Abstract
The aim of this systematic review was to compile the evidence for early vocational rehabilitation interventions for people with major injury or illness. Embase, Scopus, Cochrane Library, Medline, CINAHL, and Psycinfo databases were searched. Five hundred abstracts were reviewed for eligibility. Full-text review of 125 studies revealed a total of 25 published studies that met the eligibility criteria to be included in this review evaluating early approaches to vocational rehabilitation and return to work. Findings suggest that intervening early with respect to an individual’s vocational goals is imperative, although the definition of “early” varies. Programs achieve better vocational outcomes when specifically employing comprehensive vocational interventions, including vocational assessment, individualized planning, and follow-up support, to ensure a person’s return to employment is timely and sustained. Integration of vocational rehabilitation professionals within a multidisciplinary team and access to advocacy services were shown to be effective inclusions in early vocational rehabilitation programs for people with a serious injury or illness.
Employment is one of the most important areas of participation for people of working age. Meaningful employment is associated with several important indices of health, including physical, social, and mental health and well-being (The Australasian Faculty of Occupational and Environmental Medicine, 2015; Waddell & Burton, 2006). Across injury groups, people who are employed report a better sense of well-being, higher quality of life, less health service usage, and a better health status than nonemployed people (Manns & Chad, 2001; O’Neill et al., 2004; Wehman et al., 2005). Work is often a major area of disruption after serious injury or illness, with people often requiring periods of paid and unpaid sick leave, changes to their work environment and hours, and in some cases the cessation of a role altogether (Bylund & Björnstig, 1998; Radford et al., 2018). These disruptions in a person’s career trajectory are not only costly from a social perspective, but also from an economic perspective for both the individual and employer involved.
There is a burgeoning body of evidence pertaining to the benefits of an early, integrated approach to vocational rehabilitation (VR; Bond et al., 1995; Middleton et al., 2015; Reid-Arndt et al., 2007). This approach involves the commencement of conversations, planning, and actions relating to work resumption earlier than has traditionally been espoused in health systems. Conventional rehabilitation approaches have generally held vocational intervention as inappropriate in the primary rehabilitation phase due to the significant adjustments a person must undertake. Thus vocational intervention has typically been delivered post-discharge from hospital or the acute rehabilitation setting, through referral to disability employment services or via insurance-funded rehabilitation providers. Early intervention therefore refers to vocational services which may commence predischarge, or during the primary rehabilitation phase.
This new, earlier approach often requires specialty vocational “in-reach” expertise delivered within the hospital setting (Middleton et al., 2015; van Velzen et al., 2016), or the addition of vocational practitioners in the primary rehabilitation team (Reid-Arndt et al., 2007). Studies have suggested that this inclusion of VR can help with patient adherence to other functional rehabilitation goals and improve quality of life and psychological well-being (Avesani et al., 2005; Bell et al., 2005; Drake et al., 1996; Fadyl & McPherson, 2010), perhaps by adding greater meaning or purpose to rehabilitation tasks. Furthermore, the latency at which VR services are offered has been indicated as an important factor in predicting long-term employment outcomes; with earlier service delivery being associated with improved vocational outcomes (Babineau, 1998; Kendall et al., 2006; Malec et al., 2000). Results from studies examining earlier provision of VR indicate its potential effectiveness in enhancing employment outcomes for people who have sustained serious injury.
Given the emerging support for earlier VR and increasing recognition of the wide-ranging benefits of work on a person’s life, further development of a vocational focus within the primary health phase appears warranted. This will require researchers and clinicians to collaboratively work toward establishing evidence and best practice frameworks to inform VR programs that support people with major barriers to employment, early on in their rehabilitation. The aim of this review is to analyze the existing evidence for early VR interventions for people with major injury or illness. The guiding research questions for the systematic review were as follows:
Which serious injury/illness populations have been researched in relation to early VR interventions?
What methods have been used to evaluate early VR interventions for people with serious injury/illness?
What were the outcomes of these interventions with people with serious injury/illness?
