The Capacity Note: a communication facilitator in the sick leave process of patients with common mental disorders – a qualitative study of user perceptions
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* Paula Nordling
* Annika Jakobsson
* Gunnel Hensing

## Abstract

**Objectives** To describe the development of a communication facilitator, the Capacity Note, for the sick leave process of patients with common mental disorders (CMDs) in primary care, and to explore users’ perceptions of it.

**Design** Qualitive study.

**Setting** Primary healthcare in Region Västra Götaland, Sweden.

**Participants and methods** The Capacity Note was developed inductively based on data from six qualitative studies of work capacity and CMD and was introduced at primary healthcare centres during 2018–2019. Individual semistructured interviews were performed with 13 informants (8 patients, 2 general practitioners and 3 managers) who had used the Capacity Note at least once. Interviews were audiorecorded and transcribed verbatim and inductive manifest qualitative content analysis was used to analyse the data.

**Results** The Capacity Note comprised questions about work situation, work capacity limitations and possible work adjustments. Based on the interviews, four categories relating to its role as a facilitator for communication about work and health were identified: content and format, understanding, legitimacy and action, openness and timing, and time and efficiency. The participants considered the Capacity Note relevant and easy to use, and as having the potential to improve communication about and understanding of the patient’s situation. The increased understanding was perceived as contributing to a sense of legitimacy and agency. Achieving these benefits required, according to the participants, openness, an investment of time and using the Capacity Note at the right time in the sick leave process.

**Conclusion** The Capacity Note was found to be relevant and as having, under the right conditions, the potential to improve communication and facilitate the sick leave process.

*   PRIMARY CARE
*   MENTAL HEALTH
*   QUALITATIVE RESEARCH

### Strengths and limitations of this study

*   This study describes a novel approach to stakeholder communication about work capacity in the sick leave process of patients with common mental disorders (CMDs).

*   It is considered a strength that the communication facilitator was developed based on stakeholders’ own reports of work capacity and CMD.

*   The results regarding user perceptions represent a limited experience of the communication facilitator. A higher number of participants, in particular general practitioners and managers, may have provided richer data and greater variation in the findings.

## Introduction

A closer collaboration between stakeholders has been described as important for a good sick leave and return-to-work process but also as difficult to achieve.1–5 This study qualitatively examined how patients, general practitioners (GPs) and managers perceived and used a communication facilitator, the Capacity Note, for the sick leave process of patients with common mental disorders (CMDs).

There is today no golden standard for how to best achieve sustainable work participation for patients sick listed with CMD.6 7 In Sweden, these patients are generally treated in primary care where GPs are responsible for sickness certification when needed. To assess work capacity and need for sick leave and rehabilitation is a difficult task in general, and even more so in cases of CMD.3 8 9 In these conditions, symptoms and associated work capacity and rehabilitation needs are highly individual and often unpredictable.10–12 This makes guidelines and standard assessments less useful and calls for an increased recognition of the individual and subjective parts of the assessment.9 12–14 In addition, the work place must be considered which is yet another piece of information that is individual and difficult to assess.8 GPs rarely communicate with employers—lack of time and disclosure concerns being commonly mentioned reasons—but have to rely on the patient’s descriptions of what can be done at the work place.3 15 The assessment is further complicated by the fact that the patients with CMD themselves find it difficult to grasp and describe their reduced work capacity.10 

At the patient’s work place, the manager is responsible for facilitating the employee’s return to work, for example by providing work adjustment.16 But managers too struggle with the vagueness of mental health problems and find it hard to identify, describe and deal with them.15 17 18 In Sweden, due to confidentiality laws, employees do not have to disclose any diagnosis to the manager, only the effects of the diagnosis on functioning (eg, difficulties concentrating) and how that affects their capacity to work (eg, they cannot learn new tasks).19 Such information should be stated in the sickness certificate but is often limited, especially statements about work capacity.20 Moreover, with their medical focus, sickness certificates can be hard to interpret for managers. Consequently, with restricted knowledge of the patient’s specific problems, individualised adjustments can be hard to accomplish.

