Biographical work and returning to employment following a spinal cord injury

Development of a Programme Theory for Early Intervention Vocational Rehabilitation: A Realist Literature Review

Purpose Little is currently known about how early intervention vocational rehabilitation (EIVR) works for people with newly acquired neurological conditions such as traumatic brain injury, acquired brain injury and spinal cord injury. This study aims, from a realist framework, to identify relevant literature and develop an initial programme theory to understand how EIVR might work for people experiencing acquired neurological disability. Realist reviews are ideally placed to address the identified knowledge gap as they assist in gaining a deeper understanding of how the intervention works, for whom it works best, and the contexts that promote the activation of desired outcomes. Methods We used a seven-step iterative process to synthesise literature using a realist approach. The steps included: development of initial programme theory, literature search, article selection, extracting and data organising, synthesis of evidence and programme theory refinement. We performed a literature search using the following databases: Cinahl, Embase, EMcare, Medline, PsychInfo and Scopus. Articles were selected if they contributed to the knowledge describing what is EIVR and how it works in newly acquired neurological conditions. Data were extracted and synthesised to develop a programme theory for EIVR. Results Following screening of 448 references, 37 documents were eligible for data extraction. We developed a refined programme theory of EIVR consisting of three contexts (prioritisation of exploring work options, return to work discussed as an option, and workplace support), nine mechanisms (ensuring rehabilitation teams' culture, fostering hope, exploring options, optimising self-efficacy, maintaining worker identity, staying connected, setting goals, engaging employer, and flexing roles) and three outcomes (confidence in ability to work, psychological adjustment, and engagement in solution focussed options). Conclusions This appears to be the first paper to explore how EIVR works, for whom and in what situations. We have produced a programme theory that may provide an initial understanding of EIVR following acquired neurological conditions.

Returning to work or working on one's rehabilitation: Social identities invoked by impaired workers and professionals in health care and employment services

For persons with a long-term illness or impairment, return-to-work decisions involve considerations about work capacity, opportunities in the labour market, the impact of injuries, further treatment requirements, physical and cognitive rehabilitation, and mental health recovery. These considerations are undertaken by the affected individuals as well as by professionals in health care and employment services. Drawing upon institutional theories of organisations, especially the understanding that institutional logics provide different social identities to injured individuals, we study rehabilitation processes following multi-trauma or traumatic brain injury (TBI) within the Scandinavian welfare model. We identify which social identities are activated in professionals' considerations and in the stories of the injured individuals. The aim is to understand how professionals' reasoning about the clients' problems influences return-to-work processes. Our primary finding is that the wageworker identity, invoked by the injured individuals themselves, is subordinated by the professionals to the logic of profession and the associated patient identity. Consequently, not only is impaired people's anti-discrimination right to reasonably adjusted work ignored, ignored is also a possible resource in the rehabilitation process. Additionally, individuals who view themselves as wageworkers tend to be left unserved.

Return to work in the context of everyday life 7-11 years after spinal cord injury - a follow-up study

PURPOSE

The aim of this follow-up study was to explore experiences of return to work in the context of everyday life among adults 7-11 years after spinal cord injury (SCI).

METHODS

This study used in-depth interviews and observations in a qualitative design with eight persons who had previously been interviewed in 2008. A narrative approach was used during data gathering and analysis.

RESULTS

Return to work was experienced as something constantly needing to be negotiated in the context of everyday life. Several years after SCI expectations for work and perceptions of possibilities for meaningful work had changed. Five main themes were identified through the analysis, (1) negotiating the possibilities of working, (2) hope for future work tempered with concern, (3) education as a possible path to employment, (4) paths toward return to work in light of unmet support, and (5) unpaid occupations grounded in interest and competence.

CONCLUSIONS

Persons who have no higher education or lack viable employment to return to after SCI seem to be vulnerable in return to work. Early and timely interventions tailored to the person's interests and competencies, in which the rehabilitation team has a distinct coordinating role, are thus critical in return to work. Implications for Rehabilitation Tensions between hope and expectations for work and unmet needs of support can lead to barriers in return to work, particularly for those who have no higher education or lack employment to return to after spinal cord injury. Rehabilitation after spinal cord injury can benefit from focus on how the balance of work fits into routines in the context of everyday life. Early and timely interventions integrating the person's interests and competencies in return to work after spinal cord injury in combination with having a health care provider who has a distinct coordinating role are critical.

