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Table 3 Results of the interviews and focus group

From: Determinants for the implementation of person-centered tools for workers with chronic health conditions: a mixed-method study using the Tailored Implementation for Chronic Diseases checklist

 

Domain

Determinant

Theme

Quote

1.

The developed tools

How the tools were developed

Be in line with current developments in healthcare

Policy advisor Dutch Employee Insurance Agency: “…there are many developments that concern prevention and work in healthcare…. So there is now really room and opportunities to do more with it…”

Involving industry organizations and patient associations

Resident trainer 2: “…the chance that this is successful is considerably greater if the employer has hear from the own employers’ organization that this can be of value...”

Experiment/practice with the tools

Resident trainer 2: “…you could do pilots…you can show that its usable. That colleagues are enthusiastic about it and that patients are satisfied with it.”

Being able to work with the tools

Enhance exposure

Resident trainer 1: “We do it mainly by putting it on our website and in our newsletters.”

Changing routine work methods is difficult

Insurance physician 1: “Yes, [changing work method or routine] because they have been in a certain working method or routine for years.”

Continuity of the tools after the research period

Representative of a patient organization: “Yes, so that’s very important. … That something is not developed that actually stays left alone after the research, or after the subsidy period after 4 years.”

Do not overload professionals with new things

Insurance physician 1: “… we have to be careful … that we do not overload. … occupational and insurance physicians with this useful list, with that useful list, take this into account … and take that into account ...”

Being in line with the current way of consultation

Representative of a private insurance: “I can imagine that when such a tool is developed, it can be added to the reporting form that we have developed over the years which is a dynamic tool.”

Consulting at an early stage with existing education/training program

Resident trainer 2: “…at an early stage, in the co-creation phase, you should take a look to see if this [the curriculum] fits in somewhere with people from both educational specialization programs.”

Incorporate into guidelines

General practitioner: “Well I think, it is a problem that there is still no good guideline for work, to that work-related problem.”

Possibility for customization

Researcher 8: “It is also important that tools are not an overall, one size fits all product, … that people also have the feeling that, yes, we can shape that together in this context and in this specific situation.”

Client version of tools/information

Researcher 8: “… we also have a very important role for patients or employers in developing care standards, and they are explicitly intended for all parties to use.”

Necessary behavior for the use of the tools

Create awareness

Researcher 4: “It is also not always evident for them. Some say: I just don’t think about asking this during consultation.”

Supporting guideline for the use of tools

Resident trainer 3: “… But not accepting a guidelines [for the use of tools], or acceptance around guidelines, is sometimes a problem. So that could be a threat.”

Taking into account the background of employees

Insurance physician 2: “You should not only look at an illness, but also at the person and the system around them”

Topic is new in resident education

Resident trainer 1: “No, in the current study program we do not really have a topic ‘Chronically ill and work’ …. But we are going to put more emphasis on this in the new curriculum.”

2.

Individual health professional factors of occupational and insurance physicians

Knowledge and skills of occupational and insurance physicians

Professionals are already familiar with the topic

Insurance physician 1: “… there is already a considerable level of expertise. It’s not that you have to teach them something new.”

Cognitions, beliefs and attitudes of occupational and insurance physicians

Professionals find the topic important

Insurance physician 1: “… many professionals recognize this [the importance of tools] and also see this as something that helps them to do their work better.”

Show added-value

Medical advisor private disability insurance: “… showing them [occupational and insurance physicians] how much added-value, or how attractive it is, to use it. If an occupational health expert is greatly supported by such a tool to get a clearer picture of, for example, those environmental factors, then, I think, he will use it…”

Conviction that the tool will work

Resident trainer 2: “Much remains in the idea of ‘I am not yet convinced that this is easy for me and that it has added value’. … Then things remain unused.”

Self-confidence in own ability

Resident trainer 3: “I think, that confidence in one’s own abilities could be strengthened, especially by paying attention to it in training and education.”

