As our workforce ages and becomes more sedentary, type 2 diabetes is increasingly prevalent. As Soroyo Barnes and Anne Harriss outline, this makes it vital that, following a diagnosis, effective and proactive support is available from occupational health.
This case study evaluates how occupational health (OH) supported Patrick (a pseudonym), a 55-year-old man employed full time as a carpenter and newly diagnosed with type 2 Diabetes Mellitus (T2DM). It explores the correlative effects of T2DM on Patrick’s work performance; including assessments of the work environment, fitness to work, and the collaborative process using a bio-psycho-social approach to facilitate him to continue in employment.
Type 2 Diabetes Mellitus (T2DM) is a long-term condition characterised by the body’s inability to use insulin correctly. People with T2DM produce insulin but the body cannot use it properly – insulin resistance.
About the authors
Soroyo Barnes is an occupational health adviser and Anne Harriss is professor in occupational health and course director, Occupational Health Nursing and Workplace Health Management Programmes at London South Bank University
Initially, the body produces more insulin to override the resistance until, ultimately, there is a resulting insulin insufficiency. This combination of insulin resistance and insulin insufficiency leads to a T2DM diagnosis (Downis, 2015). T2DM is most common in middle-aged or older people and often linked to lifestyle choices (Fit for Work, 2017). The main risk factor is being overweight (National Institute for Health and Care Excellence, 2013).
Patrick, a non-smoker, had been employed as a carpenter for 25 years on a full-time basis and was diagnosed with T2DM six months previously. No further medical history was reported.
Given the increasing prevalence of this condition within an ageing workforce (Tobias, 2011) the need for effective health interventions is vital. Since 1996 the number of people with diabetes in the UK has more than doubled from 1.4 million to 3.5 million. By 2025, it is estimated that this will increase to five million (Diabetes UK, 2018).
It is associated with the risk of microvascular damage, including retinopathy, nephropathy and neuropathy, increased risk of macrovascular complications (ischaemic heart disease, stroke and peripheral vascular disease), and diminished quality of life (World Health Organization, 2018). Fatigue, resulting from diabetes can be particularly debilitating impacting work performance.
Patrick reports sometimes finding it difficult to concentrate at work, often feeling sluggish. Fatigue is frequently a significant issue for people with diabetes; they report it twice as often as non-diabetics (Weijman, 2003).
Functional assessment
An OH functional assessment is performed to determine an employee’s current physical capability to perform physically active work duties, to establish the job task/s they can perform, to know they can conduct their job safely, return to work, or even gain new employment (Healthy Work, 2017).
This is further supported by Soer (2008), who proposes these assessments provide an evaluation of capacity of activities and used to make recommendations for work participation, while considering the person’s body functions, structures, environmental factors, personal factors and health status. For employees working with chronic diseases, optimising their health and avoiding unemployment is crucial since they are often associated with social deprivation and worsening health (Black, 2018; Waddell and Burton, 2006).
Biopsychosocial model of assessment
Engel’s biopsychosocial model (1977) of health and illness links interactions between biological, psychological, and social factors that determine the cause, manifestation, and outcome of wellness and disease. This and Watson’s (2010) biopsychosocial flag model have proven significance and underpinned the functional assessment, as it takes a multi-faceted view of the individual in relation to health and recovery compared to medical models.
Evidence suggests people with diabetes are two to three times more likely to have depression than the general population (Fenton and Stover 2006; Simon et al 2007; Vamos et al 2009), therefore it is important to remain cognisant of this and offer support to empower individuals to remain in work despite living with a long- term condition such as diabetes.
The extent of fitness or impairment must be gauged in terms of the demand of their work tasks Murugiah et al. (2002). Their framework for assessing fitness to work, incorporates four main aspects: personal aspects, work characteristics, work environment and legal aspects.
This guided the case management of Patrick within the OH context, as it encourages a holistic approach of each individual employee. Everton et al (2014) emphasises that understanding the client’s job role is key to functional assessments.
With reference to Watson’s (2010) model, Patrick reported a heavy workload (black flag), his role being demanding with both physical and psychological challenges leading to him feeling stressed (blue, yellow and orange flags) across his eight to 10 hours working day. His job tasks included working with machinery and moving and handling varying loads. It was vital for OH to assess how diabetes may impact on Patrick.
As wellbeing is determined by the physical, social and psychological environment that an employee works in, it follows that when this balance is disturbed this will impact on the health and wellbeing of that workforce too (Dodge et al, 2012).
Patrick was well experienced in the construction industry having transferrable skills, should he require temporary redeployment to another work area within the company whilst his health needs are managed.
