In recent years, occupational health (OH) practitioners will have come across the concept of ‘flags’ in helping employees return to work after sickness absence, but there is still some confusion about how flags are used in practice. This article aims to help clarify the place of one category – psychosocial flags – in the rehabilitation process, and how flag assessment can be used in an OH adviser’s clinical work.
Flags are used in a variety of contexts in everyday life, but nearly always to give us information or an indication – the Queen is at home, you’re on the final lap, or you have arrived in another country. Flags in health are used in much the same way – to inform and alert us to something about a person or their problem that requires closer study.
Flags can be split into two distinct categories: clinical flags and psychosocial flags.
Clinical flags are common to many areas of health – for example, red flags for musculoskeletal disorders, which are indicators of possible serious pathology such as inflammatory or neurological conditions, structural musculoskeletal damage or disorders, circulatory problems, suspected infections, tumours or systemic disease. If suspected, these require urgent further investigation and often surgical referral. There are certain signs and symptoms that when observed in a patient’s examination or history alert us to the fact that something could be seriously wrong.1 In the case of musculoskeletal disorders, physiotherapists are highly trained to identify or rule out red flags.
Recently, orange flags were added to the spectrum, and represent the equivalent of red flags for mental health and psychological problems – alerting the clinician to serious problems that could be psychiatric in nature, and therefore require referral to a specialist in that field, rather than following the normal course of management for mild mental health conditions such as anxiety. Orange flags can include excessively high levels of distress, major personality disorders, post-traumatic stress disorders, drug and alcohol abuse/addictions or clinical depression.2
Psychosocial flags allow us to identify aspects of the person, their problem and their social context, and how those factors affect the recovery and return-to-work process. The concept was introduced in 1997 by Kendall et al3 and looked at factors that identified patients who were at risk of developing chronic disability, and did not recover as was expected for their condition.
Psychosocial flags enable us to work from a biopsychosocial model and give a framework for assessment and planning. These flags are not a diagnosis or a symptom, but an indication that someone may not recover as expected, and may need additional support to return to work. These flags are often referred to as obstacles to recovery. Psychosocial factors determine outcomes such as activity levels and participation and work, but appear to be less relevant to the reporting of symptoms.4
Psychosocial flags have been subdivided over the years to reflect the different interactions that can affect recovery. As a result, they are now referred to as yellow, blue and black flags. Briefly, yellow flags cover the features of the person which affect how they manage their situation with regard to thoughts, feelings and behaviours. Blue flags concern the workplace and the employee’s perceptions of health and work. And black flags are about the context and environment in which that person functions, which includes other people, systems and policies. Black flags can block or limit the helpful activity of healthcare providers and workplace support.
Obstacles that can be classed as yellow flags include many aspects of thoughts, feelings and behaviours. Some common examples include:
- Catastrophising – thinking the worst
- Finding painful experiences unbearable, reporting extreme pain disproportionate to the condition
- Having unhelpful beliefs about pain and work – for instance, ‘if I go back to work my pain will get worse’
- Becoming preoccupied with health, over-anxious, distressed and low in mood
- Fear of movement and of re-injury
- Uncertainty about what the future holds
- Changes in behaviour or recurring behaviours
- Expecting other people or interventions to solve the problems (being passive in the process) and serial visits to various practitioners for help with no improvement.
Blue flags can be considered in terms of the employee and the workplace. The employee often has fears and misconceptions about work and health based on their own previous experiences or those of others in the company they work for, or stories from the neighbours. Blue flags can include:
- Concerns about whether the person is able to meet the demands of the job
- Low job satisfaction
- Little or poor support at work
- A perception that the job is very stressful
- An accommodating approach in the workplace to providing altered duties or modified work options to facilitate a return to work
- Poor communication between employer and employee.
There is some overlap between blue and black flags, but they can be primarily distinguished by the black flags being those that are outside the immediate control of the employee and/or the team trying to facilitate the return to work. Black flags include:
- Misunderstandings among those involved
- Financial issues and/or claims procedures
- Sensationalist media reports
- Family and friends with strong unhelpful beliefs influencing the employee
- Social isolation and becoming disconnected from the workforce
- Poor or unhelpful company policies. Often company policies can take two forms: either there is no policy or inadequate policy surrounding sickness absence management and return to work, or there is rigid management of absence within a disciplinary policy system that does not allow sufficient flexibility to deal with genuine injury and illness rehabilitation needs.
