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A theoretical framework to describe communication processes during medical disability assessment interviews
© van Rijssen et al; licensee BioMed Central Ltd. 2009
- Received: 14 May 2009
- Accepted: 6 October 2009
- Published: 6 October 2009
Research in different fields of medicine suggests that communication is important in physician-patient encounters and influences satisfaction with these encounters. It is argued that this also applies to the non-curative tasks that physicians perform, such as sickness certification and medical disability assessments. However, there is no conceptualised theoretical framework that can be used to describe intentions with regard to communication behaviour, communication behaviour itself, and satisfaction with communication behaviour in a medical disability assessment context.
The objective of this paper is to describe the conceptualisation of a model for the communication behaviour of physicians performing medical disability assessments in a social insurance context and of their claimants, in face-to-face encounters during medical disability assessment interviews and the preparation thereof.
The behavioural model, based on the Theory of Planned Behaviour (TPB), is conceptualised for the communication behaviour of social insurance physicians and claimants separately, but also combined during the assessment interview. Other important concepts in the model are the evaluation of communication behaviour (satisfaction), intentions, attitudes, skills, and barriers for communication.
The conceptualisation of the TPB-based behavioural model will help to provide insight into the communication behaviour of social insurance physicians and claimants during disability assessment interviews. After empirical testing of the relationships in the model, it can be used in other studies to obtain more insight into communication behaviour in non-curative medicine, and it could help social insurance physicians to adapt their communication behaviour to their task when performing disability assessments.
- Communication Behaviour
- Disability Assessment
- Assessment Interview
- Sickness Certification
- Coping Attitude
In addition to their curative tasks, physicians also often perform different types of medical assessments, such as those that are needed for sickness certification, disability legislation, and social insurance. National standards for these medical assessments vary considerably, but there are several basic principles. In this paper, social insurance medicine in the Netherlands will serve as an example. An important task of physicians working in this field of medicine is to assess the medical status or work capacity of employees with prolonged sick-leave. The medical assessment is the first step in determining whether or not the employee, or claimant, is entitled to social security benefits. In addition to the available information and a physical examination, the key component of this medical assessment is the assessment interview, during which the claimant and the physician meet face-to-face. This interview differs from an ordinary physician-patient encounter, because it is of a less voluntary nature than a physician-patient encounter in curative medicine (i.e. the people who are involved have no choice with regard to participation in the assessment interview) and the physician's assessment has legal consequences for the claimant. The social insurance physician's assessment of the employee's work capacity determines the entitlement to social security benefits [1–3]. The attitude and communication behaviour of the social insurance physician during the assessment is likely to influence the behaviour and cooperation of the claimant, and may thus influence the quality of the information that is obtained and the accuracy of the disability assessment. Similarly, the attitude of the claimant and the claimant's coping behaviour will also influence the content and course of the communication during the assessment, and the quality of the information that the physician receives from the claimant.
In social insurance medicine, the style and content of communication behaviour may not only influence the disability assessment process, but possibly also the outcome of the assessment. In view of the influence of communication behaviour in these physician-claimant encounters, and in order to gain insight into the complexity and dynamics of this behaviour, it is important to develop a conceptualised theoretical framework. Therefore, the objective of this article is to describe the conceptualisation of a model for the communication behaviour of social insurance physicians and of their claimants in face-to-face encounters during medical disability assessment interviews. This conceptualisation will be based on the Theory of Planned Behaviour (TPB), and the main relationships in the TPB will be discussed in the context of disability assessment interviews. Along the lines of this theory, we will refer to literature indicating that communication behaviour of social insurance physicians during assessment interviews can be predicted from a combination of their attitudes, experienced social influence, self-efficacy, intentions with regard to behaviour, skills, and barriers for communication with claimants in general. Analogously, we will present literature findings to indicate that the communication behaviour of claimants during the assessment interview can be predicted from their attitudes, intentions, skills, and barriers for their communication with social insurance physicians, or communication with physicians in general if they had no prior experience with social insurance physicians.
