This qualitative study, exploring multiprofessional perspectives of the SRP, unveiled perceptions of suboptimal organisational support to apply best practices in SRP, resulting in process dysfunction and misalignment with patient needs and expectations. The findings revealed a pronounced gap between what the informants assessed as being the best for patients in SRP, which coincided with what was considered most effective for society, and how the SRP was perceived to work in reality. The informants depicted a process obstructing individualised care, thus risking worsening patients’ well-being and abilities. Hence, the room for process quality improvements and streamlining was believed to be huge. Identified quality gaps were inadequate assessments, lack of overall liability, shortage of interventions and mismatch between regulations and needs.

As a first main finding, it was evident that informants perceived the SRP system as generally unequal, poorly coordinated and unpredictable despite their good intentions as professionals. For example, we would like to draw attention to the fear that was expressed by informants about the prospect of being personally affected by illness and being forced to participate in SRP. This result provides a vivid insider perspective. We concluded that the informants’ narratives suggest real and extensive systemic issues within the SRP that need to be addressed fundamentally. We found no reason to perceive the notable and pervasive quality problems highlighted in this study, as solely due to isolated deficiencies in complex individual cases, local deviations or only for patient groups with specific needs. Our study aligns with previous Swedish SRP problem descriptions,9 18 and with international literature2 3 5–8 adding an in-depth, multiprofessional and front-line perspective to the reports from GPs, regional management and patients.

As a second main finding, we observed that informants described that inadequate assessments of patients’ health problems from a biopsychosocial holistic perspective resulted in conflicting messages, insecurity and worse health outcomes for patients. Based on the results, it appeared that the SRP, and GPs, often place greater emphasis on assessing eligibility for sickness benefits rather than identifying and describing the need for interventions, both medical and non-medical, which is in line with prior international research.2 3 5 6 The findings revealed that a lack of problem understanding leads to diverging interpretations, an inability to provide patients with plausible explanations, deficient problem-solving and inadequate planning around the patient. We concluded that though early assessments, careful SRP planning, process coordination and person-centredness are emphasised in current SRP guidelines,9 they are not fully implemented in reality.

The results further showed a significant discrepancy between how informants perceived societal and patient expectations on one hand, and the functioning of healthcare and the SRP system on the other hand. Patients were described to have expectations, beliefs and concerns about the handling of SRP that were in conflict with both evidence-based practices and the regulations governing SRP. For example, informants depicted a clear and significant gap between their perception of patients’ expectations of a diagnosis as an explanatory cause for their discomfort, and how the process actually unfolded. This finding is in line with previous studies highlighting how ‘being able to work’ is influenced by politics, media and the labour market,4 31 and the need to educate patients and the public.32 We concluded this finding indicates both insufficient health literacy33 and insufficient social insurance literacy in society34 from an SRP perspective. Further, our results indicated that a lack of problem analysis obstructs both clear answers to patients’ health questions and may aggravate miscommunication at all levels in SRP.

Related to assessments, the findings also indicated that patients receive different quality of care in primary healthcare depending on whether they were employed or unemployed prior to the SRP. Given that both these groups have been described as having similar complex needs,22 we find it difficult to justify these differences, if they exist. We concluded that there is a need for studying the effects of offering unemployed individuals with health issues, or unexplained difficulties in entering or re-entering the labour market, a biopsychosocial assessment in collaboration with healthcare providers, to avoid overlooking potential underlying medical issues.

A third main finding was that informants in the current study described how patients in the SRP express feelings of hopelessness and a desire to continue being on sick leave. Lack of overall responsibility for the individual’s process was seen to lead to short planning horizons, lack of plans and lack of realistic alternatives to sick leave. Further, the shortage of interventions resulted in long waiting times and lost hope, and patients’ fear of a personal financial disaster was perceived to steal focus from regaining health, function and work capacity. This finding aligns with previous research on patients’ emotional stress related to SRP1–3 while also providing an explanation for the underlying causes from a professional perspective.

The informants’ description of how they perceived that their patients act irrationally in the SRP can be understood through existing research on health literacy,33 sense of coherence,35 the normal grieving process36 and patient behaviour transitions in SRP.37

Becoming ill, and losing abilities previously taken for granted, is an unwanted turn in life. Different individuals have different abilities to cope based on health literacy.33 It would be reasonable to assume that deteriorating health and an SRP that is perceived as incomprehensible, unmanageable and meaningless could, similar to other types of grief, trigger overwhelming emotions in patients. Based on the normal grieving process, which describes that it is normal to first mourn an unwanted change, then accept it and then reorient oneself based on the new conditions,36 most individuals would eventually accept the new circumstances and reorient themselves.

