Occupational bonding after spinal cord injury: A review and narrative synthesis

1.1 Occupational bond

Shrey (1996) defines the occupational bond as the psychological bond between a person and their job; including their employer, workplace, co-workers, and job role. Interruptions in this bond can potentially occur soon after injury, and are said to lead to diminished vocational outcomes (Kendall & Muenchberger, 2009). The maintenance of the occupational bond is the basis for many workplace-based vocational rehabilitation strategies, which emphasise early contact with the injured worker and modified work tasks to facilitate reintegration with the workplace as early as possible (Kenny, 1995; Selander, Tjulin, Müssener, & Ekberg, 2015; Westmorland & Buys, 2004).

Murphy and O’Hare (2011) conceptualised the occupational bond as being maintained partly through workplace-related social support including supervisor support, co-worker support, peer support, and management-worker relationships. Their systematic review concluded that supportive work-related relationships potentially enhance RTW outcomes. This finding has been echoed within VR literature across a number of injury categories, with employer or supervisor support being potentially the most helpful. Employer support assists return-to-work both in individual cases through maintaining contact with injured workers and providing job accommodations (Driscoll, Rodger, & de Jonge, 2001; Hilton, Unsworth, & Murphy, 2017; Nordqvist, Holmqvist, & Alexanderson, 2003; Young, 2010), as well as the macro level through policy and influencing workplace culture (Jones, 2016; Miller, Gottlieb, Morgan, & Gray, 2014).

Co-worker support is also beneficial, with higher levels of co-worker support associated with enhanced RTW outcomes (Laisné, Lecomte, & Corbiére, 2013). This is primarily through empathy for the injured worker and acceptance of the adjustments made to accommodate them. Job accommodations and stigma about injured workers can contribute to unsupportive or antagonistic co-worker relationships, which diminish employment outcomes (Dunstan & Maceachen, 2014; Williams-Whitt & Taras, 2010).

1.2 Factors which impact the occupational bond

To identify variables in the employment after SCI literature which may relate to the underlying dimension of occupational bonding, it is useful to examine factors which may strengthen or diminish this bond. The assistance of the person with disability’s supervisor is important in facilitating their commitment to the workplace (Hashim & Wok, 2014; Jones, 2016). The supervisor plays an important role in establishing the inclusiveness of the workplace culture, often with their adherence to hiring policies (Jones, 2016; Schur, Kruse, Blasi, & Blanck, 2009) and willingness to approve accommodations (Hashim & Wok, 2014). A supportive supervisor creates the perception of a supportive organisation, thus facilitating commitment to the workplace (Eisenberger, Stinglhamber, Vandenberghe, Sucharski, & Rhoades, 2002; Rhoades & Eisenberger, 2002).

Likewise evidence suggests that a supervisor can bolster work commitment during the RTW process in a number of ways. Early contact with supervisors after an injury is a key component (HWCA, 2015), and is said to reinforce the occupational bond and facilitate RTW (Tjulin, Maceachen, Stiwne, & Ekberg, 2011). More concrete are the benefits of supervisors in timely approval of workplace accommodations, which can substantially reduce time to RTW and facilitate durable outcomes (Franche et al., 2005). Beyond returning to work, a supportive supervisor is key in retaining the gains made during rehabilitation (Young, 2010). Combining the evidence for a supervisor’s role in promoting work commitment both generally and during vocational rehabilitation, it is clear that supervisor support should be considered when investigating occupational bonding after SCI.

Traditional conceptualisations of occupational bonding include relationships between worker and supervisor, or worker and workplace. The role of co-workers has been minimised, but should not be overlooked. Co-workers impact on a person with disability’s work commitment primarily via workplace culture (Schur, Kruse, & Blanck, 2005). Co-worker acceptance or resentment of accommodations may also interfere with the application for or approval of such (Colella, 2001). Evidence suggests that co-workers also play a key role in reintegrating an injured worker into the workplace (Dunstan & Maceachen, 2014), and in maintaining retention after RTW has succeeded (Young, 2010). Beyond vocational rehabilitation, positive relationships in the workplace strengthen work engagement (Schaufeli & Bakker, 2004), and therefore commitment to the organisation. In this way, co-workers appear to contribute to the occupational bond. Gaps in the research remain, however, about the relevance of this information to acquired disability and the associated longer-term absence from the workplace, as is often the case with traumatic SCI.

