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Respectful encounters and return to work –
empirical study
of long-term sick-listed patients’ experiences of Swedish
healthcare
Journal:
BMJ Open
Manuscript ID:
bmjopen-2011-000246
Article Type:
Research
Date Submitted by the
Author:
30-Jun-2011
Complete List of Authors:
lynøe, niels; Karolinska institutet, Stockholm Centre for healthcare
ethics
Wessel, Maja; Karolinska institutet, Stockholm centre for healtcare
ethics
Olsson, Daniel; Karolinska institutet, Department of Environmental
Medicine
Alexanderson, Kristina; karolinska institutet, Department of Clinical
Neuroscience
Helgesson, Gert; karolinska institutet, Stockholm centre for
healthcare ethics
<b>Primary Subject
Heading</b>:
Health service research
Keywords:
MEDICAL ETHICS, Organisation of health services < HEALTH
SERVICES ADMINISTRATION & MANAGEMENT, Quality in health
care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
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BMJ Open

For peer review only
Respectful encounters and return to work – empirical study of long-
term sick-listed patients’ experiences of Swedish healthcare
Niels Lynöe1, Maja Wessel1, Daniel Olsson2, Kristina Alexanderson3, Gert Helgesson1
1Stockholm Centre for Healthcare Ethics (CHE), Department of Learning, Informatics,
Management and Ethics, Karolinska Institutet, Stockholm, Sweden; 2Unit of Biostatistics,
Division of Epidemiology, Department of Environmental Medicine (IMM), Karolinska
Institutet, Stockholm, Sweden; 3Division of Insurance Medicine, Department of Clinical
Neuroscience, Karolinska Institutet, Stockholm, Sweden.
Words: 1724
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Abstract
Aims: To study long-term sick-listed patients’ self-estimated ability to return to work
after experiences of healthcare encounters that made them feel either respected or
wronged.
Methods: A questionnaire-based survey was used to study a sample of long-term sick-
listed patients including n=5 802 respondents. The survey included questions about
positive and negative encounters as well as about reactions to these encounters, such as
‘feeling respected’ and ‘feeling wronged’. The questionnaire also included questions
about the effects of these encounters on the patients’ ability to return to work.
Results: Among patients who had experienced positive encounters, those who also felt
respected presented significantly augmented self-estimated ability to return to work [from
34% (CI: 28-40) to 62% (CI: 60-64)]. Among patients with experiences of negative
encounters, those who in addition felt wronged claimed to be significantly more impeded
from returning to work [from 31% (CI: 27-35) to 50% (CI: 47-53)].
Conclusions: The study indicates that positive encounters in healthcare combined with
feeling respected significantly facilitate sickness absentees’ self-estimated ability to
return to work, while negative encounters combined with feeling wronged significantly
impair it.
Article summary
- Do different encounters influence sick-listed patients’ self-estimated ability to return to
work?
- What happens if positive encounters are also perceived as respectful?
- What happens if negative encounters are also perceived as wrongful?
- Patients’ self-estimated ability to return to work are significantly facilitated if
encounters are perceived as respectful and significantly impeded if encounters are
perceived as wrongful.
- We examined solely the perceived ability to return to work, not the actual ability to
return to work.
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Introduction
During the last decade, there have been several interventions to reduce the previously
high sick-leave rates in Sweden [1]. The rate of long-term sick-leave cases was
particularly high [2]. Different interventions have aimed to increase the quality of the
management of sickness certification, but more knowledge is needed on how return to
work can be promoted among long-term sickness absentees [1-4].
Some studies indicate that patients’ experiences of healthcare encounters might
influence their chances of returning to work [5]. Being listened to, having one’s questions
answered, and being believed are among the most common items associated with positive
encounters among long-term sick-listed patients and have also been reported to be
important in relation to feeling respected in healthcare; correspondingly, experiences of
nonchalance, disrespect, and distrust are commonly associated with negative encounters
and are important in relation to feeling wronged [6].
The aim of the present study was to examine how, in the experience of patients on
long-term sick leave, positive and negative encounters in healthcare affect their self-
estimated possibility of returning to work, and how much difference, if any, it makes
whether or not these experiences are accompanied by feeling respected and feeling
wronged, respectively.
Material and methods
The present study derives from a population-based questionnaire survey among randomly
selected long-term sickness absentees (n=10 042) who in 2003 had an ongoing sick-leave
spell that had lasted for six to eight months. Of these 5 802 answered the questionnaire.
The survey was distributed during 2004 and different aspects of the survey have already
been reported [7-9]. In the present study we have examined the respondents’ experiences
using a questionnaire containing questions about positive or negative encounters, what
kinds of encounters they had been exposed to, and how they reacted in terms of feeling
respected or wronged. The patients were also asked to estimate how these encounters had
affected their ability to return to work, in terms of hindering, not influencing, or
facilitating return to work, respectively. In addition, the respondents were asked if they
were sick-listed for (a) psychiatric disorders, (b) musculoskeletal pain, (c) other somatic
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diseases, or (d) more than one of the previous categories. When presenting the results, we
focus on respondents in a–c.
