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Occupational Medicine Advance Access originally published online on March 15, 2008
Occupational Medicine 2008 58(4):282-288; doi:10.1093/occmed/kqn015
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© The Author 2008. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Managing low back pain: knowledge and attitudes of hospital managers

Caitriona Cunningham, Catherine Doody and Catherine Blake

UCD School of Physiotherapy and Performance Science, Health Sciences Centre, UCD, Belfield, Dublin 4, Ireland

Correspondence to: Caitriona G. Cunningham, UCD School of Physiotherapy and Performance Science, Health Sciences Centre, UCD, Belfield, Dublin 4, Ireland. Tel: +353 1 7166512; e-mail: caitriona.g.cunningham{at}ucd.ie


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Background Low back pain (LBP) is a major cause of work-related disability. Despite an increasing emphasis on the role of employers and workplace managers in reducing work disability, little research has been conducted in this area.

Aims To identify hospital line managers' knowledge, attitudes and beliefs regarding LBP and its management; the difficulties encountered in managing the worker with LBP and the organizational needs in relation to managing LBP at work.

Methods Cross-sectional survey of line managers (n = 92) at an Irish University Hospital using a self-administered questionnaire. Quantitative data were entered onto the Statistical Package for the Social Sciences (V 11) and analysed using descriptive statistics. Qualitative data were coded and analysed for common themes.

Results A 64% (n = 59) response rate was achieved. Contrary to current evidence, 54% (n = 32) of respondent managers reported that a staff member needs to be pain free prior to return to work (RTW). Managers reported difficulties in dealing with colleagues of workers with LBP and in knowing the work capacity of the worker with LBP. Managers demonstrated poor awareness of the importance of the manager–worker relationship in influencing RTW. Managers believed more information, easier access to health services, more ergonomic training and better staff resources were necessary supports in facilitating the management of workers with LBP.

Conclusions Hospital line managers' knowledge of the evidence regarding their role in LBP management needs to be improved. Managers believed better information, improved staff resources and easier access to health and ergonomic services would facilitate their management of workers with LBP.

Keywords      Back pain; managers; occupational guidelines; return to work; workplace


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Low back pain (LBP) is associated with major costs, in terms of health resource usage, worker disability and absenteeism [1] with LBP established as one of the most common causes of sick leave in the Western world [2,3]. The UK occupational health guidelines for the management of LBP in the workplace were published in 2000 and these emphasize the important role of line managers in reducing work-related disability [4]. Advice by health professionals to continue to work or to return to work (RTW) despite LBP is unlikely to be successful in the absence of both organizational and line manager support in the workplace. McLellan et al. [5] highlighted the critical role of non-medical personnel such as line managers in occupational health outcomes. Supervisors are most familiar with the requirements of the job, are the first to communicate with the workers about their RTW and usually have the authority to implement adjustments in working conditions. Those who come into daily contact with their employees are in a position to act as change and rehabilitation agents [6]. Supervisory behaviour is regarded as an important determinant of RTW by a number of authors [6–9]. Positive supervisory behaviour has been found to be associated with fewer work days lost and better job accommodation in employees who had successfully returned to work [7,10].

Despite an increasing emphasis on the role of employers in rehabilitation, little scientific knowledge has been accrued on this subject [11]. Some research has been conducted in relation to the supervisor's role in RTW of individuals after myocardial infarction or coronary bypass surgery [6]. Research regarding the line manager's role in managing the worker with LBP is lacking.

Many studies have explored LBP in relation to specific work sectors and found a high level of LBP and related disability among health service workers [12–18].

As part of a larger project aimed at developing and implementing an evidence-based organizational strategy for LBP management among hospital workers at an Irish teaching hospital, a survey of the hospital's line managers was conducted.

