Return to work after myocardial infarction involves occupational health assessment of fitness to work, the nature of the role and legal considerations. Alison McLaren and Professor Anne Harriss present a case study of a hospital porter.
This case study examines the effects of the clinical diagnosis of myocardial infarction (MI) of a 58 year old employee, Mr Smith (pseudonym) and an assessment of his fitness to work.
The assessment of the client’s functionality requires a working knowledge of the variables associated with the client’s job role, the underpinning pathology of the health condition and the effects of their illness on work performance. Price and Petch (2013) highlights the importance of a health assessment and appropriate modifications and adjustments to enable such an employee to perform their job requirements without risk to themselves or others.
Mr Smith is employed as a full time as a porter in a busy hospital; he works 12.5 hour shifts, some of which are scheduled at night. Following his MI Mr Smith was hospitalised for a week followed by a further 3 weeks of cardiac rehabilitation at home: he has been off sick for one month in total. His manager, cognisant of the seriousness of his condition and the strenuous nature of his job requirements, requested the advice of OH in planning a safe and effective return to work strategy.
Cardiovascular disease (CVD) remains a common cause of ill health and death in western society. Price & Petch (2013) notes that these are conditions commonly dealt with by occupational health physicians.
Mr Smith described the onset of the infarction as abrupt with severe pain radiating to his left arm, jaw and neck. When a history was taken he explained that he also experienced feeling clammy and nauseous. Cornelius (2014) highlights that these symptoms result from vagal stimulation and that sudden death can occur within an hour of the onset of these symptoms.
Clancy & McIver (2009) advise the more extensive the myocardial damage the greater release of enzymes, particularly Troponin 1. Both ECG changes and the raised activities of cardiac enzymes would corroborate a diagnosis of Myocardial infarction for Mr Smith.
Although, to Mr Smith the MI symptoms were sudden, Coronary heart disease (CHD) is a progressive illness and may have developed over several years (Conroy et al, 2003). Mr Smith was found to have partial coronary artery occlusion. A diagnosis of an MI was made within 12 hours of onset of symptoms, and in line with the 2013 guidelines from the National Institute for Health and Care Excellence (NICE), primary percutaneous coronary Intervention (PPCI) was performed . Mr Smith had angioplasty with insertion of a stent. After the procedure he was prescribed daily doses of Aspirin 75mg, Clopidogrel 75mg , and initial doses of Atorvastatin 10mg and Ramipril 2.5mg.
Risk factors for CVD are numerous including obesity, smoking, lack of exercise, hypertension and diabetes. Further risk factors include a diet high in unsaturated fats and sugar, low consumption of vegetables, fruit and fish, and a high consumption of alcohol (Vilahur et al, 2014).
Child & Jackson (2003) refer to the importance within the hospital protocol of the involvement in the cardiovascular rehabilitation team from the point of admission, through to discharge to the primary care team.
Mr Smith was referred to a local cardiac rehabilitation team then discharged to primary care with follow up for 12 months. As part of the OH assessment a report was requested from the rehabilitation team to confirm Mr Smith’s capability and work functionality, an effective return to work being an important recovery outcome.
Psychosocial aspects of return to work after myocardial infarction
According to Hotz et al (1991) recovery level and adjustment is dependent on elements including morale and family support and are adversely affected by loss of autonomy and independence. Social adjustment and support are predictors of the outcome of rehabilitation and adjustment to morale and these can influence recovery.
As mentioned earlier, as part of Mr Smith discharge and ongoing treatment he attended a cardiac rehabilitation programme that, according to Price & Petch (2013), is successful at facilitating return to a normal life including work. The National Institute of Clinical Excellence (2015) advises that Cardiac rehabilitation can assist in return to work through highlighting the risk factors for heart disease, treatment of symptoms, restore physical fitness, help anxieties about consequences of MI and provide counselling and family support.
Mr Smith had the added support of his wife and family who supported him in his reduction in alcohol, adopting a healthy diet and more active lifestyle all of which Kromhout et al (2002) advise are important factors in both the prevention of CVD in those predisposed to it and to those patients who are diagnosed.
