Co-operation in the prevention of work disability due to musculoskeletal disorders: A cross-sectional study among occupational health professionals in Finland

Abstract

BACKGROUND:

Occupational health service (OHS) providers and their client organizations are obligated to collaborate in promoting health and work ability. Little is known how this multiprofessional co-operation is implemented in relation to the prevention of musculoskeletal disorders (MSD).

OBJECTIVE:

The aim of this study was to investigate the working practices of co-operation among OHS professionals, and between the OHSs and workplaces.

METHODS:

In 2015 a web-based questionnaire was sent to 3900 OHS professionals in Finland. A total of 589 responded: 106 physicians, 322 nurses, 134 physiotherapists and 27 psychologists.

RESULTS:

The co-operation within OHS personnel was regarded to strengthen the processes to promote work ability of workers with MSD. Despite the positive expectations of co-operation, there is a problem of having enough time to put good ideas into practice. Four main possibilities to develop co-operation were identified: creating proactive working models with defined roles; increasing awareness of importance of early intervention models; implementing the principles of good OH practice; and adopting the knowledge of the latest information to promote work ability.

CONCLUSIONS:

Despite its recognized importance, co-operation both with OHS colleagues and with the workplaces was not always optimal. There is a need for defined roles and common proactive working models between each stakeholder for more effective co-operation.

Keywords

Occupational health services multiprofessional work rehabilitation work ability promotion

1 Introduction

The burden of musculoskeletal diseases (MSD) on health and work ability is obvious. Despite the descending trend, MSD still account for the majority of days lost due to diseases. In Finland, 14 million sickness benefit days were compensated in 2015, of which a third was due to MSD-related problems. The compensation costs of work disability due to MSD-related problems was about 280 million Euro [1]. In addition to sickness absence, the lost work productivity among workers with MSD is a substantial additional economic cost [2].

In order to enhance the health and working careers of people with MSD, it is important that work can be arranged so that employees can stay at work despite MSD. In the field of work ability promotion, the interaction of various stakeholders, the worker, employer, professionals in occupational health services (OHS) and rehabilitation, is vital in order to optimize actions and practices to prevent absences from work and promote staying at work [2]. The extended collaboration between these stakeholders is underlined as a successful factor preventing work disability due to MSD. Kekkonen & Reiman [3] showed the participatory ergonomics process as a concrete model to identify and solve physical and psychosocial load factors at municipal workplaces. The model enabled different stakeholders, i.e. employees, management and representatives of both occupational safety and health organization and human resource management (HR), to become more involved in active collaboration and to find means to manage work ability promotion.

The focus of OHS in Finland has been on maintaining and promoting the health and work ability of employees in collaboration with employers [4–5]. Successful occupational health co-operation requires trust in relationships, as well as continuous dialogue and contacts between OHS and the client organization [6–7]. More effective collaboration between OHS and occupational safety and health management at the company level has led to a change toward more promotion and prevention rather than a reactive or medical focus on work ability [6, 8]. Effective team work is also known to produce better outcomes for individual patient’s care [9]. A newly published review by Halonen et al. [5] identified three main prerequisites to good collaboration between employers and OHS. The first included time, space and contract requirements. Flexible and long-term OHS contracts and the geographical proximity of the stakeholders were the key characteristics. The second prerequisite was the characteristics of the dialogue in effective collaboration, e.g., shared goals, reciprocity and trust. The third prerequisite emphasized the competence and knowledge of OHS providers regarding the workplaces in order to be able to enhance preventive working models.

In addition to the systematic and target-oriented collaboration between the OHS provider and the workplaces, Finnish legislation obligates OHS professionals to take part in multiprofessional collaboration i.e. OHS team work [10]. According to a review by Lappalainen et al. [11], OHS covered 84% of the employed workforce, and 96% of wage earners in Finland. In almost half of the OHS units, the operating OH team consisted of a physician, nurse, physiotherapist, and psychologist. Despite the increased prerequisities [11] and the identified benefits of multiprofessional collaboration, little is known of OHS collaboration in work disability prevention due to MSD. More research is found in health care and in the field of rehabilitation [10 , 13].

This study aims to investigate the working practices and models of multiprofessional co-operation among OHS professionals and the co-operation between OHS personnel and workplaces. The literature has shown diverse interests and conflicting roles among various stakeholders in the implementation of work disability prevention actions at workplaces [2]. Therefore, we also investigate the factors influencing this co-operation, i.e. the facilitators and barriers, in the prevention of disability due to MSD.