Belief that the chronically ill worker is an expert

Researcher 8: “…the belief that the chronically ill worker is also an expert on this topic, and the expertise you need to involve in that. That’s also a very important cognition.”

Professional behavior of occupational and insurance physicians

Lack of time

Researcher 4: “Yes, but what I hear from the occupational physicians is, that they are much too busy. They are very much swamped in work.”

3.

Client factors of workers with a chronic health condition

Client needs

Attention to individual needs and competences

Representative of a patient organization: “… They mainly look at how people can work 40 h a week instead of really looking at the core, the competences of someone and, that maybe it’s better for such a person to work 4 h a day ...”

Practical and concrete information

Representative of a patient organization: “For us it really has to result in something concrete with which we can actually keep chronically ill people better in their jobs.”

Possibility to try what works (for client)

Client with a chronic health condition: “… I also always tried, together with the occupational physician … to see: ok, what can I do, what can’t I do? What is a good distribution of working hours? … a bit of trial and error of seeing what works.”

More attention for work from patient organizations

Resident trainer 2: “It could … help that … patient organization around the chronically ill refer information about work support options to their patients.”

Stress and strain

Representative of a patient organization: “… the moment you develop a condition [chronic health condition], that’s often a lot [for a person]. It also often means that you are looking for ways on how you will organize your daily life, and also your work. A lot of uncertainty: ‘what’s going to happen to me?’ A lot of stress for people.”

Self-employed person no occupational physician

Medical specialist 1: “… they are … now more and more self-employed and of course they do not have an occupational physician yet. … This is really a barrier.”

Client beliefs and knowledge

Awareness

Insurance physician 2: “And, I think, that it has to do with awareness when people maintain their own situation, because they do not want to [change]. And moving from not wanting to wanting to change requires a lot of time and energy.”

Knowledge about (preventive) role of an occupational physician

Researcher 5: “… the occupational physician also has a preventive task. But … in practice, they are mainly known for their guidance concerning absenteeism and return to work.”

Skills in communication, self-management is assumed

Resident trainer 1: “… the self-sustainability model, … is a great model. But, … a lot of people cannot do it [self-sustainability]. … they have limited health skills, limited coping.”

Negative image of occupational/insurance physician

Researcher 4: “In general, I don’t think the occupational physician has a very positive image.”

There is already a lot of information available for chronically ill employee, but it is often scattered and difficult to find

Representative of a patient organization: “There is a lot of information, but not findable. So, that is actually the very first step of making what there is findable.”

Flawed information provision

Researcher 2: “What has also been identified is that the workers have little information about the entire procedure for disability assessment ....”

Client preferences

(Trust) relationship between occupational physician and employer with a chronic health condition

Representative of a trade union for employees: “I think, that an occupational physician that the employee can trust is very important.”

Client motivation

Contributing to society

Worker with a chronic health condition: “Yes, … what motivates is simple: I want to participate in society. I don’t want to sit at home.”

Attain identity with work

Researcher 6: “… while I also had someone who said: ‘my job is just who I am.’ … Or well, not your entire identity, but a large part.”

Motivation/being motivated

Nurse specialist: “… Yes, how motivated someone is to adjust his lifestyle. And those are the conversations you also have with people.”

(Job) insecurity and vulnerability

Resident trainer 2: “… Someone who is chronically ill or elderly and has a chronic background that makes applying for a job seem hopeless, [that person] is not motivated to apply.”

Finding work less important after falling ill

Researcher 6: “Some people see their work as less important after their illness.”

Making time for treatment (no work means no income for self-employed people)

Medical specialist 2: “People who work, the younger population, do not have time for the outpatient clinic visit, because they have to work. … They are self-employed and no work means no income.”

Client behavior

Keep in touch with employer

Nurse specialist: “… if people feel heard, then I have the idea that they are less likely to report sick. That they feel involved in the company.”

Show initiative/take action/get moving as an employee with a chronic health condition

Worker with a chronic health condition: “… self-management is more in the sense that you keep the responsibility of what happens to you at work and with your workplace, for example. … And that is not decided without your consent for you by your employer or the occupational physician.”