Increased communication in the sick leave process has been approached in different ways, for example information exchange between health professionals,21 structured conversations between employer and employee,22 and a guide for patients’ discussions with various stakeholders.23 Our focus was to promote communication about health and work among the three key stakeholders: patient, GP and manager. For this purpose, we developed a communication facilitator—the Capacity Note. The idea was to have the patient as the main informant and the Capacity Note as a transmitter of written information between physician and manager. The intent was to increase the manager’s understanding of reduced capacity to work from the medical perspective, and the physician’s understanding of possible measures to adjust the work environment from the workplace perspective. The aims of this study were to describe the development of the Capacity Note and to qualitatively examine how the stakeholders perceived its content, format and use.

## Methods

### Development of the Capacity Note

The Capacity Note was developed based on data from six qualitative studies examining work capacity and CMD: three studies with individuals having personal experiences of CMD and work,10 11 24 two studies with physicians and other healthcare professionals,14 25 and one literature review.3 Data relevant to the purpose of the Capacity Note was identified inductively in the results sections of each of the six articles and condensed into items. The items were compared across the six sources and grouped into content areas. Then, considering the short consultation times in primary healthcare, a selection of representative items from each content area were chosen. Based on the selected items, questions about work situation, work capacity and corresponding work adjustments were formulated. The draft was discussed at a seminar with researchers from different fields such as medicine, occupational therapy, physiotherapy and public health. This prompted some minor revisions, after which it was completed. Characteristics of the six studies that provided data to the Capacity Note and examples of their contributions are presented in table 1.

View this table:
[Table 1](http://bmjopen.bmj.com/content/12/4/e054436/T1)

Table 1 
Characteristics of the six studies that provided data to the development of the Capacity Note, and examples of their contributions

### Study design

A qualitative study design with individual interviews was chosen as appropriate to examine the users’ perceptions of the Capacity Note. Participation was based on informed consent and participants were informed that they could withdraw at any time. No incentives for participation were offered.

### Setting and participants

The Capacity Note was used at eight public and private primary healthcare centres (PCCs) in the southwest part of Sweden in 2018 and 2019 as part of a pilot study focusing on patients’ agency and sick leave during follow-up (data not presented in this study). In the pilot study, the Capacity Note was used by 28 patients, 14 GPs and, as far as we know, 12 managers.

Participants in this study were a convenience sample recruited from the pilot study based on the following inclusion criteria: patients must have used the Capacity Note with their physician no more than 9 months previously and agreed to be contacted about the interview study; GPs must have used the Capacity Note with at least one patient no more than 9 months previously; managers must have used the Capacity Note with at least one employee no more than 9 months previously and the employee must have agreed to their participation.

The 15 patients that filled the inclusion criteria were contacted in a random order via telephone. If interest was shown, written information and a consent form were sent by mail. Eight patients agreed to participate. Lack of time or energy were the most common reasons for not participating. Ten GPs met the inclusion criteria. For one of them, we could not retrieve the correct contact information. The remaining nine GPs were invited to participate in the study via their work email. Two GPs agreed to participate, two declined due to lack of time and five did not reply to the invitation or the two reminders. Of the 15 eligible patients, four had agreed to let their manager participate. These four managers were contacted by telephone (n=3) or work email (n=1) and they all agreed to participate. One of them fell ill at the time of the interview and could not reschedule, leaving a final sample of three managers. The characteristics of participants are presented in table 2.

