Clinician experiences of implementing a new early vocational rehabilitation service within an existing rehabilitation setting: critical facilitators, barriers, and key learnings

Purpose Return to work (RTW) after a major traumatic injury (MTI; traumatic brain injury, spinal cord injury, multi-trauma orthopaedic injury) is an important rehabilitation outcome. This study aimed to explore the experience of early vocational rehabilitation (EVR) after MTI, and RTW barriers/facilitators. Methods Adopting a qualitative design, 24 people with MTI were interviewed about participating in the Early Intervention Vocational Rehabilitation Service (EIVRS). Perceptions of EIVRS timing and RTW barriers/facilitators were explored. Data were analysed using reflexive thematic analysis. Results Participants experienced EIVRS as positive. The intervention’s early timing was mostly appropriate, determined by individual factors. RTW barriers included injury impairments; difficulties adapting work roles and unstable employment; and psychological difficulties. RTW facilitators included ongoing recovery, employer flexibility, and feeling supported. Reported EIVRS benefits centred around three themes: gaining optimism and motivation through increased understanding; having a sense of control through the individualised program and vocational expertise; and feeling less worry and stress. Participants recommended long-term EIVRS availability. Conclusions Participants experienced EIVRS as an important component of their rehabilitation. Timing of vocational interventions needs to be individualised according to medical, cognitive, psychological, and employment factors. Embedding EVR within rehabilitation teams would facilitate this individualisation and may improve long-term rehabilitation outcomes.

BACKGROUND: Early vocational rehabilitation following spinal cord injury (SCI) improves return to work (RTW) outcomes, but there is limited information about who benefits from such interventions, why and in what contexts. OBJECTIVE: We aimed to describe demographic and clinical characteristics and RTW outcomes of adults with SCI who received early vocational rehabilitation. We sought to identify key mechanisms of early vocational rehabilitation. METHODS: This is a cross-sectional survey of people with SCI recruited from the New Zealand Spinal Trust Vocational Rehabilitation Service, who had sustained an SCI within the previous five years. RESULTS: Of the 37 people who responded to the survey, 54% returned to paid work (90% of whom retained their pre-injury employment). Those in autonomous roles returned to work faster with greater odds of returning to their pre-injury employer and role. Participants highlighted the importance of feeling hopeful about RTW while still in the spinal unit as a key mechanism of effect within the early vocational intervention. CONCLUSIONS: Findings suggested key mechanisms of early vocational intervention could be framed by models of hope. However, for gains to be optimised, continuity of support beyond the acute stage was suggested as an area for future research.

BACKGROUND: There are indications that specialist vocational rehabilitation is beneficial when trying to return to work after acquired brain injury (ABI). OBJECTIVE: To give a description of the Early Vocational Rehabilitation (EVR) protocol and its development in order to make it available for implementation in rehabilitation institutes to strengthen the appearance of these institutes as relevant partners and supporters during the process of (sustaining) return to work of people with ABI. METHODS: The Early Vocational Rehabilitation (EVR) protocol is a process guideline to facilitate the interdisciplinary rehabilitation team to systematically focus on return to work during an early stage of (inpatient or outpatient) rehabilitation of people with ABI. The development was expert based. RESULTS: The EVR protocol consists of four stages: 1) orientation of the rehabilitation team towards the patient’s work; 2) investigating the gap between the patient’s abilities and work; 3) work training; and 4) finalizing EVR. Cooperation among all relevant partners from inside or outside the rehabilitation institute is important for maximally adapting the EVR treatment to the individual (work) situation of the person with ABI. CONCLUSION: The EVR protocol is available for implementation in other rehabilitation institutes. Performing a context analysis for each new context in which it is implemented is recommended.

There is considerable variability in return-to-work (RTW) outcomes for individuals with major traumatic injuries, including traumatic brain injury (TBI), spinal cord injury (SCI) and multi-trauma orthopaedic (MTO) injury. This study aimed to understand how injury-related, demographic and psychosocial factors and access to vocational rehabilitation interact to determine likelihood and time to RTW at one and two years post-injury. Participants were 170 adults employed pre-injury, enrolled in a trial of early vocational rehabilitation and followed up one- and/or two years post-injury. Of the 143 and 128 participants followed up, 53.8% and 59.4% were employed at one and two years post-injury. Employment was lowest for those with SCI. Factors associated with being employed at one and/or two years post-injury included being female, having more education, higher work skill level, no pre-injury psychological issues, and lower post-injury anxiety, depression, fatigue and pain. Mean time to RTW was 189 days for the one-year cohort and 247 days for the two-year cohort. Participants with less education and lower pre-injury work skills took longer to RTW. This study highlights the impact of demographic, pre-injury psychiatric issues, pre-injury employment and post-injury sequelae on return to employment after traumatic injury in addition to early vocational rehabilitation. Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12619000521123.