The importance of communication behaviour
Communication is generally defined as a process of transferring information from one source to another. This broad definition is also applicable to the transfer of information between the social insurance physician and the claimant, i.e. the behavioural process of reciprocal contact between social insurance physician and claimant during their face-to-face assessment interview, aimed at (verbal and non-verbal) continuous, dynamic, two-directional information exchange. Information exchange is used here as a broad term to describe exchange and transmission of facts, opinions, feelings, etc. (conscious as well as unconscious), including the development of an interpersonal relationship and mutual trust within the communication process.
Good and effective communication is essential for the provision of good medical care. The importance of communication for physicians in a sickness certification or disability assessment setting is possibly even more pronounced, as has been clearly illustrated by O'Brien et al. . In their interview study, patients who visited a general practitioner for a sick note indicated that a good doctor-patient relationship was important to them, as were opportunities to talk about various illness-related issues. Moreover, many of these patients stated that doctors lack the necessary time and knowledge for this purpose . On the other hand, doctors also experience difficulties with the relationship during sickness certification consultation, but they believe that communication is one of the most important aspects of sickness certification as well .
Very few studies have focussed on the importance of communication during assessment interviews or sickness certification consultations , but it has been found that the way in which doctors approach their patients (i.e. the degree of proactive communication: taking the initiative and anticipating the claimant) when discussing return to work was related to the duration of the workers' compensation benefit. More proactive communication was associated with a shorter period of disability benefit, albeit only in the first thirty days . Moreover, the fact that communication is, indeed, important for both the social insurance physician and the claimant, was illustrated by the finding that many of the complaints made by claimants to the social insurance company concerned being treated discourteously by social insurance physicians or by labour experts . Lippel investigated the possible beneficial and adverse effects of the sickness compensation assessment process for injured employees. These claimants mentioned mental health problems as the most pronounced adverse effects of the assessment process. Stigmatisation, prejudice and lack of support were all contributing factors . Moreover, it has been suggested that increased transparency of the medical disability assessments can result in less complaints about malpractice, by increasing the claimant's satisfaction with and acceptance of the outcome of the assessment . Greater transparency might also increase their general acceptance in political decision-making and society in general .
In studies focussing on social insurance physician-claimant communication, the intentions and behaviour of the claimants were found to be just as important as the intentions and behaviour of the physicians. For example, the 'Eurocommunication Studies' focussing on communication between general practitioners and patients in ten European countries, found that it was not primarily the health care system, but patient characteristics that have the greatest influence on communication. Conversely, the contribution of physician characteristics was found to be of less importance . Other important characteristics are age, gender, and social class. Examples of physician-specific characteristics are medical speciality and income, and examples of patient-specific characteristics are prognosis, level of education and health beliefs .
The behavioural model
To gain insight into communication behaviour during disability assessment interviews, a behavioural theory (a theory according to which behaviour is learned instead of being innate) was taken as a starting point. There are many common aspects of behavioural theories (also called motivational theories or cognitive theories; for example ). Well known theories, such as the Social Cognitive Theory (SCT) , the Theory of Reasoned Action (TRA) [16, 17], the Theory of Planned Behaviour (TPB) , and the Attitude/Social influence/self-Efficacy model (ASE model) [19, 20], for example, share the concepts of attitudes, behaviour, intentions with regard to behaviour, self-efficacy, social influence, skills, and barriers. Attitudes refer to beliefs or consistent, external evaluations of another person, action, or idea; intentions are the willingness to adopt a certain behaviour; self-efficacy is the confidence and ability to be able to act adequately in a given situation; social influence is the influence of social norms and beliefs of relevant others on a person's actions; skills concern the capacity to adopt certain behaviour; barriers are potential obstructions that could prevent the occurrence of certain behaviour. Of all the theories mentioned, the TPB and the ASE model are the most recent and comprehensive models. The TPB is based on three types of beliefs: (1) beliefs about and evaluations of the likely results of behaviour, which lead to positive and negative attitudes towards behaviour; (2) beliefs about and evaluations of norms and expectations of others, which lead to compliance with or rejection of these subjective norms; and (3) beliefs about behaviour-facilitating or behaviour-impeding factors and their strength, which lead to perceived behavioural control. The combination of attitudes, subjective norms, and perceived behavioural control (also referred to as self-efficacy) leads to behavioural intentions, which then lead to behaviour [17, 18]. The main difference between the TPB and the ASE model is that the latter explicitly takes the influence of (objective) skills and barriers into account, whereas the TPB does not. However, the TPB has been studied more extensively.