2 Methods

2.1 Study population

The cross-sectional, web-based questionnaire was sent 3900 OHS professionals in Finland. A total of 589 responded. The response rates (rr) varied by profession: 106 OH physicians (rr 7%); 322 OH nurses (rr 24%), 134 OH physiotherapists (rr 23%), and 27 OH psychologists (rr 7%). The questionnaires were delivered by professional associations in the spring 2016. The target group was informed about the purpose of the study. Participation was voluntary and the personal data of the respondents were not disclosed. The research was approved by the Ethics Committee of the Finnish Institute of Occupational Health.

The average work history (in OHS) of the respondents was 16 years. One third (36%) of the respondents had a work history of 10 to 19 years, and one third (34%) over 20 years. Only 12% had worked less than four years in their present work. Almost half of the respondents (46%) worked with a profit-seeking OHS provider, one third (30%) worked at a non-profit OHS enterprise, and 17% in an integrated OHS centre inside of a larger company.

2.2 Measures of multiprofessional co-operation

The questionnaire focused on work disability prevention due to MSD. Topics concerning the practices and the nature of interprofessional collaboration both internally and with the personel of client organizations were elicited. In addition, the factors influencing the collaboration were evaluated. The questionnaire can be found in the Appendix.

The nature of collaboration within OHS was classifed into three categories: (1) “We work alone, and everyone takes care of their own tasks”, (2) “We consult or ask for help from each other” or (3) “We solve problems together”. Respectively, co-operation with workplaces was classified as (1) no co-operation at all, (2) co-operation is incidental without shared working models and (3) co-operation is systematic, with shared working models. In the results section, the categories of collaboration among OH professionals and co-operation with workplaces were combined into general categories: (1) no collaborative working model, (2) consultative collaboration and (3) participative, systematic collaboration. The questions about the nature of collaboration have been modified according to the legislation [10].

The contents of collaboration were evaluated regarding the following statutory OH services: workplace surveys, medical examinations, providing advice and guidance to the employees and managers on health and work ability, occupational health-oriented curative care, and the phases of the rehabilitation process [10].

2.3 Statistics

Descriptive statistics were used to analyze the data regarding internal co-operation within OHS and co-operation with workplaces. We used cross-tabulation with Pearson Chi-Square analyses to evaluate the association between explanatory and dependent variables, accepting statistical significances of p < 0.05.

The contents of the open-ended questions of the query were described as original statements, and a general view was created of the material. After this, the material was classified, according to the contents, into the themes (facilitators, barriers and development ideas to the co-operation), and the number of mentions in these themes was counted. Open-ended questions were used as supportive statements to the quantitative questions. Examples of the original statements, indicated by profession, are presented in the results section.

3 Results

3.1 Collaboration within OHS

Collaboration between OH physicians, nurses and physiotherapists was reported to be the most common working method. Almost 70% of these professionals reported weekly co-operation with each other in regard to work ability promotion among workers with MSD. Co-operation with the OH psychologists was clearly less prevalent. On average, 80% of all respondents reported co-operating less frequently than monthly or never with the OH psychologists.

The nature of the collaboration among OHS personnel was described as “we solve problems together” by 59% of the respondents, “we consult or ask for help from each other” by 37%, and “we work alone, and only take care of own tasks” by 3% of the respondents. Figure 1 shows the itemized collaboration according to each professional group. OH nurses most commonly rated the collaboration as “solving problems together” –68% of respondents. The corresponding figure was 54% for OH physicians and 53% for OH physiotherapists. Nearly 15% of the psychologist and 10 % of the physiotherapists chose the alternative of “we work alone”.

Fig. 1

Self-assessed nature of collaboration between OHS professionals (n = 516) in relation to prevention of work disability due to MSD.

Sufficient resources in terms of work time and staff, work experience, motivation and co-operation skills were associated with better self-assessed collaboration among OHS professionals (p < 0.001). Almost every respondent (99%) agreed that multiprofessional co-operation strengthened OHS processes that prevent work disability of workers with MSD. The respondents who desribed OHS collaboration as “solving problems together” experienced their own work as rewarding; and collaboration supported their own work tasks (p = 0.006). The OHS respondents generally considered that their motivation (82%) and skills (96%) were at a good level for internal co-operation. In addition, they experienced that multiprofessional collaboration supported their own work (97%), strengthened the OHS processes for work ability promotion (99%) and enhanced the clients’ commitment to the work ability processes (93%). Despite the well-known positive factors of OH co-operation, over half (54%) of the respondents replied that there was not enough time to implement the good ideas.

