The individual or the environment?: Workplace-The individual or the environment?: Workplace-based barriers to return to workbased barriers to return to work

Gregory C. Murphy, Ph.D.

School of Public Health

La Trobe University

Paper for the national Comcare conference, Canberra, 25-26 October, 2007.

IntroductionIntroduction

Traditionally, vocational services have been considered central to the rehabilitation effort, and return to work was the gold standard as an index for evaluating the success of rehabilitation (Rusk, 1949: Guttmann, 1954; Brittell, 1991; Levi, 1996)

Introduction (cont’d)Introduction (cont’d)

Rehabilitation medicine authorities within the field of SCI rehabilitation have been especially clear in their promotion of vocational services as central to the attainment of maximal rehabilitation outcomes (Guttmann, 1954; Brittell, 1991).

Introduction (cont’d)Introduction (cont’d)

Neff (1971) in his classic early rehabilitation psychology text considered that, in the United States at least, “‘vocational rehabilitation’ and ‘rehabilitation’ [were] virtually synonymous terms” (p. 113).

Introduction (cont’d)Introduction (cont’d)

The values of Western societies and the priorities of health services have changed over recent years, since there is evidence that rehabilitation is losing its vocational focus (see Garvin, 1981; Murphy, 1991; Young et al., 2004).

The validity of an employment focusThe validity of an employment focus

The utility of a vocational focus within rehabilitation service delivery is supported by the scientific literature describing the relationship between “employment” and “improved health and well being” (see Murphy & Athanasou, 1999; McKee-Ryan et al., 2005)

Vocational outcomes often unrelated Vocational outcomes often unrelated to degree of impairmentto degree of impairment

Research into vocational potential following serious injury such as SCI suggests that, in terms of employment outcomes, there is a wide variation and that these variations are largely unrelated to the extent of injury or degree of impairment (see Levi, 1996; Murphy et al., 2003)

Advantage of studying vocational behaviour Advantage of studying vocational behaviour post traumatic spinal cord injurypost traumatic spinal cord injury

The traumatic spinal cord injured population receives essentially homogeneous treatment (because all patients within a geographical area receive treatment at a single Spinal Injuries Unit, and most units within Australia follow a similar approach to medical and physical rehabilitation).

Thus, variation in outcomes cannot be attributed to variation in treatment or rehabilitation hospital service.

The present studyThe present study

The current study is part of a program of research into SCI rehabilitation which seeks to establish– vocational achievement following SCI– the predictors of post-injury employment– the development of (vocational) services to

promote community re-establishment following SCI injury, including enhanced return-to-work outcomes

The present study (cont’d)The present study (cont’d)

Aim: To identify barriers to return to work (post traumatic SCI) reported by a sample of 36 individuals. Particularly of interest were workplace-based barriers, as workplace variables have been relatively underinvestigated within occupational rehabilitation research (see Foreman & Murphy, 2005)

Study inclusion criteria were: (i) pre-injury employed; and (ii) discharged at least 2 years, but no more than 4 years.

The present study (cont’d)The present study (cont’d)

Participants : Within the sample of 36 individuals, 15 were without compensation, 15 were in receipt of Transport Accident compensation, and 6 were covered by workers’ compensation.

The present study (cont’d)The present study (cont’d)

Participant characteristics : – Male:female ratio was 78:22.– Paraplegia:tetraplegia ratio was 53:47.– Previous education: 61% had gained year 12.– Employment status at interview: 69.4 % employed, and

within these, almost a third were self-employed.– Hours worked: range, 13-60; mean approximately 30

hours.– Satisfaction with current occupational situation: 81%

satisfied.

Method and data analysisMethod and data analysis

Semi-structured interview, usually conducted in domestic setting, or (occasionally) conducted by phone.

In line with previous research findings (see Murphy & Young, 2006), data re barriers were to be allocated to one of four main categories: Characteristics of the individual, of the job, of the work environment, of the non-work environment.

Inter-rater reliability of the allocation to categories was .98.

RESULTS: Attributes of the RESULTS: Attributes of the individual reported as barriersindividual reported as barriers

Characteristics reported more than once n

Physical limitations threaten capacity to meet job demands

11

Lack of self motivation 6

Reduced concentration 2

Time needing to elapse before attempting a RTW 2

RESULTS: Attributes of the job RESULTS: Attributes of the job reported as barriersreported as barriers

Characteristics reported more than once n

Overly physically demanding position 11

No other job characteristic reported more than once

RESULTS: Attributes of the work RESULTS: Attributes of the work environment reported as barriersenvironment reported as barriers

Characteristics reported more than once n

Lack of wheelchair access 4

Negative attitude of employer representatives re OH&S or insurance issues

3

Limited suitable positions available 2

RESULTS: Attributes of the non-RESULTS: Attributes of the non-work environment reported as work environment reported as

barriersbarriersCharacteristics reported more than once n

Transport difficulties 6

Lack of access to employment-related support services while in rehabilitation

6

Adverse physical terrain 5

Lack of access to support for training 2

Limited funding for carers (who could facilitate RTW)

2

RESULTS: “System” attributes RESULTS: “System” attributes reported as barriersreported as barriers

Characteristics reported more than once n

Lack of access to knowledgeable health supports once leaving in-patient rehabilitation

17

Lack of access to peers 8

Distance from rehabilitation, family or work 7

Lack of required employment-related information provided while in rehabilitation (e.g., information re obtaining driver’s licence)

6

Insufficient support from rehabilitation therapy staff re preparing for a RTW

5

RESULTS: “System” attributes RESULTS: “System” attributes reported as barriers (cont’d)reported as barriers (cont’d)

Characteristics reported more than once n

No financial advantage to RTW 3

Inadequate financial resources meant that a RTW had to be attempted prematurely

3

DiscussionDiscussion

Aim was to discover both “individual” and “environmental” factors reported as interfering with RTW (“barriers”).