Palmer et al (2013), advise consideration of the following when planning a client’s return to work recovery strategy:
- functional capacity, job role, and the levels and duration of the work activitites that they can perform (Price & Petch, 2013);
- the duties that the employee can manage. When planning a structured return-to-work recovery strategy which may incorporate a temporary change of shift pattern. This may include a phased return to work gradually increasing the job demands over two to four weeks.
When considering fitness to return to work the model proposed by Murugiah, Thornbory and Harriss (2002) incorporates the recognition of four main considerations: work characteristics, working environment, personal and legal aspects.
The pace and nature of Mr Smith’s portering role, including the transportation of patients in wheelchairs, trolleys or beds to various areas around the hospital, might impede Mr Smith’s recovery. Biopsychosocial issues were important considerations; a return to work was considered possible but would require adjustments.
Mr Smith and his manager were advised that transportation of patients were best avoided until at least six weeks post MI. This element of his role should be subject to satisfactory completion of an activity stress test and angiogram.
Employers must protect employees from harm to self and to others in their employment. Section 2 of the Health and Safety at work Act (1974) places a duty of care on employers. When reasonably practicable, employers must ensure the health, safety and welfare at work of employees.
Section 7 (a) states: ‘Employees have a duty to take reasonable care for the health and safety of himself and of other persons who may be affected by his acts or omissions at work’.
As such, Mr Smith must follow his cardiac rehabilitation advice regarding his MI in order to fulfil his duty of care and his employer must put in place reasonable adjustments. The Equality Act (2010) obliges the employer to consider making reasonable adjustments to protect people from discrimination. However, it is a legal rather than a medical decision as to whether this applies.
Work characteristics are unrestricted to functionality or anatomical aspects of the employee. The occupational health nurse (OHN) requires a clear idea of the job specification, job demands and client abilities. Clear guidelines regarding phased return and the remuneration associated with that return are dependent on organisational policies and procedures – effective liaison with HR and management are fundamental to the success of a planned recovery strategy.
It should be remembered that work is therapeutic and an essential part of rehabilitation. The success of suggested return-to-work accommodations is dependent on effective communication between OH, management and employees.
The work environment
The client’s physiological, physical and psychological experiences and their impact on the individual’s ability to perform their job are important considerations. Before this cardiac event, Mr Smith worked effectively and efficiently with minimal sickness absence.
Mr Smith must accept that he now has a long-term health condition requiring lifelong medication. To minimise adverse effects on himself or others a risk assessment in order to identify the required adjustments was initiated and coupled with a phased return to work.
Important elements of the assessment included considering Mr Smith’s past occupational experience, skill levels, technique and ability in light of the medical history. Disability and sickness originate from a health condition but are heavily influenced by social and psychological factors which must be taken into account when assessing fitness to work.
A biopsychosocial framework was used in assessing the effects of Mr Smith’s medical condition. Cognisance of psychosocial flags, as highlighted by Watson (2010), were particularly pertinent factors. A recovery may not progress as expected biopsychosoical flags alert the OHN to something for closer inspection. In this case the flags were used to facilitate Mr Smith return to work after sickness absence.
It is essential for the OHN to understand the use of these clinical flags otherwise they may become obstacles to recovery. An overview follows:
- Red flags are those of a clinical nature
- Yellow flags refers to the clients’ thoughts, behaviour and feeling about their illness
- Blue flags relate to the workplace, particularly the employee’s perception of health and work.
- Black flags focus on the context and environment in which that person functions, recognises the impact of other people, systems and policies that may limit the helpful activity of healthcare providers and workplace support.
The flags which related to Mr Smith’s recovery included yellow flags relating to Mr Smith’s ongoing positive recovery outlook and blue flags recognising his positive attitude toward his return to work, his manager and work colleagues. No black flags were highlighted – his return to work was supported by his manager who works within the Trust guidelines and policies.
Section 2 of the Health and Safety at Work etc Act. (Great Britain Parliament (1974) states ‘it is the duty of every employer, so far as is reasonably practicable to ensure the health, safety and welfare of his employees’… in addition, Regulation 3 of the Management of Health and Safety at Work Regulations 1999 states that ‘Every employer shall make suitable and sufficient assessment of the risks to the health and safety of his employees to which they are exposed whilst they are at work’.