The results are presented as proportions (with 95% confidence intervals (CI)) of
those who estimated that return to work was facilitated, compared to those who stated
that return to work was not influenced or impeded, when experiencing positive
encounters/feeling respected, and of those who felt impeded, compared to those who
stated that return to work was not influenced or facilitated, when experiencing negative
encounters/feeling wronged. Focusing on the association between respectful/wrongful
encounters and return to work, we have performed logistic regression analysis adjusting
for different background variables such as sex, age, educational level, and different
diagnoses. Adjustment made, however, no substantial difference to the results.
Accordingly, we here present the crude proportions with a 95% CI.
The frequency and associations between positive encounters and feeling respected,
and negative encounters and feeling wronged, are presented as Attributable Risks (AR)
[10] with a 95% CI, using the R-package pARtial [11]. Since a majority of all encounters
concerned physicians (70%), we have replaced the wording “healthcare providers
including physiotherapists and midwifes” with “physicians” in the text.
The study was approved by the regional research ethics committee in Linköping
(Dnr 03-261).
Results
The response rate was 58% (n=5 802) of the original sample. Of the participants who had
experienced positive encounters (n=3 406), 97.7% (CI: 97.2-98.2) stated that they also
felt respected. Among those who had experienced negative encounters (n=1 403), 70.8%
(CI: 68.4-73.2) declared they also felt wronged (Figure 1).
When comparing patients who had experienced negative encounters and felt
wronged with those who had experienced negative encounters but not felt wronged, we
found a significantly higher proportion of patients in the former category who reported
that they were impeded from returning to work [50% (CI: 47-53) versus 31% (CI: 27-35)]
(Table 1). When adding feeling wronged to negative encounters, the self-rated hindering
effect on return to work was highest among patients on sickness absence for ‘psychiatric
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disorders’ [38% (29-37) as against 59% (CI: 54-64)] and lowest among those sick-listed
for ‘other somatic conditions’ [28% (19-37) as against 39% (CI: 32-47)] (Table 2).
The patients who stated that they had experienced positive encounters and felt
respected claimed to a significantly higher degree that return to work was facilitated by
the encounter, compared to those who experienced positive encounters but did not feel
respected [62% (CI: 60-64) versus 34% (CI: 28-40)] (Table 1). When adding feeling
respected to positive encounters, the self-rated facilitating effect on return to work was
highest among those sick-listed for ‘other somatic conditions’ [23% (5-41) as against
54% (51-58)] and lowest among patients sick-listed for ‘psychiatric disorders’ [53% (29-
77) as against 76% (74-79)] (Table 3).
There was no significant difference between women and men, but we noticed a
tendency for women who felt respected to reply more often that this had increased their
ability to return to work; [63% (CI: 61-64) for women as against 59% (CI: 56-61) for
men]. Men, on the other hand, tended to be more inclined to find themselves impeded
from returning to work if feeling wronged [55% (CI: 48-61) as against 49% (CI: 45-52)
for women].
Discussion
We found that patients on long-term sick leave experienced positive healthcare
encounters as facilitating return to work, while negative encounters impeded it. The
facilitating effect of positive encounters was significantly augmented when combined
with the patient’s feeling respected, while return to work was significantly reduced if
negative encounters were combined with feeling wronged. Feeling respected had a
greater effect in relation to positive encounters regarding return to work than feeling
wronged had in relation to negative encounters (Table 1).
Encounters may affect return to work
Insofar as the respondents’ experiences fully or partly reflect their actual ability to return
to work, they identify a number of aspects of physician–patient interaction that have to be
handled properly in order to facilitate patients’ chances of returning to work. There is
much discussion on how to promote return to work among long-term sickness absentee
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patients, focusing on different types of rehabilitation measures [3,5]. The present study
suggests that physicians and other healthcare staff may also have an impact on patients’
ability to return to work through the way in which they encounter patients. This tallies
with the results of an interview study indicating that such encounters had as high an
impact on return to work as the rehabilitation measures [12].
Patients’ understanding of being respected and being wronged
It should be noted that the survey does not give any details about what the respondents
meant by feeling respected and feeling wronged. In medicine, respecting patients usually
relates to respecting their right to autonomous decision-making. Physicians are supposed
not only to respect patient autonomy but also to enhance it, for example, by support and
encouragement. Showing respect for patient autonomy might enhance patients’ self-
esteem and enable them to accomplish more [5]. It may thus facilitate their self-estimated
as well as their actual ability to return to work. In practice, showing respect for patient
autonomy might concern basic things like treating them as competent and showing a
genuine interest in what they say.
This is not to say that a list of basic components of reasonable behaviour towards
patients exhausts the meaning of treating them with respect. We found that something
was added when the patients felt not only that they had experiences of positive healthcare
encounters, but also that they felt respected, as was shown in their estimations of their
ability to return to work. What this addition more specifically consists in cannot be learnt
from our questionnaire survey, but deserves to be further examined.