Method
This systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009). Figure 1 contains the PRISMA flow diagram. The search and collation was conducted between January and September 2018 and included English-language studies published in Embase, Scopus, Cochrane Library, Medline, CINAHL, and Psycinfo databases since January 1961. Search terms were as follows: “disability management” OR “vocational rehabilitation” OR “occupational rehabilitation” OR “return-to-work” OR “return* to work” OR “work-directed” OR “work directed” OR “job re-entry AND ([intervention* OR therap* OR service* OR program*] AND [earl*] OR ‘early intervention”) AND severe OR serious OR traumatic OR “spinal cord” OR amputation OR “poly trauma” OR polytrauma OR “multiple trauma” OR “blast injur*.” The individual terms “injury” and “illness” were not included as this led to results being far too broad and irrelevant for the aims of the study. Instead, the remaining concepts such as “severe,” “serious,” and “trauma,” for example, captured only articles addressing injury populations targeted for the review.
PRISMA flow diagram.
These terms yielded a total of 882 studies. A search through the reference lists of several of these articles provided 72 additional references, which resulted in a total of 954 studies. After duplicates were removed, the abstracts of the remaining 500 articles were reviewed by the two authors. Review of the 500 abstracts identified 125 published studies as relevant for full-text review. The full-text review process was shared by both authors, with consistency ensured through consensus meetings where reasons for inclusion or exclusion required unanimous agreement. Subsequently, a final number of 25 studies met the inclusion criteria for this review. The inclusion criteria required articles to be peer-reviewed original research papers; published in English with available abstract; addressing at least a subsample of serious or major illness or injury, with at least moderate severity; and interventions that were focused on vocational/work outcomes and commenced earlier than traditional services (i.e., in the hospital/in-patient setting). Excluded from this review were theses and literature reviews; studies solely covering injuries of mild severity; and studies with non-working age populations.
Quality Appraisal
Studies were evaluated using the Mixed Methods Appraisal Tool (MMAT; Pluye et al., 2011) designed for systematic reviews, which include quantitative, qualitative, and mixed-methods studies. The MMAT was chosen for its efficiency and reliability (Souto et al., 2014). It includes four criteria each for qualitative and quantitative studies, with additional criteria for mixed-methods studies. Scores are calculated as a percentage of criteria met. The overall quality of the articles included in this review was moderate to high. Of the 25 studies, 8 (32%) scored 100% on the MMAT, 11 (44%) scored 75%, and 6 (24%) scored 50%. No studies scored below 50% and all were considered of sufficient quality to be retained in the study. The majority of studies were quantitative (86%), 2 (7%) were qualitative, and 2 (7%) used a mixed-methods design. The most common sources of bias in the quantitative studies were missing data (38.5%) and selection bias in recruitment (30%). Bias in measurement was reported in 19% of the studies.
Results
Characteristics of Studies and Participants
Twenty-five studies evaluating early VR and return to work (RTW) after serious injury or illness were included in the review. Most studies were conducted in high-income countries, with most describing research from the United States of America (n = 11; 44%), while another five were conducted in the United Kingdom (20%), three in Sweden (12%), two in Australia (8%), one in Italy (4%), one in Norway (4%), one in Germany (4%), and one study (4%) was an international multicentre trial from the United Kingdom, Germany, Switzerland, Netherlands, Bulgaria, and Italy.
Most of the studies were quantitative (96%) with the majority (n = 18, 72%) being designed as prospective longitudinal studies. Three studies (12%) were randomized controlled trials (RCTs) and two (8%) were retrospective studies. The two qualitative studies were conducted using interviews and the two mixed-methods designs used retrospective survey design followed by interviews in their follow-up. Overall, 3,003 participants were investigated by the studies included in this review. The mean age of participants was 37 years, with the age range 14 to 80 years. Out of those studies that reported this information, most participants were Caucasian (63%) and male (59%), and most participants were employed (54%) in either part-time or full-time employment at the time of their injury.