View this table:
[Table 2](http://bmjopen.bmj.com/content/12/4/e054436/T2)

Table 2 
Characteristics of participants

### Data collection and analysis

Thirteen individual interviews were conducted by the first author (PN) during June–December 2019. Interviews took place in a conference room at a hotel or research centre, or at the participant’s work place if preferred, and lasted 18–58 min (mean 31 min). The interview guide was semi-structured and contained questions regarding the content, use and usefulness of the Capacity Note. All interviews were audiorecorded and transcribed verbatim. Data was analysed using manifest qualitative content analysis.26 This method was found suitable as most participants had experienced the Capacity Note only once and we sought to explore how they perceived it during this use, that is, their first impression rather than more far reaching (lived) experiences. When all the interviews had been transcribed, PN and AJ independently read the first three transcripts, first to get an overview, then line-by-line to identify meaning units. The findings were compared with ensure that they related to the research questions and that nothing relevant had been missed. At this stage, preliminary codes could be formulated but the main focus was on identifying meaning units. Then, the same procedure was applied for the remaining transcripts, three or four at a time. When all transcripts had been discussed, the authors jointly coded all meaning units. Then, similar codes were grouped into categories and related categories were grouped into higher order categories. An example of the coding process is found in figure 1. Codes and categories were rearranged several times to until no new subcategories or categories were identified. The preliminary results were presented at a seminar with external researchers which prompted a further revision of the categories into the final results.

![Figure 1](http://bmjopen.bmj.com/https://bmjopen.bmj.com/content/bmjopen/12/4/e054436/F1.medium.gif)

[Figure 1](http://bmjopen.bmj.com/content/12/4/e054436/F1)

Figure 1 
Example of the coding process.

### Patient and public involvement

There was no involvement of patients/public in the design or conduct of this study.

## Results

The Capacity Note comprised three parts with questions about work situation, work capacity limitations and possible work adjustments, respectively. It is presented in full in online supplemental appendix 1. The Capacity Note was meant to be used once for each patient during his/her sick leave process, but at two separate occasions: first a discussion between patient and GP, and then a discussion between patient/employee and employer. A schematic presentation of the intended use, and the actual use (as described in the interviews), is presented in figure 2.

### Supplementary data

[[bmjopen-2021-054436supp001.pdf]](pending:yes) 

![Figure 2](http://bmjopen.bmj.com/https://bmjopen.bmj.com/content/bmjopen/12/4/e054436/F2.medium.gif)

[Figure 2](http://bmjopen.bmj.com/content/12/4/e054436/F2)

Figure 2 
A schematic presentation of the intended use (thick arrows) of the Capacity Note (CN) and the alternative ways it was used (thin arrows) by participants as described in the interviews. GP, general practitioner.

We identified four categories relating to the role of the Capacity Note as a facilitator for communication about work and health: content and format, understanding, legitimacy and action, openness and timing, and time and efficiency (figure 3). Each is presented below, with corresponding subcategories. The categories and subcategories represent the participants’ joint perceptions of the Capacity Note as generated from the data. Within each category different perspectives and nuances were found and these are also presented.

![Figure 3](http://bmjopen.bmj.com/https://bmjopen.bmj.com/content/bmjopen/12/4/e054436/F3.medium.gif)

[Figure 3](http://bmjopen.bmj.com/content/12/4/e054436/F3)

Figure 3 
Categories and subcategories.

### Content and format

#### Providing structure and content to the conversation

The participants agreed that the Capacity Note was clear, well structured and easy to use. The content was considered relevant and, according to one participant, ‘comprehensive but not too much to handle’. As such, the Capacity Note was thought to provide a good starting point and framework for a discussion about health and work. The informants also stated that it had the potential to extend and deepen the dialogue by giving examples that had to be considered; these might not have been discussed otherwise but would now be elaborated and could take the discussion further. The structure was experienced as making it easy to see what one had missed, but also as a potential risk—that other potentially important issues were overlooked. The professionals (GPs and managers) suggested that the Capacity Note was of greatest benefit to GPs and managers with little previous experience of sick-listed patients/employees with CMD, while for more experienced professionals it was perceived as not providing any knew knowledge.

Some suggestions for further content were made: additional physical symptoms (eg, heart palpitations, shortness of breath), how the health situation affects private life, how private life affects the capacity to work, a more detailed description of the work environment (including psychosocial factors), specific situations that trigger or worsen the symptoms and other available resources (eg, support from occupational health services).

The presented suggestions for work adjustments were considered relevant but, depending on the type of job, not always possible to implement.