These Regulations also require the employer to take into account health capabilities when allocating tasks. This could cause a difficulty for the manager when trying to get Mr Smith back to work, as a major part of Mr Smith’s working day involves transferring patients in wheelchairs or trolleys to various locations around the hospital.
In this instance the manager has acted accordingly and has overcome what could have been seen as an “obstacle” to Mr Smith return to work through putting in place “reasonable adjustments”. Adjustments are set for a period of time – in Mr Smith’s case this is set for six weeks to follow hospital protocol where it states MI patients must avoid heavy physical activity for six weeks post MI.
The Equality Act (2010) obliges the employer to consider work demands and make reasonable adjustments, as the act legally protects people from discrimination in the workplace and wider society. There are no clear guidelines regarding phased return and pay, so the hospital policies and procedure have been followed by the manager and in this instance they encourage the manager to accommodate adjusted duties to enable the client to become fully fit.
The Murugiah, Thornbory and Harriss (2002) framework was used to provide a holistic assessment of Mr Smith including his work ethic, hobbies and lifestyle recognising psychological and physical assessment and Mr Smith’s attitudes towards his workplace and working environment. The approach included integrating a functional assessment of how Mr Smith may be able to fulfil his job requirements.
Mr Smith gave informed and written consent to sharing this information with his manager facilitating a greater understanding in dealing with the abilities and needs at work for Mr Smith. In line with the Trust’s confidentiality protocol written informed consent was also gained in order that a report may be obtained from Mr Smith’s Cardiologist and the Cardiac rehabilitation team in order to provide information regarding the cardiac rehab programme and the outcome of investigations including the outcome of the stress test.
Functionally Mr Smith’s job was physically demanding, and though physical activity is good for the heart his wellness was assessed using an exercise tolerance test which confirmed a good tolerance to exercise, and his ability to perform all activities of daily living. There were no other complications but it was considered that he would be unable to transport/carry heavy loads for six weeks on returning to work. Undertaking patient transfers for the first six weeks following his return was considered inadvisable but it was agreed he could transport clinical specimens during this period.
Psychologically Mr Smith maintained a positive attitude toward work and did not feel isolated from work colleagues. He remained asymptomatic of chest pain and was not short of breath, although he reported fatigue as one of his main symptoms but was reassured this would resolve over time. Mr Smith tolerated prescribed medication and no side effects were reported.
In relation to identifying the client’s functionality a number of considerations were considered important to both history taking and the subsequent decision making. These included noting whether his health condition would:
- limit, reduce or prevent him from effective job performance;
- be exacerbated by his job requirements;
- make it unsafe for him to perform job tasks; and
- put himself or others including fellow workers or patients at risk in the course of undertaking his work tasks.
Mr Smith’s recovery and return to work was uneventful. There were no further complications such as angina. He continued to be part of the Trust’s cardiac rehabilitation programme and physiological assessments including ECG and exercise tolerance tests confirmed minimal lasting myocardial damage.
Collaborative working between all parties involved in his follow up including his GP and the cardiac rehabilitation team facilitated the OHN planning an effective return to work recovery strategy. Price & Petch (2013) highlight that upto 80 per cent of people who have suffered an uncomplicated MI will return to work. An effective return to work is promoted when levels and duration of activity are increased progressively.
Mr Smith demonstrated a positive attitude to return to work, blue flags. He was able to undertake all activities of daily living and he had positive relationships with his family, colleagues and his manager.
In conclusion, important elements of Mr Smith’s return to work included a recovery strategy which was reviewed and completed over a six week period. This commenced with a risk assessment undertaken by his manager in compliance with Regulation 3 of the Management of Health and Safety at Work Regulations (1999). The aim of this was to identify and negate any high-risk, physically demanding activities such as handling heavy loads. The manager was supportive of the recommendations made by the OHN for modifications to Mr Smith’s work tasks. These included:
- recommending appropriate modifications to tasks and careful break scheduling to address any complaints of fatigue;
- providing advice on safe moving and handling of equipment;
- advising Mr Smith not to undertake patient transfers for the first six weeks following his return to work; and
- supporting Mr Smith to follow the advice of his GP and continued participation in the cardiac rehabilitation programme
A phased return to work and normal hours was completed over a four week period. Both Mr Smith and his manager were proactive and an early intervention facilitated his safe and effective return to work. All parties were responsive to OH advice including adjustments to Mr Smith’s duties and hours of work.