The mean time since injury to program commencement and the definition of “early” intervention varied widely across the injury types and are therefore described in more detail in a specific section for each injury group. All 25 studies (100%) investigated either vocational interventions or included a vocational aspect in their interventions. Studies were generally multidisciplinary (n = 12; 48%) and involved psychological or educational interventions (16; 64%), physical interventions (10; 40%), occupational therapy (9; 36%), speech therapy (7; 28%), social work (7; 28%), or physiotherapy (4; 16%). The studies investigated VR and RTW associated with brain-related injuries (15; 60%), severe psychological illness (SPI: 7; 28%), and spinal cord injury (SCI: 3; 12%).
Brain Injuries
Most studies (15; 60%) focused on brain-related injuries such as acquired brain injury (ABI) and traumatic brain injury (TBI; Aas et al., 2018; Avesani et al., 2005; Bell et al., 2005; Buffington & Malec, 1997; Grant et al., 2014; Hofgren et al., 2010; Lippert-Grüner et al., 2003; Micklewright et al., 2011; Murphy et al., 2006; Radford et al., 2013; Reid-Arndt et al., 2007; Sörbo et al., 2005; van Velzen et al., 2016). Seven studies included a sample with severe injuries (Foy, 2014; Lippert-Grüner et al., 2003; Micklewright et al., 2011; Murphy et al., 2006; Radford et al., 2013; Sörbo et al., 2005; van Velzen et al., 2016), two with moderate to severe injuries (Bell et al., 2005; Hofgren et al., 2010), two with mild to moderate injuries (Aas et al., 2018; Avesani et al., 2005), two with mild to severe injuries (Buffington & Malec, 1997; Radford et al., 2018), and one study did not report on the severity of the sample injuries (Reid-Arndt et al., 2007). The timing of early intervention ranged from one day (Micklewright et al., 2011) to 12 months for a few severe cases (Buffington & Malec, 1997) with a median of 17.5 days post-injury.
Interventions investigating ABI were primarily vocational in nature and included vocational assessment and monitoring (Aas et al., 2018; Buffington & Malec, 1997; Foy, 2014; Libeson et al., 2018; Murphy et al., 2006; Radford et al., 2013, 2018; Reid-Arndt et al., 2007; van Velzen et al., 2016). For example, Radford et al. (2013, 2018) assessed a program of Early Specialist Traumatic Brain Injury Vocational Rehabilitation (ESTVR) targeted at job retention. The intervention was individualized, taking into consideration an individual’s functional capacity and vocational aspirations. It included job training, opportunities to practise work skills, and additional help depending on patient needs. ESTVR was provided for 1 year, and patients were followed up on their vocational progress for up to 3 years if needed. The intervention was commenced relatively early, from 10 days to 10 weeks after hospital discharge. Similarly, the intervention reported by Buffington and Malec (1997) assigned a vocational case coordinator to assess vocational readiness and goals in participants, as well as provide vocational counseling and education targeting individual needs in relation to career change after injury.
Other approaches included multidisciplinary teams of health professionals that focused on physical, occupational, speech, and psychological rehabilitation, indirectly improving vocational outcomes (Bell et al., 2005; Hofgren et al., 2010; Sörbo et al., 2005) with some delivering the therapy in intensive mode (Avesani et al., 2005; Lippert-Grüner et al., 2003). The study by Micklewright et al. (2011) investigated a neuropsychological approach focused on remediating cognitive, neurobehavioral, and affective deficits after brain injury, as a means of supporting independent living and working. Finally, a telephone-based intervention providing support in information seeking, mentoring, and problem solving was also assessed in relation to RTW recovery after ABI (Bell et al., 2005).
