Recent years have seen a growing awareness of and demand for vocational rehabilitation services. In 2006 175 million working days were lost due to illness. Although long-term sickness absence comprises a small proportion of absence episodes, it constitutes more than one-third of total days lost and up to 75% of sickness absence costs.
Longer absences are associated with a reduced probability of eventual return to work and subsequent economic and social deprivation.1,2 Keeping workers at work, minimising sickness absence due to illness or injury and helping unemployed individuals back into work have been recognised as priorities in Dame Carol Black’s review of health and work.3
There has been a growth and re-emergence of occupational therapists in vocational rehabilitation settings: in NHS occupational health departments; as condition management practitioners across the UK; and in various initiatives in the NHS as well as part of mainstream NHS rehabilitation services.4
OHSAS is the NHS-based occupational health service for NHS Fife and NHS Tayside. As well as two NHS trusts, OHSAS services commercial contracts with large public sector employers, quangos and private manufacturing firms. OHSAS has had an occupational therapy service since 2000, which is bought into the contracts as required.
The occupational therapists use standardised methods to assess the functional abilities of an employee, analyse the work duties that he performs, identify those factors affecting performance, and provide practical recommendations for actions that will assist in returning an absent employee to work, or retain employees in their current work.
The occupational therapy interventions provide specific information about the employee’s functional abilities, when that employee has an existing medical condition. This assists the employers in making informed decisions when managing an employee. The interventions available from occupational therapy have been organised into the following evaluations, to improve employers’ understanding of how occupational therapy can be of use to them.
Work Ability Evaluation (WAE) – Assesses the employee’s potential to perform a specific job, whether they are currently in work or absent.
Career Search Evaluation (CSE) – Assesses the employee to identify what skills they have for alternative work. The worker can be absent from work or currently at work.
Jobsite Evaluation (JSE) – Assesses the employee at their place of work and identifies modifications or actions to promote the employee’s ability to perform their job with a reduced risk of aggravating an existing health problem.
Occupational therapists need to be able to explain to occupational health professionals and employers what role occupational therapy can play in occupational health and describe the benefits that occupational therapy intervention can provide. It was with these objectives in mind that a survey of users of the OHSAS occupational therapy service was conducted.
The aims of the survey were:
To identify employment outcomes for employees referred to occupational therapy.
To identify demographics about employers and the employees they refer.
To identify employers’ and employees’ satisfaction with the service.
The survey involved a posted questionnaire sent to employees who had received occupational therapy, as well as to the referral source. The sample was taken from employees referred to occupational therapy from July 2005 until July 2007. Only two groups were excluded. One was employees referred to occupational therapy via the OHSxtra project. This was a pilot study undertaken in NHS Fife and NHS Lanarkshire to provide a case management service for employees, which included the provision of occupational therapy, counselling, physiotherapy and cognitive behavioural therapy.5
These employees were already completing pre- and post-intervention evaluations about their treatment. The other group excluded were the OHSAS physicians and nurses. They are the primary source of referrals for occupational therapy and it was not felt to be appropriate to request them to repeatedly complete questionnaires for every employee they referred.
Two questionnaires were developed – one for employees, the other for employers. Advice on language and the content of questions was provided by an occupational psychologist. The proposed questionnaires were reviewed by the NHS Fife clinical effectiveness unit for further advice on questionnaire development. They advised that the level of sensitivity of information being requested did not require ethical approval or consent from employer organisations. Permission to invite employees and employers to participate in the survey was obtained from the OHSAS management team.
The questionnaires contained a majority of fixed questions, with participants selecting an answer from a set choice. In both questionnaires one question used a Likert scale to determine participant’s strength of agreement with given statements about the benefits of occupational therapy.
Questionnaires were sent out six months after the initial occupational therapy evaluation had been provided. The returned questionnaires were analysed using Statistical Package for Social Sciences, version 13.0 for Windows6. The responses were coded and divided into nominal or ordinal data and analysed using descriptive frequencies and cross tabulations.
Respondents: A total of 172 employees and 140 employers were eligible to be included in the survey and were sent questionnaires. The response rate was 113 employees (66%) and 110 referrers (78%). 82% of employer respondents and 79% of employee respondents worked in the public sector.
Work Status at Time of Evaluation: At the time of evaluation, 59% of employees were in work – either performing their usual duties, their usual duties with restrictions or alternative duties. Seven of these employees had just returned to work at the time of their evaluation and recorded the length of time they had been absent just before the evaluation.
Absentees and Returning to Work: Of the 46 employees absent from work at the time of the occupational therapy evaluation, 26 had returned to work within 12 weeks of the evaluation. However, by the time of completing the questionnaire, six months later, four had returned to sick leave. Of the final 22, 13 returned to their usual duties and nine to alternative duties.
Of the 67 employees who were in work at the time of their occupational therapy evaluation, at the time of completing the questionnaire, 59 (88%) were still at work performing their usual duties or alternative duties. Five were absent on sick pay, two were age retired and one had their employment terminated on ill health grounds.
Current Medical Condition: The questionnaire asked employees to report on the current status of their symptoms.
