Accommodating the Employee
This theme encompasses the ways in which the employer supported and accommodated their employee both pre and post-surgery.
Supporting Employees Prior to Surgery
Participants described modifications made to the employee’s role, and the provision of equipment, or assistance with tasks including changes implemented prior to surgery.
…we would put reasonable adjustments in place. So to keep them within the workplace and to keep them in as normal a routine until unfortunately sometimes they’re unfit to carry on work until the surgery takes place – 21 Human Resources
Modifications prior to surgery included the provision of lighter and more manageable work related equipment, and colleague support, in some cases enabling the employee to continue working until the day of surgery. Some employees had had a change in role as they were physically incapable of fulfilling them prior to surgery. Other employees had reportedly managed their work effectively without accommodations up until surgery, with the WR unaware that the employee was experiencing problems carrying out their role, or it was perceived that the employee might be reluctant to disclose this information.
I think he hid it very well…he was a keen tennis player, I think obviously it was becoming an issue with him playing tennis and less of an issue in work. So it was relatively a surprise when he said oh I need to get my hip replaced. OK, so prior to that I hadn’t really been aware of any restrictions – 18 Manager
Others had taken substantial sick leave prior to surgery. Some WRs reported that they might have considered making accommodations for the employee if the GP had advised them accordingly. WRs thought that the GP was more likely to sign the employee off sick until the time of the surgery rather than suggest work modifications that could maintain them in the workplace.
Modifying Hours and Duties
Some employees had returned to work by phased return, either in isolation or in conjunction with amended duties. The phased return could be a simple reduction in hours building up gradually over the first few weeks, up to very complex arrangements, incorporating un-used annual leave allocations and public holidays. These arrangements were generally designed with OH if available, but then implemented and reviewed by the manager in conjunction with the employee.
So we had guidelines to be honest from occupational health but we sort of, we adjusted them as we felt fit based on how he felt…. And then we effectively had weekly reviews and increased his activity as he felt appropriate, and also his hours – 18 Manager
Amended duties could include the restriction of heavy lifting; restricting work to one floor level so as to reduce the need to use stairs; the provision of trolleys and light-weight equipment. This was particularly the case with manual jobs such as cleaning, and maintenance roles involving carrying, kneeling and moving heavy equipment. With other occupations involving heavy, factory or warehouse based work, some OH practitioners advocated that there should be no manual work undertaken whilst the employee was undergoing rehabilitation. These employees were given time to re-integrate into their previous role, whereas employees in other organisations remained within the same work environment but only took on work which did not involve certain postures, e.g. kneeling, or particularly physically onerous tasks. Other employers provided respite for employees from the pressure of a mentally demanding workload.
I suppose our job isn’t physical, but it’s very mental…. What my main aim was to wait for him to give us the OK, and then possibly space out his appointment times so that his day wasn’t overfilled or overtaxing on his return…. So I kept – I selected what he got involved with and what he didn’t get involved with if you like… – 5 Colleague
Changing Equipment and Environments
WRs referred to providing additional or adapted equipment and furniture to facilitate RTW. Changes included the provision of perching stools allowing employees who would normally stand all day to take seated breaks, or by alterations to desk and office furniture, such as adjustable office chairs, seating wedges and footstools.
I referred her to occupational health for an assessment on her coming back to work and if we needed to put any adjustments in place. We did do a desk risk assessment with her. You know, just to check her chair was OK and the desk and she was sitting right and things like that. And did she need a board, you know, one of those footboards. So, we did all that when she came back – 24 Human Resources
Other WRs described concessions on workplace parking allowing employees to park closer to their place of work, sometimes allowing parking in disabled bays. Some provided taxis or arranged lifts to and from work for the period that employees were unable to access their usual mode of transport.
WRs might move employees to a different work area in order that they could access facilities more easily, or advise the employee to use lifts rather than stairs to access their workspace. Some employees were relocated to a different work site nearer to their home until they had recovered to a point that they could travel independently. Others were given the opportunity to work from home initially, if their role made this possible.
Offering Alternative Roles
It was reported that some employees requested to return to a different job as they did not feel able to satisfy the requirements of their previous role. WRs might be willing to concede in order to facilitate a timely RTW. Additional training might also be arranged.
