Rehabilitation in the Workplace
- Supporting self-management Stephen Bevan
The Work Foundation
Lancaster University, UK
© The Work Foundation, 2015
Health & Work Agenda
• Economic story about workforce health and lost
productive capacity
• The ‘burden of disease’ impact on quality of life &
independent living
• Raising rehabilitation up the policy ‘priority list’ as the
workforce ages
• Embedding ‘Work’ as a clinical outcome and a treatment
goal (clinical guidelines; care plans)
• Focusing on Job Retention, RTW & ‘Good Jobs’
• Taking a biopsychosocial approach – (comorbidity)
• Incentivising employers to invest in prevention & early
intervention
• Empowering people living with MSK to disclose & selfmanage in both clinical & workplace settings
Days Lost to Strike Action (UK)
The ‘Winter of
Discontent’ 1978-79
29
Million
Days Lost to MSK (UK)
ONS Data from 2013
31
Million
©The Work Foundation
MSK and Disability
• Ranking of major causes of death and disability (%
DALYs)
• Cardiovascular and circulatory diseases 11.8%
• All neoplasms 7.6%
• Mental and behavioural disorders 7.4%
• Musculoskeletal disorders 6.8%
• Yet MSK not considered a priority noncommunicable disease – Low mortality but High
morbidity
LTCs in the UK Working Age Population - 2030
Cancer
800k
Diabetes
1.3m
Mental
Health 7m
Mental Health
CHD
MSDs
7m
Stroke
COPD
Asthma
MSDs
Cancer
Diabetes
Comorbidity
N=21.6m
Asthma
2.6m
COPD
1.6m
Source: Vaughan-Jones & Barham, 2009
CHD
1m
Stroke
367k
Global ‘Fit for Work’ Study
McGee, Bevan & Quadrello, 2009
Why ‘Self-management’?
• Strong clinical emphasis for people with
chronic but manageable conditions
• Previous TWF study found that individuals
with MSDs who played an active role in selfmanaging their condition were less worried
about retaining their job
• Less emphasis in workplace settings or in
vocational rehabilitation
• Natural terrain for OT expertise
http://www.theworkfoundation.com/Reports/370/Selfmanagement-of-chronic-musculoskeletal-disorders-and-employment
Definition
“Self-management refers to the individual’s ability to
manage the symptoms, treatment, physical and
psychological consequences and life style changes
inherent in living with a chronic condition. Efficacious
self-management encompasses ability to monitor one’s
condition and to affect the cognitive, behavioural and
emotional responses necessary to maintain a
satisfactory quality of life. Thus, a dynamic and
continuous process of self-regulation is established.”
Barlow et al, 2002:178
Benefits
• appropriate exercise and diet
• mental strategies to cope with pain
• knowledge and ability to advocate for changes in
medication
• strategies to cope with fatigue
• ability to set and achieve goals (solutionorientation; internal locus of control*)
• maintaining a positive outlook
• cultivating discipline and motivation
*Chang et al, 2013
Four Stages of Self-management
•
•
•
•
Seeking effective self-management strategies.
Considering costs and benefits.
Creating routines and plans of action.
Negotiating self-management that fits one’s
life.
(Audulv et al., 2012:331)
Self-Advocacy & Negotiation
• Fear about the consequences of disclosure (boss, co-
workers, pay, careers, task allocation, training opportunities,
redundancy)
• Satisfied with ‘any’ job? Skill utilisation & mental
health
• Self-confidence & self-efficacy
• ‘Special treatment’, ‘being a burden’ & ‘standing out’
• Using workplace adjustments to ‘co-produce’ mutually
advantageous solutions – big role for OTs?
• Worker-led but supported adjustments are best
• ‘Best adjustment is a great line manager’
Lorig’s Stanford Model (Arthritis)
• Techniques to deal with problems such as pain, fatigue,
frustration and isolation.
• Appropriate exercise for maintaining and improving
strength, flexibility, and endurance.
• Appropriate use of medications.
• Communicating effectively with family, friends, and
health professionals.
• Healthy eating.
• Making informed treatment decisions.
• Disease related problem solving.
• Getting a good night's sleep.
http://patienteducation.stanford.edu/programs/asmp.html
Ory et al, 2013
Participant Testimony
Adjusting the ‘Rhythm’ of Work
“As far as helping me, perhaps being a bit more
lenient with my hours, that would have really
helped. Because I kept killing myself to get up early
so that I could be in work for half eight or nine
o'clock. Potentially a flexi time of sorts would really
help someone with rheumatoid arthritis. Because
classically the symptoms are at their worst, in the
mornings. First thing in the morning you can.. it’s
like a diesel engine, it takes a while to warm up. I
am not a petrol engine, I am diesel.”
