7 Principles for Sucessful Return to Work: a Guide for Occupational Therapists in Singapore

AN

SAOT TTSH PUBLICATION

ADAPTEDFROMTHEINSTITUTEFORWORK& HEALTH, CANADA

7PRINCIPLES FORSUCCESSFUL

RETURNTOWORK: AGUIDEFOR OCCUPATIONALTHERAPISTS INSINGAPORE

EDITEDBY HEIDITAN

Page

FOREWORD The World Health Organization (2003) has espoused that working with employers and workers to plan and implement return-to-work strategies is an important health promotion activity and health promotion is essential to empowering people to increase control over their health.

Helping injured workers return to work (RTW) is an important aspect of Occupational Therapy practice. RTW services enable the re-integration of individuals into the workplace following disruption from physical or mental health conditions.

Occupational therapists (OTs) communicate, co-ordinate and collaborate with clients, supervisors, employers, and healthcare professionals to facilitate early RTW services. It is timely that these principles are adapted to our local context, reviewed by a group of OTs from various health and social organisations, and published.

In July 2015, the Ministry of Manpower (MOM) announced increased compensation limits for work injuries under the Work Injury Compensation Act (WICA) from 1 January 2016. Keen to facilitate an early RTW for injured workers, MOM will now permit expenses that speed up RTW to be claimable under the WICA, such as hiring an OT to assess the workplace and provide suggestions to management on how to facilitate an individual?s re-entry to employment.

FLORENCE CHEONG President, Singapore Association of Occupational Therapists (SAOT)

This set of principles serves to guide OTs in Singapore on their missions to assist clients to RTW successfully. I hope you will find this a useful tool in clinical practice, and that the society will benefit from insightful use of this publication.

Head of Department, Occupational Therapy, Tan Tock Seng Hospital (TTSH)

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PREFACE OT?s role in work rehabilitation services is multi-faceted.

OTs conduct ergonomics assessment and education to prevent work-related injuries, use simulated work activities to build up one?s work tolerance, conduct Functional Capacity Evaluations (FCEs) to determine a worker?s fitness to work and facilitate workplace-based interventions.

In 2010, TTSH conducted a randomized controlled trial funded by the Ministry of Manpower (MOM) to explore the effectiveness of a Return-to-Work Coordinator (RTWC) model to facilitate RTW for injured workers. In this study, the OT ?doubled up? as a RTWC and facilitated communication between the worker, employer, doctor and other health professionals to address any RTW issues. The OT also performed workplace-based interventions, such as workplace assessments and job accommodations. Results of the study showed that the RTWC intervention facilitated earlier RTW and stakeholders valued the RTWC role in bridging the communication gaps between healthcare and workplace systems.

This guide was developed to help fellow OTs understand our roles in facilitating RTW at different stages of a worker?s recovery and to facilitate dialogue on RTW with various stakeholders. The 7 principles are workplace-based strategies which have been found to reduce work disability duration and costs. Using these principles together with our OT skills, we can help clients achieve their RTW goals.

I hope this guide will interest more OTs in Singapore to develop our niche in facilitating RTW.

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About t he Edit or: HEIDI TAN (M.Erg, M.WIMOR) Heidi joined TTSH as an OT since 1998. She was the key developer of ergonomics and RTW services in the department. She is now Senior Principal OT with TTSH and her current work focuses on work fitness determination, ergonomics consultancy services, work rehabilitation service development, training and research. Heidi was the principal investigator in a MOM funded research study from 2010 to 2012 exploring the effectiveness of RTWC in helping workers RTW after a work injury. In addition to her clinical role, Heidi holds education leadership roles within the allied health division in TTSH. In Nov 2015, Heidi took on a joint appointment lecturer position at the Singapore Institute of Technology (SIT).

ACKNOWLEDGEMENTS This guide would not have been possible without the consent and inputs from Ron Saunders and Emma Irvin from the Institute for Work & Health (IWH) to adapt the two IWH publications for use in Singapore. Thank you for the support from across the globe! I am grateful to Florence Cheong, my Head of Department, for her unwavering support in my OT journey. Special thanks to my comrade OTs in TTSH, Doreen Yeo and Joanna Giam, who have closely partnered me in the RTWC study. Thanks to SAOT council for the support of this publication. Lastly, my sincere thanks to the 15 OTs from various institutions in Singapore who have reviewed this guide and shared your thoughts with me about the possible future developments for OTs in RTW.: Anna Lee, St Andrew's Community Hospital Chen Changwu, JurongHealth Doreen Yeo, Tan Tock Seng Hospital Gribson Chan, St Luke?s Hospital Jane Sim, Khoo Teck Puat Hospital Joanna Giam, Tan Tock Seng Hospital Jovin Ho, Singapore Association for Mental Health Li Zhong Ying, Institute of Mental Health Lilian Lim, Abilities Beyond Limitations and Expectations M.Murugeswaran, Handicaps Welfare Association Ng Lip Chin, Ren Ci Hospital Ng Shixian, SPD Pow Siok Kee, National University Hospital Quek Lew Hui, Changi General Hospital Yang Zixian, Singapore General Hospital

And not forgetting the creative inputs from : OT mascots designed by Nurul Nafsiah Binte Sulaiman, TTSH Case studies illustrated by Chan Yu Rong and coloured by Nurul Ain Bte Rahmat, TTSH Design and layout by Florence Cheong, TTSH / SAOT Graphics designed by Freepik 4

CONTENTSPAGE Foreword

2

Preface

3

Acknowledgments

4

Contents page

5

Introduction

6

Overview of the 7 principles

8

Stage 1 - Principle 1

9

Stage 2 - Principle 2, 3, 4

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Stage 3 - Principle 5 to 6

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Stage 4 - Principle 7

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Case studies -

One phone call may be all it takes Return to work as therapy goal The return to work co-ordination process Chronic disease self-management at work Assessment of fitness to work at the worksite Vocational exploration, training and job placement Low cost accommodation benefits all Workplace support is key!