3.2 Collaboration between OHS provider and client organization

OH co-operation means systematic, target-orientated co-operation between the employer, OHS, and employees or their representatives. According to the OH professionals, co-operation with the client organization was usually dealt with by the line management (19%); HR representatives (12%); well-being representatives (10%); and occupational safety organization (8%). OH physicians (33%) and OH physiotherapists (23%) were the most active professionals in collaboration with the workplaces; i.e. co-operation with the line management took place weekly.

Almost all the respondents (98%) agreed that the client organizations benefit from fluent and effective collaboration models. The major part of the respondents (93%) considered OH professionals to be responsible for active communication in OHS processes. Over half (66%) of the respondents felt that client organizations were committed to the collaboration. However, nearly a third of the respondents disagreed with this statement. Responses to the statement that OHS has up-to-date knowledge of changes that take place in client organizations differed sightly; 53% of the respondents agreed, whereas 45% disagreed with this statement. The majority of the respondents (67%) regarded that client organizations have knowledge about the OHS operations and contents. Nearly 80% of the respondents regarded that collaboration between workplaces was fluent, whereas a fifth of the OH professionals experienced the opposite (Fig. 2).

Fig. 2

The experience of occupational health co-operation related to work ability promotion with MSD (n = 516).

3.3 Self-assessed nature of OH co-operation

Most of the respondents felt that their collaboration among OHS personnel was systematic and documented in relation to workplace surveys (80%), medical examinations (84%), and providing information, advice and quidance (79%) (Table 1). However, 20% of the respondent experienced collaboration in these services as non-systematic and incidental. The same trend in multiprofessional OHS collaboration was found concerning the rehabilitation process; almost half of the respondents (49%) experienced co-operation as non-systematic and incidental during and after the rehabilitation of clients with MSDs.

Table 1
Percentages of self-assessed quality of OH co-operation both among OH professionals in their own OHS and between client organizations and different OHS. Values are all OHS professionals together (n = 516). The original choices of collaboration categories are presented as footnotes below the table

OHS “Participative, systematic collaboration” “Consultative collaboration” “No collaborative working model”

Among OH professionals^(OHS1) Between OHS and workplaces^(WP1) Among OH professionals^(OHS2) Between OHS and workplaces^(WP2) Among OH professionals^(OHS3) Between OHS and workplaces^(WP3)

Workplace survey 80 77 19 23 4 0

Medical examination 84 77 15 22 1 1

Information, advice and guidance 79 71 21 28 1 4

OH-orientated curative care 71 66 29 33 1 2

Referring workers to rehabilitation 64 78 34 21 2 1

Referral to rehabilitation 65 54 34 43 1 2

Follow-up during rehabilitation 47 53 49 44 4 3

Follow-up of coping at 49 41 49 53 3 6

work after rehabilitation

Supporting return to work 67 41 31 55 1 4

OHS	“Participative, systematic collaboration”	“Consultative collaboration”	“No collaborative working model”
Workplace survey	80	77	19	23	4	0
Medical examination	84	77	15	22	1	1
Information, advice and guidance	79	71	21	28	1	4
OH-orientated curative care	71	66	29	33	1	2
Referring workers to rehabilitation	64	78	34	21	2	1
Referral to rehabilitation	65	54	34	43	1	2
Follow-up during rehabilitation	47	53	49	44	4	3
Follow-up of coping at	49	41	49	53	3	6
work after rehabilitation
Supporting return to work	67	41	31	55	1	4

(OHS1) “Solving problems together”, (OHS2) “Asking for help/consulting other OHS professionals for help”, (OHS3) “Working alone, everyone takes care of their own tasks”, (WP1) Co-operation is systematic, with shared working models, (WP2) Co-operation is incidental with no shared working models and (WP3) No co-operation at all.

A similar trend was also found in the nature of OH co-operation with workplaces (Table 1). This was rated as “systematic with shared working models” in relation to workplace surveys (77%), medical examinations (77%), providing information, advice and guidance (71%), and monitoring sickness absences (78%). Respectively, a quarter of the respondents experienced collaboration in these processes as “incidental, with no shared working models”. A clear difference was found in relation to the rehabilitation process; on average half of the respondents rated the nature of OH co-operation as “incidental, with no shared working models” in work ability promotion and follow-up during (53%) and after (55%) rehabilitation.