Previous analyses of vocational rehabilitation services for unemployed cancer survivors indicated that counseling and guidance, job search assistance, and job placement services are significantly associated with increased odds for employment. However, many cancer survivors with jobs to return to may require vocational interventions that are different from unemployed cancer survivors. It is unclear whether the public rehabilitation system provides vocational services that are based on the work status of cancer survivors rather than providing the same set of services for all cancer survivors. This study examined whether differences in the types of services were indeed based on the employment status of those with a history of cancer at the time of application. Administrative data on 1,460 cancer survivors were obtained through the US Rehabilitation Services Administration Case Service Report (RSA-911) dataset for fiscal year 2007. Data on demographic characteristics and vocational service patterns were extracted and analyzed. Multiple discriminant analysis was used to identify differential services received by cancer survivors based on employment status at time of application for vocational rehabilitation services. Results of the multiple discriminant analysis indicated one significant canonical discriminant function, with Wilks's λ = .92, χ (2)(19, N = 1,456) = 114.87, p < .001. The correlations between the discriminating variables and the significant canonical discriminant function were highest for diagnoses and treatment (-.526), job placement (.487), transportation (.419), job search (.403), vocational training (.384), job readiness (.344), university training (.307), and rehabilitation technology (-.287). The group centroids along the significant discriminant function (the distance of each group from the center of the canonical function) indicated that the employed applicant group (-.542) and the unemployed applicant group (.153) can be differentiated based on vocational rehabilitation services received, with the employed applicant group receiving primarily diagnostic and treatment services and rehabilitation technology/job accommodation services, while the unemployed applicant group received more vocational training, job seeking skills training, and job placement services. Employed cancer survivors who are at risk of losing their job and unemployed cancer survivors who are looking for a job receive different vocational services tailored to needs, suggesting that state vocational rehabilitation services for cancer survivors is responsive to individual client needs.

The aim of this systematic review was to compile the evidence for early vocational rehabilitation interventions for people with major injury or illness. Embase, Scopus, Cochrane Library, Medline, CINAHL, and Psycinfo databases were searched. Five hundred abstracts were reviewed for eligibility. Full-text review of 125 studies revealed a total of 25 published studies that met the eligibility criteria to be included in this review evaluating early approaches to vocational rehabilitation and return to work. Findings suggest that intervening early with respect to an individual’s vocational goals is imperative, although the definition of “early” varies. Programs achieve better vocational outcomes when specifically employing comprehensive vocational interventions, including vocational assessment, individualized planning, and follow-up support, to ensure a person’s return to employment is timely and sustained. Integration of vocational rehabilitation professionals within a multidisciplinary team and access to advocacy services were shown to be effective inclusions in early vocational rehabilitation programs for people with a serious injury or illness.

Purpose: The purpose of this study was to evaluate (1) the feasibility of an early vocational rehabilitation (EVR) protocol in the standard rehabilitation process, (2) promoting factors and barriers encountered with the EVR protocol, and (3) perceived effectiveness of the protocol in facilitating return to work (RTW) following acquired brain injury (ABI). Method: A pre- and post-process evaluation was performed in a Dutch rehabilitation center. Dependent variables were feasibility (defined by the usability on process level and fulfillment of usability expectations), promoting factors and barriers, and perceived effectiveness of the protocol. Usability (defined by 13 performance and timing goals) was evaluated with existing forms and registrations. Fulfillment of usability expectations, perceived promoting factors and barriers, and perceived effectiveness were investigated with questionnaires. Data of 23 patients were available for process evaluation. Nine rehabilitation professionals, 10 patients with ABI, nine employers, and six occupational physicians completed the questionnaires. Results: Two-thirds of the performance goals and one-fourth of the timing goals were reached. All respondents cited the structured protocol as a promoting factor. Thirty-two of the thirty-four participants perceived the protocol as being suitable facilitating RTW after ABI. Conclusions: The EVR protocol provides a structured strategy to focus on RTW during standard rehabilitation. It is now possible to implement and test the protocol in other rehabilitation settings.Implications for RehabilitationThe early vocational rehabilitation (EVR) facilitates an interdisciplinary and systematic focus on return to work during rehabilitation of people with acquired brain injury.The feasibility of the EVR protocol has been tested.The EVR protocol is ready for implementation and wider testing in other rehabilitation settings.

