Occupational health practitioners may need to manage and support mental as well as physical consequences following a workplace accident, especially if an employee is exhibiting symptoms of post-traumatic stress disorder. Jane Whitaker and Anne Harriss outline best practice approaches.
Post-traumatic stress disorder (PTSD) is a mental health disorder caused by trauma and stress (American Psychiatric Association 2013). It can have damaging effects on the ability to maintain employment and may result in occupational health nurses (OHNs) encountering employees experiencing PTSD (Bowsfield and Samra (2015).
Indeed, the National Institute for Health and Care Excellence (NICE) claims that between 25% and 30% of people that experience a traumatic occurrence, may later develop PTSD (NICE 2005). Rosen et al (2017), deems clinicians have little knowledge regarding PTSD, nurses require an understanding of the particular health needs of clients with PTSD, in order to deliver evidence-based care (Cooper et al, 2016; Miltner et al, 2013).
About the authors
Jane Whitaker is an occupational health nurse and Professor Anne Harriss is professor of occupational health at London South Bank University
This case study presents the occupational health support of a commercial diver returning to work following a work-related injury. Commercial diving is a safety critical, high-risk occupation (Courtenay et al, 2012) presenting significant hazards (Health and Safety Executive, 2015); divers are often employed to work on maintenance of ships and submarines using pneumatic tools.
John (pseudonym), a welder had been employed for several years as a commercial diver. Aged 59, he was physically strong and attended the gym regularly. He was considered fit to dive in accordance with Regulation 15 of the Diving at Work Regulations (Health and Safety Executive,1997). He was an experienced vocational diver and assisted in the mentorship of new members of the diving team.
On one particular dive he was holding a stud bar, whilst a colleague cut it with a grinder. The grinding wheel “jumped” striking the dorsum of John’s right hand, causing a large laceration, loss of movement and altered sensation to his index finger.
John required surgery to repair the extensor tendons of his finger. He was referred for physiotherapy that was completed in six weeks supplemented with additional exercises to assist the recovery of movement in his hand.
Progress was slow, initially his grip was significantly reduced compared to his other hand. Nevertheless, John returned to work six months after the accident and was assessed by the occupational physician (OP) prior to his return and deemed unfit to dive, due to swelling and reduced grip to his hand. John was then referred for physiotherapy with the aim of improving his power and grip.
A review date of three months was made with the occupational health nurse (OHN) to assess his progress. At this appointment John was communicative, maintained good eye contact and stated he felt ready to return to work. A phased return to work (RTW) was arranged starting with office based tasks prior to recommencing his normal job role. An OHN review at the beginning of his third week back was arranged to review his capacity to return to full hours of employment.
On the second week of his return, his co-workers noticed a change in John’s disposition. He was uncharacteristically irritable, introverted, displayed poor concentration and was less willing to assist members of the team. At home John was argumentative, short-tempered and unsociable, causing friction between himself and his family.
Diagnosis of PTSD
He was seen by his GP who diagnosed PTSD and referred him to the community mental health team for further assessment and cognitive behavioural therapy (CBT) was commenced. He stated reluctance to take the medication, Sertraline, prescribed by his GP. John reflected on his return to work and recalled that he froze on hearing the sound of a grinder being used. This may have precipitated his PTSD symptoms.
PTSD, “an anxiety disorder associated with a traumatic event” (Crabtree 2017), first recognised in veterans of the Vietnamese war (NHS Choices, 2009). It has had various titles, such as “shell shock” or “battle fatigue”.
PTSD is classified as a trauma and stressor-related mental health disorder, onset of symptoms usually surface within three months but can become apparent several months or years after a traumatic event (American Psychiatric Association, 2013). It is a disabling anxiety disorder (Plat et al, 2013), that can have a negative effect on marriage and family functioning (Sparks 2018) and can also cause lack of concentration and irritability (Vance et al, 2013).
A range of symptoms typically define PTSD (Sparks, 2018, Vance et al, 2013). Crabtree (2017) notes that those with PTSD may experience:
- Reliving aspects of what happened. This can include flashbacks, nightmares, intrusive images or thoughts, distress at reminders of the trauma.
