The aim was to elucidate the social construction of chronic pain as a cause of work absence in the UK, focusing on negotiation of sickness certification and return to work, in the context of recent policies to tackle rising sick-listing rates, including a national educational programme about the health benefits of work, and introduction of the ‘fit note’. Following a literature review, two qualitative studies were conducted from a symbolic interactionist perspective. The first comprised semi-structured interviews with doctors and chronic pain patients, leading to a second study in which employers and employees with chronic pain were interviewed. Interviews were transcribed verbatim and analysed according to constructivist grounded theory principles. The first study revealed tensions in the doctor-patient relationship as the process of sickness certification was negotiated. The indeterminacy of chronic pain rendered the biomedical approach to diagnosis and assessment of capability for work problematic, while a shift to the psychosocial model could generate feelings of invalidation in patients. A wide range of moral and socio-cultural factors was invoked by doctors and patients to contest sick-listing decisions. The second study identified difficulties that can emerge when chronic pain patients return to work. Employees discussed how managers failed to understand their problems or make sustained adaptations; employers reported difficulty reconciling the needs of employees with organisational imperatives and argued that employees and doctors colluded in sanctioning low resilience. All stakeholder groups supported the fit note’s focus on capacity not incapacity, but were skeptical about whether it would surmount the tensions and difficulties that arise in sickness certification and return to work for chronic pain patients. Struggles for meaning and construction of identities are difficult for policy to address, but deeper understanding of the processes behind them and rich accounts of stakeholders’ views, may nudge the system towards more appropriate responses.

The ability to work can be reduced if a person has health problems which may lead to periods of sick leave. In Sweden sickness certification is issued by physicians. Many general practitioners (GPs) find sickness certification to be problematic. Some studies indicate that collaboration with other health care professions could be beneficial. The aim of the thesis was to provide knowledge on how the work with the sick leave process in primary health care can be improved and how occupational therapists’ (OT) assessment could be used prior to the decision on sick leave and rehabilitation. Initially seven focus groups were held, four with OTs and three with physicians. The discussions in the focus gropes were analysed by qualitative content analysis. An intervention project was initiated, where four health care centres in northern Sweden tested a working approach where sick listed patients were offered a supplementary assessment of activity and work-related problems by an OT. Data on sick leave, sickness certificates and patient questionnaires were collected from intervention health care centres (IHCC) and other health care centres (OHCC). Interviews were conducted with patients, GPs and OTs. The quality of the information in the collected sickness certificates was evaluated. Average values of sick leave were compared between the IHCCs and the OHCCs in the county. The interviews with sick listed patients were analysed by qualitative content analysis. In order to analyse the implementation of the intervention the Consolidated Framework for Implementation Research, CFIR, was used. An overall theme and four categories emerged from the focus groups. The theme expressed work ability as an obscure, complex and unique concept. The four categories illustrate the affecting factors and confirmed the complex structure of work ability: the person, the context of life, the work, and the society. No significant differences between IHCCs and OHCCs in data on sick leave or the mandatory information in the certificates were found. Thirty-four percent of the collected sickness certificates did not contain all requested information. More certificates issued for women than certificates issued for men lacked the required information. Full-time sick leave was significantly more often prescribed for male patients than for female. Two themes revealed that highlight important areas for persons on sick leave in their healthcare encounters. The theme ‘Trust in the relationship’ contains categories describing the patients’ feelings of participation, being believed, confirmed, and listened to. The second theme ‘Structure and balance’ contains the participants’ views on important factors that could facilitate the return-to-work process such as a structured plan and support to balance activity. The analysis with CFIR clarified that coaching and education for all the users are crucial to get fidelity when new interventions are tested as well as involvement by the clinical department manager. The work with sick leave issues in primary health care can be improved by developing cooperation with several different professionals. To achieve an increased cooperation new working approaches are required. These working approaches must be anchored in management and requires an applied implementation strategy. More focus on the quality of encounters with healthcare professionals can also improve the sick leave process in primary health care centres. The healthcare encounters must build on a mutual trust and sick-listed persons’ return to work can be facilitated by providing a clear structure in the process and support in occupational balance. For issuing sickness certification further education about the descriptions of functioning and the tasks included in the patient’s work is needed. A better gender awareness in the health care encounters is also necessary.

