Motivating factors for return to work

Motivating factors for return to work

GUVNOR GARD Department of Physical Therapy, Lund University Sweden.ANN CHRISTINE SANDBERG Department of Physical Therapy, Karolinska

Institute, Stockholm, Sweden.

ABSTRACT Background and Purpose. A new concept to increase return to work forpatients listed as sick with chronic musculoskeletal pain has been used at a rehabilitationcentre in Luleå, Sweden. The programme includes work for three days a week and inten-sive rehabilitation for two days a week, for 12 weeks, as a combination of ‘on the job’training and rehabilitation after a period off work sick. The rehabilitation programmefocused on pain reduction, identifying and finding solutions to pain problems in actual workand life situations and training of the functional capacities needed in the work and life situa-tion. The aim of the study was to describe patients’ perceptions of motivating factors forreturn to work. Methods. A phenomenological method was used. A naïve reading of inter-view notes was followed by structural analyses and reflections on the interpreted whole.Inclusion criteria for the study were musculoskeletal pain for at least one year and a periodof at least four weeks’ sick leave during that time. Ten patients, aged 30–54 years, partici-pated in the study. An initial conceptual framework was developed to inform the scope ofthe study and to guide data collection and analysis. Results. Different factors in the studyframework influenced motivation to return to work. Among structural factors the divisionof labour at work was the most important motivator, particularly the ability to do as muchas work colleagues, quantitatively and qualitatively. All the patients had jobs in the health-care or service sectors, jobs with many social contacts. They perceived their work task con-tent as being of minor importance compared to whether the tasks were perceived asmeaningful or highly needed by others. All wanted a meaningful job content and a job whichthey could do in a satisfactory way according to their own norms and compared to col-leagues. This highly increased motivation for return to work. Relationships (in terms of co-operation with colleagues and service to patients or clients) were important motivating factorsfor return to work. Self-confidence was a new factor of importance for return to work; worktasks had to be meaningful and needed by others, work must be done in a way satisfactoryfor the individual and in a way that was acceptable to others in the group. Everyday respon-sibility, feedback and support in daily work tasks were important. These aspects increased

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self-confidence. The results supported the development of a new conceptual framework forpossible motivating factors for return to work. Conclusions. Structure, content, relation-ships, health and self-confidence were all important motivating factors for return to work.

Key words: chronic pain, motivation, return to work.

INTRODUCTION

A new concept to increase return to work for patients listed as sick with chronicmusculoskeletal pain has been used at a rehabilitation centre in Luleå, Sweden since1995. The programme includes three days’ work a week and two days’ intensiverehabilitation, for 12 weeks, as a combination of ‘on the job’ training and rehabilita-tion after a period off work sick.

The first part of the rehabilitation programme focused on pain reduction as painis a main inhibitor for return to work. The motivation for return to work can beassumed to be low as long as patients suffer from pain. Physical therapy and psycho-logical treatments were used as pain reduction methods. Studies have shown thateffective pain reduction is a primary need in rehabilitation. Physical therapy andpsychological pain treatments, respectively, can reduce patients’ levels of pain andincrease their return to work (Fordyce, 1986; Estlander et al., 1991; Ekberg &Linton, 1994; Lansinger et al., 1994).

The second part of the programme focused on increasing patients’ ownresources to deal with pain situations. Studies have shown that working withone’s own resources can be an effective way of increasing self-confidence andthus improve motivation for return to work (Edquist, 1994; Brattberg, 1995).This part of the programme also focused on identifying and finding solutions topractical pain problems in patients’ work and life situations. Critical pain situa-tions at work and in everyday life were identified and discussed, and copingstrategies for these situations were developed and learned. Studies have shownthat learning new coping strategies to deal with pain can make rehabilitationmore effective (Ektor-Andersson & Nymansson, 1995). Functional copingstrategies may reduce patients’ perceptions of work demands and act as a bufferagainst the development of symptoms. It was assumed that the motivation forreturn to work was low as long as patients lacked coping strategies, but that themotivation for return to work increased when functional coping strategies wereidentified and learned.