Stay positive

Worker with a chronic health condition: “… So in that respect, like me, he has always tried to see the positive side: ‘look, what you can still do.’.

 

Be transparent

Representative of a trade union for employees: “… it is, of course, important to get a good picture of the exact effects on work of that chronic health condition. And what someone needs in order to function properly. What is possible and what is not possible. And what you have to take into account.”

4.

Professional interactions

The influence of beliefs, ideas and communication between healthcare professionals

Mutual trust between occupational physicians and curative physicians

Researcher 6: “And the internist indicated that he actually did not have that much confidence in the knowledge and medical knowledge of the occupational physicians.”

Protective advice with regard to work in curative care

Medical advisor private disability insurance: “… it may be that the practitioners have a very protective influence and actually do not want patients to meet the challenge of returning to work.”

Personal interest of physician

Occupational physician 1: “It also varies per specialist. Some are more open than others. Sometimes I see people directly, where the specialist said: ‘also go and talk to your occupational physician’.”

Teamwork between professionals

Much involvement in guidance by the health and safety service

Resident trainer 2: “… in practice, you often see that other people also do that consultation hour … guidelines are still based on the idea that there is a single physician who acts while it is different in practice.”

Little or no feedback on the actions of the insurance physician

Insurance physician 2: “… what I find a pity, also for our clients, is, that you will never actually get to hear how it continues with them.”

Medical specialist at consultation hour with occupational physicians

Insurance physician 2: “I do not rule out that we go to situation that an insurance physician is present in the hospital, who does consultation hours and/or gives advice to medical specialist colleagues …”

Creating a sense of group-belonging among professionals

Resident trainer 2: “… the most important part of training is not so much the transfer of knowledge. It is the collective idea of: ‘we are going to do something with this’.”

Coordination and collaboration between healthcare professionals

Attention towards work in curative care

Occupational physician 1: “That is also a general problem, the focus on work within curative care. ... But that should, … become almost normal for the various specialists.”

Thinking from a medical model/perspective

Resident trainer 1: “As doctors, we often tend to focus on the disease. The fact that someone has a medical condition also asks for focus on functioning, but also: ‘what is hindering him?’. … The context often determines someone’s ability to function and feeling healthy more than anything else.”

Inadequate information transfer and exchange

Medical specialist 1: “Never before has an occupational physician called me. Maybe it’s not allowed, I don’t know. I don’t think consultation with each other would hurt.”

Knowledge about work in curative care

Occupational physician 1: “That the healthcare professional says: ‘also talk to your occupational physician´. If patients are unfamiliar with occupational healthcare, that a treating physician knows occupational medicine, then you [occupational physician] can also give tips and discuss what will help.”

Medical knowledge and working method of occupational and insurance physician

Insurance physician 2: “… I think, it [occupational health] is a separate kind of field. … what you should have, … is the interest in the client and in what such an illness means for someone and how you could get someone out of the vicious circle of incapacity.”

Experienced hierarchy between medical specialists

General practitioner: “You also have a sort of hierarchy ranking where cardio-thoracic surgery and neurosurgery are high up in the hierarchy … GPs are somewhere in between … and occupational physicians are lower ranked. That also, partly, determines the willingness to cooperate.”

Make use of task delegation

Resident trainer 3: “I think, in this domain, a lot of work is done together with other disciplines.”

Common/shared interest with involved stakeholders

Resident trainer 3: “… point incentives and means in the same direction. Do not work against each other.”

5.

Incentives and resources

Availability of required resources

Need for a good instrument

Occupational physician 1: “Especially If you have it [digital screening support] for self-management or self-control, a kind of questionnaire that quickly shows how someone is dealing with it. Of course, we [occupational health services] are also increasingly moving towards digital questionnaires to fill in before people [workers with a chronic condition] come to consultation hours.”