17 18 19 20 21 22 23 24

Competencies of OTs facilitating RTW

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References

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" THISISAQUOTE INYOURARTICLE" INTRODUCTION In Singapore, there are various national initiatives to prevent injuries at work and extend the retirement age. These address challenges posed by the pressure for productivity and an ageing workforce.

Policies to promote societal inclusiveness are also in place to enhance the employability and employment options for persons with disabilities.

The continuum of RTW programmes in Singapore for workers with an injury or medical condition is at its infancy stage. In public hospitals where injured/ ill workers could benefit from early RTW intervention, there are no structured programmes in place to facilitate workers to return to their previous employment. Some Occupational Therapy departments in the hospitals have set up work rehabilitation services providing work conditioning, functional capacity evaluation and worksite visits. However, utilization of such services is low.

Comparatively, vocational rehabilitation and job placement services are more established in the community and social sector in assisting workers with significant permanent disability to RTW. The discrepancy in the focus on RTW between health and social sectors could be due to the perception that employment is deemed more as a social outcome, rather than a health outcome.

There is increasing evidence that work is good for an injured worker?s health and wellbeing.

Staying at work is not just the end point of rehabilitation, but is a valued part of the worker?s rehabilitation. Healthcare professionals need to recognize the health benefits of work and support injured/ ill workers to RTW as soon as it is safe to do so (Australasian Faculty of Occupational and Environmental Medicine, 2011).

The Canadian Association of Occupational Therapists Position Statement: RTW and Occupational Therapy (2009) states that OTs have the knowledge and skills to provide quality and comprehensive RTW services. This is similarly echoed in the World Federation of Occupational Therapists Position Statement on Vocational Rehabilitation (2012) which affirms that OTs have the expertise in vocational rehabilitation to enable individuals?participation in work. OTs?belief in the interrelationships among the person, occupation, and environment uniquely positions OTs to provide RTW services.

With the increasing awareness and need for RTW interventions at a national level, OTs in Singapore need to be ready to enable individuals with injury or illness to continue to engage in the meaningful occupation of work.

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INTRODUCTION This guide was adapted from 2 publications with permission from the Institute for Work & Health (IWH), Canada: 1. ?Seven Principles for Successful Return to Work? (IWH, 2007; rev 2014) This was developed based on a systematic review by IWH on RTW research studies, which identified elements contributing to successful RTW (Franche et al. 2005 & MacEachen et al. 2006). Overall, the literature review found that workplace-based RTW interventions have a positive impact on duration and costs of work disability. Tailoring and implementing these evidence-based strategies in our local context can assist workplace parties and healthcare professionals in the development of successful RTW programmes.

2. ?Working Together: Successful Strategies for Return to Work? (IWH, Ontario Society of OTs, College of OTs of Ontario, 2008) This was created by the Occupational Therapist Educationally Influential (OT EI) network in Ontario, Canada, a network of OTs with work practice experience who were nominated by their peers. The OT EI

network was developed by the IWH in partnership with the Ontario Society of Occupational Therapists and the College of Occupational Therapists of Ontario. ?Working Together? was designed to transfer the research evidence into practice principles that can be incorporated at the workplace. The tool is organized into four stages that are related to the various elements of successful RTW and highlights the role of OTs at different stages of the RTW process.

Based on these 2 publications, the ?7 Principles for Successful Return to Work- A Guide for OTs in Singapore? is adapted to the local context first by the editor, and then reviewed by 15 other OTs working in both the public and community sectors to ensure the adaptation is relevant and applicable to the Singapore context. 8 case studies had been included to enhance the applicability of the 7 principles in various settings. A set of competencies that OTs can develop to enhance their abilities to facilitate RTW for workers are also included at the end of this guide.

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Overview of t he 7 Principl es STAGE 1: EARLY CONTACT Principl e 1

The employer makes an early and considerate contact with the injured/ ill worker.

STAGE 2: PLANNING FOR THE WORKER?S RETURN Principl e 2

Someone has the responsibility to coordinate RTW.

Principl e 3

With the worker?s consent, employers and health care providers communicate with each other about workplace demands, as needed.

Principl e 4

The employer makes an offer of modified work (also known as work accommodation) to injured/ ill workers so they can return early and safely to work activities suitable to their abilities.

STAGE 3: IMPLEMENTING A SUCCESSFUL RTW PROGRAM Principl e 5

RTW planners ensure that the plan supports the returning worker without disadvantaging co-workers and supervisors.

Principl e 6

Supervisors are trained in work disability prevention and included in RTW planning.

STAGE 4: CREATING A RTW-FRIENDLY WORKPLACE Principl e 7

The workplace has a strong commitment to health and safety which is demonstrated by the behaviours of the workplace parties.

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Principl e 1 : STAGE 1:

THIS ISA CONTACT "EARLY QUOTE INYOUR SIDEBAR"

The empl oyer makes an earl y and considerat e cont act wit h t he injured/ il l worker.