The applicability of the TPB to communication behaviour in medical encounters has been assessed in several reviews, for example by Perkins et al.  and Eccles et al.  who investigated the relationship between intentions and behaviour. Physician-patient communication was investigated (i.e. education of the patient by the physician) in one study  in the Perkins et al. review , and it was concluded that the intentions of the general practitioners to provide patients with information were related to their attitudes and, in combination with self-efficacy, also to their behaviour. One study in the Eccles et al. review  concerned physician-patient communication in terms of patient education . From the results of this study it was concluded that the TPB (e.g. self-efficacy regarding the education of patients) is a better predictor of intentions and future behaviour than the TRA.
Godin et al.  pointed out the weaknesses of both reviews [21, 22] and they performed another review of many social behavioural theories. They identified six studies in which physician-patient communication was included, for instance by providing education and addressing mental health problems. It is remarkable that all of these studies used the TPB as their theoretical basis. The review  resulted in two important conclusions. Firstly, it showed that the efficacy of the TPB in predicting intentions and behaviour differed when different physicians participated in the study, different behaviour was studied, different methodology was applied, etc. Secondly, it nevertheless seems possible to predict the intentions and behaviour of health professionals on the basis of the social behavioural theories. The authors conclude that the TPB provides a good theoretical framework with which to predict behaviour . In the field of sickness certification and social insurance medicine, we are not aware of any reviews that have been carried out to evaluate the application of the TPB to communication behaviour. We do, however, know of one study in which the TPB was applied to communication behaviour. Croon and Langius  studied the process of sickness certification assessment by social insurance physicians. They took the TPB as a starting point, because they wanted to find out why social insurance physicians assess in a certain way, and were therefore interested in their motivation. They found the TPB very useful .
The TPB has also been applied to assess patient behaviour by many researchers. It was used by Munro et al.  in their review of adherence to medication, and by Brawley and Culos-Reed  in their review of adherence and behaviour change. As will be explained below, the unique features of the contact between a social insurance physician and a claimant, compared to contact between other doctors (such as general practitioners or specialists) and their patients, support the choice of the TPB as a basis from which to investigate social insurance physician-claimant communication.
Specific features of social insurance physician-claimant communication
The core concept of the present conceptualisation is communication behaviour, and in the social insurance physician-claimant contact there are two important aspects of this behaviour: "to gather sufficient information ... in a caring way" (, p. 1118). In other words, according to the Ong et al. review , the two main purposes of communication behaviour are "(a) creating a good inter-personal relationship and (b) exchanging information" (p. 903). From the social insurance physician's point of view, these two perspectives could be summarised respectively in the interview as patient-centred behaviour (i.e. behaviour that puts the patient and his/her concerns, perspective and information needs first), and physician-centred behaviour (i.e. behaviour that puts the physician's perspective and information needs first) . The distinction between the two perspectives resembles the division in health care between instrumental (also referred to as task-oriented, paternalistic, or disease-oriented) and affective (also referred to as patient-oriented) patient-doctor relationships [e.g. [30–32]]. Instrumental relationships concern aspects of the relationship between the social insurance physician and the claimant that explicitly serve a goal (information-giving and information-seeking), and affective relationships concern collaborative, social-emotional aspects of the relationship between the social insurance physician and the claimant (positive and negative social talk). This also resembles differences in psychotherapeutic approaches, such as person-centred or client-centred psychotherapy and the more directive therapies. The instrumental model used to be a popular approach in medicine, but the affective approach is now more common [33, 34]. However, different patients might prefer a different type of approach, depending for instance on the nature of their health complaints .