Corresponding remarks can be made regarding negative encounters and feeling
wronged. Instead of empowering patients’ self-esteem, experiences of being wronged
might make patients impaired and decrease their ability to return to work. Thus,
disrespecting patient autonomy is not only regrettable as such, but might have negative
consequences for patients’ wellbeing [13].
Feeling wronged is, however, not necessarily the same actually being wronged, and
it might be debated whether patients sometimes provoke the doctor to act in a less
appropriate way [14-15]. Provoked or not, there may be situations where patients
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perceive the doctor as intimidating, condescending, or patronising, while the physician
does not realise until afterwards that the encounter could be perceived that way [15].
We find it interesting that patients who were sickness absent due to psychiatric
disorders seemed to be more affected by feeling wronged in their encounters than those
with somatic disorders. Perhaps psychiatric patients are more sensitive to having their
autonomy questioned. But when feeling respected was added to the experience of
positive encounters, it had little influence on patients sick-listed for psychiatric disorders.
In this case, patients with ‘other somatic conditions’ were the most sensitive group. We
have no explanation for this inverse result.
Limitations
Since our data concern a special patient group, the results may not be generalisable to the
general patient population. Long-term sick listed patients may, for instance, have faced
greater disappointments in their healthcare contacts than many other patient groups. They
may also have had more experience of not being believed. However, regarding the effect
of positive encounters, our results are supported by other studies. One study points to a
reduction in sick-leave duration for patients suffering from tonsillitis [16], while another
study identifies improvements in HbA1c and LDL-cholesterol for patients suffering from
diabetes [17].
Another limitation is that the study concerns patients’ self-estimations of the
influence of positive and negative healthcare encounters on their ability to return to work.
Such estimates may be difficult to make, and patients may over- or underestimate the
influence of these encounters. Further research is needed to establish the influence of
positive and negative healthcare encounters on the ability to return to work in real life.
A third limitation is the drop out, which, as is so often the case, is somewhat higher
among men and younger patients. Compared to other studies of sick people, the response
rate was high and the large number of subjects provides a solid base for conclusions.
Conclusion
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Our study indicates that feeling respected in healthcare significantly facilitates long-term
sick-listed patients’ self-estimated ability to return to work, while feeling wronged
significantly impairs it.
Contributorship statement:
Niels Lynøe made the first statistical analysis and made the draft. Maja Wessel and
Daniel Olsson conducted all further statistical analyses and contributed to the second and
final draft. Kristina Alexanderson and Gert Helgesson contributed both substantially and
intellectually with critical analysis and contribution to the second and final draft.
Financial statement:
We have not received any funding for this specific study.
Competing interest statement:
We have received no support from any organisation for the submitted work; we have had
no financial relationships with any organisations that might have an interest in the
submitted work in the previous three years; there are no other relationships or activities
that could appear to have influenced the submitted work
Exclusive licence:
The Corresponding Author has the right to grant on behalf of all authors and does grant
on behalf of all authors, an exclusive licence on a worldwide basis to the BMJ Publishing
Group Ltd and its Licensees to permit this article (if accepted) to be published in BMJ
editions and any other BMJPGL products and sublicences to exploit all subsidiary rights,
as set out in our licence.
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References
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Karolinska Institutet; 2010.
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the role of economic conditions, legislation, demography, work environment, and alcohol
consumption. International Journal of Social Welfare. 2011;2(20):167-79.
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on the significance of promoting positive social emotions among sickness absentees.
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6. Wessel M, Helgesson G, Olsson D, Juth N, Alexanderson K, Lynöe N. Why do
patients feel wronged? Empirical study of sick-listed patients’ experiences of healthcare
encounters. Re-submitted; revisions considered by Scand J Pub Med.
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Sick-Listed Persons' Experiences of Interactions with Rehabilitation Professionals. Social
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encounters with healthcare and social insurance professionals among people on long-term
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encounters with healthcare. A study of long-term sickness absentees. Scand J Pub
Health. 2007;35:577-84.
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11. Benichou, J. A review of adjusted estimators of attributable risk. Stat Methods Med
Res 2001;10:195
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12. Östlund G, Alexanderson K, Cedersund E, Hensing G. “It was really nice to have
someone”: Lay people with musculoskeletal disorders request supportive relationships in
rehabilitation. Scand J Pub Health 2001;29(4):285-91.
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reappraisal effects in humans. Nature Medicine 2010;16(11):1277-83.
14. Swartling MS, Hagberg J, Alexanderson K, Wahlström RA. Sick-listing as a
psychosocial work problem: a survey of 3997 Swedish physicians. J Occup Rehabil
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15. Malterud K, Thesen J. When the helper humiliates the patient: a qualitative study
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Positive encounter s Negative encounters
n=3406 n=1403
Positive encounter & not Positive encounters & Negative encounters & not Negative encounters &
feeling respected (n=79) feeling respected (n=3327) feeling wronged (n=410) feeling wronged (n=993)
Figure 1. The left-hand side of the figure displays the distribution of answers regarding
experiences of positive encounters with healthcare in relation to self-estimated influence
on return to work. The sample is divided into those who experienced positive encounters
but did not feel respected and those who experienced positive encounters and felt
respected. The right-hand side of the figure shows the distribution of answers regarding
negative encounters in relation to self-estimated influence on return to work. The sample
is divided into those who did not feel wronged and those who felt wronged.
