On an average day, approximately 4% of the entire U.S. workforce is absent from work.1 The National Safety Council estimates that occupational injuries or illnesses cause more than 80 million lost workdays. About 1.2 million employees lost an average of 7 days due to injury or illness. According to the Work Loss Data Institute, the estimated costs to employers for these absences exceed $1.275 trillion. Employers can spend up to 21.7% of total payrolls covering direct and indirect costs associated with these absences.2
Patients often ask NPs to write work excuses, but this may not be in the patient's best interest. The longer an employee is away from work, the less likely he or she will return to work.3 Most people identify their sense of self-worth from what they do for a living, and a prolonged absence from work can inadvertently encourage a patient to assume a sick role.3 By using specific strategies that address the work environment, the patient can be returned to work at the earliest yet safest time.
Case study
A 45-year-old man presents to a primary care clinic on Monday morning with a chief complaint of back pain. The patient claims the back pain began at the end of his shift the previous Thursday. He was unable to work on Friday, and he did not report to work this morning. His back pain is located in the lumbar sacral area, and he claims he has had similar pain in the past and that it usually lasts a few days. Musculoskeletal and neurologic examinations are negative except for muscle spasms present in the lumbar sacral area on palpation. The NP prescribes a muscle relaxant and a nonsteroidal anti-inflammatory drug (NSAID). Then the patient asks for a medical excuse to explain and account for his time away from work and wants it backdated from last week to the end of this week. The NP's response should be:
a. I can't excuse the time off of work before I saw you, but I will provide documentation for the rest of this week.
b. No problem.
c. I don't give work excuses.
d. What do you do for a living?
Determining levels of disability
Disability is the inability to work because of a diagnosed medical condition. Patients routinely ask healthcare providers for a note to bring to their employers authorizing these absences. NPs may be unaware of the requirements of a patient's job and reluctant to "force" the patient back to work. However, research has repeatedly demonstrated that the longer employees are away from work, the more likely they are to be disabled permanently. If someone is out of work for 6 months, there is a 50% chance of returning to work. If the individual is absent for 1 year, the chance of returning to work drops to 25%. If an employee is out of work for 2 years, there is virtually no chance of returning to work.4 This is regardless of severity of illness or injury. In addition, it has been suggested that up to 80% of paid temporary disability is medically unnecessary.5
NPs also understand that extended rest can sometimes be harmful. Deconditioning occurs almost immediately with bed rest and can lead to a loss of 1% to 1.5% of muscle mass per day, with a 15% loss of aerobic capacity in just 10 days.6 If a professional athlete is injured and sidelined for only 1 to 2 days, he begins rehabilitation and reconditioning to ensure a quick return to play and to prevent further injury. An industrial athlete, an employee with physically challenging work requirements, can be out for weeks following an injury. Returning this employee to the job may predispose him to reinjury because of this deconditioned state. It is important to maintain physical and muscular health or it can deteriorate. An injured arm may need rest, but the remainder of the body needs to continue working.
NPs should also weigh this information within the context that meaningful work is an important part of the human identity. Loss of work equates a loss of identity for a lot of people. This can lead to a negative sense of self, resulting in depression, anxiety, isolation, or substance abuse. It can also affect relationships, financial stability, and social interactions. Patients may develop an "ill/injured" persona after being off work for a very short time.7 This might include prolonged TV viewing, staying in bed, sleeping late and/or staying up late, lack of grooming, poor dietary habits, and isolation. Lack of motivation may become problematic. Patients may incorporate previous minor, nonworrisome ailments into this adopted sick role and compound the disability. These all contribute to poor health outcomes and can be discouraged by establishing a clear return-to-work goal at the onset of the illness/injury.
NPs will also assess patients whose work is so vital to their self-worth that they insist on returning to work before they are physically or mentally capable of doing so. Allowing these patients to return to work, despite serious health issues, could result in harm to both the patient and his colleagues. Those who pose a health threat to themselves or others must be restricted at work or from work completely.
Work restrictions
Although NPs are experts in diagnosing and treating illness and injury, understanding work restrictions is an area where the knowledge base is sometimes lacking. What should a work restriction include? What is the difference between light duty and sedentary work? How long should work be restricted? What if the employer doesn't accept the work restrictions? What is the NP's liability? These are just some of the problems NPs face on a daily basis within a clinic setting.
Work restrictions-also known as light duty, modified duty, transitional work, or early return-to-work programs-are necessary in many workplaces today. These programs help injured or ill employees return to work safely when the employee is capable of performing meaningful work. The first step in this process is to obtain a statement from the NP identifying specific health issues and the related needs of the employee. This allows the employer to evaluate whether possible modifications to the job are available to accommodate the employee. This can only be done if the restrictions outline specific details that may interfere or impede the employee overall. For an NP to construct an appropriate work restriction, he or she needs to understand the job requirements, the work environment, the employee's ability, and the effect of the injury or illness and the treatment regimen on the employee.