The experience of attempting to return to work following spinal cord injury: a systematic review of the qualitative literature

PURPOSE

This review sought to answer the question "What are the barriers and facilitators influencing people's experience of return to work following spinal cord injury?"

METHODS

Studies that met the selection criteria were identified, presented and critically appraised using National Institute for Health and Care Excellence guidelines. Thematic synthesis was completed with studies possessing strong methodological rigor. Synthesis and interpretation involved three stages; coding of primary data; development of descriptive themes reflective of the primary data; and establishment of analytical themes to answer the review question.

RESULTS

Data from nine papers were included in the thematic synthesis. Several descriptive themes and three analytical themes were drawn from the data to answer the research question. Analytical themes included: a matrix of personal and environmental factors exists requiring complex navigation in order to create possibilities and opportunities for postinjury employment; the process of seeking or gaining employment shares a reciprocal relationship with the temporal nature of adjustment to spinal cord injury; and there is an intrinsic need for occupational engagement through paid employment.

CONCLUSIONS

Returning to or gaining employment after spinal cord injury is a fundamentally difficult experience for people. Multiple strategies are required to support the navigation of the process. There is, however, a need in people with spinal cord injury, to be a worker, and with that comes the inherent benefits of being employed. Implications for rehabilitation Returning to work should be a significant focus of spinal cord injury rehabilitation. Employment is both possible and health promoting following spinal cord injury. Multiple strategies are required to support people to navigate the return to work process. It is important to be cognizant of the individual motivations for being a worker and the complexity of the adjustment process. Spinal cord injury centers can provide a consistent and supportive framework and culture of positivity about employment after spinal cord injury.

Integrated services and early intervention in the vocational rehabilitation of people with spinal cord injuries

INTRODUCTION

The design was a narrative review. The objective of the study was to investigate the potential for early vocational rehabilitation (VR) interventions for people with spinal cord injury (SCI) in overcoming barriers in returning to work, and to pinpoint factors contributing to effectiveness in early VR intervention for this population. The setting was at Queensland, Australia.

MATERIALS AND METHODS

Synthesis of the findings of a literature search of online databases ProQuest and CINAHL, using keywords relating to the employment situation and VR of people with SCI. Themes were identified and analysed in accordance with the research objectives.

RESULTS

Despite increasing government commitment to the workforce and social participation of people with disabilities, Australians living with SCI have significantly diminished employment outcomes compared with the general population. Current VR approaches usually do not commence until some months post discharge, potentially missing a window of opportunity to preserve pre-existing employment or assist in vocational decision making. The review found that there are opportunities for enhancing VR service provision following SCI, namely integrating the VR programme within the primary rehabilitation team thus facilitating early VR intervention.

DISCUSSION

Emerging evidence shows promising results for early intervention in VR; however, questions remain regarding ideal intervention approaches, and it is clear that further empirical investigation is required to support the use of early intervention models post SCI. The study was sponsored by Motor Accident Insurance Commission (MAIC).

Environmental barriers and social participation in individuals with spinal cord injury

OBJECTIVE

The study aimed to examine the relationship between environmental barriers and social participation among individuals with spinal cord injury (SCI).

METHOD

Individuals admitted to regional centers of the Model Spinal Cord Injury System in the United States due to traumatic SCI were interviewed and included in the National Spinal Cord Injury Database. This cross-sectional study applied a secondary analysis with a mixed effect model on the data from 3,162 individuals who received interviews from 2000 through 2005. Five dimensions of environmental barriers were estimated using the short form of the Craig Hospital Inventory of Environmental Factors-Short Form (CHIEF-SF). Social participation was measured with the short form of the Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF) and their employment status.

RESULTS

Subscales of environmental barriers were negatively associated with the social participation measures. Each 1 point increase in CHIEF-SF total score (indicated greater environmental barriers) was associated with a 0.82 point reduction in CHART-SF total score (95% CI: -1.07, -0.57) (decreased social participation) and 4% reduction in the odds of being employed. Among the 5 CHIEF-SF dimensions, assistance barriers exhibited the strongest negative association with CHART-SF social participation score when compared to other dimensions, while work/school dimension demonstrated the weakest association with CHART-SF.