Duration of Medical Condition: As this data was reviewed it soon became apparent that missing from this picture was measurement of how long the employees had suffered from their medical condition. Subsequently, all of those employees who returned a questionnaire had their occupational therapy notes reviewed, and information recording the duration of their presenting medical condition was collected.
Benefits of Occupational Therapy to Employees and Referrers: Each questionnaire asked respondents to express their level of agreement with statements about the benefits of the occupational therapy intervention.
One of the key themes raised by this survey is the picture of the employees who are referred to occupational therapy. The majority of employees have musculoskeletal conditions and report suffering from their medical condition for at least seven months.
Many of these individuals fit Waddell’s7 description of individuals typically having mild/moderate musculoskeletal conditions, characterised more by their symptoms than by tissue abnormality.
He describes them as common health problems, not severe in a medical sense, but with a risk for progressing onto long-term incapacity. Some 34 out of 46 employees absent at the time of the evaluation had been absent for between four and 18 months. Typically, these employees have had primary care-based interventions, yet their problems with work persist.
The survey reveals that six months after their occupational therapy evaluation, 22 out of 46 employees originally absent were back at work, defying the statistical trends for such a group. Previous research has found that the longer an employee has been absent from work, the lower their chances are for a return to work.8,9
The feedback from the employers reveals that the information provided by the occupational therapy evaluation helps them to make decisions about managing the client at work, and gives them confidence to help return an absent employee to work. The absent employees report that the evaluations help them to better understand their capabilities, improve their confidence for work and help them work without aggravating their existing condition.
Limitations of the survey
An obvious limitation of such questionnaires is the self-selecting nature of the respondents. The replies may reflect the response bias of those motivated to reply to the questionnaire. Another limitation is the timing of collecting data to demonstrate outcomes in vocational rehabilitation. This can be problematic, as employees will move in and out of work in the months and years following rehabilitation, sometimes, but not always, due to their medical condition.10
The results of the survey created a valuable picture of the types of employees typically referred to occupational therapy; a distinctive group of individuals with chronic conditions that represent a significant cost to the employers.
The ability of these individuals to work is the result of a complex interaction between the worker, their physical capacities, the demands of their job, the work environment, employer attitude and various psychosocial factors. Occupational therapists can perform useful assessments that address these factors.
In occupational health it is the worker’s ability to safely perform their job that is the focus. An occupational therapist’s traditional role is to promote an individual’s functioning and independence. In work rehabilitation this focuses more on a worker’s ability to do their job and less on measuring the extent of the impairment caused by the medical condition.
This survey illustrates how an occupational therapist working in occupational health can provide a valuable service to these individuals and also for their employers. Visits by an occupational therapist to an employee in the workplace can produce advice and recommendations for modifications that retain the employee in their job, minimising the risk for aggravating their condition.
An occupational therapist performing vocational evaluations can help produce valuable information about an individual’s potential for work and identify actions to support an employee in work. Such information can help in appropriately managing and supporting individuals to remain in work and avoid long-term incapacity.
Occupational therapists hold bachelors or masters degrees. All occupational therapists in the UK are required to be registered with the Health Professions Council.
There are occupational therapists working in NHS occupational health services across the UK as well as occupational health services in police forces. Other occupational therapists work in various vocational rehabilitation roles in the Department for Work and Pensions, the NHS and in private work.
Malcolm Joss is an occupational therapist for OHSAS
1 Barham, C & Begum, N. (2005). Sickness absence from work in the UK. Labour Market Trends Office for National Statistics; April: 149-158.
2 Henderson, M., Glozier N. & Holland Elliot, K. (2005). Long Term Sickness Absence. British Medical Journal; 330: 802-803.
3 Black, C. (2008). Working for a Healthier Tomorrow. Health Work Wellbeing.
4 Barnes, T & Holmes, J. (2007). COT Specialist Section Work Vocational Rehabilitation Toolkit. College of Occupational Therapy.
5 Hanson, M., Murray, K. & Wu, O. (2007). Evaluation of OHSxtra, a pilot occupational health case management programme within NHS Fife and NHS Lanarkshire. Final report to steering group.
6 Pallant, J. (2006). SPSS Survival Manual 2nd Edition, Open University Press.
7 Waddell, G. (2006). Preventing incapacity in people with musculoskeletal disorders. British Medical Bulletin; 77 & 78: 55-69.
8 Waddell, G., Burton, K. & Kendall, N. (2008). Vocational Rehabilitation. What Works, For Whom, and When? The Stationary Office.
9 Matheson, L., Isernhagen, S. & Hart, D. (2002). Relationships Among Lifting Ability, Grip Force, and Return to Work. Physical Therapy: 82 (3); 249-256.
10 Fishbain, D., Cutler, R., Rosomoff, H., Khalil, T., Abdel-Moty, E., Sadek, S., Zaki, A., Saltzman, A., Jarrett, J., Martinez, G. & Stelle-Rosomoff, R. (1996) “Movement” in Work Status After Pain Facility Treatment. Spine; 21 (22): 2662-2669.