The main categories reported by the OHPs along the given interview guide were: first, the self-perception of the OHPs’ situation; second, a description of the organizational culture towards mental health issues and third, a description of the behavior and attitude of the company’s managers, which was (in the perception of the OHPs) determined by managers qualification and selection.
Self-perception of the OHPs: highly engaged between patient care and commitment to the company
The participants described themselves as being very engaged in their work and reported a high commitment, despite difficulties in dealing with sometimes conflicting interests in their work.
Many of the OHPs reported to enjoy taking high responsibility in their company and expressed a motivation to develop structures for an adequate handling of their employees. For example, one OHP working in a bigger company reports his high motivation to achieve something for his employees and his company:
OHP: “It’s quite exciting! For me, that was always the point: if you do occupational medicine, then you best do it in a large company, because it's more exciting then (…). I have completely different structures, you know. I can rely on a social service, we have our own health insurance, we have sports programs, we now also have our own occupational health management department, we are also represented in a steering committee as occupational physicians. Of course, you can achieve much more here. (I5)
This engagement and enthusiasm in work is also present in the following quotation:
OHP: "... taking time for (...) employees, and I also find that very positive in the company compared to, well (...), to working as a resident doctor for example, because you simply have the time. And I take my time; because I think, that I can do that quite well: really listening to people, showing empathy, but also leading conversations; of course, not with everyone, that's clear. But I think I can do that quite well and I also think, that I can mediate quite well between managers and employees." (I11)
As a particular challenge in their job, they reported meeting the high demands in an overdetermined environment. Overdetermined means in this context, that other actors’ interests in the company are in conflict with each other and that the physician not only has to prevent sickness and initiate treatment, but at the same time inevitably has to take sides in a diffuse and complex situation.
Interviewer: “So, your role in that context, how would you describe that? What is your main task?”
OHP: “Well, that is what I thought as well (…) that was quite difficult for me, perhaps. The employee wanted me to take part, because we, as I said, have had an occupational rehabilitation talk with him before. And some more talks, when he always expressed towards accusation of mobbing. And then, I realized that today in the talk, too, what role do I have? What can I really do, or what does he expect now? What do the others expect? Should I say something? How far do I distance myself? What else can I do (laughing)? Yes, that was a little difficult for me.” (I12)
The OHPs thus play an important role and participate actively in conflicts between the needs of employees versus the constraints of the company. This becomes very apparent when, for example, rehabilitation conditions are discussed.
OHP: “So the issue “rehabilitation”, how can I accompany that well? How can I prevent burnout? Because many (employees) come to see me with the overburdening, and they explain their symptoms: I have sleep disorder, I have a headache. How do I find a good recommendation, for the employer, too? What cannot be considered? How much do I respond to the wishes of the employee, because sometimes it gets quite absurd: «I have to work in home office five days and I only can have minitime-tasks.»” (I24)
Among these more general conflicts, especially the treatment of mental disorders was described as a major task by the OHPs and caused a lot of insecurity in them:
OHP: “I noticed that I somehow lack the tools to handle mental, psychosomatic or psychiatric disorders, which appear again and again in work life. And there are situations in conversations: I’m partly not trained for, not prepared for, and I have to solve them somehow with my own common sense. And there were situations, again and again, which were really difficult and where I wished for some support. (…) And this is where I recognized, that I’m partly not proficient in and in part I’m not able to conduct those conversations, too.” (I15)
At the same time, the OHPs repeatedly report that they feel their patients trusting them and speaking openly about their issues. This trust by the employees however causes an even bigger insecurity of the OHPs.
OHP: “But I felt the boundary for me. I don’t know how to help him further. Trust was there, yes, so that you had the feeling, he wants to talk more deeper about the issues, but I didn’t know, how should I do that with him.” (I8)
Despite their high motivation, the OHPs feel restricted by their knowledge and see the need for further education.
OHP: “But really rather in the acute situation, someone comes with a complete unknown issue, gets an appointment and then unburdens himself so to speak, his troubles or cries than all of a sudden in front of me, because he is just, or she is just completely overstrained. So, handling that, having conversations techniques and so forth, these are things I lacked in certainty, a little bit in the past.” (I5)
After completing the training, the OHPs reported being more certain on the subject of mental health and more capable on how to treat employees with psychical strains or even suffering from mental illness. In general, they conclude that the training helped them on a practical level concerning everyday work-problems, too.