Research Evidence (Principle 1): Employers who have a process in place to make an early and considerate contact with injured/ ill workers are more successful in return in work.

Init iat e discussion regarding RTW:

- Find out from the worker about his/ her work demands, RTW plans, self-efficacy and any concerns to RTW following the injury.

These processes are characterized by: a) contact by immediate supervisor (ideally) with an injured/ ill worker. b) contact ?within the first week or two? should be seen as a guideline only, as the actual timing will depend on the worker?s specific situation.

- Find out if there are any contextual factors that may affect the worker?s motivation to RTW e.g. family?s support, relationship with employer, involvement in medico-legal claims.

- Educate worker on legislation and social

c) conversation conveys concern for the worker?s health and well-being and should not involve issues such as injury causation, blame or employer financial concerns.

resources related to RTW where relevant e.g. Work Injury Compensation Act, Assistive Technology Fund.

In general, early contact is most successful when it builds on a workplace environment characterized by a shared sense of goodwill and confidence.

severity of the functional deficits, expected recovery progress and prognosis of the worker's injury or medical condition, and the impact on work ability .

How OTs can f acil it at e RTW:

- Find out if the employer had contacted

Stage 1 starts when the worker?s injury or medical condition is still in the acute or sub-acute phase of recovery and the OT may be attending to the worker as part of medical rehabilitation e.g. hand therapy, neurology rehabilitation. After the basic self-care and discharge issues have been addressed, the OT can initiate discussion regarding the worker?s RTW during regular therapy sessions.

- Discuss with the healthcare team on the

the worker. If appropriate, offer to contact workplace personnel to update on rehabilitation expectations and explore any options for work accommodations.

Workplace personnel may be the worker?s supervisor, human resource professional, management or health and safety personnel.

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STAGE 2:

Principl e 2 : Someone has t he responsibil it y t o co-ordinat e RTW.

PLANNING FOR THE WORKER?S RETURN

Principl e 3: Wit h t he worker?s consent , empl oyers and heal t h care providers communicat e wit h each ot her about workpl ace demands, as needed.

Research Evidence (Principle 2): Organizations

Research Evidence (Principle 3):

that have identified a key person (internal or

Opportunities for successful RTW are more

external) to coordinate RTW are more likely to

likely to occur when employers and health

be successful in RTW.

care providers, with the worker?s consent,

This coordination involves:

communicate with each other about workplace demands as needed. Ideally the

- providing individualized planning and coordination adapted to the worker?s initial and on-going needs, - ensuring the necessary communication does not break down at any point,

worker should participate in the communication between the healthcare provider and the workplace.

Communication, depending on the complexity of the case, may involve:

- ensuring the worker and other

- a paper-based information exchange

stakeholders involved understand what to

(e.g. information on job demands and/ or

expect and what is expected of them.

work accommodation options sent to the

RTW stakeholders include workers, family

healthcare provider by the employer),

members, co-workers, supervisors, managers,

- a telephone conversation about work

healthcare providers, disability managers and

and job demands (initiated by either

insurers, unions or worker representative.

party), - a workplace visit by a health care provider to view the work activities and work environment, and converse directly with the supervisor or employer, - rehabilitation and/ or occupational health professionals acting as a ?bridge? between the workplace and healthcare system when physicians do not have time to consult with the workplace .

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Principl e 4 : STAGE 2: PLANNING FOR THE WORKER?S RETURN

The empl oyer makes an of f er of modif ied work (al so known as work accommodat ion) t o injured/ il l workers so t hey can ret urn earl y and saf el y t o work act ivit ies suit abl e t o t heir abil it ies.

Research Evidence (Principle 4): Based on research evidence, employers who make an offer of modified work or accommodations, that are suitable to the worker?s abilities, are more successful in achieving early and safe RTW for employees.

An early and safe modified work offer can be achieved by: - improving the fit of the worker with the work environment - ensuring that the modified work can be performed by the returning worker - ensuring, where possible, that the worker is returned to his/ her original work area where the environment, people and practices are familiar - including ergonomic assessment to aid in creation of appropriate physical modifications in complex situations

Coordinat e - the process of communication between all RTW stakeholders and establish single points of contact of different groups of stakeholders to minimise communication gaps, - and ensure follow up of recommendations and manage sensitive, confidential information pertaining to the worker and workplace, - and facilitate appropriate referrals to other healthcare providers or expertise where required.

This coordination role is particularly crucial for OTs in the acute setting to undertake as there are usually no other health professionals who have a focus on facilitating workers?RTW. In the community setting, this role may be carried out by other professionals such as job placement support officers or case managers.

How OTs can f acil it at e RTW:

Assess

Stage 2 is when the OT is most likely to be involved in the RTW process for injured/ ill workers, as it taps on the core knowledge and skills that OT professionals are trained in.

The roles and interventions that can by carried out by the OTs are summarized in this acronym ? CARE.

- the worker?s abilities and resources for RTW through functional abilities assessment, - the job through interviews with worker, employer, job descriptions and/ or job databases that provide information on the physical, cognitive, behavioural and emotional demands of work,

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Principl e 2 : Someone has t he responsibil it y t o co-ordinat e RTW.

STAGE 2: PLANNING FOR THE WORKER?S RETURN

Principl e 3: Wit h t he worker?s consent , empl oyers and heal t h care providers communicat e wit h each ot her about workpl ace demands, as needed.

