People with learning disabilities often struggle to first secure and then maintain paid employment. That puts occupational health in a pivotal position when it comes to supporting health, continuing employment and return to work after absence. Lisa Watkins and Professor Anne Harriss outline best practice you can be applying.
For people with learning disabilities, securing and then maintaining paid employment can be extremely challenging.
Indeed, statistics published by the Health and Social Care Information Centre suggests that, for regions across England in 2014-15, fewer than 8% of working-age people have such employment; although generally it is less than 5%. And for the West and East Midlands it troughs at 4.3% and 3.2% respectively (Health and Social Care Information Centre, 2015).
Therefore, where those with learning disabilities are employed, it is essential they are supported to maintain their employment. Occupational health professionals can be pivotal to this.
This case study highlights the holistic assessment of Geraldine, aged 33, employed for the previous six years in a role involving supporting students and staff within a college environment.
The occupational health (OH) service support she received resulted from a management referral which was requested to establish if the employee is fit for work and whether any reasonable adjustments are required to support her attendance. It considers the:
- patho-physiology underpinning of Geraldine’s health needs; and
- potential impact of her health on her fitness to work.
Geraldine is contracted to work term-time for four days per week from 12pm-2pm. Although her attendance had generally been good, her manager had noted a decline in her wellbeing and there had been a number of incidents of Geraldine becoming unwell during working hours requiring her to leave early.
The management referral included a job description and indicated that Geraldine was awaiting bariatric surgery. Her manager was keen to support her wellbeing and attendance in the pre- and post-operative periods.
The referral confirmed Geraldine has a known learning disability and was keen to be referred to OH. It included her consent to attend and for the information to be shared with a “third party” (Lewis and Thornbory, 2012). Her job and independence were very important to Geraldine and her family; the organisation was keen further to support any needs she may have during this pre-operative stage in enabling her to maintain her current role, without detriment to her physical health.
Wadell et al (2008), Black and Frost (2011), and Lewis and Thornbory (2012) highlight the importance of early referral to OH and the positive impact on quality case management. It was established that her mother was her named family support and she agreed to accompany her daughter to OH appointments.
OH assessments establish whether an individual is “fit” to undertake their role within their working environment without risk to themselves or others. The Murugiah et al (2012) Fitness to Work model was used to facilitate a holistic assessment of four key areas (personal aspects, the work environment, characteristics of the work and legal aspects).
Geraldine’s consent to partake in the assessment and for this information to be shared with her manager was confirmed (Kloss and Ballard 2012). To establish Geraldine’s functional mental capacity to understand the issues around consent and thereafter assessment and recommendations, her mental capacity, as covered by the Mental Capacity Act (2005), was discussed and Geraldine’s capacity assessed.
It was determined that she had a cognitive impairment and that she was able to make specific decisions (National Health Service (NHS), 2016). In partnership with Geraldine, her mother and the OH nurse, it was established that she could communicate effectively, understand, retain and act on the information discussed within the consultation.
It was agreed by all that Geraldine could participate in the assessment independently. Thereafter, her mother was invited to review the assessment and made aware of recommendations made. The following were established and documented:
- occupational and social history;
- past and current health history, and details of absences from work; and
- her work requirements, responsibilities and working relationship with her manager and colleagues.
Geraldine’s employment is an important social outlet for her. Geraldine, and her parents had concerns that she could lose her job because of recurrent absence. It became apparent that Geraldine attended work when unwell for fear of the impact of frequent absences on her future employment. Although Geraldine lives alone, her parents support her with activities of daily living including shopping and financial management. They ensure a supply of ready-meals and snacks that she can prepare independently.
Geraldine attends work regularly. A current risk assessment was in place which considered the implications of her learning disability and increased body mass index (BMI) of 53.1. It confirmed that her manager had provided appropriate bariatric seating and safe, manageable tasks for Geraldine to undertake.
Geraldine confirmed her responsibility for washing up and clearing lunch-time residue. She socialises and interacts with students conducting gaming sessions weekly. Geraldine prefers to manage life independently; her mother confirming that she attempts to support her but Geraldine refuses her help. As an adult with capacity, she feels she cannot impose herself if Geraldine asserts her independence.
Geraldine declared a recent episode of shortness of breath following exertion but had never been diagnosed with any specific cardiac abnormalities requiring treatment. This episode resulted in an emergency admission to A&E she was sent home and advised “to rest”.
Geraldine is classified as morbidly obese with a BMI of 53.1 (NHS Choices 2015a). Bariatric surgery is planned for later this year. Her consultant is approaching surgery holistically, inclusive of physical and psychological wellbeing. Investigative preparatory tests have already commenced with a possible “Insulin resistance” underpinning Geraldine’s morbidly obese state.
