Experiences of Employees With Arm, Neck, Shoulder Complaints
Experiences of Employees With Arm, Neck, Shoulder Complaints
To our knowledge this is the first study to investigate the experiences of employees suffering from CANS. In both their daily life and at work, employees suffering from CANS are faced with the challenge to deal with their complaints. The present study indicates that participants do not always have sufficient insight into the causes of complaints, and are not always fully aware of the possibilities to influence their complaints and of their own role in coping with their complaints. Generally, all participants suffered from pain and feel that they cannot manage this adequately. Some participants are aware that they have a problem with taking their own limits into account, while others often approach/go beyond their individual limits because they have a relatively high threshold before asking for help. Many participants feel that fatigue has a serious impact on their daily life and the management of their complaints. They feel uncomfortable about dealing with various disrupting physical factors (pain, disability, fatigue), psychosocial factors (stress, lack of balance work/private life, difficulties in communication, misunderstanding from others), personal factors (difficulties in setting limits, high threshold before asking for support, high level of personal standards and expectations) and environmental factors (non-optimal workplace, culture within the organization). All these factors should be addressed in future interventions.
The identified needs of participants include information about possible causes of CANS and possible solutions (e.g. treatment, facilities); (relaxation) exercises; working and dealing with pain, limitations, fatigue, workload and stress; work(place) adaptations; workstyle; taking into account one's own limits and asking for help; communication with others; and awareness of one's own advantage. Tools for dealing with these factors should be provided.
Although the etiology of CANS is multifactorial, most participants in the focus groups mention physical factors as the primary cause of their problems. Although this can indeed be the case, people may not be fully aware of the contribution of other factors in the etiology of their problem. Although psychosocial, personal and environmental factors are also mentioned, this is generally more in the sense of more aggravating factors.
The fact that CANS is a 'non-visible' complaint has various consequences. On the one hand participants indicate that this may contribute to their feeling of not being well understood whereas, on the other hand, it prevents colleagues from asking questions during the day. Thus, it seems that at least some participants find it difficult to communicate about their complaints. Moreover, if colleagues are not aware of the complaints, asking for help and obtaining social support may seem to be even more difficult.
Employees suffering from CANS are often confronted with a wide range of problems. Although most participants have taken many steps in an attempt to reduce their complaints, which vary from workplace adaptations to different types of (physical) therapies, they still have complaints and some are still looking for alternative treatment options. A few participants stated that their complaints had worsened when performing fitness training. Therefore, it seems important that people with CANS have sufficient knowledge and insight into the possible benefit and harm of sports activities, and that activities are well chosen and properly 'dosed'. However, the awareness that there are opportunities for self-management differs between participants and most do not know how to cope with the working environment. Given the multifactorial origin of CANS, it was found that the variability between participants in taking into account all the possible contributing factors was relatively high.
In our study population the mean duration of symptoms was 222 weeks, indicating that most had suffered from these complaints for several years. This also implies that this group might be a useful source of relevant information for other employees with CANS in the a similar work environment, because they have experience in working with and finding solutions for their complaints. On the other hand, although most have tried various ways to reduce their complaints, the majority still suffer from CANS and still reported coping problems due to work environmental factors, to personal factors, and due to physical factors.
It should be noted that, because this study setting is rather specific and the participants relatively highly educated, the participants in this study are a specific group thereby making it difficult to generalize these results to other populations and to other settings. Therefore, the information gathered in this study will be used to select the most important topics for the self-management intervention; employees with CANS must be empowered to take control over their complaints in their work environment. The exact content of the identified topics may vary between different types of work settings.
The present study provides insight into perceptions and experiences of employees suffering from CANS and identifies a number of recurring problem areas. The results endorse the multifactorial (e.g. physical, psychosocial, environmental and personal) etiology of CANS. Our results may help identify important areas that need attention in the treatment of employees suffering from CANS. This study identified several needs of employees with CANS. Insight in the symptoms of CANS and in its causal factors seems to be the first important point. Secondly, awareness and reflection on one's own behaviors related to the working circumstances are considered important. Thirdly, participants need to develop their exercise, relaxation, coping, management and communication skills to deal with their problems on the long term. It is likely that knowledge and sufficient insight in the different causes of the complaints are important in order to raise awareness and reflection, and develop communication skills. All these items could be topics in the self-management intervention.
This study has several limitations. First, selection bias may have occurred regarding the study group as most participants were working in a hospital and, generally, have a long period of living with CANS. However, because participants in our study experienced some problems similar to those of employees with other types of chronic diseases, it seems plausible that these problems are also experienced by employees with CANS working in other settings. Moreover, we think that not (only) the work environment, but rather the personal characteristics of employees with CANS are (also) important when considering the causes of the complaints and when dealing with the complaints. However, this study was conducted in a healthcare and an educational setting, and the participants were relatively highly educated. Therefore, participants in our study group may be 'better equipped' to express themselves regarding CANS, due to the setting they work in and their higher level of education. Therefore, our results do not reflect the experiences of workers in different types of setting, such as factory workers.