Principl e 4: The empl oyer makes an of f er of modif ied work (al so known as work accommodat ion) t o injured/ il l workers so t hey can ret urn earl y and saf el y t o work act ivit ies suit abl e t o t heir abil it ies.

- the work environment, including the physical and social supports, through worksite evaluation,

- strategies to assist in the process of monitoring and adjusting work demands as worker?s ability changes over time.

- the barriers to and facilitators of successful RTW for worker and for the workplace,

Job modifications or accommodations can include changes or adjustment to a job or work environment that enables the injured/ill worker to perform the job more productively with his/her functional abilities. Most accommodations recommended are low cost but require some effort from the workplace to make arrangements. Nevertheless, it is useful for OTs to be aware of the possible sources of funding that employers can tap on as there may be situations that require higher cost work accommodations.

- the suitability of modified work or work accommodations for injured/ ill worker and any potential safety issues to worker or co-workers.

Such assessments can be conducted through use of functional interviews and observational assessment. It is not always necessary for the OT to conduct a standardized functional capacity evaluation. Worksite evaluations are usually beneficial and should include observation of the injured/ill worker performing core work activities and discussion with employer to address environmental challenges.

Recommend - rehabilitative interventions and/ or assistive technology to improve a worker?s functional abilities, - modifications or accommodations to the work tasks and duties and / or the work environment, - a feasible progressive RTW plan for injured/ ill worker after synthesizing information from all aspects of RTW,

Educat e - all RTW stakeholders to develop a shared understanding of the benefits of early RTW and their roles in facilitating the RTW process, - healthcare professionals on the worker?s functional abilities, work demands and use of work as part of rehabilitation, - employers and co-workers on the importance of early return to modified work, performance expectations and the support the worker requires during the RTW process, - workers on the importance of full participation in all aspects of the evaluation, planning and monitoring of the RTW processes and transitions.

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STAGE 3: IMPLEMENTING A SUCCESSFUL RTW PROGRAM

Principl e 5 : RTW pl anners ensure t hat t he pl an support s t he ret urning worker wit hout disadvant aging co-workers and supervisors.

Principl e 6: Supervisors are t rained in work disabil it y prevent ion and incl uded in RTW pl anning.

Research Evidence (Principle 5): RTW is more successful when the RTW plan meets the needs of the injured worker while minimising disadvantage to co-workers.

RTW planners should anticipate and plan for the potential pitfalls and barriers to cooperation identified by supervisors and co-workers including: - how others may be disadvantaged by the RTW plan - how the social factors (new relationships and work routines, productivity expectations) as well as the physical or job demands for both worker and co-workers may be altered as RTW plan is implemented Research Evidence (Principle 6): Organizations that train their supervisors in work disability prevention and include them in RTW planning are more successful in RTW. Training supervisors is key to RTW success because they work closely with the worker and they manage the immediate RTW environment. Training supervisors in safety, ergonomics, positive and empathetic early communication with the worker, arranging accommodations, follow up and problem solving, contributes to RTW success.

How OTs can f acil it at e RTW: In Stage 3, the workplace plays the more active role in ensuring the successful implementation of the RTW plan. This is especially critical in the community setting where long term follow up on the RTW of the injured/ ill worker is required. For OTs in the acute or sub-acute setting, it is good practice for the OTs to follow up with the employer and/ or injured/ ill worker for at least 1-month post-RTW. The OT can highlight potential workplace issues/ concerns to the employers and use their expertise to offer proactive strategies to prevent or mitigate these problems during the RTW process as the injured/ ill workers? abilities change over time.

Ident if y impact of t he RTW pl an on workpl ace - Partner with employers throughout the process in using their insight of the job and the workplace to create appropriate and workable job modifications, while maintaining a sense of control over work productivity and human resource planning in the workplace.

- Analyse the positive and negative impact of each RTW modification option.

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STAGE 3: IMPLEMENTING A SUCCESSFUL RTW PROGRAM

Principl e 5 : RTW pl anners ensure t hat t he pl an support s t he ret urning worker wit hout disadvant aging Principl e 6: co-workers and supervisors.

Supervisors are t rained in work disabil it y prevent ion Principl e 6: Supervisors are t rained in work disabil it y and incl uded in RTW pl anning. prevent ion and incl uded in RTW pl anning.

Of f er sol ut ions t o mit igat e negat ive impact - Suggest ways to minimize negative impact on all stakeholders, particularly the co-workers, involved.

- Training of supervisors on work injury management and ergonomics, how to manage and prevent occurrence of re-injuries of workers with physical or mental impairments, how to arrange work accommodations and problem solve regular RTW issues.

Monit or t he RTW process - Facilitate the participation of the worker in the RTW plan and develop strategies for self-monitoring, enacting social supports and creating an environment of respect in RTW programmes.

- Monitor the RTW process of the worker and adjust the RTW plan as the worker?s abilities change over time.

- Follow up and problem solve with workers and employers during the RTW process.

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Principl e 7 : STAGE 4: CREATING A RTW-FRIENDLY

The workpl ace has a st rong commit ment t o heal t h and saf et y which is demonst rat ed by t he behaviours of t he workpl ace part ies.