1.3 Work commitment

The organisational psychology field has produced numerous similar constructs. Arguably the most popular is ‘work commitment’, which measures the degree to which a person is devoted to their work (Randall & Cote, 1991). This is an umbrella term which encompasses several other forms of commitment, including commitment to the specific job role, the employing organisation, the profession, the group of co-workers, and the value of work itself (Cooper-Hakim & Viswesvaran, 2005; Randall & Cote, 1991). These concepts have all found varying degrees of empirical support, with some being correlated to each other. Some researchers assert that this is the result of conceptual redundancy, while others argue that these various forms of commitment are pieces of the same puzzle: an underlying concept which encompasses the entire story of a person’s psychological attachment to the world of work (Cooper-Hakim & Viswesvaran, 2005; Randall & Cote, 1991). Regardless of whether these are unique constructs, the delineation of these separate concepts allows for consideration of different facets of the occupational bond, and different targets for potential vocational intervention.

Evidence suggests that work commitment might function differently, or have additional barriers, for people with disability. Perceptions of low levels of support from the organisation can impact work commitment (Rhoades & Eisenberger, 2002). People with disability have been found to have more negative perceptions of their workplace, particularly if the workplace is less accommodating (Schur et al., 2009). Hashim and Wok (2014) reported that a person with a disability’s commitment and loyalty to their employer may be impacted by the organisation’s ability to provide accommodations. This finding has been replicated and further linked to an inclusive work climate, such that disability inclusive workspaces foster the person’s commitment to their organisation (Wittmer & Lin, 2017).

Although work commitment has not been consistently extended to the vocational rehabilitation field, evidence supports this construct’s relationship to some RTW-related variables. High job involvement is associated with RTW following traumatic limb amputation (MacKenzie et al., 2006) and sickness absence (Brouwer et al., 2009); work commitment predicts RTW among sick-listed women (Holmgren, Ekbladh, Hensing, & Dellve, 2013); and valuing work is a factor in maintaining work attendance during breast cancer treatment (Nilsson, Olsson, Wennman-Larsen, Petersson, & Alexanderson, 2013). Work commitment is also related to more general work performance variables, including absenteeism (Garland, Hogan, Kelley, Kim, & Lambert, 2013; Giffords, 2009), turnover intention and job satisfaction (Zopiatis, Constanti, & Theocharous, 2014). Clearly, work commitment is relevant to a person’s desire to work, performance at work, retention of employment and enjoyment of work.

Given the relationship between work commitment to RTW variables and general work performance, as well as the conceptual overlap with occupational bonding, there is scope to support the integration of the concept of work commitment within the overall conceptual framework of occupational bonding, suggesting that the bond encapsulates both the relationship with the employer/workplace, and with the concept of working in general. There is little research, however, on the nature of this attachment in the instance of acquired disability, such as SCI, during which time the bond might be weakened. Examining the factors underpinning this bond, including supervisor and co-worker support in the existing research about employment after SCI, has the potential to provide preliminary evidence to inform the design of interventions and further research.

Therefore the aims of this review were:

To identify psychological constructs which may relate to the occupational bond after SCI, and summarise the support for these.

For the purposes of this review, ‘occupational bond’ and ‘work commitment’ will be used interchangeably, given the overlapping nature of the concepts and that the primary focus of this review is to inform potential interventions rather than a dissection of theory.

2.1 Search strategy

A search of published literature was conducted between August and September 2017. Relevant studies were identified using the electronic databases CINAHL, ProQuest, ScienceDirect and Medline. Boolean phrases were tested in ProQuest and adapted to the other databases. Search terms included: “spinal cord injury”, “occupational bond”, “work commitment”, “co-worker”, “employer”, “work attitude”, “importance of work”, “work primacy”, and “value of work” and various combinations thereof. The small number of studies identified meant that a broader search strategy was implemented, including the terms: “employment”, “return to work”, “occupational rehabilitation”, “vocational rehabilitation”, and “attachment”. Google Scholar and searching of reference lists were also used to reach saturation.

2.2 Inclusion and exclusion criteria

The studies were required to meet the following criteria to be considered for review:

Study investigated variables identified as being relevant to the concept of occupational bonding.