> I believe it resulted in a deeper conversation. […] Because in some way you had something to relate to, not just my notes but this was slightly more… here you had a few more examples… some structure. (Interview 11)

#### Finding the right format

Participants expressed disparate views on the best format for the Capacity Note. The paper format was questioned by the two participating physicians; an electronic form was suggested as a smoother and more dynamic alternative, preferably connected to the sickness certificate and one where all three stakeholders could add and update information continuously. Patients appreciated seeing things ‘black on white’. Informants also mentioned that using the Capacity Note over the telephone was less suitable as it made the conversation more static.

> I think it was great, what’s annoying… was annoying was, uh… the paper format. (Interview 7)

#### Putting words to the patient’s situation

Patients said that the specific wordings in the Capacity Note were helpful for putting words to what they experienced, and that this was a relief. Similarly, the physicians said that the Capacity Note could facilitate the difficult task of describing the patient’s cognitive functional limitations in the sickness certificate.

> …it became clearer, partly for me and that I could put it into words [to the doctor] … which I couldn’t before but when I got them [the words] here… it was, well, that’s exactly how it is. (Interview 1)

### Understanding, legitimacy and action

#### Contributing to one’s own and others’ understanding

According to informants, the patient’s own understanding of his/her situation could improve when reflecting on the questions in the Capacity Note. One patient described it as an ‘aha-experience’. This, according to one GP, made it easier for the GP to explain things to the patient. It was also said that using the Capacity Note could add to the GP’s understanding of the patient’s situation, and that this was depending on how much had been discussed at previous consultations. One manager stated that discussing the suggested work adjustments could help the patient see what the manager was already doing to improve the work situation.

None of the participating managers had discussed part 2 of the Capacity Note with their employee, that is, the part which describes the work capacity limitations. The managers agreed that it could have increased their understanding of the patient as a person but were uncertain whether it would have affected the discussion about and execution of work adjustments.

> …possibly I would say that the advantage of the form for… from the employee’s point of view, I noticed, may be that he, she gets a, eh… what should we call it… a little eye-opener about his, her situation at work. (Interview 11)

#### Understanding promotes action

Some informants stated that when the patients understood their situation better, it helped them to choose strategies and make decisions, such as accepting the interventions offered by the healthcare or adopt new strategies at work. The impact on physicians’ and employers’ actions was less evident but one participant felt it had facilitated team work at the PCC.

> …I think it motivated the patients to, eh… take their… interventions that we recommend, like therapy, like taking their medications […] … and some of the patients also noticed that they did not take breaks normally and now they have begun… (Interview 7)

#### Legitimacy before oneself and others

Legitimacy was touched on in several interviews. According to the patients, the Capacity Note gave legitimacy to their situation by describing it so well, which made them understand that their problems were normal and real. Also, getting the physician to really listen was perceived by patients as a benefit of using the Capacity Note. Informants noted that the Capacity Note could be a support for the patient in the conversation with the manager, which was described as an even more vulnerable situation. One informant, however, questioned whether it would be enough support.

> I felt that… I’m not imagining. When I saw it on paper or like when I had ticked it […] you felt that it… it was really like this. […] And then I also think in front of others too, it was good to have this as a support […] that I knew that this is how it is and then I could sort of, uh… take it in a different way when others might think that, well… you are on sick leave. (Interview 5)
> 
> If he [the boss] had sat with this note, he might have understood what I have been trying to tell him for six months. […] that what I have been saying all these months is actually true. […] Because when you do it with a doctor, there’s another authority in the whole thing, unfortunately. (Interview 6)

### Openness and timing

#### The role of openness and honesty between stakeholders

The issues of openness and honesty were also discussed, and the perspectives were contradictory. It was said that how much you want to disclose will differ from person to person and that the patient’s agenda and how he/she perceives the purpose of the Capacity Note will affect his/her answers. On the other hand, it was also said that the Capacity Note could help the patients to be honest about their symptoms, work disabilities and needs when they saw that they were legitimate. The patients stressed that the Capacity Note helped them to more fully explain their situation to the GP, which was perceived as positive. In contrast, the willingness to disclose the same information to the manager was described as depending on the manager’s attitude. None of the patients had actually discussed it with their manager. To some, this was a relief, as they did not want to reveal their ‘shortcomings’. Others said that they would have wanted the manager to see it, as they believed it would have increased the manager’s (and the whole workplace’s) understanding of what it was like to work with CMD.