The third element of the programme focused on training in the functional capac-ities needed in work and life situations, increasing patients’ opportunities for self-care in all aspects of life. Studies have shown that training in functional capacitiesmay reduce pain, and pain behaviour, and increase the motivation for return to work(Estlander et al., 1991; Papciak & Feuerstein, 1991; Saal, 1991). Significant correla-tions have been shown between psychological variables such as pain level, distress,coping ability and measures of functional capacities (Papciak & Feuerstein, 1991).Training for physical fitness, strength and endurance, physical capacity assessment

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and work technique training were used. Ergonomic changes at the work place wereundertaken when needed.

To identify and use all motivating factors for return to work in the rehabilitationprocess as well as reducing the effects of all demotivating factors is important in therehabilitation of patients with pain. Cognitive processes as motivation can affectand change the perception of pain according to the ‘gate-control’ theory (Melzack &Wall, 1965). According to this theory, different aspects in an individual’s life canopen or close the transfer of pain signals. Cognitive factors, such as increased con-centration and motivation, may help to close the ‘pain gate’, implying reduced trans-fer of pain signals. According to cognitive theory, pain behaviour may also becontrolled by its consequences. Pain behaviours may be reinforced in a negative wayby the healthcare system which provides services and attention contingent uponpain (Fordyce, 1986). Patients in pain may get increased support and sympathywhen they express suffering, which then increases pain behaviour. Pain rehabilita-tion may be more effective if it focused on identifying and using patients’ motivatingfactors for return to work in rehabilitation and reduce the effects of demotivatingfactors.

Motivation to work can be defined as all activities aiming to drive, direct andsustain work performance (Schou, 1991). It is the result of different factors withinan individual or outside an individual in a work organization. The selection of moti-vating factors depends on the needs of an individual, personality and background.Motivation for return to work after a period of sick leave may be a result of interac-tion between individual, work-related and social factors.

The aim of the study was to describe patients’ perceptions of motivating anddemotivating factors for return to work as an evaluation of the rehabilitation fromthe patients’ perspective.

METHOD

A phenomenological method was used. A naïve reading of interviews notes was per-formed first, in order to get the sense of the text. This was followed by structuralanalyses to identify areas with meaningful connections to the research questions.The text was then seen as a whole again, taking into consideration both the naïvereading and the structural analyses. The interpreted whole was reflected upon(Ricoeur, 1976).

Subjects

Criteria for participating in the 12-week rehabilitation programme and the studywere musculoskeletal pain for at least one year and a period of at least four weeks’sick leave during this time. Ten patients were randomly selected from the applica-tion list to participate in the first rehabilitation group. This group was also selectedfor the study. Nine females and one male participated in the first group. Their meanage was 47 years (range 30–54 years). Duration of pain was from three to 15 years

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(mean 8.5 years). Five subjects had pain due to shoulder/neck diagnoses (myalgia,chronic pain syndrome) and five had low back pain diagnoses (lumbago, lumbagoishias, chronic pain syndrome). They had been sicklisted from two to eight periodsduring the last year of work. The pain seriously affected all of them in their work sit-uation. All the subjects worked within the community in different jobs, as nurses ornursing assistants, administrative secretaries or waiters. They had worked in theirpositions for five to 17 years (mean 8.5 years). Eight subjects were married or livedwith a partner; five of them also had children. All the subjects were part-time sick-listed during the programme because of pain.

Instrument

An initial conceptual framework was developed to bound the scope of the study andto guide the data collection and analyses (Figure 1). This framework identified possi-ble motivating and demotivating factors for return to work in spite of muskuloskele-tal pain problems. The framework was developed by data collection from 10 patientsselected randomly from all patients who visited their doctors and were sicklisted formusculoskeletal pain problems at a primary health care centre in another commu-nity during one week in October 1994. All the patients described possible motivat-ing and demotivating factors in their work and life situations for return to work aftertime off sick. These data were categorized and developed as the initial conceptualframework (Figure 1). The factor ‘Structure’ included answers concerning division oflabour, time schedules and physical and psychosocial work environments. The factor‘Content’ included a description of work tasks and tasks at home. ‘Relations’included relationships with collegues, supervisors and relatives, and the factor‘Health’ included physical and psychosocial health. The conceptual framework,along with the purpose of the study, guided the development of the research designand the formulation of questions for the qualitative interview (Table 1). Hypotheti-cal formulations of the questions were aimed at identifying all possible motivatingand demotivating factors in patients’ total work and life situations.


FIGURE 1: Initial framework for possible motivating and demotivating factors for return to workdespite musculoskeletal pain problems.