Other employers opted to move the employee into another team with a less physically demanding role. This included support from work colleagues,
She’s been having a phased return back to work…we’ll give her two extra afternoons now from next week…being a primary school, because obviously they teach all lessons and her class is being covered for PE lessons probably for the next six months just to make sure there’s no running about on her part – 19 Manager
Smaller businesses found it more difficult to offer alternative roles, and resorted to what they perceived to be ‘light duties’ such as cleaning, sweeping and delivery driving to enable the employee to return.
Assistance from Other Workers
Although there was an expectation that colleagues would provide informal support for those returning to work following surgery, some WRs facilitated this by requesting assistance from other staff.
We’ve got staff who will help her take, when she’s finished her day or when she’s beginning her day, they will help her take stuff to and from her car. She does have one of those wheelie trolleys but even so pulling it isn’t easy, so we support her as a team – 20 Staff Liaison Manager
Colleagues might be asked to step in and assist with certain activities, with one employee returning to work initially on a supernumerary basis so that she was effectively an extra ‘pair of hands’.
Accommodations: Temporary or Permanent?
Some participants reported that the employee had not returned to work, or was back at work but remained on modified duties.
So that’s how we’re accommodating things at the moment…. I suppose if it is something that’s going to be permanent and she’s not going to improve any further, then maybe we may need to look at some equipment to help her do her job, you know. Would she need a special chair for sitting in a delivery room, you know, things like that, and I would look to [OH provider] to help me with that – 23 Ward Manager
Issues around the inability to kneel post-surgery resulted in employees having to be relieved of some of their previous duties. This was particularly the case in physically demanding roles. Not all employees were able to RTW even with work adjustments or altered hours as the problems they were having were insurmountable at that point in their recovery.
…she’s been off about three months so with that altogether it took a lot longer for her to come back into it from that point of view. We are quite quick at getting them back in actually because, a lot of the time they do, as I say, come on this phased return bit so they don’t actually do the full role. But she was just not fit even for amended duties. – 13 OH Nurse
In some cases employees had returned to work but were unable to fulfil their duties and as a consequence had gone back on sick leave.
Barriers and Facilitators to Return to Work
This theme incorporates the strategies and processes which facilitated RTW following THR/TKR and highlights those aspects which were seen to impede a timely return to the workplace.
The Pros and Cons of an Occupational Health Service
There was a view that organisations with an on-site OH service were at an advantage in supporting RTW due to their perceived better understanding of the job demands. OH advisers could also give reassurance to employers that they were acting in accordance with best practice, and complying with current employment legislation.
…occupational health are there to support and guide, and I think that’s really important when we’re talking about people who are working outside in the community or in a ward environment. I think it’s important for all people, but more so people who are patient-facing – 20 Staff Liaison manager
Some organisations reported having regular clinics held with an OH/company doctor rather than an on-site service. In some organisations all employees undergoing THR/TKR would be referred to OH. However, in other cases referral was at the discretion of the manager, and not necessarily before the employee had returned to work.
OH input was generally positively received, however not all interviewees valued every OH intervention but felt it necessary if they had received insufficient medical advice from the employee’s GP or surgeon, or as a ‘back up’.
I have no idea what we pay for the service through our occupational health provider, but to me I’m perfectly capable of reading that on the intranet myself, so has it added value having it in a headed letter from a health provider, probably not…. So has it helped me manage that absence better through the occupational information? Probably not, but it gives me the reassurance that should I need anything I’ve got access to it… – 16 Manager
Some questioned whether OH practitioners had sufficient in-depth knowledge of the employees’ work tasks, that employees themselves might have a negative perception, or misunderstand the role of OH, limiting their potential cooperation. Those interviewees who represented OH often felt that their departments were under-resourced, however there was a perception that, as medical staff such as surgeons and GPs were not sufficiently trained in work-related issues, OH services were imperative to a successful RTW.
Lack of Advice and Support from the Orthopaedic Team
There was a consensus amongst WRs that there was insufficient communication between the orthopaedic team and themselves. It was reported that they would value the opportunity to discuss the specifics of their employees’ recovery from surgery, the anticipated longevity of the new joint, the time scales involved and what the employee could and could not do on RTW.
