It is estimated the incurable, inflammatory bowel condition Crohn’s disease affects at least 115,000 people in the UK. Managing it in the workplace, and managing return to work for someone with the condition, can bring with it specific challenges, as Lauren David and Anne Harriss outline
Crohn’s disease (CD) is an incurable inflammatory bowel condition can affect any part of the gastrointestinal (GI) tract (Ng, 2012). Symptoms and prognosis vary considerably amongst affected individuals.
It is estimated that there are at least 115,000 cases in the United Kingdom (NICE, 2017). It forms one of two GI conditions encompassed within the umbrella term of Inflammatory Bowel Disease (IBD), the other being ulcerative colitis (UC). Although both conditions have similar presenting symptoms, there is a key distinction to the patho-physiology and location of disease (Madan and Hellier, 2013).
About the authors
Lauren David RN Adult is a student occupational health nurse. Anne Harriss MSc, BEd, RGN, OHNC, NTF(HEA), PFHEA, CMIOSH, FRCN, Hon FFOM is professor in occupational health and course director occupational health nursing and workplace health management programmes at London South Bank University
Despite its aetiology being uncertain, ulcerative colitis is an inflammatory condition whilst CD is considered an autoimmune disease. That is, in CD rather than fulfilling its protective function, the immune system attacks the body’s tissues and cells (Moore, 2012). Smoking and genetic predisposition are important causal factors (NICE, 2017).
Predominant symptoms include persistent abdominal pain, diarrhoea, constipation, weight loss and fatigue (Malarcher et al, 2017). It is a chronic condition, characterised by periods of acute exacerbation (relapse) with spontaneous or treatment-induced remission (Maddan and Hellier, 2013). Treatment is directed at symptom relief and includes drug therapy, nutrition management and (in severe cases) surgery (NICE, 2017).
The typical age of onset of CD disease is during young adulthood, when individuals are arguably most active in their professional and personal lives (Ng, 2012). Research demonstrates the potentially devastating impact of IBD upon educational attainment and employment (Gay et al, 2011). Its fluctuating nature can severely disrupt working life, with symptoms and treatment having a significant effect on career choice and progression, work productivity and job satisfaction (Gay et al, 2011; Maddan and Hellier, 2013; NICE, 2017).
Occupational health assessment
Employees experiencing long-term sickness absence (LTSA) should undergo a thorough OH assessment to determine fitness and barriers to returning to work (NICE, 2009). The purpose of this is to ensure the individual is fit to perform their job role effectively and without risk to themselves or others. The intention is to make appropriate adjustments to support them to work efficiently and safely (Palmer and Brown, 2013). This is not without its challenges requiring clinical knowledge of health conditions, an understanding of job demands, and the expertise to undertake history-taking (Everton et al, 2014).
A key element of determining fitness for work is functional assessment, in other words estimating the individual’s level of function relative to the likely requirements of the workplace (Palmer and Brown, 2013). The functional demands of their job are considered in the light of the impact of the individual’s condition on normal day-to-day activities (Thornbory, 2013; Everton et al, 2014). Richardson (2008) argues that face-to-face consultations facilitate good rapport between the occupational health nurse (OHN) and client and achieve the best possible outcome.
A biopsychosocial model can be used to provide a structure to the assessment. This is as an individual-centred approach used to understand illness and disability, and addresses the biological, psychological and social dimensions of the individual and their health problem (Waddell and Burton, 2004). In addition, the model of Murugiah et al (2002) offers further guidance ensuring consideration of the following essential criteria:
- Personal aspects
- Work characteristics
- Work environment
- Legal aspects
This article will look at each of these in turn.
Personal aspects
- Presenting illness
The first stage of the OH assessment is to establish the presenting situation and history (Thornbory, 2013). The client’s GP may have issued a fit note indicating their opinion that they are fit to return to work with amended hours and or amended duties and this will be a useful starting point within the assessment.
The client may indicate experiencing increasing frequency of diarrhoea, abdominal pain, fatigue and weight loss; during an acute exacerbation symptoms will have increased in severity until the client is eventually unable to attend work. The clinician responsible for their care may have advised them to rest at home facilitating their recovery.
- Pathophysiology
To further understand the functional limitations of CD, it is useful to consider the normal anatomy and function of the gut. Its overall role is to get food into the body, convert it into useful fuel to be delivered to the organs, and to dispose of waste products (Langmead and Irving, 2008).
Although the exact cause of CD remains undetermined, the typical pathological process begins with small bowel inflammatory lesions.
spread slowly and progressively.
As a result, enlarged lymph nodes block the flow of lymph in the bowel sub-mucosa leading to oedema, ulceration, fissures and granuloma that form as a result of inflammatory process. Abscesses within the abdomen may result from bowel contents leaking outside the gut. Peyer’s patches, small patches of closely packed lymph follicles, then develop within the bowel.