Introduction: Clinicians often determine an ‘expected body weight’ (EBW) for patients who have lost weight due to an eating disorder (ED). However, there is inconsistent guidance and limited empirical research on whether and when these weights should be shared with patients. This study explores clinician and patient perspectives on discussions of EBWs.Methods: Semi-structured interviews were conducted with 24 multidisciplinary clinicians treating EDs and 16 individuals with recent outpatient ED treatment experience (i.e., in the past 6 months). Clinicians shared their experiences with and rationales for sharing EBWs with patients and patients’ family members. Patients shared their experiences being informed of their EBWs in ED treatment, factors influencing their comfort level discussing EBWs with clinicians, and perceived impact of these discussions on their recovery. Interviews were analyzed using reflexive thematic analysis with a critical realist lens. Results: Clinician and patient perspectives aligned regarding when, how, and why to hold these discussions. Both groups emphasized that these discussions should occur after patients are medically stable and underscored the importance of framing the EBW as one aspect of a holistic recovery. Additionally, clinicians and patients highlighted the potential therapeutic benefits of these discussions, while also acknowledging challenges relating to parental involvement and weight bias. Discussion: Findings suggest that when discussions of EBWs are approached intentionally—accounting for timing, framing, and individual patient needs—clinicians and patients see potential therapeutic benefit. Future research can focus on developing evidence-based guidelines for sharing EBWs, addressing patient willingness to be informed of their EBW, weight bias, and parental involvement.

Early intervention vocational rehabilitation for return to work following traumatic injury: A randomized controlled trial.

Background: Reflexive thematic analysis is widely used in qualitative research published in Palliative Medicine, and in the broader field of health research. However, this approach is often not used well. Common problems in published reflexive thematic analysis in general include assuming thematic analysis is a singular approach, rather than a family of methods, confusing themes and topics, and treating and reporting reflexive thematic analysis as if it is atheoretical. Purpose: We reviewed 20 papers published in Palliative Medicine between 2014 and 2022 that cited Braun and Clarke, identified using the search term ‘thematic analysis’ and the default ‘relevance’ setting on the journal webpage. The aim of the review was to identify common problems and instances of good practice. Problems centred around a lack of methodological coherence, and a lack of reflexive openness, clarity and detail in reporting. We considered contributors to these common problems, including the use of reporting checklists that are not coherent with the values of reflexive thematic analysis. To support qualitative researchers in producing coherent and reflexively open reports of reflexive thematic analysis we have developed the Reflexive Thematic Analysis Reporting Guidelines (the RTARG; in Supplemental Materials) informed by this review, other reviews we have done and our values and experience as qualitative researchers. The RTARG is also intended for use by peer reviewers to encourage methodologically coherent reviewing. Key learning points: Methodological incoherence and a lack of transparency are common problems in reflexive thematic analysis research published in Palliative Medicine. Coherence can be facilitated by researchers and reviewers striving to be knowing – thoughtful, deliberative, reflexive and theoretically aware – practitioners and appraisers of reflexive thematic analysis and developing an understanding of the diversity within the thematic analysis family of methods.

This study investigated the association of state vocational rehabilitation services in the USA and work outcomes of cancer survivors who were unemployed prior to receipt of services. Administrative data obtained during fiscal year 2005 from the Rehabilitation Services Administration (RSA) database consisting of 1,201 closed cases with the diagnosis of cancer formed the sample of this study. All cancer survivors were unemployed at the time of application. Data on demographic characteristics, employment and vocational service variables were extracted and analyzed in relation to employment outcome data. Multivariate logistic regression was used to examine the relationship among services provided and work outcomes accounting for demographic characteristics of the participants. Cancer survivors represented 0.4% of the total population that received vocational services in the state-federal vocational rehabilitation program. Of the unemployed cancer survivors who received services, 903 (57%) achieved successful employment while 670 (43%) were not employed following receipt of services. Gender (women; OR = 0.77, 95% CI = 0.61-0.97), lower educational levels (OR = 0.52, 95% CI = 0.33-0.81), provision of cash or medical benefits (e.g., Social Security Disability Insurance benefits; OR = 0.64, 95% CI = 0.50-0.82) were all associated with a greater likelihood of being unemployed at the end of vocational services. Counseling (OR = 1.33, 95% CI = 1.02-1.73), miscellaneous training (OR = 1.61, 95% CI = 1.06-2.44), rehabilitation technology services (OR = 1.22, 95% CI = 0.72-2.08), job placement services (OR = 2.37, 95% CI = 1.72-3.27), job search assistance (OR = 1.43; 95% CI = 1.02-2.01) maintenance services (OR = 1.92, 95% CI = 1.29-2.86), and other services (OR = 1.43, 95% CI = 1.07-1.90) were found to be significantly associated with increased odds for employment. Vocational rehabilitation services were found to be associated with employment status. Future studies investigating the specific effects of certain vocational services for unemployed cancer survivors who qualify for these services are warranted. Cancer survivors who are seeking employment or experiencing problems maintaining employment who can qualify should be encouraged to pursue services from state vocational rehabilitation agencies. Medical providers should also become familiar with services offered by state vocational rehabilitation agencies and consider the use of these services..

