A functional assessment is a key part of any occupational health consultation, yet effective history-taking is something many coming into the profession have to learn from scratch. Helena Brady looks at what should be included in an assessment and how best to carry one out.
A functional assessment (FA) is an essential component of an occupational health (OH) consultation to determine if the individual is fit for work.
About the author
Helena Brady BSc (Hons), RN, SCPHN (OH) is a registered nurse and clinical performance manager at Team Prevent
Palmer, Brown & Hobson (2013) suggest that the primary purpose of an assessment of fitness for work is to make sure that an individual is fit to perform the tasks involved effectively without risk to their own or other’s health and safety. Anderson-Cole et al (2017) advocate that a functional assessment is the basic functional component of the individual task or role and it is key to the functional assessment that the OH nurse has an effective understanding of the individual’s functional and job role.
Thornbory (2013 b) argues that the primary objective for the analysis of a disability in the context of an OH consultation is not to diagnose or treat, but to assess the functional effects of a person’s condition/s on day to day living.
This article utilises a case study approach and explores the types of consultation including face-to-face, telephone and virtual approaches and the factors to consider during a functional assessment. The importance of good communication skills is also incorporated.
The opening paragraph above suggests that the concept of a functional assessment is an important part of an OH consultation. But what does this mean and how is it done?
Importance of good communication skills
Before examining how to undertake a FA, therefore, it is important to emphasise the importance of using good communication skills from the outset of the consultation. This is for the purpose of establishing a rapport with the client and to promote confidence and trust which entails an introduction of self, confirmation of the client’s identity and reassurance about data protection and governance of information.
The basic tenets of effective communication are: active listening, observation, awareness of non-verbal cues, showing empathy, and being culturally sensitive. In addition, continued use of good communication skills is required throughout the consultation to undertake an accurate assessment.
Thornbury (2013b) suggests that the assessment includes taking a history, which involves asking questions about the client’s current and presenting symptoms, their past medical history, ongoing treatment and medical interventions. This should be supplemented with a psychological and social history addressing the client’s account of any concerns, perceptions and expectations of the consultation.
In addition, it is necessary to obtain details about their job tasks and responsibilities of the role. Why is this a necessary part of the assessment process to determine fitness to work? When making a decision about fitness to work it is vital to the assessment process that discussion takes place about the impact of the current health related issues upon the client’s ability to undertake their job tasks. Conversely, it is also important to consider how work could impact upon the current health related issues especially if the client is going back to work imminently.
Taking a history and details about the job role have been identified as vital components of the assessment process and their stated facts will be subjective to the client’s situation. This concept is recognised by Palmer, Brown & Hobson (2013), who suggest that the functional assessment should consider the systems of the body, particularly those that are disordered and are relevant to the job tasks of the role in the workplace.
Such elements include physical, sensory and psychological symptoms in addition to the effect of the treatment regime that should also be taken into consideration. This could be more formally categorised and captured during the assessment by using a biopsychosocial approach to the history taking, which is recommended by Anderson-Cole et al (2017), Watson (2015) and Smith (2015), who also purport that the occupational health consultation process should encompass knowledge of the job demands, abilities of the individual and clinical knowledge of any health condition to inform the opinion about fitness to work.
The Concise Oxford Dictionary (2002) defines disease as “an unhealthy condition”. Clients will often present with physical symptoms such as pain, swelling, stiffness or nausea. This is not an exhaustive list of physical symptoms, and it is important to consider that there is a biological component to all disease and illness regardless of where it is considered to be a physical health problem or a mental health condition.
Psychological factors to consider are the client’s sleeping pattern, eating habit, mood, cognitive function such as memory and ability to focus or to concentrate, motivation, confidence , risk of self-harm or harm to others and suicidal ideation or intent. Social factors that are relevant to the client’s recovery and return to work include the support that is already available to the client from a network/circle of family and friends.
Other social factors could include economic concerns such as loss of earnings or financial difficulties that could potentially influence the client’s subjective opinion about their fitness to work and/or the client’s subjective opinion about a timescale for a return to work. Other social factors include lifestyle factors such as alcohol intake, smoking habit, recreational drug use and participation in exercise are important considerations with regards to wellbeing and self-care to augment recovery and promote an earlier return to work.