This results in thickening of the bowel wall, causing stenosis then serositis – an inflammation of the serous membrane lining the bowel. Inflamed loops of bowel adhere to other portions of bowel with diseased segments then become interspersed with healthy ones. The diseased sections of bowel eventually become thicker, narrower and shorter.
Abdominal pain and diarrhoea are symptoms indicative of CD and bowel inflammation (Hodgson, 1998). Langmead and Irving (2008) suggest that abdominal pain in CD is caused by contraction of inflamed sections of colon. [AH6]Pain may also arise from other mechanisms including the release of bacterial toxins in the bowel, pressure on nerve endings resulting from oedema and distension of the gut (Marieb and Hoehn, 2013; Bielefeldt et al, 2009).
The specific location of pain is reflective of the type of CD. Ileo-colitis, for example, is associated with the most common form of CD, affecting almost 50% of all sufferers (Peake et al, 2012). Disease is localised to the ileum and the colon. The primary function of the ileum is the absorption of nutrients, achieved through mechanical and chemical digestion (McErlean, 2017). Inflammation therefore reduces its ability to absorb crucial vitamins and minerals (malabsorption) leading to malnutrition (Cadwaller, 2008). Vitamin supplements and focusing on nutrition aids recovery. Identifying dietary “triggers” and for sufferers to avoid foods high in insoluble fibre during any relapses is helpful. IBD specialist nurse can help advise sufferers with a tailored food re-introduction plan.
Some sufferers experience frequent episodes of diarrhoea each day as a result of colon inflammation. As the normal function of the colon is absorption of water from food residue and form semi-solid faeces (McErlean, 2017). In CD the inflamed colon is unable to reabsorb water normally resulting in stool of liquid consistency (Langmead and Irving, 2008).
The major risk associated with diarrhoea is dehydration, further complicated in IBD as individuals can be tempted to reduce oral intake in order to prevent further episodes (Rutherford, 2012[AH7]). Increasing fluid intake and drinking an oral rehydration solution to replace lost fluids and electrolytes can assist.
Fatigue, overwhelming sense of lack of energy, continued tiredness or exhaustion not relieved after rest or sleep is associated with CD (Crohn’s & Colitis UK, 2015), presenting a substantial risk for sickness absence (Varekamp and van Dijk, 2010).
More than 75% of individuals with CD report fatigue during a relapse (Crohn’s & Colitis UK, 2015). [AH8]Stress can trigger an IBD relapse and be detrimental to recovery (Goodhand et al, 2012; Schreiner et al, 2017).
- Medication
To establish fitness for work, medication and the functional impact of any side effects should be considered (Palmer and Brown, 2013). Azathioprine, an immunosuppressant suppressing the cells of the immune system reducing bowel inflammation (Crohn’s & Colitis UK, 2018a) is frequently prescribed as it is effective in managing symptoms of CD. An additional medication includes infliximab that targets a specific protein produced during the body’s immune response reducing inflammation (Crohn’s & Colitis UK, 2018b) although a common side-effect is drowsiness (Crohn’s & Colitis UK, 2018b), which may impact on the employee’s tolerance to attend, or return, to work.
Similar to azathioprine, infliximab suppresses the response of the immune system. Thus, while both drugs reduce bowel inflammation, they also increase susceptibility to infection. It is therefore crucial to consider the implications of this for the employee’s fitness for work, particularly if job requirements make the employee particularly vulnerable to opportunistic infection. Patients with CD should have an up-to-date immunisation status Baumgart and Sandborn (2012) and this is particularly important if they work in health care due to exposure to biohazards.
Of particular importance for healthcare workers would be evidence of immunity to tuberculosis (TB), varicella, measles, rubella and hepatitis B should be confirmed and the health care worker reminded of the importance of avoiding close or prolonged contact with viral rashes or patients known or suspected to have open TB.
Work characteristics and work environment
- Employment History
Determining fitness for employment or return to work after sickness absence requires consideration of the functional demands of their post, including work demands such as a high level of physical and intellectual ability. It is important to address the organisational and temporal demands of the person’s work (Palmer and Brown, 2013), shift work may be of particular relevance.
Identification of exacerbating and relieving factors is vital in effectively managing chronic illness (Varekamp and van Dijk, 2010). During periods of remission shift-workers may report that night shifts have little impact on their condition as they may sleep well during the day. However, their routine may become unsettled by frequent rotating shifts with the potential to exacerbate symptoms and disrupt sleep patterns. For some, particularly those working in healthcare, rest breaks may be ad hoc and dependent on workload with little time for meal breaks resulting in these being rushed. Regular breaks, are essential to promote recovery.
The employee should be asked whether they perceive any barriers to a RTW, having a high degree of job control and a supportive line manager are particularly important factors recognised to be significant in facilitating a RTW (Preece and Royles, 2013).