- Alertness or feeling on edge. This can include hypervigilance, becoming easily upset and angry, disturbed sleep, irritability, aggressive behaviour, anger, lack of concentration, easily startled, reckless, anxious.
- Avoiding feelings or memories. This can include feeling emotionally numb and unable to express affection, avoiding reminders of the trauma, using drugs and/or alcohol to avoid painful memories.
- Difficult beliefs or feelings. This can include feeling that “no-one understands”, blaming themselves for the accident/incident, feeling unsafe, unable to trust anyone and feelings of sadness, guilt, shame or anger.
Opinions vary regarding the timescale for diagnosis. Sparks (2018) considers PTSD cannot be diagnosed until symptoms have continued for one month. Bowsfield and Samra (2015) considers symptoms are usually evident within the first three months and typically within six months after the traumatic incident (Royal College of Psychiatrists, 2015).
However, the American Psychiatric Association (2013) states there is a possibility that symptoms may only emerge months or years after the traumatic event. Early diagnosis and treatment can assist in an improved outcome Palmer et al (2013).
Formal diagnosis is based upon characteristic symptoms of the PTSD diagnostic criteria in the 5th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5), (American Psychiatric Association, 2013). There are eight different diagnostic criteria. To diagnose PTSD, all of the conditions listed in the eight different criteria require at least one statement to be identified by the patient (American Psychiatric Association, 2013).
The Royal College of Psychiatrists (2015) proposes that the intense memories of trauma causes the sufferer to become irritable and experiencing difficulties in their ability to relax. There are a range of available effective treatments for PTSD (NICE, 2005) including pharmacological treatment, psychological interventions, or both (Bowsfield and Samra, 2015). Whichever treatment undertaken, it should be supported with information, written and verbal, for the patient and family (NICE, 2005).
Psychological interventions include CBT and Eye Movement Desensitisation and Reprocessing (EMDR). CBT is a “talking” treatment focused on how attitudes, thoughts and beliefs can affect emotions and conduct, and challenges the way people think and behave. (Kar 2011) argues that it incorporates “coping skills” for different problems (Crabtree, 2017). CBT can assist in altering the intense ways of thinking and help to make a client feel better and behave differently (Royal College of Psychiatrists (2015).
EMDR is considered an effective treatment for PTSD (WHO, 2013) and considers the past, present, and future, with focus given to distressing recollections past events Shapiro (2001). EMDR incorporates rhythmic eye movements simulating the way the brain processes experiences and memories, when asleep (Crabtree, 2017) enabling the brain to process flashbacks assisting in the understanding of traumatic experiences (Royal College of Psychiatrists, 2015).
An eight-phased treatment procedure guided by an adaptive information processing (AIP) model (Shapiro, 2001) is utilised. According to Shapiro (2001), when PTSD is experienced, the AIP becomes “imbalanced” causing the traumatic memory to remain intense. EMDR treatment is believed to reactivate neutral information processing assisting the traumatic memory becomes distant (Shapiro and Maxfield 2002).
Pharmacology treatments for PTSD should last for a minimum of eight to 12 weeks (Bowsfield and Samra, 2015) and full benefits may not be reached until at least 36 weeks. NICE (2005) recommends that anyone taking medication to treat PTSD should be advised of the side-effects, which can vary from diarrhoea to suicidal ideation and increased anxiety (Sparks, 2018). NICE (2005) recommends drug treatments should only be considered for patients who have had little or no benefit from a course of psychological treatment.
On reviewing John’s return to work fitness assessments by the OP, it appeared the focus was on his manual dexterity and ability to return to a functional role as a diver. There was no mention of his mental wellbeing in any documentation prior to his return. Murugiah et al (2002) indicate fitness to work assessments should consider physical and psychological aspects of health and that an injury causing a disability has potential to leave psychological scars.
It was unknown if John was displaying traits of PTSD prior to his return; he claimed this was not the case. Equally, it was unclear if the trigger was, indeed, the sound of the grinder on his first week on returning to work.
The use of psychosocial flags should also have been considered in a pre-RTW assessment to ascertain any psychological problems that John may have. Ghisi et al, (2013), consider that assessment of psychological performance after an accident at work is as important, as the review of physical injuries.