Young adult cancer survivors report difficulties related to employment. This study investigated the association of vocational services on work in young cancer survivors unemployed prior to receipt of services. Administrative data obtained for years 2004 and 2005 from the Rehabilitation Services Administration (RSA) database was used in the analyses. A total of 368 cases aged 18-25 who were closed during the 2 years with a diagnosis of cancer were identified. All cancer survivors were unemployed at the time of application. Data on demographic characteristics, employment and vocational services were extracted and analyzed in relation to employment. Multivariate logistic regression was used to examine the relationship among services provided and work outcomes accounting for demographic characteristics. Cancer survivors represented 0.4% of the total population that received vocational services in the state-federal vocational rehabilitation system. Of the unemployed cancer survivors who received services, 190 (51.6%) achieved successful employment while 178 (48.4%) were not employed following receipt of vocational rehabilitation services. Gender (woman) (OR = 1.79; 95% CI: 1.16 to 2.76), vocational training (OR = 2.03; 95% CI: 1.03 to 4.00), miscellaneous training (OR = 4.01; 95% CI: 1.80 to 8.97), job search assistance (OR = 4.01; 95% CI: 1.80 to 8.97), job placement services (OR = 2.24; 95% CI: 1.11 to 4.52), on-the-job support (OR = 4.20; 95% CI: 1.66 to 10.63), and maintenance services (OR = 2.85; 95% CI: 1.38 to 5.90) were all related to an increased odds for employment. Provision of cash or medical benefits (e.g., Social Security Disability Insurance benefits) (OR = 0.43; 95% CI: 0.28 to 0.67) was associated with lower employment following vocational services. Very few young adult cancer survivors were involved in the state-federal rehabilitation program. Despite this, the provision of certain vocational rehabilitation services was related to increased employment in this group. Those who received job search assistance and on the job support were four times more likely to be employed following such services. While those in receipt of benefits were less likely to be employed, it is very likely that those receiving such benefits are the more severe cases. It is worth noting that the exact direction of these relationships can not be determined with the current design. Young adult cancer survivors who are seeking employment and can qualify for such services may benefit from certain services offered by state vocational rehabilitation agencies. This represents another service to consider when employment is a goal.

Purpose To examine the lived experiences of adults who have received community-based rehabilitation (CBR) services in Australia or New Zealand for cognitive-communication disorders (CCDs) following traumatic brain injury (TBI) and their support people. Participants’ recommendations for future models of care were also explored to enhance rehabilitation services for people with TBI. Method A qualitative descriptive approach grounded in phenomenology was used, whereby semi-structured interviews were conducted with each participant. A total of 28 interviews were completed, four in-person and 24 via video conferencing. Two participant groups were recruited: Adults with TBI; and their support people. Sixteen adults with a self-reported diagnosis of cognitive-communication disorder (CCD) following TBI who had received CBR and 12 support people were included. Interviews were analysed using reflexive thematic analysis. Result Four themes were identified by the participant groups indicating the core pillars of CBR models of care. They included the importance of: (a) accessible and inclusive CBR services; (b) specialised clinical skills and treatment approaches; the acknowledgment that (c) knowledge is power; and the significance of (d) peer networks and support. Conclusion This study further advances the evidence base of how services can be optimised to meet the complex needs of adults with CCDs following a TBI. Clinicians, researchers, and service providers should endeavour to incorporate the four core pillars outlined to enhance future CBR models of care for this clinical population.