Positive aspects of the management of this case included:
- Mr Smith being both cooperative and open to the disclosure of information throughout this process enabling the OHN to advise accordingly.
- Mr Smith showed a positive attitude toward his health condition through attending the cardiac rehabilitation programme, and his ongoing commitment toward a healthier lifestyle including healthy eating and regular exercise.
- Mr Smith maintained a positive psychological approach toward his health condition enabling him to return to work successfully following his MI.
- Continuing dialogue between the OHN, Mr Smith and the Manager enabled efficient progress and a sound management plan.
- Keeping Mr Smith informed and involved regarding his fitness/or otherwise and explaining the adjustments and the workplace implications are a key part of the nurse adviser role.
The management of Mr Smith’s return to work incorporated an awareness of elements of work characteristics, working environment, personal and legal aspects suggested by Murugiah, Thornbory and Harriss (2002). The OHN considered Mr Smith duties at work evaluating his functional abilities against the health condition of an MI highlighting any difficulties that Mr Smith could encounter when considering his work environment, and considered all legal requirements. This enabled the smooth transition for Mr Smith to return to work with the suggested adjustments.
Alison McLaren BSocSc (Social Anthropology) BSc (Hons) Occupational Health Nursing, RGN, RSCPHN is a specialist occupational health and wellbeing nurse at Guy’s and St Thomas NHS Foundation Trust. Professor Anne Harriss MSc, BEd, RGN, OHNC, RSCPHN, CMIOSH, Queens Nurse FRCN, Hon FFOM is course director occupational health at London South Bank University.
Child A and Jackson G (2003) Cardiovascular Rehabilitation Team. Protocol for the Identification, Assessment and Management of Patients. NHS Trust.
Cornelius J (2014) Chapter 32 Disorders of Cardiac Function in Grossman SC and Porth CM (2014) (ed) Porth’s Pathophysiology. Concepts of Altered health States. 9th Edn. Philadelphia: Lippincott Williams & Wilkins.
Clancy J and McIver A (2009) Physiology and Anathomy. For nurses and healthcare practitioners. A hoemeostatic Approach. 3rd edn. London Hodder Arnold.
Conroy RM et al. (2003) Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project, European Heart Journal, 24 (11), pp.987-1003 Science Direct [Online].
Great Britain. Parliament (1974) Health and Safety at Work etc. Act. London: HMSO
Hotz SB, Cazabon AM, O’Farrell P and Robbins B (1991) ‘Adjustment to Heart Disease, Helping Families Cope’. Canadian Family Physician 37 pp. 641-647
Kromhout D, Menotti A, Kesteloot H, Sans S, (2002) ‘Prevention of coronary heart disease by diet and lifestyle’. American Heart Association 105, pp 893-898
Murugiah S, Thornbory G. Harriss A, Assessment of Fitness. (2002) Personnel Today (Accessed 20 February 2016)
Palmer KT, Brown I, Hobson J (2013) Fitness for work the medical aspects. 5th Ed. Oxford University press: Oxford
National Institute of Health and Care Excellence (2013)[CG167] Myocardial infarction with ST-segment elevation: The acute management of myocardial infarction with ST-segment elevation. (Accessed 15 February 2016)
The National Institute of Health and Care Excellence (2015) Myocardial Infarction Secondary prevention overview. (Accessed 20 March 2016)
Price AE & Petch MC in Palmer KT, Brown I, Hobson J (2013) Fitness for work the medical aspects. 5th Ed. Oxford University press: Oxford
Mayo Clinic. Illustrations of the heart. (Accessed 30 March 2016)
Vilahur G, Badimon JJ, Bugiardini R, Badimon L (2014) Perspectives the burden of cardiovascular risk factors and coronary heart disease in Europe and worldwide, European Heart Journal Supplements, 16 (A), pp.7-11 Oxford Journals [Online].(Accessed 27 March 2016)
Watson H (2010) CPD: Psychosocial Flag System. (Accessed 20 03 2016).