CONCLUSIONS

Environmental barriers are negatively associated with social participation in the SCI population. Working toward eliminating environmental barriers, especially assistance/service barriers, may help enhance social participation for people with SCI. (PsycINFO Database Record

The association of assistive mobility devices and social participation in people with spinal cord injuries

OBJECTIVE

We assumed that assistive technology in mobility devices (that is, wheelchairs with external power and driving modified vehicle (MV) with or without driving on wheelchair) may facilitate social participation for wheelchairs users who have spinal cord injuries (SCIs). This study examined the relationship between mobility devices and social participation in this population.

METHODS

We included 2986 individuals who had received initial rehabilitation at one of 18 regional centers of the Model Spinal Cord Injury System in the United States, had been interviewed between 2004 and 2010, and were wheelchair users (use a wheelchair > or = 40 h per week and cannot ambulate 150 feet at home). We performed secondary panel-data analysis using a mixed-effect model on data from 3498 follow-up interviews. Participation (measured by the Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF) and employment status) and the use of wheelchair and MV were recorded.

RESULTS

Among the participants, 33% drove an MV, and 44% used an external-powered wheelchair. The use of an MV was positively related to employment and CHART-SF score, regardless of driving directly or driving with a wheelchair. People who drove an MV were found to have approximately two more business associates to contact to once a month and ∼2 additional days out of home per week compared with those without an MV. No significant association was shown between the type of wheelchair used and participation.

CONCLUSION

The use of an MV was found to be positively associated with social participation in an SCI population.

"The final piece of the puzzle to fit in": an interpretative phenomenological analysis of the return to employment in New Zealand after spinal cord injury

PURPOSE

Little is known about employment experience after spinal cord injury (SCI) because most research to date concentrates on employment predictors. We explored the experiences of people with SCI, and vocational rehabilitation (VR) professionals working for a VR programme, in pursuing a return to employment in New Zealand (NZ) post-SCI.

METHODS

Twelve people with SCI (four employed, three job-seeking, five unemployed) and six VR professionals were interviewed, and the transcripts subjected to an Interpretative Phenomenological Analysis.

RESULTS

The core meaning of employment post-SCI was to live a normal life. Work advantages were social connectedness, a sense of self-worth, earning a living, and being occupied. Employment was the zenith of rehabilitation but not the first priority post-SCI. Employment barriers and facilitators were congruent with those found in similar studies. The role of VR was to sow the seeds of return to employment and to partner with the SCI client.

CONCLUSIONS

For persons employed pre-SCI, we posit that employment identity modification is part of the return to employment process, alongside a supportive social context and networks, and adapted work environments. VR professionals may facilitate return to employment through understanding and fostering the process of employment identity modification and supporting clients to find work opportunities congruent with employment identity.

Geographic variation in participation for physically disabled adults: the contribution of area economic factors to employment after spinal cord injury

This study investigates the role of area economic characteristics in predicting employment-a key aspect of social participation for adults with physical disabilities-using data from a national registry of persons with spinal cord injury (SCI). SCI results in chronic impairment and most commonly occurs during young adulthood when working is a key aspect of the adult social role. Geocoded data were collected from two of the 14 SCI Model Systems (SCIMS) centers involved in the National SCIMS database and used to link individual-level data with area-level measures extracted from the 2000 US Census. The analysis included participants of working-age (18-64 years) and living in the community (N=1013). Hierarchical generalized linear modeling was used to estimate area-level variation in participation and the relative contribution of area-level economic indicators, adjusted for individual-level health, functioning, and background characteristics. The likelihood of employment for adults with SCI varied by area and was associated with area SES and urbanicity, but not area unemployment. These findings suggest that variation in area economic conditions may affect the feasibility of employment for persons who experience chronic physical disability during adulthood, thus limiting full participation in society.

The injured and diseased farmer: occupational health, embodiment and technologies of harm and care

Occupational health in agriculture is a significant public health issue in industrialised agricultural nations. This article reports on 26 in-depth interviews with farmers throughout New Zealand. Farmers are exposed to a range of technologies which place them at risk of injury and disease and/or prevent injury and disease. In this article these technologies are respectively conceptualised as technologies of harm and technologies of care. Despite being vulnerable to high rates of injury, fatality and occupationally related diseases the uptake of technologies of care amongst farmers in New Zealand is poor. The analysis draws on body theory to explore the meaning attached to injury and disease and to examine the socio-cultural field of agriculture. It is argued that the key features of subjective embodiment and social, cultural and symbolic capital can undermine the uptake of technologies of care, ensuring poor occupational health outcomes on New Zealand farms.