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Table 1. Self-estimated effect, among long-term sick-listed patients, of positive and
negative healthcare encounters on return to work in relation to feeling/not feeling
respected and feeling/not feeling wronged. The results are presented as proportions of
those who were facilitated, not influenced, or impeded, with a 95% confidence interval.
Return to work was:
Facilitated Not influenced Impeded
Positive encounters
Not feeling respected (n=79) 34% (28-40) 63% 3%
Feeling Respected (n=3327) 62% (60-64) 37% 1%
Negative encounters
Not feeling wronged (n=410) 8% 61% 31% (27-35)
Feeling wronged (n=993) 4% 46% 50% (47-53)
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Table 2. The table shows patients’ self-estimated ability to return to work when feeling
wronged, in relation to reason for sickness absence: (1) psychiatric disorders, (2)
musculoskeletal pain, or (3) other somatic disorders. The table shows the proportion of
statements to the effect that return to work was facilitated, not influenced, or impeded as
the patients felt wronged in their healthcare encounters.
Return to work was:
Type of medical disorder Facilitated Not influenced Impeded
Psychiatric disorders
Not feeling wronged (n=104) 5% 57% 38% (29-37)
Feeling wronged (n=316) 4% 37% 59% (54-64)
Musculoskeletal disorders
Not feeling wronged (n=142) 7% 66% 27% (20-34)
Feeling wronged (n=302) 7% 49% 44% (38-49)
Other somatic disorders
Not feeling wronged (n=86) 5% 67% 28% (19-37)
Feeling wronged (n=161) 4% 57% 39% (32-47)
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Table 3. The table displays the patients’ self-estimated ability to return to work when
feeling respected, in relation to reason for sickness absence: (1) psychiatric disorders, (2)
musculoskeletal pain, or (3) other somatic disorders. The table shows the proportion of
statements to the effect that return to work was facilitated, not influenced, or impeded as
the patients felt respected in their healthcare encounters.
Return to work was:
Type of medical disorder Facilitated Not influenced Impeded
Psychiatric disorders
Not feeling respected (n=17) 53% (29-77) 47% 0%
Feeling respected (n=931) 76% (74-79) 23% 1%
Musculoskeletal disorders
Not feeling respected (n=28) 28% (11-45) 68% 4%
Feeling respected (n=1018) 53% (50-56) 45% 2%
Other somatic disorders
Not feeling respected (n=22) 23% (5-41) 73% 4%
Feeling respected (n=798) 54% (51-58) 45% 1%
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RESEARCH CHECKLIST
As far as we understand, this requirement is not applicable to this questionnaire-based study.
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Respectful encounters and return to work –
empirical study
of long-term sick-listed patients’ experiences of Swedish
healthcare
Journal:
BMJ Open
Manuscript ID:
bmjopen-2011-000246.R1
Article Type:
Research
Date Submitted by the
Author:
19-Aug-2011
Complete List of Authors:
lynøe, niels; Karolinska institutet, Stockholm Centre for healthcare
ethics
Wessel, Maja; Karolinska institutet, Stockholm centre for healtcare
ethics
Olsson, Daniel; Karolinska institutet, Department of Environmental
Medicine
Alexanderson, Kristina; karolinska institutet, Department of Clinical
Neuroscience
Helgesson, Gert; karolinska institutet, Stockholm centre for
healthcare ethics
<b>Primary Subject
Heading</b>:
Health services research
Keywords:
MEDICAL ETHICS, Organisation of health services < HEALTH
SERVICES ADMINISTRATION & MANAGEMENT, Quality in health care
< HEALTH SERVICES ADMINISTRATION & MANAGEMENT
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open

For peer review only
Respectful encounters and return to work – empirical study of long-
term sick-listed patients’ experiences of Swedish healthcare
Niels Lynöe1, Maja Wessel1, Daniel Olsson2, Kristina Alexanderson3, Gert Helgesson1
1Stockholm Centre for Healthcare Ethics (CHE), Department of Learning, Informatics,
Management and Ethics, Karolinska Institutet, Stockholm, Sweden; 2Unit of Biostatistics,
Division of Epidemiology, Department of Environmental Medicine (IMM), Karolinska
Institutet, Stockholm, Sweden; 3Division of Insurance Medicine, Department of Clinical
Neuroscience, Karolinska Institutet, Stockholm, Sweden.
Words: 1885
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Abstract
Aims: To study long-term sick-listed patients’ self-estimated ability to return to work
after experiences of healthcare encounters that made them feel either respected or
wronged.