A positive relationship was found between the systematic nature of OH co-operation and different services; the longer the work experience in OHS, the better the co-operation was organized in workplace surveys (p = 0.01), medical examinations (p = 0.003), as well as OH-oriented information/advice and guidance (p = 0.003), OH-orientated curative care and follow-up of sickness absences (p < 0.001). In addition, the quality of multiprofessional collaboration in OHS was positively related to the systematic collaboration with the client organizations. The respondents who experienced that work ability issues of workers with MSD are managed together with OH colleagues and other OHS professionals rated the co-operation with client organizations as more systematic in workplace surveys, medical examinations, information/advice and guidance, occupational health-orientated curative care, follow-up of sickness absences and rehabilitation processes (p < 0.001). The respondents who experienced no systematic collaboration inside OHS also rated the co-operation with client organizations as incidental or non-existent (p < 0.001).

3.4 Factors influencing the co-operation

Four main facilitators related to collaboration, both within the OHS and with the client organizations, were identified. The two most often reported facilitators for collaboration were shared working models and defined roles for better opportunites of co-operation, and characteristics of the operations in the client organizations (Table 2). Defined roles and responsibilities for systematic team work, regular meetings and easy consultation arrangements were reported to be important facilitators in the processes of work ability promotion among workers with MSD. Roles and responsibilites were seen as key factors for co-operation both in OHS teams and between OHS professionals and workplaces. Implementing well-known, shared working practices were important for collaboration between OHS and employers, particularly in early support and intervention models, and when monitoring sick leave periods. Examples of the original quotes, indicated by profession, are presented below (in italics).

Table 2
Facilitators and obstacles of collaboration in OHS and with client organizations in regard to work ability promotion of workers with MSD. Facilitators and barriers are presented with the examples of mentions from the open-ended questions. The number of these mentions are presented in brackets

Facilitators, main categories Examples of facilitators, multiprofessional co-operation in OHS (Number of mentions) Examples of facilitators, co-operation between OHS and workplaces (Number of mentions)

Shared working Defined roles and responsibilities for Regular meetings; implementation of working

models and practices systematic teamwork; regular meetings models into practical work (early intervention

and consultations easy to arrange; models, sickness absence monitoring);

shared ways of documenting (256) clear roles of OHS and workplace (350)

Client organization’s Coverage of OHS contract; client Sufficiently wide-ranging OHS contract;

knowledge and understanding organization considers multiprofessional client organization understands the preventive role

of OH co-operation work important; client organization of OHS; client organization is ready to adapt work

recognizes significance of preventive tasks; client organization works in co-operation

work; client recognizes own role with OHS when drawing

in work ability issues (115) up action plan (224)

Sufficient resources OHS is familiar with workplace’s working

and competence of conditions and operations; employees’

OHS professionals competence is good; OHS has sufficient

resources; multiprofessionalism (120)

Factors associated with Long client relationships;

confidential customer familiar people, which leads

relationship to good interaction; trust

Obstacles, Examples of obstacles, Examples of obstacles,

main categories multiprofessional co-operation in OHS co-operation between OHS and workplaces

(Number of mentions) (Number of mentions)

Inadequate resources and No time for meetings; working OHS is not sufficiently familiar

functions of OHS providers at different locations makes practices with the workplace; patients have

(time, staff) difficult; high staff turnover; poor to visit different doctors; information

induction training (307) does not flow; confidentiality

issues make co-operation difficult (48)

– Mainly time pressure at the workplace;

also OHS’ own lack of time due

to lack of resources (72)

No structured working No common, agreed way of recording Information does not flow from client

models for multiprofessional things; not used to co-operating; not aware organization to OHS; early intervention models

co-operation of others’ competences; different individuals’ not in use; sickness absence

different ways of working (143) monitoring does not work (44)

Factors associated with OHS contracts limit multiprofessional Poor leadership in client organization; client

defective functioning of client activity; client organization does not know organization is not familiar with OHS activities;

organization, OHS contracts how to demand multiprofessionalism (63) unrealistic expectations of OHS; supervisors too

timid to talk about work ability issues/negative

attitude to work ability problems; supervisors do

not want co-operation; co-operation

responsibilities undefined (310)

– OHS contract limits use of specialists (119)

