Reporting Patients' Work Abilities: How the Use of Standardised Work Assessments Improved Clinical Practice in Fife

Introduction

The accurate reporting of work abilities aims to empower people with disabilities to find, return to or remain in work. It could also enable employers to make better decisions about an employee’s fitness to work and how to make reasonable adjustments to the workplace, thereby helping them to fulfil the requirements and the ethos of the Disability Discrimination Act 1995 (DDA).

Mountain (2001) defined work as ‘paid employment’. Sokka et al (1999) defined work disability as permanent disability before the age of 65 years, at least partly due to the presenting condition. Stratton et al (1996) defined work disability as the inability to perform work owing to physical, mental or other health conditions. Hagberg et al (1995) suggested that the ‘mislabelling of patients and mismanagement at the early state of presentation may well have an effect on the subsequent course of the disorder’. It is therefore reasonable to suggest that timely and accurate reporting on work abilities is beneficial. Unfitness due to an acute illness is self-evident, but other cases are not straightforward and can have serious financial and legal implications for those involved (Davies 1996). But what standards are there to measure fitness or unfitness to work? How do employers know if they are being fair or reasonable?

In March 1997, audit funding was granted by Fife Health Care NHS Trust (now Fife Primary Care NHS Division) to produce a means of assessment that could assist employers to meet their obligations under the DDA. The lead occupational health consultant and the rehabilitation medicine consultant set up a team consisting of themselves, the head occupational therapist, the research coordinator and a senior I occupational therapist. The occupational therapists did not use a standardised work assessment (SWA), nor did they adhere to a recognised or agreed standard of practice in work assessment or reporting. The occupational therapists did make recommendations regarding work ability, but only in broad and mainly nonspecific terms. An audit of reports and a collation of anecdotal evidence were felt to be the best ways to evaluate the effects of using a SWA on reporting work abilities.

Rationale for choosing the VCWS and the WRI
The Valpar Component Work Samples (VCWS) (Valpar 1993) are physical devices which, when completed satisfactorily, demonstrate that a person can probably perform actual jobs that make similar demands on him or her. In 1997, the trust staff did not have access to the internet, so the main contact used for advice was the College of Occupational Therapists. It recommended the VCWS as the most widely used work assessment tool in the United States and was unaware of an equally well used tool in the United Kingdom. The occupational health consultant and the head occupational therapist visited Queen Margaret University College, Edinburgh, to view and discuss the VCWS. This visit confirmed the team’s decision to purchase nine VCWS and supplementary materials (Table 1).

Table 1. VCWS (Valpar 1993) and supplementary materials

1. Numerical sorting, VCWS 3
2. Problem solving, VCWS 6
3. Simulated assembly, VCWS 8
4. Whole body range of motion, VCWS 9
5. Physical capacities/mobility screening, VCWS 201
6. Mechanical assembly, VCWS 202
7. Mechanical reasoning, VCWS 203
8. Fine finger dexterity, VCWS 204
9. Independent perceptual screening, VCWS 205
10. The computerised assessment COMPASS LITE, which rates a person’s general educational development (Valpar 1993)
11. The Revised Handbook for Analysing Jobs (US Department of Labor, Employment and Training Administration 1991a)
12. Classification of Jobs (Field and Timothy 1992)
13. Dictionary of Occupational Titles (US Department of Labor, Employment and Training Administration 1991b)

The Worker Role Interview (WRI) (Velozo et al 1990) is a semi-structured interview developed for use in work rehabilitation in combination with a physical and/or work capacity assessment. It considers the psychosocial and environmental variables that may have an effect on the ability of the individual to return to work. One of the therapists was aware of the WRI and introduced it to the team for consideration. The team felt that the WRI would balance the VCWS and that together they would present a holistic work assessment package.

Other assessments, including a Work Site Analysis developed by the authors, were conducted as appropriate.