Lifesituation

Structure Content Relations Health

Return to work

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Procedure

Subjects were interviewed one month after the end of the rehabilitation programme,as the study was an evaluation of the programme from the patients’ perspective. Allinterviews were tape recorded. The low degree of structure in the questions allowedboth the subjects and the researcher to bring new aspects into the dialogue. Aftereach interview the recording was transcribed and sent to the participants, and theyhad the opportunity to add or change anything they wanted. To test the inter-raterreliability of the categorization of the interview material all interviews were analysedindependently by the two researchers and major themes were identified separately.An agreement of inter-rater reliability of 95% was found between the two researchers.

RESULTS AND DISCUSSION

The results supported the development of a new conceptual framework for possiblemotivating and demotivating factors for return to work (Figure 2). The different fac-tors in the framework influenced the motivation to return to work differently.

FIGURE 2: Developed conceptual framework for motiving and demotivating factors for return to work.


TABLE 1: Questions for the qualitative interview

Tell me about your home situation? Positive aspects? Negative aspects?Tell me about your work? Positive aspects? Negative aspects?Tell me about the result of the rehabilitation? Positive/negative aspects?In what ways has the rehabilitation changed your situation?How would you like to change your work to make it ‘the work of your dreams’?How would you like to live if you had total economic security?

Total life situation

Structure Content Relations Health

Work environment Work tasks Collegues PhysicalTime schedules Task at home Supervisors PsychosocialDivision of labour Task in rehabilitation RelativesControl Care givers

Self confidence

Return to work

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Structure

Among structural factors, the division of labour at work was the most importantfactor for return to work, particularly the ability to do as much as collegues, bothquantitatively and qualitatively:

‘Yes, I feel that I must do as much as the others, I have the same job and I want to do my part ofit.’ (Informant 5)

Opportunity for job control was also an important motivating factor for return towork. Job control was related to information and communication. Eight of 10 subjectsperceived that they received too little information from their supervisors and that com-munication with them was poor. They wanted to have more frequent and regular infor-mation from supervisors. As a consequence, patients perceived reduced job control:

‘My supervisor only works in her office, I have very little contact with her.’ (Informant 1)

The division of labour at work, in particular the ability to do as much as others,and job control were perceived as important motivating structural factors for returnto work.

Content

All subjects had jobs in the healthcare or service sectors, jobs with many social con-tacts. They perceived their work task content as being of minor importance com-pared to whether the tasks were perceived as meaningful or highly needed by others.All wanted a meaningful job content and a job which they could do in a satisfactoryway according to their own norms and compared to colleagues. This highlyincreased motivation for return to work:

‘What I do is to help patients to do all possible activities of daily life, wash them, feed them, Iam satisfied, for me this is a meaningful job.’ (Informant 7)

‘I say that this hospital is not only a place for keeping people alive as long as possible, theremust also be a meaningful work content.’ (Informant 4)

Tasks at home were perceived as important. These were perceived as meaningfulas they were needed. A changed attitude to what needed to be done at home wasnoted, but this changed attitude had not yet changed behaviour:

‘You have to ask others for help, it is wrong to always do everything by yourself.’ (Informant 10)

‘I must teach my husband, I know he can help me.’ (Informant 6)

Eight subjects had no leisure activities due to lack of time or pain problems. Theywere all aware of the importance of self-care and physical training activities, but per-ceived they had no leisure possibilities due to time, physical distance, economy, lackof equipment, pain problems or lack of energy:


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‘I have so much to do at home, I have no time for leisure time activities. You don’t go back totown for physical training.’ (Informant 2)

The tasks and content of the rehabilitation programme were perceived as positiveand meaningful by all the subjects and eight of them could understand and copebetter with their situation after the rehabilitation period:

‘The rehabilitation helped me to meet others and exchange experiences and find that we haveexactly the same way to perceive our pain problems and the same symptoms. I don’t feel so oddany more.’ (Informant 5)

‘I try to think of my working techniques. I think more about myself, I don’t need to do every-thing, we can help each other, it is wrong to do everything by yourself.’ (Informant 10)

Work tasks perceived as meaningful in job content, highly needed by othersand/or done in a satisfactory way according to own norms were important motivat-ing factors for return to work.