Separate processes and Co-operation is not organized;

co-ordination with other health public health services’ poor functioning;

care organizations; i.e. poor information flow

rehabilitation services between individuals (29)

and The Social Insurance

Insitution of Finland

Facilitators, main categories	Examples of facilitators, multiprofessional co-operation in OHS (Number of mentions)	Examples of facilitators, co-operation between OHS and workplaces (Number of mentions)
Shared working	Defined roles and responsibilities for	Regular meetings; implementation of working
models and practices	systematic teamwork; regular meetings	models into practical work (early intervention
	and consultations easy to arrange;	models, sickness absence monitoring);
	shared ways of documenting (256)	clear roles of OHS and workplace (350)
Client organization’s	Coverage of OHS contract; client	Sufficiently wide-ranging OHS contract;
knowledge and understanding	organization considers multiprofessional	client organization understands the preventive role
of OH co-operation	work important; client organization	of OHS; client organization is ready to adapt work
	recognizes significance of preventive	tasks; client organization works in co-operation
	work; client recognizes own role	with OHS when drawing
	in work ability issues (115)	up action plan (224)
Sufficient resources		OHS is familiar with workplace’s working
and competence of		conditions and operations; employees’
OHS professionals		competence is good; OHS has sufficient
		resources; multiprofessionalism (120)
Factors associated with		Long client relationships;
confidential customer		familiar people, which leads
relationship		to good interaction; trust
Obstacles,	Examples of obstacles,	Examples of obstacles,
main categories	multiprofessional co-operation in OHS	co-operation between OHS and workplaces
	(Number of mentions)	(Number of mentions)
Inadequate resources and	No time for meetings; working	OHS is not sufficiently familiar
functions of OHS providers	at different locations makes practices	with the workplace; patients have
(time, staff)	difficult; high staff turnover; poor	to visit different doctors; information
	induction training (307)	does not flow; confidentiality
		issues make co-operation difficult (48)
		– Mainly time pressure at the workplace;
		also OHS’ own lack of time due
		to lack of resources (72)
No structured working	No common, agreed way of recording	Information does not flow from client
models for multiprofessional	things; not used to co-operating; not aware	organization to OHS; early intervention models
co-operation	of others’ competences; different individuals’	not in use; sickness absence
	different ways of working (143)	monitoring does not work (44)
Factors associated with	OHS contracts limit multiprofessional	Poor leadership in client organization; client
defective functioning of client	activity; client organization does not know	organization is not familiar with OHS activities;
organization, OHS contracts	how to demand multiprofessionalism (63)	unrealistic expectations of OHS; supervisors too
		timid to talk about work ability issues/negative
		attitude to work ability problems; supervisors do
		not want co-operation; co-operation
		responsibilities undefined (310)
		– OHS contract limits use of specialists (119)
Separate processes and	Co-operation is not organized;
co-ordination with other health	public health services’ poor functioning;
care organizations; i.e.	poor information flow
rehabilitation services	between individuals (29)
and The Social Insurance
Insitution of Finland

“Well-organized work processess – knowing the skills of different occupational groups – joint development to improve MSD-sufferers’ processes.” (OH physiotherapist)“The fact that we work in the same premises. The workers get on well with each other and honestly advise and help each other in challenging client situations. Workplace visits are made together with, for example, an OH physiotherapist.”(OH nurse)“The co-operation practices at the different stages of work ability promotion are agreed upon, and both (client organiations and OHS) have their own agreed methods/ways of working in their own activities.” (OH physician)

In order to enhance collaboration, OHS providers consider it important that employers understand their own responsibilities in the processes of work ability promotion, especially in multiprofessional co-operation. In the client organization, attitude towards and motivation for collaboration, as well as willingness to modify work and the work envionment contribute to effective collaboration between OHS and workplaces. The relevant contents of OHS contracts was regarded as an important facilitator of co-operation both among OHS personnel and in co-operation with the workplaces.

In order to create workable practices to co-operate with employers, OHS providers’ knowledge and understanding of work and the conditions at the workplaces, as well as competence and the critical level of resources, are basic issues related to effective co-operation. In addition, the characteristics of customer relationships, i.e. mutual confidential interaction and sufficient trust and familiarity between partners, also contribute to effective collaboration between OHS professionals and employers.

“The concrete goals of co-operation recorded in the strategy for each workplace/work station. The courage of an employer representative/line supervisor to recognize a worker suffernig from MSD at an early stage, and to refer them to OHS.” (OH physician)

“Mutual trust, the employer takes OHS suggestions seriously and the employer can trust OHS competence. Trust is born through planning the co-operation structures together.” (OH physician)

Despite these well-known advantages of collaboration, it may not work well in practice. Many individual and organizational factors in OHS and client organizations impair the fluency of co-operation. The most frequently reported obstacles differed slightly depending on whether the collaboration was with other OH professionals or with representatives of the workplaces (Table 2). For effective internal multiprofessional co-operation, inadequate providers resources of OHS and differences in working methods were regarded as significant obstacles. In addition, working in different offices and high turnover of OH professionals give rise to practical problems concerning co-operation.

