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Graduated Return to Work and Activity

Graduated Programmes:

  • Are an effective tool for workers to gradually build up both the type of duties performed and the hours worked

  • Have three components - starting point, gradient, and duration


Closely related sections: Developing an Action Plan, Developing a Stay at Work Plan, Developing a Return to Work PlanResilience


WHY Graduated Programmes


FACT: People can be helped to stay at, and return to, work. The pivotal thing is to provide a supportive workplace. To achieve the best work outcomes there are seven key principles to follow.

A key tool is the Graduated Return to Work Programme. These are sometimes abbreviated as 'GRTW' programmes and also known as Graded Return to Work Programmes. It's the same thing.

A graduated early return to work is a useful rehabilitation tool to enhance a worker's recovery. It enables injured workers to return safely to work before they have recovered fully. They can do modified or alternative work on a temporary basis and gradually resume their original job. The benefit is not only from the managed activity, but also at a psychosocial level, resulting in a faster and more durable recovery.


WHO Graduated Programmes Are For


Graduated programmes are appropriate for those who can return to work gradually, within a realistic timeframe, and can complete the programme without setbacks.


This means they will suit ill or injured workers who are fit for selected/suitable duties. That is, they have a capacity to complete some type of work, but can’t return immediately to their full pre-illness/injury job.


Workers Suitable for Graduated Programmes:


Include when worker:

  • is able to return to work on suitable selected duties and/or hours

  • is unable to work at all - usually only applicable for the immediate acute period of common health problems

  • has advice available about their current functional ability - what he or she can do

  • has line manager who understands the tasks and requirements of the job and whatever modified or alternative duties can be made available


Exclude when worker:

  • is able to continue normal work hours and duties


WHO is Involved

Line managers and senior management should be aware that graduated return to work programmes help workers return to work sooner, reduce length of absence durations, and result in lower costs. For this reason, line managers should be willing to accommodate workers with temporary restrictions.

Workers are often unfamiliar with the benefits of early rehabilitation and the concepts of graduated return to work. This might make it difficult and time consuming unless they get access to the necessary knowledge about common health problems. Always ensure this happens!

Role for Others: In most cases common sense will dictate how much the worker does and how often. However, it may be appropriate to ask a professional case manager, an occupational health nurse, or an occupational therapist to devise the programme. If several parties are involved, a case conference may be needed to ensure everyone agrees to the plan and knows what is happening and when. As always, it is important to communicate effectively and keep all relevant parties informed to help ease the worker's transition back to the workplace.


EFFECTIVE Graduated Programmes


The goal is simple - gradually build up both the type of duties performed and the hours worked until the person achieves the goal of pre-injury/illness full-time work, wherever possible.


Effective graduated programmes:

  • Are based on functional capacity, what the person can and will do

  • Are time bound, with a beginning and an end

  • Are goal oriented

  • Have clear accountabilities, defining who is responsible for what and when

  • Engage all key players

  • Are monitored, and revised when necessary


The aim is always to build duties gradually, within a realistic timeframe, and completing the programme without setbacks.


Practical Tip: While it is always important to promote activity and work, it is also important to ensure there is the best chance of success. The experience of failure in a stay at work, or return to work, programme can have a negative impact on all involved - with loss of confidence, and even worse an unwillingness to try again. This makes it very important to learn how to use graduated programmes effectively.


Graduated programmes are like 'working to a quota'. The idea behind this is summed up in the phrase ‘do no more on a good day, and no less on a bad day’. The approach is aimed at reducing the learning relationship between symptoms (e.g. pain, fatigue, feeling stressed) and activity and work. This replaces the unsatisfactory symptom-contingent activity with time-contingent activity - this means it prevents symptoms of common health problems taking over your life and ruling everything you do!


The working to quota approach is used to disrupt an erroneous relationship between activity and symptoms levels from being learned. The purpose is to ensure a pre-set level of activity/work occurs irrespective of symptom intensity experienced, and then to gradually increase this over time as the body ‘habituates’ to the experience of the symptom, and recovery occurs. This means graduated programmes are a very useful way to build or rebuild tolerance and resilience.


HOW to Use Graduated Programmes

There are three components to a graduated programme, and you need to learn how to do each of these:

  1. Starting Point - manageable for the worker and guaranteed of success

  2. Gradient - how fast the type of duties and number of hours worked will be increased

  3. Duration - the period of time from start to finish

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Choosing a Starting Point for the Graduated Programme


The goal is to ensure the worker can cope with the initial workload and type of job tasks. This provides the springboard for a gradual and steady increase, while minimising the likelihood of setbacks.


Establishing the initial quota is a question of judgement, not formulaic. However, a practical approach is to list some key activities as tasks with the duration that they are performed. Work with your client to place these into a hierarchy from ‘least problematic/concerning’ to ‘most problematic/concerning’. This allows you to develop a working baseline, based on a starting point of what the client feels they ‘can do on a bad day’. This is used as your guide, not the client’s. If necessary, start the client even slightly below this level. It is imperative that the client experiences success from the outset, and is not set up to fail.


Practical Tip: Try and work out what the individual is capable of, or has been doing, then start at somewhere between 50% and 80% of that level.