One manager suggested that a form for communication between only physician and manager would lead to more honest communication about the patient/employee, as it can be difficult to be fully honest in front of the patient. Other participants suggested that a joint meeting with all three stakeholders would lead to a better common understanding of the situation as everyone hears what is said. It was suggested that the Capacity Note could serve as a basis for such a meeting.

> I might not have wanted to show it to him, the boss I had then, because it… it was too hard. […] It was just… that boss was not receptive to it. (Interview 3)

#### Uncertainty about the right timing

The participants expressed uncertainty about when would be the best time to use the Capacity Note. Generally, an early use was advocated—to map the situation and/or to stimulate return to work. But not too early, some said, as it might take focus off the medical aspects and the patient might not have enough energy or motivation yet to discuss return to work. For those that had partially returned to work when they used the Capacity Note it was perceived as less useful since they had already gained an understanding of their situation and work adjustments had already been discussed.

> There is much to go into at a first doctor’s visit and sick leave, which may well be high on the patient’s agenda but it… it must have a lower medical priority, we must first find out if the patient is about to die or… or has something that requires medicine… (Interview 8)

### Time and efficiency

#### Time is essential for good communication and understanding

The issue of time was often discussed in the interviews, especially the lack of it. Patients expressed that the physicians’ lack of time could cause feelings of stress and lead to thinking less before answering, and that the managers’ lack of time (or interest) resulted in a limited discussion of the Capacity Note (the employee did not have a say, the manager just ticked the boxes) or in it not being used at all.

> I: How do you think it affected your conversation [with the doctor] to complete it?
> 
> IF: Well… I was probably a little affected by the fact that there were so many 'yes'. […] Eh… at the same time we didn’t have much time, I felt, to talk about it…
> 
> […]
> 
> I: If you had had more time, would you have wanted to discuss it more?
> 
> IF: Mm, yes, I would have. (Interview 12)

#### Striving to be efficient

One GP had used the Capacity Note over the phone, after the consultation, and perceived it as lengthy (approx. 7–8 min) and not very useful. The other GP had used it several times within the consultation and described it as taking even longer (approx. 15–20 min) but worth the effort, due to the increased understanding it provided, as discussed above. The GPs’ lack of time was recognised by both patients and GPs and several suggestions and attempts to resolve it were described. For example, it was suggested that patients fill in the form alone or with other healthcare personnel before the doctor’s visit. One patient filled it in by herself during the consultation, explicitly to save the GP’s time. At the same time, participants recognised the benefits of discussing the Capacity Note together.

> Yes, I probably would have wanted to do it myself first, without her [the GP] sitting in the same room. … Because I was stressed, it’s part of the disease sort of… (Interview 4)
> 
> … if the patient had completed it at the beginning, before we met, I’m not sure but then… I think that maybe the sick leave assessment itself could have become a little sharper in less time, a bit… fewer questions and so on. On the other hand, it might not have been an equally open conversation, unconditional, but perhaps the conversation risks being mostly about the sick leave issue, perhaps. […] …you think about being able to work or not, rather than in what way I am sick and what suffering I’m actually experiencing and what we should do. (Interview 8)