WORKPLACE

Research Evidence (Principle 7): We know that workplaces that have a strong commitment to health and safety, demonstrated by the behaviours of the workplace parties, have more success in RTW. Those behaviours include: - top management actively invests company resources and people?s time to promote safety and coordinated RTW - labour actively supports safety policies and return to work programs (for example, demonstrated by inclusion of RTW job placement practices in policies/ procedures and/ or the collective agreement), commitment to safety issues is the accepted norm across the organization How OTs can f acil it at e RTW: In Stage 4, OTs may be engaged by the workplace to look into system and policy changes that can support RTW in the workplace. This may happen as part of the process when the OT facilitates the RTW of an individual worker or as part of a work injury management and rehabilitation consultancy service at an organizational level. These activities may include:

Review of workpl ace pol icies - Review, develop and refine workplace policies and practices that support safe and timely RTW. - Identify barriers and opportunities to improve or create a workplace culture respectful of health & safety and supportive of RTW. - Develop strategies to implement an effective social support system for the organization.

Educat e al l workpl ace part ies on - the research and clinical evidence to support RTW policies and practices in the workplace, - the role of and need for social supports in RTW programmes, - the impact of health problems (depression, stress, pain) on workplace productivity and potential solutions, - the value of tailoring the RTW approach to meet the needs of an individual worker, - the complexity of RTW and the need to spend time on RTW planning, implementation and follow up.

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CASESTUDIES The following case studies are scenarios of how the 7 principles can be applied in practice by OTs in Singapore. As illustrated, OTs come across a wide range of cases who may require RTW interventions. These cases range from young adults to aged workers, resident to foreign labour, workers with physical deficits to mental incapacities, and those who sustain work injuries or suffer from chronic diseases. Each worker with an injury or illness is unique and may experience different types and severity of impairment, which limit their functional work abilities and affect participation in their worker role. Using the 7 principles with the OT professional expertise in work assessment and rehabilitation, OTs can enable the re-integration of injured/ ill workers into the workplace.

Special thanks to the following organisations who have contributed the case studies: -

Changi General Hospital Institute of Mental Health SPD Tan Tock Seng Hospital

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Onephonecall maybeall it takes Pri ncipl es used by OT: Principle 1: Early contact Principle 3: Communication between employers and healthcare providers Principle 4: Offer of modified work

Kai, a 30-year old sushi chef, accidentally cut his left thumb extensor tendon while slicing sashimi at work. The hand specialist referred him to the OT at the hand therapy outpatient clinic for a mallet splint. He advised Kai to wear the splint 24 hours a day for 6 weeks to allow his tendon to heal and gave him 6 weeks of medical leave.

1 week later, the OT saw Kai to review the splint. He appeared to be in low mood. Kai revealed that his employer questioned why he had to wear the splint for a small cut in his left thumb and if he was trying to prolong his medical leave unnecessarily. Kai feared that his employer would employ another chef to replace him. The OT offered to contact his employer to explain his condition and the treatment plan. Kai agreed and gave her his employer?s contact.

The OT called the employer. The employer was suspicious of Kai?s intent as he could not explain the recovery progress clearly. She was also concerned that he may still not be able to resume work after 6 weeks of medical leave. That would be a big problem for her as she only had 1 other chef working at her Japanese restaurant. The OT explained to her about the rehabilitation progress of mallet thumb during and post-splint regime and explored if there were alternative work duties that Kai can do without using his left thumb. The employer thanked the OT for helping her better understand Kai?s condition.

With the OT?s assurance that there are suitable modified work tasks that Kai can do without compromising the splint regime, the doctor agreed to reduce Kai?s medical leave to 2 weeks, followed by 6 weeks of light duty. Kai returned to modified duty in 2 weeks and resumed his usual work as a sushi chef 2 months after his work injury.

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Return-to-workasa therapygoal Lim, a 55-year-old male, was admitted to an acute hospital after a right cerebellar infarct which resulted in weakness and ataxia of his right upper and lower limbs. Lim was single and lived alone in a 2-room flat. He had worked as a coffee shop helper for the past 15 years, at least 8 hours/ day. He took pride in his job.

After 1 week, Lim was transferred to the rehabilitation ward and seen by the OT. Lim could walk about 10 metres unsteadily. He could recall items and events during therapy but his ability to perform mental calculations diminished, especially when he was tired or distracted. He was keen to RTW as work had been the main purpose in his life. With Lim?s consent, the OT raised the issue of RTW with his boss. Lim?s boss was supportive of his RTW goals. He shared that Lim had been a dedicated and reliable worker, and often voluntarily worked overtime when needed. He was efficient in taking orders and collecting payment from customers, and could carry up to 10 drinks on a tray at a time.

Subsequent OT sessions focused on improving Lim?s coordination, activity tolerance and higher cognitive functions, which are critical to his work capacity. Simulated activities such as taking multiple drink orders, mental payment calculations and carrying a few drinks on a tray, were included in the therapy regime. After 1 month, Lim showed improvements in his upper limb coordination, gait and cognition. He could even carry a tray of 5 filled cups with minimal spillage for 5 metres. Just before Lim?s discharge, the OT updated his boss and discussed modified work arrangements. His employer was willing for him to start work during off-peak periods for a few hours each day and gradually increase. His co-workers were happy for him to RTW earlier to give ?a few hours of help?, rather than ?no help at all?.

Lim gradually improved to work 8 hours a day. Though not as efficient as he used to be, he is satisfied that he can continue to contribute in his job.

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Principl es used by OT: Principle 1: Early contact Principle 3: Communication between employers and healthcare providers Principle 4: Offer of modified work Principle 5: RTW plan do not disadvantage co-workers

Thereturn-to-work coordinationprocess Principl es used by OT: Principle 2: RTW co-ordination Principle 3: Communication between employers and healthcare providers Principle 4: Offer of modified work

Suri, a 25-year old Myanmar warehouse worker sustained a T12 burst fracture and underwent surgery at an acute hospital. The OT saw Suri for self-care training. By post op day 5, he was independent showering and walking with walking frame, with moderate low back pain during activities. Pending discharge in 2 days?time, Suri expressed his worries over medical bills and RTW issues.