Only one man participated; this is due to the larger proportion of woman working in the hospitals and the fact that women have a higher risk of developing CANS compared with men. Moreover, we purposively selected participants based on some specific characteristics. We were interested in employees with complaints of the arm, neck and/or shoulder persisting for longer than 12 weeks. Moreover, the complaints must be caused or worsened by their job and/or limit their participation in work. Therefore, we purposively selected employees who met these criteria, using the described selection criteria. Because the aim of focus groups is not to infer but to understand, not to generalize but to determine the range, and not to make statements about the population but to provide insight into how people in the groups perceive a situation, the present results represent the experiences and perceptions of the participants of this particular study.
Moreover, three participants were interviewed individually as they were unable to attend any of the focus group meetings. This implies that these participants were not part of a group process and that, for these participants, the ideas did not emerge from the group. However, because these three participants wanted to participate and fulfilled the inclusion criteria, and all information about the experiences of employees with CANS was needed, we decided to perform interviews and analyze them together with the focus group results. Although this could have influenced the results, this does not seem to be the case, because no major differences in perceptions and experiences between participants of the focus groups and the interviews were identified.
The question guide was based on a recent multidisciplinary guideline for nonspecific CANS. The question guide was also based on the original self-management program in order to determine how the topics of the original program should be adapted. We assumed that some multifactorial aspects of CANS (physical characteristics; personal factors, e.g. stress management) would be mentioned and discussed by the participants themselves. Other topics (psychosocial characteristics, e.g. social support; the work environment, e.g. facilities; and some personal factors, e.g. asking for help) would perhaps need some more facilitation during the focus group. Therefore, these topics were individually addressed in the question guide to assist the moderator. Moreover, if new topics were introduced by the participants these were also facilitated. Due to the fact that the same issues were identified and discussed in all three focus group meetings and no new topics were introduced in the final session, it is highly likely that saturation was reached.
Another limitation is that, given the aim of this study (i.e. investigating the experiences of employees with CANS) and the multifactorial origin of CANS and many influencing factors, it was not possible to investigate all the topics and to extensively discuss all the emerging topics. We were mainly interested in the participants' perception of the topics addressed in the question guide and therefore focused on topics fulfilling this aim.
Although member checking was performed, this took place one year after the focus group meetings. Therefore, it is possible that participants did not (exactly) remember the details of the focus group meetings. However, by providing the preliminary results of each session to the participants it seemed possible to check whether our interpretation of the data was correct; this was endorsed by the fact that none of the participants indicated that our interpretation was not correct.
Data were coded by one researcher. Multiple coding involves the cross-checking of coding strategies and interpretation of data by independent researchers. However, the degree of concordance between researchers is not very important; the main value of multiple coding is to supply alternative interpretations. It is important that a transparent and systematic process is followed which can be carried out by one researcher, by a team, or by involving independent experts. By discussing the emerging themes and looking for alternative interpretations in a small expert group, we addressed the potentially competing explanations.
In the present study, it is noteworthy that participants experienced some problems similar to those in employees with other types of chronic diseases. Problems related to their illness, insufficient communication with supervisors, working together with healthcare professionals, colleagues and management, and adaptations at the workplace are considered important among employees with chronic somatic diseases. Therefore, it seems plausible that a self-management intervention, including an ehealth module, covering these topics, and adapted to employees suffering from CANS with disease-specific information, may be effective in employees with CANS. Although there is inconsistent evidence for the effect of self-management programs for patients with chronic musculoskeletal pain, there is evidence that group-delivered short programs (<8 weeks) with a healthcare professional have the best potential. In a recent study, a multi-component pain and stress self-management group intervention had better effects than individually administered physical therapy in the treatment of persistent musculoskeletal tension-type neck pain in terms of patients' self-reported pain control, self-efficacy, disability, and catastrophizing over the 20-week follow-up.
The topics identified in the present study can contribute to the adaptation of an existing self-management program, combined with ehealth, to the experiences and needs of employees with CANS. Moreover, the results may also be useful for healthcare professionals and management aiming to support these employees. As part of the needs assessment (step one in the IM protocol) we also reviewed the Dutch multidisciplinary guideline for nonspecific CANS and conducted focus groups with intervention and ehealth experts. We expect that focus groups with experts can have a surplus value. By comparing experiences of clients and interventionists we are able to analyze in which way the ehealth and self-management program needs to fit existing intervention strategies and which delivery strategies should be used. The results of these latter focus groups, and the results of the development of the intervention following the IM protocol, will be published in two separate forthcoming articles.