The aims of this managers' survey were to identify

(i) knowledge, attitudes and beliefs of hospital line managers regarding LBP and its management,
(ii) difficulties encountered by hospital line managers in managing the worker with LBP and
(iii) organizational supports needed by hospital line managers in relation to managing LBP at work.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflicts of interest
 References
 
This study was carried out at a major Irish University Hospital which had 2237 staff members. A cross-sectional survey of line managers at the hospital was conducted using a self-administered questionnaire. Ethical approval was obtained from the local ethics committee. The line managers of frontline staff at the hospital were categorized into three main groups: consultant hospital doctors (n = 120), nursing managers (n = 56) and heads of department (n = 32), giving a total of 208 managers. The Statistical Package for the Social Sciences (SPSS V.11) was used to generate random samples of 30 from each of the two larger management groups: nursing and consultant doctors. To ensure representation of managers of all worker groups, all the heads of department (n = 32) were included in the study sample, giving a final study sample of 92 managers.

No questionnaire specific to this study's needs was found in the literature and a self-administered questionnaire was therefore devised. This was divided into four discrete sections regarding

(i) manager profile,
(ii) managers' knowledge of hospital policy, procedures and services in relation to LBP,
(iii) managers' attitudes towards
(a) evidence-based guidelines for the management of LBP in the workplace and
(b) facilitation of the worker with LBP
(iv) managers' difficulties and needs in relation to managing LBP in the workplace.

Questions were a mix of closed- and open-ended questions for sections one and two. Section three was comprised of a series of statements which generated from the evidence-based LBP guidelines for the management of LBP in the workplace [4]. Respondents were asked to indicate their level of agreement on a Likert scale where 1 = completely disagree and 5 = completely agree. Statements were a mix of true and false statements to avoid respondents becoming biased towards one end of the scale.

Very little research has been conducted regarding managers' approaches or needs in relation to managing LBP in the workplace. Thus, the final section of the questionnaire was comprised of three open-ended questions, allowing for diversity and richness of responses regarding managers' difficulties, perceived barriers to RTW and organizational supports needed in relation to managing LBP at work.

The study questionnaire was piloted on a group of health service managers at an equivalent Irish hospital for content and clarity and minor adjustments were made.

The questionnaire was also reviewed by the occupational LBP management team at the research site, who deemed it to have good content and face validity, with clear and unambiguous questions.

The final questionnaire was distributed to managers (n = 92) using the internal mail system at the hospital. Reminders were sent to non-respondents at 2 weeks.

Questionnaire data were entered onto SPSS V.11. For section three of the questionnaire, data relating to the categories of agree and completely agree were combined, as were data in the disagree and completely disagree categories.

Descriptive statistics were used for the analysis of quantitative data. Qualitative data analysis methods were used for the responses to the open-ended questions regarding managers' difficulties, perceived barriers to RTW and organizational supports needed. These data were transcribed and a coding scheme was generated based on the themes that emerged from the data. Codes were applied by the principal investigator on two separate occasions and two independent researchers also applied codes to the transcripts. The reliability of the coding scheme was checked using a recognized formula (number of agreements/total number of agreements and disagreements), where >90% agreement is deemed to represent good reliability [19]. Intra-rater reliability was >95% for all codes with inter-rater reliability >88%. In addition, kappa coefficients were calculated based on the codes given by the researcher and each of the two other coders. The kappa coefficient values were all >0.7 indicating good inter-coder agreement [20].


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
An overall response rate of 64% (n = 59) was achieved. Response rates differed between manager groups with a 93% (n = 28) response rate from nursing managers and 59% (n = 19) from heads of department. Only 40% (n = 12) of consultant doctors, who were surveyed, responded. Thus, all manager groups were represented among respondents but 47% (n = 28) of respondents were from nursing management, 20% (n = 12) from medical management and 32% (n = 19) were from heads of department. Seventy-five per cent of respondents (n = 44) were female and 25% (n = 15) were male. The number of staff managed by respondents ranged from 2 to 130 (median = 12). In the previous year alone, 54% (n = 32) of managers had experience of managing a worker whose LBP had affected work performance with 49% (n = 29) of respondents having a staff member on LBP-related sick leave in the previous year. Seventeen per cent (n = 10) of managers reported having had difficulties managing a worker with LBP.