There is much more in-depth information about flags in the Tackling Musculoskeletal Problems – a Guide for Clinic and Workplace – Identifying Obstacles Using the Psychosocial Flags Framework document, available from the Stationery Office at www.tsoshop.co.uk/flags.
Pink flags are unofficial, but they are included in this list because they can be useful in practice, although as yet there has been little research to provide an evidence base. These were described by pain specialist physiotherapist Louis Gifford in 20055 to reflect his concern at the constant focus of medicine on the things that make people worse, rather than looking for factors that can help make people better.
The psychosocial factors that are focused on are those that promote a poor outcome, so we should look for attitudes or ideas that promote a good outcome as well. Pink flags are positive factors that we should look out for and emphasise, and even try to help create, that give people the chance of a better outcome. Examples would be someone who enjoys their job and is keen to work with the team to find a way back to work, and an employee who has discovered that activity actually helps them feel better, so wants to stay active at home and at work.
We can influence pink flags by giving reassurance, educating appropriately to avoid unhelpful beliefs developing, and supporting and giving confidence in the planning process. Remember, an accommodating workplace is a pink flag, and we know that the right sort of work is good for peoples’ health and wellbeing.6
So how do we go about assessing for psychosocial flags? The literature recommends an early intervention and stepped approach to common health problems. It is believed that psychosocial factors start to become increasingly important between two and six weeks of onset of the problem, and assessment can begin during this period.
A stepped approach means using an assessment tool as appropriate for the needs of the employee – for instance, starting by asking some key questions and undertaking a screening questionnaire, and then making further in-depth assessment where indicated by these processes.
There are several useful methods for assessing flags:
1. Observation – of the way the employee behaves, interacts with others, and talks about their condition and work.
2. Key questions – these will give you an idea for the flags that may be present. Useful questions (from Tackling MSDs, Kendall & Burton 2009) include:
- What do you think has caused the problem?
- What do you expect is going to happen?
- How are you coping with things?
- Is it getting you down?
- When do you think you’ll get back to work?
- What can be done at work to help?
3. Screening questionnaires – a number of screening questionnaires exist that can help to identify flags in more detail. It should be remembered, however, that questionnaires are just one part of the overall assessment process and should be used alongside other methods as well. A useful one for back pain is the acute low back pain screening questionnaire,7 which includes sections on pain management, anxiety levels, beliefs about work and activity levels. The questionnaires and some excellent guidance on how to use them can be found on the New Zealand Guidance website.8
Other questionnaires exist for measurement of fear avoidance, fear of movement and self-efficacy, and may be a useful addition where indicated.
4. Structured interview – if the methods above have confirmed the presence of flags, then the structured interview is the next step in getting more information about particular issues and flags. An acronym has been developed to help remember which areas to ask more about: ABCDEFW. A for attitudes and beliefs, B for behaviours, C for compensation, D for diagnosis and treatment, E for emotions, F for family and W for work.9 In addition, the conclusion of researchers and working group members at the ‘Decade of the Flags’ conference in 2008 suggests that there are seven key workplace factors that are important to include in screening, and give some sample questions:11
Heavy physical demands: Are you concerned that the physical demands of your job might delay your return to work?
Inability to modify work: Do you expect your work could be modified temporarily so you could return to work sooner?
Stressful work demands: Are there stressful elements to your job that might be difficult when you first return to work?
Lack of workplace social support: What kind of response do you expect from co-workers and supervisors when you return?
Job dissatisfaction: Is this a job you would recommend to a friend?
Poor expectation of recovery and return to work: Are you concerned that returning to your work may be difficult given your current circumstances?
Fear of re-injury: Are you worried about any repeat episodes of (back) pain once you return to work?
5. A visit to the workplace – an excellent additional method of assessing flags. Whether an informal visit or a more structured one for ergonomic assessment, a wealth of information can be gathered when you are familiar with the flags system and what to look out for.
Once you have gathered all your information, it helps to keep using the flag descriptions, and thereby help identify who needs to be involved in the action plan for addressing the recovery and return-to-work obstacles. It is important to recognise that multiple factors do occur most of the time, and that the presence of flags in one area makes the presence of flags in others more likely, because they all interact.4
The results of your assessments equip you with the tools to put together a suitable plan for rehabilitation with the employee and the other stakeholders in the process. Dealing with the psychosocial findings will result in better functional outcomes for the employee. The presence of psychosocial flags should never be a reason to exclude people from treatment programmes or rehabilitation, or to write them off as people who will not recover, but to give them every opportunity to recover through the provision of suitable support.