Every workplace has an outline of the specific functions required by workers for each job classification. These are the essential functions of the job and allow companies to determine what a worker must be physically capable of performing to be effective. As part of the employment process, each applicant is assessed as to whether they can perform these essential work functions. These tasks often include the ability to lift, push, pull, operate heavy machinery, perform repetitive movements, work on ladders, or in climate extremes. Employees should be aware of the physical requirements of the job they perform, but a patient who requires prolonged time off or repeated time off should supply the NP with a hard copy of these specific job details.
In the absence of a job description, the NP must rely on the patient's perception of the job requirements. These may be minimized or distorted to allow the patient to return to work too soon or to unnecessarily lengthen the amount of time off. The NP needs the patient to identify the specific job requirements he feels he cannot perform. In some cases, the fear of reinjury, exacerbation of symptoms, or increased discomfort may be the rationale for more time off. By addressing these fears and discussing intervention strategies, the patient will be more comfortable resuming normal work activities.8 Certain approaches may be helpful in discussing potential work issues with patients. They include direct questioning, a "what if..." questioning approach, making comparisons, and suggesting a trial run.
Direct questioning requires the patient to identify what parts of the job he will not be able to perform. Encourage the patient to be as specific as possible. Statements such as "I won't be able to lift anything" should be challenged. A can of soda weighs 16 ounces or 1 pound, a bag of sugar or flour weighs 5 pounds, and a bag of potatoes weighs 10 pounds-medical restrictions are rarely necessary in these situations. "I can't use my arm" should be similarly challenged: Can you comb your hair? Feed yourself? Carry your purse or your child? After identifying tasks that are affected, the work restriction can be specific and appropriate to the patient's needs. For example, "The patient is unable to lift more than 10 pounds from the floor to the waist for 1 week" is more descriptive and easier to accommodate than the general statement "unable to lift."
Using a "what if" approach allows the patient to view the situation from a different perspective. "What if .... I take you off work this week. What are you going to do at home? How will the kids get to school? Who will go grocery shopping? Who would replace you at bowling league, PTA, Cub Scouts?" This makes it clear to the patient that being restricted at work also indicates a similar restrictive disability within the nonwork lifestyle.
Offering generalized comparisons allows the patient to see the illness or injury within a larger perspective. Open-heart surgery patients often begin exercise programs within 2 weeks after surgery. A patient who has had a laparoscopic cholecystectomy can expect to return to work in 2 to 3 days. Uncomplicated fractures heal within 4 to 6 weeks.9 This information allows the patient to put his illness or injury into an overall perspective and, with assurance from the NP about ongoing recovery, may create a more positive transition back to work with minimal fear of relapse or potential harm.
For some patients, a trial period may be necessary to assess whether the patient can physically perform the work required. This might involve a short period to allow the patient to ease into the work environment before resuming a full load. An example of this restriction would be to allow a worker to return to work on a Thursday and/or Friday with the weekend off to rest before resuming an entire 5-day workweek. A planned return office visit can reassess the patient's injury and revise the plan, if needed. This reassures the patient that his injury is being taken seriously, yet encourages return to work in a controlled manner with planned follow-up.
Establish a treatment plan
When establishing a return-to-work plan with patients, it is critical to consider the treatment plan. The use of medications, physical therapy or occupational therapy, pain management, and rest periods must be included. In some cases, work hardening (the process of preparing to return to work through structured physical therapy sessions designed to increase endurance and combat the physical deconditioning that may occur with prolonged absences) or a transitional part-time work schedule may be appropriate. In these cases, working with the occupational health nurses (if the company has one) at the employee's worksite may be helpful. By communicating with the workplace directly, the NP can better facilitate the resumption of normal work while avoiding potential setbacks or miscommunication. The employee needs to provide written consent to ensure Health Insurance Portability and Accountability Act(HIPAA) compliance for this type of communication, but it can be useful in workers with serious mental or physical issues requiring a prolonged period of transitional work.10
The effects of medications must be considered when returning someone to the work environment. Some environments can be hazardous, and delayed reaction times or other adverse reactions can be extremely dangerous for the employee and coworkers. A trial period to see how the medication may affect the patient while at home or using the medications only when not in the work environment may help avoid a possible catastrophe. This should be weighed carefully when returning someone to work and should be reflected in the documentation to minimize liability.
A good work restriction document should always be as detailed as possible, including what the patient can as well as what he cannot do, how often or how long he can do it, when he should or shouldn't do it, and where work should take place. The restrictions should be reasonable and not excessive. By addressing each of these topics, the patient's abilities and disabilities can be adequately addressed. Patients need to be reminded that if restrictions are medically necessary, they should be followed at home as well. If the patient is unable to lift 5 pounds at work, he would also be unable to throw a 12-pound bowling ball or lift a 20-pound baby.