Although both the instrumental aspect and the affective aspect are important, the main focus of social insurance assessment interviews is an instrumental aim, i.e. gathering information to make the most accurate assessment of the functional capacity of the claimant, whereas in curative medicine there is often an equally strong focus on the affective aim, i.e. empathy, because patients often have a great need for reassurance. Within the assessment, the social insurance physician's main task is to assess the claimant's work capacity in relation to the medical disabilities, and not to cure or care for the claimant. Van den Brink-Muinen et al. [12, 31] also concluded from their international comparison study that communication patterns between Dutch general practitioners and their patients are oriented towards instrumental behaviour (e.g. giving information and advice). Affective behaviour was also observed, but to a lesser degree than in other European countries . Of course, the claimant might also ask for information, for example about the assessment process and the outcome (e.g. method of assessment, perceived work capacity, consequences for disability benefits, etc.). In addition, the claimant has an explicit or implicit need for a certain degree of empathy (e.g. someone to listen to his/her worries and frustrations, reassurance, emotional support in talking about disabilities), and possibly needs to be motivated or slowed down with regard to job performance. In this respect, the social insurance physician's background knowledge and experiences could, in general terms, be seen as his/her intentions during the communication, his/her self-efficacy, his/her skills, and perhaps even the social influence of others, such as colleagues and the employer.
Social insurance physicians generally work under substantial time-restrictions, and in some cases they only meet the claimant once, the latter unlike other physicians, such as general practitioners or specialists. Therefore, the social insurance physician's previous experience of communication with claimants and intentions, or general and claimant-specific preferences with regard to this communication, will have considerable influence on the communication behaviour during each specific contact. Moreover, the physician and the claimant have no choice with regard to participation in the assessment interview. They are thus dependent on each other, and whether or not they like each other initially - whatever the reason may be - will influence their communication. Empirical findings from social psychology research suggest that similarities in attitudes and behaviour are important in first-time encounters between people, and lead to better communication and personal attraction. This also applies to many other similarities in attitudes and behaviour [36–39], and can help to solve language problems and remove emotional barriers. It is important to note that these similarities not only increase the effectiveness of the exchange of information, but they also influence the emotional relationship: similarity in behaviour leads to personal attraction between people. Moreover, research findings indicate that this personal attraction is closely related to feelings of security and trust , and that during medical encounters, similarities between physicians and their patients enhance their communication and their satisfaction with it . However, cultural differences cause problems in communication . Similarities or differences between the social insurance physician and the claimant might therefore influence the course of their communication. Especially, during a once only or occasional contact, or when there is limited time to establish a relationship, the physician must quickly make the claimant feel at ease in order to obtain the information that is necessary for the assessment. In such situations the claimant has little time to gain trust in the physician in order to feel comfortable enough to talk in detail about his of her medical problems.
In social insurance medicine, not only the communication behaviour itself, but also satisfaction with that behaviour may play an important role, because to a certain extent satisfaction determines how, and how efficiently information is exchanged. If a physician is unhappy with the communication during an assessment interview, he is more likely to change his behaviour and look for different ways in which to gather the necessary information. Similarly, the satisfaction of a claimant will probably influence his or her willingness to provide the physician with the necessary information. Moreover, assessment interviews are daily routine for social insurance physicians, whereas they are only incidental for claimants.
From the perspective of the physician it is important to note that there are two distinct groups of claimants. Those in the first group have had previous experience of an assessment interview, which means that they already know what to expect (their expectations and attributes are perhaps more realistic), or at least know more about how an assessment interview is conducted (whether good or bad) and will behave accordingly. For this reason, they will probably feel that they have more control over the interview and the communication. Their intentions and preparations will probably differ from those of the claimants in the second group, for whom it is the first assessment interview for a disability benefit. For example, claimants with previous experience will probably base their expectations on visits to physicians in general or a description of the procedure, which may be based on positive or negative stories about assessment interviews.