The questionnaire explored for many organization—specific factors regarding LBP management, only some of which are reported here as being of more general interest. Although all managers were aware that Irish legislation requires that staff receive manual handling training in accordance with the Safety, Health and Welfare at Work Act [21], only 41% (n = 24) of managers were aware that the responsibility for ensuring staff received such training lay solely with them. Sixty-nine per cent (n = 41) of managers were aware of the ergonomic service provided by the Physiotherapy Department at the hospital and 44% (n = 26) of managers had availed of this service in their work area. A majority (88%) of managers were aware of the need for a medical assessment in cases of workers sustaining a back injury at work.

Section three of the survey questionnaire explored the level of manager agreement with a series of guideline-based statements and these results are given in Table 1.


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  		Table 1. Proportion (%) of managers in agreement with guideline-based statements regarding the management of LBP in the workplace (n = 59)

 
Seventy-eight per cent (n = 46) of managers were aware that LBP is common. However, overall knowledge of LBP and the fact that a majority of cases of LBP are not serious and will resolve needs to be emphasized with managers. Only 47% (n = 27) of managers reported being aware that an active approach is appropriate in most cases of LBP. Contrary to current evidence, 56% (n = 33) of managers indicated that they believed a staff member needs to be pain free prior to RTW which is likely to lead to unnecessary prolonging of sick leave. Although the latest evidence emphasizes the provision of modified duties as a means of facilitating earlier RTW, 22% (n = 13) of managers believed workers should stay off work until they could perform full work duties. Fifty-eight per cent (n = 34) of managers appeared to be aware that contact should be maintained with the staff member who is on sick leave but it is important that all managers are aware of the benefits of such contact.

This survey also explored the level of manager agreement with a series of statements regarding staff issues which arise in relation to LBP in the workplace and facilitating the worker with LBP (Table 2). Fifty-eight managers responded to most of the questions in this section but some questions had only 56 or 57 respondents as indicated in Table 2. Sixty per cent (n = 35) of respondents agreed that having a worker with LBP can make work more difficult for other staff with 40% (n = 23) reporting that staff can display a negative attitude towards the worker with LBP. Thirty-eight per cent (n = 22) of managers reported that offering modified duties to a staff member with LBP was difficult and 53% (n = 30) of respondents reported that knowing what level of work to expect from the worker with LBP was difficult.


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  		Table 2. Manager attitudes towards managing LBP in the workplace

 
The themes identified among the transcribed data and some of the related quotes for each of the three open-ended questions relating to manager's difficulties, perceived barriers to RTW and organizational supports needed are given in Tables 3–Go5. Lack of information regarding the level of work to expect from the worker with LBP and how to progress the worker's capacity was a clear difficulty.


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  		Table 3. Manager difficulties in managing the worker with LBP

 

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  		Table 4. Manager perception of barriers to RTW for the worker with LBP

 

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  		Table 5. Organizational supports needed by managers for the management of LBP among staff

 
As might have been expected, reduced productivity of the worker with LBP presented a difficulty for managers. The impact on colleagues of having a worker with LBP was a commonly cited difficulty and this appeared to be a result of the reduced productivity of the worker with LBP. More information regarding LBP and its management was identified as a necessary support. Managers believed that more ergonomic assessments and staff training would also be of benefit. Improved access to staff back services was deemed to be important in managing the worker with LBP. Finally, greater staff resources to allow normal productivity levels when some staff are operating at reduced work capacity was identified as facilitating managers in their management of workers with LBP.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
Overall, there was insufficient awareness of the current evidence regarding LBP management and greater familiarity with hospital back policies and services was required among managers at this hospital. Managers were aware of the difficulties that physical workload may present for the worker with LBP but felt they needed greater organizational support in order to provide modified duties. The need for more emphasis on psychosocial factors such as the importance of having good staff relations and improved communication between all involved in the management of the individual with LBP for the facilitation of RTW was evident.

