Early intervention vocational rehabilitation for people with newly-acquired spinal cord injuries

Abstract

Work is increasingly viewed as an important part of life after spinal cord injury (SCI). A vast, multidisciplinary research field has highlighted the barriers and facilitators of returning to work (RTW) for this population, yet employment rates remain consistently low. The development of targeted vocational rehabilitation (VR) interventions has increased in the twenty-first century to address this issue, with one such family of interventions operating within primary rehabilitation. Early intervention vocational rehabilitation (EIVR) aims to intervene at the earliest appropriate time after injury to ultimately diminish the latency between injury and RTW. The outcomes of this emerging field are promising, but the research supporting these interventions is focused largely on clinical outcomes, potentially overlooking the experiences of the consumer. Qualitative research could complement the existing research base by providing the consumer’s viewpoint on EIVR interventions, centralising the consumers’ perspective in the ongoing development and refinement of EIVR. This study aimed to explore the consumer’s account of EIVR in the words of participants of the Back2Work program, an EIVR program operated in South-East Queensland, Australia. The research questions related to participants’ experiences of the program and their subsequent RTW pathways post-discharge. The process of researching these questions revealed a methodologically complex literature field, and implied the existence of common mechanisms that underpin the success of EIVR. Thus, the project was undertaken in three phases in order to a) clarify the extant literature base and establish conceptual frameworks for EIVR, and b) elucidate the consumer’s viewpoint of EIVR. To address the research questions, the study utilised a large systematic literature review and a qualitative, longitudinal design. The findings of the systematic review (Phase 2) were used to further inform the development of the qualitative project (Phase 3). The Phase 3 design aimed to capture participants’ attitudes and experiences within one year of discharge from the hospital-based EIVR program. Participants were interviewed at three time points—as close to discharge from hospital as possible, three months after the first interview and again three months after the second interview. Though efforts were made to recruit participants as close to discharge as possible, recruitment difficulties meant that some participants were recruited later post-discharge than others. Participants were asked to describe their RTW journeys thus far, reflect on challenges and areas of need, and highlight sources of support in their RTW journeys. The data were analysed using an interpretative phenomenological framework. The findings revealed two distinct trajectories of RTW: a potential ‘fast track’ involving return to the prior employer, and a more complex pathway when employment with a new employer or a different role was sought. Analysis revealed a trajectory of increasing readiness to engage with services, plan and eventually enact a RTW. Importantly, data suggested that this trajectory was staged, with distinct attitudinal shifts at each stage. These were contextualised within the transtheoretical (‘stages of change’) model of health behaviour change, providing targets for potential intervention to increase participant readiness. EIVR was valuable in supporting participants to progress through planning and enacting their RTW. Participants described a hope-inspiring process of planning, goal setting, strategising and support when speaking to the employer. The findings also suggested that EIVR reaches beyond pragmatic vocational support to also inspire hopefulness and empower consumers, working towards restoring autonomy during a time when participants’ independence was challenged. EIVR is theoretically underpinned by the notion that those who RTW sooner generally do so with their previous employer. The person’s attachment to their employer, or occupational bond, is capitalised upon to preserve pre-injury jobs. Despite the importance of the occupational bond within EIVR, these is very little research that directly investigates the concept. Rather, there are many smaller studies that explore concepts which conceptually overlap or are adjacent to occupational bonding. This study affirmed the existence of the occupational bond, and extended the conceptualisation of this construct to include attachment to the world of work in general. It seems that EIVR can promote supportive contact with the employer, and reinforce the salience of work within consumers’ rehabilitation programs, to protect the occupational bond and facilitate strong connections to work, ultimately encouraging RTW. This study addressed the knowledge gap relating to consumers’ perspective of EIVR services. It supported the early timing of EIVR, concluding that readiness to RTW is a staged process, beginning with readiness to engage with VR and moved through to readiness to implement the RTW program. The findings of this highlighted the role of EIVR in inspiring hope and empowering consumers after SCI as complementary to the broader rehabilitation program. Also complementary is the use of employment-related goals, which consumers report are very meaningful, and therefore, drive motivation to engage with rehabilitation. The study affirmed that EIVR addresses a clear need in early rehabilitation to support consumers’ working lives, providing them with clarity and hope regarding their employment situation and a sense of confidence in their long-term career pathways.