With Suri?s consent, the OT called his supervisor to discuss Suri?s discharge and RTW. As Suri still needed to use a walking frame, the OT advised the supervisor to relocate Suri to a ground floor dormitory. The OT reminded the supervisor to file the MOM work injury notification so that the medical and rehabilitation bills can be claimed from work injury compensation. The OT then explored if there were any possible ?light duties? for Suri to return to. The supervisor suggested that Suri can return to operating the forklift first, which he used to do occasionally.

Before Suri?s discharge, the OT confirmed that Suri?s hospitalization leave was given till the surgeon?s appointment and that Suri had outpatient physiotherapist (PT) and OT driving assessment appointments. 1 month later, the OT gathered from the PT that he could slowly walk without aids and the driving OT had assessed him to be safe to drive the forklift. The OT updated the doctor on Suri?s rehabilitation progress and modified work option. As the X-ray showed good fracture healing, the surgeon agreed for Suri to start work conditioning and "light duty? after 2 weeks. The OT requested the surgeon to indicate ?Avoid climbing and handling of more than 5kg? in the ?light duty? chit to the supervisor.

Suri returned to modified work and started work conditioning sessions 2 weeks later. Suri was taught proper body mechanics during manual handling, and ergonomics to avoid aggravation of his back pain. The OT maintained communication with Suri, the supervisor, the surgeon and PT over the next 3 months as Suri gradually resumed his previous full work duties as a warehouse worker.

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Chronicdisease self-management at work David, a 60-year old security guard, was admitted to a community hospital for right lower limb cellulitis due to poorly controlled diabetes mellitus (DM). He had ischemic heart disease and switched from being an odd job worker to a security guard due to decreased activity tolerance. He mainly worked night shift. This resulted in him having poorer DM control as he had irregular meal times.

David was referred to OT for activities of daily living (ADL) assessment. After two sessions, the OT asked David about RTW. David was worried his supervisor may terminate him due to frequent medical leave. With David?s consent, the OT contacted the supervisor to understand his expectations of David?s RTW. The supervisor was supportive of David?s RTW as he had been willing to work the unpopular night shift but was worried about his diabetic condition. The OT asked the supervisor regarding work demands as a security guard and ascertained that David would be able to perform the critical job demand of monitoring the CCTV at the guardhouse. However, with his right lower limb cellulitis, it is likely that David would have difficulty climbing the 6 flights of stairs during patrolling, 3 times each shift.

Using motivational interviewing techniques, the OT highlighted David?s reluctance to change his lifestyle versus his goal to maintain his worker role. David agreed to participate in a 6 week diabetic self-management workshop to learn lifestyle changes to improve DM control. The OT negotiated with the supervisor for David?s co-worker to cover his patrolling duties for the first 2 months of his RTW. When David?s right leg swelling resolved, he returned to modified work. After working for 1 month, he started patrolling once every shift, and gradually resumed patrolling 3 times/ shift within 2 months. He now takes his meals regularly to keep his diabetic symptoms under control as he values his occupational role.

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Principl es used by OT: Principle 1: Early contact Principle 3: Communication between employers and healthcare providers Principle 4: Offer of modified work

Assessment of fitnessto workat theworksite Principl es used by OT: Principle 2: RTW co-ordination Principle 3: Communication between employers and healthcare providers Principle 4: Offer of modified work Principle 5: RTW plan do not disadvantage co-workers

Jane, a 42-year old office helper, had an operation for C1-2 laminectomy and tumour excision 6 months ago. Jane?s employer had not contacted her for the past 6 months since she commenced medical leave., and had now sent her a form for the doctor to certify her fitness to continue working. The doctor then referred her to see the OT. During the initial assessment, Jane was observed to walk with an unsteady and shuffling gait. She was also observed to lose her balance when she turned her body to do simulated work tasks.

With consent from Jane, the OT initiated contact with her employer. Her employer revealed that they were concerned with Jane?s safety moving around the office with her unsteady gait since 2 years ago. Jane?s sister had been fetching her to and from her workplace and packed food for Jane to minimize her need to walk out of her office alone. The employer was worried that her balance might have worsened following the operation and long medical leave.

The OT arranged a worksite visit to assess Jane?s fitness to work.

During the visit, Jane was able to perform all the tasks with distant supervision. She took a longer than usual time to steady herself while lifting and transferring equipment from an industrial trolley to the table top. The OT recommended for the employer to purchase a trolley with higher platform to minimize the need for Jane to bend her knees when lifting the equipment.

This would also encourage better ergonomics for other trolley users. The OT also recommended for a buddy to provide Jane with any physical assistance during the first month of her RTW. The OT updated the doctor of the worksite visit assessment and recommendations and the doctor certified her fit to RTW. 1 month later, the OT contacted Jane, her sister and her employer to monitor her RTW progress. Jane continues to work at a slow but steady pace with support from her sister and work buddy.

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Vocational exploration, trainingandjobplacement Mary, a 27-year old lady, was diagnosed with depression during her second year of university studies in business administration.

1 year later, after a psychotic episode and admission to the mental health hospital, she dropped out from university. Mary?s psychiatric symptoms were well controlled with medication after 3 years and she was referred to OT for vocational rehabilitation.