Relationships

Relationships were a strong motivating factor for return to work. Relationshipswith colleagues were perceived as most important. All the subjects had a lot of co-operation with colleagues and service to patients or clients. They all mentionedparticipation in work and work satisfaction as strong reasons for returning toemployment:

‘My work satisfaction is very high, we all started from the beginning with each other and we arenow a group, it takes a year.’ (Informant 10)

Satisfaction and intellectual fellowship were compounded by a feeling of belong-ing to the others in the work group and being needed and appreciated. The feed-back, psychological support and understanding from colleagues were perceived asvery important among all the subjects.

Relationships with supervisors were perceived as bad, as a demotivating factor forreturn to work, with too little support, understanding and little opportunity for dia-logue. Relationships with relatives were only important for four subjects. The othersix had no supportive relationships at home or outside work. Instead they had sup-porting relationships with their work colleagues. Lack of support outside work, aswell as support at work, were motivating relationship factors for return to work. Neg-ative experiences from contacts with earlier care-givers, implying lack of support anda feeling of disappointment were perceived as demotivating relationship factors forreturn to work.

Relationships, in terms of co-operation with colleagues and service to patients orclients, were important motivating factors for return to work. All subjects men-tioned participation in work and work satisfaction as strong reasons for returning toemployment.


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Health

Eight subjects perceived that they could understand and manage their symptoms in abetter way after the rehabilitation programme. The physical symptoms were per-ceived as demotivating factors for return to work as soon as they prevented subjectsfrom doing their work in a satisfactory way:

‘My symptoms appear and disappear, I have my chronic pain problems, but I have learnt how tocope with them.’ (Informant 10)

‘Yes, sometimes I must have a sickleave period, I have learnt that I have a personal limit andthen I have to call my doctor.’ (Informant 5)

All the subjects had had their pain problems for a long period of time and werealso mentally affected by their pain. They were worried about how to cope with painin their job situations. To have a job and to manage it in a successful way was impor-tant and gave them dignity. In summary, the fact that eight subjects could under-stand and manage their symptoms in a better way after the rehabilitation programmewas a motivating health factor for return to work. The fact that physical symptomswere perceived as demotivating factors for return to work as soon as they preventedthe subjects from doing their work in a satisfactory way was a demotivating healthfactor for return to work.

Self-confidence

Self-confidence was a new factor of importance for return to work. Work tasks mustbe meaningful and needed by others. Work must be done in a way satisfactory for thesubjects and in a way that is acceptable to others in the group. Everyday responsibil-ity, feedback and support in daily work tasks were important. These aspects increasedself-confidence:

‘Dignity as a worker is a very important part of my pride as a human being.’ (Informant 1)

‘I don’t want to walk around at home, I want a higher human value. I want to have an ordinaryjob and work satisfaction.’ (Informant 3)

Studies indicate that people’s self-confidence and self-beliefs of efficacy may affecttheir level of work motivation (Bandura & Cervone, 1986) as well as how muchstress and depression they experience in threatening situations (Steers & Porter,1991). Self-beliefs of efficacy also affect thought patterns that may be self-aiding orself-hindering and the level of personal goals. The stronger the self-efficacy thehigher the goals people set for themselves (Bandura & Cervone, 1986). Rehabilita-tion may help an individual to formulate and realize new goals, which may increasework motivation if the goals are specified, demanding and accepted by the individualand if feedback is possible (Locke & Latham, 1984). Personal goals and a positivefeedback of thoughts and feelings are important for positive self-confidence and work


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motivation (Klein, 1989). If no feedback is possible, self-confidence may be reducedand a critical low threshold limit value may be reached, where the motivation toreturn to work disappears. In this study self-confidence was a new factor of impor-tance for return to work.

CONCLUSIONS

The division of labour at work and the ability to do as much as others and job controlwere motivating structural factors for return to work. Work tasks perceived as meaning-ful in job content, highly needed by others and/or done in a satisfactory way accordingto own norms were motivating content factors. Relationships, in terms of co-operationwith colleagues and service to patients or clients, were motivating factors. All the sub-jects mentioned participation in work and work satisfaction as strong reasons for returnto work. The fact that eight study subjects could understand and manage their painsymptoms in a better way after the rehabilitation programme was a motivating healthfactor for return to work. A critical level of self-confidence was also needed.

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Address correspondence to: Guvnor Gard, Institute of Musculoskeletal Disorders, Department of PhysicalTherapy, Lund University, Box 5134, 22005 Lund, Sweden.

Submitted 15 May 1997; accepted 14 December 1997.


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Motivating factors for return to work