Methods: A cross-sectional and questionnaire-based survey was used to study a sample of
long-term sick-listed patients including n=5 802 respondents. The survey included
questions about positive and negative encounters as well as about reactions to these
encounters, such as ‘feeling respected’ and ‘feeling wronged’. The questionnaire also
included questions about the effects of these encounters on the patients’ ability to return
to work.
Results: Among patients who had experienced positive encounters, those who also felt
respected (n=3327) presented significantly augmented self-estimated ability to return to
work, compared to those who did not feel respected (n=79) [from 34% (CI: 28-40) to
62% (CI: 60-64)]. Among patients with experiences of negative encounters, those who in
addition felt wronged (n=993) claimed to be significantly more impeded from returning
to work, compared to those who did not feel wronged (n=410) [from 31% (CI: 27-35) to
50% (CI: 47-53)].
Conclusions: The study indicates that positive encounters in healthcare combined with
feeling respected significantly facilitate sickness absentees’ self-estimated ability to
return to work, while negative encounters combined with feeling wronged significantly
impair it.
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Introduction
During the last decade, there have been several interventions to reduce the previously
high sick-leave rates in Sweden [1]. The rate of long-term sick-leave cases has been
particularly high [2]. Different interventions have aimed to increase the quality of the
management of sickness certification, but more knowledge is needed on how return to
work can be promoted among long-term sickness absentees [1-4].
Some studies indicate that patients’ experiences of healthcare encounters might
influence their chances of returning to work [5]. Being listened to, having one’s questions
answered, and being believed are among the most common items associated with positive
encounters among long-term sick-listed patients and have also been reported to be
important in relation to feeling respected in healthcare; correspondingly, experiences of
nonchalance, disrespect, and distrust are commonly associated with negative encounters
and are important in relation to feeling wronged [6].
The aim of the present study was to examine how, in the experience of patients on
long-term sick leave, positive and negative encounters in healthcare affect their self-
estimated possibility of returning to work, and how much difference, if any, it makes
whether or not these experiences are accompanied by feeling respected and feeling
wronged, respectively.
Material and methods
The present study derives from a population-based and cross-sectional questionnaire
survey among randomly selected long-term sickness absentees (n=10 042) who in 2003
had an ongoing sick-leave spell that had lasted for six to eight months. Of these 5 802
answered the questionnaire. The survey was distributed during 2004, and different
aspects of the survey have already been reported [7-9]. In the present study we have
examined the respondents’ experiences using a questionnaire containing questions about
positive and negative encounters, what kinds of encounters they had been exposed to, and
how they reacted in terms of feeling respected or wronged. The response-options were
“yes” and “no” to the questions regarding whether or not they had experiences of positive
and negative encounters in healthcare. When asked about how the participants felt when
experiencing positive and negative encounters, there were several response options, such
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as: I felt respected/wronged, I was happy/disappointed, I felt satisfied/became angry, etc.
The participants were asked to respond whether or not they agreed/disagreed completely
or agreed/disagreed to a large extent. When presenting the results, those who agreed
completely or to a large extent were collapsed into one group (agree) and so were those
who disagreed completely or to a large extent (do not agree).
The patients were also asked to estimate how these encounters had affected their
ability to return to work, in terms of being impeded, not being influenced, or being
facilitated. Response options were not being influenced,being impeded, facilitated very
much, or impeded, facilitated to a certain extent. When presenting results, the latter
response-options were collapsed into those who were impeded or facilitated. In addition,
the respondents were asked if they were sick-listed for (a) psychiatric disorders, (b)
musculoskeletal pain, (c) other somatic diseases, or (d) more than one of the previous
categories. When presenting the results, we focus on respondents in a–c.
The results are presented as proportions (with 95% confidence intervals (CI)) of
those who estimated that return to work was facilitated, compared to those who stated
that return to work was not influenced or impeded, when experiencing positive
encounters/feeling respected, and of those who felt impeded, compared to those who
stated that return to work was not influenced or facilitated, when experiencing negative
encounters/feeling wronged. Focusing on the association between respectful/wrongful
encounters and return to work, we have performed logistic regression analysis adjusting
for different background variables such as sex, age, educational level, and different
diagnoses. Adjustment made, however, no substantial difference to the results.
Accordingly, we here present the crude proportions with a 95% CI.
The frequency and associations between positive encounters and feeling respected,
and negative encounters and feeling wronged, are presented as Attributable Risks (AR)
[10] with a 95% CI, using the R-package pARtial [11]. Since a majority of all encounters
concerned physicians (70%), we have replaced the wording “healthcare providers
including physiotherapists and midwifes” with “physicians” in the text.
The study was approved by the regional research ethics committee in Linköping
(Dnr 03-261).
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Results
The response rate was 58% (n=5 802) of the original sample. Of the participants who had
experienced positive encounters (n=3 406), 97.7% (CI: 97.2-98.2) stated that they also
felt respected. Among those who had experienced negative encounters (n=1 403), 70.8%
(CI: 68.4-73.2) declared they also felt wronged (Figure 1).
