Fitness for Duty and Return to Work

Issues of Concern

Fitness-for-duty evaluations are typically conducted by a licensed medical provider as a condition of employment. The field of occupational health strives to promote the highest degree of well-being through physical, mental, and social disciplines across all jobs. The aim is to prevent a decline in the employee's health caused by the current working conditions and to protect workers from adverse health factors. This approach aims to align employees in an environment adapted to their capabilities. Hence, occupational health aims to adapt work to the workers and each worker to their job.[4]

A key function of the occupational healthcare provider is to certify whether a worker is fit for duty, fit with accommodations, or unfit for duty. This determination is based on an evidence-based assessment of whether the worker can perform the required duties independently or if accommodations are necessary. A stepwise approach is helpful for this determination (see Table 2. Stepwise Return-to-Work Framework).

Table 2. Stepwise Return-to-Work Framework

Mental health issues are also causes of physical disabilities. With the current shortage of healthcare providers, there is often a significant gap in understanding and evaluating patients' illnesses before certifying their ability to return to work. Both employees and employers benefit when employees return to work as soon as possible after an absence due to a work-related injury or a prolonged absence due to a health condition affecting their ability to work, such as a stroke or nerve damage from disc degeneration. Employers are primarily responsible for making the return-to-work decision. However, these decisions may depend on interpreting a fitness test or a more comprehensive assessment to ensure the worker is medically and physically capable of performing the job tasks. Consequently, many employers rely on the opinions of medical providers.[5]

Occupational health providers should evaluate a worker's fitness for work based on 3 main criteria—worker's capacity, workplace risk, and the necessity of making reasonable accommodations as per worker disability, allowing them to work with minimal risk to themselves and the employer. Various specific and cost-effective assessment techniques can be used for return-to-work evaluations, though no single technique can always provide a definitive answer.

Outcomes from fitness-for-work assessments may be categorized as fit for duty subject to work modifications, fit for duty with restrictions, or unfit for duty. Under the first 2 conditions, the employer must consider changes at the work site to accommodate working conditions. Confusion regarding the decision-making process for judging fitness exists in the scientific literature, and no standardized methodology can fit all jobs and work conditions.[6] Several recently encountered disease processes, such as COVID-19, may severely affect individuals' functional capacity.[7] A careful understanding of the patient's functional capacity using a variety of tests is often required to arrive at reasonable and safe circumstances for return to work, allowing accommodations whenever possible.

In the United States, a fitness evaluation may be conducted only after an official job offer. The ADA does not permit disability testing of qualified individuals with disabilities before employment. An employer can request inquiries into the prospective employee's ability to perform job-related functions or an agility test without medical examination or monitoring; it is prohibited to ask a prospective employee in this early stage to undergo a fitness-for-work examination. When employers refer a candidate for a pre-employment fitness exam, the employer must always provide the specifics of the job description and duties.

Clinical Significance

Occupational health providers must consider the main factors when assessing fitness for work—safety and health risks. Health and safety risk can be defined as the probability of an adverse health effect on the worker. The primary focus of the fitness-for-duty evaluation is to determine whether the employee can perform the required job duties safely. The ADA mentions that the priority is to ascertain that the level of risk involved is acceptable for a fit worker to do their job.[8] For example, the risk has to be significant, likely, imminent, and severe, supported by scientific evidence, and based on an individual assessment.[9]

Research has concluded that there is poor evidence regarding the ability of medical preplacement evaluations to prevent future risks. Fitness decisions are often based on prior evidence and healthcare assumptions about underlying illnesses and inherent work-related dangers, which can lead to the unnecessary exclusion of candidates.[10] For example, assessing physical capacity for highly demanding and risky occupations, such as firefighting and military service, requires evaluating medical and physical performance based on essential job functions.[11] 

The recommendation to include specific criteria in the job description and exclude nonessential job functions aims to ensure fairness in the hiring and employment process. Psychological and mental capacity should be assessed in situations where there is a history of psychiatric illness, following an extended leave due to a psychiatric condition, or when there are signs of reduced performance, absenteeism, or unexplained behavior. This assessment is particularly important for applicants seeking jobs with high psychological demands, such as law enforcement officers, astronauts, pilots, oil rig workers, and construction crew members.[12] 

Several assessment tools exist for fitness of duty and return to work and may require clarification. At a minimum, clinicians should perform a clinical interview, a focused physical examination, laboratory testing with drug and alcohol screens, and a set of standardized questionnaires such as the Work Ability Index.[13][14][15][16] The assessment should be tailored to the functional requirements, job risks, and functional capacity. Functional capacity refers to the worker's capacity to perform their job without any accommodations and can be assessed through a job analysis based on quantifying the physical demands.[17] 

The clinician's awareness of the requirements of a particular job is another crucial aspect when assessing fitness for work. For example, when evaluating a firefighter who returns to work with cardiac disease, a standardized stress test and questionnaire may not be sufficient. In addition, an occupational-specific functional capacity assessment gives doctors and patients a better idea of the patient's capabilities to return to work.[18] 

The ADA governs protection against discrimination in the United States. Individual worker confidentiality has significantly improved over the years. Previously, employers had direct access to candidates' medical histories. However, it is now required that employers only have access to the outcomes of assessments without specific medical diagnoses being disclosed. In addition, the details shared must be limited to aspects directly related to the work to be performed.[19][20] Individual employees also have the right to appeal in case of disagreement through specialized committees or tribunals to organizations such as the Equal Employment Opportunity Commission.[21][22] 

Fitness-for-work assessments impact prevailing job opportunities. The decision-making process should be based on a case-by-case basis and according to the clinical judgment of the individual clinician. Standardized criteria for disease groups should be applied whenever possible, and a focused functional capacity exam should be performed where applicable. 