Depending on the flags that have been identified, a number of different stakeholders and professionals will need to be involved in the action plan to overcome the obstacles and return someone to work. It may be necessary to make referrals for health treatment, undertake medical investigations, organise case meetings with the workplace, and arrange advice from external support agencies, such as debt counselling.
Your professional role will dictate to some extent the obstacles that you can assist with on your own, and which areas you need help with.
One of the most important things to remember is that all aspects of the rehabilitation programme should run concurrently10 – it is not possible to address each problem in sequence, because it would delay the rehabilitation process and make it ineffective, so the following points are a guide to the elements that need to be included in the action planning:
Reassure and educate the patient about the biomedical aspect of their problem, and the fears and concerns they may have about the future. Include the employee in the planning process.
Advise appropriate healthcare intervention/treatment where indicated, which can be applied alongside workplace rehabilitation plans and facilitate an early return to work.
Communicate to all the stakeholders – employee, employer, healthcare, family, external agencies (debt, housing advice as relevant) with shared goals and focus, and identify who is responsible for each part of the rehabilitation programme.
Support workplace co-operation and assistance in providing suitable duties, hours and support to enable the employee to return to work.
Although the flags system can seem like a minefield to begin with, it is an effective and straightforward way of identifying and assessing obstacles to recovery for your clients. Once you are familiar with the different classifications, you will become more adept at spotting flags easily in conversations, and asking more questions when a seemingly little flag persistently waves at you. Over time, flags become a natural part of your assessment process, and integrated into your return-to-work planning.
Heather Watson MCSP, Adv Cert OH, PGC App Ergonomics, occupational health physiotherapist (ESP), is education officer for the Association of Chartered Physiotherapists in Occupational Health & Ergonomics (ACPOHE) www.acpohe.org.uk. Contact email: firstname.lastname@example.org
Much of the material for this article is based on the updated information in the document developed by the Flags Think Tank book written by Nicholas Kendall and Kim Burton in 2009, published by the The Stationery Office (TSO) (ISBN 978-0-11-703789-2). It is recommended reading for more in-depth information about using the psychosocial flags framework. There is also an increasing number of free downloadable resources available linked to the book, including leaflets for employees, employers and health professionals, and speaking notes with Powerpoint presentation slides (www.tsoshop.co.uk/flags).
1 Greenhalgh, S & Selfe, J. 2006 Red Flags: a guide to identifying serious pathology of the spine. Churchill Livingstone, Edinburgh
2 Main, C.J., Philips, C.J., & Watson, P.J. 2005 Secondary prevention in healthcare and occupational settings in musculoskeletal conditions (focusing on low back pain) in Handbook of complex occupational disability claims: Early risk identification, intervention and prevention. I Z Schultz & R J Gatchel, (eds) Springer Science & Business Media, New York.
3 Kendall, N., Linton, S.J., and Main, C.J. 1997 Guide to assessing psychosocial yellow flags in acute low back pain: Risk factors for long term disability and work loss. Accident rehabilitation and Compensation Insurance of New Zealand and the National Health Committee, Wellington, New Zealand
4 Kendall, N & Burton K. 2009 Tackling musculoskeletal problems – a guide for the clinic and workplace. The Stationery Office.
5 Gifford, L. 2005 Physiotherapy Pain Association Journal, Editorial 1 “Now for pink flags”. Issue 20, December Physiotherapy Pain Association
Gifford L. 2006. Red and Yellow Flags and improving treatment outcomes: or “top down before bottom up”. Summer 2006 In Touch, PhysioFirst
6 Waddell, G. & Burton, K. 2006 Is work good for your health and wellbeing? The Stationery Office
7 Linton, S.J. & Hallden, K. 1997 Risk Factors and the natural course of acute and recurrent musculoskeletal pain: developing a screening instrument. Proceedings of the 8th World Congress on Pain.
8 New Zealand Guidelines Group (2004) New Zealand Acute Low back Pain Guide. Published online at www.nzgg.org.nz
9 Waddell, G. 2004 The Back Pain Revolution. Churchill Livingstone, Edinburgh
10 Waddell, G. & Burton, K. 2004 Concepts of rehabilitation for the management of common health problems. The Stationery Office.
11 Shaw, W.S., van der Windt, D. A, Main, C.J., Loisel, P., Linton, S.J., Decade of the Flags Working Group. 2008. Early patient screening and intervention to address individual level Occupational Factors (“Blue Flags”) in Back Disability. J Occ Rehab. Published online 12/12/08. Springer Science & Business Media. LLC 2008.