Carol Coole

What Concerns Workers with Low Back Pain? Findings of a Qualitative Study of Patients Referred for Rehabilitation

Introduction Health and workplace strategies to address work loss and sickness absence due to low back pain are urgently required. A better understanding of the experiences of those struggling to stay at work with back pain may help clinicians and employers with their treatment and management approaches. Methods A qualitative approach using thematic analysis was used. Individual semi-structured interviews were conducted with a convenience sample of 25 low back pain patients who had been referred for multidisciplinary back pain rehabilitation. All were in employment and concerned about their ability to work due to low back pain. Initial codes were identified and refined through constant comparison of the transcribed interview scripts as data collection proceeded. Themes were finally identified and analysed by repeated study of the scripts and discussion with the research team. Findings Five main themes were identified: justifying back pain at work; concern about future ability to retain work; coping with flare-ups; reluctance to use medication; concern about sickness records. Conclusions In this study, workers with low back pain remained uncertain of how best to manage their condition in the workplace despite previous healthcare interventions and they were also concerned about the impact back pain might have on their job security and future work capacity. They were concerned about how back pain was viewed by their employers and co-workers and felt the need to justify their condition with a medical diagnosis and evidence. Clinicians and employers may need to address these issues in order to enable people to continue to work more confidently with back pain.

Hip Precautions Following Primary Total Hip Replacement: A National Survey of Current Occupational Therapy Practice

Background: The aim of this research was to investigate the day-to-day work of occupational therapists with patients following elective total hip replacement (THR). The research question was ‘What is routine practice in United Kingdom (UK) occupational therapy in advising on hip precautions following primary THR?’ Method: A questionnaire was designed and piloted. Following minor revisions, 263 questionnaires were posted to occupational therapists in the UK. Results: Responses were analysed from 174 occupational therapists from 65 counties in the UK. There was generally consensus from therapists about which movements should be avoided postoperatively, on the activities discussed and practised with patients and on the equipment supplied. However, there was variation in the reasons given to justify precautions, on the timescales for precautions to be followed and on the amount of time spent with patients, in relation to both face-to-face contact and administration. Discussion and conclusion: Although more is now known about the content of occupational therapy following THR, this research has highlighted areas of disagreement and a lack of consensus in the reasoning behind using precautions. There is now a need to evaluate whether precautions are effective in preventing dislocation and this study provides an important first step in doing so.

Communicating with employers: experiences of occupational therapists treating people with musculoskeletal conditions.

Purpose Many employed people with musculoskeletal conditions rely on healthcare practitioners, including occupational therapists, for work-related advice and support. Good communication between healthcare practitioners and employers is considered vital in facilitating work retention and return to work. The purpose of this study was to explore the experiences of occupational therapists in communicating with patients’ employers. Methods Qualitative data were collected from the responses of occupational therapists to ten statements/open questions in a questionnaire survey of UK occupational therapists. Data were copied verbatim into word documents and analysed thematically. Results A total of 649 comments were made by 143 respondents. Five themes were identified that were associated with communicating with employers: patient-dependent; employer-dependent; therapist-dependent; extrinsic factors; methods of communication. Conclusion This study has identified that communication between occupational therapists and employers is influenced by a number of factors, including those which are outside the therapists’ control. These need to be acknowledged and addressed by therapists, their professional organisation, employers, commissioners, therapy service managers, educators and employees in order to support return-to-work and work retention of people with musculoskeletal conditions.

What do we tell patients about elective total hip replacement in the UK? An analysis of patient literature.

BackgroundAlthough hip information literature is given to people following total hip replacement (THR) almost routinely, little evaluation has been conducted on it to date. Our aim was therefore to analyse and evaluate the literature provided to patients by occupational therapists concerning elective hip surgery in the UK.MethodsThis was a pragmatic, descriptive analysis of information leaflets routinely given to patients undergoing primary total hip replacement (THR). The literature was collected as part of a national survey of occupational therapy practice. In the absence of a suitable evaluation tool, the patient leaflets were compared using a checklist devised by the researchers. The three areas of interest were: accessibility including presentation of information, breadth of information covered and specific activities of daily living described.Results111 information leaflets and booklets were examined. These ranged from hospital publications which were professionally printed to those produced by individual departments. There was a variation in the readability of the leaflets ranging from 13% to 83%; the mean was 45% (SD 15). There was also variation in the content ranging from those covering surgery and possible complications, to those including diet and hip exercises. The most commonly covered activity of daily living was advice on sitting (99; 89%); the least commonly covered was work (26; 23%). Only 3 (2.7%) booklets had involved patients in their production and only 22 (20%) signposted obtaining information in another language or in Braille.ConclusionsThere was a range of literature in terms of presentation and content given to people who had a total hip replacement (THR). Although some booklets and leaflets scored highly, some did not meet basic standards such as providing contact details for help, using good quality diagrams, suggesting further reading or involving patients in their design. These results highlight important and fundamental deficiencies in the literature routinely provided.

