Reflections of a rehabilitation professional: Research 5 – answering a complex question – assessing RTW

When is an easy question a difficult one? The answer is when you want to evaluate a VR programme.

One might think that assessing one’s success in achieving a good outcome is simple – when did the disadvantaged individual (DI) return to work (RTW)? but in fact it is much more complicated. The issues seem to revolve around the following areas:-

1. When does one make the assessment?
2. What issues should determine the outcome
3. Severity of the DI’s health problem(s)
4. Pre-injury/illness factors that may influence outcome.
5. When does one make the assessment? This may reflect commissioners of service requirements – they may want to know results at a predetermined time e.g. 3-months or 1-year. Clearly, on its own, this is not satisfactory as many outcomes will take shorter or longer periods of time. In addition, many VR professionals (VRPs) feel it is essential to be able to provide further support after RTW has taken place and documenting this is important. If, on the other hand, one takes consideration of completion of a vocational rehabilitation (VR) process, then timing can be measured, but what are the issues that determine a good outcome?
6. In the ideal world, every DI would RTW full time, but this is not possible for many, and where possible, other factors will need to be documented e.g. with or without:

• reasonable adjustments
• working from home
• need for mentoring/extra support
• same or different employer

In reality, we recognise that other satisfactory results arise which are the best achievable:

• Working part time less than, or more than, say 16 hours or twenty hours per week (See issues around part-time/flexible working [1]
• Permitted work
• Voluntary work
• Starting retraining
• Returning to further education part or full time
• Retirement

3. Clearly the base of disadvantage that one is starting off with may be critical to any outcome. Such measurements may be generic – just reflecting a measure of disability e.g. the Barthel Index [2], or a problem-specific score e.g. for back pain [3] or neck pain [4]. It is best to choose a simple score that can be easily used without taking too much time and which is used by other teams so that comparison can be made between teams. Linking with universities can enable more time consuming and more detailed assessment to be made by allocating measurements to externally funded researchers. This also has the clear advantage that the external assessor can be blind to the nature and timing of any interventions.
4. Other factors may also be important to understand, and to document where possible. This review cannot cover all the important facets of the DI’s personality, but some important factors relating to RTW include their level of education [5], [6], [7], beliefs and expectations regarding RTW [5], [8], [9] work motivation [10], [11] and locus of control [5], [12]. Many will feel that some assessment of mental health should be performed on all DIs at commencement of their programme and at the end – which has the benefit of documenting any improvements in the DI’s mental state. Clearly showing clinical improvements is valuable even if RTW is not achieved.

Being in work prior to therapy [13] and a high level of job satisfaction prior to illness [14] increase the chances of a RTW. Work motivation is a complex concept which may be influenced by many factors including comorbid psychological difficulties, access to good support (both from employer and other sources e.g. family and health professionals [15], [16], [7], fear of discrimination or of losing benefits [7], feelings of vulnerability [16] etc.

Conclusions

The first important issue is to document very clearly the findings of your initial assessment:-

• Where possible in an objective format (assists before and after evaluations)
• Document factors that might influence outcome e.g. level of education
• Agree with your purchasers/commissioners your how outcome should be measured – after all they are paying for your time doing the assessments.

I would be delighted to know how any teams are doing with the measurements of outcomes – something that the VRA may take an interest in sometime.

This concludes my reflections on research unless you feel that there are other areas to explore or issues to take more thoroughly?

I am happy to discuss any of the issues raised in these reflections with colleagues who can email me and head the email VRA – professional reflections.

Andrew Frank

Trustee and Past-Chair, VRA

References

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10. Karlsson P. Assistive technology in the classroom for students with cerebral palsy: “The team approach, the number one key to making it successful”. Developmental Medicine and Child Neurology, 2016; 58: p. 43. Papers (wiley.com)
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12. Torres X et al. Pain locus of control predicts return to work among Spanish fibromyalgia patients after completion of a multidisciplinary pain program. General Hospital Psychiatry, 2009; 31(2): 137-145.
13. Black, Dame Carol. An Independent Review into the impact on employment outcomes of drug or alcohol addiction and obesity. London: Department for Work and Pensions, 2016
14. Fiabane E et al. Does job satisfaction predict early return to work after coronary angioplasty or cardiac surgery? International Archives of Occupational and Environmental Health 2013; 86(5): 561-569.
15. Imber D. and Booth D. Employment advice – what works for disadvantaged people. 2015, step: skills training for effective practice. STEP_Research_paper_Employment_advice_for_disadvantaged_people_en.pdf