Discussion
To our knowledge this is the first study to investigate the experiences of employees suffering from CANS. In both their daily life and at work, employees suffering from CANS are faced with the challenge to deal with their complaints. The present study indicates that participants do not always have sufficient insight into the causes of complaints, and are not always fully aware of the possibilities to influence their complaints and of their own role in coping with their complaints. Generally, all participants suffered from pain and feel that they cannot manage this adequately. Some participants are aware that they have a problem with taking their own limits into account, while others often approach/go beyond their individual limits because they have a relatively high threshold before asking for help. Many participants feel that fatigue has a serious impact on their daily life and the management of their complaints. They feel uncomfortable about dealing with various disrupting physical factors (pain, disability, fatigue), psychosocial factors (stress, lack of balance work/private life, difficulties in communication, misunderstanding from others), personal factors (difficulties in setting limits, high threshold before asking for support, high level of personal standards and expectations) and environmental factors (non-optimal workplace, culture within the organization). All these factors should be addressed in future interventions.
The identified needs of participants include information about possible causes of CANS and possible solutions (e.g. treatment, facilities); (relaxation) exercises; working and dealing with pain, limitations, fatigue, workload and stress; work(place) adaptations; workstyle; taking into account one's own limits and asking for help; communication with others; and awareness of one's own advantage. Tools for dealing with these factors should be provided.
Although the etiology of CANS is multifactorial, most participants in the focus groups mention physical factors as the primary cause of their problems. Although this can indeed be the case, people may not be fully aware of the contribution of other factors in the etiology of their problem. Although psychosocial, personal and environmental factors are also mentioned, this is generally more in the sense of more aggravating factors.
The fact that CANS is a 'non-visible' complaint has various consequences. On the one hand participants indicate that this may contribute to their feeling of not being well understood whereas, on the other hand, it prevents colleagues from asking questions during the day. Thus, it seems that at least some participants find it difficult to communicate about their complaints. Moreover, if colleagues are not aware of the complaints, asking for help and obtaining social support may seem to be even more difficult.
Employees suffering from CANS are often confronted with a wide range of problems. Although most participants have taken many steps in an attempt to reduce their complaints, which vary from workplace adaptations to different types of (physical) therapies, they still have complaints and some are still looking for alternative treatment options. A few participants stated that their complaints had worsened when performing fitness training. Therefore, it seems important that people with CANS have sufficient knowledge and insight into the possible benefit and harm of sports activities, and that activities are well chosen and properly 'dosed'. However, the awareness that there are opportunities for self-management differs between participants and most do not know how to cope with the working environment. Given the multifactorial origin of CANS, it was found that the variability between participants in taking into account all the possible contributing factors was relatively high.
In our study population the mean duration of symptoms was 222 weeks, indicating that most had suffered from these complaints for several years. This also implies that this group might be a useful source of relevant information for other employees with CANS in the a similar work environment, because they have experience in working with and finding solutions for their complaints. On the other hand, although most have tried various ways to reduce their complaints, the majority still suffer from CANS and still reported coping problems due to work environmental factors, to personal factors, and due to physical factors.
It should be noted that, because this study setting is rather specific and the participants relatively highly educated, the participants in this study are a specific group thereby making it difficult to generalize these results to other populations and to other settings. Therefore, the information gathered in this study will be used to select the most important topics for the self-management intervention; employees with CANS must be empowered to take control over their complaints in their work environment. The exact content of the identified topics may vary between different types of work settings.
The present study provides insight into perceptions and experiences of employees suffering from CANS and identifies a number of recurring problem areas. The results endorse the multifactorial (e.g. physical, psychosocial, environmental and personal) etiology of CANS. Our results may help identify important areas that need attention in the treatment of employees suffering from CANS. This study identified several needs of employees with CANS. Insight in the symptoms of CANS and in its causal factors seems to be the first important point. Secondly, awareness and reflection on one's own behaviors related to the working circumstances are considered important. Thirdly, participants need to develop their exercise, relaxation, coping, management and communication skills to deal with their problems on the long term. It is likely that knowledge and sufficient insight in the different causes of the complaints are important in order to raise awareness and reflection, and develop communication skills. All these items could be topics in the self-management intervention.
This study has several limitations. First, selection bias may have occurred regarding the study group as most participants were working in a hospital and, generally, have a long period of living with CANS. However, because participants in our study experienced some problems similar to those of employees with other types of chronic diseases, it seems plausible that these problems are also experienced by employees with CANS working in other settings. Moreover, we think that not (only) the work environment, but rather the personal characteristics of employees with CANS are (also) important when considering the causes of the complaints and when dealing with the complaints. However, this study was conducted in a healthcare and an educational setting, and the participants were relatively highly educated. Therefore, participants in our study group may be 'better equipped' to express themselves regarding CANS, due to the setting they work in and their higher level of education. Therefore, our results do not reflect the experiences of workers in different types of setting, such as factory workers.