2.3 Database development

The review formed part of a broader systematic review, the detailed methodology is described elsewhere (Bloom et al., 2018). Briefly, the systematic review method used was outlined by Pickering and Byrne (2014), yields reproducible and reliable assessments of the literature field, and has been widely adopted across disciplines (Pickering & Byrne, 2014). The method entails systematic identification, screening and database entry of the selected studies that is transparent and minimises the potential for bias. This method also allows for tabulating of the studies in a set area, to identify the amount of evidence for a concept or intervention in situations which preclude meta-analysis. In accordance with the method, a Microsoft Excel database was developed to record details including: author(s), year of publication, focus of the research (injured person, employer, or co-worker), research design and method, results, and any limitations identified.

2.4 Selection and screening

Screening of titles and abstracts was completed by the first author. Studies which fit the inclusion criteria were read in full and subjected to further screening. Studies that were arguable in fulfilling the inclusion criteria were determined through discussion and included through unanimous agreement of the authors.

2.5 Quality appraisal

Studies were appraised using the Mixed Methods Appraisal Tool (MMAT) designed for systematic reviews which include quantitative, qualitative and mixed-method studies (Pluye et al., 2011). The MMAT was chosen for its efficiency and reliability as well as its applicability to complex, context-dependent interventions (Pluye et al., 2011). The MMAT includes four criteria each for qualitative and quantitative studies, with additional criteria for mixed-method studies. Scores are calculated as a percentage of criteria met. In accordance with the appraisal method, efforts were made to obtain supplementary reports and publications to minimise the risk of underestimating the quality of the studies reviewed. Considering the overall high quality of the studies, studies were not weighted or excluded on the basis of the quality appraisal, and are discussed in the results below.

2.6 Analysis and synthesis

Studies were tabulated using the Microsoft Excel database generated. Studies were grouped by research focus (person, employer, or co-worker) to facilitate analysis. Studies which reflected more than one focus were analysed within each relevant category, such that studies which investigated both employer and co-worker were analysed under both the employer and co-worker categories. This was intended to maximise the amount of information gathered, given the small number of studies in some categories. Re-using studies, combined with the significant methodological heterogeneity, precluded quantitative analysis. Thus a narrative approach to synthesis was used.

3.1 Studies included

The initial search strategy yielded 546 studies, which were downloaded for further screening. Screening for relevance to the inclusion criteria reduced this number to 162. Further reading identified 137 articles to be excluded on the basis of relevance to the topic, leaving 25 included in the review. Figure 1 shows PRISMA flowchart for this screening process.

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Fig.1

PRISMA Flowchart describing the literature search and screening process.

The overall quality of the studies included was high. Of the 25 studies, 16 (64%) scored 100% on the MMAT, with seven (28%) scoring 75% and two (8%) scoring 50%. Sampling procedures and low response rates were the most common sources of bias. The high quality of the qualitative research included in this review was notable.

3.3 Study characteristics

Sixteen of the included studies (64%) were published between the years 2010–2016. Studies were descriptive, and mostly cross-sectional (80%). Considering the longitudinal designs, there were six (24%) prospective studies and one (4%) retrospective study. Data collected was mainly quantitative, with 16 (64%) collecting quantitative data and nine (36%) of the studies having a qualitative design. One (4%) study utilised mixed methods. Samples ranged in size, with the qualitative samples being necessarily smaller (ranging from six to 60), and quantitative larger (from 57 to 1134). Most of the studies (56%) investigated variables intrinsic to the person, including work attitudes, work importance and interest measures. Twelve (48%) papers investigated employer support. Co-worker support and vocational rehabilitation services had the least publications (12%). Four (16%) studies fit into multiple categories, with three (12%) investigating both employer and co-worker, and one (4%) investigating employer and injured worker.