Evaluations are often completed over multiple sittings; additional evaluations and referrals may be necessary. The evaluator may request special medical tests, such as radiographs, advanced imaging studies, or pulmonary function studies, as deemed appropriate for the proscribed job. In some cases, consultation with additional specialists and the employee's personal healthcare practitioner may be necessary. In addition, a safety assessment by an industrial hygiene officer or safety officer within the employer's company is required.

Key features of the process of fitness-for-duty evaluations include but are not limited to:

• Medical assessment: This is a comprehensive examination conducted by a qualified healthcare professional to evaluate the employee's physical health and any medical conditions that may affect their ability to work.
• Psychological evaluation: Mental health is equally vital in determining fitness for duty. Psychologists or psychiatrists may conduct assessments to evaluate cognitive function, emotional stability, and readiness to return to work.
• Functional capacity evaluation: The functional capacity evaluation assesses an individual's physical abilities, such as strength, flexibility, and endurance, to determine their capacity to perform specific job tasks safely.
• Job analysis: Employers may provide the practitioner a description of job demands to ensure that the employee's capabilities align with the requirements of their position. This analysis helps identify any necessary accommodations or modifications.
• Communication and collaboration: Clear communication between the employee, healthcare professional, and employer is essential throughout the evaluation process. Collaboration ensures all parties understand expectations and work together to facilitate a successful return to work. Medical and physical standards are occasionally used based on known safety risks and essential functions and can be validated for each role. For specific occupations, especially military personnel, construction workers, and firefighters, establishing absolute physical capacity standards, independent of age, sex, ethnicity, and disability, can be justified.[6][23]

The functional capacity assessment is a critical test for assessing a worker's ability to perform the job. This assessment includes an evaluation of the physical strength to perform the job and the mental and social capacities that are needed, taking into account the safety and available options for workplace accommodation. An example of this assessment could involve performing a task simulation or validated tests to assess functional capacity. A more comprehensive approach involves first analyzing work conditions and required health standards for the job, then aligning this information with medical findings, and finally conducting a joint assessment of all relevant factors.[24][25]

Occupational healthcare practitioners should always strive to balance the risks posed to the patient in performing the job and the duty of employers to offer a safe environment. These healthcare providers require medical diagnostic tools and in-depth knowledge of the tasks necessary to perform the job diligently and to assess fitness for work. With this information, practitioners can determine several potential outcomes—fit, fit with conditions or restrictions, temporary or permanent, and not fit. The not-fit option is always an exception, and effort should be made to allow for employee or employer options with accommodations. Standardized criteria are applied when they exist, and new criteria are needed.

Clinicians should remain updated on changes in laws and conditions related to drug, alcohol, and marijuana testing, as amendments may affect their scope of practice. For instance, recent amendments to the marijuana laws in certain states permit its use in nonpsychoactive (recreational) forms. The employer must inform the employee that they can return to work only after meeting the necessary requirements. If the employee and employer agree to disclose this requirement, the employee may be terminated even if they have not completed a fitness-for-duty certificate for their health condition. There is a growing interest in research on the prevention and cost-effectiveness of fitness assessments for work. However, scientific evidence is still scarce and rarely based on experimental designs.[26][27][28] This scarcity is due to the complexities of fitness assessments for work regarding their conceptual constraints, varying work conditions and requirements, and ethical implications.

Nursing, Allied Health, and Interprofessional Team Interventions

A multidisciplinary team approach involving the employee, employer, clinician, allied health team, and other healthcare providers is key to successful outcomes. The fitness-for-work assessment, including pre-employment physical examinations, evaluates the employee's capacity to work in the environment without posing risks to their health, safety, or that of their colleagues. These assessments are carried out to prevent future health and safety risks for the worker or candidate, coworkers, and the public. A balance must exist between job health and safety risks and job description. Research shows that tailoring the work environment to individual needs can help reduce job cuts in high-demand, safety-critical roles.[6][25]

Providing a complete job description is recommended to allow for reasonable accommodation. Establishing a threshold or acceptable level of risk is sometimes difficult and often requires a multipart, expert-based consensus. An example could be a nurse who has sustained an injury that prevents them from fully performing their nursing duties. A collaborative approach involving occupational clinicians, healthcare supervisors, and the nurse can help rehabilitate the individual to enable them to perform their pre-injury tasks with appropriate accommodations.

The following key considerations are suggested for the team when assessing the return to duty. 

• Job safety and physical demands primarily determine fitness for work rather than the medical conditions of candidates.

• Fitness for work assessments that focus on specific job requirements predict the future of health outcomes better than those focused on health history.

• Reliable, evidence-based tools should be prioritized and correctly used when evaluating the fitness for work.

Certain specialized occupations, such as pilots, have more rigorous qualifications and physical fitness requirements. The Federal Aviation Administration regulates and sets standards for specific medical conditions. Psychological assessments are included and may lead to disqualifications based on particular medical diagnoses. Consulting specialists for the evaluation of such individuals is often beneficial.[29][30] 

Despite being common occupational medicine practice, there is still a need for more precise, practical tools for making judgments on certifying an individual as fit or unfit for work. These tools should be evidence-based or formulated as consensus by occupational health organizations wherever possible. 

Further research is required to develop reliable tools and assessment methods to improve the effectiveness of fitness-to-work exams. The ADA guidelines should be regularly reviewed and updated by relevant government agencies, incorporating the latest scientific evidence and best practices.[31]

In summary, occupational providers face several challenges regarding fitness-for-duty certifications, and the focus should be on striking a balance between the employer and employee and performing the job functions that lead to the most successful outcomes.