Only one man participated; this is due to the larger proportion of woman working in the hospitals and the fact that women have a higher risk of developing CANS compared with men. Moreover, we purposively selected participants based on some specific characteristics. We were interested in employees with complaints of the arm, neck and/or shoulder persisting for longer than 12 weeks. Moreover, the complaints must be caused or worsened by their job and/or limit their participation in work. Therefore, we purposively selected employees who met these criteria, using the described selection criteria. Because the aim of focus groups is not to infer but to understand, not to generalize but to determine the range, and not to make statements about the population but to provide insight into how people in the groups perceive a situation, the present results represent the experiences and perceptions of the participants of this particular study.
Moreover, three participants were interviewed individually as they were unable to attend any of the focus group meetings. This implies that these participants were not part of a group process and that, for these participants, the ideas did not emerge from the group. However, because these three participants wanted to participate and fulfilled the inclusion criteria, and all information about the experiences of employees with CANS was needed, we decided to perform interviews and analyze them together with the focus group results. Although this could have influenced the results, this does not seem to be the case, because no major differences in perceptions and experiences between participants of the focus groups and the interviews were identified.
The question guide was based on a recent multidisciplinary guideline for nonspecific CANS. The question guide was also based on the original self-management program in order to determine how the topics of the original program should be adapted. We assumed that some multifactorial aspects of CANS (physical characteristics; personal factors, e.g. stress management) would be mentioned and discussed by the participants themselves. Other topics (psychosocial characteristics, e.g. social support; the work environment, e.g. facilities; and some personal factors, e.g. asking for help) would perhaps need some more facilitation during the focus group. Therefore, these topics were individually addressed in the question guide to assist the moderator. Moreover, if new topics were introduced by the participants these were also facilitated. Due to the fact that the same issues were identified and discussed in all three focus group meetings and no new topics were introduced in the final session, it is highly likely that saturation was reached.
Another limitation is that, given the aim of this study (i.e. investigating the experiences of employees with CANS) and the multifactorial origin of CANS and many influencing factors, it was not possible to investigate all the topics and to extensively discuss all the emerging topics. We were mainly interested in the participants' perception of the topics addressed in the question guide and therefore focused on topics fulfilling this aim.
Although member checking was performed, this took place one year after the focus group meetings. Therefore, it is possible that participants did not (exactly) remember the details of the focus group meetings. However, by providing the preliminary results of each session to the participants it seemed possible to check whether our interpretation of the data was correct; this was endorsed by the fact that none of the participants indicated that our interpretation was not correct.
Data were coded by one researcher. Multiple coding involves the cross-checking of coding strategies and interpretation of data by independent researchers. However, the degree of concordance between researchers is not very important; the main value of multiple coding is to supply alternative interpretations. It is important that a transparent and systematic process is followed which can be carried out by one researcher, by a team, or by involving independent experts. By discussing the emerging themes and looking for alternative interpretations in a small expert group, we addressed the potentially competing explanations.
In the present study, it is noteworthy that participants experienced some problems similar to those in employees with other types of chronic diseases. Problems related to their illness, insufficient communication with supervisors, working together with healthcare professionals, colleagues and management, and adaptations at the workplace are considered important among employees with chronic somatic diseases. Therefore, it seems plausible that a self-management intervention, including an ehealth module, covering these topics, and adapted to employees suffering from CANS with disease-specific information, may be effective in employees with CANS. Although there is inconsistent evidence for the effect of self-management programs for patients with chronic musculoskeletal pain, there is evidence that group-delivered short programs (<8 weeks) with a healthcare professional have the best potential. In a recent study, a multi-component pain and stress self-management group intervention had better effects than individually administered physical therapy in the treatment of persistent musculoskeletal tension-type neck pain in terms of patients' self-reported pain control, self-efficacy, disability, and catastrophizing over the 20-week follow-up.
The topics identified in the present study can contribute to the adaptation of an existing self-management program, combined with ehealth, to the experiences and needs of employees with CANS. Moreover, the results may also be useful for healthcare professionals and management aiming to support these employees. As part of the needs assessment (step one in the IM protocol) we also reviewed the Dutch multidisciplinary guideline for nonspecific CANS and conducted focus groups with intervention and ehealth experts. We expect that focus groups with experts can have a surplus value. By comparing experiences of clients and interventionists we are able to analyze in which way the ehealth and self-management program needs to fit existing intervention strategies and which delivery strategies should be used. The results of these latter focus groups, and the results of the development of the intervention following the IM protocol, will be published in two separate forthcoming articles.
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