Positive and negative financial incentives

Continuity of the company in the event of an employee’s illness

Representative of an employer’s organization: “Where big and small companies differ in continuity of business operations is, that large companies have the scale to do more in the sense of guidance and discontinuity problems …”

Non-financial positive and negative incentives

Employer invests in a good employee

Representative of a trade union for employees: “… if an employer is satisfied with an employee who has a chronic health condition, … then most employers are likely to make required work adjustments.”

Have confidence in the employee with a chronic health condition and take it seriously

Representative of a patient organization: “I also hear stories from people who have complaints, that they do not feel understood by the occupational physician and, that they think the occupational physician is too much on the side of the employer.”

Adding work to programs/teams in the curative sector

Medical specialist 1: “The cardiac rehabilitation tool. That program runs very well. So you can easily merge them.”

Corporate culture

Representative of a trade union for employees: “…it all depends on the type of employer and the culture in the company. Much more [change towards work improvement] is possible in one company than in another.”

Information systems

Join with existing IT systems

Resident trainer 2: “… it could be useful if something can be included in the software that we already use to write consultation hour reports.”

Quality and patient safety

Work as an outcome measures for the inspectorate and registration

Medical specialist 1: “You have to make it compulsory. It [work-related support] just has to become one of the outcome measures of the inspectorate.”

Refresher course training systems

Accreditation points for re-registration

Resident trainer 1: “But, you just need 40 points a year to re-register for 5 years. So, if necessary, you choose a training that yields points.”

 

Work more embedded in basic medical training

Medical specialist 1: “I think, that work and health are so intertwined. … that it is good that we pay lot of attention to this in all phases of medical training. Also if you become a medical specialist.”

Presence of practical tools for healthcare professionals

No standardized tool is available yet

Researcher 2: “… occupational and insurance physicians in any case did not indicate that they already use a tool [to support work-related issues] structurally.”

6.

Capacity for change in organizations/by employers

Mandate and authority

Employer has responsibility

Occupational physician 1: “For someone who works with a partial disability benefit for an employer, the employer also has the responsibility to see how someone is doing.”

Skilled leadership

Open and communicative atmosphere in the workplace

Representative of an employer’s organization: “Employers need that knowledge to know what to ask of people [employees with a chronic health condition].”

Strength of support and opposition

Employer must be flexible, sympathetic and cooperative

Resident trainer 1: “… it also depends on the employers. How willing is an employer to keep someone with a chronic health condition employed and give them the opportunity to work.”

Costs associated with an employer with a chronic health condition/continued payment in the event of illness

Representative for a trade union for employees: “So, we look at: what is good for the company? And what, in our opinion, is the best approach to have employees working as much as possible? Because, yes, we pay for productive employees, and sick employees or employees who do not perform well. They cost money instead of making money.”

Express appreciation

Representative of a trade union for employees: “The employer’s appreciation for the employee. So, a kind of mutual appreciation, reciprocity, is, I think, a very important precondition moving forward.”

Acceptance and inclusivity at the workplace

Researcher 6: “That they [workers with a chronic health condition] are accepted and that we also want to keep you working. … you are important to the company.”

Regulations, rules, policy at employers/organizations

Occupational health services are commercially competitive

Resident trainer 2: “… there is no uniformity [in occupational health services], because the government has decided that it [the occupational health service] is a commercial and competitive service.”

Priority of desired change

Employer must be open to prevention

Occupational physician 1: “When a workers needs it, you can go for a preventive consultation. We all have to work much more towards prevention. Even, if you already have a chronic health condition ….”

Perception that the employee with a chronic health condition is difficult/expensive for the employer

Resident trainer 1: “I think that in many work places there is less room for people with disabilities, because employers think: ‘Yes, this person is difficult’.”

Demanding attention for topics at the occupational health services

Resident trainer 2: “… you can distinguish yourself in the market, if you pay attention to this [specific support needs for workers with chronic health conditions] as an occupational health service.”

Appropriate workplace adaptations

Representative of an employer’s organization: “It is important that the employee can return to work within the company as good as possible. Just integrate well into the company, as in return to his old position.”