The factors reported by participants as impacting on their post-injury vocational attainments were varied but included some individual as well as environmental factors that had good potential for use in interventions to enhance post-injury vocational achievement.

Discussion (cont’d)Discussion (cont’d)

While this was a group with high vocational potential (see above average pre-injury education, and above average post-injury employment rate), some of the individual factors mentioned suggest room for psychosocial interventions likely to be successful (e.g., motivational interviewing, exposure to successful models).

Discussion (cont’d)Discussion (cont’d)

With respect to job characteristics, what job accommodations and/or equipment modifications were available or had been explored by a health professional?

?Extent of use of Occupational Physicians for this purpose

Discussion (cont’d)Discussion (cont’d)

With respect to work environment characteristics, (holding aside wheelchair access issues that may have been unmanageable) what employer education had been undertaken?

Particularly important are the attitudes of immediate supervisors.

Discussion (cont’d)Discussion (cont’d)

With respect to non-work environment characteristics, the lack of suitable transport is an obvious barrier to job seeking or RTW.

Discussion (cont’d)Discussion (cont’d)

With respect to system barriers, there were a number of reported vocational rehabilitation service gaps.

In a busy hospital environment, how can vocational services be provided when needed to complement the physical rehabilitation services currently dominating in-patient programs?

What partnerships between hospitals and external parties might be effective re RTW?

Discussion (cont’d)Discussion (cont’d)

Study limitations: The main study limitation has to do with the

atypical (higher) pre-injury education of the sample. No participant mentioned job-related barriers beyond the obvious physical challenges facing those with SCI who attempt to perform many jobs. According to Fine and Wiley’s job analysis scheme, jobs generally have a data component and a people component, as well as a physical component (Fine & Wiley, 1971).

Discussion (cont’d)Discussion (cont’d)

Study limitations (continued): Surveying more of those with less formal education would

have given appropriate opportunity for better exploration of non-physical job demands facing those with SCI who attempt to RTW.

A secondary “limitation” was the reported high (>80%) degree of reported satisfaction with current occupational situation at the time of survey. This suggests a bias in the recruitment so that those who agreed to participate were either those who were satisfactorily employed and/or who were happy not to be employed.

Discussion (cont’d)Discussion (cont’d)

Self-employment issues seem central to a number of returns to the labour force. Rehabilitation Counsellors traditionally are ignorant of self employment (see Arnold, 2003).

ConclusionConclusion

Interviewees reported both individual and workplace barriers that were amenable to intervention by rehabilitation service delivery staff; in addition, wider environmental and system factors were reported to be inhibiting RTW achievements.

The latter set of factors call into review the adequacy of resource allocation within the health and rehabilitation “system”.

Thank you.

ReferencesReferences

Arnold, N., Seekins, T., Ipsen, C. & Colling, K. (2003). Self-employment for people with disabilities in the United States. Australian Journal of Career Development, 12, 58-65.

Britell, C. (1991). Why aren’t they working? Journal of the American Paraplegia Society, 15 (1), 1-2.

Fine, S. and Wiley, W. (1971). An introduction to functional job analysis. Washington, DC: Upjohn Institute.

Foreman, P. and Murphy, G. (2005). Return to work: Barriers and facilitators. Melbourne: AIPC, La Trobe University.

ReferencesReferences

Garvin, R. (1981). Vocational guidance and counselling: The core of the rehabilitation process. Journal of Applied Rehabilitation Counselling, 12, 205-207.

Guttmann, L. (1954). Statistical survey of one thousand paraplegics and initial treatment of traumatic paraplegia. Proceedings of the Royal Society of Medicine, 47, 1099.

ReferencesReferences

McKee-Ryan, F. et al. (2005). Psychological and physical well-being during unemployment. Journal of Applied Psychology, 90, 53-76.

Murphy, G., Brown, D. Foreman, P., Athanasou, J. & Young, A. (1997). Labour force participation and employment among a sample of Australian patients with a spinal cord injury. Spinal Cord, 35, 238-244.

ReferencesReferences

Murphy, G., & Young, A. (1998). Contradictory effects of social support in rehabilitation. Australian Journal of Primary Care, 4, 8-17.

Murphy, G., & Athanasou, J. (1999). The effect of unemployment on mental health. Journal of Occupational and Organisational Psychology, 72, 83-99.

Murphy, G. & Young, A. (2006). Employer-based facilitators of return to work following disabling injury. International Journal of Disability Management Research, 1, 125-134.

ReferencesReferences

Murphy, G., Young, A., Brown, D. & King, N. (2003). Explaining labour force participation following spinal cord injury: The contribution of psychological variables. Journal of Rehabilitation Medicine, 35, 276-283.

Murphy, G. (1991). Vocational rehabilitation: A review with implications for service delivery. In Rehabilitation: Restoring purpose, place and pride. Melbourne: Commonwealth Rehabilitation Service.

Neff, W. (1971). Rehabilitation psychology. Washington, D.C.: APA.

ReferencesReferences

Young, A. & Murphy, G. (2003). Vocationally-oriented rehabilitation service requests: The case of employed persons experiencing spinal cord injury. Australian Journal of Career Development, 12, 17-24.

Young, A., Webster, B., Giunti, G., Pransky, & Nesarthurai, S. (2004). Services provided following work-related tetraplegia. Spinal Cord, 42, 248-260.