When comparing patients who had experienced negative encounters and felt
wronged with those who had experienced negative encounters but not felt wronged, we
found a significantly higher proportion of patients in the former category who reported
that they were impeded from returning to work [50% (CI: 47-53) versus 31% (CI: 27-35)]
(Table 1). When adding feeling wronged to negative encounters, the self-rated hindering
effect on return to work was highest among patients on sickness absence for ‘psychiatric
disorders’ [38% (29-37) as against 59% (CI: 54-64)] and lowest among those sick-listed
for ‘other somatic conditions’ [28% (19-37) as against 39% (CI: 32-47)] (Table 2).
The patients who stated that they had experienced positive encounters and felt
respected claimed to a significantly higher degree that return to work was facilitated by
the encounter, compared to those who experienced positive encounters but did not feel
respected [62% (CI: 60-64) versus 34% (CI: 28-40)] (Table 1). When adding feeling
respected to positive encounters, the self-rated facilitating effect on return to work was
highest among those sick-listed for ‘other somatic conditions’ [23% (5-41) as against
54% (51-58)] and lowest among patients sick-listed for ‘psychiatric disorders’ [53% (29-
77) as against 76% (74-79)] (Table 3).
There was no significant difference between women and men, but we noticed a
tendency for women who felt respected to reply more often that this had increased their
ability to return to work; [63% (CI: 61-64) for women as against 59% (CI: 56-61) for
men]. Men, on the other hand, tended to be more inclined to find themselves impeded
from returning to work if feeling wronged [55% (CI: 48-61) as against 49% (CI: 45-52)
for women].
Discussion
We found that patients on long-term sick leave experienced positive healthcare
encounters as facilitating return to work, while negative encounters impeded it. The
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facilitating effect of positive encounters was significantly augmented when combined
with the patient’s feeling respected, while return to work was significantly reduced if
negative encounters were combined with feeling wronged. Feeling respected had a
greater effect in relation to positive encounters regarding return to work than feeling
wronged had in relation to negative encounters (Table 1).
Encounters may affect return to work
Insofar as the respondents’ experiences fully or partly reflect their actual ability to return
to work, they identify a number of aspects of physician–patient interaction that have to be
handled properly in order to facilitate patients’ chances of returning to work. There is
much discussion on how to promote return to work among long-term sickness absentee
patients, focusing on different types of rehabilitation measures [3,5]. The present study
suggests that physicians and other healthcare staff may also have an impact on patients’
ability to return to work through the way in which they encounter patients. This tally with
the results of an interview study indicating that such encounters had as high an impact on
return to work as the rehabilitation measures [12].
Patients’ understanding of being respected and being wronged
It should be noted that the survey does not give any details about what the respondents
meant by feeling respected and feeling wronged. In medicine, respecting patients usually
relates to respecting their right to autonomous decision-making. Physicians are supposed
not only to respect patient autonomy but also to enhance it, for example, by support and
encouragement. Showing respect for patient autonomy might enhance patients’ self-
esteem and enable them to accomplish more [5]. It may thus facilitate their self-estimated
as well as their actual ability to return to work. In practice, showing respect for patient
autonomy might concern basic things like treating them as competent and showing a
genuine interest in what they say.
This is not to say that a list of basic components of reasonable behaviour towards
patients exhausts the meaning of treating them with respect. We found that something
was added when the patients felt not only that they had experiences of positive healthcare
encounters, but also that they felt respected, as was shown in their estimations of their
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ability to return to work. What this addition more specifically consists in cannot be learnt
from our questionnaire survey, but deserves to be further examined. For instance, people
might understand ‘being respected’ as being respected as a person more broadly and not
solely as having one’s autonomy respected.
Corresponding remarks can be made regarding negative encounters and feeling
wronged. Instead of empowering patients’ self-esteem, experiences of being wronged
might make patients impaired and decrease their ability to return to work. Thus,
disrespecting patients is not only regrettable as such, but might have negative
consequences for their wellbeing [13].
Feeling wronged is, however, not necessarily the same as actually being wronged,
and it might be debated whether patients sometimes provoke the doctor to act in a less
appropriate way [14-15]. Provoked or not, there may be situations where patients
perceive the doctor as intimidating, condescending, or patronising, while the physician
does not realise until afterwards that the encounter could be perceived that way [15].
We find it interesting that patients who were sickness absent due to psychiatric
disorders seemed to be more affected by feeling wronged in their encounters than those
with somatic disorders. Perhaps psychiatric patients are more sensitive to having their
autonomy questioned. But when feeling respected was added to the experience of
positive encounters, it had little influence on patients sick-listed for psychiatric disorders.
In this case, patients with ‘other somatic conditions’ were the most sensitive group. We
have no explanation for this inverse result.
Limitations
Since our data concern a special patient group, the results may not be generalisable to the
general patient population. Long-term sick listed patients may, for instance, have faced
greater disappointments in their healthcare contacts than many other patient groups. They
may also have had more experience of not being believed. However, regarding the effect
of positive encounters, our results are supported by other studies. One study points to a
reduction in sick-leave duration for patients suffering from tonsillitis [16], while another
study identifies improvements in HbA1c and LDL-cholesterol for patients suffering from
diabetes [17].