He reports that his diet has not been great since his wife passed away. He reports being unable to cook healthy meals due to shift demands and cites commute to and from work as a hindrance to lifestyle adjustments, such as exercising.
Patrick reported sleep disruption managing only four to six hours each night. Regularly sleeping less than seven hours a night is associated with impaired immune function, obesity, type 2 diabetes mellitus, hypertension, cardiovascular disease, stroke and depression (Consensus Panel, 2015; Medic, 2017). These are relevant to successful diabetes management and can be detrimental to health outcomes and well-being and relevant to Patrick whose job includes significant physical demands.
Patrick’s Body Mass Index was above 30, indicative of obesity, which is often associated with type 2 diabetes. As Patrick is at greater risk of cardiovascular disease and diabetes complications (National Institute for Health and Care Excellence, 2017) he was given lifestyle advice at the consultation, including the importance of losing weight, regular exercising and modifying his eating habits. He was encouraged to enquire about exercise on prescription from his GP and a referral to the Diabetes dietitian for individually tailored support was recommended.
Patrick’s psychological wellbeing assessment was achieved using the PHQ9 and GAD7 tools. Addressing the psychological needs of people with diabetes can improve clinical outcomes, quality of life, relationships with healthcare professionals and carers, dietary control and overall prognosis (NHS Diabetes and Diabetes UK 2010; Alum et al 2008). Patrick actively engaged with the assessment and accessed support options available to him aiming to improve his functional capacity.
Assessing risk at work
Section 2 of the Health and Safety at Work Act (1974) states that employers have a general duty of care to ensure (so far as is reasonably practicable) the health, safety and welfare of all their employees. The starting point is to assess the risks and if the risk assessment is carried out properly it will show where there is a significant residual risk to health even after reasonably practicable control measures have been applied (Health and Safety Executive, 2007).
Patrick revealed his employer was unaware of his diagnosis. An important factor in assessing fitness for task is cognizance of the requirements of the Equality Act (2010) that imposes a duty on employers to make reasonable adjustments and provide legal defence against discrimination on the grounds of disability, including disability relating to diabetes. Employers must assess risks posed to their workers and, where necessary, take action to safeguard health and safety achieved by undertaking comprehensive risk assessments (Institution of Occupational Safety and Health 2018).
Some workers have reported workplace discrimination due to having diabetes. Diabetes UK (2018) suggest that a third of people living with diabetes have received a lack of support and understanding from colleagues. Patrick was reassured of his protected rights against discrimination due to his diagnosis and given the opportunity to make the informed decision to disclose this to his employers. He consented to this being disclosed in the OH report to his manager with recommendations for current and future management.
Patrick reported feeling pressured to meet deadlines, resulting in him missing meals putting him at risk of hypoglycaemia detrimental to his health and job role which entails both working at heights and manually handling heavy loads. Although not disclosing that Patrick was diabetic, OH ensured on-site first aiders could recognise and treat diabetic emergencies should they occur.
Working at height remains a major cause of fatalities and major injuries (Health and Safety Executive, 2017). Patrick’s manager was advised to update previous risk assessments he confirmed that Patrick had received recent manual handling training. It was recommended that working at heights should be avoided until his diabetes has been sufficiently stabilised and that Patrick should recognise any physical limitations and prioritise his breaks moving away from his immediate working environment entirely.
He lives alone and is largely independent with daily tasks such as shopping and personal care. He has supportive children and a friend close by who support him with tasks at home. His working within a wider team provided the opportunity for Patrick to receive support such as task re-allocation when needed including those requiring working at heights.
Patrick’s work tasks involved the risk of injury from handling tools or from loose objects. Mousley (2003) refers to longer wound healing times in people with diabetes making and increased susceptibility to complications. Patrick was therefore advised to wear strong, thick gloves when handling sharp objects to reduce this risk.
Patrick has been prescribed metformin to be taken three times a day with meals. Metformin. This biguanide works by increasing muscle cell sensitivity to insulin so that they are more effective in removing sugar from the blood. It also reduces the amount of sugar produced by liver cells and delays the post-prandial absorption of sugar from the intestines into the bloodstream reducing less of a spike in blood sugar levels after meals. It is the first medicine usually recommended to treat type 2 diabetes. This is indicative as he is overweight, and metformin should not cause additional weight gain but may cause mild side effects, including nausea and diarrhoea (NHS Choice, 2009).
