COU3204

KAUNSELING PERSONEL
ASSIGMENT INDIVIDU

NAMA NURAISHAH BINTI MOHAMAD ALI SABRI

NO MATRIK UK35248

PROGRAM SARJANA MUDA KAUNSELING

NAMA PENSYARAH DR. ZUHDA BT HUSAIN

SEMESTER SEMESTER 3

TARIKH HANTAR 4 NOVEMBER 2015

PENGENALAN

Kaunseling personel merupakan kaunseling di organisasi iaitu di tempat kerja.

Kaunseling personel merupakan proses perbincangan di antara kaunselor dengan
pekerja mengenai masalah yang dihadapi biasanya masalah yang berbentuk
emosional. Oleh itu kaunselor haruslah membantu pekerja (klien) faham dan dapat
menyelesaikan isu yang dihadapinya dengan berkesan. Kaunseling personel bertujuan
membantu pekerja membina kesihatan mental yang lebih baik supaya menjadi individu
yang yakin pada diri sendiri, berupaya mengawal diri, bekerja secara produktif dan
berkesan. Selain itu, kaunseling personel membantu memaksimumkan potensi setiap
pekerja supaya matlamat organisasi dapat dicapai dan mengekalkan prestasi pekerja
pada tahap optima. Kaunseling personal juga memberi penekanan kepada penjagaan
keselamatan, kesihatan dan kebajikan pekerja dengan menyediakan program-program
yang sesuai.

Definisi

Salah satu isu dalam organisasi yang harus ditangani oleh kaunselor adalah isu
ketidakhadiran pekerja iaitu pengambilan cuti sakit oleh pekerja. Kaunselor atau pihak
atasan organisasi harus memastikan sebab pekerja mengambil cuti sakit. Kaunselor
terutamanya, bertanggungjawab untuk membantu pekerja yang mengambil cuti sakit
terlalu kerap adakah pekerja berkenaan mengambil cuti sakit disebabkan benar-benar
sakit atau mengambil cuti disebabkan bebanan kerja.

Kaunselor harus mengambil tahu mengapa pekerja kerap mengambil cuti sakit, jika
pekerja berkenaan mengambil cuti disebabkan sakit yang semakin kronik atau masalah
kesihatan yang teruk, kaunselor harus membantu klien untuk mengatasi situasi
berkenaan dengan informasi yang sesuai dan sokongan untuk menghadapi situasi
berkenaan. Manakala pekerja yang mengambil cuti sakit untuk lari dari bebanan kerja
yang banyak, kaunselor harus membantu pekerja berkenaan untuk menghadapi
masalah berkenaan hingga pekerja berkenaan dapat mengawal keadaan dengan
melakukan tugas yang diberi dengan sempurna dan berkualiti tinggi.
ISI

Jurnal pertama yang berkaitan dengan ketidakhadiran pekerja disebabkan mengambil

cuti sakit bertajuk “ Reducing work related psychological ill health and sickness absence
: a systematic literature review”. Jurnal ini menyatakan kunci utama menyebabkan
pekerja mengambil cuti sakit adalah disebabkan oleh waktu kerja yang lama, berlebihan
bebanan kerja dan tekanan menyebabkan gangguan dalam diri pekerja seperti tidak
dapat menyiapkan kerja, tidak melibatkan diri dalam membuat keputusan dalam
organisasi, kurang sokongan sosial, dan kurang jelas mengenai peranan dalam
organisasi. Selain itu, terdapat juga beberapa bukti yang menyatakan pekerja
mengambil cuti sakit disebabkan oleh gaya pengurusan organisasi yang tidak mantap.

Dalam kajian yang dilakukan di United Kingdom melibatkan pekerja yang terlibat dalam
bidang kesihatan seperti doktor dan jururawat mengambil cuti sakit disebabkan oleh
waktu bekerja yang panjang, bebanan kerja yang banyak, tekanan kerja dan kurang
jelas dengan bidang tugas. Selain itu gangguan diluar waktu bertugas atas permintaan
pesakit dan kes kecemasan. Terdapat juga faktor seperti kurang penglibatan dalam
membuat keputusan serta tidak menggunakan kemahiran yang ada dalam diri pekerja
berkenaan dengan sepenuhnya. Selain faktor kekurangan sokongan sosial di tempat
kerja terutamanya dalam kalangan rakan setugas, terdapat juga kes buli dalam
organisasi terutamanya pihak pengurusan atasan kepada pekerja bawahan. Faktor-
faktor ini menyebabkan pekerja mengambil cuti sakit dalam kalangan pekerja dalam
bidang kesihatan.

Jika jurnal menyatakan mengenai pekerja yang berkerja dalam bidang kesihatan, jurnal
ini turut menceritakan pekerja dari bidang lain seperti dalam bidang bukan kesihatan
yang menghadapi situasi yang sama menyebabkan mereka mengambil cuti sakit untuk
lari seketika dari beban kerja. Oleh itu, organisasi melaksanakan program latihan pada
pekerja seperti melatih pekerja untuk melibatkan diri dengan penyelesaian masalah dan
membuat keputusan untuk organisasi selain diajar untuk menangani isu tekanan kerja.
Ini mendatangkan kesan positif kepada pekerja iaitu mampu untuk menangani beban
kerja dan lebih mudah untuk bekerjasama dengan rakan sekerja.
Apa yang ingin dinyatakan dalam jurnal ini secara ringkas adalah faktor utama
mengapa pekerja mengambil cuti sakit adalah disebabkan waktu kerja yang lama,
bebanan kerja yang banyak dan tekanan di tempat kerja hingga menyebabkan pekerja
berkenaan tidak dapat mengawal bebanan kerja yang berlebihan, tidak melibatkan diri
dalam membuat keputusan dalam organisasi. Oleh itu, organisasi telah melakukan
beberapa program yang berjaya menurunkan kadar pekerja mengambil cuti sakit
disebabkan bebanan ditempat kerja seperti latihan kemahiran, menggalakkan pekerja
terlibat dalam membuat keputusan dan memberi sokongan serta galakan dalam
melaksanakan kerja selain meningkatkan komunikasi yang baik antara pihak atasan
dan bawahan.

Jurnal kedua melibatkan pekerja mengambil cuti sakit disebabkan tekanan kerana
berasa tidak selamat dalam posisi pekerjaan kerana ada sebilangan organisasi yang
mengurangkan jumlah pekerja. Hal ini menimbulkan rasa tidak selamat dalam kalangan
pekerja, menyumbang kepada tekanan yang menyebabkan pekerja yang tidak dibuang
kerja akan mengambil cuti sakit kesan dari tekanan berasa tidak selamat berada dalam
organisasi berkenaan. Jurnal kedua ini bertajuk “Factors underlying the effect of
organizational downsizing on health of emmployees: longitudinal cohort study”. Kajian
dari jurnal ini mengkaji keberkaitan tekanan dalam kalangan pekerja disebabkan
organisasi mengecilkan jumlah pekerja dengan masalah kesihatan hingga
menyebabkan pekerja mengambil cuti sakit.

Dapatan dari jurnal ini menyatakan apabila organisasi mengecilkan jumlah pekerja
menyebabkan berlaku perubahan tugas dan pertambahan tugas kepada pekerja yang
tidak dibuang kerja. Ini menyebabkan komitmen pekerja terhadap tugasnya bertambah
selain berasa tidak terjamin kedudukannya dalam organisasi berkenaan menyebabkan
pekerja mengambil cuti sakit disebabkan pertambahan peranan dalam tugas, selain
peningkatan rasa tidak terjamin dalam organisasi berkenaan dan tidak dapat mengawal
bebanan tugas yang diberi oleh pihak atasan menyebabkan pekerja mengambil cuti
sakit untuk lari sebentar dari bebanan kerja yang dihadapi.
Ringkasan dari jurnal kedua adalah mengurangkan jumlah pekerja oleh organisasi
menyebabkan peningkatan beban pada pekerja dan rasa tidak terjamin dalam diri
pekerja meningkat. Selain itu, seperti jurnal yang pertama pekerja mengambil cuti sakit
adalah disebabkan oleh tidak melibatkan diri dalam membuat keputusan di organisasi
dan ingin melarikan diri dari sebentar dari bebanan kerja yang dihadapi.