3.4 Psychological constructs

Fourteen (56%) of the papers included investigated psychological factors intrinsic to the injured worker after SCI. These focused primarily on the value, importance or primacy of work to the person. Focus group research indicated that employed participants rated the importance of work more highly than their unemployed counterparts (Chan & Man, 2005). This was echoed by Fadyl and McPherson (2010), who indicated that a person’s values about working are taken into consideration when deciding to RTW after injury. Quantitative analysis further supported this link, with importance and primacy of work, and work ethic, being significantly associated with job-seeking behaviours and returning to work in cross-sectional analyses (Burns, Boyd, Hill, & Hough, 2010; Crewe, 2000; Krause & Reed, 2011; Marti, Reinhardt, Graf, Escorpizo, & Post, 2012; Murphy & Young, 2005; Murphy, Young, Brown, & King, 2003). Similarly, acceptance of masculine gender norms was associated with RTW in one study (Burns et al., 2010), a variable which stresses the primacy of work and self-reliance.

Two studies also investigated a motivational component, including RTW intentions (Kennedy & Hasson, 2016) and desire to RTW (Hay-Smith, Dickson, Nunnerley, & Anne Sinnott, 2013), which were both identified as being important in the RTW process. One study found that the number of people who intended to RTW after SCI increased over time, presumably in response to vocational support services (Kennedy & Hasson, 2016). Related to RTW motivation is vocational interests, or the types of jobs or training to which the person may return. Four of the extracted papers investigated these measures, which identified the types of jobs a person might be interested in after SCI, and whether these interests were stable or changed after injury. Researchers found that these interests do change after injury onset and eventually stabilise, potentially as a function of adjustment (Krause & Ricks, 2012; Krause, Saunders, Staten, & Rohe, 2011; Krause & Clark, 2014; Ullah, Sarker, & Chowdhury, 2015). Taken together, the motivational and interest studies highlight that attitudes towards work are made vulnerable in response to traumatic events such as SCI, and that there is an opportunity to develop and reinforce these attitudes during adjustment to the injury.

The evidence for work-related psychological constructs generally suggests that work value and importance impact RTW after SCI. There were, however, some limitations to these studies. There were moderate generalisability issues, either due to a lack of diversity in the sample or the limited geographical area in which the research was conducted. Small sample sizes, the use of self-reported data, participant attrition, and a lack of consideration of contextual factors were also identified. More quantitative, longitudinal research is needed to overcome these limitations and establish the exact nature of the relationship between work-related psychological constructs and RTW after injury.

3.5 The role of the employer and co-workers

Twelve of the papers investigated the role of employer support in returning to work after SCI. These primarily investigated returning to the pre-injury employer, with seven studies reporting this as related to positive employment outcomes. Krause (2003) found that returning to the previous employer is associated with a significantly earlier return, a result that is reinforced in three other cross-sectional studies (Krause, Terza, & Dismuke, 2010; Ramakrishnan, Mazlan, Julia, & Abdul Latif, 2011; Schonherr, Groothoff, Mulder, & Eisma, 2005). Hills and Cullen (2007) found that the majority of employed participants returned to the pre-injury employer, concluding that this support from pre-injury employers was instrumental in the RTW process. In qualitative analysis, SCI participants indicated that returning to the pre-injury employer assists RTW through familiarity and predictability of the pre-injury job role (Hay-Smith et al., 2013) and through the support of the employer themselves (Chapin & Kewman, 2001; Murphy & Young, 2006).

Two prospective longitudinal studies nominated social support from the employer as being vital to returning to work after injury. Murphy, Middleton, Quirk, De Wolf, and Cameron (2011) identified that social support (including from the employer) plays a significant role in returning to work within two years of discharge. An ethnographic study further reinforced this, with support from employers in the form of contact and connections reported as useful in sourcing job leads after injury (Cotner, Keleher, O’Connor, Trainor, & Ottomanelli, 2013).

Beyond obtaining work, two studies identified the role of the employer in supporting job retention after SCI. Gray, Morgan, Gottlieb, and Hollingsworth (2014) outlined that worksite receptivity, including the willingness of the employer to provide job accommodations, was significantly correlated with job satisfaction. Qualitative investigation further indicated that supportive employers were instrumental in integrating assistive technology into the workplace (Driscoll et al., 2001). Both studies noted that the participants involved were already ‘success stories’, suggesting bias and limiting generalisability of their conclusions to people who are struggling to retain work, rather than RTW generally.