Post-intervention outcomes in ABI
The mean RTW rate at 1-year post-injury in the ABI group was 49%. Some studies reported very high RTW rates between 70% and 80% (Buffington & Malec, 1997; Radford et al., 2013, 2018), while others reported much lower rates of 30% to 40% (Lippert-Grüner et al., 2003; Sörbo et al., 2005) and even as small as 18% (Hofgren et al., 2010). The studies’ samples did not differ in terms of injury severity (i.e., mostly moderate to severe ABI); however, the studies with smaller RTW rates rarely used vocational-specific interventions. The studies with higher RTW rates employed a vocational intervention where specific vocational goals were assessed, monitored, and evaluated over time. The other key differentiating factor in those that achieved higher RTW rates was that the intervention was received early, from 10 days post-hospital discharge. Conversely, the study that was solely focused on improving physical functioning with a primary outcome of RTW but without vocationally specific intervention showed the lowest RTW rates.
Intervention gains seem to gradually improve over time with most participants returning to work between 3- and 6-month post-intervention (Buffington & Malec, 1997; Radford et al., 2013, 2018). For example, the majority of participants in Radford et al.’s (2018) study returned to work within the first 3 to 6 months. Buffington and Malec (1997) found that the mean time taken to RTW was 3.7 months. Similarly, Radford et al. (2013) found that 20% of their sample returned to work at four weeks, 64% at three months, 75% at six months with no further improvements at 12 months. The majority of intervention gains were shown to occur within the first six months post-injury and there appeared to be a positive correlation between early VR and RTW between 3 to 6 months following the interventions.
Commencing the intervention early appears to have other positive implications, including better social integration and emotional well-being as well as less reliance on other program resources, such as transitional community support and counseling (Reid-Arndt et al., 2007). Another study found that a significantly higher percentage of the participants in early formalized rehabilitation were living and working independently at discharge and at 1-year follow-up (Micklewright et al., 2011) and had better outcomes in neurological and day-to-day functioning in comparison to the group that received late or no formalized rehabilitation (Sörbo et al., 2005). However, not all the patients returned to a full-time position or to their preinjury roles (Radford et al., 2018), indicating that significant adjustment may be needed for successful RTW recovery.
RTW facilitators in ABI
Being a woman, of younger age, with less severe TBI, independent in daily activities, and with less need for rehabilitation, were all found to be associated with a higher rate of RTW (Aas et al., 2018; Hofgren et al., 2010; Radford et al., 2013). Noncomorbidity was associated with faster RTW (Aas et al., 2018). More severe disability and longer in-patient length of stay (Avesani et al., 2005) was more prevalent among those who were not re-employed after the intervention (Avesani et al., 2005). In a Norwegian study, meetings with the social insurance office were associated with delayed RTW, but patients with comorbid disorders had more of these meetings (Aas et al., 2018). Finally, behavioral and speech deficits were found to be the major barriers to professional reintegration for those patients who had only minor physical restrictions (Lippert-Grüner et al., 2003).
Qualitative analyses revealed patients’ RTW recovery was affected by their motivation to RTW; and the ongoing recovery and social support they received, including support from the employer, colleagues, and vocational occupational specialist (Radford et al., 2018; van Velzen et al., 2016). An RTW program, financial incentives, work modifications, and work preparation were further identified as important and beneficial factors (Radford et al., 2018). The most common limiting factors were tiredness, having returned to work too early, and cognitive difficulties (Radford et al., 2018; van Velzen et al., 2016).
Severe Psychological Illness
Severe psychological illnesses (SPIs) (e.g., schizophrenia and other severe mental health conditions) were evaluated in seven (28%) studies (Bond et al., 1995; Catty et al., 2008; Drake et al., 1996; Killackey et al., 2008; Lehman et al., 2002; Mueser et al., 2004; Nuechterlein, 2008). The definition of early intervention in this group differed greatly from the brain injuries group, with some participants receiving the intervention up to 5 years from their initial hospital admission (Bond et al., 1995). This is not surprising as some studies, in order to ensure the severity of illness in their sample, treated the presence of a psychological disorder for at least 2 years as an inclusion criterion.
