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

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.

3.1 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”.

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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.

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).

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Fig. 2

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

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.

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).

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).

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.

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.

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.

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.

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).

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.

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.

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.