The specific capabilities should be outlined in the work restrictions. The patient can lift and push 10 pounds. This changes the focus of the restriction from disability (cannot lift more than 10 pounds) to ability (can lift 10 pounds). It reinforces the patient's ability to work and avoids the "sickness/injured" connotation.11 Other specifics that need to be addressed include standing, sitting, bending, stooping, and squatting. Most workplaces allow a break every 2 to 3 hours. By incorporating this into the work restriction, the patient has a "prescription to rest" every 2 to 3 hours. This would be written as "the patient may stand for two hours and then should be allowed to sit for 15 minutes." If the patient sits for 2 to 3 hours at a time, he should be encouraged to stand and stretch for 15 minutes.
Special accommodations should be addressed as well. If the patient needs to keep his foot elevated while sitting, needs to alternate between sitting and standing, or needs to use crutches, these should be stated directly to help the workplace correctly assess the needs of its employee. Several factors must be assessed before an employee may be allowed to return to work:
* Will the employee be safe?
* What is the risk of reinjury or another injury occurring?
* Are coworkers safe?
* Can the environment be altered safely?
* Can safety equipment or procedures be upheld if the employee returns to work with a restriction?
* Can the employee wear mandatory safety equipment, such as steel-toed boots, hearing protection, or respirators?
How often or how many times the patient can perform certain tasks should also be addressed in the work restriction. Lifting a 10-pound piece of metal once may not be difficult, but lifting it from the floor to above the head 40 times an hour could be problematic. The statement "may lift 10 pounds from the floor to the waist 12 times per hour (once every 5 minutes)" describes the capabilities of the employee clearly. The employer may accommodate this particular restriction by slowing the work process down, but may not accommodate the blanket statement of "no lifting." The use of ladders, operating heavy equipment, or other adjuncts should also be included.
Many workplaces operate in environmental extremes, such as very hot or cold conditions, confined workspaces, or safety-sensitive positions. The environment may also be loud, subject to vibration, or involve heights. The NP should address these specifically in the work restriction. Statements such as "the worker needs to be in a climate-controlled warm environment," or "should avoid heights above 5 feet", or "unable to perform safety-sensitive work" are all appropriate restrictions.
It is not uncommon for workplaces to schedule overtime or operate day and night shifts. These conditions may affect recovery. An employer may be able to accommodate "patient should work no more than 8 hour shifts with no overtime." It is important that the NP acknowledge that the employer will consider all aspects of the workplace and the possible ramifications of a restriction before deciding whether to accommodate it or not. The workplace may avoid accepting a restriction that may set a precedent for future accommodations.12 For example, the employer may not want employees obtaining restrictions to avoid overtime work.
The NP must indicate how long restrictions should remain in effect. From the employer's perspective, accommodating an employee for 1 week is very different than accommodating an employee for several months. By indicating the probable length of time the restrictions might be needed, the employer and the employee know when the condition should be resolved. The NP should emphasize the return to normalcy for the patient. If a patient is hesitant or reluctant to return to work when it is medically safe to do so, the NP should explore other possible issues. Depression, anxiety, or serious work-related issues with other employees or supervisors may be the real issue, not the initial injury or illness.
Case study revisited
The best approach to this case is to ask the patient what he does for a living and address restrictions specifically based on his answer. Work tasks such as lifting, pushing, pulling, sitting, and standing should be addressed, as should the effects of the NSAID and muscle relaxant medications. Other considerations include the operation of heavy equipment, required use of ladders or elevated platforms, the work environment or climate itself, and the length of the work shift. The patient's request to excuse time taken off before presenting to the clinic is a precedent that should be discouraged. An appropriate statement might be:
The patient was seen in this clinic on XYZ date for back pain. He indicated he has had difficulty for the past 3 to 4 days and has been unable to work. He can return to work on XYZ date with the following restrictions: He may lift, push, and pull 10 pounds or less from the floor to the waist 12 times per hour. He should be allowed to sit or stand for comfort as needed. He should avoid using sedating medication while working. He should work no longer than an 8-hour shift with no overtime. He should avoid safety-sensitive work or environmental extremes until he is seen in this clinic for a follow-up exam in 1 week.
The patient may be concerned that the employer will not have restricted work available or that the company will not allow him to work unless he can perform his job at 100%. The NP should address this concern directly. The patient needs to know that the NP understands his work is important and allowing him to return to work is a step toward healing. The company may not have a restricted work plan available, but the patient will then understand that it is in his best interest to return.
Conclusion
Many workplaces have policies regarding how long an employee may be excused from work before they pay certain benefits or for time off. Although these are of concern to patients, they are not medical issues and should not play a significant role in the NP's treatment of patients. By establishing a precedent of continually approving extended time off work for patients, the NP becomes identified as the local healthcare professional who will approve time off work regardless of the patient's health status.
It is very important for the NP to emphasize the importance of work and the need for safe workplaces. Healthcare professionals need to facilitate the healing process and help people get their lives back to normal. By establishing a rapport with the patient and focusing care toward return to work early and appropriately, transitioning the patient back to work can occur more smoothly.
Work restrictions are a clinical issue NPs are expected to address on a daily basis. Although work restrictions are often perceived as another laborious task, it is important to view them as part of the holistic care NPs provide. The NP can allow for a safe return to work in a more structured and consistent way by using these simple strategies.
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