## Discussion

In this study, we presented the development of the Capacity Note and qualitatively examined how users (patients, GPs and managers) perceived and used it. Overall, the participants were pleased with the content and structure of the Capacity Note. An important perceived benefit of the Capacity Note was the ability to increase the users’ understanding of the patient’s situation, especially the patient’s own understanding. This is an important finding because patients with CMD have expressed uncertainty about their condition and what can be expected regarding work participation,10 as well as concerns about the legitimacy of being on sick leave due to CMD.13 The precise descriptions in the Capacity Note of how the patient’s work capacity was affected represented one way to bring clarity. Putting words to this has been described as difficult by patients,13 physicians27 and employers.17 To think about the questions and finding the right words contributed to the patient’s understanding and feelings of legitimacy and agency.28 Moreover, the Capacity Note could help the GP describe the patient’s cognitive functional limitations more clearly. This is equally important as the sickness certificate is the basis for the patient’s entitlement to sickness benefits. The benefits of describing the specifics of the situation is also interesting in relation to the modern practice of focusing on abilities instead of disabilities in vocational rehabilitation.29 One could assume that focusing on what the patient *can* do will increase the patient’s motivation and agency. But by focusing only on abilities, the question of how to work with disabilities cannot be answered properly.30 31 In line with this, we found that putting words to what the patient cannot do was the catalyst for further actions.

Having enough time was found to be important for good use of the Capacity Note, which is in line with previous research on work capacity assessments,3 and collaboration.32 Informants who experienced that they had given or been given the time to discuss the Capacity Note more in-depth more often stated that they had gained a better understanding of the situation and were the most positive about the Capacity Note.

GPs lack of time was described as being ‘the bottleneck’ and suggestions for a more ‘effective’ use were given. One was electronic information transfer, which physicians also have suggested in other studies.33 As a working tool for professionals it might be the smoothest option, but confidentiality regulations can be a hindrance to implementation.34 Despite the perceived lack of time, several suggestions for additional items in the Capacity Note were made. Also, joint meetings with all stakeholders were proposed as better for achieving a common understanding, but these are indeed time consuming and hard to achieve.32 On the whole, this suggest a tension between what you want to achieve and what is possible. The suggestions for streamlining should perhaps not be seen as ways to achieve an optimal tool but as ways to make the most of what you have got. There was a common understanding among the participants that understanding takes time and participants acknowledged that streamlining comes with a risk of losing the core of the Capacity Note—the discussion. It also raises the question of who is the primary owner and beneficiary of the Capacity Note. The stakeholders all had different needs. The professionals primarily wanted to receive information that would facilitate their job of managing the patient/employee’s sick leave, something which can be achieved in many ways. The patients, on the other hand, seemed primarily to want understanding which requires more purposeful interaction.13 

Openness and honesty were identified as necessary for good communication and understanding. The Capacity Note was perceived both as a potential help and hindrance for this, depending on how the patient perceived its purpose. The GP’s traditional role as the patient’s advocate was reflected in the patient’s stories about how the Capacity Note helped them explain their situation to their GP. At the same time, there is a power balance,35 where the patient is at a disadvantage in relation to both the physician (to get the sickness certificate) and the employer (to get adjustments, to keep position, etc) which could affect the patient’s answers. In relation to this, communication directly between GP and manager was suggested. However, confidentiality regulations prohibit the physician from sharing any information without the patient’s consent.19 Also, information transfer without involving the patient might not efficiently affect work resumption.21 From the patients’ point of view, being open and honest with the employer was more difficult and depended greatly on the employers’ attitude. This is in line with previous research identifying support and mutual trust as important for the sick leave and return-to-work process.35–37 In addition, stigma regarding mental health can make employees reluctant to share health information with their employer.11 38 Managers might be sceptical,15 or lack sufficient knowledge,39 of the causes and effects of CMD, which affects how they address it and support the employee.

The Capacity Note was perceived by the GPs and managers as most beneficial to inexperienced professionals, a finding also reported by Hoefsmit *et al* 40 regarding their ‘conversation roadmap’ for employers and employees. While the professionals in this study did not perceive that their understanding of the patient’s situation increased, several patients felt that their GP understood them better after using the Capacity Note. The same was not said about the managers, most likely because the employee’s health and work capacity (part 2 of the Capacity Note) were not discussed in those conversations, only work adjustments. The conversation between employee and manager about the employee’s work capacity limitations was an important part of the Capacity Note and an aspect that has not, to our knowledge, been examined before. However, due to the lack of descriptions of such a conversation and its potential benefits and drawbacks, it was not possible to analyse further. This could be approached in future studies. For managers, the perceived usefulness of the Capacity Note was also limited by the fact that the suggested work adjustments were not always possible to execute.41 