An overview of the conceptualisation
At the centre of the model is the actual assessment interview, during which both the physician and the claimant are present. This is the action phase that follows the preparatory phase. The core issue of an assessment interview is the communication behaviour, and how this is perceived and evaluated by the people involved. Since both people are present during the assessment interview and the exchange of information is a continuous, dynamic process, the model states that the behaviour of the physician influences that of the claimant, and vice versa. The psychological mechanisms of "transference" (the claimant expresses feelings, wishes and experiences towards the physician that are actually felt towards other people who are of were important in the claimant's life) and "counter-transference" (reactions from the physician to the claimant) might be involved here. Moreover, there will always be interaction between the occurrence of and satisfaction with the communication behaviour, both of which are constantly changing and influencing each other. This is in line with findings that the general consultation characteristics of patients and physicians might influence their satisfaction [e.g. [43, 44]], and that satisfaction is related to a patient's perceptions of an encounter, but not to more objective observations . Therefore, the core of our framework stresses the more subjective, perceived communication behaviour and people's evaluations of that behaviour (i.e. satisfaction), instead of objective, observable behaviour. The full theoretical framework that results is substantial, in that it covers the communication process as a whole, including the relationships between the different aspects and persons involved, and 'environmental' aspects, such as the personal characteristics of the people involved. This 'ecological approach' (i.e. an approach that states that behaviour results from multiple sources which interact, including the person himself/herself, other people, and the context, including the situation and environment), is advocated by Street et al. , who argue that an ecological approach is the most suitable method for describing physician-patient communication. They stress that from an ecological viewpoint all relevant influences on the communication are taken into account within the context of the medical consultation.
Because not every aspect is visible for the social insurance physician, the conceptualisation for claimants will be only partly analogous to that for the social insurance physician, and only part of the TPB will be conceptualised for the claimant. Attitudes and intentions are the core concepts of the TPB, so it is likely that the physician will be aware of the influence of the claimant's attitudes and intentions during the assessment interview. The other aspects of the model will have their influence through the intentions. The only exceptions are the skills and barriers, which influence the relationship between intentions and behaviour. Because of the direct influence of skills and barriers on behaviour, these are included in the claimant's side of our theoretical framework. The included aspects are intentions with regard to behaviour, attitudes, skills, and barriers. The way in which claimants cope with assessment interviews - their communication behaviour and their satisfaction with the communication - is also included, because this is directly relevant, visible, and experienced by physicians. The application of these aspects of the theoretical framework to claimants will now be presented.
Behaviour and satisfaction
Because it is believed that the dimensions of patient or claimant satisfaction are mostly similar to the dimensions of physician satisfaction , the communication behaviour and perceived behaviour of the claimant during the assessment interview is conceptualised in the same way as that of the physician. Communication behaviour and satisfaction with that behaviour are conceptualised as multidimensional, with the same dimensions as for the physician.
Intentions, skills and barriers
Although attending an assessment interview is not a routine activity for the claimant - as it is for the physician - the claimant's normal way of communicating will probably be similar to the way in which he or she will communicate with the physician. Moreover, we know from research that the communication style of the patient is equally important as that of the physician , and that this communication style (i.e. intention) is also the claimant's way of handling communication in general and communication with other physicians in particular. Folkman and Lazarus  argue that before stressful encounters - such as examinations during a study, and also assessment interviews - people tend to handle the situation in an instrumental way (problem-focussed), and afterwards they tend to display more emotion-focussed coping (e.g. seeking social support). This conceptualisation is supported by Carver et al. , who discriminate between the use of instrumental support and the use of emotional support (among other types of coping), and by the results of studies in general health care, as mentioned above. Thus, the claimant's intentions with regard to communication can be both instrumental and affective. Bramsen et al.  made a more detailed distinction: problem-focussed coping according to a preceding plan, psychological distancing and avoiding (i.e. mentally creating distance between oneself and the environment), and seeking social support . These last two styles are forms of emotion-focussed coping, which Miller  referred to as a "blunting" and a "monitoring" coping style, respectively. Patients who blunt will avoid information, and those who monitor are very alert and are keen to receive information. According to Nordin et al. , these coping styles moderate satisfaction with the communication behaviour of medical staff. We therefore suggest that claimants, apart from seeking social support, may also intend to seek practical support. For example, they may intend to gather information about the assessment interview before attending, they may ask someone to go with them to the assessment interview, or they may practice beforehand by giving the relevant information to someone else.
