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

1. The individual or the environment?: Workplace-based 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.

2. Introduction • 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)

3. 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).

4. 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).

5. 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).

6. The 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)

7. Vocational outcomes often unrelated to 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)

8. Advantage of studying vocational behaviour post 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.

9. The 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

10. 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.

11. 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.

12. 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.

13. Method 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.

14. RESULTS: Attributes of the individual reported as barriers

15. RESULTS: Attributes of the job reported as barriers

16. RESULTS: Attributes of the work environment reported as barriers

17. RESULTS: Attributes of the non-work environment reported as barriers

18. RESULTS: “System” attributes reported as barriers

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

20. Discussion • 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.

21. 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).

22. 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

23. 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.

24. Discussion (cont’d) • With respect to non-work environment characteristics, the lack of suitable transport is an obvious barrier to job seeking or RTW.

25. 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?

26. 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).

27. 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.

28. 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).

29. Conclusion • 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”.

30. Thank you.

31. References • 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.

32. References 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.

33. References • 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.

34. References • 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.

35. References • 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.

36. References • 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.