<p>There is no common understanding on what constitutes good sick-listing, a frequent and problematic task for many physicians, especially general practitioners (GPs) and orthopaedic surgeons. Aiming to achieve a deeper understanding of sick-listing practices, 19 GPs (I, III) and 18 orthopaedic surgeons (II) in four counties were interviewed, and data analysed qualitatively for views on good sickness certification and barriers to desired practice. Data from a survey of all 7665 physicians in two counties on emotionally straining problems in sickness certification (IV) was analysed quantitatively. </p><p>Some GPs exposed narrow views of sick-listing, where their responsibility was limited to issuing a certificate, while GPs with the most inclusive view had a perspective of the patient’s total life-situation and aimed to help patients shoulder their own responsibility (I). The orthopaedic surgeons´ perceptions of good sick-listing were mainly related to their views on their role in the health-care system. Some perceived their responsibility as confined to the orthopaedic clinic only, while others had the ultimate goal of helping the patient to become well functioning in life with regained work capacity – by means of surgery <i>and</i> proper management of sick-listing (II). </p><p>Difficulty handling conflicting opinions was a barrier to good sickness certification for GPs (III), and problematic for about 50% of all physicians and about 80% of GPs (IV). Orthopaedic surgeons’ handling of such situations varied from being directed by the patient, via compromising, to being directed by professional judgement (II). Other barriers included poor stakeholder collaboration (III). GPs with a workplace-policy on sickness certification reported fewer conflicts and less worry of getting reported to the disciplinary board in relation to sick-listing (IV).</p><p>Understanding physicians’ underlying views on and barriers to practicing “good sick-listing” can inform efforts to change physician practice. Communications skills training in handling sick-listing situations with conflicting opinions is recommended.</p>

There is no common understanding on what constitutes good sick-listing, a frequent and problematic task for many physicians, especially general practitioners (GPs) and orthopaedic surgeons. Aiming to achieve a deeper understanding of sick-listing practices, 19 GPs (I, III) and 18 orthopaedic surgeons (II) in four counties were interviewed, and data analysed qualitatively for views on good sickness certification and barriers to desired practice. Data from a survey of all 7665 physicians in two counties on emotionally straining problems in sickness certification (IV) was analysed quantitatively. Some GPs exposed narrow views of sick-listing, where their responsibility was limited to issuing a certificate, while GPs with the most inclusive view had a perspective of the patient’s total life-situation and aimed to help patients shoulder their own responsibility (I). The orthopaedic surgeons´ perceptions of good sick-listing were mainly related to their views on their role in the health-care system. Some perceived their responsibility as confined to the orthopaedic clinic only, while others had the ultimate goal of helping the patient to become well functioning in life with regained work capacity – by means of surgery and proper management of sick-listing (II). Difficulty handling conflicting opinions was a barrier to good sickness certification for GPs (III), and problematic for about 50% of all physicians and about 80% of GPs (IV). Orthopaedic surgeons’ handling of such situations varied from being directed by the patient, via compromising, to being directed by professional judgement (II). Other barriers included poor stakeholder collaboration (III). GPs with a workplace-policy on sickness certification reported fewer conflicts and less worry of getting reported to the disciplinary board in relation to sick-listing (IV). Understanding physicians’ underlying views on and barriers to practicing “good sick-listing” can inform efforts to change physician practice. Communications skills training in handling sick-listing situations with conflicting opinions is recommended.

The increase in certified sickness absence recorded in most European countries during the last decade is of increasing concern to public health agencies. While sickness absence can promote rest and recovery from illness, it may also have negative consequences, including increased risks of inactivity and isolation, poorer quality of life and increased uptake of health services. In the Republic of Ireland (ROI) sickness certification is part of General Practitioners’ (GPs’) contractual service to the Department of Social Protection (DSP). Sickness certificates are also issued to patients as evidence of illness for employment purposes. There is limited research exploring GPs certifying practices in the Republic of Ireland. The aim of the thesis was to explore perspectives on sickness certification in general practice in Ireland. The data collection consisted of three stages. Study 1 consisted of in depth individual interviews with 14 GPs across 11 primary care practices in Ireland. Study 2 was based on an on-line questionnaire survey using a number of vignettes with 62 GPs working in primary healthcare. Finally, study 3 consisted of a focus group conducted with eight GPs in a large urban practice in Ireland. Qualitative analysis was conducted in vivo using content and simple thematic analysis techniques. Quantitative data was analysed by descriptive and inferential statistics using PASW version 18 statistical software. Combined results indicate that GPs can find their role as certifiers’ problematic and a source of conflict during the consultation process with patients. GPs concerns are with breaching patient confidentiality and in particular disclosing illness to employers. They reported feeling inadequate in dealing with some cases requesting sickness leave, including certification for adverse social circumstances and they felt a need for better communication between themselves, employers and relevant government departments. Willingness to issue a sickness cert may be influenced by the nature of the patient’s presenting problem. A psychological problem generated greater belief that patients were unfit for work, and GPs were more sympathetic and showed greater satisfaction with the decision they had made to certify these patient in comparison to patients with a physical problem. Average sickness certification periods were longer in cases of psychological nature (1-2 weeks) in comparison to the physical complaint (4-7days). Overall GPs displayed a negative feeling towards prescribing sickness leave and there was a perception that sickness certificates were being used by employers as a management tool in controlling absenteeism. GPs also mentioned cultural factors in work place absenteeism and lack of rehabilitative pathway as impacting on sickness certification practices in Ireland. Issuing a sickness certificate appears influenced by medical and non-medical factors. Potential exists for improving the system, but requires significant engagement with other stakeholders such as employers and social benefit agencies. Focus should be placed on referral and rehabilitative pathways for patients to ensure appropriate certification and early return to work.