One in six hospital beds across England is occupied by someone with diabetes. While guidance on inpatient diabetes care is available, national audit data demonstrate that people still experience significant and avoidable diabetes-related harms. This study is unique in exploring how people with diabetes admitted to hospital for any medical reason experienced diabetes care from admission to discharge. It is part of a bigger project aiming to develop and test a Patient Reported Experience Measure for inpatients with diabetes. A qualitative approach was used to explore experiences of inpatient diabetes care. Twenty-seven participants with type 1 or type 2 diabetes, hospitalised for any reason, were recruited using purposive sampling across four acute NHS Trusts in the South of England. Data collected in semi-structured interviews were analysed with reflexive thematic analysis. In diabetes care, the emphasis is on supporting people with self management of their diabetes. The inpatient care setting compromises this by limiting self management behaviours. These restrictions may apply to those who want to and can be actively involved in their diabetes care and may contribute to less effective diabetes management and poorer outcomes. For some participants in this study, diabetes self management was discouraged in three ways. First, their knowledge of their diabetes and willingness to self-manage were not taken into account on admission or in planning their inpatient diabetes care. Second, their involvement in decisions about their ongoing diabetes care was limited. Third, their needs related to diabetes management were not met because of the lack of flexibility in hospital practices and schedules. Inpatient care is not always conducive to diabetes self management. Understanding the patient experience in the inpatient setting related to self management is important in reducing harm to patients while they are in hospital. Our findings emphasise the importance of involving people with diabetes in planning and managing their care while hospitalised. Further work needs to be done to ensure that the knowledge, involvement and flexibility of care of people with diabetes are incorporated into an inpatient setting.

BackgroundModified constraint‐induced movement therapy (mCIMT) improves upper limb (UL) function after stroke. Despite up to one‐third of stroke survivors being eligible, clinical uptake remains poor. To address this, a multi‐modal behaviour change intervention was implemented across a large seven‐site early‐supported discharge (ESD) rehabilitation service. This study investigated the acceptability of mCIMT implementation within this ESD service and identified adaptations required for sustained delivery.MethodsThis qualitative study was nested within a mixed‐methods process evaluation of mCIMT implementation. Four focus groups (n = 24) comprising therapists (two groups), therapy assistants (one group), and allied health managers (one group) were conducted. Data were analysed using reflexive thematic analysis and mapped to the Theoretical Domains Framework (TDF).Consumer and Community InvolvementConsumers were not directly involved in this study; however, lived experience research partners have helped shape the larger mixed‐methods implementation study.FindingsFour themes were generated and mapped to the TDF. Factors related to acceptability included interdisciplinary practice in sharing workloads (belief about capabilities), practice opportunities across a range of UL presentations (skills), clinician attitudes influencing patient engagement (optimism), time constraints (belief about consequences), and cognitive overload from multiple systems and processes (memory, attention, and decision‐making processes). Factors facilitating sustained delivery included improving stroke survivor education (knowledge), sharing success stories across teams (reinforcement), manager facilitation (social/professional role and identity), and the perception that the ESD setting was optimal for mCIMT delivery (social influences).ConclusionmCIMT was acceptable in the ESD service, with clinicians feeling a responsibility to provide it. Key adaptations for sustained delivery included ongoing training, resource adaptation, and enhanced patient and carer engagement. Successful implementation and sustained delivery of mCIMT in the ESD service could enhance UL function and reduce the burden of care for potentially hundreds of stroke survivors and their carers.PLAIN LANGUAGE SUMMARYModified constraint‐induced movement therapy (mCIMT) helps improve arm movement after a stroke. However, many stroke survivors do not get this therapy. To fix this, we started a program in a large home‐based rehabilitation service. This study looked at how well mCIMT could fit into this service. We also wanted to know what changes were needed to make sure it was regularly provided.We held four group discussions with therapists, therapy assistants, and health managers. A total of 24 people took part.From these discussions, we found several important points. Therapists needed to work together as a team. They also needed to practice mCIMT to get better at delivering it. Therapists having a positive attitude would encourage more stroke survivors to take part. For long‐term success, stroke survivors need better education about mCIMT. Managers need to encourage therapists to provide mCIMT. The rehabilitation service should also share their success stories about this therapy to encourage therapists to deliver it and stroke survivors to ask for it.Therapists enjoyed delivering mCIMT in the rehabilitation service. It worked better than other therapies to improve a stroke survivor's arm function. Because of this, they also felt it was their duty to offer mCIMT. Having ongoing training and better resources would help keep mCIMT going. If mCIMT can be provided regularly in this service, it could lead to better arm function and less care needed for many stroke survivors and their carers.