Setting the Gradient for the Graduated Programme

The next step is to establish a gradient, so that small increments can be added at regular intervals (usually daily). Set an initial ‘timetable’ for at least a week, in collaboration with your worker. Ensure they have coping skills to manage fluctuations of symptom intensity, and that they have both a recording system and some kind of a reward, or praise, in place for when they successfully adhere to the plan. Set a review date.


Practical Tip: At the review, reset the activity schedule. It is imperative to maintain or increase activity level at this time, do not reduce demands. It is important that activity level is not reduced because the effect of this is to reinforce that symptoms are a 'threat', they are to be avoided, and that you do not trust that the worker to be able to cope.


Setting the Duration for the Graduated Programme

The length of time required to build up to the same level as before illness or injury will vary according to several factors. What is needed is a 'Goldilocks amount' - not too little, not too much. The duration can be adjusted if necessary.


Defining the duration of any work-shortening or selected duties (rather than leaving it open ended) helps to establish clear expectations and will be less stressful to the worker, the line manager, and work colleagues. With this information, they’ll be more likely to manage in the worker’s absence or help out with duties the worker can’t do.


Practical Tip: We all find it difficult to wait for long periods to achieve things, and gain that sense of achievement when we reach our goal. In general, it is much easier to plan a programme lasting a few weeks, not months. If a longer period is absolutely unavoidable for whatever reason, break down the goals into steps or sections. For example, if a case is complex, or there are multiple obstacles, progress may happen like this:


Part-time suitable selected duties > THEN > Part-time usual duties > THEN > Full-time usual duties


Useful Variations in Graduated Programmes

It is often important to take into account practical real-life issues when setting up a graduated programme to help someone stay at or return to work. Common examples are the need to fit in with trasport, or childcare arrangements.


This may influence initial decisions about how to distribute part-time hours across the days of the week. For example, if the goal is to commence with 15 hours, this could be done as:

  • 5 hours on each of 3 days per week, e.g. Monday, Wednesday, and Friday

  • 3 hours on each day of the week


When issue such as childcare or transportation are an issue, it might be practical to adopt specific working times, e.g. from 9.30 am to 2.20 pm.


Practical Tip: When working out how to start a graduated programme try to think about how it will work as it progresses. This is because there will invariably choices to make, some of which will suit the worker and the workplace more or less than others. For example if you start with 5 hours on 3 days per week, you could then choose to increase hours one of two different ways: (1) add more days per week, or (2) add more hours to the same 3 days. Each of these may have very real practical implications that you need to take into account.


If the worker's symptoms appear to be aggravated by their usual duties and job tasks, then these should be gradually reintroduced. This process is sometimes referred to as 'work hardening' or 'work conditioning'.


This means that in addition to gradually increasing the number of hours being worked it is necessary to gradually move from 'alternative' to usual duties and job tasks. One way to do this is to intersperse normal work duties that are within the workers’ capacity with the alternative selected duties. The employer may be able to temporarily ‘lighten’ the job by selecting discretionary tasks, prioritising activities to match variations in work capacity, or providing simple tools such as lifting aids to reduce strain for the worker.


Example ONE: Graduated programme with a set number of hours a day

This plan allows for a variety of work duties and tasks to be done, including normal duties.

Programme commences with a specific number of working hours per week in a pattern that allows for pacing and an appropriate level of resting. e.g. three mornings only.

As tolerance improves, extra half-days are added. The progressive extension of the working day to normal hours can be done with (1) larger increments on alternate days; or, (2) a small increase each day


Try to build into the plan breaks for rest and fitness activities (such as going to the gym) that can eventually be moved into the worker’s own time, or discontinued altogether.


Potential advantages for the worker to this approach using shorter working hours include:

  • help them to avoid fatigue, rush-hour traffic, and other energy demands

  • signal to their organisations that they have not yet fully recovered

  • encourage others (in both work- and non-work-related situations) to continue helping out

  • ensure the workers have ongoing contact with the workplace


Example TWO: Graduated programme with a set number of hours a week


This plan allows greater flexibility in the work schedule (than the plan using a set number of hours per day). It may not be possible to establish a rigid timetable for each day due to variability in the worker’s symptoms, e.g. mental health problems such as depression.


Line managers may also have difficulty providing set number of hours per day. This might be due to the nature of the work. Some jobs don’t lend themselves to regular shortened-hours routines, such as those with periods of intensive activity to meet deadlines, interspersed with quiet spells.


In these situations use a total number of hours per week, rather than a specific number of hours per day. This allows the worker to participate more when more work is available, within an overall target. Selecting discretionary tasks and prioritising work will help to match variations in work capacity.


Monitoring progress


When problems arise in a graduated programme the focus should be on easing the duties rather than the hours at work, until the person is ready to move on. As long as they feel able to report any deterioration in symptoms, harm is unlikely to result.

Practical Tip: If there is any type of setback that results in the need to reduce hours or change the type of duties, do not stop the graduated programme altogether. Reset the programme, so that it starts again at a realistic level, e.g. 80% of what the worker is now able to do. If necessary adjust the gradient, or sub-divide the duration into separate goals.

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