Bouncing back

Many OH nurses take an active role in the process of
rehabilitating the worker. A new model helps to identify the key issues and
achieve effective team working with management to succeed in this process, by Rebecca
Elliott & Sue Gee

Sue Gee is a senior occupational health adviser within a large city council
in West Yorkshire. Having recently taken over responsibility for the education
sector, Gee has tackled the increase in sickness absence referrals due to
workplace stress by implementing a rehabilitation model.

This is in line with government guidelines, which have placed vocational
rehabilitation high on the national agenda. Indeed, the Health and Safety
Executive (HSE) is making the availability of rehabilitation one of its key
targets for 2010 in the Securing Health Together1 document.

Scale of the problem

Keeping people in work is essential to the wealth of the country. With
demographic changes pointing to an ageing workforce in the next 10 to 15 years,
the potential pool of staff is due to decline over the next decade and it is
imperative that we keep these people in work as long as possible.

Currently, 19 million work days are lost because of workplace injuries and
illness, and rehabilitation can reduce this enormous loss of talent and
productivity.2 Retention of teachers is particularly important, as recent
international research3 identifies shortages in the profession that threaten to
diminish the quality of education at a time when the need for new knowledge and
skills is growing dramatically.

In a recent Occupational Health Review survey,4 it emerged that employers
are increasingly looking to address the issue of long-term sickness absence
through such rehabilitation programmes.

And statistics released by the Department for Education and Skills (DfES)
indicate that periods of sickness absence lasting more than 20 days accounted
for 45 per cent of sickness absence by state school teachers – 283,600 teachers
took sickness and absence leave in total (56 per cent of the workforce) and out
of a total 2,799,00 days taken, 1,258,700 days were taken in episodes lasting
longer than 20 days.5 The number of teachers taking early retirement on the
grounds of ill health has risen by 10 per cent.6

Bradford Council’s rehabilitation programme

Rehabilitation is the process of assisting the worker back into the work
environment, to their full capacity or potential. Within any model, it is based
on consultation and co-operation, in particular working with management to
facilitate the process.

There have been reports of individuals returning to work as part of a
rehabilitation process following work-related stress episodes and the problems
reoccurring, resulting in claims against the employer.7 The model used by
Bradford Council identifies specific action points for the employer to take to
help promote the success of the process, ensure a successful return to work
and, therefore, lessen the chances of any tribunal action.

On meeting with clients who were currently absent from work with workplace
stress issues, it was often the case that not only were they experiencing
problems (real or perceived), but that often the attempts that had been made to
address the issues had resulted in animosity or conflict. This then compounded
the problem. In practice, it can be difficult for the occupational health nurse
to see the issues raised by the client and to understand how they had arrived
at their perceptions.

At the initial interview, a client’s thoughts, ideas and dialogue are often
centered on subjective feelings – "nobody listens to me, nobody cares
about what I think, I don’t feel valued".

To turn these feelings into action, evidence needs to be collated to
validate the client’s interpretation of the situation and thus create a change
in the working environment and facilitate effective rehabilitation.

This evidence can then be shared with the manager to identify the
adaptations required to ensure a safe return to work.

Sue Gee has developed this model in a similar way to a solution-focused
approach.8 The model (see box, p27) aims to elicit three things:

– The client’s perception of the problem

– The evidence that supports their perception of the problem

– Possible solutions to the problem that can be used as a negotiation tool
with the management.

Stage 1

It is imperative that at the first meeting trust is established and that the
employee understands that whatever the particular circumstances, occupational
health will accept their perception and interpretation of the situation.

It has to be made clear that OH will not endorse or agree with their
perception, but will accept that the client believes it to be so. (In other
words, we will not be used as a tool to tell management they are not doing
their job.)

It is important to do this before using the model as it ensures the
practitioner can stay impartial and not get into conflict with either the
client or management. It is also important to stress that the process is to
facilitate a way forward; that it is not a blaming exercise, but rather an
opportunity to reflect upon the situation and the circumstances around it,
which should enable a move to a satisfactory outcome.