Namun, bagi pekerja yang benar-benar sakit seperti sakit kronik hingga boleh
membawa maut dan memerlukan rawatan susulan , organisasi memberi gaji penuh
kepada pekerja berkenaan pada 60 hari pertama dan dua pertiga untuk 180 hari
kemudiaan. Pada pekerja yang sakit kronik yang mengambil cuti sakit lebih lama pihak
majikan akan membayar gaji kepada pekerja dan kemudiaannya pihak insuran akan
membayar balik kepada majian iaitu Social Insurance Institusion. Inilah yang dilakukan
oleh organisasi luar negara untuk membantu pekerjanya yang benar-benar mengambil
cuti sakit disebabkan oleh penyakit kronik.

Jurnal ketiga mengenai pekerja yang kembali semula bekerja setelah mengambil cuti
sakit yang lama seperti pekerja yang menghidap penyakit membawa maut. Judul jurnal
ialah “Return to work of cancer survivor : a prospective cohort study into the quality of
rehabitation by occupational physicians”. Jurnal ini melihat perkaitan kualiti pekerja
kembali kepada keadaan normal apabila kembali bekerja selepas cuti sakit.

Kualiti pekerja yang bercuti sakit disebabkan oleh sakit kronik boleh ditingkatkan secara
berperingkat terutamanya apabila mendapat rawatan susulan dengan baik. Apa yang
ingin disampai oleh jurnal berkenaan adalah kurangnya kajian mengenai pekerja yang
menghidap penyakit kronik seperti kanser. Selain itu, kualiti pekerja yang bercuti
disebabkan masalah kesihatan yang kronik boleh diukur menggunakan indikator
penilaian prestasi yang berbeza dari pekerja yang sihat tanpa masalah penyakit kronik.
Selain perlunya untuk mempunyai cara yang sesuai untuk membantu pekerja yang
kembali bekerja setelah berjuang melawan penyakit kanser.

Tuntasnya dalam jurnal ketiga ini pekerja yang kembali bekerja setelah berlawan
dengan penyakit seperti kanser boleh ditingkatkan kualiti kerjanya selain mencipta cara
dan penilaian yang sesuai bagi mengukur prestasi pekerja berkenaan.
KESIMPULAN

Sebagai kaunselor dalam organisasi, kaunselor memainkan peranan penting untuk

membantu mengatasi isu pekerja yang mengambil cuti sakit disebabkan oleh sakit
hingga boleh membawa maut atau mengambil cuti sakit akibat dari bebanan kerja.
Kaunselor membantu dari segi membuat program yang bersesuaian dengan pekerja
seperti program latihan untuk mengatasi tekanan kerja atau latihan menambah
kemahiran pekerja berkenaan. Manakala bagi pekerja yang mengambil cuti sakit
disebabkan oleh penyakit, kaunselor haruslah membantu dari segi memberi sokongan
dan perkongsian maklumat apa yang terbaik untuk pekerja berkenaan. Selain itu,
kaunselor harus berkongsi cara bagaimana untuk menghadapi situasi berkenaan tanpa
membuat sesuatu yang membahayakan diri pekerja berkenaan selain memberikan
motivasi agar pekerja berkenaan tidak putus asa dan harapan untuk meneruskan hidup.
Sememangnya peranan kaunselor adalah amat penting dalam organisasi bagi
membantu tenaga kerja tidak kira pihak atasan mahupun bawahan untuk menjadi lebih
produktif dan mampu memberikan prestasi mereka yang terbaik.
Factors underlying the effect of organisational
downsizing on health of employees:
longitudinal cohort study
BMJ 2000; 320 doi: http://dx.doi.org/10.1136/bmj.320.7240.971 (Published 08 April 2000) Cite
this as: BMJ 2000;320:971

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1. Mika Kivimäki, senior researcher (mika.kivimaki@occuphealth.fi)a,

2. Jussi Vahtera, senior researcherb,
3. Jaana Pentti, statisticianb,
4. Jane E Ferrie, senior research fellowc

Author affiliations

1. Correspondence to: M Kivimäki

 Accepted 7 December 1999

Abstract
Objective: To explore the underlying mechanisms between organisational downsizing and
deterioration of health of employees.

Design: Longitudinal cohort study. Data were assembled from before downsizing (time 1);
during major downsizing affecting some job categories (time 2); and after downsizing (time 3).
Contributions of changes in work, support, and health related behaviours between time 1 and
time 2 to the relation between downsizing and sickness absence attime 3 were assessed by
multilevel modelling. Mean length of follow up was 4.9 years.

Setting: Raisio, a town in Finland.

Subjects: 64 municipal employees who remained in employment after downsizing.

Main outcome measures: Records of absences from work from all causes with medical
certificate.
Results: Downsizing was associated with negative changes in work, impaired support from
spouse, and increased prevalence of smoking. Sickness absence rate from all causes was 2.17
(95% confidence interval 1.54 to 3.07) times higher after major downsizing than after minor
downsizing. Adjustment for changes in work (for instance, physical demands, job control, and
job insecurity) diminished the relation between downsizing and sickness absence by 49%.
Adjustments for impaired social support or increased smoking did not alter the relation between
downsizing and sickness absence. The findings were unaffected by sex and income.

Conclusions: The exploration of potential mediating factors provides new information about the
possible causal pathways linking organisational downsizing and health. Downsizing results in
changes in work, social relationships, and health related behaviours. The observed increase in
certificated sickness absence was partially explained by concomitant increases in physical
demands and job insecurity and a reduction in job control. A considerable proportion of the
increase, however, remained unexplained by the factors measured.

Introduction
Driven by alterations in the national and global economy, international competition, and the
rapid pace of technological change organisational downsizing (that is, reduction in numbers of
staff by businesses and other organisations) became an important aspect of working life in
developed countries in the last decades of the 20th century.1 Regardless of whether downsizing
is an effective business strategy resulting in better corporate performance, its potential
deleterious consequences on the health of employees have become apparent.2–4 Vahtera et al, for
example, reported that the health of those who kept their jobs depended on the extent to which
staffing levels were reduced in the category of job concerned.3 Medically certified long term
sickness absences, irrespective of cause, were twice as common after major downsizing (>18%)
than after minor downsizing (<8%).

Although the association between organisational downsizing and the health of employees has
been shown, much remains to be discovered about the mechanisms through which downsizing
affects health. Only indirect evidence has hitherto been available. This evidence comes, on the
one hand, from studies of the relation between downsizing and changes in factors related to
employees' working and private lives 5 6 and, on the other, from research into relations between
such factors and health outcomes.7–10 From results of the two groups of studies three
mechanisms that may link downsizing and health can be identified: firstly, alterations in
characteristics of work, increasing perceived job insecurity and job demands and decreasing job
control; secondly, adverse effects on social relationships—for example, reduction in social
support; and, thirdly, behaviour prejudicial to health—for example, smoking and excessive
alcohol consumption may become more prevalent.

We prospectively investigated associations between downsizing, changes related to work and

other aspects of life, and medically certified sickness absence from 1990 to 1995. The target
population was municipal staff in the town of Raisio in south western Finland. Unemployment
gradually declined in Finland in the 1980s, reaching its lowest level in 1990.11 At that time,
employees with permanent public sector contracts had come to expect their jobs to be safe.12
From 1991 to 1995, however, Finland faced its most severe economic decline since the first
world war. According to the International Labour Organisation/European Union definition,
unemployment rose from 3% in 1990 to 16% in 1993 and was still 15% in 1995.11 The number
of Finnish municipal employees fell by 12% from 1990 to 1993, after which it slightly increased.
At the same time, days worked in Raisio decreased by 15% from 1991 to 1993 and increased 4%
from 1993 to 1995.3 Downsizing was related to socioeconomic status, employees with low
income being most at risk.3 10

Methods
Participants and design

In 1990 we began a prospective cohort study to investigate the impact of the psychosocial work
environment on health. In total 1110 full time municipal employees (95% of a total staff of 1168
employees) in Raisio responded to the baseline survey. Of the respondents, 892 were still
working three years later at the time of follow up survey, and 812 of them (91%) responded to
the follow up.10 Another cohort, based on the employer's registers of contracted days worked for
at least six months in 1991 before major changes and for at least six months in 1993 when the
most extensive downsizing occurred, was established to study the effect of organisational
downsizing on health.3 Of this cohort, 764 (189 men, 575 women) belonged to the original
cohort and had completed the 1990 and 1993 questionnaires designed to allow assessment of
characteristics of work, social relationships, and health behaviours. They comprised the final
cohort of the present study: 29% were higher grade white collar workers (for example, managers,
physicians, teachers), 45% lower grade white collar workers (for example, technicians, registered
nurses, office workers), and 26% blue collar workers (for example, cleaners, maintenance
workers, kitchen assistants). The mean (range) age was 41.4 (20-62) years, and the average
organisational tenure was 11.5 (1-33) years. Data covered 936 person years of follow up for men
and 2800 person years of follow up for women. Approval from the ethics committee of the
Finnish Institute of Occupational Health was obtained for the study.