“Different competences of different employees. Turnover of team members and discontinuity of the care relationship.” (OH physician)

“There’s no separate agreement or formula for co-operation: it’s not planned ... it’s more like general empty talk - no routine is formed in the middle of everyday hustle and bustle, when co-operation is just a quick mention of something in the coffee room, for example.” (OH physician)

Internal problems in OHS, associated with client organizations, were reported to prevent collaboration both within OHS and with the workplaces. Problems like poor management and unwillingness to plan and organize preventive models for work ability promotion were mentioned as examples of negative factors. In addition, restrictive OHS contracts that did not include services of, e.g., OH physiotherapists, reduced effective co-operation. This is especially challenging when trying to solve MSD-related problems. Also, factors associated with reciprocity and the operational agreements with client organizations prevent co-operation among OHS personel.

“The coverage of the organization’s OHS contract isn’t enough. The organization doesn’t understand the necessity of referral to care for MSD symptoms.” (OH physician)

“Everyone’s constantly busy, it’s difficult to arrange appointments, always have to think what appointments we can have, and whether the worker’s employer will pay when the appointment is invoiced.” (OH nurse)

Poor collaboration with other organizations, e.g. specialist-level health care, insurance companies, Social Insurance Institution, and rehabilitation service providers were also regarded as negative factors for the fluency of OHS collaboration.

“Organizational limits, very little co-operation with the different experts in the organization or stiff forms of co-operation in these situations, information doesn’t transfer from, for example, specialised medical care to the rehabilitation centre and so on.” (OH nurse)

3.5 Successful OH co-operation in work ability promotion

The respondents valued the advancement of co-operation in many ways, both internally in OHS, and with the workplaces. The ideas were in line with the reported facilitators and barriers of co-operation practices. Proactive working models with defined roles and responsibilities were perceived as the most common factor for both the improvement of internal OHS teamwork (298 mentions) and better collaboration with workplaces (184 mentions). The respondents emphasized the importance of regular meetings between workplaces and OH professionals, not forgetting the co-operation with the representatives of occupational safety. Examples of the original quotes, indicated by profession, are presented below (in italics).

“I would emphasize the active intervention model, early intervention model, so that the client organization could go through it even more actively with the employees- investing in OHS negotiation- low threshold to contacting each other.” (OH physician)

“More comprehensive OHS contracts. Increasing organizations’ know-how and understanding of how sickness absences and enjoying work can be influenced cost effectively through co-operation with the employer.” (OH physician)

According to the respondents, the employers’ and employees’ awareness of their opportunities to impact work ability processes with OHS would improve OH co-operation. Developing workplaces’ own activities for solving work ability problems was viewed as one possibility to strengthen OH co-operation. In particular, more education and information on the early intervention model, work ability management, and the costs of work disability (59 mentions) was regarded as an important measure to strengthen the role of the employee in this collaboration. In addition, it was regarded as important to revise the employees’ understanding and opportunities (56 mentions) to manage workplace modifications and alternative duties.

“More training for supervisors in work ability issues and flexible workplaces for disabled employees.” (OH physician)

“Clearer, jointly agreed roles in work ability issues. Training for supervisors and the entire personnel, more knowledge regarding work ability issues. Also some sort of change in culture, way of thinking and attitudes to partial work ability. We still consider it too much as OHS’s responsibility.” (OH nurse)

OH professionals considered their own operations according to the (VNA 708/2013) to be important for promoting co-operation with the workplaces (111 mentions). The respondents emphasized resources for co-operation, i.e. having enough professional competence, being able to work in a multiprofessional team, and having up-to-date knowledge regarding working conditions at workplaces, opportunity to conduct workplace surveys, and skills to justify the importance of preventive work at the workplace.

“By taking advantage of multiprofessional knowledge and competence. Co-operation between occupational safety and health and OHS should be developed through joint workplace visits and risk assessment; in a way that the realization of OHS’s suggested measures in practice can be ensured, and developed if needed. It would also be good to agree on follow-up practices together. Employees’ opinions should be heard and developing one’s own work should be supported/enabled.” (OH nurse)

4 Discussion

According to the Finnish Government Decree on the principles of good occupational health care practice [10], OHS activities should be systematic and target-oriented, with the emphasis on multiprofessional and multidisciplinary collaboration between different stakeholders. Our questionnaire for OHS professionals revealed that co-operation within OHS, and between OHS and the client organizations was considered important for the promotion of work ability among employees with MSD. However in reality, this co-operation did not always take place as planned. We found several cases requiring development and removal of obstacles to successful co-operation in work ability promotion processes.