Geraldine reports leg ulcers, cellulitis and lymphoedema of both lower legs. These are managed by her GP practice nurses with district nurses providing additional support regarding her medication needs should antibiotics or analgesics be prescribed. At the time of the assessment she had neither open wounds nor significant swelling. Currently Geraldine takes no regular medication. She sees the college nurses regularly for support when required and reports good, open and supportive relationship with her manager, colleagues and students.
Regarding Geraldine’s mental health: she confirms currently feeling happy and her employment supports this. She was cheerful with no concerns regarding her impending surgery as she knows the surgeon well and sees her regularly.
Pathophysiology and potential impact on the working environment and rehabilitation
The OHN must evidence clinical knowledge of the employees’ health conditions when establishing whether an employee is fit to meet the requirements of their job description without risk to themselves or others. It became apparent there were a number of health issues, as well as a learning disability affecting this employee which required review in relation to their potential impact within the working environment. These included the:
- patho-physiology of insulin resistance and obesity;
- importance of pre-operative health and early intervention; and
- potential impact of a learning disability.
Pathophysiology of Insulin intolerance and obesity
Insulin is produced in the pancreas (Muralitharan and Peate 2013) which Marieb and Hoehn (2010) refer to as containing both endocrine and exocrine gland cells. These produce enzyme rich fluid secreted into the small intestines aiding food digestion. Alpha, beta and delta endocrine cells produce hormones to control blood glucose levels.
- Alpha cells produce glucagon that breaks down liver stored glycogen into glucose, and promotes synthesis of glucose from fatty and amino acids. This is released into the blood stream – the stimuli to release glucagon are deceased levels of glucose and increased levels of amino acids , conditions which occur after a protein-rich meal.
- Beta cells are the most numerous and produce insulin that reduces blood glucose levels and assists in the breakdown of, and the metabolism of fat. Insulin promotes the transport of glucose into the cell that produces adenosine triphosphate, the fuel of body cells. Insulin, produced in response to raised blood sugar levels, promotes the conversion of remaining glucose into glycogen, fat and promotes amino acid uptake by muscle tissue.
The reciprocal effect of each of these hormones results in the release of the other hormones and their production is consistently adjusted leading to a level homeostasis, preventing large fluctuations in blood glucose. Delta cells secrete somatostatin, a glucagon and insulin inhibitor. In the event of an endocrine disorder, as with insulin resistance, there is an imbalance to this homeostasis.
Insulin resistance is a state in which a given concentration of insulin produces a less-than-expected biological effect, leading to increased insulin secretion to maintain normal glucose and lipid homeostasis. Mechanisms responsible for insulin resistance syndromes including genetic or primary cell defects and abnormal or dysfunctional mitochondria resistance. This is associated with an increased risk of coronary heart disease, hypertension, insulin intolerance and non-insulin dependent diabetes have been suggested by and Kim, Wei, and Sowers (2008).
The World Health Organization (2006) advises that patients are provided with information and support to understand their endocrine disorders inclusive of the need to take control of their health and well-being. High-quality patient education regarding the nature of their illness and adoption of a healthier lifestyle coupled with screening of the individual at risk is essential.
Geraldine’s mother highlighted that healthcare professionals throughout Geraldine’s development to adulthood had suggested a possible undiagnosed syndrome affecting her growth and learning disability, which now seems to have resulted in her current morbid obesity and insulin resistance.
Obesity, largely resulting from the secretion of excessive adipokines, is an exaggeration of normal adiposity . It is a central player in the pathophysiology of diabetes mellitus, insulin resistance, dyslipidemia, hypertension and atherosclerosis.
Obesity is a major contributor to the metabolic dysfunction involving lipid and glucose. This metabolic dysfunction extends to cells within multiple organs and systems with the result inducing abnormal inflammatory responses with long-term effects, being detrimental for both fatty liver development and pancreatic insulin release.
Obesity contributes to immune dysfunction from the effects of inflammatory adipokine secretion, a major risk factor for many cancers (Redinger 2007). Redinger (2007) reports on the importance of promoting and supporting healthy eating habits and physical exercise.
Pre-operative health and bariatric surgery
Geraldine awaits bariatric surgery used to treat people dangerously overweight (NHS Choices 2015 b). The details of the bariatric surgery Geraldine will undergo has not yet been established but it is major surgery with a significant recovery period.
Early referral facilitates the OH nurse monitoring and supporting pre- and post-operative support. Following confirmation of surgery details, a rehabilitation plan can be designed involving both employee and manager. This is of importance in order to facilitate Geraldine being fully aware of how her health and wellbeing can be proactively supported.