Data were assembled for three periods: before downsizing (1990-1); during major downsizing
affecting some job categories (1993); and when downsizing slowed down (1993-5).3 Data
relating to the first period consisted of questionnaire survey information from 1990 and records
on sickness absence from 1 January to 31 December 1991. Data for the second period consisted
of information obtained by questionnaire survey and information about the extent of downsizing
(for instance, reductions in contracted days worked in different job categories from 1991 to
1993). For the third period, data consisted of records relating to sickness absence from 1 January
1993 to 31 December 1995.

Measures

We noted the extent of downsizing for each job category, as in our earlier study.3 Information
obtainable from the employer's records for all periods included dates of commencement and,
when appropriate, termination of employment, job titles, places of work, and dates on which
each period of sickness absence began and ended. We calculated the number of contracted days
worked by subtracting days equivalent to number of days off work, irrespective of cause, from
total possible working days for each job category from 1 January to 31 December 1991 and from
1 January to 31 December 1993. Job categories were those used by Statistics Finland (32
occupational groups). Person years worked in 1991 and 1993 were calculated for each job
category. Percentage reductions in the number of contracted days worked from 1991 to 1993
were calculated for each job category as a measure of the extent of downsizing. The mean extent
of downsizing was 14.5%.

Changes in characteristics of work, social relationships, and health behaviours were assessed by
using the information obtained by questionnaire surveys in 1990 and 1993. Characteristics of
work were measured by internally consistent sets of questions relating to physical and
psychological demands of work13; skill discretion, authority to take decisions, and opportunities
to participate in decision making as elements in job control 10 13; and job insecurity (measured
only in 1993).10 Sets of questions on social relationships covered topics such as support from
supervisor, colleagues, and spouse.13 We also determined whether subjects smoked regularly
(yes or no), how much alcohol each consumed (g of alcohol per week), the level of physical
activity, and height and weight to assess body mass index.14 15 A detailed description of the
survey measures used is available in the studies cited.

Data on sick leave were collected from computer based records kept by the Raisio occupational
healthcare unit. They include data for each employee on when sick leave begins and ends. All
certificates relating to sick leave, irrespective of place of issue, must be forwarded for recording.
For periods of absence of up to three days employees may complete their own certificates. For
absences of more than three days medical certificates are required. This paper deals only with
medically certified absences. We grouped all periods of sickness absence that occurred before
downsizing (from 1 January to 31 December 1991) and all such periods that occurred after
downsizing (from 1 January 1993 to 31 December 1995). We checked records for
inconsistencies and combined any overlapping or consecutive periods of sickness absence.

Other variables included were sex, age, and income (median split for high versus low income;
medians were 126 000 and 114 000 Finnish markka (£12 764 and £11 548) per year for men and
women, respectively).

Statistical analyses

The first step of the analysis compared changes in characteristics of work, social relationships,
and health behaviours for employees who had experienced a minor downsizing (reduction of less
than 8% of the work force in a person's job category) with employees who had experienced
either intermediate downsizing (8-18% reduction) or a major downsizing (>18% reduction).
Such data cannot be analysed by comparing simple differences because the magnitude of the
change would depend on the level at baseline (that is, characteristics of work, social
relationships, and health behaviours before downsizing).4 An imbalance in the means (or
percentages) at baseline between employees facing minor, intermediate, or major downsizing
would result in the comparisons being biased. Thus for continuous variables differences after
downsizing were assessed by analysis of covariance with age, sex, and baseline level of the
variable of interest as covariates. For the dichotomous variable smoking, logistic regression was
used to compare employees who faced different degrees of downsizing in terms of odds ratios
and to adjust for age, sex, and the level of the variable of interest before downsizing. Because the
association between downsizing and health is linear, only linear trends between downsizing, on
one hand, and changes in characteristics of work, social relationships, and health behaviours, on
the other hand, were tested. Tests for linear trends were performed by modelling the group score
of downsizing (minor=1; intermediate=2; major=3) as one variable.16 To explore whether the
associations between downsizing and characteristics of work, social relationships, and health
behaviours were dependent on sex or income, we tested the interactions between downsizing,
sex, and income as suggested by Cohen and Cohen.17

Table 1.

Means (SE) of work characteristics, social support, and health habits after downsizing (adjusted
for their means before downsizing, age, and sex)

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We calculated number of long periods of sickness absence (more than three days) and person
years of follow up for each employee. Ratios of rates of sickness absence after minor,
intermediate, and major downsizing and corresponding 95% confidence intervals were
calculated. Poisson regression models were fitted to the data relating to number of sickness
absence spells.3 9 18 We used multilevel modelling, individual employees representing the first
level and work units (n=23) the second level, to adjust for the potential bias resulting from the
fact that employees' responses to questionnaires on work characteristics, social relationships, and
health behaviours could be affected by other employees in the same work unit.19 Such effects
violate the assumption of independent observations underlying the traditional Poisson modelling
strategy.

For analyses of the linking mechanisms between downsizing and sickness absence we selected
those characteristics of work, social relationships, and health behaviours that we found to change
according to the level of downsizing. In the first step, sickness absence after downsizing was
adjusted for sickness absence before downsizing, age, and sex (we did not adjust for income
because of its association with downsizing). Next, we assessed the contributions made by
changes in characteristics of work, social relationships, and health behaviours to the association
between downsizing and sickness absence by inclusion in the model of the level before and after
downsizing in characteristics of work, social relationships, and health behaviours. To study
whether the linking mechanisms were dependent on sex or socioeconomic status, men and
women and employees with high and low income were analysed separately.

For all statistical analyses we used the SAS program package complemented by the program
prompt GLIMMIX to carry out multilevel analyses for Poisson models calculated by using the
GENMOD procedure.

Results
Downsizing was associated with changes in work characteristics, social relationships, and health
behaviours (table 1). Major downsizing was associated with increased levels of physical work
demands and job insecurity and decreased levels of skill discretion and participation.
Downsizing was also associated with lowered levels of spouse support and increased prevalence
of regular smoking. There were only two differences between the sexes or income groups in
these linear trends. The effect of downsizing on participation was stronger among women (F
1,567 =5.48, P<0.05) than among men (F 1,185 =4.36, P<0.05) and its effect on physical
demands was stronger in employees with low income (F 1,431 =55.9, P<0.001) than in those
with high income (F 1,322 =9.6, P<0.01).

Sickness absence was more than two times greater after major downsizing than after minor
downsizing (table 2). We found a considerable attenuation in this rate ratio when changes in
work characteristics were taken into account, indicating their considerable role in the
downsizing-sickness absence relation. After adjustment for work characteristics in multilevel
models, the ratio of the rate of sickness absence after major downsizing compared with that after
minor downsizing decreased by 49% in the entire sample. The results were similar in men and
women and employees with high and low income (table 3).

Table 2.

Rate ratios (95% confidence interval) for sickness absence from all causes after downsizing
(adjusted for sickness absence before downsizing, age and sex, work characteristics, social
support, and health habits). In all cases the rate ratio for minor downsizing* (n=231) was 1.00

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Table 3.

Rate ratios (95% confidence interval) for sickness absence after downsizing by sex and
socioeconomic status (adjusted for sickness absence before downsizing, age and sex, work
characteristics, social support, and health habits). In all cases the rate ratio for minor downsizing
was 1.00

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Of the separate work characteristics, adjustments for increased physical demands, decreased
participation in decision making, reduction in skill discretion, and heightened job insecurity
attenuated the ratio of absence rates related to major versus minor downsizing by 28%, 19%,
12%, and 8%, respectively (table 4).

Table 4.

Rate ratios (95% confidence interval) for sickness absence for all causes after downsizing
(adjusted for sickness absence before downsizing, age and sex, and separate work
characteristics). In all cases the rate ratio for minor downsizing (n=231) was 1.00
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Adjustment for changes in social support and health behaviours did not significantly affect the
associations between downsizing and sickness absence (table 2 and table 3).

