RTW myths can hurt employers, impair employees' recovery
April 1, 2007 8 minutes read
RTW myths can hurt employers, impair employees' recovery
Set end date for return period, work closely with physician
When it comes to getting injured or sick employees back to work, there are some accepted truths. Chief among them is that the sooner an employee can come back to work safely, the better his or her recovery will progress and the greater the likelihood of a return to full duty.
But there are also plenty of myths about return to work (RTW) that have become accepted as truth, to the detriment of some RTW efforts, according to Elayne Preston, RN, DOHS, COHN(C), COHN-S/CM, president of Employee First Health and Safety Services, a British Columbia, Canada-based occupational health service that provides training, program development, and individual disability case management to clients in the United States and Canada.
"Disability management practices should be evidence-based, founded on the reproducible results of research studies," says Preston. "Practices should be amended to reflect new evidence as it becomes available," she says.
However, this foundation is not always used, Preston says. "Often, decisions are made based on misinformation, negative stereotypes, and single past experiences that were less than positive — beliefs that could be classified as return-to-work myths."
- "RTW plans can be open-ended" myth.
A graduated RTW plan, which is a step-by-step plan that brings the employee back to full duty gradually, is often the best choice for returning workers. "To have a graduated return to work, you have to graduate," Preston says. "But a lot of my clients have found they have gotten into a never-ending return to work, one that's not evidence-based, and it sure puts a lot of strain on both the employer and the employee."
The open-ended — or neverending — RTW plan begins with the treating physician who, rather than specifying how long the RTW plan should last, leaves the return period undetermined. "Rather than saying the return to work should be four weeks long, the physician says he can't set a time, and to check back in two weeks," Preston explains. "Then it's two more weeks, and two weeks after that."
The worst-case scenarios can be so bad that the employee and employer lose sight of the original goal: to get the employee back to his original duties. "I spoke with an employer last week who had an employee whose return to work had extended three years," she says. "After that long, the employee doesn't have a goal to work toward anymore."
When RTW extends over months or years, the employee carves out a new niche within the company that supplants the original job he or she was supposed to be returning to. The occupational health nurse can intervene to help the physician set boundaries for the return and to keep the employee focused and on pace to return to full duties. "What the nurse can do is to set an end date, even if it is only a tentative or anticipated one," Preston advises. Remember, it's the employer's offer to accept a return-to-work plan, she says. "The employer doesn't have to accept everything in the physician's recommendation," she says. In terms of length, the average return to work is three to four weeks in duration, Preston says. "The most I'll ever go is 12 weeks, and that has to be pretty unique circumstances," she says.
"We don't have 'return to work when able' here," says Shelly A. Arntson, RN, COHN, an occupational health nurse at Allen Memorial Hospital in Waterloo, IA. "We have restrictions [on the length of RTW periods], and usually it is that the employee has scheduled RTW physician visits until they are released [to return to work]. They have a plan signed and with an end date, not 'return when able.'"
A goal date gives employees two benefits, nurses explain. One, it lets them know that the evidence suggests they will be feeling better and able to do more by that time (thereby encouraging them). It also defines that they have that much time in which to graduate to full duty, so they don't feel they have to do it all in the first week, says Preston.
If an employee doesn't have enough recovery of function that a successful RTW can be forecast in a three- to four-week window, the return period might need to be delayed until the worker has made more progress in recovery, Preston says.
- "The doctor knows my job" myth.
In the six minutes that are allotted to patients in an average doctor visit, it is very likely that the treating physician doesn't get the whole picture of an employee's duties. This limited time can mean the physician concludes the job duties are more rigorous or less demanding than they really are. "The information physicians can get in those visits is sketchy at best and may not provide the full picture in terms of physical and cognitive-behavioral demands or the workplace environment," Preston says. Many employers ask physicians to complete a catch-all checklist that the company has prepared, which lists do's and don'ts that might not apply to everyone.
The occupational health nurse usually knows the rigors of the jobs quite well and knows what information to include in a brief summary that gives the physician the pertinent information needed to set a realistic RTW. "We put doctors in these positions of knowing everything, and I think the physicians get sort of uncomfortable with some of the questions we ask them," says Preston. "[Occupational health nurses] can take the nature of the medical condition and, knowing what the treatment plan is and applying some nursing judgment, come up with an idea of how long we think the return to work should be."
Arntson goes a step further: She brings local primary care physicians to the workplace, to let them see what the employees do on the job. Assuming a physician knows what a nurse's job is can be a mistake, says Julie Miehe, RN, BSN, COHN-S, CM, employee health nurse at St. Mary's Hospital Medical Center in Madison, WI. Some physicians have misconceptions about nursing jobs and hospital jobs, "and sometimes it's up to me to make sure that they have that information," says Miehe.
