The role of OH in sickness absence is well known, because as a profession we understand that being at work is better for health and wellbeing than being out of work. Therefore, our aim is to support employees in remaining at work or returning to work earlier. With sickness absence rising in 2019, 2020 and very likely 2021 due to the current pandemic, more so than ever will OH be relied upon to assist with sickness absence.
An employer commonly refers an individual to OH when an individual is struggling in work, there is a risk of them falling out of work or when the individual has already had sickness absence, whether long term, potentially long term, or significant episodes of absence. The referral contains a number of questions posed to the clinician in relation to the health of the individual so that the manager/employer can obtain information to aid their management of that individual. It is well known that the line manager is the most significant person in the individuals working life and has the most influence (NICE) and therefore they need the guidance OH can provide them. However, our added value is the clinical support we can also provide to the employee, therefore reflecting well on the employer. During the appointment with OH, the clinician needs to assess the individual clinically, using the biopsychosocial model, so as to obtain information on their health matched to work. Taking the information gained, the OH clinician then uses critical thinking skills to make decisions so as to provide justified and evidence-based advice to the employer, answering the questions they have posed. A quality outcome report is essential for a productive partnership between the employer and OH and this requires justification taken from the assessment. Using motivational interviewing skills, they support work as an outcome goal for the individual whilst providing professional and credible clinical advice. This would not be possible without an effective assessment of the individual’s functional capability matched to work, a type of assessment unique to OH. Assessing functional capability requires an objective but empathetic assessment which is evidence-based. This evidence, not only comes from research but from the use of evidence-based tools, of which there are many.
The use of health assessment tools allows for information to be collected systematically and facilitates proficiency in critical thinking, recognising patterns, and evaluating function. This is particularly important when the assessment involves safety-critical elements of work; risks of work on health and health on work, conflict in the workplace; domestic concerns, and potential impact on an employees’ workability including finances. Assessment tools have been developed from research and are universally accepted as systematic measures of a particular concern. The use of targeted tools provides confidence that the OH assessment is robust and evidence-based, which is important for all stakeholders but specifically supports the professional and expert opinion of the OH clinician.
A sickness or presenteeism-based referral could be for any health condition which is why OH is so focused on the functional capability of the individual. There are many evidenced tools that support an assessment and it is up to the clinician to target which tool they feel would help them in their decision-making process. Tools should not be used as a sole factor in an assessment, as the skill of an OH clinician is to marry the outcome of these with their observations, the health history, and questions on current functioning so as to build a picture from which conclusion is drawn. This is of course based on the clinician’s knowledge of the workplace and what adjustments could support that individual if any, based on the risks.
In some cases, the tools are easy to choose because they relate specifically to the reason for the referral but in others, the tool can be relevant to a variety of conditions and is adjusted to the functional detriment noted by the individual.
Examples of Tools
Should an individual have respiratory issues impacting their capability then the MRC dyspnoea scale is useful to ascertain the impact on their current function with a score of 3 or more indicating some significant impact. However, there can be more than one use of a tool as the MRC scale is also useful to understand the risk of severe illness should an individual get coronavirus.
A common tool used to assess anxiety and depression is the PHQ (Patient Health Questionnaire) 9 and GAD (Generalised Anxiety Scale) 7. Valuable when used together as often anxiety and depression go hand in hand. Both provide an understanding of the impact on cognitive functioning with sleep, appetite, concentration, motivation, and confidence being of particular importance. Of great significance is question 9 of the PHQ as this allows the question around suicide ideation to be asked, although clinicians need a robust process on how to deal with the outcome should the resulting answer be positive.
NICE in their guidance on sickness absence advise that mental health should be assessed with any absence that is longer than 4 weeks. This is because of the impact worklessness and health conditions can have on an individual’s mental health. The PHQ4 is a shortened version of the PHQ9 and GAD7 and is quick and easy to use in this regard. This enables the clinician to ascertain the biopsychosocial elements of an individual’s impact on work. Often a physical condition can have a psychological impact and therefore adversely impact the ability to cope effectively.
The EQ5DL is a commonly used outcome measure tool used by physiotherapists, but for OH it can equally be useful in understanding the impact of a condition on an individual’s day-to-day activity and helpfully includes a question on mood; which often co-exists with disability. This then helps not only to understand functional capability but whether any psychological impact is impairing ability and what support can be put in place to improve this for a better work outcome.
The use of targeted tools provides confidence that the OH assessment is robust and evidence-based, which is important for all stakeholders but specifically supports the professional and expert opinion of the OH clinician.
The AUDIT and CAGE tools are really helpful when assessing alcohol use. Useful even those who declare no issues where clearly there are concerns, either observed or within the history, as it gives a clear indication of insight. These are important not only when alcohol use impacts health but also for safety-critical roles.
PTSD is a real concern today, especially in those roles where exposure to trauma is common like emergency services, but also in frontline workers working with COVID and those who may have been treated within ICU. The PCL-L PTSD Civilian assessment tool is easy to use and can support an understanding of an individual’s behaviour and reactions but also drive treatment needs either via the employer or in directing the GP.
The fatigue assessment scale can be used for shift work; burnout; Chronic Fatigue; Fibromyalgia, Lupus, and any condition that can cause fatigue, including arthritis conditions, to understand the impact on cognition and enable signposting appropriately; but also helps with assessing ability to undertake shift and safety-critical work.
STOP-BANG for sleep apnoea; important for LGV drivers and other safety-critical roles. This replaces the Epworth sleepiness scale although this latter scale is still used in the Rail industry
The standardised mini cognitive assessment tool is commonly used in primary care to screen for memory concerns in older adults. There are times when individuals are referred into OH as memory concerns have become apparent and therefore having a tool to use in these cases is useful in enabling a direction to be provided to the individual and the organisation. Other tools are the 6 item cognitive impairment scale or the Montreal cognitive assessment scale although this latter requires some training in use.
These are a few of the available tools; there are many more with some being condition-specific. MDcalc is an American site with a large number of electronic tools available, all with the evidence base and outcome results that are easy to understand and use. Patient UK also has medical calculators which are electronic and easy to use. Clinicians need to provide the evidence of tools used in their clinical notes; not just the outcome result but all elements of the tool used as this is the evidence that they are basing their opinion on. Other clinicians and perhaps even a tribunal must understand the reasoning behind all decision-making. ⬛
Melody Rasmor and Carol Brown, Health Assessment for the Occupational and Environmental Health Nurse, JULY 2001, VOL. 49, NO.7, AAOHN