Discussion
The most powerful method for examining causal relations is to carry out a randomised
experiment. Such an experiment is, however, from the ethical and practical point of view,
impossible to perform when the effect of organisational downsizing on health is studied. In such
cases the strongest evidence derives from natural experiments in which causal inferences are
made on the basis of the time ordering of the variables and explicating the potential linking
mechanisms. Our longitudinal design, which allowed the same individuals to be followed from
before any rumour of downsizing and during and after it, provided a natural experiment that has
rarely been feasible. Although temporal succession is no evidence of causal relations, alternative
explanations for the present results cannot be supported by the evidence available.

Another methodological advance of the study was the measurement of downsizing from records
of actual days worked in each job category of the organisation. Such a measure has been shown
to be sensitive to variations across organisations as well as within organisations across types of
worker. Both these variations have relevance in predicting health.3

During the study period municipal employees received full pay for the first 60 days of sick leave
and two thirds for the next 180 days from the employer. For longer sick leaves, they received
benefits from the Social Insurance Institution. The institution also provided compensation to
employers for salaries paid to employees on sick leave after the first eight days. We used
medically certified sickness absences of more than three days as an indicator of health. On the
basis of the extensive Whitehall II studies, spells of sickness absences accurately reflect the
health of employees.22

Linkages between downsizing and health

Much of the effect of major downsizing on sickness absence was attributable to adverse changes
in work characteristics. Increases in physical demands and job insecurity and reductions in job
control, particularly in skill discretion and opportunities to participate in decision making, were
the most important ones. The largest proportion of the association between downsizing and
health was explained by the combination of these changes in work characteristics. Thus, the
findings show that multiple mechanisms rather than a single change in work may underlie the
adverse effect on health in employees after major downsizing. In previous research work
demands, job insecurity, and job control have been shown to be associated with sickness
absence, morbidity, and mortality.4 9 10 16 23 24

The manner in which major downsizing was undertaken in Raisio was typical of the public
sector in Finland and other countries. The workforce had to be reduced in response to national
economic decline to contain costs. Staff numbers were reduced partly through retirement and
partly through not filling vacancies. Savings were also gained by not hiring cover for those
absent from work. Only employees without permanent contracts of employment lost jobs.
Reactive implementation of downsizing is common in public organisations,6 and the effects on
health of such a downsizing are probably less than would occur when downsizing also affects
those with permanentcontracts. This potential underestimate of effects, particularly in relation to
job insecurity, needs to be borne in mind when the implications of these findings are
considered.2

Conclusions

The present data on health, characteristics of work, social relationships, and health behaviours
before and after downsizing extend existing knowledge on the potential pathways through which
downsizing may affect health.

It is likely that downsizing and other threats to job security will continue to be an important trend
within industrialised countries for the foreseeable future.1 We show that records of contracted
days worked allow identification of the degree of downsizing in each job category and thus
indicate employees at greatest risk of health impairments. The threat of job loss generated by
downsizing resulted in increased morbidity. This increase was not only mediated through job
insecurity, which is the expected correlate of threatened job loss, but also through changes in
other psychosocial work characteristics.

What is already known on this topic

There is an association between organisational downsizing and the health of employees

Until now evidence about the mechanisms through which downsizingaffects health has been
lacking

What this study adds

The threat of job loss generated by downsizing results in increased morbidity

This increase seems to be mediated not only through job insecurity but also through increased
job demands and lowered job control

Acknowledgments
We thank Dr Marja Lampio from the occupational health care unit in Raisio for her help in
collecting the data on sickness absences and Mr Pertti Keskivaara for his help in multilevel data
analysis.

Contributors: MK was the principal investigator and together with JV designed and conducted
the study and wrote the paper. JP developed the downsizing measure and helped in data analysis.
JEF contributed to the analyses and interpretation of data and writing of the paper.
Footnotes
 Conflict interests None declared.
 Funding Academy of Finland (project No 44968) and the Emil Aaltonen Foundation for
MK and the Finnish Work Environment Fund for JV.

References
1. 1.↵
1. Hurrell JJ

. Editorial. Am J Pub Health 1998; 88: 1012–1013.

MedlineWeb of Science

2. 2.↵
1. Beale N,
2. Nethercott S

. Certificated sickness absence in industrial employees threatened with redundancy. BMJ

1988; 296: 1508–1510.

3. 3.↵
1. Vahtera J,
2. Kivimäki M,
3. Pentti J

. Effect of organisational downsizing on health of employees. Lancet 1997; 350: 1124–

1128.

CrossRefMedlineWeb of Science

4. 4.↵
1. Ferrie JE,
2. Shipley MJ,
3. Marmot MG,
4. Stansfeld SA,
5. Smith GD

. An uncertain future: the health effects of threats to employment security in white-collar

men and women. Am J Pub Health 1998; 88: 1030–1036.

MedlineWeb of Science
Reducing work related psychological ill
health and sickness absence: a systematic
literature review
1. S Michie1,
2. S Williams2

+ Author Affiliations
1
1. Reader in Clinical Health Psychology, Centre for Outcomes Research and Effectiveness,
Department of Psychology, University College London, Gower Street, London WC1E
6BT, UK
2. 2Consultant in Occupational Medicine, Royal Free Hampstead NHS Trust, London NW3
2QG, UK

1. Dr S Michie, Reader in Clinical Health Psychology, Centre for Outcomes Research and
Effectiveness, Department of Psychology, University College London, Gower Street,
London WC1E 6BT, UK; s.michie@ucl.ac.uk

 Accepted 14 May 2002

Abstract
A literature review revealed the following: key work factors associated with psychological ill
health and sickness absence in staff were long hours worked, work overload and pressure, and
the effects of these on personal lives; lack of control over work; lack of participation in decision
making; poor social support; and unclear management and work role. There was some evidence
that sickness absence was associated with poor management style. Successful interventions that
improved psychological health and levels of sickness absence used training and organisational
approaches to increase participation in decision making and problem solving, increase support
and feedback, and improve communication. It is concluded that many of the work related
variables associated with high levels of psychological ill health are potentially amenable to
change. This is shown in intervention studies that have successfully improved psychological
health and reduced sickness absence.

L evels of ill health, both physical and psycho logical, and associated sickness absence are high
among those working in health care in the UK.1,2 This problem is not unique to the UK.3 Poor
psychological health and sickness absence are likely to lead to problems for patients in that both
the quantity and quality of patient care may be diminished. Because most health care is provided
by staff working in teams, ill health and sickness absence in any one individual is likely to cause
increased work and stress for other staff.
Several explanations have been put forward for this high level of ill health, including the nature
of the work, organisational changes, and the large amounts and pressure of work.4 A comparison
across UK hospitals in the public sector found that rates of psychological ill health varied from
17% to 33%, with lower rates in hospitals characterised by smaller size, greater cooperation,
better communication, more performance monitoring, a stronger emphasis on training, and
allowing staff more control and flexibility in their work.5 This supports the notion that
organisational factors may contribute to the level of psychological ill health experienced by staff.

To tackle the problem of work related psychological ill health, evidence is needed about the
work factors associated with psychological ill health and sickness absence, and about
interventions that have been implemented successfully to prevent or reduce psychological ill
health and sickness absence. The primary focus of this review is the association between work
factors and psychological ill health among health care staff. However, because of the paucity of
evidence in health care,1 evidence was reviewed across all work settings, although presented
separately for health care workers where appropriate.

METHODS
Our review method was based on that used by the NHS Centre for Reviews and Dissemination.6
This method involves a systematic examination of selected databases using a variety of
strategies, including keywords and subject headings. It allows the integration of quantitative data
across studies, where they have similar outcome measures, and the summary of findings where
methods used are diverse.

Identification of papers

Four electronic databases were used: Medline (1987–99), PsychInfo (1987–99), Embase (1991–
99), and the Cochrane Controlled Trials Register (1987–99). Relevant papers up to and including
1997 were selected from a larger study.1 The search strategy in the larger study was of MeSH
key words and text words in each of three categories: work factors; staff; and ill
health/absenteeism/economic consequences. The search included all types of employment and all
developed countries but was limited to abstracts in English. Secondary references were chosen
from the primary paper references and by contacting academics researching this area.
Psychological ill health included measures of anxiety, depression, emotional exhaustion, and
psychological distress (“stress” was excluded since it is a mediating hypothetical construct rather
than an outcome measure of psychological ill health). For the purpose of this review, papers
from 1998 and 1999 were identified using the same search strategy, but excluding physical ill
health and economic consequences.