All of the studies investigating SPI evaluated an Individual Placement and Support (IPS)-based intervention, with the exception of Bond et al.’s (1995) study, which evaluated the outcomes of the “Accelerated Approach to Supported Employment” program. This intervention includes vocational assessment, job-search assistance, negotiating with employers, intensive job coaching, follow-up support, and case management for nonvocational needs (Bond et al., 1995). It is considered accelerated because it does not include lengthy prevocational training and emphasizes quick placement of individuals into employment. The principles of IPS intervention are similar, having been based on the earlier work of Bond et al. (1995), offering participants a range of services over a long term, including vocational assessment; development of the individualized vocational treatment plan; vocational support groups; vocational counseling; job-search support; skills training and practise; obtaining and maintaining a job; and advocacy and collaboration with employers.
Vocational and other post-intervention Outcomes in SPI
The average RTW rate in SPI was 55%, 6 months to 5 years post-diagnosis. Specifically, the RTW rate was 65% at 6 months in a small sample of participants with first-episode psychosis and a mean age of 21 years, all of whom expressed motivation to find work (Killackey et al., 2008). Compared to treatment as usual, this group showed significantly better rates in hours worked per week, jobs acquired, longevity of employment, and reduced reliance on welfare benefits. However, in another study assessing RTW at 18 months post-treatment in a similar sample of young patients with first-episode psychosis, the RTW rate was 33%, suggesting that motivation to find a job and intervening as early as practicable may be necessary for successful RTW in this demographic. The benefit of early intervention, as well as early entry into employment without prevocational training, was also found by Bond et al. (1995).
The mean RTW rate in the SPI category at 18 months was 55.8% (Catty et al., 2008; Drake et al., 1996; Nuechterlein et al., 2008). The highest IPS-related RTW rate was recorded in Drake et al.’s (1996) study where 75% of participants returned to work. Compared to a community-based group-skills training group (which provided pre-employment skills training and support in obtaining and maintaining jobs), the IPS group in this study earned significantly more and worked more overall; however, there were no differences found in the longevity of job and work status. The IPS evaluations at 24 months showed a RTW rate of 42% (Lehman et al., 2002) and 74% (Mueser et al., 2004). Both samples were highly similar across all demographic details including relatively high mean age of participants (M = 41) in contrast to other studies assessing IPS. Interestingly, 90% of the sample in the latter study (Mueser et al., 2004) remained in the program for the whole 24 months, suggesting that the length of stay in the program may bring positive long-term IPS benefits for older participants with SPI.
RTW facilitators in SPI
Early entry into the program (Bond et al., 1995; Catty et al., 2008; Killackey et al., 2008), longer provision of monitoring and follow-up support, and the integration of vocational and psychological intervention services (Mueser et al., 2004) were factors that differentiated the programs from other less-effective interventions, such as standard psychological therapy and VR. Motivation to find a job, previous work history, better relationships with a vocational consultant, and fewer met social needs were reported in participants who were more likely to obtain employment and maintain work for longer (Catty et al., 2008; Drake et al., 1996; Killackey et al., 2008). The authors suggested that the fewer met social needs may have been associated with higher motivation to participate in the program and find a job to satisfy these needs, but motivation was not directly assessed in their study. Remission was also found to be associated with working more (Catty et al., 2008). Finally, qualitative interviews showed that appropriate interventions can be formulated to best meet the individual’s vocational and mental health needs.
Spinal Cord Injuries
Three (11.5%) studies investigated RTW outcomes after early VR in SCI—Forchheimer and Tate (2004); Hilton et al. (2017); and Middleton et al. (2015). The Forchheimer and Tate (2004) sample included 51.7% tetraplegia, 34.5% paraplegia, and 13.8% ASIA Grade-D patients. Hilton et al. (2017) and Middleton et al. (2015) included samples with an almost even split of tetraplegia and paraplegia. Across these three studies, the mean age of participants was 41 years and the interventions were commenced 2 to 4 weeks post-injury (Hilton et al., 2017), 1 to 8 weeks post-injury (Middleton et al., 2015), and 2 weeks prior to hospital discharge (Forchheimer & Tate, 2004).