This was one of the first studies to explore the role of line managers in the management of LBP in the workplace and as such gave important new insights into the management of occupational LBP. Doctors were underrepresented among the respondents thus limiting conclusions regarding this manager group. This low response from doctors may reflect a lack of commitment to managing LBP among their staff or less exposure to LBP and related disability among medical staff. The focus on health service workers only and in one specific work setting did not allow these study results to be applied to other worker groups or other work settings and the lack of previous research in this area did not allow direct comparison of this study's methods or results.

Despite most managers having had experience of managing staff with LBP, familiarity with the organization's policy regarding LBP management was lacking in many cases. In addition, the attitudes of many managers surveyed here were unlikely to encourage ongoing work or RTW of workers with LBP.

Current evidence emphasizes that psychosocial aspects of health and work in combination with economic aspects have a significantly larger impact on RTW when compared to relatively physical aspects of disability and physical requirements of the job [22]. Most remarkable in the results was the managers' seeming lack of appreciation of how their management style or relationship with the worker might influence the RTW process. This finding is reflected in a Canadian study which found that human resources managers and health care professionals attributed motivation to personal characteristics whereas injured workers, worker representatives and health and safety managers described workplace culture and the degree to which workers well-being was considered as having a strong influence on workers‘ motivation [23].

Maintaining sympathetic contact with the employee on sick leave and the importance of workers feeling valued is advocated in the literature [9,24,25]. Yet, only 58% (n = 34) of respondents appeared to have supported this principle. The Whitehall II study [26] emphasized the importance of manager and co-worker support in reducing sick leave but managers surveyed here appeared to be over-focusing on organizational supports and the physical workplace issues. This is despite research which shows that workers believe their supervisor has a significant role to play in the RTW process and that manager support, high job satisfaction and good industrial relations are regarded as the most important organizational characteristics associated with low back disability and back-related sickness absence [4].

Fifty-three per cent (n = 30) of managers reported having difficulty in knowing the level of work to expect from the individual with LBP and this was reflected in the qualitative analysis, where managers reported needing more information regarding the work limits of the individual with LBP. Many managers believed that provision of modified duties would be difficult in their department. This issue needs to be addressed as the weight of evidence is in favour of the provision of modified duties, with research to show that injured workers who are offered modified duties RTW about twice as often as those who are not [27]. Similarly, modified work programmes have been found to reduce the number of lost work days [27,28].

Managers identified that more information and improved communication regarding management of the worker with LBP were necessary. Perhaps many of the difficulties experienced by managers, including access to back services and handling relations between colleagues, could be resolved through improved communication. Indeed, McLellan et al. [5] advocated disability management training for supervisors in order to allow proactive and supportive disability management in relation to musculoskeletal disorders in the workplace.

Systems for improving manager awareness of the current evidence and local policies and procedures relating to back pain management need to be developed at the hospital site. Manager workshops may be of benefit. Managers indicated that provision of staff cover to support modified duties was necessary and that more ergonomic assessments and advice would be beneficial. Greater support for the concept of modified duties at an organizational level needs to be attained. The occupational health practitioners will need to develop systems which facilitate communication with line managers on a more routine basis.

The qualitative research methods utilized in this study allowed the identification of key areas of concern for managers which might not have been identified using other study methods. Further research using focus groups or in-depth interviews with managers should prove valuable. Future studies are needed to explore managers' actual practice and how it influences levels of LBP-related disability in the workplace. The efficacy of interventions aimed at changing manager attitudes and practice will need to be researched.


Key points
  • Managers need to be more familiar with current evidence regarding the management of LBP in the workplace, including their important role in facilitating the worker with LBP.
  • Managers are aware of physical workload factors but also need to consider psychosocial factors when facilitating RTW of individuals with LBP.
  • Improved communication between back clinicians, workplace managers and the worker with LBP is advocated.

 


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
References
 
None declared.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

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