4.1 Co-operation within OHS and with the client organizations

The co-operation in matters related to promoting the work ability of employees with MSD most often took place among OH physicians, OH nurses and OH physiotherapists. According to a Finnish review by Lappalainen et al. [11], the prerequisites for multiprofessional collaboration in OHS have clearly improved in accordance with increased OHS personnel resources.

Previous studies showing that MSDs are commonly related to psychosocial factors [14, 15] create pressure and challenges to increase collaboration e.g. between OH physiotherapists and OH psychologists. It is not enough that we only know or assume the expertise of each professional. It would be important to actively and consciously create new collaboration models in OHS. Our results showed that the co- operation with OH physiotherapists and OH psychologists was less prevalent compared with other professions. This was, however, an expected result, because the services of OH physiotherapists and psychologists are based on the needs analysis carried out by OH physicians and OH nurses, which means that a prerequisite of systematic collaboration between physiotherapists and psychologists is the awareness and competence of either OH physician or nurse.

The majority of the respondents regarded the collaboration within OHS and with the client organizations as solving problems together. Only a minor part of the respondents believed that there was no co-operation at all; just working alone, only taking care of ones’s own tasks. Collaboration was less systematic and participatory in rehabilitation processes. It is important to continue developing practical models of early intervention for work ability problems and develop the need for rehabilitation processes. The early intervention model, for example, and the systematic follow-up of sickness absences are relevant means for both the employer and OHS. The earlier the possible problems are identified and discussed, the better are the possibilities to find solutions for difficulties in work and work ability. The quality of relationships is imperative for developing purposeful OHS delivery in processes to promote work ability. Trustful relationships, shared vision for co-operation and long-term contrats facilitate for successful proactive actions between OHS and workplace [7].

In our study, fruitful co-operation was related to sufficient resources in terms of time and staff, work experience, motivation, and co-operation skills. These results are in line with previous studies [5 , 16]. The need for multiprofessional co-operation and team work should be emphasized already at the beginning of the working career and during basic and continuing OH education. Multiprofessional and systematic collaboration benefits both OHS and the client organization, as the required services can be better tailored to the clients’ needs [8]. For more systematic co-operation, OHS providers should have competence and up-to-date knowledge about the workplace, and respectively employers should understand their responsibilities in the processes of work ability promotion. Co-operation concerning the rehabilitation processes were experienced less-systematic and incidental compared to workplace surveys and medical examinations; as well as providing information, advice and guidance to the workplaces. Therefore, active co-operation and dialogue between the stakeholders (OHS provider, employer and employee and rehabilitation provider) is needed for successful working practices.

4.2 Factors influencing the co-operation

OHS services are expected to be multiprofessional and customer-oriented. In Finland, the Government Decree on the principles of good occupational health care practice [10] emphasizes co-ordination within OHS, client organizations and other health care organizations. Almost all the respondents felt that OHS played an active role in contact with client organizations. The co-ordinative role of OHS does not mean unilateral communication, but fluent and flexible working together, with clear roles and responsibilities. In Finland, the legislation change of 2012 [10], obligates the employer to inform OHS of sick leaves exceeding 30 days. With referecne to this, Halonen et al. [17] found an increasing awareness among management of prolonged sickness absences. They found that sustained return to work and work participation increased among the employees with prolonged sickness absence after the legislative change that enhanced OH co-operation.

In the present study, we found two common facilitators of both multiprofessional co-operation within OHS and co-operation between OHS and workplaces: (1) shared working models and practices and (2) the client organization’s knowledge and understanding of OH co-operation. We also found that sufficient resources and competence among OHS professional and confidental customer relationships facilitate collaboration with the client organizations. The need for shared working models and practices was also emphasized in studies by Uitti et al. [18] and Halonen et al. [5]. Co-operation in the field of work ability promotion requires commitment to collaboration processes and willingness to modify work and the work environment [17]. In order to promote co-operation, practical models were considered important, such as regular meetings and information sessions with the managers about, for example, work ability processes and work modifications. A change from medical care and reactive services towards more promotion and prevention is also emphasized in studies by Schmidt et al. [6] and Halonen et al. [5]. As our study and previous studies [17–18] have found, in addition to more target-oriented collaboration forums, there is also a need for more informal contacts between stakeholders. Confidential discussions about work ability issues and OHS activities is a key factor for effective collaboration. OHS is responsible for producing services that are beneficial for both the work community and the individual worker.