Having knowledge of sick leave rights and obligations

General practitioner: “I notice, that many GPs, they advise patients to contact the occupational physician …. Yesterday, a patient who had a heart attack relatively recently showed up at his boss who asked: ‘when can you start again’. … He could use the protection from the occupational physician very well.”

Monitoring and feedback

Discontinuity in guidance of workers with a chronic health condition by the occupational health service

Occupational physician 1: “It occurs that I guide a sick-listed worker and then, due to change of occupational health services, I have to transfer him to a colleague, who also needs to get to know the worker and study the worker’s medical records.”

Help needed with change in organizations

Take the burden from the employer

Representative of an employer’s organization: “It is also important to minimize the burden for the employer. Ensure that it does not become an administrative hassle. That’s a basic requirement.”

Tailor-made advice for the employer

Representative of a trade union for employees: “.. an employer would prefer an occupational health service and occupational physician who takes the company and the interests of the company into account as much as possible.”

Information is applicable and implementable

Representative of an employer’s organization: “Information provision, not only to give dry, technical information, but also to give the information that can be directly applied, … aimed at ‘doing’.”

Practical and solution-oriented information

Representative of an employer’s organization: “… employers never ask for answers. They ask for solutions. … how a problem can be solved, and how he can continue to supply his product or continue to provide his service.”

7.

Social, political and legal aspects

Contracts

Major differences between (contracts with) occupational health services

Occupational physician 1: “Yes, there is no uniformity, because the government has decided that it is a commercial and competitive service. As in every market, there a different needs and wishes and employers can look at a price and quality differences and buy something that they think matches to what they want.”

Many changes in occupational physicians within occupational health services

Representative of a trade union for employees: “… the problem is that employers can replace the occupational health service and occupational physician at any time, for whatever reason.”

Legislation

Curative care and occupational health are strictly separated

Medical specialist 2: “I don’t know who the occupational physician is … I never actually get information form the occupational physician.”

Insufficient support for employers

Representative of an employer’s organization: “… a mismatch between the functional abilities of an employee [with a chronic health condition] and the job requirements can be challenging for an employer. First an employer needs to know what appropriate workplace adjustments are, next application and then it takes time to realize these adjustments, that is costly. These things don’t help.”

Unknown with regulations, rights and obligations

Medical specialist 3: “Look, you also have people who work at a small company, who say: ‘Do we have an occupational physician, I would not know’. Or they say: ‘my supervisor does not allow me to go there’. So, I always say that you just have to, you are entitled to that.”

Financing policy

Incentives for insurance companies

Representative of a patient organization: “The disability insurance company, so, they have to pay premiums when people drop out. To see if they [the disability insurance company] can, for example, give incentives to companies that make these tools accessible to their HR department. … get a discount on the premium, or something like that.”

No reimbursement for work-related healthcare in the curative sector

Medical specialist 1: “It [the current system] makes it difficult to get reimbursement for work-related healthcare. What I also thought of is that you could make a kind of outpatient clinic for work. But that, of course, does not fall under reimbursed care. So, that is for us, I think a pity, that we cannot just do an occupational health consultation. What we can do for all other medical specialisms.”

Financing policy municipalities

Insurance physician 2: “… that is municipal policy. … yes, the municipality usually wants to be in the first place for saving money. So, actually, they want to have research as good as possible and as cheap as possible.”

Public funding of work-related care is needed

Occupational physician 1: “Work-related care within primary and secondary care is actually not covered. You could say let the employers pay for all of that. I think, that is not always entirely realistic. Certainly for people with a chronic health condition, work-related care should partly fall under reimbursed care.”

Influential people

Deploy role models

Resident trainer 2: “Physicians look very closely at whether someone of their own kind gives a positive advice.”

Political stability

Influence of political decision-making

Insurance physician 2: “… they really want something [a relation] with the client, but it is not always clear what the underlying motive is. Sometimes it is really just the political pressure to guide people [clients with a chronic health condition].”