Choosing a work assessment standard
A literature search for a standard for reporting work abilities was unsuccessful. The core elements of the VCWS and the WRI (Valpar 1993, Velozo et al 1990) were therefore combined to produce the following standard:

Fife Work Assessment Standard (FWAS)
Work assessment reports should describe the demonstrated skills, abilities and educational levels of the disabled person:
(a) compared with the same requirements of their current job
and
(b) the ability or potential for employment.

An audit tool was derived from the FWAS, the VCWS (Valpar 1993) and the WRI (Velozo et al 1990), and consisted of a yes/no checklist against 12 items reported in the case notes (Table 2).

Table 2. Fife Work Assessment Standard checklist*
Is there evidence in the person’s report of:    Yes   No

Job description................................................	.....
General educational development................	.....
Skills..................................................................	.....
Physical demands...........................................	.....
Environmental conditions.............................	.....
Temperaments.................................................	.....
Personal causation.........................................	.....
Values...............................................................	.....
Interests...........................................................	.....
Roles..................................................................	.....
Habits................................................................	.....
Recommendations..........................................	.....

*Derived from the FWAS, the VCWS (Valpar 1993) and the WRI (Velozo et al 1990).

Method

The reports on consecutive patients who had been referred to occupational therapy for a work assessment over a 2-year period were reviewed (Table 3). The reports were divided into two groups: group 1, SWA not carried out (retrospective, before acquisiton of SWAs), and group 2, SWA carried out. The reports were audited by an occupational therapist not known to the patients. All the patients gave informed consent and a copy of the work assessment report was offered to them. Ethical approval was granted by the Fife Research Ethics Committee, Fife Health Board.

Results

Eighty-three reports were audited. Forty-two and 41 reports were reviewed in groups 1 and 2 respectively.

Meeting the standard
Group 2 reports referred to eight out of the 12 areas more often than those in group 1 (Fig. 1).

Job description: group 2 = 27% increase
Although there was an increase in recording job descriptions in group 2 compared with that in group 1, half of the group 2 reports did not refer to them. The reasons for this were that some patients did not have a job description and some job descriptions were so vague as not to resemble what the patients currently did. It was also noted that, due to rationalisation, some jobs, particularly skilled trades, had become hybrids and were difficult to define.

Educational development: group 2 = 63% increase
The improvement in reporting educational development in group 2 may be attributable to the COMPASS LITE (Valpar 1993) screening assessment.

Skills: group 2 = 58% increase
The reason for the improvement in group 2 could have been the fact that the VCWS are criterion based and measure current skills whereas the norm-based tools commonly used by the occupational therapists measure impairment.

Physical demands: group 2 = 43% increase
The improvement in reporting the physical demands in group 2 may be because the VCWS give a clear definition of the physical requirements for each of the tests. The occupational therapists were able to choose the appropriate test and to make specific recommendations about the patient’s physical abilities.

Table 3. Demographic information about the two groups

	Group 1 (n = 42)	Group 2 (n = 41)
Age
Range	16-62	18-53
Mean	37.5	34.1
Gender
Male	27	21
Female	15	20
Employment status
At work	8	9
Employed on sick leave	26	21
Unemployed with experience	5	4
Unemployed with no experience	3	7
Diagnostic group
Musculoskeletal (eg body and joint injuries,rheumatoid arthritis)	11	12
Neurological (eg stroke, traumatic brain injury, multiple sclerosis)	31	27
Other (eg depression)	0	2
Referral source
Occupational health (80% musculoskeletal)	0	13
Fife Rehabilitation Service (neurological)	32	25
Fife Rheumatic Diseases Unit	10	2
Other	0	1
Category of occupation
1. Professional, technical and managerial occupations	7	6
2. Clerical and sales occupations	7	8
3. Service occupations	7	5
4. Agricultural, fishery, forestry and related occupations	6	1
5. Processing occupations	4	7
6. Structural work	4	6
7. Unemployed, unskilled	2	6
8. Unemployed, no previous work experience	5	2

No significant statistical demographic differences were found between the two groups.