Lanyon et al (2014) investigated the role of good versus poor pre-operative health prior to gastric banding surgery, concluding that pre-operative health status served as a powerful moderator in predicting continued weight loss and many other health variables. Those participants having good pre-operative health and psychological preparation experienced better post-operative outcomes than those lacking this preparation.
A supported health education programme for Geraldine will impact positively on her abilities to remain fit for work given her diagnosis of insulin resistance, consequent obesity, pre-operative health and rehabilitation needs.
The Valuing People report (Department of Health, 2001) defines a learning disability as a condition that commences before adulthood with a lasting effect on development. It suggests the person has a significantly reduced ability to understand new or complex information with difficulties learning new skills (impaired intelligence). There is a reduced ability to cope independently (impaired social and physical functioning); these mental and physical impairments are covered by the Equality Act (2010). It is established that Geraldine is assessed as and registered disabled as she is in receipt of Personal Independence Payment (previously Disability Living allowance) for working-age adults with a disability.
“People with ‘Learning Disabilities are amongst the most vulnerable and socially excluded in our society. Very few have jobs, live in their own home or have choice over who cares for them. This needs to change: people with learning disabilities must no longer be marginalised or excluded” (Department of Health, 2001).
Wadell and Burton (2006), within their review Is work good for your health and wellbeing?, concluded that despite the diverse nature of the evidence and limitations considered, there remains strong evidence that work is good for physical and mental health and wellbeing.
Geraldine expressed the significance of her work to her and, having achieved employment, it makes it even more important to support her and her manager during this period. She comments that the opportunity to work makes her feel “part of it all” and is essential to promoting her mental health.
Although it could be argued that Geraldine’s ill-health may be exacerbated by attending work during this period, and is recognised she may benefit by resting, given her comments, current health status, minimal contracted hours and support available, it is determined there are more benefits associated with attending work than not.
By combining clinical knowledge and considerations, an evidenced-based report was prepared for her manager and recommended that:
- Geraldine should continue to attend work as per her contracted hours with a view to potentially reducing these hours temporarily during her pre-operative stage if necessary and agreed in the future.
- It is confirmed to Geraldine and her mother that the purpose of occupational health reviews is to focus on supporting her to remain in post and ensure appropriate support is in place during both pre and post-operative phase where her wellbeing may affected.
- She should be enabled to access the in-house staff health and wellbeing advisory service where the senior nurse conducts one-to-one health and wellbeing awareness with assessment and education around necessary and requested areas of health, including the introduction of a healthy, fresh ready-meal delivery service.
- Lengthy discussion with Geraldine and her mother recommending to Geraldine that she has assistance and support at her medical appointments. This is not reflective of her ability to be independent but a sensible approach to medical reviews, allowing all parties to partake and share information in the limited time given for such appointments.
- Geraldine should be driven to work by her father, planning to arrive at work 15 minutes before the start time of her work shift. This will provide opportunities to rest if necessary and prepare for her duties.
- Geraldine may benefit from support by her line manager to contact and apply for assistance from Access to Work, the Government-led initiative which helps employees with a disability to stay in work. Grants may be available to assist with travel costs on her return to work post-operatively.
- Geraldine was advised to only attend work when well. She was given information on how to report absences should this be necessary pre- or post-operatively.
- HR, Geraldine and her line manager should meet and review the sickness and absence procedure triggers during this period and agree any temporary alteration if this was felt appropriate.
- If Geraldine becomes unwell at work she should inform her line manager and parents immediately to facilitate her collection from work and seek the medical support required.
- Geraldine will ensure any open wounds/ulcers she may develop will remain covered during duty, otherwise she should refrain from duty.
- Geraldine’s current risk assessment to be reviewed and further amended in partnership with Geraldine, HR and her line manager.
- The OHN would contact Geraldine’s GP following her bariatric surgeon review and thereafter post-operatively to request up-to-date information to underpin a return to work recovery strategy.
Harriss and Cooper (2005) suggest that, to effectively support the employee and assist the employer to fulfill their duties under the Equality Act 2010, the OH nurse requires full knowledge and understanding of the employee’s health needs.
This case management review outlines the processes used by the OH nurse in conducting a bio-psycho-social assessment conducive in establishing the employee’s fitness for work with reasonable adjustments which will be repeated once Geraldine’s surgery has been completed.
It provides an overview of pathophysiological elements of Geraldine’s health needs; the potential impact on her fitness and safety to work have been presented. The in-depth knowledge held by the OH nurse regarding the organisation, its staff, organisational culture and policies facilitated multidisciplinary support.
Central to this were multi-professional approaches involving the OHN, the line manager, HR and other members of the health team. The OH nurse remained an impartial advisor to both employer and employee. Geraldine, her family and line manager were able to continue to access OH in support of a planned and effective return to work strategy.
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