Mary expressed she previously tried to work in various jobs such as administrative assistant, cashier, and promoter but could not sustain any job for more than 3 months. Mary had limited insight about her vocational interests, skills and limitations. After a few sessions of vocational counseling and exploration with the OT, Mary chose to look for administrative-related jobs as she felt most comfortable working in office environment and it matches her skill set.

However, she was anxious and lacked confidence to cope with regular full time jobs.

The OT referred her for vocational training in administration to build up her skills and confidence. Concurrently, the OT networked with potential employers to explore suitable job placement. One company shortlisted Mary for their administrative assistant (AA) position. The OT arranged for an interview between Mary and the office manager. Mary was offered the job. All parties agreed for Mary to start with 3 half days per week and gradually increase her working hours if she can cope. The office manager also assigned another staff to orientate and guide her at work initially.

After Mary started working, the OT visited her at the office. The OT educated the supervisor and the assigned staff on how to better communicate and support Mary at work, highlighted the importance of compliance to psychiatric treatment, and the need for her to take time off for medical appointments. Mary converted to full time AA with the company after 6 months.

The OT continues to follow up with her and her supervisor through phone calls and e-mails regularly.

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Principl es used by OT: Principle 2: RTW co-ordination Principle 3: Communication between employers and healthcare providers Principle 4: Offer of modified work Principle 6 : Supervisors trained in RTW planning

Lowcost work accommodationbenefitsall Principl es used by OT: Principle 2: RTW co-ordination Principle 3: Communication between employers and healthcare providers Principle 4: Offer of modified work Principle 5: RTW plan do not disadvantage co-workers

Helen, a 52-year old female, underwent a left external hemipelvectomy due to Chondrosarcoma. She was prescribed with left lower limb prosthesis. Her condition resulted in her having decreased activity tolerance, especially during standing activities. Prior to her illness, she worked as a machine operator in a manufacturing company for the past 20 years.

Helen was referred to the OT for vocational assessment and training to return to work. During the initial assessment, she reported that her employer had been in contact with her since her illness and was keen to have her back at work. At the vocational training center, she was prescribed with endurance activities to improve on her activity tolerance. The OT conducted community mobility trainings to improve her independence in taking public transport.

The OT suggested for a worksite visit to assess Helen?s ability to perform tasks as specified in Helen?s job description as a machine operator. During the worksite visit, Helen was observed to be able to perform all the tasks in standing with distant supervision. However, she reported that she was tired after 30 minutes of standing. The OT recommended for the employer to place a high chair for Helen to sit at her workstation to conserve energy. Working materials were relocated so that Helen was able to reach them easily from her seat. The OT advised for Helen to start with a 3-day work week to gradually build up activity tolerance. On her alternate off-work days, Helen continued training with the OT at the vocational training centre.

Helen has resumed her usual 5-day work after 2 months. She expressed that she is able to perform all the tasks with the accommodations made and she is also less tired now compared to 2 months ago. The employer informed the OT that the accommodations suggested for Helen had also been implemented for other co-workers as they also found them useful for their work.

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Workplacesupport iskey!

Nora, a 22-year old female, was diagnosed with Arthrogryposis multiplex congenital from birth. She had severe weakness in her upper and lower limbs and required help from her mother in most basic self-care tasks. She was independent in using a powered wheelchair for mobility. Despite her physical disabilities, Nora excelled in her polytechnic studies and her 6 months internship as an IT service coordinator.

Nora was job-matched to a call centre service agent job at a multinational company (MNC) by the Employment Support Specialist (ESS). The ESS referred her to the OT as her prospective employer was concerned with her ability to cope with the workplace challenges.

Principl es used by OT: Principle 3: Communication between employers and healthcare providers Principle 4: Offer of modified work Principle 5: RTW plan do not disadvantage co-workers

From a worksite visit with Nora to the MNC, some of the barriers she faced include needing assistance to :

Principle 6: Supervisors trained in RTW planning

1. Access her work station from the building entrance independently due to a heavy double swing door and an access control card reader along the route which was too high for her

Principle 7: RTW friendly workplace

2. Turn on/ off her computer, type on a usual keyboard and mouse and wear a headset 3. Fill up her water bottle and changing her diapers The OT, together with the assistive technology specialists, supervisors, co-workers and facilities personnel, explored various task and environmental modifications to address the barriers: 1. Replaced heavy swing door to automated sliding door and lowering position of access card reader 2. Replaced usual keyboard and mouse to mini keyboard and touchpad 3. Identified a work buddy to assist in turning on/ off computer, putting headset on for Nora and filling up of water bottle 4. Nora?s mother to assist in changing her diapers during lunch time

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Workplacesupport iskey!

The OT conducted an education session to Nora?s employers and co-workers before she started work and gave inputs to an emergency evacuation plan for persons with disabilities (i.e. recommended purchasing evacuation chairs).

Since then, a rotational work buddy system had been worked out among 5 co-workers to ensure sustainability of the assistance provided to Nora. Nora is happily sharing her expertise with the customers of MNC.

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Compet encies of OTs f acil it at ing RTW This set of competencies was developed for OTs to better understand the knowledge, performance skills, critical reasoning and attitudes required to enhance their ability to facilitate RTW for workers. As there are no established competencies for work rehabilitation OTs internationally, these are derived based on the experiences of OTs working in work rehabilitation services in Singapore.