The skills and barriers that claimants experience are conceptualised to affect the relationship between intentions with regard to behaviour and actual behaviour, and as we mentioned earlier, some connections do exists between these two factors, but they also have their own specific characteristics. Cegala et al.  found that training patients' skills in handling medical interviews resulted in a more patient-controlled communication, and that trained patients gave physicians more detailed information about their disabilities and were more able to summarise the information they received. Thus, training the skills needed to seek, provide, and verify information, seems to be important . For claimants, seeking information is not usually the primary goal during an assessment interview, so this skill is not included in the framework, whereas the other two are. Some examples of such skills are command of language, ability to explain their functioning, and ability to understand the physician. As the CanMed Physician Competency Framework states, it is important that physicians can gather information and understand it, as well as establish a good relationship with the patient . Presumably, the same applies to claimants, since their claim depends on the physician's assessment. Being able to influence the course of the interview and to handle difficult situations (solving problems) seem to be particularly relevant skills for claimants [86, 87].
Claimants might anticipate several barriers which may be related to the characteristics of the physician, for instance a different socio-cultural background from that of the claimant or the use of difficult language. The claimant's own characteristics, possibly related to the disability, could also form a barrier, such as concentration problems or physical fatigue.
Parallel to the importance of the physician's attitude towards communication, the attitude of the claimant might also influence the communication during an assessment interview. Claimants might have different attitudes with regard to the role of the physician in the communication, and these might hinder or aid the physician. These attitudes can be conceptualised analogously to the attitudes that the social insurance physician has about his or her own role in the communication. Therefore, the attitude of claimants towards the communication is conceptualised as relationship-focussed, result-directed/information-focussed , and focussed on the patient-centeredness of the physician . Relevant aspects of such attitudes are: expectations about support, listening, and asking questions for the relationship-focussed attitude; asking and thinking about return to work and talking about possibilities of return to work for the result-directed attitude; and expectations about reassurance and a good atmosphere for the caring attitude. As mentioned above, claimants who have attended an assessment interview before and those who have not will probably have different attitudes.
In addition to the attitude towards the contribution of the physician to the communication, the claimant will also have an attitude towards his own contribution to the communication. We refer to this as the coping attitude, because it concerns the way in which the claimant anticipates handling (coping with) the communication. Moreover, claimants will use certain general coping strategies while preparing for the assessment interview. Kloens  advised psychologists to take general coping strategies into account during the assessment of a patient. He distinguished three components of coping attitudes: a passive avoiding coping pattern of responding to the assessment, a problem-focussed coping pattern, and an emotion-focussed coping pattern, which includes the degree of seeking social support and expressing emotions. The passive avoidance coping attitude could then be sub-divided into a passive coping attitude and an avoidance (wait-and-see) coping attitude, in line with the Schreurs definition .
We have already stated that the number of previous assessment interviews a claimant has experienced, is an important claimant characteristic, explaining the difference between a first-time claimant and a claimant who has already attended one or more interviews. As in the conceptualisation for social insurance physicians, prominent characteristics which may be similar for claimants and social insurance physicians are age, gender, and socio-cultural background [41, 46]. Moreover, the claimant's level of education might influence the communication, for example because claimants with a higher level of education are generally more assertive, and physicians tend to give them more information [31, 41, 46]. In addition to attitudes and intentions, the claimant's personal characteristics will influence the communication. For example, an anxious claimant is likely to communicate quite differently with the physician than a depressed or confused claimant . This depends on the claimant's 'locus of control' (i.e. a personality trait indicating the degree to which gains are thought to result from one's own efforts or considered to be random events; according to the claimant, for example, who is responsible for whether or not the claimant will receive a disability benefit), and the related degree of control experienced in the communication.
We have presented a theoretically conceptualised model, based on the TPB, to study the communication behaviour of social insurance physicians and their claimants during (the preparation of) medical disability assessment interviews. This model will help us to understand the communication process during assessment interviews, and how this communication could go wrong, and we have made suggestions that could be appropriate to improve this communication. Because the conceptualisation specifically focuses on non-curative medicine, with social insurance medicine as an example (a field in which to our knowledge no such conceptualisation has been applied), this model might be of assistance in future research in this context.