Legal aspects
The OHN should be fully conversant with the legislation relevant to assessing fitness for work (Murugiah et al, 2002). Under common law, employers have an obligation to take steps to ensure the employee’s safety and eliminate risk (Howard, 2013). Furthermore, employers owe a higher duty of care to vulnerable employees with pre-existing medical conditions, as demonstrated in Paris v. Stepney Borough Council [AH9](1951) (Howard, 2013).
Section 2 of the Health and Safety at Work etc. Act (1974) requires employers to ensure, so far as is reasonably practicable, employees’ health, safety and welfare at work (Great Britain Parliament, 1974). Regulation 3 of the Management of Health and Safety at Work Regulations 1999 requires employers to assess risks to employee health and safety (Health and Safety Executive [HSE], 2000).
From the perspective of the OHN, there is a further duty to consider legal requirements pertaining to the client’s right to confidentiality requiring an understanding of data protection legislation and the Access to Medical Reports Act 1988. The Equality Act 2010 mandates that discrimination due to disability is unlawful. An individual is considered disabled under the Equality Act (2010) if they have a physical or mental impairment having a substantial and long-term adverse effect on their ability to undertake normal day-to-day activities (Howard and Williams, 2013).
This therefore emphasises the importance of assessing function, rather than the condition itself. Given that CD can affect the ability to control bowel movements, resulting in faecal incontinence, many cases are likely to covered by the disability provisions of the Act. For those affected, their employer has a duty to make reasonable adjustments to assist them to maintain or return to employment. The OHN may be asked to advise on the likelihood of the Equality Act applying and the adjustments the employer should consider implementing (Howard and Williams, 2013).
Ultimately, the question of whether the Act applies is a legal decision and can only be determined by the employment tribunal or court (Smedley et al, 2013).
Rehabilitation and the role of the OHN
Ultimately, OHNs are at the forefront of the drive to protect and promote the health of the working population (Thornbory, 2014). Although they assume a multifaceted role, their primary concern is to prevent employee ill health, and this therefore requires consideration of the two-way relationship between work and health (Bagley, 2008).
The review of sickness absence conducted by Dame Carol Black and David Frost (2011) acknowledged that OH intervention is highly effective in managing LTSA. An early RTW, with appropriate adjustments, is often a crucial step in helping someone return to full health (Black, 2008; Everton et al, 2014). Indeed, the psychological wellbeing of clients highly motivated to return to the workplace can be enhanced, there is extensive evidence that work is generally good for health (Waddell and Burton, 2006; Marmot, 2008). Encouraging and supporting individuals with health conditions to RTW as early as possible has therapeutic benefits: it promotes recovery and rehabilitation, improves quality of life and health outcomes (Waddell and Burton, 2006).
Biopsychosocial flags
Biopsychosocial factors can perpetuate sickness and disability and present an obstacle to successful rehabilitation (Aylward et al, 2013). ‘Biopsychosocial flags’ identify barriers to an employee’s RTW (Watson, 2010). Using a biopsychosocial approach enables the OHN to consider any relevant psychosocial flags. The rationale for psychosocial assessment fundamentally two-fold. Firstly, as identified earlier, LTSA is associated with psychological distress and poorer mental health (Waddell and Burton, 2006). Secondly, rates of perceived stress, anxiety and depression are higher in IBD patients and it is therefore crucial to identify and manage psychological distress to facilitate better health outcomes (Canal, 2016). The permanence, unpredictability, perceived stigma and antisocial consequences of CD can have a profound impact on psychological wellbeing (Taft et al, 2011; Bannaga and Selinger, 2015).
With this in mind, the OHN should be mindful of psychosocial flags that may impede an effective RTW. Such an assessment should comprise the following aspects:
- Mental health including concentration, mood, anxiety and any suicidal ideation
- Motivation
- Lifestyle – interest and pleasure in usual activities
- Exercise, diet, drugs and alcohol, personal relationships and home stresses/strains
(Harrington, 2014)
The literature emphasises the value of a multidisciplinary approach to OH rehabilitation. Effective sickness absence management relies on collaboration with management and communication between multidisciplinary professionals (Ferguson, 2008; NICE, 2009; Preece and Royles, 2013). With regard to supporting a return to work for an employee with a chronic debilitating condition such as CD the multi-professional team may incorporate liaison with medical practitioners such as the client’s GP and nurses specialising in chronic bowel disease.
An understanding of the implications of both the pathophysiology of CD, and the work requirements will assist the OHN in supporting an effective return to work.
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Waddell, G. and Burton, K.A. (2006) Is work good for your health and well-being? Available from: http://iedereen-aandeslag.nl/wp-content/uploads/2016/07/hwwb-is-work-good-for- you.pdf
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