Trust, familiarity and long client relationships were found to be important factors for collaboration between OHS and client organizations. Trust and confident collaboration have also been emphasized in earlier studies [17, 19]. Beyer et al. [20] pointed out the importance of individuals’ roles in the interactions between the different stakeholders. They also stated that the objectives of each practitioner may be different, which impacts the success of collaboration. Gewurtz et al. [21] highlighted the need to identify both system-level and individual-level challenges and opportunities for successful return to work following a work-related injury. Well-coordinated, timely return to work and appropriately modified work tasks were significant employment factors affecting work ability. As found in our study, diverse stakeholders, both OHS professionals and client organization, should have a common goal of high-quality co-operation. It is important to highlight the aims of each partner for work ability processes to be successful. The competence of OHS professionals was seen as especially beneficial for successful co-operation with the client organization. For example, multiprofessionalism and familiarity with the working conditions were seen as facilitators of effective collaboration.

Even if the facilitators are known, the co-operation does not always proceed as planned. The barriers to collaboration were almost exactly opposite to the facilitators. Inadequate resources of OHS providers, i.e. time and staff, were seen as obstacles to both multiprofessional co-operation within OHS and that between OHS and client organizations. Lack of time was regarded as being related more to collaboration with the client organization than within OHS. Having no time for regular meetings with OHS colleagues and with client organizations may cause problems in the flow of information, for example, thus preventing fluency and successful collective promotion of work ability. The high staff turnover in OHS also creates challenges to fluent co-operation.

Many well-known general factors are related to succesful collaboration, but within OHS some factors are more specific, like the employer’s obligations and reimbursements. As for the practical factor, limited OHS contracts which did not include, for example, the services of OH physiotherapists, were believed to reduce effective co-operation within OHS and between OHS and client organizations. The review of van Vilsteren et al. [22] found workplace interventions and work modifications to be effective for better work ability and health among workers with MSD. Co-ordinated return-to-work programmes, especially among MSD sufferers, have increased participation in work after sickness absence [23], although additional research of the benefits and implementatios of these programmes is still needed [24].

OHS professionals find several possibilities for beneficial work accomomodations. At the same time, employees and employers have a need for more information and incentives for applying these procedures [25]. This is parallel with our study, which showed that the obstacles for successful co-operation between OHS and client organizations were related to poor leadership in client organizations and supervisors’ negative attitudes to work ability problems and co-operation. Many of the OHS respondents felt that poor leadership in the client organization, unrealistic expectations in the OHS, and unwillingness to co-operate were negative factors for promoting work ability processes among workers with MSD.

This cross-sectional study combined both quantitative and qualitative data gathered by a questionnaire. These two approaches provide stronger inferences about collaboration than one alone. Another strength of the study was the diverse target based on the groups of OHS professionals: OH physicians, OH nurses, OH physiotherapists and OH psychologists. The query enabled simple way to gather information on the contents of multiprofessional collaboration. Despite the low response rate, the respondents were active also to answer the open-ended questions of the query. An average 70% of the respondents gave their opinions on the implementation of multiprofessional collaboration. A bias could have occurred if the replying respondents were more motivated for multiprofessionl collaboration than those who did not participate. The generalisation of the results is weakened by quite low response rates, varing from 7% to 24% by professions. However, the results can be interpreted as an interesting multiprofessional sample among OHS professional in Finland.

4.3 Conclusion

When the client organization identifies OHS as a partner in the promotion of health and work ability and enables multiprofessional co-operation according to the OHS contracts, it improves the possibilities for co-operation between different stakeholders. It is also important that each stakeholder recognizes its own role in co-operation when measures for developing work and work ability issues are needed. The study showed that co-operation between OHS and client organizations was mainly regarded as systematic. However, several barriers and factors that require development were revealed. This conflicting result suggests that the possible vision of co-operation may reflect the awareness of desirable good practices, while the open-ended questions described experiences of working life in which the co-operation is not carried out as planned.

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in the study were in accordance with the Finnish National Board on Research Integrity (TENK) and the Coordinating Ethics Work Group of Finnish Institute of Occupational Health.

Funding

This study was funded by The Social Insurance Institution of Finland (grant number 33/26/2014).

Footnotes

The Appendix is available in the electronic version of this article: .

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