In the first of two articles on assessing an employee’s fitness to work as part of a management referral, Anne Harriss and Dr Sue Smith offer advice on taking a health history.
History taking is a skill that continues to improve and mellow with clinical experience. It is important not to forget what a professional privilege it is to be able to ask someone, whom we may never have met before, quite personal questions about anything, from their innermost thoughts and feelings to their bowel movements.
Taking a good history and trying to improve one’s technique can be one of the most challenging and rewarding aspects of the work of an occupational health nurse (OHN).
The effect of work on health, and health on work, is the essence of OH practice. Fundamental questions about functional ability and how work affects health and vice versa must underpin the whole approach to OH history taking.
For an experienced OHN, the actual assessment of fitness may take only a few moments once all the facts have been identified. However, without a systematic, thorough and relevant history, there is a risk of giving inappropriate advice with potentially costly safety and legal consequences.
Some managers may wrongly assume that referral to OH will solve the poor attendance levels within their department. OH practitioners have neither a magic wand nor a crystal ball. A successful outcome associated with a management referral depends on the manager understanding the role and function of an effective OH service and providing information such as the employee’s job requirement and their absence patterns. Of further importance to the success of the consultation is that the client understands the reason for that referral.
1. Client profile
2. Previous occupations
3. Work effects on health
4. Health effects on work
5. Health effects on activities outside work
The client should give their informed consent to an OH referral. They should be advised of the purpose and nature of the assessment and know what will be included within any reports provided to their manager. Guidance from the Faculty of Occupational Medicine highlights that ideally this consent should be in writing but this is difficult in the case of telephone consultations.
The client may withdraw their consent at any time. It is helpful to highlight that OHNs are impartial advisers to all parties. The referral may detail the diagnosis, poor performance or conduct concerns and the OHN must keep an open mind, start with a “clean slate” and, most importantly, listen carefully to what the client has to say.
1. Listen to what the client is saying
2. Be aware of what the client is not saying
3. Think “functional ability”
4. Limit open questions
5. Explore relevant answers with work function in mind
At the same time, it is important to be aware of what the client is not saying. OH consultations following a management referral generally require an opinion regarding fitness to work. A systematic approach is used in order to effectively:
- identify the reason for the referral, their concerns and expectations;
- document the client’s health history; and
- note and respond to the occupational history.
An appreciation of the effects of the client’s condition on their activities of daily living and on their ability to perform their job requirements safely and effectively is what is of particular importance within the consultation, rather than the actual diagnosis.
A systematic approach
Many OH services now use customised pro formas or structured, onscreen records which serve as a useful aide memoire, provide a clear framework to the interview and enable colleagues to make sense of the records more easily.
Functional ability: impairments of function to be considered
One system can never fit all – the clinician’s experience and professional judgment enables them to adapt and tailor the process to suit the individual client most appropriately. These systems evolve with changes to disability discrimination legislation. Periodic review of these systems should be part of the service’s staff training and quality assurance programmes.
Having a systematic approach also helps with the flow and speed of history taking, as well as remaining focused.
It can help the client see that the OHN is applying a consistent and professional approach to assessing their case and that this is not a random, overly personal or potentially unfair process. It allows for awkward and sometimes very personal questions to be posed in a straightforward way, which makes things easier for the clinician and the client.
This is a journey of exploration and discovery, which becomes smoother and more rewarding with practice. It should never be a case of just plodding mindlessly through lists of questions, although the lists are many and unavoidable.
It should be a well-choreographed process, progressing with reason and logic but with occasional flights of improvisation where clinical acumen needs to be applied to each new strand of enquiry.
Making a start
The consultation should start with the OHN introducing themselves followed by an explanation of their role and the reasons for the referral. A profile of the client is then documented including their age, occupation and health to date. A few moments need to be allowed for the client to give a brief outline of their key problems.
Explaining early on the need to go through a few standard questions helps the OHN keep the consultation on track, allowing them to draw back the focus to the interview if the client tends to digress. This professional approach demonstrates a thorough approach to the assessment.
Face-to-face or telephone consultations?
Use of telephone consultations for client assessments has increased in recent years with debatable pros and cons. The importance of observing body language in communication is of obvious value. Telephone assessments may be convenient, saving time and cost, but if the clinician is inexperienced there is the potential for some detail to be lost as so much of an assessment is based on observation.
Seeing the client’s difficulty moving or noticing a reticence about completing a consent form, may be useful indicators, for example, of musculoskeletal or learning difficulties that might otherwise not be declared.
Important early questions
The occupational history should ascertain work type, exposure to hazards such as physical, chemical and biological agents and reasons for leaving previous work. Levels of previous sickness absence and work adjustments will help predict future attendance and performance.
Recording the degree to which work has been affecting health and how health is affecting work is crucial. Understanding the client’s range of skills will be useful if redeployment is needed.
Knowing the client’s current medication early on frequently helps define the client’s health condition and steers lines of questioning. It is worth taking time to brush up on anti-psychotic medication in current use and reflect on the relevance of these in mental health assessments.
Hobbies and sport activities leading to some exposure to chemicals or risk of musculoskeletal injury should also be noted. It is not unknown for a case of suspected repetitive strain injury to have been related to many hours of knitting at home.
Establishing the client’s preferred outcome for the assessment can be illuminating and useful, particularly if this matches the clinician’s own recommendations.
Home circumstances can be explored in the context of social support for any disability and can provide valuable insight when exploring mood and mental health.
Unlike the GP or hospital clinician whose aims are diagnosis and treatment, OH practitioners assess fitness for work and offer appropriate solutions for both them and their employer.