There were no studies which explored the role of co-workers in isolation; this was inextricably linked to the role of the employer and the workplace environment. Three studies found that co-worker support assists with returning to work after SCI. Quantitatively, Gray et al. (2014) found that accessibility and co-worker support contributed significantly to work satisfaction. Qualitative analysis identified that co-worker relationships were important for both sourcing jobs through networking (Cotner et al., 2013), and retaining jobs by supporting the integration of assistive technology (Driscoll et al., 2001), echoing the data for employer support.

The evidence for the impact of employer support on returning to work after SCI generally suggests that employers are important in facilitating both RTW and ongoing job retention. As was the case for psychological factors, the strength of the conclusions made was impacted by concerns for sample size and generalisability. Furthermore, while the studies reviewed highlighted the importance of the role of the employer and co-workers in RTW after SCI, the majority of the studies investigated the injured worker’s perspective. More evidence is needed to more fully investigate the nature of employer and co-worker roles during RTW after SCI and to investigate how these stakeholders may themselves be supported during and beyond the reintegration of the injured worker.

4.1 Key findings

The current review sought to identify the role of occupational bonding and its malleability in vocational rehabilitation after SCI. Shrey’s original conceptualisation of the occupation bond described a relationship between the injured worker and their employer or workplace which could be either strengthened or weakened during the RTW process (Shrey, 1996). This was tentatively reinforced in the research about returning to work after SCI, which indicated that returning to the pre-injury employer was predictive of a sooner RTW (Krause, Terza, Saunders, et al., 2010; Ramakrishnan et al., 2011), suggesting that the occupational bond was maintained for those participants.

Supportive employers were nominated as being key to this early RTW after SCI, with their role as providers of job accommodations and assistive technology being particularly valuable (Driscoll et al., 2001; Krause, Terza, Saunders, et al., 2010; Schonherr et al., 2005). Including the employer to the fullest extent is best practice within injury and disability management (Westmorland & Buys, 2004), and the results of this review underscore the utility of this approach. The role of co-worker support was less well-reported in the literature. This potentially indicates a lack of awareness of the importance of the co-worker perspective in supporting RTW and ongoing job retention. The reviewed studies found that co-workers are helpful for ongoing maintenance of the occupational bond after RTW has occurred (Driscoll et al., 2001; Gray et al., 2014), but more research is needed to establish type, intensity and impact of the support provided.

Interestingly, substantial evidence was found which suggested that a person’s attitude to work, primarily its importance or primacy, impacted RTW outcomes after SCI. Importance of work (Krause & Reed, 2011; Marti et al., 2012), work attitude (Murphy & Young, 2005; Murphy et al., 2003), primacy of work (Burns et al., 2010), work ethic (Crewe, 2000), value of work (Chan & Man, 2005), desire to RTW (Hay-Smith et al., 2013) and RTW intentions (Kennedy & Hasson, 2016) were all associated with job seeking or labour market participation after SCI. These findings echoed concepts outlined in the literature on work commitment and related forms of work attachment, indicating that there is potentially a broader relationship with working which encompasses the importance or centrality of work in a person’s life and their self-identification as a ‘worker’. While many of these measures were investigated by only one or two studies, taken together they suggest that an intrinsic attachment to “working” exists beyond the bond to the employer, and that a stronger attachment is potentially related to enhanced vocational outcomes after SCI.

4.2 Implications for research

The majority of the research was undertaken from the perspective of the worker, highlighting a gap in the understanding of employers’ and co-workers’ experiences of the RTW process after SCI. Investigating this gap could identify ways to support employers and co-workers in this complex process, inform the development of holistic vocational rehabilitation interventions, and better serve the needs of people with SCI and their employers.

The evidence for underlying psychological factors such as work attitude indicate that there may be different components of the occupational bond which work together; the relationship with the employer and the relationship with the concept of “working” more generally. Given the lack of research on the occupational bond specifically, there is an opportunity for qualitative research to articulate participants’ attitudes towards the world of work after SCI and inform the development of a potential model of occupational bonding which incorporates these two components.

Aside from the gaps in research already identified, there was no research identified which considered the impact of other psychological factors on occupational bond or related constructs. Of particular relevance was self-efficacy, which has been found to be related to both RTW after SCI (Kent & Dorstyn, 2014), and to work commitment (Klassen & Chiu, 2011; Luthans, Zhu, & Avolio, 2006), indicating a potential relevance to the occupational bond. Although there was substantial evidence on self-efficacy after SCI, no studies linked this to work importance, work primacy or other related constructs. Research is required to establish whether these concepts are indeed linked, and describe the nature of this relationship.