The client is given a piece of paper and asked to put their
perceptions/feelings about the situation in one column. In another column, they
are asked to evidence their perceptions.

An example of this may be the client has said "nobody listens to
me". As a standalone statement this is difficult to evidence, therefore,
just as a court of law would do, the comments need to be justified or evidenced.
Clients are then asked to detail specific examples of how they have arrived at
their belief.

Stage 2

The clients are then asked to write down the five most important issues in
their work situation that need to be addressed (using specific examples from
the evidence), and how these should be resolved so they can return to their
workplace and perform their job – this is the development of the wish list.

The aim of the wish list is to find out what the client wants and to use
this information as a negotiating tool with their manager. The benefit is that
although all their wishes cannot be guaranteed, in most cases some can be

Approaching it in this manner means that the individual plays a major part
in their return to work, with the additional benefit that they are directly
responsible for enabling some or all of the problems to be resolved. From the
manager’s perspective, it provides valuable information that allows them to
assist the employee in a positive way.

The chief advantage of this approach is that it takes the sting of blame out
of the situation – in other words, the manager is not made to feel neglectful
or stupid. By having a thorough understanding of the process, they have a
valued part to play in the rehabilitation role and in helping the employee.

Stage 3 – Implementation

The first two stages are completed in confidence with the OH staff and the
next stage is to meet with the client and their manager. The purpose of this is
to open communication between the two parties and allow the client to share
their views in a positive way. However, there are a number of considerations to
keep in mind when running the meeting:

– It is vital that the information is given in a way that makes a manager
want to listen and respond

– Once the client has shared the information, an opportunity must be given
for the manager to respond

– The role of the OHN is to actively listen, be aware of eye contact and
other non-verbal communication. Only interrupt to clarify issues when it is

– If progress is made and agreement reached, try to get both parties to
agree to review dates to discuss adjustments/ support and, if possible, arrange
a return to work date. Reiterate the support that will be available on return
to work

– Before closing the meeting, ask both parties if all the pertinent issues
have been addressed.


Once a return to work is in progress, it is important to monitor the
situation carefully. It is imperative that any policy directives ensure that
all parties are aware of the restraints of medical confidentiality and that the
OH practitioner works to the Nursing and Midwifery Council Code of Professional

An ongoing audit is demonstrating this model to be effective in practice,
and research is currently being undertaken by the department to help identify
areas for improvement.

To the manager, this model helps them adhere to the Management of Health and
Safety at Work Regulations as part of their risk assessment.10 By being given
assistance in identifying specific areas in need of redress, the manager can
document if changes have been completed or why they have been left uncompleted.
This information would also be invaluable to the organisation should the
rehabilitation become unsuccessful and an industrial tribunal pursued.

Rebecca Elliott, BSc (Hons), PGCE, RGN, OHNC, MILTHE, senior
lecturer/course leader occupational health, Leeds Metropolitan University. Sue
Gee, BSc (Hons) RGN, principal occupational health adviser, Bradford
Metropolitan Council


1. Health and Safety Executive (2000), Securing Health Together: A Long Term
Occupational Health Strategy for England, Scotland and Wales, London

2. Tudor, O (2001) Rehabilitation the missing link, NHS Plus chartered
Society of Physiotherapy conference, accessed online

3. ILO UNESCO, ILO Study cited in European Health and Safety Magazine
accessed online Nov 2002,

4. Ballard, J (2002), Rehabilitation at Work, Occupational Health Review

5. DfES, Teacher sickness absence 2001 provisional, DfEE, London. Accessed
online November 2002, DB/SFR/s0335/index.html

6. Hinsleff, G (26/05/02) Sick leave Rises as Teachers Buckle, The Observer,

7. Moore, N (September 2002) Managing Stress Returnees, Occupational Health

8. De Shazer, S (2002), Paradox is a muddle, an interview with Steve de
Shazer, Rapport 34, pp41-49, Accessed online November 2002, Mark McKergow
Associates, www.mckergow. com/interview.htm

9. Nursing and Midwifery Council (2002), Code of Professional Conduct,

10. Health and Safety Executive (1992), Management of Health and Safety at
Work Regulations, HMSO, London

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