OHP: “Very appropriate and very necessary (both are laughing). Well, because it is helpful now with the daily work, too, to classify things and even conversations, you become a little more certain in conversation techniques and you dare to say: Yes, come again later. Like some sort of psychological surgery. Well, I don’t want to overstate that, but just to say: Yes, we can talk again about that and, and after all, well, that has helped much.”
Interviewer: Do you have the feeling that something changed a little bit over the time you were here? For example, your motivation or how you handle such conversations?
OHP: “Yes, you simply become more confident, a little bit, and you simply dare to do that, so to say. Yes, for example I’ve got a lady with eating disorder, I consequently summon her every four weeks. She is ill for a very long time, too, is doing her rehabilitation, and simply to stabilize her a little bit, I tell her: Just come, we can talk. Although I always say I’m not a therapist in that sense, but we can talk it over.” (I2)
Perception of organizational culture
The OHPs also described the prevailing organizational culture, mainly towards mental health issues. One group of OHPs reported a relatively open culture:
OHP: "So I think this is taken very seriously and at (my company) there is not only the medical service, where I am working now, but there is also the internal counseling service, which is more or less a psychological counseling center, where all employees can turn to and (...) that shows that the topic is taken seriously and that they also try to give assistance somehow or to provide the employees with counseling, so to speak, and so I think this is taken seriously.” (I18)
In line with that, some OHPs gave descriptions of elaborated psychological and psychosocial institutions (e.g., psychosocial counselling) in their company and reported, that issues of mental health were taken serious on almost all levels of their company. The openness within the company towards mental health issues was also reported in comparison to other companies.
OHP: „It becomes apparent, I think, that we really take up the issue psychical risk assessment in the company. I think one can always do more, but that it was integrated properly… I know that from other companies, where it’s not implemented, so I think that we are quite ahead in our company. For example, that (we) offer a compulsive training on risk assessment and psychical health. A bargaining agreement was properly singed, to both topics and management as well as workers’ council pushed these topics. We also not only have physicians, but have social workers in the company, too, and we cooperate well. All of that are signals. And that the training for managers was offered, compulsive on the issue and offers were established, too, for example a contact to and rapid integration in a psychosomatic clinic and coaching, training for resilience building and moderation in conflict-talk and such things.” (I5)
Other OHP reported more skeptically that mental health-topics were treated rather careless or with little attention in their company:
OHP: "…nice words and nice pictures, but whether it is really what is wanted, if, in other words, we really want to reintegrate everyone, I don't know. It's also a question of, well, the work has to be done and we're not... we can't keep all the chronically ill here. That is also an announcement.” (I19)
While these reflections describe at least a certain interest in the topic from the company side, mental health seems to be met with open rejection in other companies. Here, the interviewees describe that the topic is well known in the company, but is actively resisted.
OHP: "the management thinks very little of the topic of psyche" (I6)
Most of the time, physicians mainly describe the current situation and do not go into further detail about its background. When this happens, reference is usually made to the cost-effectiveness of the measures and the company's fear of putting them at risk by addressing psychological issues too much.
OHP: "...because the company of course also sees the days of incapacity to work continue to rise. Of course, we (the physicians) want to do something against that, but if you then say: “we would recommend this and that”, or then they (the company) think “Oh no, that, somehow, is too much of an effort or is expensive or could somehow, yes, bring negative results." (I6)
Here a situation is described where companies are aware of the strain on employees, but do not want to draw consequences, and are rather afraid that this could have negative consequences for the company (presumably primarily in economic terms). After all, there are also physicians who describe an open ambivalence in their company, in the sense of a contrast between set out concepts and everyday practice, which falls far short of these ideals:
OHP: "…it really depends on the people who have to do with it, …on the responsible person in the personnel department, on the manager, it really depends on them.” (I32)
Perception of company managers
A common claim in our interviews was, that much of the realization of a company's culture depends on the managers. According to that argument, managers play a crucial role for the mental health of the employees.
OHP: “I’m doing this now for seven years and I’m here in this company for seven years. And leadership is the crucial factor, which lets the employee enjoy going to work. And once someone enjoys doing something, he learns easily, he works easily, we all know that. And as soon as someone enjoys what he does, he becomes less ill.”
Interviewer: “And you are saying, leadership plays a crucial part – in which way?
