Appendix 4.I – MSD (back pain) vignette

Situation

Adele, a hard-working nurse, has been working for years in a hospital in the emergency department where she feels recognized and useful. At 58, she has always enjoyed working with the public and has shown initiative and autonomy. Her long days and being overweight led her to develop back pain. Then one morning, while lifting a patient into bed, she felt a sharp pain in her lower back.

 

She communicates the information to her immediate supervisor. He gives her a temporary assignment form (specific form of light work, unique to Quebec) duly completed, including the description of the tasks available to her. She consults her attending physician who approves the performance of administrative work in a sitting position as proposed by her immediate supervisor.

 

A week later, Adele noticed that the pain was getting worse and went back to see her doctor. He signs a four-week work stoppage form for her. In addition, the doctor prescribed rehabilitation at a clinic combining physiotherapy and occupational therapy.

Actions/actors by RTW stages

1. Time off and recovery period

  • Adele informs the human resources person by phone of her absence and agrees to be contacted by her immediate supervisor, if necessary. She also contacts the union representative.
  • She made an appointment at her local physiotherapy and occupational therapy clinic, but ultimately did not attend her first and subsequent appointments. According to her, “the pain will pass”.

2. Initial communication with the worker by the workplace

  • His immediate supervisor calls him and inquires about his condition.
  • He avoids questioning her about her rehabilitation and her return to work. He favours social support and reassures her that she can return to her usual job.

3. Assessment of the worker (work capacity) and his/her work (job demands)

  • No assessment of Adele’s work capacity or her workstation was conducted.
  • Although an occupational injury prevention policy is available at the hospital where Adele works, it is not applied systematically (concept of integrated prevention, Appendix 4.O).

4. Development of the RTW plan with workplace accommodations

  • Implementation of the temporary assignment measure by the immediate supervisor: administrative work performed in a sitting position for three days a week for a period of three months.

5. Return to work (day 1) & 6. Follow-up of the RTW (in the following weeks)

  • On the day of the return to work, the immediate supervisor warmly welcomes Adele.
  • In the days that followed, he noticed that Adele needed to be monitored to ensure that she did not exceed the limits set by her doctor, as “she was always overdoing it”. He made sure she took her breaks and lunch at the designated time and duration. He also allows her to manage her breaks herself, according to her needs.
  • At the end of the temporary assignment, Adele was discouraged: her pain persisted, the task she was doing was not motivating, and she missed her colleagues in the emergency room.

 

Learning Elements

Adele’s case management strengths:

  • Temporary assignment, which allows the worker to reduce the work requirement in hours and intensity, even before considering full recovery. It also allows the worker to maintain positive contact with the workplace.
  • The immediate supervisor’s involvement in the RTW process: he provides Adele with a completed temporary assignment form and monitors her “engaged and enthusiastic” work behavior. This behavior may compromise the fit between her actual current abilities and the demands of the job.
  • Referral by the treating physician to a physical and occupational therapy clinic (multidisciplinary/interdisciplinary interventions), which promotes collaborative action and targets the following:
    • The physiotherapist intervenes, among other things, in prevention and health promotion, and in the evaluation and treatment of MSD;
    • The occupational therapist intervenes, among other things, in the realization of activities of daily living, the evaluation of work requirements and the physical preparation of the worker during a RTW.
    • Rehabilitation in a multidisciplinary or interdisciplinary context also helps the worker recognize the signs of relapse and strategies to avoid it (psychotherapist, occupational therapist).

Weaknesses in Adele’s case management:

  • Failure of the temporary assignment proposal:
    • The prolonged sitting position may have exacerbated Adele’s pain. The immediate supervisor was probably unaware that this position was deleterious in a case of back pain. It would have been necessary for the treating physician to be sensitive to this information and to prescribe alternating postures (standing, semi-seated, and sitting) throughout the day.
    • In developing the RTW plan, Adele’s perspective was not considered. The immediate supervisor based his decision more on her functional limitations than on Adele’s abilities/strengths or preferences.
    • As a result, the tasks she was assigned were probably not appropriate as a RTW measure: they did not make use of Adele’s professional skills and unique qualities. In addition, she was distanced from her co-workers in the emergency department.
  • The lack of concerted action within the organization. A meeting with the immediate supervisor and the union representative with Adele present would have allowed for a more thorough discussion of the options available to her. In addition, the presence of the hospital preventionist or an occupational therapist would have been of significant help.
  • The absence of an integrated work injury prevention policy in Adele’s workplace. The introduction of such a policy would allow Adele’s incident to be reported to the OHS committee (in this case the preventionist) so that the task of moving patients could be reviewed. In addition, training on safe patient movement techniques could be planned. The changes made, if any, would help prevent this type of incident for the benefit of all nursing staff as well as the organization’s beneficiary attendants.

Tool for Quebec employers

  • Although temporary assignment is a favourable measure for healthy and sustainable RTW, actors or workplaces are often ill-equipped to plan and implement it. A tool is now available to help you operationalize good RTW practices and involve the worker more systematically in the process. It is the tool: Soutien à la Pratique de l’Assignation Temporaire (Support for the Practice of Temporary Assignment) intended for Quebec employers (Lemelin, Durand and Sultan-Taieb, 2017).
  • When temporary assignment is done optimally, there are many benefits for both the organization and the worker.