Selection criteria

Abstracts were selected for retrieval of the paper if they were judged to include data about both
work factors and psychological ill health or absenteeism. Dissertations were excluded, as were
studies of very specific staff groups or settings, work patterns (for example, shift working), or
events (for example, violence). All abstracts were selected independently by two researchers
(three researchers were involved in this activity). The percentage of abstracts for which two
researchers agreed about inclusion and exclusion varied between 80% and 90%. Disagreements
were resolved by discussion.

Information extraction

Information from papers was extracted and coded within the following categories: study aim,
study design, type of study population (for example, occupational group), sampling strategy,
sample size and response rate, demographic characteristics, type of intervention, type of study
measure, main outcomes, and summary of results.

Further selection criteria

Coded papers excluded from the review were studies with: volunteer or inadequately described
sample; response rate of less than 60%; no standardised measures of psychological outcome.

RESULTS
Of the studies identified as part of the larger study,1 40 were selected for this study (34
associations and six interventions). A further nine studies meeting the above selection criteria
were identified in the period 1998–99, all of associations. No studies were found in the Cochrane
Controlled Trials Register. The results are summarised in tables 1–4.

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Table 1

Summary of observational studies of associations between work factors and ill health: health
care workers in UK

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Table 2

Summary of observational studies of associations between work factors and ill health: health
care workers in developed countries beyond the UK

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Table 3

Summary of observational studies of associations between work factors and ill health: non-health
care workers

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Table 4

Summary of studies of interventions

Because these studies were diverse in terms of outcomes and measures used to assess these
outcomes, a meta-analysis was not appropriate.

Associations with work

The results are presented in three groups: health care workers in the UK, health care workers in
other developed countries, and non-health care workers. This enabled an assessment of whether
associations between work factors and psychological ill health are similar across sector and
country.

Health care

In the UK, factors associated with psychological ill health in doctors, from junior to senior
grades, are long hours worked,9 high workload and pressure of work,7,16,11 and lack of role
clarity12 (table 1). Pressure of work has also been found to be associated with poor mental health
in dentists.10 In family doctors, the issues were interruptions during and outside surgery hours
and patient demands.16

Among UK nurses, the most frequently reported source of psychological ill health was workload
pressures.17 Distress in student nurses has been caused by low involvement in decision making
and use of skills, and low social support at work.13 In a study of health care workers across job
type, bullying was found to be prevalent, carried out mainly by managers and associated with
both anxiety and depression.14 Of the two studies addressing sickness absence, one found a
negative association with job demands,13 while the other found no association with control over
work.15

Similar factors are associated with psychological ill health in health care workers in the rest of
Europe, the USA, and Australia (table 2). The one study of doctors found an association between
work control and social support and psychological distress.22 Among nurses, lack of co-worker
support,24,27 job influence,26 and organisational climate and role ambiguity28 were associated with
psychological distress. Among other hospital workers, work overload and pressure, role
ambiguity, lack of control over work, and lack of participation in decision making were all found
to be associated with distress.18,20,25

Sickness absence was associated with work pressures and lack of training,23 unsupportive
management style,21 role ambiguity, tolerance of absenteeism, and low pay.19

Beyond health care

The picture among non-health care workers in Europe and the USA was similar to that of health
care workers (table 3). The key work factors associated with psychological ill health were: work
overload and pressure31,34,36,39–40,41,47,48; conflicting demands47; lack of control over work and lack
of participation in decision making34,36,37,39,40,46–48; poor social support at work31,33,35,38,39,41,47,48;
unclear management and work role29,30,41,34,38; interpersonal conflict42,46; and conflict between
work and family demands.46 Long hours were found to be associated with depression in women,
but not in men.44

Sickness absence was negatively associated with high job demand,45 and positively associated
with monotonous work, not learning new skills and low control over work,36,37,45 and non-
participation at work.43

Evaluated interventions

Six intervention studies met our methodological criteria (table 4). Three were randomised
controlled trials,49,50,52 three were conducted in the USA,50,51,54 one in the UK,53 and two in
Scandinavia.49,52 Three were of health care workers.50,52,54 Five were training programmes offered
as part of the working day and one was an organisational intervention.53

Skills to mobilise support at work and to participate in problem solving and decision making
were taught to care staff of people with mental ill health or mental disability in a randomised
controlled trial.50 Groups of 20 had six sessions of 4–5 hours training over two months, and were
trained to train those in their workplace. Compared to those in the control group, the intervention
group reported more supportive feedback, more ability to cope, and better work team functioning
and climate. Among those most at risk of leaving, those undergoing the training reported reduced
depression. The second randomised controlled trial compared receiving support, advice, and
feedback from a psychologist with having the passive presence of the same psychologist at staff
meetings in a geriatric hospital facing organisational change.52 Staff were taught skills of stress
management, and how to participate in, and control, their work. The intervention was an hour a
fortnight during the 10 weeks before, and the 10 weeks after, the organisational change. There
was a significant difference between groups, with a decrease of stress hormone levels in the
intervention group.

Staff of a psychiatric hospital were taught verbal and non-verbal communication and empathy
skills.54 Groups of 6–8 had eight hour weekly sessions for four weeks involving information,
videos, modelling, and role playing. Compared to a matched control group, the intervention
group showed reduced staff resignations and sick leave, although no statistical tests are reported.
Among physically inactive employees of an insurance company, a randomised controlled trial
found stress management training and aerobic exercise interventions had mixed effects.49 After
three sessions a week for 10 weeks, stress management training resulted in improved perceived
coping ability but no change in physical or psychological health. Aerobic exercise resulted in
improved feelings of wellbeing and decreased complaints of muscle pain.

Employees of a fire department underwent one of seven training programmes emphasising one
or more aspect of stress management: physiological processes, coping with people, or
interpersonal awareness processes.51 Weekly sessions for 8–10 people were run over 42 weeks.
There was no control group. Compared to baseline, there were reductions in depression, anxiety,
psychological strain, and emotional exhaustion immediately after the programme. There was a
further reduction in psychological strain and emotional exhaustion at 9–16 months follow up.

A structural intervention for local authority staff on long term sickness absence was effective in
reducing sickness absence. Referral to occupational health services was triggered after two or
three months absence, rather than at six months which was the practice before the intervention.
The average duration of sickness absence reduced from 40 to 25 weeks before resumption of
work and from 72 to 53 weeks for those staff who left employment for medical reasons. The
authors describe large financial savings but no statistical tests are reported.53

DISCUSSION
This systematic review of a large number of studies covers a wide range of employment sectors
in the developed world and summarises those studies that use rigorous methods. The studies
show that, while levels of psychological ill health are higher in health care than in non-health
care workers,5 the associations between work factors and psychological ill health are similar.
They are also similar across continents. This suggests that a generic approach to reducing work
related psychological ill health may be appropriate.

The most common work factors associated with psychological ill health were work demand
(long hours, workload, and pressure), lack of control over work, and poor support from
managers. These were also associated with sickness absence. The findings of this review,
summarised in tables 1–4, are consistent with the demand-control model of job strain.36
Interventions aimed at changing these workplace factors reduced psychological ill health.

Main messages

 Key work factors associated with psychological ill health and sickness absence in staff
are long hours worked, work overload and pressure, and the effects of these on personal
lives; lack of control over work; lack of participation in decision making; poor social
support; and unclear management and work role.
 There is some evidence that sickness absence is associated with poor management style.
 Successful interventions that improve psychological health and levels of sickness absence
use training and organisational approaches to increase participation in decision making
and problem solving, increase support and feedback, and improve communication.
This review highlights limitations in the research identified. The studies that have been carried
out are limited in the questions addressed and in the study designs used. Since most studies are
cross sectional, causal relations cannot be shown. It may be that the associations found reflect a
tendency for more vulnerable people to choose work in caring roles or other types of job which
are well represented in published research studies. The question of what aspects of work lead to
ill health and sickness absence can only be addressed by longitudinal studies that are able to
investigate the causal relations between work factors and health outcomes and by randomised
controlled trials of interventions. A longitudinal study that directly addressed the nature of the
relation found a causal relation between psychological stress and psychosomatic complaints.55

There are several practical implications suggested by the studies of association in this review, for
both employment practices and management style. Intervention studies, however, have focused
mainly on staff training. There is a need for future studies to evaluate interventions based on
employment practices and management style. This would represent primary prevention, reducing
sources of psychological ill health, rather than secondary prevention, training individuals who
are already experiencing work related stress, to be more robust in the face of such pressures.
Only one of the intervention studies included an economic evaluation: such evaluations are
important in facilitating employers to make decisions about whether or not to implement
interventions.