Patrick reports that he often forgets to take his medication or takes them without food. He was advised on strategies to help him to remember such as setting alarms. The importance of taking metformin with food was discussed and the implications of non-compliance were highlighted. It was suggested to Patrick that he be referred to a diabetes specialist nurse for ongoing support. Recommendation to his employer included giving Patrick time off to attend appointment.
As T2D is a progressive condition, Patrick may eventually need to commence on insulin medication, usually in the form of injections. A future risk assessment may need to take this in consideration and require further OH input.
Support for employee to stay in work
Patrick’s manager was supportive upon being informed of Patrick’s diagnosis, an important factor as manager behaviour influences employee wellbeing (Chartered Institute of Personnel and Development (CIPD) (2009).
According to the Centre for Ageing Better (2018), two in five people with a health condition do not receive workplace support. They suggest that early access to support, empathetic management with small adjustments to working patterns and the working environment facilitate people with long-term conditions to remain in employment for longer.
As Patrick reported sleep difficulties, he was provided with contact details for his local Improving Access to Psychological Therapies (IAPT) service offering Cognitive Behaviour Therapy (CBT) and self- management courses. Cognitive behavioural therapy for insomnia (CBT-I) is effective for adults with persistent insomnia (Trauer, 2015).
CBT-I addresses underlying problems without the risks of medication (Reynolds, 2017), aiming to examine and change the individual’s beliefs and attitudes about insomnia and is combined with a behavioural intervention (National Institute of Clinical Excellence 2015). Patrick’s employer provided proactive support, inviting a sleep specialist on site to discuss sleep management.
Diabetes is likely to be considered a disability under the Equality Act (2010), which defines disability as a physical or mental impairment with a substantial long-term negative effect on a person’s ability to perform day-to-day activities. Although whether this Act applies is ultimately a judicial matter and not an OH decision (Kloss and Ballard, 2012), making reasonable adjustments enabled Patrick to continue in his role as far as practicable (Smedley et al, 2013) is good practice.
The management of Patrick’s case demanded active collaborative approaches involving the OH adviser, line manager, HR and Patrick’s GP. Recommendations for managing T2DM were focused on patient education, dietary advice, managing cardiovascular risk, managing blood glucose levels, and identifying and managing long term complications (National Institute of Clinical Excellence, 2017).
Patrick did not self-monitor his blood glucose at home and had limited knowledge regarding self- management of diabetes (yellow flag), progression and possible implications to start with. OH supported Patrick by collaborating with his GP, and his employer to facilitate Patrick to attend the Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) self-management programme.
Fitness to work
Patrick was declared fit for his role, provided appropriate adjustments were instituted ameliorating functional barriers identified at the assessment. The government recognises the need to encourage employers to implement reasonable adjustments in the workplace and to enable an ageing workforce to remain economically active (Department for Work and Pensions, 2014).
Collaborative working throughout each stage of the process and in compliance with ethical guidelines (Nursing and Midwifery Council (NMC), 2015) is essential. Ensuring no harm, access to diabetes services set out in the National Institute of Clinical Excellence (NICE) guidelines, such eye screening and being given access to a diabetes dietitian was expedited for Patrick at the point of OH contact.
Diabetes is an increasingly common life-long condition with significant physical, psychological and behavioural implications. Self-management can be complex and challenging. Collaborative approaches to care between healthcare professionals and patients are essential to promote self-management skills. Evidence suggests that, with effective education and support, these skills can be developed and strengthened, even among those initially less confident, less motivated or with low levels of health literacy (Hibbard and Greene, 2013).
OH monitored Patrick regularly over a 12-week period. His GP updated blood tests, and he received support from a diabetes specialist dietitian and specialist nurse, achieving the joint OH/employee goal of ensuring Patrick received the necessary monitoring and education. This illustrates the importance of health promotion with a proactive OH service. It also proves that timely, effective collaboration among experienced professionals can achieve positive health outcomes.
OH nurses are well placed to promote easy-to-understand and achievable behavioural change within the workforce (NMC, 2015). OH monitored Patrick at reviews for adherence and safety reasons and he received continued assessment of fitness for work. This improved his knowledge and brought about a noticeable change in HbA1c and blood glucose readings (compared to results at the start), he attended podiatry screening and vision testing which showed no abnormalities.
Conclusion
Diabetes can have devastating impacts on individuals both within and beyond the workforce. Given its prevalence, it is imperative that OH is actively at the forefront of workforce health promotion and ill health preventative practice. OH practitioners must develop leadership roles to embrace opportunities that influence service change and development to meet business needs on a strategic level particularly with regards to supporting employees with long-term conditions.
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These are likely to become more prevalent within an ageing workforce and an increasing age at which employees qualify for a state pension.
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