Tips for returning injured workers to work
Fear and greed could threaten your program
Return-to-work programs have proved to be an effective way of rehabilitating and retaining injured workers, but what if some employees resist your efforts to get them back on the job?
Gael A. Uhl, MS, RN, CS, COHN, CCM, workers' compensation coordinator at Partners Health Care System/Massachusetts General Hospital in Boston, says explaining that the return-to-work program is a "very attractive package" does the trick in most cases. The most appealing feature of that package probably is that workers continue to earn their full salaries while in the program, compared with receiving only a percentage of their wages if they collect workers' compensation.
"In Massachusetts, employees on workers' comp get a maximum of 60% of their average weekly wage untaxed. For most people, particularly a nurse because she's such a high wage earner, that's a significant loss of income. Nurses here make $70,000 to $80,000 a year, but their maximum on workers' comp is only about $655 a week," Uhl says. "Our incentive for our injured workers is that they have the opportunity to come back and rehabilitate themselves through our transitional duty program, and we pay them 100% of their salary and full benefits regardless of type of work they do."
For those reasons, most injured workers opt for returning to work in transitional duty jobs leading back to full duty. However, Uhl has encountered others who resist. Those generally fall into two categories: those who are fearful but can be coaxed into returning, and those who seek to capitalize on their injury.
Use objective medical findings
Workers in the first group may fear reinjury, or may regard any injury-related pain they feel as an obstacle to returning to work. Uhl says the key to managing those workers is to communicate objective medical findings.
"If they resist you, look at them objectively, medically assess them, and sit down and tell them what you see objectively from their health care provider," she explains. "We say, 'Your back may hurt, your knee may hurt, but from what we see objectively, we don't think you're disabled. If you come into the transitional duty program, we will start you off gradually and bring you up to full duty. If somewhere along the line, something fails, we'll put you back out.' It's all in their favor."
When injured employees stay home, they develop "disability behaviors," Uhl says, one of which is fear of reinjury. Such fears are "very real" and must be addressed seriously and supportively.
"When someone has a very bad back injury so they can't even take care of their children at home, they're often going to be very scared to go back into the workplace," she notes. "In that case, we get them hooked up with employee assistance programs and with occupational health, and really try to counsel and coach and support them along the way. We start them out gradually and try to help them develop their confidence. If you let them sit at home, those fears are going to increase. The longer they're away from work, the more likely they are not to go back, not from a scamming standpoint but from fear of reinjury."
Some won't go back no matter what
While most employees can be counseled, coaxed, or coached into return-to-work programs, there remains a population that doesn't want to go back no matter what. That's the population that ends up in litigation, Uhl says.
According to state law, workers' compensation benefits are for employees who are disabled from work. If medical evaluations indicate that an employee can come back to work in a modified capacity, failure to do so could result in termination or decreased workers' comp benefits. "They make the choice," Uhl says. "Of those who don't choose to come back, most of those cases are litigated, and they never return to the hospital to work."
While most injured workers opt for light duty, about 10% refuse and hire an attorney, looking for a "lump sum" settlement for their alleged disability. Hospitals sometimes go along with this rather than engage in protracted litigation. Workers could collect $10,000 for four months' worth of projected disability, for example, "but then they get their money and go out and get another job somewhere else. Money is their motivation," Uhl says.
But some workers who seek to scam the system don't fare as well. In California, employees trying to collect workers' compensation checks by claiming their injuries are disabling may find themselves unwitting film stars.
Cynthia Hentley, PhD, cost containment project director for the Team Care program in California, which has successfully reduced hospitals' workers' compensation costs through a total systems approach (see related story, p. 109), says if objective medical findings do not support workers' disability claims, a "sub rosa" or undercover investigation is launched.
When employees insist they are in too much pain to return to work, hospitals or occupational health physicians might be concerned about liability issues if they insist otherwise. Team Care handles those concerns.
"If we can't find anything wrong with [workers claiming to be disabled] objectively, we hire an investigative company to help us," Hentley says. "We do what it takes to make sure the system is in place and that there are programs in place to take care of any barriers we identify."
In one case, an employee who said he had a disabling back injury was videotaped taking an engine out of his car.
"We show those videotapes to the occupational physician. He can then confront his patient and say, 'I don't think you're being honest with me. This is the video we've seen of you; now you explain to me what's going on.' That way it takes the liability off the physician. It's a matter of being as creative and innovative as we possibly can," Hentley says.