Policy implications

 Many of the work related variables associated with high levels of psychological ill health
are potentially amenable to change.
 More evaluations of interventions are required, based on randomised or longitudinal
research designs.
 Interventions for which evidence of effectiveness exists should be piloted and evaluated
across different work settings.

Future research should adhere to minimum scientific standards absent in many of the studies
reviewed, such as adequate design, sufficiently large samples, and valid outcome measures.
Lessons that are learnt from rigorously evaluated interventions can then be applied more
generally.

Acknowledgments
We are grateful to Shriti Pattani for help with literature searching and to Frédérique Cooper for
help with preparing this manuscript.

REFERENCES
1. ↵

Williams S, Michie S, Pattani S. Improving the health of the NHS workforce. London:
The Nuffield Trust, 1998.
 2. ↵

Confederation of British Industry. Managing absence: in sickness and in health.

London: CBI, 1997.

3. ↵

Whitley TW, Allison Jr EJ, Gallery ME, et al. Work related stress and depression among
practicing emergency physicians: an international study. Ann Emerg Med1994;23:1068–
71.

[Medline][Web of Science]

4. ↵

Cox T, Griffiths A. The nature and measurement of work stress: theory and practice. In:
Wilson, JR, Corlett E, Nigel E, et al, eds. Evaluation of human work: a practical
ergonomics methodology, 2nd edn. London: Taylor & Francis, 1995:783–803.

5. ↵

Wall TD, Bolden RI, Borrill CS, et al. Minor psychiatric disorder in NHS trust staff:
occupational and gender differences. Br J Psychiatry1997;171:519–23.

[Abstract/FREE Full text]

6. ↵

University of York. Understanding systematic reviews of research on effectiveness.

CDR report 4. York: NHS Centre for Reviews and Dissemination, 1996.

7. ↵

Agius RM, Blenkin H, Deary IJ, et al. Survey of perceived stress and work demands of
consultant doctors. Occup Environ Med1996;53:217–24.

[Abstract/FREE Full text]

8. ↵

Baglioni Jr AJ, Cooper CL, Hingley P. Job stress, mental health and job satisfaction
among UK senior nurses. Stress Medicine1990;6:9–20.

Occup Environ Med 2003;60:352-357 doi:10.1136/oem.60.5.352

 Original article
Return to work of cancer survivors: a
prospective cohort study into the quality of
rehabilitation by occupational physicians
1. J Verbeek1,
2. E Spelten1,
3. M Kammeijer1,
4. M Sprangers2

+ Author Affiliations
1
1. Coronel Institute for Occupational and Environmental Health, Academic Medical
Center, Division of Public Health, University of Amsterdam, Netherlands
2. 2Department of Medical Psychology, Academic Medical Center, University of
Amsterdam

1. Correspondence to: Dr J H A M Verbeek, Coronel Institute for Occupational and

Environmental Health, Academic Medical Center, Division of Public Health, University
of Amsterdam, PO Box 22700, 1100 DE Amsterdam, Netherlands;
j.h.verbeek@amc.uva.nl

 Accepted 17 September 2002

Abstract
Aims: To describe and assess the quality of rehabilitation of cancer survivors by occupational
physicians and to relate the quality of the process of occupational rehabilitation to the outcome
of return to work.

Methods: One hundred occupational physicians of a cohort of cancer survivors were interviewed
about return to work management. Quality of rehabilitation was assessed by means of four
indicators that related to performance in knowledge of cancer and treatment, continuity of care,
patients complaints, and relations at work. The cohort of patients was prospectively followed for
12 months to assess time to return to work and rate of return to work. Patients’ and physicians’
satisfaction with care was also assessed. The relation between performance and these outcome
measures was studied in a multivariate analysis, taking into account the influence of other work
and disease related factors that could potentially predict return to work.

Results: For knowledge of cancer and treatment, only 3% had optimal performance because
occupational physicians did not communicate with treating physicians. For continuity of care,
patient complaints, and relations at work, performance was optimal for 55%, 78%, and 60% of
the physicians respectively. After adjustment for other prognostic factors, overall physician’s
performance (hazard ratio (HR) 0.5, 95% CI 0.3 to 0.8) and continuity of care (HR 0.5, 95% CI
0.3 to 0.9) were related to the return to work of patients. Overall optimal performance was also
related to a small but significant higher level of satisfaction with care, both for patients and
physicians.

Conclusion: Quality of occupational rehabilitation of cancer survivors can be improved

substantially, especially with regard to communication between physicians and continuity of
care. There is a need for the development of more effective rehabilitation procedures which
should be evaluated in a randomised controlled trial.

The number of patients that survive cancer has increased substantially in recent decades.
However, many cancer survivors experience problems in returning to everyday life. Work
resumption is one of these problems, with a return to work rate that varies among studies from
44% to 100%.1 In the literature, many factors are examined that were found to impede work
resumption. Such factors are disease related, such as a burdening treatment or advanced disease
stage; person related, such as fatigue, pain, or concentration problems; and work related, such as
physical demands at work or difficult relationships with colleagues and superiors. To overcome
these problems a number of solutions have been suggested, including gradual return to work,
increase of autonomy on the job, decrease of workload, and communication between
occupational physicians and attending physicians.2,3

Main messages

 There is a lack of research on return to work of cancer survivors.

 Physicians should pay more attention to work resumption after treatment is finished in
cancer patients.
 Quality of care of return to work management of cancer survivors can be measured by
means of performance indicators.
 Quality of vocational rehabilitation of cancer survivors by occupational physicians can be
improved, especially with respect to the knowledge of the occupational physician of
cancer and cancer treatment and better continuity of care.
 There is a need for more effective interventions in return to work management of cancer
survivors.

It is one of the main tasks of occupational physicians to facilitate return to work by means of
rehabilitation procedures.4,5 Usually rehabilitation encompasses all kinds of activities that
facilitate return to work. In some countries, such as the UK and the Netherlands, associations of
occupational physicians have constructed guidelines for the management of return to work by
occupational physicians for specific disorders.6–8 From these guidelines it is possible to derive
indicators for quality of rehabilitation. A procedure for the assessment of quality of rehabilitation
of workers with back pain and the construction of performance indicators for occupational
physicians has been described in detail.9 In the study where this procedure was used, a better
quality of care was associated with a shorter period of sick leave and a higher satisfaction rating
of patients.10 Similar quality assessments are made in other sectors of health care.11,12

Policy implications
  Physicians should pay more attention to return to work in cancer survivors.
 There is a need for more effective vocational rehabilitation procedures in cancer patients.
 Occupational physicians should improve the quality of their care for cancer survivors by
better communication and continuity of care.

Based on these experiences we were interested in the management of return to work of cancer
survivors by occupational physicians. We assumed that general principles of occupational
rehabilitation would apply to rehabilitation of cancer survivors and that interventions would be
needed to overcome the most frequently mentioned problems of work resumption. This enabled
us to make an instrument for assessment of the quality of occupational rehabilitation. As part of a
study on factors affecting return to work among cancer survivors, we were able to interview
occupational physicians about the quality of their work. We hypothesised that better quality
would lead to a shorter time to return to work and a higher patient and physician satisfaction.

Therefore, the aims of the present study are: (1) to describe the activities of occupational
physicians in relation to return to work of cancer survivors and to assess the quality of these
activities by means of performance indicators; and (2) to assess the relation between the quality
of rehabilitation on the one hand, and return to work and patient and physician satisfaction on the
other hand.

PHYSICIANS, PATIENTS, AND METHODS

Starting from earlier experiences with quality of care we assumed that a study of 100
occupational physicians and their patients would have sufficient power to detect relevant
differences in return to work.10 Patients who entered a cohort study on the prediction of return to
work of cancer survivors were asked for permission to contact their occupational physician. The
patients were interviewed and completed a first questionnaire to assess prognostic factors; they
were followed for 12 months to enable the assessment of return to work measures. For further
details, see paragraph on patients and measures. The occupational physicians of these patients
were interviewed by telephone six months after patients completed the first questionnaire to
enable the assessment of the quality of rehabilitation.