I would like them to be able to say whether he could drive, whether he could walk, whether he’d be in – how much pain they would expect him to be in. I think it would be more just the day to day things and then we could get occupational health to do an assessment related to his particular job – 25 Head of HR
They were also unclear as to what the final expected functional outcome might be, with some employers expecting their employee to be ‘fixed’ and working more productively than they were pre-surgery.
WRs felt too reliant on employee-reporting of their recovery leading to suspicions that employees might be imparting misleading or misguided information, or even manipulating the situation to fulfil a personal agenda. They felt that, once the decision to operate had been made, that the surgeon should advise the employee and their employer on how the procedure might impact on work. As there was usually at least a two month gap between the surgical decision and the operation, this would give the employer time to plan ahead to provide staff cover, and prepare for any necessary modifications.
Yeah I think once the person has been informed by their GP that the recommendation is a knee or hip replacement and that they’ve agreed to it, therefore it’s definitely going to happen, at that point because it’ll be a few months before it actually happens, but at that point there should be some understanding for the manager and the person themselves and what this means in terms of work – 12 Commissioning Manager
However, other WRs felt that they would prefer to receive this advice post-surgery when the result of the operation and any potential complications were known as this would give the employer a more accurate prediction of the RTW date.
The Limited Role of the GP
Interviewees reported that GPs were variable in the RTW support they provided, that GPs were limited in time and expertise, and reliant on the patient for information about work issues. Although fit notes were perceived by some employers to be of benefit, others disagreed and felt that the information provided on fit notes was often limited. Employers felt that the fit note provided the opportunity for GPs to make recommendations on possible work modifications but these were seldom made.
There was also a view that GPs were inclined to be overcautious, or might raise an employee’s expectations inappropriately, or only consider the employee’s current job, rather than any potential alternatives. Some employees were thought to consider the fit note as ‘gospel’, rather than advisory, although likewise the employer might also be reluctant to act against fit note advice,
And if the, sometimes the GP will put down a long time on a fit note, and that person takes that fit note as god. They won’t veer from that: my GP says I can only return back to work after that date. And you cannot make them change their minds about coming back to work any sooner. Actually you can come back to work before that date, because you can do X Y and Z and you just show me you can do X Y and Z – 6 OH nurse
As a result WRs were more likely to rely on OH advice if available, or would request further information from the GP. However, obtaining more detailed advice from GPs was limited by communication systems, often making the process protracted and problematic.
Some WRs felt that they needed to get GP approval for a RTW, others did not necessarily pay too much attention to the fit note.
And occasionally you sort of, we’ve gone and said to individuals, individuals who are going to come back to work against the GP’s advice, which is interesting, or come back early because I feel great. So the doctor’s signed me up for a month but after three weeks I feel great so I’m going to come back in and that creates issues at work when you’ve got people working against medical advice – 18 Manager
A number of WRs expressed concern regarding the pain relief medication prescribed by GPs to employees following surgery, particularly if this presented a risk to the employee or others due to the possible effects of the medication on their ability to perform their role. This was particularly the case with roles involving public safety or the use of heavy machinery. It was felt that this information should be imparted to the employer as the patient was not always aware of the effects of the medication that they were taking.
Employee Motivations and Drivers
The employee’s personal characteristics were perceived to be potentially both a hindrance and a help to their effective RTW. Some employees were keen to RTW as soon as possible—in some cases too early—due to the loss of their usual routine, and boredom, finding it difficult to adapt to not being at work,
So it is hard telling somebody that they’ve got to be off that little bit longer when they’re desperately wanting to return. It is difficult, especially when they’re pleading to you and they’re wanting to come in – 13 OH nurse
Others were keen to return due to job demands and responsibilities, or for reasons of finance or job security.
WRs recognised that it was important to re-establish a work routine as early as possible, and that some employees might be anxious about returning to work. Other employees were reported to have delayed surgery because of anxiety about the operation itself.
WRs thought that those in manual jobs might struggle to consider moving onto lighter, more sedentary office-based duties, or be reluctant to return to jobs which they felt might have contributed to their arthritis.