The concept of different coloured psychosocial flags was introduced in 1997 by Kendal et al to highlight potential clinical or psychosocial problems and used initially by physiotherapists.
A flag system has been developed for overcoming incapacity (Main, 2007) and identifying obstacles for returning to work. This is described by Vivian (2014) as:
- Red flags. Presence of pathological change
- Orange flags. Presence of diagnosed psychological disorder
- Yellow flags. Key psychological issues, including low mood, inaccurate thoughts, avoidance behaviour and external locus of control
- Blue flags. Factors in the workplace
- Black flags. Refers to the overall situation.
PTSD and high levels of distress are encompassed by the orange flag Watson (2010). Factors highlighted by the flag system assist in the understanding of how recovery and the return-to-work process may be affected and are not a tool for diagnosis (Watson, 2010), while Nicholas et al (2011) maintain clients found to be in the orange flag category will require specialist mental health referral.
Watson (2010) agrees and goes on to state that suitable healthcare intervention and communication with the employee, family, healthcare providers and external agencies should be encouraged, to support workplace rehabilitation plans and enable the return to work of the employee.
The OH team involved in John’s assessment and the decision making in fitness to return to work was led primarily of the OP, followed by involvement of the occupational physiotherapist. Both visited John’s place of work to ascertain a greater understanding of his role, equipment used and the conditions in which John worked. On his return to work, OHNs were involved in facilitation of modified duties and the phased return.
Anderson-Cole et al (2018) consider OHNs capable to undertake assessments and advise on any limitations that the employee requires, while Smith and Harriss (2016) deem OHNs offer appropriate solutions following a fitness for work assessment for both the employer and employee.
The OHNs continued to assess John’s progress and welfare, initially on a weekly basis, following his diagnosis of PTSD. Consideration regarding his medication, the side effects and their impact on health and safety (Murugiah et al, 2002) was taken into account, when advising on roles he would be able to undertake, within the working environment.
Establishment of good communication and liaising with his manager, considered to be invaluable by Kremer et al (2006), assisting with a successful RTW (Watson, 2010). John’s welfare and safety within the team was also monitored, with informed consent to prevent relapse, which Lewis and Thornbory (2010) consider a possibility on returning after sickness absence.
As time continued, it became evident John would be unable to return to his role as a diver, due to reduced manual dexterity, following injury. He was offered a role on the diving support team, where his experience could be utilised and where, he stated, he felt “useful” and had a purpose to his working life. Hannah (2011) claims a meaningful return to work is important, while MacDonald and Asanati (2016) deem work modifications, whether temporary or permanent, as effective interventions in reducing sickness absence.
There were a series of flaws in John’s management of sickness absence. Departmental policies, inter-departmental communication and multi-disciplinary collaboration could have been improved, which Aldridge and Harriss (2017), consider to be fundamental in the development of successful return to work strategies.
OHNs involved in the assessment of staff returning to work, following sickness absence is an element of their role Ghiasse and Harriss (2015) and Anderson-Cole et al (2018) The utilisation of a structured framework, similar to that advocated by Murugiah et al (2002), was used to insure a comprehensive assessment for employees returning to work, following sickness absence.
In conclusion, it is recognised that, following a traumatic injury, PTSD may develop (Ghisi et al, 2013). It is a complex and debilitating condition (RMS, 2017), with negative effects on the individual, their family and working life. It is characterised by defined signs and symptoms, including flashbacks, hypervigilance, and anger (Crabtree, 2017).
Following formal diagnosis of PTSD, medication and recognised psychological interventions can assist with its treatment (Bowsfield and Samra, 2015).
John’s return to work was not facilitated as well as it could have been, changes in the methods for return to work assessments might have improved his experience. The use of psychosocial flags (Vivian, 2014) may have assisted in identifying obstacles for John’s return.
It is hoped that the recent changes implemented within the occupational health department including improved multi-disciplinary collaboration and a review of departmental policies will impact positively. These changes to strategy will ensure employees returning to work will have a robust assessment facilitating a satisfactory return to work.
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