Occupational physicians and procedure

From the 120 physicians who were named by their patients, one did not consent to participate,
four physicians could not be reached after the maximum of 10 telephone calls, and 15 were
already named by another patient. This resulted in the participation of 100 occupational
physicians. The physicians were asked to report on the management of their patient using a
structured questionnaire which was sent to them in advance. During the telephone interview they
were asked to keep the medical files of the patient at hand. The data from the interview were
used to calculate the following performance indicators for the quality of occupational
rehabilitation.

Performance indicators
Based on general principles of occupational rehabilitation and literature on return to work of
cancer survivors, we designated the following four aspects as essential in the management of
return to work of cancer patients:

 Medical knowledge of the disease process and treatment of the patient

 Continuity of care
 Interventions for cancer related complaints, such as fatigue
 Interventions to improve relations at work.1,9,13,14

We called these aspects performance indicators. For each performance indicator we formulated
criteria which had to be met in case of optimal quality of care. If one or more of the criteria were
not met, in case of deviant performance, the case was assigned a 0 score for that performance
indicator. If all criteria were met in case of optimal performance, the resulting score for a
performance indicator was 1 for that case. Scores of all cases were added to a percentage optimal
performance for each indicator. The criteria are based on an if–then logic: if a problem is present,
then the occupational physician must intervene to help it being solved. Details of the structure of
each performance indicator are given in the appendix.

All performance indicators were formulated before the data collection started. Both the
interviews and calculations of the scores were done blindly—that is, without knowledge of the
outcome in the patients.

Satisfaction with care

Physicians’ satisfaction with care was measured by 13 items derived from a longer questionnaire
used in previous research to measure patient satisfaction with care by the occupational
physician.10 The questionnaire was reworded to fit the physicians’ perspective. We rephrased
questions such as “the occupational physician treated me in a very friendly manner” for the
patients into “I treated this worker in a very friendly manner” for the occupational physicians.
Cronbach’s alpha for the questionnaire was 0.77. A total score was calculated by summarising
the items and transforming them to a scale between 0 and 100. A higher score indicates a higher
satisfaction rating.

Physicians’ opinions

In addition we asked the occupational physicians for their opinion on the importance of
rehabilitation of workers on sick leave (five point scale), sickness certification (five point scale),
and rehabilitation of cancer survivors (yes/no).

Patients and measures

The patients had to have a reasonable chance of return to work. This implies that they had to
have a favourable prognosis and that follow up should not be too soon after diagnosis because
extensive treatment will in many cases prevent a rapid return to work. Therefore, patients had to
meet the following inclusion criteria: a primary diagnosis of cancer, 4–6 months since reporting
sick, paid work at the time of diagnosis, an expected survival of at least one year or treatment
with curative intent, capable of completing a questionnaire in Dutch, and not older than 55 years
of age. Patients were asked for participation by their attending physicians from the following
departments of the Academic Medical Center: surgery, gynaecology, haematology, oncology,
radiotherapy, and urology. At baseline, patients were interviewed at home or at any location of
their preference. During the interview a questionnaire was completed, which consisted of
questions about factors potentially predictive of return to work, return to work measures, and
satisfaction with occupational physicians’ care. The following potentially predictive factors were
measured by means of validated questionnaires wherever possible (questionnaire mentioned
between brackets):

 Sociodemographic and person related factors: age, gender, marital status, breadwinner
status, working partner, children at home, education, self efficacy.15
 Disease and treatment related complaints: diagnosis, treatment type (operation,
chemotherapy, radiation), co-morbidity, depression (CESD), pain, psychological
complaints (RSCL), physical complaints (RSCL), activity restrictions (RSCL), fatigue in
general, mental related, motor related, activity related, body related (MFI), sleep (PSQI),
cognitive failures (CFQ).16–20
 Work and working conditions: discomfort by physical factors, irregular shifts, relation
with superiors (VBBA), relation with co-workers (VBBA), autonomy (VBBA), variation
(VBBA), physical load (VBBA), emotional burden (VBBA), work pressure (VBBA).21

At follow up, 6 and 12 months later, patients were asked to fill in a mailed questionnaire about
return to work measures and satisfaction with occupational physician care.

Return to work measures

For return to work we used both the rate of return to work and time to return to work. Rate of
return to work was defined as the number of patients at latest follow up answering “no” to the
question “Are you still on sick leave?”, divided by the total number of patients. Time to return to
work was calculated as the number of days on sick leave between the moment of reporting sick
and the moment of any kind of work resumption.

Patient satisfaction with occupational rehabilitation

With the same 13 item questionnaire as was used for the physicians, we assessed patient
satisfaction with care by the occupational physician. Items referred to communication, manner,
independence of the occupational physician, and satisfaction with outcome.10,22 Cronbach’s alpha
was 0.94. Patients were asked at baseline and at follow up about their satisfaction with the
occupational physician. We used the satisfaction score from the last moment of follow up.

Statistical analysis

First, we described activities performed by the physicians. Next we calculated percentages of

optimal performance for each of the four single performance indicators. A sum score of all
performance indicators was calculated. We dichotomised this sum score into overall optimal
performance, if performance for all indicators was optimal, and overall deviant performance, if
performance was deviant for one or more indicators.

To assess a bivariate relation between performance and time to return to work, Kaplan-Meier
curves were estimated and differences were tested with the log rank test. Next, we assessed the
bivariate relation between other potential prognostic variables and return to work with the same
method at a significance level of p < 0.10. From the list of other prognostic factors we selected
factors to be included in the multivariate regression model of performance and prognostic factors
on time to return to work. To this end we used Cox’s proportional hazards analysis for survival
data.

To assess the bivariate relation between performance and other prognostic factors with the rate of
return to work we used the χ2 test. We used logistic regression analysis to adjust for the influence
of other prognostic factors.

To assess a relation between performance and satisfaction, the t test was used; if data were not
distributed normally, the Mann-Whitney U test was used. If confounders were present, linear
regression analysis was used to adjust the results.

RESULTS
Occupational physician performance

In nine cases the occupational physician had not seen the patient at all. In four of these cases
there was information in the patient file on the diagnosis obtained through the work organisation.
If no information was available, performance was scored as deviant. Therefore, performance
scores could be calculated for all 100 physicians interviewed (table 1).

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Table 1

Activities and performance of occupational physicians in occupational rehabilitation of cancer

survivors (n=100) (due to missing values, percentages relate to 80–100 cases)

Performance for medical knowledge of cancer and treatment was poorest, with an optimal
performance score of 3%. This was mainly due to the fact that only six physicians had
communicated with the attending physician. In 95% and 66% respectively, the physicians knew
the correct diagnosis and treatment.

Continuity of care performance did satisfy our criteria in 55% of all patients. This was mainly
due to the fact that the time period between contacts was too long or a new appointment was
lacking. Continuity of care in the meaning of seeing the same physician always was reasonable,
with 70% of patients seeing same physician always.

Performance for complaints related interventions was optimal in 78%. In 84% of all cases at
least one intervention was carried out. The occupational physician had had some form of contact
about the patient with the organisation or health care professionals in 75%.

In 60% of all cases performance for interventions in relations at work was optimal. In 75% the
occupational physician did talk about the relation with workers or superiors. In 87% and 82%
respectively this relation was assessed as not hampering return to work.

When we added all performance indicators to one overall performance sum score we left out
performance for knowledge about diagnosis and treatment because there was no variability in
this indicator. The overall performance was therefore based on three performance indicators
only. This resulted in an overall optimal performance in 35% of all cases.

Physicians’ opinions

Ninety eight per cent of the occupational physicians were of the opinion that rehabilitation was
an important occupational health task, and 89% thought that it enhanced return to work. Sixty
per cent of the physicians regarded themselves mostly as a helping professional and as having a
special task for cancer patients.

Patients

Thirteen patients were lost to follow up: seven refused further participation, four died, and from
two patients the questionnaires were missing. Four were already at work at the time of the first
data collection and for seven patients we could use the data of the latest moment of follow up.
So, for 11 patients of those lost to follow up we could calculate return to work measures. For two
patients insufficient data were available to assess the time to return to work. Finally, therefore,
we could calculate a return to work measure for 98 patients.

Patients had been treated for different tumours. There was a predominance of women treated for
breast cancer and cervical cancer. The median (IQR) sick leave at inclusion was 144 (48) days
(table 2).