She usually makes a phone call to the employee's doctor after he or she has seen the employee. "I will tell them that in addition to what the employee has said, here is that person's job description, and more importantly, here's what his or her supervisor expects," Miehe says. "Expectations vary from one shift to another, even, so I make sure I let the physician know that."
- The "stress leave" myth.
If an employee's treating physician says that the worker needs time off for "stress," the occupational health nurse needs to dig deeper, Preston advises.
"Stress leave" is not an accepted benefit for most companies, so finding out the source of the stress will be necessary to determine whether the employee is ill or qualifies for an accepted form of leave. "Stress might be a factor contributing to illness, but is not itself a medical condition," says Preston. "And in fact, it is the employer's responsibility — not the physician's — to approve or grant benefits such as leaves based on information received from the employee."
If an employee is stressed by an event or situation at work, or stress is caused by something occurring outside work, that factor needs to be considered in crafting a RTW plan, Preston says. However, the nurse needs to ensure the company "isn't granting leave for a complaint that doesn't really exist." Chronic stress can cause someone to become ill, she continues, and the nurse's role is to find out what the root problem is and what the employer's leave policies can do to help.
- The "accommodation is forever" myth.
Special accommodation of a disability, through modified work schedule or tasks, are intended to be temporary, but employees often expect them to be permanent, Preston says. While some accommodations — wheelchair-friendly desks, for example — are not meant to be temporary, permanent accommodations often unnecessarily restrict the employer and the employee. Because many medical conditions improve over time, keeping accommodations in place in those cases does not encourage return to capacity, Preston adds. "I always recommend that accommodation of disability be reviewed on a regular basis, with a review of updated medical information and a determination of whether the nature of the workplace accommodation is still appropriate," she says.
Miehe says updates are an important part of the "psychological game" that is part of RTW. "The employee sometimes is thinking 'Will I ever get better?' and wanting to just get out of the house and get back to work, so helping them see that they will get back to work, back to using their nursing skills, plays a huge role in people working their way back from an injury or illness," she says.
[Editor's note: One additional myth is that one form fits all conditions. See story, below.]
One-size-fits-all approach hinders RTW in depression
Occupational health nurse Elayne Preston, RN, DOHN, COHN-S/CM, COHN(C), president of British Columbia, Canada-based Employee First Health and Safety Services, was called by one of the employers she advises — a municipal fire department — to help untangle a breakdown in communications between the employer and the treating physician for a firefighter who was off work due to a depressive disorder.
The firefighter was sent to his doctor with a form the employer wanted completed. The form asked about functional abilities and not about cognitive/behavioral deficits. "The firefighter and his doctor both look at this form, and it has nothing to do with the depressive disorder he is suffering, so the doctor scrawls 'Not Applicable' across the form and sends it back," Preston recalls.
Her experience has been that employers have a form that works well for physical types of limitations, like lifting, stooping, bending, she says. "These forms are restricted to physical limitations; they don't apply to depressive conditions, so the physician is unsure of what to write, and the employer was really frustrated when the form came back with 'Not Applicable' written in," Preston says.
Too often, Preston says, companies have one standard form that is used to gather functional abilities information, regardless of the medical condition. These forms are restricted to physical limitations and do not account for cognitive-behavioral deficits. When one of these forms is delivered to the treating physician with the expectation that he or she sign it, it's not unusual for the physician to return it with a "not applicable" message attached. "Functional limitations resulting from mental illnesses are really quite different from physical limitations," says Preston. "Thus, a one-size-fits-all form does not work."
The occupational health nurse should be on the lookout for these "one-size-fits-all" checklist forms, especially when the employee is off work for a mental illness rather than a physical one, Preston says. The form the employer wanted completed dealt with physical limitations, but that was not the issue in this case. His limitations far outweighed anything he could do physically," Preston says. "For him, it was cognitive-behavioral things: confrontation, conflict, short-term memory, dealing with the public," she says. The doctor finally got the information that applied, and Preston could go back to the employer and say "he's not ready to come back yet." "For him, [difficulties lay in] dealing with the public and being overwhelmed by multitasking," she says.
Unfortunately, his job was doing presentations and education for the public, Preston says. "So we eventually brought him back on a return to work plan, and I discussed with his manager about what tasks to assign him and which ones not to, and what to watch for as far as improvement."
After a RTW period in which the firefighter was assigned one task at a time, with each task done to completion before another was assigned, he was able to gradually work his way back to multitasking again, Preston reports.
The lesson from this example is that the occupational health nurse should consider providing a sick employee's treating physician with a list of several cognitive-behavioral limitations commonly associated with mental illnesses, such as ability to concentrate, ability to make decisions, short-term memory, ability to handle confrontation, and the ability to supervise others, she says.
When it comes to getting injured or sick employees back to work, there are some accepted truths. Chief among them is that the sooner an employee can come back to work safely, the better his or her recovery will progress and the greater the likelihood of a return to full duty.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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