Diagnost ic considerat ions

Demonstrates knowledge of: - the impact of primary and secondary conditions on work abilities - the possible aggravators of medical condition due to work activities

RTW model s

Demonstrates knowledge of peer-reviewed OT and RTW models: Some examples are: - OT Person-Environment-Occupation- Performance (PEOP) model - WHO International Classification of Functioning, Disability and Health (ICF) - Work Disability and Prevention Paradigm (WDP)

Eval uat ion

Demonstrates knowledge of relevant assessment tools and evidence, specific to evaluation in RTW: - Analysis of job demands - Matching of worker?s work abilities to work and workplace demands - Hierarchy of RTW outcomes in planning RTW goals Administers assessments related to RTW, consistently integrating clinical observations throughout the evaluation process: - Identify critical work demands of the worker's job - Assess and evaluate the functional work abilities and task performances of the worker - Assess and evaluate workplace environmental challenges Synthesises and interprets assessment data and clinical observations related to the worker, context, and performance: - Determine the match between worker?s functional abilities and job demands

- Identify potential barriers and facilitators to RTW and recommend strategies to overcome barriers - Develop realistic RTW goals and intervention plan to meet these goals

- Determine frequency of re-evaluation to monitor worker?s progress towards RTW goal

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Compet encies of OTs f acil it at ing RTW Int ervent ion

Demonstrates knowledge of relevant evidence, specific to intervention in RTW: - Best practices to facilitate RTW

- Strategies to overcome barriers to RTW Performs interventions related to RTW, while integrating impact of varying worker factors and context: - Select suitable therapeutic activities which improve RTW functions of workers at the clinic or workplace setting - Provide education and advice on job and workplace modifications

- Communicate issues related to worker's RTW abilities with healthcare professionals and employers Recognises immediate and long-term implications of psychosocial issues related to challenges in RTW: - Awareness of the immediate psychosocial implications on workers with challenges in RTW - Provide basic education to address these issues Regul at ions

Demonstrates knowledge of local laws and policies related to RTW and employability: Some examples: - Work Injury and Compensation Act (MOM)

- Workplace Safety and Health Act (MOM) Et hical Pract ice

Identifies ethical implications associated with delivery of RTW services and recommendations pertaining to RTW - Awareness of the ethical implications at the patient and organization level

Est abl ishes net works

Establishes and collaborates with referral sources and stakeholders to help the worker and relevant others to achieve outcomes that support health and participation at work - Collaborate with healthcare professionals and employers on RTW issues.

- Awareness of community resources that workers can be referred for vocational training, job placement, assistive technology and environmental modifications Advocat es f or change

Influences RTW services for workers through independent or collaborative educational or advocacy activities.

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Compet encies of OTs f acil it at ing RTW In addition, there are a range of non-technical competencies and attributes which were identified to be essential for RTW coordinators managing the RTW process between the workplace, healthcare professionals and other stakeholders (Pranksy et al, 2010).

Essential RTW coordinator competencies: - Active listening, especially the ability to elicit concerns about RTW from workers, employers, healthcare professionals and others - Ability to communicate well in person and in writing with various stakeholders involved in the RTW process - Ability to relate well to a wide range of personalities - Effective problem solving around common issues that arise in RTW - Respecting and maintain confidentiality - Effectively informing each involved party about the types of information that will be exchanged in the RTW process

These general personal characteristics or specific interpersonal skills would enhance the OTs?effectiveness when providing RTW services.

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REFERENCES -

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Australasian Faculty of Occupational and Environmental Medicine (2011). Position Statement: Realising the Health Benefits of Work, Australasian Faculty of Occupational & Environmental Medicine, Sydney. Retrieved from https:/ / www.racp.edu.au/ docs/ default-source/ default-document-library/ afoem-pos-aus-nz-con-health-benefits-work-pack.pdf?sfvrsn=0 Canadian Association of Occupational Therapists (CAOT) Position Statement: Return-to-Work and Occupational Therapy (2009). Retrieved from https:/ / www.caot.ca/ pdfs/ positionstate/ Return% 20to% 20Work.pdf Franche R-L, Cullen K, Clarke J, Irvin E, Sinclair S, and Frank J. (2005) Workplace-based return-to-work interventions: A systematic review of the quantitative literature.

Journal of Occupational Rehabilitation, 15(4): 607-631 General summary of systematic review: www.iwh.on.ca/ sys-reviews/ workplace-based-rtw-interventions Institute for Work & Health (2007; rev 2014). Seven "Principles" of Successful Return to Work. Retrieved from http:/ / www.iwh.on.ca/ seven-principles-for-rtw Institute for Work & Health, Ontario Society of OTs, College of OTs of Ontario (2008).

Working Together: Successful Strategies for Return To Work. Retrieved from http:/ / www.iwh.on.ca/ working-together MacEachen E, Clarke J, Franche R-L, Irvin E. (2006) The process of return to work after injury: findings of a systematic review of qualitative studies. Scandinavian Journal of Work, Environmental & Health, 32(4): 257-269 Pransky G., Shaw W., Loisel P, Hong Q.N., and Desorcy B. (2010) Development and Validation of Competencies for Return to Work Coordinators. Journal of Occupational Rehabilitation, 20(1): 41-48 WFOT (2012) Position statement on Vocational Rehabilitation CM2012. Retrieved from http:/ / www.wfot.org/ ResourceCentre.aspx

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Notes

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Notes

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7 Principl es f or Successf ul Ret urn t o Work: A Guide f or Occupat ional Therapist s in Singapore First publ ished January 2016

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