Reports sought from the medical practitioner responsible for the client’s care may include extensive clinical detail but, without an assessment of the employee’s functional ability, the information will be of little practical value.
It is helpful to have a list of functional impairments in mind when considering any of the client’s health complaints, whether these have been formally diagnosed or not. Using those listed in the guidance on disability under the Equality Act (2010) such as cancer or multiple sclerosis is a useful starting point enabling the OHN to provide clear criteria in the records when considering if the client has a disability as defined by the Act. Any impairment identified needs full functional assessment relevant to the client’s work in order to recommend appropriate modifications.
Filtering and algorithms
Algorithms help to ensure that only relevant questions are asked. Stem questions may ask about specific clinical features such as breathing difficulties or skin rashes with more detailed exploration following for any positive responses. Stem questions based on functional ability, such as mobility and cognitive function, assist the assessment of fitness to work providing a sound basis for definition of disability and necessary workplace adjustments.
Recording information about subjective health complaints such as pain, fatigue and low mood is not easy. Using a 1-10 score, with definition for best and worst scores can help to monitor day-to-day variability and show trends for recovery or deterioration. Physical and mental stamina, frequently overlooked by other clinicians, requires careful consideration by the OH clinician as particularly relevant for work.
Some awkward questions
How should potentially difficult questions be asked without the OHN feeling awkward? There is no easy answer, but practice undoubtedly helps. Including the question among a list of other more ordinary questions, using a matter-of-fact tone and rattling off the questions reasonably quickly sometimes works best. Spot the awkward question below:
- How many cigarettes do you smoke a day?
- How many units of alcohol do you drink in a week, on average?
- What about recreational drugs? Or Do you use recreational drugs? Explore any concerns after completing this section.
- What about caffeine consumption?
All of these are relevant where anxiety, low mood or behavioural problems are a concern but rarely do people feel comfortable asking questions on drug usage. Including caffeine in the list helps this seem ordinary.
Some clinicians are wary of asking about so called “taboo” subjects such as tuberculosis (TB) and HIV.
These are important questions for those working in healthcare, particularly relating to those undertaking exposure-prone procedures. Both are treatable conditions and dealt with just as any other infectious condition, in a matter-of-fact professional manner. Address batches of related questions exploring any positive responses only once that batch is completed. Questions might include the following:
- Have you ever been treated for TB or been in contact with a case of open TB in the last two years?
- Do you know if you have or might be at risk of having any blood-borne viral infections such as hepatitis B, hepatitis C or HIV?
- Have you been travelling in any tropical areas in the last year? or known to have had any tropical infections?
Questions relating to conditions affecting cognitive function and behaviour can be particularly awkward for both clinician and client. Bear in mind that some clients may have difficulty with memory or concentration or significant learning difficulties. Occasionally they may have complete lack of insight into a serious thought disorder. Hopefully, these are sensed at an early stage of the interview but, without a keen awareness of these possibilities, the problem may pass unnoticed with potentially dire consequences.
We live in a “can-do” society but we do no one any favours if we overlook learning difficulties in a fitness for work context. Sample questions on cognitive function might include:
- Have you noticed any difficulty with your ability to concentrate, or with your memory lately?
- Did you have any difficulties performing your duties at work?
If a significant learning difficulty is suspected, questioning may need to go back towards earlier life, especially if poor performance has been a concern by asking:
- When you left school, did you have any qualifications? and/or
- Were you given any additional support when you were at school?
This might prompt mention of special schooling, being “statemented” or struggling with academic examinations.
Gaining an impression of the impact of the person’s health condition on their functional ability, particularly on their ability to perform their job requirement, is key to the OH assessment. The client’s health status may be associated with difficulties that have a significant negative impact on them in the workplace.
The recommendations made by the OHN could include suggested job modifications, particularly important should they have a condition that may be covered by the Equality Act 2010. If the adverse effects of the condition are likely to be short term, then suggested modifications should be time limited with further OH reviews should there be concerns regarding progress.
Occasionally it may be necessary to gain supplementary information from a clinician responsible for the care of the client. The key word is “occasionally”: such requests only being made in order to gain additional information that cannot be obtained from the client.
A recent discussion with an HR director suffering from a long-term condition revealed that the OHN who assessed her wished to write to her GP for their opinion regarding necessary suitable and sufficient modifications to assist her in the workplace.
That OHN lost all credibility: there was no reason why he or she could not ascertain that information on their own behalf, particularly as they, not the GP, are specialists in workplace health and workplace knowledge.
The OHN should end the consultation with a brief overview of what was discussed and the information that will be included within the response to management. It is good practice for the client to have the opportunity to see the OH report before it is sent and to be provided with health promotion literature which they may find useful.
Some OHNs type the report before the client leaves, others send them a copy indicating that unless they hear from the client within a certain time scale, often between three and five days, the report will be sent to the referring manager. A further workplace assessment may also be necessary, for example a display screen user having had spinal or shoulder surgery may benefit from a further workplace risk assessment.
It is impossible to list all the questions for any one history. Experience and clinical judgment determine the range and scope of the questions needed. For newcomers to OH, observing an experienced clinician in action and then studying the reports sent to management proves helpful. There is a risk that, as history taking becomes more standardised through use of algorithms, clinicians
may lose sight of the individual with their own very specific problems and needs. It is important to remember that each assessment involves a unique person in their own unique set of circumstances, which, of course, makes the job of the OHN more challenging but infinitely more interesting.
The second part of this article will explore formulating a response to management.