Being able to shift goals is associated with positive feelings.38 Interestingly, patients in SRP who experience ambivalence about returning to work have weaker sense of coherence and goal direction, while those who have reoriented themselves within the context of being sick regain stronger sense of coherence and goal direction.37 We find it relevant to further investigate whether unpredictability in SRP, in combination with patient unawareness of other realistic options than sick leave, maybe a driver of patients reorienting themselves to identify with their sick role.

Patients losing control of SRP, as depicted by informants in this study, aligned with previous research from a patient perspective, which highlighted how SRP-related stress affects patients’ mental health in a negative way.2 3 Considering how the results indicated that the SRP puts patients in a situation where they lose control, it is relevant to compare the findings with previous research showing how prolonged loss of control due to external stressors can lead to fatigue and impaired cognitive function.39 Based on the results, we found it reasonable to highlight the risk that over time, a dysfunctional SRP process may lead to or perpetuate stress-induced impairments or incite prolonged sick leave. We argue this needs to be further investigated.

A fourth main finding was that informants found it nearly impossible to distinguish symptoms of illness in a legally sound manner from what can be described as normal reactions to life events, which is required by SRP regulations. Rigid SRP rules and procedures, and a unilateral medical paradigm, were perceived to contribute to legal uncertainty and hinder person-centredness.

The importance of non-medical factors for the need for sick leave has been described in previous research.4 31 40 However, this study indicated that the SRP system appears to need to be aligned with the available evidence. Our findings pinpointed that the combination of (1) difficulties distinguishing symptoms of illness from normal reactions and (2) suffering resulting from illness being valued highly in the Swedish social insurance system, carried the risk of medicalising common, non-medical, symptoms. In line with previous guidelines, research and position papers,2 3 5 11 41 42 we concluded that uncalled for sick leave (overdiagnosis) could entail the risk of passivity of the individual (through misapplied sick leave), but also the risk of overlooking non-medical factors that could be managed.

Based on this finding, we also argue that neither eligibility for sickness benefits, nor the SRP as a whole, meet the requirements for person-centred care17 as patients may need more confidence that support will be available when needed. Informants described deficiencies in the management of medical treatments and rehabilitation, impaired management of work-oriented rehabilitation, shortage of interventions, and lack of consensus and coherence of the process. Furthermore, the informants emphasised that the time to have a dialogue with the patients in the initial phase of the SRP about a person-centred and coherent SRP plan needed to be improved.

Overall, informants in our study described an SRP that was, in many respects, both dysfunctional and challenging for patients to navigate (with local exceptions). Notably, although our study examined the perspectives of professionals and not the perceptions of the patients, our findings are consistent with the results from previous qualitative studies with both patients1–4 and professionals.2 3 5–8

We concluded that the informants perceived it a veritable challenge for most SRP patients with lingering symptoms to take responsibility for contributing to adequate care and support in their rehabilitation process under the present circumstances. If the patients also have a lower health and social insurance literacy, conditions become increasingly suboptimal.

The chosen qualitative study design and data collection with focus group interviews were considered adequate to meet the purpose of the study. The focus group dialogues were sincere, dedicated and rich with details about personal experiences and contextual examples, thus allowing the researchers to comprehend the complexity of the SRP.

Front-line employees from various professions and organisations often described the same challenges differently. For example, one profession expressed frustration with another’s handling of SRP tasks, while the criticised group explained they faced limitations affecting their performance. This contrast highlighted the complex interdependencies within the SRP and the importance of understanding challenges from multiple professional angles. Despite working in different locations and public service organisations, the informants depicted a surprisingly coherent holistic view of the process as a whole. Not every informant explicitly stated everything, but in cases where there was disagreement, it has been indicated in the results.

Considering the transferability of the findings in this article, it is system specific, that is, dependent on how a particular SRP is defined on organisational macrolevel, mesolevel and microlevel.43 Our data suggested great local variation, which implies low transferability. However, the findings were to a large extent consistent with previous international studies, which indicates similar SRP challenges in differing contexts.