Patient Perspectives on Key Outcomes for Vocational Rehabilitation Interventions Following Traumatic Injury

Illness Narrative Master Plots Following Musculoskeletal Trauma and How They Change over Time, a Secondary Analysis of Data

Introduction; to the best of the authors knowledge, no past research has established how illness narrative master plots are expressed initially and then if and how they change longitudinally following musculoskeletal trauma. The aim of the present research was to consider how specific master plots were expressed, interact, and change across time following musculoskeletal trauma.

METHODS

A narrative analysis was undertaken that included individuals who had experienced a musculoskeletal traumatic injury. Individuals were included if they were an inpatient within 4 weeks of the first interview, had mental capacity to participate, and were able to communicate in English. Three interviews were undertaken (within 4 weeks of injury, then at 6- and 12-months post-injury). A 5-stage categorical form-type narrative analysis was performed.

RESULTS

Twelve individuals (49.9 ± 17.5 years; 7 male, 5 female) completed interviews at three time points following the trauma event (<4 weeks, 6 months, and 12 months). Three main narrative master plots appeared to work together to facilitate a positive accommodation of the trauma event into the individual's life. These included the resumption narrative, the activity narrative, and the quest narrative. Finally, less often regressive narratives were identified, although these narratives were, at times, actively avoided.

DISCUSSION

The current results provide important consideration for how narratives are used within clinical practice, in particular the value of how these three narratives could be accessed and promoted.

Development of a vocational rehabilitation intervention to support return-to-work and well-being following major trauma: a person-based approach

OBJECTIVES

Major trauma centres (MTCs) save lives but rehabilitation to support return-to-work (RTW) is lacking. This paper describes development of a vocational rehabilitation intervention (the ROWTATE intervention) to support RTW following traumatic injury.

DESIGN

Sequential and iterative person-based approach in four stages-Stage 1: review of evidence about the efficacy and mechanisms of RTW interventions; Stage 2: interviews (n=38) and focus groups (n=25) with trauma survivors and service providers in five UK MTCs to identify the issues, and challenges faced postinjury; Stage 3: codesign workshops (n=43) with trauma stakeholders in MTCs to conceptually test and identify intervention delivery barriers/enablers; Stage 4: meetings (n=7) with intervention development working group (IDWG) to: (1) generate guiding principles, (2) identify key intervention features (process, components, mechanisms) to address unmet rehabilitation needs; (3) generate a logic model and programme theory to illustrate how the intervention works; and (4) develop a training package to support delivery.

RESULTS

Trauma survivors described unmet needs relating to early advice about RTW; psychological support; pain management; hidden disabilities (eg, fatigue); estimating recovery; and community, amputee and musculoskeletal rehabilitation. Mechanisms of effective interventions identified in the review included early intervention, colocation, employer engagement, case coordination and work accommodations. Intervention features identified by IDWG members (n=13) from stages 1 and 2 were use of stepped-care approaches by occupational therapists (OTs) and clinical psychologists (CPs), OT/CP formulation for complex cases, assessment of mental health problems, individually tailored rehabilitation including vocational goal setting, cross-sector coordination/communication, employer engagement, phased RTW, education/advice for family/employers, exploration of work alternatives, ongoing review of physical and mental health needs, work stability monitoring. Conceptual testing ratified the logic model. Geography and long waiting lists were identified as potential delivery barriers.

CONCLUSIONS

Real-world testing of the intervention is underway in a randomised controlled trial.

Patients' Needs Regarding Work-Focused Healthcare: A Qualitative Evidence Synthesis

PURPOSE

To identify, appraise, and synthesize qualitative research evidence exploring patients' needs regarding work-focused healthcare.

METHODS

A systematic review was conducted in accordance with the PRISMA statement guidelines to identify studies reporting patients' needs regarding work-focused healthcare. Four databases (MEDLINE, Embase, PsychInfo and Web of Science) were systematically searched from January 2000 until May 2023 and screened in duplicate by pairs of two reviewers. Inclusion criteria were qualitative data collection method, and patients' perspectives regarding healthcare focusing on work when experiencing work-related problems due to chronic medical conditions. Data extraction and synthesis was executed by means of an inductive thematic analysis approach. The quality of the included studies was assessed using the CASP Qualitative Study checklist. Confidence in the review findings was assessed through the Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach.

RESULTS

Out of 23,677 records, 97 qualitative studies were included. Needs regarding four main themes were identified: (1) Substantive guidance, which comprises the specific content of work-focused healthcare; (2) Clear and continuous process, which comprises clarification and optimization of the work-focused healthcare process; (3) Supportive attitude and behavior, which comprises a positive and supportive attitude and behavior from professionals towards the patients; and (4) Tailored approach, which comprises the delivery of tailored care to the individuals' needs. 17 subthemes were identified.

CONCLUSION

The broader insight in patients' needs in work-focused healthcare can help (occupational) healthcare professionals adopt a more patient-centred approach in practice.