Hilton et al. (2017) evaluated an approach to early intervention vocational rehabilitation (EIVR) that prioritized the vocational identity of the individual, forming a vocational plan, and tailoring interventions to suit the person’s goals and situation. Their program (commenced 2–4 weeks post-injury and delivered up to 12 months post-hospital discharge) was aided by the inclusion of a VR-dedicated position within the multidisciplinary team focused on building a positive expectancy and culture of RTW and the facilitation of employment pathways through specialist vocational interventions. Middleton et al. (2015) evaluated an early VR program, integrated within the in-patient setting that employed professional vocational consultants to deliver services, including career planning and coaching, job-seeking skills training, workplace assessment, task analysis, work experience and work trial opportunities, and employer liaison and support. The program was relatively short, with a median delivery period of 11 weeks and 9.1 hours of service delivery. The program evaluated in the Forchheimer and Tate (2004) study, although targeting vocational participation outcomes, differed in focus from the other two studies. The program was designed to provide independent-living services and community reintegration support following SCI, without vocational assessment, intervention, or monitoring, as in the other studies.
RTW following SCI
RTW rates were between 33% and 35% at 3 weeks post-intervention and they remained in the same range up to 2 years post-intervention (Hilton et al., 2017; Middleton et al., 2015). While these rates are not significantly divergent from traditional RTW rates after SCI, they do represent a potentially fast-tracked approach to the identification and achievement of vocational goals, with people returning to work sooner than had been expected or previously supported. In the sample followed by Forchheimer and Tate (2004), the return to vocational activity was 32%, which was lower than the nonparticipant rate of 35%; however, the preinjury employment rates of the two comparison groups were markedly different preinjury (58% participants versus 76% nonparticipants). It should be noted that the provision of vocational services in this program was perhaps minimal in comparison to legal, advocacy, housing, and other independent-living services.
RTW facilitators for SCI
Preinjury education status (i.e., tertiary education) was the strongest predictor of being employed in the 2 years post-discharge from hospital, followed by being in a relationship and subjective well-being at the time of the injury (Hilton et al., 2017). Motivation to participate in the vocational intervention and secure employment, as well as self-efficacy in one’s ability to be employed may be additional important variables associated with positive vocational outcomes (Middleton et al., 2015). Most participants in Middleton et al. (2015) felt confident in their ability to find a job relatively soon within the first 6 months from the time of the study interview at baseline. They agreed that work was an important part of their life and reported a sense of personal responsibility to secure a job but with additional help from others.
Discussion
Twenty-five studies met the inclusion criteria of this systematic literature review, which included studies covering a total of 3,003 participants with a mean age of 37 years. The quality of studies according to the MMAT was moderate to high. Quantitative methods were used in most studies with mostly prospective longitudinal design. Most studies evaluated brain-related injuries (15) and severe psychological disorders (7) with only a few investigating spinal cord injuries (3). Interventions across all injury types were, at least in part, focused on RTW and included multidisciplinary care teams. The mean time since injury to program commencement varied widely across each injury type; however, intervening as early as possible seemed to be associated with greater RTW regardless of the injury group investigated.
Compared with solely neuropsychological, physical, or telehealth-based interventions, the early vocationally targeted interventions for moderate to severe ABI achieved higher RTW rates, prioritizing individualized vocational readiness and goal setting through vocational assessment and counseling. Patients with ABI who returned to work mostly did so within the first 6 months from injury, indicating this early post injury period that is crucial to functional recovery is also a crucial time for vocational intervention for this population (Buffington & Malec, 1997; Radford et al., 2013, 2018). Intervening as early as possible is also shown to be beneficial for RTW rates after SPI (Drake et al., 1996; Killackey et al., 2008; Mueser, 2004) and in promoting timelier RTW after spinal cord injuries (Hilton et al., 2017; Middleton et al., 2015). To further note in relation to this early timing is Middleton et al.’s (2015) study in which participants with SCI expressed early identification of work as a central aspect of their lives; traditionally considered much later in the rehabilitation trajectory.