Participants were unsure about when would be the best time to use the Capacity Note. In general, an early use was considered desirable, which is in line with the intended use as well as national sick leave recommendations for patients with CMD. But readiness for returning back to work was also mentioned as important. This tension between recovery and return to work has been observed in several other studies and supports our finding that the timing of the intervention is important and must be considered for each patient individually.28 36 

To sum up, this study focused on participants’ perceptions of the Capacity Note and the results showed that there may be important benefits from using it but there are also barriers to its use and the proposed benefits. The results from the pilot study, in which the Capacity Note was used and from which the participants in the current study were recruited, will provide further information about the feasibility of the intervention.

Finally, a future study focusing on the implementation of the Capacity Note in regular clinical practice is needed given the reluctance previously found among GPs to change their ways of working.

### Methodological considerations

All interviews took place at a ‘neutral’ place, and participants seemed to be at ease. PN performed all interviews, ensuring similar interviews for all participants. She was a medical doctor with work experience in Swedish primary care, and had been involved in the development of the Capacity Note and as a research assistant in the pilot study. This ensured a good understanding of the content and context of this study. PN also analysed the data. To reduce the risk of preconceptions influencing interpretation of data, the analysis was performed together with the second author (AJ) who had not taken any prior part in the project.

The main limitation of the study is the low number of participating GPs and managers. Recruitment of GPs proved difficult, presumably due to time constraints.42 Managers were positive to participation but since only four patients had consented to us contacting their manager, only four managers could be contacted. A broader representation of GP and manager characteristics (eg, in working experiences) might have led to greater variation in the findings. Also, a higher total number of participants may have added additional aspects to the results, as most participants had used the Capacity Note only once. The Capacity Note was meant to be used once for each patient during his/her sick leave process and therefore, patients and managers in the pilot study would naturally use it only once. GPs, on the other hand, could use it several times (with different patients).

We cannot rule out that those most positive to the Capacity Note participated while those less positive refrained participation. However, wanting to help research concerning mental health issues (regardless of opinion of the Capacity Note) was a commonly stated reason for participating. Recall bias may have occurred since the interviews took place up to 9 months after using the Capacity Note. We also noted occasional bias regarding giving socially desirable answers, for example, following up a negative comment with a positive one. Some, but not all, participants were aware of the interviewer’s central role in the project.

### Conclusion

The participants considered the Capacity Note relevant and easy to use and as having the potential to improve communication about and understanding of the patient’s situation. The increased understanding could contribute to a sense of legitimacy and agency in the patients. Achieving these positive effects required openness, an investment of time, and using the Capacity Note at the right time in the sick leave process.

## Data availability statement

Data are available on reasonable request. Data supporting the findings of this study are available from the corresponding author on reasonable request.

## Ethics statements

### Patient consent for publication

Not applicable.

### Ethics approval

This study involves human participants and was approved by The Regional Ethical Review Board in Gothenburg, Sweden, reference number 1115-17.

## Acknowledgments

The authors would like to thank the participants for their valuable contributions to the study.

## Footnotes

*   Contributors GH is the principal investigator and the initiator and guarantor of the project. GH and PN designed the study. PN performed the data collection. PN and AJ performed the data analysis. PN drafted the manuscript, AJ and GH contributed with critical revision of the manuscript. All authors contributed to, read and approved the final version of the manuscript and were involved in the decision to publish.

*   Funding This study was funded by the Swedish Research Council for Health, Working Life and Welfare (FORTE), grant number 2013-02216. The first author’s salary was paid by the county council Region Västra Götaland in Sweden.

*   Disclaimer The funding bodies had no influence on study design, data collection, analysis and interpretation of data, writing of the manuscript or the decision to publish the article.

*   Competing interests None declared.

*   Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

*   Provenance and peer review Not commissioned; externally peer reviewed.

*   Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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