While no solid data exist on the percentage of employees intent on committing workers' compensation fraud, "it's not as big a problem as people think it is," says Tricia Day, president of Business Health Systems, the Santa Rosa, CA-based consulting firm that manages the Team Care program. This is especially true when employers have comprehensive systems in place to manage injured workers.
Most workers' reluctance to return stems from fear of reinjury, Day says. To overcome that obstacle, Team Care administers the STAR (Stress and Tension Anxiety Reduction) program, which gives workers the option of 10 therapy sessions with a counselor trained in job injury issues, following an initial debriefing subsequent to the injury. The program initially was established for workers who were assaulted by patients, but has been expanded to include other traumatic injuries, repeat injuries, and anyone with fears about returning to work.
Many of the factors contributing to reluctance to return to work after an injury relate to burnout, Day says.
"If we can eliminate some of the reasons why people don't want to be at work, we can help solve the problem," she states. "Once you get a system in place and people are held accountable, and if they get good quality care and a return-to-work program is set up, we can get them back to work."n
Corser WD. Occupational exposure of health care workers to bloodborne pathogens: A proposal for a systematic intervention approach. AAOHN J 1998; 46:246-252.
In this review article, the author (a doctoral nursing student and nursing school teaching assistant) outlines the main epidemiological characteristics of the four major bloodborne pathogens involved in most occupational transmissions or deaths, summarizes body substance exposure control systems, categorizes occupational exposure research conducted since 1990, and suggests a comprehensive intervention approach for decreasing bloodborne pathogen exposures.
Occupational Bloodborne Pathogens
Hepatitis B virus (HBV)
· Health care workers have demonstrated exposure susceptibility rates up to 10 times higher than the general population.
· A 1992 Centers for Disease Control and Prevention survey determined that 6,800 HCWs become infected annually. Of about 2,100 symptomatic HCW infections, 100 to 200 annually result in death from cirrhosis, hepatocellular carcinoma, or fulminant hepatitis.
· Needlestick injuries cause approximately 80% of all environmental exposures. Highest-risk locations for needlestick injuries are emergency departments, clinical laboratories, operating rooms, post-anesthesia suites, and hemodialysis units.
· Serologic evidence of transmission after a single needlestick exposure involving infected blood ranges from 27% to 45%, with 6% to 14% of those total injuries advancing to clinical hepatitis.
· HBV can survive in dried blood at room temperature on surfaces for more than seven days.
Human immunodeficiency virus (HIV)
· Until 1993, the number of HCWs confirmed to have sustained occupational HIV transmission ranged from 37 to 120.
· Percutaneous exposure is the predominant mode of transmission in those cases.
· The HIV seroconversion rate averages 0.3% from occupational needlestick injury.
· HCWs found at greatest risk include laboratory technicians, nurses, and physicians.
Hepatitis C virus (HCV)
· Transmission to HCWs occurs by percutaneous needle or sharps exposures to contaminated blood or blood products.
· Thirty percent of hemodialysis clients have been diagnosed with HCV.
· Risk of worker infection from a single percutaneous exposure is estimated at about 3%.
Cytomegalovirus (CMV)
· Risk of infection from a single exposure to a unit of packed erythrocytes containing the virus is estimated at less than 1%.
· Possible increased exposure risk for perinatal nurses is now coming under closer scrutiny.
· Most HCWs are now expected to sustain at least one CMV infection during their careers.
Exposure Control Systems
The following systems have been implemented since the 1980s:
· Traditional category-specific infection precautions (1983) - includes intervention categories such as "blood and body fluid precautions," "enteric precautions," "contact isolation," and "strict isolation," which indicate the type of protective wear to be used.
· Body substance isolation (1987) - provides criteria for protective wear and instructions for disposing of soiled trash, linen, sharps, etc.; purpose is to reduce cross-contamination to clients via HCWs' hands.
· Universal precautions (1988) - provides guidelines for use of gloves and other protective measures, trash handling, etc.; based on epidemiologic framework intended to prevent bloodborne pathogen transmission to HCWs.
· Bloodborne pathogens standard (1991) - The U.S. Occupational Safety and Health Administration rule aims to minimize occupational exposures through continued use of universal precautions, the HBV three-dose vaccine series, communication of bloodborne hazards, creation of exposure control plans, and other engineering and work practice controls.
· Safety precautions (1994) - employs a more limited systematic approach toward reducing occupational and client exposure risks; organizes risk-reduction steps within the hierarchy of engineering controls, work practice controls, and personal protective equipment, in addition to observance of universal precautions.