Strengths and weaknesses of the behavioural model
Our choice to make use of existing behavioural theories, particularly the TPB, has advantages as well as disadvantages, both of which have been stressed by several authors. For instance, Ogden [91, 92] argued that behavioural models are pragmatic in guiding research because, although they are considered to be an appropriate basis for the development of interventions to change certain types of behaviour, their conceptual basis is less sound. However, Ogden's arguments based on problems in applying these theories and measuring the concepts, were refuted by Ajzen and Fishbein . The only argument they did not refute is that the concepts are not specific enough. We believe that we have countered this argument by specifying the concepts adequately in our proposed model. Moreover, in our opinions, the advantages of using the TPB to understand the communication processes in social insurance medicine (e.g. focus on the instrumental as well as the affective dimension, application in studies in related areas, and the amount of detail that is possible within the model) far outweigh the disadvantages. This is mainly because the conceptualised model is pragmatic in guiding further research, functional in formulating hypotheses, and useful in developing interventions to improve social insurance physician-claimant communication.
The resulting theoretical framework is quite comprehensive. In order to ensure that the model was feasible, we chose not to assume relationships between the conceptualisations of the aspects within the framework (e.g. the relationship between a problem-solving communication style or an insurance-technological communication style, and a practice-directed attitude or a result-directed attitude). The comprehensiveness of the framework may be both positive and negative. The positive aspect of a comprehensive framework is that there is a choice of focus, i.e. our conceptualisation is suitable for different types of research. For instance, the focus could be on the social-emotional or on the task-oriented aspects. Moreover, parts of the framework could be used for more in-depth evaluations, for instance in observational or qualitative studies. With regard to the negative side, when research is based on such a comprehensive model, there is a danger of wanting to investigate too much all at once. This means that studying the model as a whole implies a more general, less in-depth, procedure with, for example, questionnaires or structured interviews.
Implications for future research
Based on this conceptualisation, we hypothesise that the main relationships, indicated by arrows in Figure 1, will be found in an empirical test of the conceptualisation. According to the TPB theory, it is expected that the communication behaviour of social insurance physicians during assessment interviews can be predicted from a combination of their attitudes, experienced social influence, self-efficacy, intentions with regard to behaviour, skills, and barriers in the communication with claimants in general. Analogously, it is expected that the communication behaviour of claimants during the assessment interview can be predicted from their attitudes, intentions, skills, and barriers in the communication with social insurance physicians, or in the communication with physicians in general if they have had no previous experience with social insurance physicians. During the assessment interview, it is hypothesised - according to the proposed conceptualisation - that the communication behaviour of both the social insurance physician and the claimant will be the result of their input during the preparatory phase, their personal characteristics, and the degree to which these match those of the other person, their satisfaction with the communication behaviour, and the other person's behaviour.
When the relationships in the conceptualisation have been tested empirically, the TPB-based model for communication behaviour in social insurance medicine can be applied in empirical studies to obtain more insight into communication behaviour in non-curative medicine. We also expect that the concepts and relationships in the conceptualised model could be used in a communication skills training course for social insurance physicians. The model may help these physicians to recognise communication behaviour, and to intentionally and purposefully adapt their communication behaviour to their task when assessing the functional capacity and medical disabilities of claimants.
We have presented a conceptualisation of a behavioural model, derived from the TPB, for social insurance physician-claimant communication. This conceptualisation was based on studies focussing on physician-patient communication and the specific characteristics of social insurance physician-claimant contacts. Of course, just like any model, this model is merely a simplified representation of the reality. Although, obviously not every aspect, dimension, or variation is represented in the framework, it provides ample insight to professional communication from the perspective of non-curative and social insurance medicine.
The authors thank M. Berkhof, MSc, for her practical assistance. The research project this article resulted from is funded by the Dutch 'Stichting Instituut Gak', a foundation that initializes and supports innovative projects in the Dutch welfare sector. In addition, support was obtained from the Dutch Institute of Employee Benefit Schemes (UWV).
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