Early vocational rehabilitation and psychological support for trauma patients to improve return to work (the ROWTATE trial): study protocol for an individually randomised controlled multicentre pragmatic trial

BACKGROUND

Moderately severe or major trauma (injury severity score (ISS) > 8) is common, often resulting in physical and psychological problems and leading to difficulties in returning to work. Vocational rehabilitation (VR) can improve return to work/education in some injuries (e.g. traumatic brain and spinal cord injury), but evidence is lacking for other moderately severe or major trauma.

METHODS

ROWTATE is an individually randomised controlled multicentre pragmatic trial of early VR and psychological support in trauma patients. It includes an internal pilot, economic evaluation, a process evaluation and an implementation study. Participants will be screened for eligibility and recruited within 12 weeks of admission to eight major trauma centres in England. A total of 722 participants with ISS > 8 will be randomised 1:1 to VR and psychological support (where needed, following psychological screening) plus usual care or to usual care alone. The ROWTATE VR intervention will be provided within 2 weeks of study recruitment by occupational therapists and where needed, by clinical psychologists. It will be individually tailored and provided for ≤ 12 months, dependent on participant need. Baseline assessment will collect data on demographics, injury details, work/education status, cognitive impairment, anxiety, depression, post-traumatic distress, disability, recovery expectations, financial stress and health-related quality of life. Participants will be followed up by postal/telephone/online questionnaires at 3, 6 and 12 months post-randomisation. The primary objective is to establish whether the ROWTATE VR intervention plus usual care is more effective than usual care alone for improving participants' self-reported return to work/education for at least 80% of pre-injury hours at 12 months post-randomisation. Secondary outcomes include other work outcomes (e.g. hours of work/education, time to return to work/education, sickness absence), depression, anxiety, post-traumatic distress, work self-efficacy, financial stress, purpose in life, health-related quality of life and healthcare/personal resource use. The process evaluation and implementation study will be described elsewhere.

DISCUSSION

This trial will provide robust evidence regarding a VR intervention for a major trauma population. Evidence of a clinically and cost-effective VR intervention will be important for commissioners and providers to enable adoption of VR services for this large and important group of patients within the NHS.

TRIAL REGISTRATION

ISRCTN: 43115471. Registered 27/07/2021.

Development and feasibility testing of a psychoeducational tool to support the return to work (RTW) of individuals with traumatic brain injury (TBI): The RTW after TBI app

To document the development and clinician evaluation of a psychoeducational and support tool: the return to work after traumatic brain injury app (RTW after TBI app). Co-design of the app involved the collaboration of traumatic brain injury (TBI) /vocational rehabilitation (VR) expert researchers (n = 4) and lived experience co-designers (individuals with TBI who had previously returned to work; n = 4). Twelve TBI/VR clinician reviewers then evaluated the app. Content analysis of TBI/VR clinician reviewers' interviews revealed four themes: content, usability (functional ease of use), utility (applicability to RTW after TBI) and suggestions for improvements. All clinicians reported that they would use the RTW after TBI app in their clinical practice. Although several aspects were reported to potentially limit the app's appropriateness for some TBI clients, many feasible improvements were suggested to address limitations. These improvements aim to increase the utility of the app with a wider range of clients and extend its use to other settings. Future research should evaluate, in a clinical trial, the efficacy of the RTW after TBI app in supporting individuals with TBI and their vocational providers and optimizing RTW success.

Psychological and psychosocial aspects of major trauma care: A survey of current practice across UK and Ireland

Introduction

Psychological and psychosocial impacts of major trauma, defined as any injury that has the potential to be life-threatening and/or life changing, are common, far-reaching and often enduring. There is evidence that these aspects of major trauma care are often underserved. The aim of this research was to gain insight into the current provision and operationalisation of psychological and psychosocial aspects of major trauma care across the UK and Ireland.

Methods

A cross-sectional online survey, open to health professionals working in major trauma network hospitals was undertaken. The survey had 69 questions across six sections: Participant Demographics, Psychological First Aid, Psychosocial Assessment and Care, Assessing and Responding to Distress, Clinical Psychology Services, and Major Trauma Keyworker (Coordinator) Role.

Results

There were 102 respondents from across the regions and from a range of professional groups. Survey findings indicate a lack of formalised systems to assess, respond and evaluate psychological and psychosocial aspects of major trauma care, most notably for patients with lower-level distress and psychosocial support needs, and for trauma populations that don't reach threshold for serious injury or complex health need. The findings highlight the role of major trauma keyworkers (coordinators) in psychosocial aspects of care and that although major trauma clinical psychology services are increasingly embedded, many lack the capacity to meet demand.