Completion of Fit Notes by GPs: A Mixed Methods Study

Aims: The aim of this study was to investigate the completion of fit notes by UK general practitioners (GPs). A series of actual fit notes issued to employed patients were examined, and their GPs’ reflections and experiences of fit note completion explored. Methods: A mixed-methods design was used. Data were collected from copies of 94 fit notes issued to employed patients by 11 GPs, and from 86 questionnaires completed by these GPs reflecting on the fit notes they had issued. Face-to-face interviews were then conducted with each GP. Results: Fit note completion is not meeting expectations for a number of reasons. These include the following: limited knowledge and awareness of the guidance in fit note completion; problems with the fit note format; lack of mandatory training in completing fit notes; lack of incentive to change practice; incomplete implementation of the electronic fit note; GPs’ lack of confidence in, and doubts about the appropriateness of performing this role. Conclusion: If UK GPs are to continue their contractual responsibility for completing fit notes, further consideration of their education and training needs is urgently required. Weaknesses in the design and format of the fit note and the availability of the electronic version also need to be addressed.

Individual work support for employed patients with low back pain: a randomized controlled pilot trial

Objective: To investigate the feasibility and effectiveness of individual work support for employed patients with low back pain. Design: Pilot randomized controlled trial of a 16-week vocational intervention with six-month follow-up. Setting: Community/outpatient. Participants: Fifty-one employed participants concerned about their ability to work due to low back pain. Outcome data was obtained for 38 participants at six-month follow-up. Interventions: The intervention group received up to eight individually targeted vocational sessions in conjunction with group rehabilitation for low back pain. The control group received group rehabilitation. Outcome measures: The feasibility of the intervention was assessed by the recruitment rate, drop-out and loss to follow-up of the participants and the content and delivery of the intervention as recorded by the researcher. The primary outcome measure was perceived work ability. Results: Seventy-three participants were referred to the study over six months. Eighty-seven individual work support sessions were delivered. Thirty-one participants (61% of those retained in the study) attended more than half of the group rehabilitation sessions. The intervention was influenced by the uptake of group rehabilitation, the willingness of the participants to involve their workplace and of their workplace to involve the research therapist. The effect of the intervention on work ability was equivocal. Conclusions: Although it was possible to recruit participants and to deliver the intervention, considerable methodological problems were identified. However, even if these were addressed, the impact of such interventions is likely to be limited unless there is an integrated approach between healthcare, employers and employees. Further research is required to evaluate work-focused interventions with this client group.

Exploring the barriers to and facilitators of implementing research into practice

District and community nursing roles have changed rapidly in recent years. Community nurses are increasingly being tasked with carrying out multiple roles, which require them to put research into practice and use evidence-based tools and interventions. The implementation of interventions and tools needs to be developed from empirical research, requiring evidence, to be translated into practice. However, this process may be compromised or enhanced by a number of factors. This exploratory, descriptive qualitative study sought to identify barriers and facilitators to community nurses implementing research into practice. Four focus groups were conducted with registered community nurses and district nurses (n=22). Analysis identified four main themes: keeping up to date with evidence; using a clinical tool; education/training and implementation. Findings suggest that there are barriers at a personal, professional and organisational level. Strategies are suggested to overcome these obstacles.