Occupational Exposure Research
The body of research is categorized into four major groups:
Compliance with exposure control systems and exposure rates
· Consistent decreases in occupational exposure rates have been demonstrated when HCWs routinely complied with any of the major exposure control systems. Compliance rates were correlated with one or more of the following:
- assessment of HCWs' exposure control behaviors during annual performance evaluations;
- initial and continued bloodborne pathogen risk training;
- effective barrier equipment availability and design.
· A national survey of HCWs found that 42% of the patient care staff completed the HBV vaccination series.
· In the same survey, 55% of patient care staff reported recapping needles, resulting in 25% of total reported percutaneous exposures.
· The survey showed percutaneous exposure rates during the past 12 months were 24% of patient care staff, 34% of physicians, and 18% of housekeepers.
Effect of training on occupational exposure rates
· Reported exposure rates declined after some form of inservice education.
· Staff compliance with exposure control systems varied significantly among individuals within each setting, regardless of type or amount of education provided.
· Workers continued to use only certain exposure control interventions during specific patient care situations, despite achieving improved test scores after education.
Perceived risks/concerns of HCWs related to exposure
· HIV exposure risk has been found to be of greater concern to HCWs than HBV, despite data pointing to HBV as the predominant risk.
· HCWs' attitudes toward occupational exposures seem to be more related to emotion than logic or information.
· Measures that make adoption of protective behaviors appear more emotionally acceptable and pragmatically feasible include:
- updating and re-evaluating exposure control system education;
- improving accessibility and acceptability of protective wear to accommodate work demands;
- including staff in decision making and policy development;
- creating simpler protocols for obtaining the HBV vaccine series.
Variables related to completion of the HBV vaccine series
· Efficacy of the complete series ranges between 80% and 95%, with no significant side effects.
· Vaccines have been determined to be 70% to 88% effective when administered within one week postexposure.
· Acceptance and completion rate of the entire series continues to fall below 50% among most HCW groups.
· HCWs who fail to start or complete the vaccine series cite a perceived lack of risk of occupational infection and/or fear of HBV or HIV transmission from the vaccine.
· Younger nurses tend to be more accepting of the vaccine than their older counterparts.
Comprehensive intervention approach
The author recommends a more comprehensive intervention program for occupational health professionals to decrease bloodborne pathogen exposure rates for HCWs in high-risk environments. He suggests the following program:
· Continued use of conventional exposure control measures, including continual updating of exposure control policies paired with equipment vendors incorporating caregivers' suggestions into barrier device modifications.
· Customized inservicing and educational offerings to improve HCWs' protective behaviors. This could include:
- conducting focus group meetings to discuss workers' concerns;
- inviting workers infected from occupational exposure to speak at inservices;
- coordinating worker self-assessment exercises;
- disseminating work site and industry risk statistics.
· Immediate exposure reporting and treatment mechanisms that maximize reporting rates without seriously interrupting work flow or employee productivity.
· Improved HBV vaccine series accessibility and titering, including possible use of portable vaccine carts taken to patient care units to ensure employee completion of the vaccine series. Vaccine could be offered in conjunction with mandatory annual tuberculin skin testing. Occupational health professionals must provide easily accessible literature about HBV vaccination guidelines.
· More consistent source patient identification, with hospitals proactively using infection surveillance data to decrease the risk of bloodborne pathogen transmission to patients and employees.
· Contemporary work systems engineering techniques, including the use of needleless intravenous delivery systems, sheathed needle delivery systems, better-designed sharps boxes, and strategic placement of personal protection equipment on patient care units.
· Administrative practices, such as including staff at meetings to formulate or update exposure prevention policies and protocols, use of consistent feedback mechanisms for staff during performance evaluations about observed compliance, and consistent positive and proactive messages from administrators.
Education alone is not enough
The author concludes that variables affecting whether HCWs comply with protective behaviors are complicated. Simply educating workers to comply provides only temporary or negligible effects.
"Literature, to date, points to the greater potential of comprehensive interventions to effectively reduce occupational exposure rates to bloodborne pathogens. The attainment of this goal through the increased use of systemwide and work site engineering techniques has been advocated by numerous experts, and demands increased consideration from health care planners and researchers in the future," he states.n
Strategies for Shift Workers is a 12-page brochure ($15 for a packet of 25) from the National Sleep Foundation (NSF) suggesting ways workers and employers can make changes to lessen the negative effects of shift work on health and productivity. Day/Night Strategies for Shift Workers is an 11-minute companion VHS videotape ($29.95). Contact: NSF, 729 15th St. NW, 4th Floor, Washington, DC 20005; fax (202) 347-3472.n
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