While early intervention is increasingly justified in the pursuit of vocational gains after injury, longer-term job retention after vocational intervention also requires consideration (Drake et al., 1996). Several factors seem to be related to this issue. Motivation and self-efficacy to find work have both been associated with better employment outcomes but also with working for longer in studies investigating ABI, SCI, and SPI (Killackey et al., 2008; Middleton et al., 2015; Radford et al., 2018; van Velzen et al., 2016). Previous work history, unmet social needs, and strong rapport with a vocational consultant appear to be factors supporting both the obtaining and retaining of employment in the case of SPI (Catty et al., 2008; Drake et al., 1996; Killackey et al., 2008). Targeting relational skills and maintaining high treatment fidelity are further associated with increased job longevity (Catty et al., 2008).
Perhaps the most salient findings from this review in relation to enhanced vocational outcomes after serious injury or illness are regarding the type of intervention itself. Interventions that were primarily vocational in nature and included specific vocational assessment, intervention, and monitoring showed overall improved employment outcomes than interventions targeted at functional recovery and community reintegration more broadly, including in ABI (Buffington & Malec, 1997; Radford et al., 2013); SPI (Drake et al., 1996; Mueser, 2004); and in SCI (Hilton et al., 2017; Middleton et al., 2015). While prevocational services alone were found to be redundant in the SPI group (Bond et al., 1995), early entry to an integrated vocational and psychological program with sustained monitoring and follow-up were associated with better vocational outcomes (Bond et al., 1995; Catty et al., 2008; Killackey et al., 2008; Mueser et al., 2004). Furthermore, advocacy services were found to play an important role regardless of injury type, with patients requiring support across the different domains involved in recovery, including financial, employment, clinical, and legal sectors (Aas et al., 2018; Avesani et al., 2005; Forchheimer & Tate, 2004; Hofgren et al., 2010; Mueser et al., 2004; Radford et al., 2018). Clearer communication and multicomponent integration between clinical and vocational services was associated with better outcomes in SPI (Mueser et al., 2004) and noted as important precipitants of program success in SCI (Hilton et al., 2017; Middleton et al., 2015). This approach, integrating or at least linking the health care and vocational responses to injury and illness, is likely to achieve better outcomes through shared acknowledgment of the importance of work in health and recovery and the common goal of reducing disability.
Overall, while interventions targeted at functional recovery and broader community reintegration are undoubtedly crucial for patient recovery and independence goals, the results of this review indicate they are less effective than early, comprehensive VR programs in achieving quality vocational outcomes after serious injury or illness. These findings suggest a key inclusion in rehabilitation programs will be early, supported opportunities for participants to identify and target their vocational goals and needs, alongside other functional goals. This corroborates the increasing recognition of the value of VR expertise being integrated in primary health settings, where people’s vocational goals should be supported equally with other recovery goals.
Conclusion
The research in early VR following severe injury has predominantly been conducted in ABI and SPI, with only a few studies investigating SCI. More research is required to enable conclusive findings regarding the processes and long-term effects of early vocational intervention. The existing research is mostly quantitative, enabling recruitment of wider participation and better generalization of findings, but it can also miss out on documenting people’s nuanced experiences and lead to higher drop-out rates and associated biases in data sets. Qualitative research would further assist this field of research by enabling a more in-depth understanding of the return-to-work barriers and supports for people after serious injuries. Despite research being dominated by certain injury types, across these injury groups, it appears that intervening early is imperative, although the definition of early in the literature varies across and within injury groups. Overall, a program seems to produce better vocational outcomes if it specifically targets vocational assessment and intervention early after injury/onset, and also involves sustained monitoring and follow-up support to ensure job retention. Involving a multidisciplinary team, integrating vocational expertise, and offering access to advocacy services were shown to be effective inclusions in early VR programs.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors received financial support from Menzies Health Institute Queensland for the research conducted for this article.