OHP: “Completely. So – you cannot differentiate that. If you have a reasonable style of leadership, they (the employees) will come motivated to work.” (I14)
Other OHPs directly confirm this assessment and draw a direct link to employees (mental) health:
OHP: "Well, that's what I actually believe, that a person who is well led and has trust in managers, stays significantly healthier and performs better even in stressful situations and can achieve more and that, of course, negative leadership is often also the cause of mental illness and that's what I experience in many staff rounds." (I24)
None of the interviewees reported that managers and their behavior were unimportant to the mental well-being of employees, even though it was also reported that mental stress is also brought along from home or can arise as a result of interactions with colleagues from the same level of hierarchy.
Also, when asked for what reasons the physicians were consulted by employees, difficulties with managers were named (more than conflict with colleagues and stress form private environment) as an outstandingly important point.
OHP: "I think that plays a very big role... so whether the employees are doing well or not, depends to a large extent on the manager. That's what we see time and again." (I25)
Apart from that, the OHPs also regularly mention that managers are to a high degree a transmission medium of the organizational culture and may embody it in the employees' everyday experience. The otherwise abstract organizational culture manifests itself by this way to the employees in daily work routines.
OHP: "In that case, I don't think that it’s actually a climate that promotes good health. And even if there’s a written statement like 'We have a great health management system and a great psychosocial counseling center': if I then have managers who are known to be incapable of managing employees and leave these managers in their position, perhaps simply transfer them somewhere else and say 'Well, then they should just destroy the employees there,' then I don't know if this is the right way to deal with things. You can sense a certain frustration in me (laughs). Because that's just something that I notice again and again in everyday life." (I16)
Many OHPs criticize the way managers deal with their employees. They claim that most managers are mainly competent in professional, instead of leadership or social skills.
OHP: "That is the problem, that they are allowed to lead without having learned it. Not everywhere, but often. Someone is given a management task who has never proven that he is qualified for it, except by his professional skills. And perhaps you have to look more carefully when someone takes on a management task. Just because someone seems like a “jack-of-all-trades” and can do some great things…, you still somehow have to look if he can also lead." (I26)
From the perspective of the OHPs this is particularly disadvantageous because managers play an important role in the company in three different ways. First their work is largely responsible for how healthy a department is. Second, they realize the fundamental ideas of an organizational culture. Third, they could also fulfill an important role referring ill employees.
OHP: "The manager can notice in time if something is not right with the employee and then he or she can intervene in time, speak to the employee and can ensure that the employee has enough trust and is perhaps sent on to the appropriate help centers or comes to us for advice.” (I19)
All in all, the OHPs’ evaluation of managers remains very mixed for all three areas mentioned. Although some open-minded managers are described, they rarely live up to their responsibility for their employees. The perception of the managers remains rather not empathetic. Sometimes the OHP sense the managers’ own difficulties, such as sandwich positions, but nonetheless for the most part, the OHPs’ descriptions lead to the impression of a rather difficult relationship to the managers.
Skills of managers: professional versus interpersonal. “Leadership cannot be learned!”
Many OHPs state that a major problem in the collaboration with managers is that managers are usually not selected on the basis of their social, but of their professional skills.
OHP: "For me, it starts at the point in hiring, when management personnel are hired. That leadership quality, in other words, what I call emotional intelligence, is given such a low priority by the leaders compared to supposedly technical competencies, that that doesn't get any real importance!" (I16)
According to the OHPs social skills of managers are of bigger importance for employees than just technological skills or economic expertise. The lack of these skills is identified as a major obstacle to a healthy work environment.
OHP: "Well, I think the problem is that professionalism is so much in the foreground in the selection of managers that social competence usually only plays a subordinate role in their evaluation. This is why executives get into managerial positions even though they are not really suitable for it and I personally think that the (...) professional qualification is easier to develop than developing the (...) personality structure in the person himself, so that he is a good manager.” (I29)
One possibility to deal with this issue are educative workshops. Here however, the OHPs often report that such workshops are unfortunately usually only attended by managers who are already competent in dealing with their employees. In contrast, managers whose management style would lead to stress with the employees would reject such offers and could not be "forced" to be interested in the topic.
OHP: "The problem I see is that the people who have already reached the point where they say "Yes, I have my own role as a manager, i have a responsibility for my employees and I have to see how I deal with them”. They gratefully accept this and improve their skills, and they are very open to it. But the managers who have no awareness of the problem, who say "I'm not to blame for the situation, it's all the employee's fault and I'm great and whatever", you can't get to them. You can train them as much as you want, they don't come to any training voluntarily (now and then to a compulsory training course to which they are sent), and those are the ones you simply can't reach at all and who nevertheless ruin everyone.” (I29)