Socially constructed ‘value’ and vocational experiences following neurological injury

Purpose: Paid work is seen as a key outcome in rehabilitation. However, research demonstrates that because of normative expectations in the job market and workplace, experiences of disability can be intensified in a work context. We sought to explore this issue in more depth by analysing the effects of societal constructions of worker ‘value’ within individual case studies of people with acquired neurological injury. Method: Instrumental case study of four heterogeneous participants, employing a discourse analysis approach. Results: Participants described a perpetuation of discourses in which a disabled body or mind itself is seen to qualify, disqualify or limit a person’s value in employment. Nevertheless, interviews also highlighted discourses that constructed other worker identities: based on pre-injury identities, life experiences and other aspects of self. The contrasts between individuals illustrated how worker identities, when situated within broader societal discourses of worker ‘value’, can either constrain or expand the vocational opportunities available to individuals who experience disability. However, current and historical interactions about worker ‘value’ shaped the identities genuinely available to each individual. Conclusion: Understanding how societal discourses enable and constrain worker identities may be vital to (a) facilitating valid opportunities and (b) navigating situations that could unintentionally hinder vocational possibilities.Implications for RehabilitationThis study shows how worker identities, situated within societal discourses of worker ‘value’, can constrain or broaden vocational opportunities available to individuals who experience disability.Barriers to gaining, maintaining and developing in employment could be re-envisaged in terms of what is limiting a person’s ability to embody an enabling identity.A knowledge of both societal discourses and individuals’ interactions with them may be vital to facilitating opportunities that users of rehabilitation services experience as valid options. This knowledge can also provide information with which to navigate situations that could potentially (sometimes unintentionally) constrain vocational possibilities

Effectiveness of vocational interventions for gaining paid work for people living with mild to moderate mental health conditions: Systematic review and meta-analysis

Objectives: To evaluate the effectiveness of vocational interventions to help people living with mild to moderate mental health conditions gain paid work. Methods: Systematic review of international, peer-reviewed literature. Development of the prepublished protocol and search strategy was done in consultation with stakeholder reference groups consisting of people with lived experience of long-term conditions, advocates and clinicians. We searched academic databases MEDLINE, EMBASE, PsychINFO, AMED, CINAHL, Proquest Dissertations and Theses database, and Business Source Complete for controlled trials comparing a specific vocational intervention against a control intervention or usual care, published between 1 January 2004 and 1 August 2019. Two authors independently screened search results, extracted data and appraised studies using the Cochrane risk of bias tool. Results: Eleven studies met inclusion criteria. Seven studies investigated Individual Placement and Support (IPS) modified for people who were not in intensive mental health treatment services. These studies occurred settings such as community vocational rehabilitation services, a housing programme and community mental health services. The studies provided very low quality evidence that people who receive IPS-style vocational rehabilitation are more likely to gain competitive employment than people who receive usual care (risk ratio 1.70, 95% CI 1.23 to 2.34, seven studies, 1611 participants). The remaining four studies considered cognitive behavioural therapy or specific vocational rehabilitation interventions designed to fit a unique context. There was insufficient evidence from these studies to draw conclusions regarding the effectiveness of non-IPS forms of vocational rehabilitation for people with mild to moderate mental health conditions. Discussion: The meta-analysis showed a clear intervention effect but low precision, and more high-quality studies are needed in this field. There is currently very low quality evidence that IPS-style intervention results in more participants in competitive employment compared with &lsquo;usual care&rsquo; control groups in populations with mild to moderate mental health conditions.</jats:sec

Facilitating return to work through early specialist health-based interventions (FRESH): protocol for a feasibility randomised controlled trial

Background Over one million people sustain traumatic brain injury each year in the UK and more than 10 % of these are moderate or severe injuries, resulting in cognitive and psychological problems that affect the ability to work. Returning to work is a primary rehabilitation goal but fewer than half of traumatic brain injury survivors achieve this. Work is a recognised health service outcome, yet UK service provision varies widely and there is little robust evidence to inform rehabilitation practice. A single-centre cohort comparison suggested better work outcomes may be achieved through early occupational therapy targeted at job retention. This study aims to determine whether this intervention can be delivered in three new trauma centres and to conduct a feasibility, randomised controlled trial to determine whether its effects and cost effectiveness can be measured to inform a definitive trial. Methods/design Mixed methods study, including feasibility randomised controlled trial, embedded qualitative studies and feasibility economic evaluation will recruit 102 people with traumatic brain injury and their nominated carers from three English UK National Health Service (NHS) trauma centres. Participants will be randomised to receive either usual NHS rehabilitation or usual rehabilitation plus early specialist traumatic brain injury vocational rehabilitation delivered by an occupational therapist. The primary objective is to assess the feasibility of conducting a definitive trial; secondary objectives include measurement of protocol integrity (inclusion/exclusion criteria, intervention adherence, reasons for non-adherence) recruitment rate, the proportion of eligible patients recruited, reasons for non-recruitment, spectrum of TBI severity, proportion of and reasons for loss to follow-up, completeness of data collection, gains in face-to-face Vs postal data collection and the most appropriate methods of measuring primary outcomes (return to work, retention) to determine the sample size for a larger trial. Discussion To our knowledge, this is the first feasibility randomised controlled trial of a vocational rehabilitation health intervention specific to traumatic brain injury. The results will inform the design of a definitive trial

Returning to work after stroke: perspectives of employer stakeholders, a qualitative study.