Environmental considerations: group 2 = 8% increase
The reporting of environmental factors was low in both groups. The reason for this was not fully understood. It could be that the occupational therapists reported environmental factors only where there was a problem or it could be that these were missed out. Either way, it was highlighted that the reporting style was not sensitive enough to make this clear.

Temperaments: group 2 = 38% increase
Temperaments refer to personality traits, such as dealing with people, performing repetitive work and being effective under stress. They indicate the degree to which a worker can adapt to different situations. The 38% improvement in meeting this standard in group 2 reports was probably due to temperaments being a component of the VCWS.

Personal causation: group 2 = 12% increase
The increase in reporting personal causation in group 2 may be because it is referred to in the WRI. Personal causation seeks information from patients about their abilities and limitations, their expectations of success and their willingness to take responsibility.

Values: group 2 = 18% decrease
The reduction in reporting values in the group 2 reports was surprising. The reasons for this are difficult to suggest. It could be that the occupational therapists chose not to refer to values in some reports if they thought that it did not have an impact on the patient’s work abilities.

Interests, roles and habits
The differences were negligible in each of these three subsets. They all, however, indicated a lower level of standard being met in the group 2 reports and the reasons for this may again be due to the factors mentioned in ‘Values’.

Recommendations: group 2 = 32% increase
The improvement in reporting recommendations is perhaps the most important factor in that every patient in group 2 had recommendations regarding his or her work ability.

Discussion

The anecdotal evidence from the patients suggested that even if the recommendations did not propose a return to paid employment, they were satisfied that a thorough assessment had taken place. Furthermore, the patients also reported their satisfaction that alternatives were suggested, which included alternative work, further education, voluntary work and an increased uptake of hobbies and leisure pursuits. These recommendations were acknowledged to play an important role in helping to minimise the harmful effects of the loss of paid employment.

The anecdotal evidence from the occupational health consultants was very positive in that they found the detail of the reports particularly useful in ascertaining employees’ work abilities. This could be because the reports defined terms such as light, heavy and sedentary work, and referred to the disabled employees’ demonstrated skills rather than their presumed skills. Another effect was an increase in the referrals for work assessments by medical staff in rehabilitation and rheumatology services.

While the authors feel that their practice has improved, they acknowledge a number of limitations in this study. First, the protocol and formation of the standard were established after the start of the project because the funding was granted quickly and was time limited. Another factor that may have influenced the better results in group 2 was the increasing skill level of the occupational therapists in using the SWAs as the project progressed.

Cost-effectiveness was not analysed and this, along with a focus on the longer-term outcomes of vocational intervention, requires further investigation.

Conclusion

Not surprisingly, this audit raised questions as well as answering some. Velozo (1993, p208) stated: ‘The area of work evaluation is fertile ground for future research and development by occupational therapists.’ The authors hope to use these findings to answer some of these questions through further development, audit and research in this important area. They also agree with Frank and Chamberlain’s (2001, p1204) suggestion that ‘every district should have a highly trained therapist specialising in vocational rehabilitation’ and they consider that occupational therapists should be appointed to occupational health services.

Acknowledgements
The authors would like to thank Fife Primary Care NHS Division for funding the project. They would also like to thank A Carver, Janice Duke, Dr M Kettle, I McMillan, Dr C Pugh and Dr R L Sloan for their support.

References
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Authors
Margaret Jackson, BScOT, Head of Occupational Therapy, Physical Disabilities, Fife
Primary Care NHS Division, Sir George Sharp Unit, Cameron Hospital, Windygates,
Fife KY8 5RR. Email: MargaretJackson@fife-pct.scot.nhs.uk

Janet Harkess, BScOT, Clinical Specialist Occupational Therapist, Rheumatology.

John Ellis, BScOT, Senior Occupational Therapist, Occupational Health and Safety
Advisory Service.

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