The discussion so far has brought the reader through the interview process of the consultation that entails a history taking using a biopsychosocial approach to the assessment. Thornbory (2013b) purports that a patient’s history is key to helping an OH professional to decide if someone is fit for work.
Assessment of fitness to work
An assessment of fitness to work may be required if an employee is changing role, being recruited for a new job or returning to work after a significant period of sickness absence. This concept is supported by Baxter et al (2000), who note that most patients are able to return to work even after a period of significant illness, and advice may be sought about fitness to work if there are residual disabilities either of a temporary or permanent nature.
The concept of a functional assessment is not part of the nursing curriculum outside of an occupational health setting. Thornbory (2013b) suggests that taking a history is an essential component of the functional assessment noting that, traditionally, history-taking has been a part of the doctor’s role. Suffice to say that learning how to undertake a functional assessment is a new skill that has to be learned.
Thornbory (2013b) argues that, unlike the role of a treating doctor, which incorporates making a diagnosis and a treatment plan following the history taking, the role of an occupational health nurse is required to assess the functional effects of a person’s condition on day-to-day living as a determinant of fitness for work.
In other words, the functional assessment takes into account any difficulties or restrictions the individual is having with their routine day-to-day activities. To simplify this concept, the functional assessment should identify the difficulties imposed by the current symptoms along with a prognosis to enable advice about a return to work. In addition, the assessment has to take into account the job requirements of the client and how their health condition affects both their activities of daily living and their ability to undertake their job role.
Options for the assessment
So far, this article has examined how to undertake a functional assessment using a biopsychosocial approach and the notion that the consultation takes the format of an interview has been mentioned.
The options for the assessment will now be considered. Anderson-Cole et al (2017) suggest that this assessment may take place by one of two methods as a face-to-face appointment or a telephone consultation. A third option is a virtual consultation by video link.
A telephone or video consultation has distinct advantages over one undertaken as a face-to-face consultation. Rhodes (2015) suggests that a telephone assessment is convenient for the client because there is no travel involved, the travel costs associated with public or private transport such as mileage allowance and parking fees are negated. Furthermore, the client may be more relaxed in a familiar environment enhancing engagement and facilitating an earlier return to work.
As D’Arcy Jones & Harriss (2016) note, a telephone consultation may be considered as a form of triage with potential for onward progression and an opportunity to signpost for further help and support. A telephone consultation is not only advantageous to the client, there is no need for the OH provider to be located in a specific hub; team members may be engaged to work from home with associated savings to the provider.
In the changing face of business within a competitive market, the OH provider must be able to meet the demands of the customer and to robustly adhere to organisational policies in relation to organisational policies and procedures. This is a concept recognised by D’Arcy-Jones & Harriss (2016), who suggest that a telephone assessment can help businesses to meet the demands for key performance indicators (KPIs) with particular reference to long-term sickness absences.
Good communication is key to a successful consultation (Rhodes 2015). Effective consultations require excellent communication skills: the ability to recognise voice cues in particular is an essential component of an assessment undertaken by telephone, as the cues picked up visually in a face-to-face consultation are not possible.
Thornbory (2013b) suggests that the effective use of communication skills is of particular importance at the beginning and the end of the consultation. The information obtained at the start of the appointment sets the scene. The exchange of information at the closure of the consultation gives an opportunity for both client and practitioner to check understanding and for the employee to be advised of the information that will be incorporated in the response to the referring manager.
Employee engagement comes from open communication and co-operation. D’Arcy Jones & Harriss (2016) also suggest that client engagement is likely to be enhanced in an environment familiar to them. They emphasise that it is imperative to the success of a telephone consultation that a rapport is established quite quickly and that boundaries with regards to the timeframe and outcomes of the consultation are established at the outset of the consultation.
Subsequent to the push for telephone health consultations has been the development of virtual consultations. Hughes (2018) suggests that virtual reality is now an actual reality and Butler (2017) suggests that every nurse should be an e-nurse and be able to embrace the digital tools available to undertake their work.