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Another limitation is that the study concerns patients’ self-estimations of the
influence of positive and negative healthcare encounters on their ability to return to work.
Such estimates may be difficult to make, and patients may over- or underestimate the
influence of these encounters. Further research is needed to establish the influence of
positive and negative healthcare encounters on the ability to return to work in real life.
A third limitation is the drop out, which, as is so often the case, is somewhat higher
among men and younger patients. Compared to other studies of sick people, the response
rate was high and the large number of subjects provides a solid base for conclusions.
Conclusion
Our study indicates that feeling respected in healthcare significantly facilitates long-term
sick-listed patients’ self-estimated ability to return to work, while feeling wronged
significantly impairs it.
Competing interest statement:
No support from any organisation for the submitted work; no financial relationships with
any organisations that might have an interest in the submitted work in the previous three
years [or describe if any], no other relationships or activities that could appear to have
influenced the submitted work
Exclusive licence:
The Corresponding Author has the right to grant on behalf of all authors and does grant
on behalf of all authors, an exclusive licence on a worldwide basis to the BMJ Publishing
Group Ltd and its Licensees to permit this article (if accepted) to be published in BMJ
editions and any other BMJPGL products and sublicences to exploit all subsidiary rights,
as set out in our licence.
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References
1. Löfgren A. Physician’s sickness certification practices [PhD thesis]. Stockholm:
Karolinska Institutet; 2010.
2. Lidwall U, Marklund S. Trends in long-term sickness absence in Sweden 1992-2008:
the role of economic conditions, legislation, demography, work environment, and alcohol
consumption. International Journal of Social Welfare 2011;2:167-79.
3. Waddell G, Burton K, Aylward M. Work and common health problems. J Insur Med
2007;39:109-20.
4. Alexanderson K, Norlund A. Swedish Council on Technology Assessment in Health
Care (SBU). Chapter 12. Future need for research. Scand J Pub Health 2004;32:256-8.
5. Svensson T, Müssener U, Alexanderson K. Pride, empowerment, and return to work:
on the significance of promoting positive social emotions among sickness absentees.
Work 2006;27:57-65.
6. Wessel M, Helgesson G, Olsson D, et al. Why do patients feel wronged? Empirical
study of sick-listed patients’ experiences of healthcare encounters. Submitted.
7. Mussener U, Svensson T, Söderberg E, et al. Encouraging encounters: Sick-Listed
Persons' Experiences of Interactions with Rehabilitation Professionals. Social work in
health care 2008;46:71-87.
8. Mussener U, Festin K, Upmark M, et al. Positive experiences of encounters with
healthcare and social insurance professionals among people on long-term sick leave. J
Rehabil Med 2008;40:805-11.
9. Upmark M, Borg K, Alexanderson K. Gender differences in experiencing negative
encounters with healthcare. A study of long-term sickness absentees. Scand J Pub Health
2007;35:577-84.
10. Lehnert-Batar A. pARtial: pARtial package, R package Version 0.1, 2006.
11. Benichou, J. A review of adjusted estimators of attributable risk. Stat Methods Med
Res 2001;10:195
12. Östlund G, Alexanderson K, Cedersund E, et al. “It was really nice to have someone”:
Lay people with musculoskeletal disorders request supportive relationships in
rehabilitation. Scand J Pub Health 2001;29:285-91.
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13. Tracey I. Getting the pain you expect: mechanisms of placebo, nocebo and
reappraisal effects in humans. Nature Medicine 2010;16:1277-83.
14. Swartling MS, Hagberg J, Alexanderson K, et al. Sick-listing as a psychosocial work
problem: a survey of 3997 Swedish physicians. J Occup Rehabil 2007;17:398-408.
15. Malterud K, Thesen J. When the helper humiliates the patient: a qualitative study
about unintended intimidations. Scand J Public Health 2008;36:92–8.
16. Olsson B, Olsson B, Tibblin G. Effect of patients’ expectations on recovery from
acute tonsillitis. Family Practice 1989;6:188-92.
17. Hojat M, Louis DZ, Markham FW, et al. Physicians’ Empathy and Clinical Outcomes
for Diabetic Patients. Academic Medicine 211;86:359-64.
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Table 1. The table shows the self-estimated effect, among long-term sick-listed patients,
of positive and negative healthcare encounters on return to work in relation to feeling/not
feeling respected and feeling/not feeling wronged. The results are presented as
proportions of those who were facilitated, not influenced, or impeded, with a 95%
confidence interval.
Return to work was:
Facilitated Not influenced Impeded
Positive encounters
Not feeling respected (n=79) 34% (28-40) 63% 3%
Feeling Respected (n=3327) 62% (60-64) 37% 1%
Negative encounters
Not feeling wronged (n=410) 8% 61% 31% (27-35)
Feeling wronged (n=993) 4% 46% 50% (47-53)
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Table 2. The table shows patients who have experienced negative healthcare encounters
and their self-estimated ability to return to work when feeling/not feeling wronged, in
relation to reason for sickness absence: (1) psychiatric disorders, (2) musculoskeletal
pain, or (3) other somatic disorders. The table shows the proportion of statements to the
effect that return to work was facilitated, not influenced, or impeded as the patients felt
wronged/not wronged in their healthcare encounters.