What Do Clinicians Think about Hip Precautions following Total Hip Replacement

Introduction: Hip precautions are routinely recommended by occupational therapists to reduce the risk of dislocation following total hip replacement. The purpose of this study was to report the views and experiences of clinicians on the use of hip precautions with this client group. Method: Data were gathered from six National Health Service trusts, through 16 semi-structured telephone interviews. Participants included occupational therapists, physiotherapists, surgeons and nurses and data were analysed thematically. Results: Themes identified were: the rationale for, and disadvantages of, routine hip precautions and issues in the consistency of their application; the barriers and facilitators to relaxing hip precautions and the process and impact of changing practice; the contextual factors of service change and support for further research. Conclusion: There is variation in the views of clinicians regarding hip precautions due to differences in surgical opinion and lack of evidence as to whether precautions affect the risk of dislocation. Relaxing the routine provision of hip precautions is perceived to have an impact on patient recovery and satisfaction, the role and skill mix of therapy services, length of hospital stay and resource use. Trials are urgently required to investigate the effect of hip precautions on patient and surgical outcomes.

Assessing the feasibility of collecting health care resource use data from general practices for use in an economic evaluation of vocational rehabilitation for back pain

The cost of back pain to the UK economy is considerable inrespect of both direct and indirect health care. In 1998, the directhealth care costs alone were estimated as £1632 million [1]. Asa result, the inclusion of health economic outcomes for muscu-loskeletal disorders is an agreed research priority for non-pharmalogical therapies [2] and vocational rehabilitation [3].Establishing accurate and feasible methods of data collection istherefore essential in studies measuring the effectiveness of backpain rehabilitation.Economic evaluations estimate the costs and benefits of two ormore competing interventions in order to inform resource alloca-tion decision making about the likely value for money. In a fixedbudget national health service, it is important to undertake suchevaluations in order to maximize the efficient use of resourcesandpatientoutcomes.However,theusefulnessofsuchevaluationsdepends on both the quality and availability of the necessary dataupon which they are based. Resource use data and outcomes datacan be collected in a number of ways, including patient self-reportquestionnaires, diaries and interviews, clinical report forms andpatient records. Several studies have investigated the use of alter-native ways of collecting resource use data but findings are mixedas to the most reliable method [4–7]. However, very few of theseeconomicevaluationsdescribehowsuchdatacollectiontoolsweredeveloped, or have compared case notes with self-report for backpain [8].This study describes pilot work conducted in preparation for afeasibility randomized controlled trial of vocational rehabilitationfor low back pain. In the trial, patients were to be recruited from amultidisciplinary group rehabilitation programme for back pain(The Nottingham Back and Pain Team) and randomized into oneof two groups; routine group rehabilitation, or routine group reha-bilitation plus an individually targeted vocational intervention.Aneconomic evaluation was proposed to estimate the comparativecosts and outcomes of the interventions from a national healthservice and social service perspective, the patient perspectivebeing presented separately.Health care resource data are often collected throughself-report, but such methods may not be accurate due to,for example, poor completion rates [9] and recall errors [5].This research letter focuses on the practicability of collectinghealth care resource use data from general practitioner (GP)practices only, as this approach has been shown by some to bemore technically accurate [10]. The feasibility trial would seek tocapture any change in health care resource use following theintervention. Such knock-on data would be used to comparelevels of health care resource use over a set period of time, thatis, 6 months before and 6 months after rehabilitation betweenthose receiving the intervention and those not. Data would becollected retrospectively.The aims of this study were therefore to establish the dataroutinely collected by GPpractices, and how easily this data couldbe extracted for the feasibility trial.

Engaging workplace representatives in research: what recruitment strategies work best?

Background Workplaces are key stakeholders in work and health but little is known about the methods used to recruit workplace representatives (WRs), including managers, occupational health advisers and colleagues, to externally funded healthcare research studies. Aims To detail the strategies used in recruiting WRs from three areas of the UK to a qualitative study concerning their experience of employees undergoing hip or knee replacement, to compare the strategies and inform recruitment methods for future studies. Methods Six strategies were used to recruit WRs from organizations of different sizes and sectors. Data on numbers approached and responses received were analysed descriptively. Results Twenty-five WRs were recruited. Recruitment had to be extended outside the main three study areas, and took several months. It proved more difficult to recruit from non-service sectors and small- and medium-sized enterprises. The most successful strategies were approaching organizations that had participated in previous research studies, or known professionally or personally to team members. Conclusions Recruiting a diverse sample of WRs to healthcare research requires considerable resources and persistence, and a range of strategies. Recruitment is easier where local relationships already exist; the importance of building and maintaining these relationships cannot be underestimated. However, the potential risks of bias and participant fatigue need to be acknowledged and managed. Further studies are needed to explore how WRs can be recruited to health research, and to identify the researcher effort and costs involved in achieving unbiased and representative samples.