Technology is already in use in other areas of healthcare provision. Haynes (2017) suggests that technology has been very purposeful with regards to wearable devices for health and wellbeing purposes and, suggests that artificial intelligence has a place in e-health, including remote (GP) services.
Haynes (2017) also suggests that the terms telemedicine and tele-health are interchangeable as both entail an exchange of data between a patient at home and their clinicians to assist in diagnosis and monitoring. Hughes (2018) furthermore highlights a shift in the way that we access health information with the use of technology often the first port of call for advice.
Case study one – “Sharon”
Sharon, a 55-year-old administrator, was experiencing an episode of long-term sickness absence from work due to depression and anxiety.
She had symptoms of low mood, high anxiety and low energy levels. The psychological impact of these symptoms upon her ability to function was that she was experiencing difficulty concentrating, her memory was reduced and she was experiencing difficulty leaving the house, going outdoors and socially engaging with others.
The physical impact of these symptoms resulted in Sharon experiencing reduced stamina and she tired easily. This resulted in her reduced participation in routine activities such as household duties. Her absence from work had resulted in a loss of earnings with the potential to significantly reduce her household budget.
Using a biopsychosocial approach during the consultation, the outcome of the assessment was that Sharon was temporarily unfit for work. The conclusion that she was temporarily unfit for work was based on the findings of the assessment, which took into account her current symptoms and current difficulties in conjunction with the impact upon her activities of daily living.
The requirements and demands of job were also taken into consideration. Her role was of an administrative nature, was customer facing and involved travel to her place of work where she working in a shared office.
As she was unable to leave her home, was experiencing difficulty concentrating and was unable to socially interact with other people at this time she was considered to be unfit for work. Further treatment was required to help her to manage her symptoms before being in a position to consider a return to work.
Management were advised to consider supporting a further period of sickness absence as this would likely promote recovery. Although a specific return to work date was not identifiable during the consultation, her manager had been advised about the requirement for reasonable adjustments and support upon her eventual return to work.
The recommendations for support included a gradual return to work over a four-week period encompassing 50% of her contractual hours for the first two weeks followed by 75% over the subsequent two weeks. A period of ongoing support including regular 1:1 meetings with management for support was also suggested.
A follow-up review by OH was not considered necessary; the recommendations for support on her return to work were likely to be suitable to enable Sharon to manage her symptoms.
Should her manager require further advice, then referral back to OH was recommended. The identification of the actual return to work date was left to be decided between the employee and the manager and would be based on the information included in the fit note completed by her GP.
Case study two – “Sam”
Sam, a 45-year-old healthcare support worker, was referred for an OH opinion as a result of his frequent periods of short-term sickness absence which were causing commercial harm to service provision.
Sam was referred because of concern about intermittent episodes of lower back pain. A biopsychosocial approach was incorporated into the assessment process to determine the impact upon his activities of daily living and his role.
His symptoms included lower back pain and sciatica, which he had noticed were aggravated by movement and alleviated by rest. Sam’s symptoms were likely to be manageable with suitable analgesia and input from physiotherapy.
His line manager was advised that the management of the physical, manual and ergonomic hazards in the workplace were required, with time out from work to attend appointments for physiotherapy provided this was operationally feasible.
This advice was provided as it was likely that, if followed, Sam would be able to remain at work and simultaneously manage his symptoms. Further follow-up was not required and management were advised to refer him back for a further opinion should further advice be required.
This article has demonstrated the reason why a functional assessment may be required and supported by various authors.
The vital components of the assessment were discussed including the physical, psychological, socio-economic factors that are contributory to the decision about fitness to work. Examples from clinical practice were provided for the purpose of illustration.
Communication was identified as a vital aspect to the success of the consultation. The options for undertaking the consultation including face-to-face, telephone or virtual meeting were identified.
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Baxter P J, Adams P H, Tar-Ching A W, Cockcroft A and Harrington J M. (2000) Hunters Diseases of Occupations 9th ed. Arnold, London Oxford University Press
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