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Table 2

Characteristics of cancer survivors and factors potentially predictive for return to work,
measured at baseline (n=100) (due to missing values not all percentages relate to 100 cases)
Return to work

At the end of follow up, 67% of patients had returned to work. Time to return to work ranged
from 4 to 651 days with a median of 293 days. There was a steady increase of return to work
from 22% at work at inclusion to 49% at 6 months, and 67% at 12 months follow up.

Satisfaction

Physician and patient satisfaction scores were missing in 20 and 23 cases, respectively.
Physicians’ ratings were missing because either physicians had not seen the patient at all (n = 9)
or the patient was seen by another physician (n = 11). Patient data were missing because 13 were
lost to follow up and 10 had not completed this part of the questionnaire. Mean patient
satisfaction score was 77 (SD 16). For physicians the average satisfaction score was 83 (SD 7).

Relation between performance and outcome

In the bivariate analyses, performance indicator scores were not significantly related to outcome.
From the other prognostic factors, educational level, self efficacy, diagnosis, treatment, co-
morbidity, psychological complaints, physical complaints, activity restrictions, fatigue,
emotional burden at work, work pressure, and autonomy at work were related at the p < 0.10
level to return to work.

To retain sufficient statistical power we included the following factors from different categories
in the Cox’s proportional hazards model to adjust for their influence: educational level, self
efficacy, diagnosis, treatment, co-morbidity, activity restrictions, fatigue, and work pressure.
After adjustment for prognostic factors, relations between overall performance and continuity of
care and time to return to work were more precise and were statistically significant (fig 1). In
particular, diagnosis turned out to be a confounder (table 3).

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Table 3

Cox proportional hazards analysis of occupational physician performance in occupational

rehabilitation of cancer survivors and time to return to work (n=98)
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Figure 1

Survival curve of time to return to work of cancer survivors, with optimal rehabilitation by
occupational physicians or deviant performance in one or more performance indicators after
adjustment for other prognostic factors (n = 98).

An overall optimal performance was related to a higher patient satisfaction. Overall optimal
performance, optimal performance for continuity of care, and optimal performance for
interventions and relations were significantly related to a higher physician satisfaction (table 4).
For patient satisfaction, patients’ age and marital status were confounders, but multivariate
analysis did not change the results.

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Table 4

Relation between performance of occupational physicians (n=83) and patient satisfaction (n=80)

DISCUSSION
Based on performance indicator scores, there is ample room to improve quality of occupational
rehabilitation of cancer survivors by occupational physicians, especially with respect to medical
communication. A better performance was associated with a small but significantly higher level
of satisfaction of both patients and physicians. After adjustment for confounders, we found a
significant relation between overall performance of occupational physicians, continuity of care,
and return to work.

In comparison with other studies on the quality of occupational health, such as an audit of patient
files, we were able to improve the quality of the data by interviewing the physicians. Therefore,
we were not merely dependent on the interpretation of the patient files by the researchers, but we
could ask the physician for clarification. We gathered a suitable cohort of patients with detailed
data on the management of their occupational physicians. We followed them for a sufficiently
long and appropriate period in which an additional 45% of the cohort resumed work. We had
hardly any loss to follow up. Apart from data on rehabilitation management we could also make
an inventory of a large number of potential prognostic factors which could be checked for
potential confounding. Most of these prognostic factors were measured by means of validated
questionnaires.

For measuring the quality of care we are inevitably restrained to non-randomised observational
studies, which are easily subject to confounding.23,24 This was evident in our study too. Prognosis
of return to work was determined by, among others, diagnosis, treatment, self efficacy, and
pressure of work. In turn, performance indicators were also related to these prognostic factors.
Therefore, one of the strengths of our study is that we could check the influence of more than 30
potential prognostic factors. Even though we cannot be sure that unknown confounders bias a
relation between performance and outcome, this does not seem very plausible.

The finding that both patients and physicians were more satisfied with a better performance
indicates that the performance indicators were related to, at least, a perception of better quality of
care.

The satisfaction questionnaires had sufficient internal reliability. With average satisfaction scores
around 80, they compare well with those found in patients with back pain that were around 70%
of the maximum score.10

There are only few studies on the quality of rehabilitation or return to work management in
cancer patients. In Germany, Cole et al reported that cancer patients made substantial progress
during in-patient rehabilitation.25 In this uncontrolled study it is, however, unclear what the
impact of rehabilitation measures is. Patients in the study of Maunsell et al complained about the
lack of attention to work problems from health care professionals.26 Recently, a more general
lack of attention to vocational rehabilitation has also been noted.27 Furthermore, in our study, half
of the patients indicated that they had not discussed work with their attending physician (results
not shown).

In 1992, van der Wouden et al found a return to work rate of 44% in a postal survey of long term
cancer survivors in the Netherlands.28 With a return to work rate of 67% and a shorter follow up
period, the results of our study compare favourably to theirs. Many factors, such as improved
treatment and improved survival, could be the cause of this difference. However, it could also be
an indication that the increasing attention for vocational rehabilitation of cancer patients has had
a positive impact on the problem.

We did not find a relation between all performance indicators and outcome. It is remarkable that
continuity of care was a predictor of return to work. This has been found before for patients with
back pain.10 There could be two explanations for this finding. Patients who lose contact with the
occupational physician could be especially problematic and have therefore a longer time to
return to work. It is also possible that better contact with the occupational physician in terms of
frequency and person leads to better return to work. It is the first time that these performance
indicators were used. To better validate them, findings should be corroborated in future studies.
In general, relations between processes of care and outcome are not straightforward.10,12 In future
quality studies, it is recommended that more specific indicators are developed. The lack of
studies on return to work of cancer survivors should also stimulate interest in conduct of
randomised studies in which the efficacy of rehabilitation procedures for cancer survivors is
more thoroughly evaluated. These results could be used in future quality studies.

Conclusion

This study shows that the quality of occupational rehabilitation for cancer survivors can be
improved substantially, especially with regard to communication between occupational
physicians and specialists in cancer care. Improvement of quality will probably lead to higher
return to work rates. In addition, development and evaluation of more effective intervention
methods for return to work management of cancer survivors is needed.

APPENDIX: PERFORMANCE INDICATORS FOR

QUALITY OF OCCUPATIONAL REHABILITATION OF
CANCER SURVIVORS BY OCCUPATIONAL
PHYSICIANS
(1) Criteria for optimal performance in medical knowledge

1. Diagnosis had to be known by occupational physician and correct, and if so,

2. There had to be a written or vocal contact with the attending physician, and if so,
3. Treatment had to be known by the occupational physician and correct for operation,
chemotherapy, and radiation or their combinations.

(2) Criteria for optimal performance in continuity of care

 1. The last contact should be less than half a year ago if the patient was not at work yet and
if so,
2. There had to be at least two contacts with the patient within one episode of sick leave
3. The patient should have had contact with no more than two different physicians
4. If not yet returned to work at the moment of contact there had to be a new appointment.

(3) Criteria for optimal performance in complaint related interventions

1. At least two of the following complaints should have been discussed with the patient:
fatigue, problems in sleeping, problems in concentration, emotional distress, feeling
depressed, other complaints due to disease or treatment
2. If these problems hampered return to work, at least one out of the following possible
interventions had to be mentioned by the occupational physician:

1. Advice to the patients: stay in contact with work, confer with superior about decrease of
workload
2. Referral to attending specialist, general practitioner, social worker, occupational
physiotherapist, occupational psychologist, personnel manager, superior, insurance
physician
3. Advice about work resumption, decrease of work tasks, use of aids, own work pace, other
interventions directed towards worker, other interventions directed towards work
4. Consultation with social team at work, attending physician, general practitioner, social
worker, personnel manager, superior, insurance physician, other persons
5. Workplace visit, objective information to co-workers or superiors, house visit, other
interventions

(4) Criteria for optimal performance in interventions in relations at work

1. Attitude of superior and colleagues should be discussed with the patient

2. If attitude of superior or co-workers hampered return to work there had to be at least one
intervention from the same range as mentioned under (3).

Acknowledgments
This study was supported by a grant from the Dutch Cancer Society (AMC 97-1385). We are
grateful to all patients for participation in this study. In addition, we would like to thank the
medical staff involved at the Academic Medical Center, the Onze Lieve Vrouwe Gasthuis, and at
hospital De Heel for their indispensable contribution to this study.

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