4.3 Implications for practice

Practitioners should be aware of vulnerability of the occupational bond after SCI. Given the changeability of attitudes and interests in this early stage, preservation of this attachment is best targeted at the early stages of the injury; during inpatient rehabilitation (Krause & Ricks, 2012; Krause & Clark, 2014; Krause, Terza, Saunders, et al., 2010). Integrating vocational rehabilitation within the inpatient context could also preserve the occupational bond by reinforcing the plausibility and primacy of work after SCI (Johnston et al., 2016). Integration of VR also allows for medical or allied health interventions to be targeted towards vocational goals, enhancing employment outcomes.

In supporting the employer relationship aspect, current vocational rehabilitation practices attempt to maintain the bond through contact between the worker and employer or co-workers, or workplace based strategies. Given the seriousness of the injury, workplace-based (or ‘recover at work’) approaches are infeasible during this early time, meaning that regular contact between the worker and their employer or co-workers is key. There is some evidence to suggest, however, that the quality of these interactions is more important than the quantity, with some workers describing feeling ‘harassed’ by regular contact (Selander et al., 2015). The rehabilitation professional should support positive contact as much as possible, by providing and facilitating free-flowing and proactive communication.

The psychological aspect also provides some targets for intervention from the work commitment literature. For example, professional commitment describes the attachment between a worker and their profession (Randall & Cote, 1991). This may be maintained outside the workplace through professional development activities, reading trade journals, or mentoring less experienced workers. This would also have the effect of preserving professional skills, enhancing re-employability in the event that the worker cannot return to their pre-injury job. As mentioned above, self-efficacy enhancing efforts could also underpin RTW after SCI and potentially reinforce the occupational bond.

Taken together, these strategies could form the basis for a holistic plan which keeps the worker connected to their occupation and identity as a “worker”, while also facilitating job accommodations and workplace-based social support.

4.4 Limitations

There were several important limitations to this review. The methodological heterogeneity rendered quantitative synthesis less meaningful, resulting in the need for narrative synthesis of the results. This may have somewhat limited the benefits of adopting the systematic quantitative review method. The review also combined studies that investigated concepts which theoretically overlapped, but which were in fact distinct from each other, introducing some uncertainty into these results. Similarly, there is no current empirical link between the concepts of occupational bonding and work commitment. Nevertheless, the authors suggest that these concepts are complementary, and that there is evidence to suggest that these are two components of the same concept; the relationship between a person and work.

4.5 Conclusions

Although early recovery at work is implausible in the SCI space, early intervention vocational rehabilitation efforts have shown promise in this population (Middleton et al., 2015). Additionally, Krause (2003) indicates that returning to the previous employer can preserve jobs and reduce time taken to RTW. Although the occupational bond was not specifically researched in these cases, these studies indicate that maintenance of this bond could be a factor in the RTW outcomes of people with spinal cord injuries.

Results from the review indicate that the person’s psychological bond to the idea of work has been researched in more depth. Constructs including the importance of work and employment identity support the notion that a stronger bond to the world of work itself can facilitate employment outcomes. Theoretically, this relationship is via motivation, with a stronger occupational bond potentially generating internal drive, or vice versa. This research is relatively sparse, but shows promise for utility in VR programs. A person’s bond to their workplace, and to the idea of work, can be reinforced by the vocational rehabilitation counsellor. Some authors indicate that social support forms a crucial piece of this puzzle, with work-related social support acting to preserve the bond (Murphy & O’Hare, 2011). This support can be provided through consistent, quality contact with co-workers and the employer during recovery (Selander et al., 2015). Other strategies may include early reinforcement of the possibility and primacy of work by the rehabilitation counsellor; integrating vocational rehabilitation activities within the primary rehabilitation environment; maintaining professional identity through professional development, and raising self-efficacy. Although these strategies are often already utilised within VR contexts, more research is needed to explore their extension into the earlier stages of a SCI, to inform the development of holistic approaches to vocational rehabilitation in this space, and to support the conceptualisation of a model for the occupational bond.