Conclusion

Neglecting psychological and psychosocial aspects of major trauma care may extend peritraumatic distress, result in preventable Years Lived with Disability and widen post-trauma health inequalities. A stepped psychological and psychosocial care pathway for major trauma patients and their families from the point of injury and continuing as they move through services towards recovery is needed. Research to fulfil knowledge gaps to develop and implement such a model for major trauma populations should be prioritised along with the development of corresponding service specifications for providers.

Psychological and psychosocial aspects of major trauma care in the United Kingdom: A scoping review of primary research

Introduction

More people are surviving major trauma, often with life changing injuries. Alongside physical injury, many survivors of major trauma experience psychological and psychosocial impacts. Presently, there is little guidance at the UK national level for psychological and psychosocial aspects of major trauma care. Set in the context of the regional model of major trauma care implemented in the UK in 2012, the purpose of this review was to identify and bring together primary research about psychological and psychosocial aspects of major trauma care in the UK to produce an overview of the field to date, identify knowledge gaps and set research priorities.

Methods

A scoping review was undertaken. Seven electronic databases (MEDLINE, Cochrane Library, CINAHL, Embase, PsycINFO, SocINDEX with Full Text and PROSPERO) were searched alongside a targeted grey literature search. Data from included studies were extracted using a predefined extraction form and underwent bibliometric analysis. Included studies were then grouped by type of research, summarised, and synthesised to produce a descriptive summary and overview of the field.

Results

The searches identified 5,975 articles. Following screening, 43 primary research studies were included in the scoping review. The scoping review, along with previous research, illustrates that psychological and psychosocial impacts are to be expected following major trauma. However, it also found that these aspects of care are commonly underserved and that there are inherent inequities across major trauma care pathways in the UK.

Conclusion

Though the scoping review identified a growing body of research investigating psychological and psychosocial aspects of major trauma care pathways in the UK, significant gaps in the evidence base remain. Research is needed to establish clinically effective psychological and psychosocial assessment tools, corresponding interventions, and patient-centred outcome measures so that survivors of major trauma (and family members or carers) receive the most appropriate care and intervention.

Patients views on which return-to-work outcomes should be prioritised: A nominal group technique focus group

Objective

Injuries can have a long-lasting effect on ability to return to work, but there is little research on which outcomes are most important to patients. This study aims to identify and prioritise return-to-work outcomes important to patients for evaluating vocational rehabilitation interventions.

Methods

Nominal group technique focus group with trauma patients.

Results

Focus group participants ( n = 6) included mostly traumatic brain injuries, a range of occupation types, ages and both genders. Participants identified and prioritised their eight most important outcomes which were: sense of purpose and life satisfaction, understanding the impact of injury, assessment of readiness to return to work, using SMART (specific, measurable, achievable, relevant and time-bound) goals, facilitated reintegration to work, assessing capacity to return to work, collaboration between key stakeholders and improved employer and employee knowledge. Many of these were measures of the process of, rather than change outcomes of vocational rehabilitation.

Conclusions

The range of outcomes identified by trauma patients highlights the complex process of return to work and the need for vocational rehabilitation evaluations to incorporate a broader range of outcomes. Measures of the process of vocational rehabilitation are also important to trauma patients and should be included in such evaluations.

Mental health and other factors associated with work productivity after injury in the UK: multicentre cohort study

INTRODUCTION

Mental health conditions are a major contributor to productivity loss and are common after injury. This study quantifies postinjury productivity loss and its association with preinjury and postinjury mental health, injury, demographic, health, social and other factors.

METHODS

Multicentre, longitudinal study recruiting hospitalised employed individuals aged 16-69 years with unintentional injuries, followed up at 1, 2, 4 and 12 months. Participants completed questionnaires on injury, demographic factors, health (including mental health), social factors, other factors and on-the-job productivity upon return to work (RTW). ORs were estimated for above median productivity loss using random effects logistic regression.

RESULTS

217 adults had made an RTW at 2, 4 or 12 months after injury: 29% at 2 months, 66% at 4 months and 83% at 12 months. Productivity loss reduced over time: 3.3% of working time at 2 months, 1.7% at 4 months, 1% at 12 months. Significantly higher productivity loss was associated with preinjury psychiatric conditions (OR 21.40, 95% CI 3.50 to 130.78) and post-traumatic stress avoidance symptoms at 1 month (OR for 1-unit increase in score 1.15, 95% CI 1.07 to 1.22). Significantly lower productivity loss was associated with male gender (OR 0.32, 95% CI 0.14 to 0.74), upper and lower limb injuries (vs other body regions, OR 0.15, 95% CI 0.03 to 0.81) and sports injuries (vs home, OR 0.18, 95% CI 0.04 to 0.78). Preinjury psychiatric conditions and gender remained significant in analysis of multiply imputed data.

CONCLUSIONS

Unintentional injury results in substantial productivity loss. Females, those with preinjury psychiatric conditions and those with post-traumatic stress avoidance symptoms experience greater productivity loss and may require additional support to enable successful RTW.