To work or not to work? The occupational trajectories of wheelchair users

PURPOSE

To throw light upon the dynamic processes which may or may not lead persons with severe motor disability to employment.

METHOD

A qualitative approach to the chronology of both the professional and non-professional occupations of wheelchair users between acquisition of the disability and the interview; this approach focuses upon actions and meanings, thus allowing the authors to identify the diverse factors which help build the occupation situation at the time of the study. The narratives of 36 wheelchair users of working age were used. The objective of the analysis was to reconstitute the occupation trajectories of the participants and hence to suggest a typology. This involved pinpointing the various actors, the external and cognitive contexts of their decisions and actions, and their consequences and related feelings.

RESULTS

The wide diversity found in the trajectories forced the authors to go beyond any simple notion of 'work versus non-work' and to focus on the quality of the individual's process of occupation appropriation. Indeed, it is possible to successfully appropriate both work and non-work situations, just as, inversely, it is possible for a person to fail to appropriate either type of situation. Analysis of this process allows one to pinpoint different types of trajectory. On the one hand, trajectories within which people appropriate their occupations--gradual, intermittent, through rupture and successive adjustment--and, on the other hand, unstable or endured occupation trajectories.

CONCLUSIONS

The findings suggest that with regard to rehabilitation practices, we should be focussing as much on the appropriation process as on return to work.

An analysis over time (1990–2000) of the experiences of living with HIV

Qualitative data from three research projects carried out in France are used to analyze changes in the experiences of persons living with HIV during the 10-year period 1990-2000. During this decade, 167 in-depth interviews were conducted with 118 HIV-positive people in 1990-1991, 1996-1997 and 1998-2000. A three-fold typology-"continuity with drawbacks", "discontinuity and reversal" and "withdrawn"-is proposed to account for the experiences of living with HIV in relation to changes over time and the discovery of new treatment, i.e. highly active antiretroviral therapy (HAART), in the spring of 1996.

Meaning and coherence of self and health: an approach based on narratives of life events

Using contributions from the fields of interactionist sociology and narrative studies and the results of an empirical study, in this article we examine the subject's mediation between life events and state of health. Examining narratives focusing on significant life events from 26 men and women aged between 51 and 73 from the administrative region of Ile de France, we suggest that dimensions of meaning and coherence of self need not be taken as internal dispositions, but rather as the product of sociocognitive work on self-narration. The characterisation of the types of causal relationships that the narrators establish between significant events and other events, situations or periods in their lives, opens up avenues for the development of a methodological tool to replace traditional ways of measuring sense of coherence and meaning/purpose in life using psychometric methods. This alternative perspective based on a conception of the self as narrative might provide a remedy for certain conceptual and methodological difficulties that are found within the field of coping research.

Quality of life after spinal cord injury: a meta-synthesis of qualitative findings

STUDY DESIGN

Meta-synthesis of qualitative research.

OBJECTIVES

To identify, compare and synthesize the factors found to contribute to, or detract from the experience of a life worth living following spinal cord injury (SCI).

METHODS

Published articles were identified from the Medline, CINAHL and Sociological Abstracts databases, a hand search through selected journals published since 1990, and from reference lists. These were assessed for their relevance to the focus of interest and appraised for rigour and quality. The key themes that emerged from the data were summarized, compared and synthesized.

RESULTS

The search located 64 papers and four books, of which seven papers met the review criteria for relevance and rigour, and in which 10 main concepts were identified: (1) body problems, (2) loss, (3) relationships, (4) responsibility for, and control of one's life, (5) occupation, and ability to contribute, (6) environmental context, (7) new values/perspective transformation, (8) good and bad days, (9) self-worth, (10) self-continuity.

CONCLUSIONS

This study demonstrates the utility of synthesizing qualitative research to provide a greater depth of insight into the factors that contribute to, and detract from, quality of life (QOL) after SCI. It also provides a more nuanced understanding of the experience of QOL following SCI than is achievable by quantitative methods. Future qualitative research is required to probe further the concepts and connections identified in this study, and to identify how rehabilitation services might best address these issues.