Return to work was:
Type of medical disorder Facilitated Not influenced Impeded
Psychiatric disorders
Not feeling wronged (n=104) 5% 57% 38% (29-37)
Feeling wronged (n=316) 4% 37% 59% (54-64)
Musculoskeletal disorders
Not feeling wronged (n=142) 7% 66% 27% (20-34)
Feeling wronged (n=302) 7% 49% 44% (38-49)
Other somatic disorders
Not feeling wronged (n=86) 5% 67% 28% (19-37)
Feeling wronged (n=161) 4% 57% 39% (32-47)
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Table 3. The table displays patients who have experienced positive healthcare encounters
and their self-estimated ability to return to work when feeling/not feeling respected, in
relation to reason for sickness absence: (1) psychiatric disorders, (2) musculoskeletal
pain, or (3) other somatic disorders. The table shows the proportion of statements to the
effect that return to work was facilitated, not influenced, or impeded as the patients felt
respected/not respected in their healthcare encounters.
Return to work was:
Type of medical disorder Facilitated Not influenced Impeded
Psychiatric disorders
Not feeling respected (n=17) 53% (29-77) 47% 0%
Feeling respected (n=931) 76% (74-79) 23% 1%
Musculoskeletal disorders
Not feeling respected (n=28) 28% (11-45) 68% 4%
Feeling respected (n=1018) 53% (50-56) 45% 2%
Other somatic disorders
Not feeling respected (n=22) 23% (5-41) 73% 4%
Feeling respected (n=798) 54% (51-58) 45% 1%
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Checklist of items of the present cross-sectional questionnaire-based study entitled Respectful encounters and return to work – empirical study of long-term sick-listed
patients’ experiences of Swedish healthcare - bmjopen-2011-000246.R1
STROBE 2007 (v4) checklist of items to be included in reports of observational studies in epidemiology*
Checklist for cohort, case-control, and cross-sectional studies (combined)
Section/Topic Item # Recommendation Reported on page #
(a) Indicate the study’s design with a commonly used term in the title or the abstract 1
Title and abstract 1
(b) Provide in the abstract an informative and balanced summary of what was done and what was found 1
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 2
Objectives 3 State specific objectives, including any pre-specified hypotheses 2
Methods
Study design 4 Present key elements of study design early in the paper 2-3
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data
collection
2-3
(a) Cohort study—Give the eligibility criteria, and the sources and methods of selection of participants. Describe
methods of follow-up
Case-control study—Give the eligibility criteria, and the sources and methods of case ascertainment and control
selection. Give the rationale for the choice of cases and controls
Cross-sectional study—Give the eligibility criteria, and the sources and methods of selection of participants
2
Participants 6
(b) Cohort study—For matched studies, give matching criteria and number of exposed and unexposed
Case-control study—For matched studies, give matching criteria and the number of controls per case
NA
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic
criteria, if applicable
2-3
Data sources/ measurement 8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe
comparability of assessment methods if there is more than one group
2-3
Bias 9 Describe any efforts to address potential sources of bias 2-3
Study size 10 Explain how the study size was arrived at 2
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen
and why
2-3
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(a) Describe all statistical methods, including those used to control for confounding 3
(b) Describe any methods used to examine subgroups and interactions 3
(c) Explain how missing data were addressed 3
(d) Cohort study—If applicable, explain how loss to follow-up was addressed
Case-control study—If applicable, explain how matching of cases and controls was addressed
Cross-sectional study—If applicable, describe analytical methods taking account of sampling strategy
3
Statistical methods 12
(e) Describe any sensitivity analyses NA
Results
Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,
confirmed eligible, included in the study, completing follow-up, and analysed
2-3
(b) Give reasons for non-participation at each stage 2-3
(c) Consider use of a flow diagram 10
Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and
potential confounders
2-3
(b) Indicate number of participants with missing data for each variable of interest 2-3
(c) Cohort study—Summarise follow-up time (eg, average and total amount) NA
Outcome data 15* Cohort study—Report numbers of outcome events or summary measures over time NA
Case-control study—Report numbers in each exposure category, or summary measures of exposure NA
Cross-sectional study—Report numbers of outcome events or summary measures 2-3
Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95%
confidence interval). Make clear which confounders were adjusted for and why they were included
2-3 + 11-13
(b) Report category boundaries when continuous variables were categorized NA
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period -
Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses 2-3
Discussion
Key results 18 Summarise key results with reference to study objectives 4-5
Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction
and magnitude of any potential bias
6-7
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results
from similar studies, and other relevant evidence
6-7
Generalisability 21 Discuss the generalisability (external validity) of the study results 6
Other information
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Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on
which the present article is based
NA
*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE
checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at
http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.
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77x61mm (300 x 300 DPI)
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