Employees’ compliance with rehabilitation and self-management of their health was seen as a key factor in RTW. There was a view that some employees needed more active support in the recovery process, particularly those people who do not have anyone to support them at home or are lacking in motivation and enthusiasm to RTW.
Proximity to retirement was also considered a factor, and concerns that RTW might impact on the new joint.
Because they’ve only either got a few months left or a couple of years left, and they just think do you know what, it’s not worth coming back and heaven forbid but doing any more damage – 3 Human Resources
Employee beliefs about the RTW process were thought to create obstacles, for example not knowing or understanding about phased returns, or any of the other work modifications and accommodations that might facilitate the process. However the motivation of the employee to RTW was seen to be paramount.
Impact of Workplace Size and Structure
Some interviewees took the view that the size of the organisation had an impact on the employee’s RTW, for example, managers in smaller organisations might be less skilled in the process. Managers might also have little access to support systems—and less experience of joint replacement surgery.
I guess in a bigger business you’d have a HR department or you’d have a HR person who is allocated to each member of staff or whatever…. No, I think it’s probably, given my limited experience on it because we’re a small business and we haven’t been through it other than this one recent case – 11 Managing Director
However even the representatives from larger organisations felt that line managers might not be aware of the organisational support available to them in managing RTW. Those larger organisations that had their own on-site rehabilitation service were perceived to enable line managers to better manage an optimal RTW experience, and provide ongoing rehabilitation in the workplace. However, in smaller businesses, there were seen to be fewer options for work adjustments and changes to how work was organised.
Very large organisations were more likely to have set procedures for employees returning to work following THR/TKR as they had more experience of the issues involved. It was observed that lengthy periods of sickness absence were more easily accommodated by larger organisations as they had more capacity to cover periods of sickness absence.
…can’t remember how many months it was now, but it was definitely three to four months if not longer where she worked in this other team before planning her return into her post – 20 Staff Liaison Manager
Employees in smaller organisations or teams were thought to be less comfortable about taking sick leave because of the demands that their absence would place on their colleagues and employer. However there was a perception that some organisations might be less supportive than others, and that some posts were more difficult to provide cover for. Even within the same organisations, sick pay arrangements, phased returns or access to health schemes might differ between departments and the seniority of staff, which consequently impact on the success of the RTW.
Office-based and non-manual work roles were seen as easier to return to. However some interviewees perceived that adjustments might also be required for office-based work particularly in terms of work station assessments and altered working practices to ensure workers remained mobile.
Once an individual had returned to the workplace it was thought that colleagues might need prompting to be supportive with any adjustments and accommodations, and even employees in sedentary tasks still needed to be able to travel to work and be mobile within the workplace.
Factors Relating to Surgery and Postoperative Care
Factors relating to surgery itself were perceived to impact on RTW. Where there had been complications such as infections or blood clots, or ongoing symptoms and after-effects of surgery such as stiffness, pain, swelling, low mood and fatigue, a full and successful RTW was protracted. However some WRs were surprised as to how well their employee was coped considering the amount of physical effort required to fulfil their role.
The impact of successive joint replacements on sick leave was also a consideration, and perceptions of insufficient or delayed post-operative care and physiotherapy, with some employers opting to take advantage of the services of private providers associated with their organisation.
they’re waiting three weeks for physio-that’s three weeks of their time lost here…he wasn’t referred for physio. He was just given exercises. Whereas everybody else I’ve known has been referred to a physio…. So I think unfortunately it’s a postcode lottery is the impression I get, but I could be wrong. And we’ve actually had to say to this guy well look, we can get you physio private…you can claim up to six sessions back – 3 Human Resources
Surgery undertaken privately was seen by some to facilitate the process, and that NHS delays and cancellations were a hindrance, however, others had not experienced any such problems.
For large organisations with highly structured RTW policies for THR and TKR, the variation in expected duration of sickness absence and RTW advice between different surgeons and Trusts was seen as a potential hindrance.
And I suppose the difference then in NHS is that you may then have some people that are off for six weeks, some people are off for eight weeks, maybe ten weeks and it could potentially then cause problems – 2 OH Physiotherapist