we analysed data from answers to a population-based questionnaire sent out to a random selection of half of all people in Sweden who in March 2004 had an on-going sick-leave spell that had lasted for at least four and at the most eight months (n = 10,042). This duration of the sick-leave spell was chosen so that the absentees would have had a chance to have personal contact with the social insurance office but still have a good chance to return to work. A comprehensive questionnaire was developed, based on several qualitative and quantitative studies of how sickness absentees experience encounters with social insurance and health care staff [14, 19–21].

We studied their experiences of positive and negative encounters with social insurance office staff. All participants received the same questionnaire. Those who had experienced positive encounters only were subsequently asked to specify the experience by choosing from a list of different positive encounters, such as ‘Listened to me’ and ‘Believed me’. They were also asked what kind of feeling the encounters had resulted in, including feeling respected. Those with experiences of negative encounters only or a mix of positive and negative encounters were similarly presented to a list of negative encounters, such as ‘Did not listen’ and ‘Was too impersonal’, and they were also asked what kind of emotions the encounters resulted in, including feeling wronged. Finally all participants were asked whether or not the encounters had influenced their ability to return to work, response alternatives being ‘facilitating’, ‘not influencing’, or ‘impeding’. The lists of encounter items were developed partly based on the outcome of focus-group interviews [19].

In addition, the respondents were asked if they were sick-listed due to (a) mental disorders, (b) musculoskeletal pain, or (c) other somatic diseases.

Focusing on the associations between feeling respected / wronged in encounters with social insurance office staff and self-estimated ability to return to work, we performed logistic regression analysis adjusting for different background variables such as sex, age, educational level, and diagnosis. Adjustments made no substantial difference to the results. Therefore, we present the results as proportions with a 95% confidence interval (CI) for those who estimated that return to work was facilitated when experiencing positive / respectful encounters compared to those who stated that it was not influenced or impeded. The same was done for the proportion of those whose self-estimated ability to return to work was impeded when exposed to negative/wrongful encounters compared to those who stated that it was not influenced or facilitated.

The study was approved by the Regional Research Ethics Committee in Linköping, Dnr 03–261.

The response rate was 58% (n = 5,802) of the original sample (Table 1). When asked about experiences of negative and positive encounters, there was an internal drop-out of 231 ending up with 5,571 participants. Of these, 78.4% had experienced positive encounters and 21.6% had experienced negative encounters. When the respondents were asked about feeling respected or wronged, there was an additional internal drop-out, leaving 4,535 participants, of whom 76.5% had felt respected and 23.5% had felt wronged (Figure 1).

Of those participants who had experienced positive encounters, 87.8% (n = 3,047) reported that they had also felt respected. Of those who had experienced negative encounters, 55.1% (n = 586) reported that they had also felt wronged (Figure 1).

We found high ARs for positive encounters with social insurance office staff and feeling respected and for negative encounters and feeling wronged. We also found that feeling respected had a facilitating effect on a self-reported return-to-work ability. Similarly, we found that feeling wronged had an impeding effect on self-reportedly ability to return to work. The positive effect of feeling respected on self-estimated ability to return to work was particularly manifested among patients with mental disorders. Our results are in line with previous findings that long-term sick-listed patients are sensitive to whether their encounters are respectful or not [9].

Specific items of positive encounters particularly associated with feeling respected were being listened to, being believed in, and having one’s questions answered. Specific items of negative encounters associated with feeling wronged were not being believed, having one’s condition doubted, and having one’s motivation for work questioned. “Nonchalant behaviour” was the item of negative encounters with the highest AR, but it is highly unspecific and might cover several of the more specific items. The same goes for the item of positive encounters with the highest AR, “Treated me with respect”.

From other studies it has been reported that female sick-listed patients have special preferences when it comes to rehabilitation and return to work [9]. On this backdrop it is interesting that we did not find any gender differences. This difference might be due to different methods; it might be easier to recognize gender aspects in qualitative research compared to quantitative studies.

A majority of patients with positive experiences from encounters with social insurance office staff also felt respected and estimated that their return to work was facilitated by these types of encounters. Feeling respected was especially associated with being listened to and being believed in. The positive effect of feeling respected was particularly manifested among patients with mental disorders. Correspondingly, a majority of those who, in addition to having experienced negative encounters, also felt wronged stated that their return to work was impeded. Feeling wronged was especially associated with being disbelieved, getting one’s condition doubted, and having one’s motivation to work questioned.

Even though encounters with social insurance office staff seem to have less effect on patients’ self-estimated ability to return to work than corresponding encounters in healthcare, the impact is not negligible. The results indicate that there is room for improving patients’ encounters on the part of social insurance office staff, in particular by listening to and believing the patients, refraining from expressing doubt regarding their conditions, and not questioning their motivation to return to work.