Disclosure & Openness
“I used to wear a wrist splint on the days that I
felt particularly bad. Because even if it wasn’t
my wrist, I just felt it would be a good way for
people to know that everything wasn’t ok,
without having to tell people.”
Job or Career?
“I decided not to go for the head of the area
[post] but to take a role that would allow me to
put myself and my condition first. It’s frustrating
that is where I am stuck at career wise ....there’s
no chance of career progression. It can be quite
frustrating .........doing the same thing knowing
I’m not going to get anywhere.”
Self-Employment?
“I made the big decision that I just couldn’t do a
normal job and work for a normal company. The
only way I could stay in work was to work for
myself, where I was more in control of things.”
Reflections
• Over 60% of people with MSK are primary
income earner in their household – anxiety about
job loss can be serious, but so can disclosure &
‘under-employment’
• We can’t just ‘do’ workplace adjustments ‘to’
people – they have both knowledge about & a
stake in a good outcome for them & their boss
• Supported self-management, led by the worker,
frequently monitored, supported and updated
with OT input can improve confidence and
support recovery & productivity
Is any job a ‘Good Job’?
‘Good Jobs’: A Message From HILDA
• Household, Income and Labour Dynamics in Australia
(HILDA) Survey
• Analysis (Butterworth et al, 2011) of seven waves of
data from 7,155 respondents of working age (44,019
observations) from a national household panel survey.
• Longitudinal regression models evaluated the
concurrent and prospective association between
employment circumstances (unemployment and
employment in jobs varying in psychosocial job quality)
and mental health, assessed by the MHI-5
Psychosocial Job Quality (1)
Job demands
&
complexity
1. My job is more stressful than I ever imagined
7. My job is complex and difficult
8. My job requires learning new skills
9. I use my skills in current job
Job control
10. I have freedom to decide how I do work
11. I have a lot of say about what happens
12. I have freedom to decide when I do work
Job security
Effortreward
fairness
4. I have a secure future in my job
5. Company I work for will be in business in 5yrs
6. I worry about the future of my job
3. I get paid fairly for the things I do in my job
Source: Butterworth et al, 2011
Psychosocial Job Quality (2)
“As hypothesised, we found that those respondents
who were unemployed had significantly poorer
mental health than those who were employed.
However, the mental health of those who were
unemployed was comparable or more often superior
to those in jobs of the poorest psychosocial quality.”
Source: Butterworth et al, 2011
Challenges for OTs
• The future is multi-disciplinary
• Too modest for your own good?
• "hey, the therapist didn't even do anything - I
just did it all myself!“
• A voice at national level debate AND in
business
• ‘Activities of Daily Living’ need to include work
– especially ‘Good Work’
Resources
Arthritis Care
http://www.arthritiscare.org.uk/LivingwithArthritis/Selfmanagement/Waystoself-manage
Health Foundation
http://www.health.org.uk/news-and-events/press/new-onlineresource-launched-to-support-self-management/
MS Society
http://www.mssociety.org.uk/ms-resources/working-yetworried-toolkit
www.theworkfoundation.com
sbevan@theworkfoundation.com
@StephenBevan
References & Disclosure
Audulv, Å., Asplund, K., and Norbergh, K. G, The integration of chronic illness self-management. Qualitative
health research, 22(3), 332-345, 2012.
Bevan S https://theconversation.com/any-job-isnt-necessarily-a-good-job-for-people-out-of-work-35217
Butterworth, P., Leach, L. S., Strazdins, L., Olesen, S. C., Rodgers, B. et al. (2011). The psychosocial quality of
work determines whether employment has benefits for mental health: results from a longitudinal national
household panel survey. Occupational & Environmental Medicine, first published online on March 14, 2011,
doi:10.1136/ oem.2010.059030
Chang, N, Chiou, C, Wang, C, Su, M and Lo, S Correlation Study Between Health Locus of Control and Dyspnea
Self-Management Strategies in Patients With Chronic Obstructive Pulmonary Disease, Journal of Nursing &
Healthcare Research, Vol. 9 Issue 1, p42, 2013.
Ory, M, Ahn, S, Jiang, L, Smith, Matthew L, Ritter, P, Whitelaw, N and Lorig, K, Successes of a National Study of
the Chronic Disease Self-Management Program: Meeting the Triple Aim of Health Care Reform, Medical Care,
51(11), pp 992-998, 2013.
Summers K, Bajorek Z and Bevan S, Self-management of chronic musculoskeletal disorders and employment,
London: The Work Foundation, 2014.
Disclosure
The Work Foundation is a not-for-profit organisation. It receives a grant from Abbvie to fund the Fit for Work
initiative in Europe and in other parts of the world. The Work Foundation retains editorial control over all Fit for
Work outputs.