Nurses Journal Scan, November 2006

Laurie Scudder, MS, NP; Marilyn W. Edmunds, PhD, NP


December 01, 2006

Journal for Nurse Practitioners

Journal Scan is the clinician's guide to the latest clinical and research findings in The Journal for Nurse Practitioners, The Nurse Practitioner: The American Journal of Primary Care, The Journal of the American Academy of Nurse Practitioners, Journal of Pediatric Primary Care, and selected other scholarly journals having articles of value to advanced practice nurses and other clinicians. Links to article abstracts are provided when they are available. Links to related articles on Medscape are available for readers seeking information that is more detailed.

Getting Your Patient Back to Work: Writing Return-to-Work Restrictions After Illness or Injury

Getting the patient back to work after an illness or injury is a major goal for clinicians. How to write back-to-work restrictions and instructions so that they are both understood and implemented by both the employee and employer is important for patient safety. It is also often a complicated process. The healthcare provider has the responsibility to determine when and under what restrictions an employee should return to work.

Recovery from injury and illness is influenced by many conditions: pre-existing medical conditions, workers' compensation issues, surgical or medical complications, and emotional or family stress associated with recovery from illness and injury.

Employees should be encouraged to return to work as soon as they are able. Research has suggested that the longer the recovery time, the less the chance that individuals will return to work. Effective return-to-work programs can decrease medical costs, improve outcomes, and decrease the recovery time. Some individuals may develop a "disability mindset" as soon as 2 weeks after an injury, so a plan for return to work needs to be in place as soon as it is feasible and begins with the first employee visit.

Who gets injured? The top 10 jobs that are responsible for 30% of job injuries are topped by truck drivers and then followed by laborers, nurses aides, construction laborers, janitors and cleaners, assemblers, carpenters, cooks, registered nurses, and stock handlers or baggers. Men have 65% of the injuries, people between the ages and 20 and 44 years have more injuries, and 42% of injuries occur within the first year of work. It is often this later group of individuals who recover and then move on to another job to avoid reinjury.

The standard process followed in getting employees back to work involves 4 distinct tasks: gathering data, assessing expectations, performing the physical examination, and writing restrictions.

Gathering data helps establish the diagnosis and clarify any problems that might arise. It will also rule out any serious medical conditions. In order to determine a back-to-work plan, the clinician should collect a description of the injury, the past and current status of symptoms, medications being taken, allergies, and work history. A visit to the workplace to meet with safety and management personnel is important, particularly if the work site is associated with many injuries or they have requested your input about return-to-work issues.

Part of talking with the patient should include assessing their expectations for recovery and return to work. Assessing the patient's perceived ability to do the work involved, as well as psychological and financial issues, should be explored. The patient who is able to return quickly to work is likely to have more financial security, positive self-image, and reinforcement of other efforts for recovery. Injury or illness may surface or aggravate other problems such as substance abuse, somatoform or personality disorders, depression, or anxiety. Personnel issues with others at work may also influence the desire of the patient to return to work. Discussing and dealing with these issues are important if the patient is going to be willing to cooperate in going back to work.

The physical examination is important in determining the physical fitness of the individual and their ability to do the specific work of their job. In addition to the relevant musculoskeletal, neurologic, cardiac, or respiratory examinations, mood, pain behaviors, gait, vital signs, and preinjury limitations all impact current ability to work.

Work restrictions should then be crafted in a way that is clear and meaningful. Functional activity requires comparing job demands and the patient's abilities. This is a step-by-step process facilitated by a treatment plan to promote recovery. The conditions under which the employee can work need to be stated in a way that management can understand and apply. Based on the physical evaluation, functional limitations should be based on an assessment of the stamina, strength, and cognitive function that will affect the patient's ability to do the job. This will involve looking at what the patient must physically and cognitively do on the job and writing specific restrictions that the patient must face as they initially return to work. The clinician may make a table indicating what physical activity is required for a job using the neck, shoulders, elbow, back, or knees and then writing any restrictions the patient may have in those areas. For example, the patient may be unable to squat or kneel, climb stairs, or stand for long periods of time. The employer may be required to offer some accommodation or modification of the job for the employee to return to work. This requires that all levels of management support the employee in their gradual resumption of work activities.

Sometimes it is required that the work environment be modified so that a patient could sit or avoid turning in a particular direction. Based upon the clinician's recommendations, the patient may also return to work for reduced hours. The progress in returning to work should be monitored frequently and consistently and the restrictions gradually removed as the patient improves.

Editor's Note

This article provides several case studies so clinicians can test their understanding of how to devise back-to-work restrictions. The overall principle in getting the person back to doing even some work as soon as possible underlies the handling of most employee cases.


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