Purpose: More than 40 % of working age adults with stroke fail to return to work. The work context is a key factor in return to work, but little is known about the experiences of employers in supporting employees with stroke. The aim of this study was to explore return to work after stroke from the employer perspective, to identify key features associated with success and to seek participants’ views regarding the role of healthcare in return to work. Methods: Data was gathered through 18 semi-structured interviews with employer stakeholders and included small business owners, line managers, human resources and occupational health staff. Data was analysed thematically. Results: The main themes identified were: the impact of stroke on the employer, characteristics of the employee, communication, knowledge and information, experience of other stakeholders, integrating healthcare in return to work. Conclusion: Employers face complex emotional and practical issues when helping an employee return to work after stroke, for which many lack knowledge and experience. The range and quality of support networks that they access is variable and advice and support from clinicians is welcomed. Further research is necessary to investigate how such support could be funded and integrated within existing service provision

Illness perceptions and work participation: a systematic review

Self-regulatory processes play an important role in mediating between the disease and the health outcomes, and potentially also work outcomes. This systematic review aims to explore the relationship between illness perceptions and work participation in patients with somatic diseases and complaints. The bibliographic databases Medline, PsycINFO and Embase were searched from inception to March 2008. Included were cross-sectional or longitudinal studies, patients with somatic diseases or complaints, illness perceptions based on at least four dimensions of the common sense model of self-regulation, and work participation. Two longitudinal and two cross-sectional studies selected for this review report statistically significant findings for one or more illness perception dimensions in patients with various complaints and illnesses, although some dimensions are significant in one study but not in another. Overall, non-working patients perceived more serious consequences, expected their illness to last a longer time, and reported more symptoms and more emotional responses as a result of their illness. Alternatively, working patients had a stronger belief in the controllability of their condition and a better understanding of their disease. The limited number of studies in this review suggests that illness perceptions play a role in the work participation of patients with somatic diseases or complaints, although it is not clear how strong this relationship is and which illness perception dimensions are most useful. Identifying individuals with maladaptive illness perceptions and targeting interventions toward changing these perceptions are promising developments in improving work participatio

Problematizing ‘Productive Citizenship’ Within Rehabilitation Services: Insights From Three Studies

Background: The idea that everyone should strive to be a ‘productive citizen’ is a dominant societal discourse. However, critiques highlight that common definitions of productive citizenship focus on forms of participation and contribution that many people experiencing disability find difficult or impossible to realize, resulting in marginalization. Since rehabilitation services strive for enablement, social participation, and inclusiveness, it is important to question whether these things are achieved within the realities of practice. Our aim was to do this by examining specific examples of how ‘productive citizenship’ appears in rehabilitation services. Methods: This article draws examples from three research studies in two countries to highlight instances in which narrow understandings of productive citizenship employed in rehabilitation services can have unintended marginalizing effects. Each example is presented as a vignette. Discussion: The vignettes help us reflect on marginalization at the level of individual, community and society that arises from narrow interpretations of ‘productive citizenship’ in rehabilitation services. They also provide clues as to how productive citizenship could be envisaged differently. We argue that rehabilitation services, because of their influence at critical junctures in peoples’ lives, could be an effective site of social change regarding how productive citizenship is understood in wider society.Implications for rehabilitation ‘Productive citizenship’, or the interpretation of which activities count as contributions to society, has a very restrictive definition within rehabilitation services. This restrictive definition is reflected in both policy and practices, and influences what counts as ‘legitimate’ rehabilitation and support, marginalizing options for a ‘good life’ that fall outside of it. Rehabilitation can be a site for social change; one way forward involves advocating for broader understandings of what counts as ‘productive citizenship’

Interrogating discourse: the application of Foucault’s methodological discussion to specific inquiry

Discourse analysis following the work of Michel Foucault has become a valuable methodology in the critical analysis of a broad range of topics relating to health. However, it can be a daunting task, in that there seems to be both a huge number of possible approaches to carrying out this type of project, and an abundance of different, often conflicting, opinions about what counts as ‘Foucauldian’. This article takes the position that methodological design should be informed by ongoing discussion and applied as appropriate to a particular area of inquiry. The discussion given offers an interpretation and application of Foucault’s methodological principles, integrating a reading of Foucault with applications of his work by other authors, showing how this is then applied to interrogate the practice of vocational rehabilitation. It is intended as a contribution to methodological discussion in this area, offering an interpretation of various methodological elements described by Foucault, alongside specific application of these aspects