Results from phase one of an early intervention vocational rehabilitation trial for people with spinal cord injury conducted in Queensland,Australia

2.1 Objective

The central objective of the research was to evaluate the efficacy of the Back2Work EIVR program in facilitating RTW for people with newly acquired SCI. Key indicators included employment rate and time taken to RTW. We also aimed to describe the key services delivered as part of the intervention and summarise the consumer experience of the program. The research questions were:

Is the Back2Work EIVR program effective in achieving an increase on the baseline RTW of 35% rate of people with SCI in the 24 months following hospital discharge?

2.2 Research design

The study utilised a prospective, longitudinal and mixed-methods design to evaluate the outcomes of the Back2Work program.

2.3 Recruitment and ethics

All adult patients undergoing initial rehabilitation at the Queensland SIU and participating in the Back2Work program were invited to participate in the research. Following medical clearance and referral from SIU staff, potential participants were approached by a Back2Work vocational rehabilitation counsellor (VRC) and invited to participate in the Back2Work program and evaluation. Potential participants were provided with verbal and written information about the program, an opportunity to have questions addressed and a written consent form. All research participants provided voluntary written consent to participate in the evaluation. All procedures were approved and monitored by the Human Research Ethics Committees of the relevant institutions (MSHREC: 15/QPAH/755; GUHREC: 2016/047).

2.4 Data collection

There were six data collections points. All data were collected via interview with the interviewer reading the questions and recording the responses. Initial (time 1) data were collected by face-to-face interview with the VRC at commencement in the Back2Work program and again at the time of discharge from hospital (time 2). Post-discharge, telephone interviews were administered by a member of the research team every 6 months following discharge (up to 24 months).

2.5 Measures

The following data were collected at intake, discharge and follow-up interviews:

Demographic information (i.e., age, gender, education, work status);

The interviews took approximately 30-50 minutes to complete. In addition, a bespoke service satisfaction survey, The Back2Work Satisfaction Survey was conducted via a telephone interview at 4-6 weeks post-discharge from hospital, by a member of the research team.

2.6 Data analysis

Quantitative data were analysed using Statistical Package for the Social Sciences (SPSS) version 21.0 (IBM Corp., Armonk, NY, USA) to identify demographic characteristics and correlates of employment at each time point. Analysis incorporated both parametric and non-parametric tests including independent and paired-samples t-tests, McNemar’s exact test, exact sign tests, and Fisher’s exact tests. Thematic analysis techniques were used to analyse the qualitative data, in line with the six steps outlined by Braun and Clarke (2012). All qualitative coding was undertaken independently by two members of the research team and results compared and discussed until consensus was achieved.

3.1 Sample and attrition

Of the 83 Back2Work participants engaged in the evaluation between October 2016 and February 2020, four (4) withdrew consent, resulting in a total sample of 79 research participants (N = 79). Over the course of the project, one (1) participant died and 29 were lost to follow-up. The 38% attrition rate is at least partially explained by the complex adjustment and difficulties people with SCI can experience when re-entering the community after hospital. At the conclusion of the initial funding period (February 2020), many participants had not yet reached the final time point, with 16 participants having completed the 24 months post-discharge follow-up interview.

3.2 Participant demographics

Based on the intake data (N = 79), the majority of participants were males (79%) with an average age of 43 years; 70% of participants’ injuries were of traumatic origins, with road trauma (30%) and falls (11%) being the most common causes of injury. Participants tended to have incomplete injuries (65%) and/or paraplegia (59%). Most participants lived in major cities (61%), with approximately a third (34%) in regional areas and 5% in remote or very remote locations. Study demographics are presented in Table 1.

4.1 Employment

4.2 Intervention data

The average number of service delivery hours per participant was 33.97 (SD = 31.34 hours). Service hours were broken down into six categories and 14 subcategories, with Back2Work VRCs devoting an average of 12.35 hours per client to job seeking and placement support interventions, such as workplace modifications and employer liaison. Vocational exploration and counselling was the next most frequent VR intervention (M = 8.25 hours/client), involving such activities as vocational assessment, vocational counselling, and role research. Expressed as a proportion, job seeking and placement comprised approximately 40% of total service delivery hours, vocational exploration comprised 27%, case management 15%; establishing the therapeutic relationship 9%; and service development and meetings comprised the remaining 9%.

The total number of intervention hours were analysed for the employed and unemployed groups at each time point. Employed participants received more Back2Work intervention hours (M = 72.38, SD = 40.83) than unemployed participants (M = 32.54, SD = 27.98) at six months post-discharge (t(36)=3.41, p = 0.002), and 12 months post-discharge (t(21.44)=2.39, p = .026). Significant differences were found between the employed and unemployed groups in job seeking and placement and case management from discharge through to 12 months post-discharge, such that employed participants averaged a higher number of hours for case management, and unemployed participants for job seeking and placement support. Differences were also seen in the number of hours of vocational exploration, such that participants who were employed at the 18-month time point received significantly more hours of vocational exploration and counselling than those who were unemployed at 18 months.

5.1 Qualitative responses in follow-up phone surveys

The qualitative data collected during the 6, 12, 18, and 24 months post-discharge interviews added a depth of insight about the perspectives of the early vocational journeys of newly injured people with SCI. Data are thematically and chronologically presented below.

5.2 Satisfaction with the program

A key recurring theme from the satisfaction survey was the impact of Back2Work in promoting a positive attitude towards returning to work or study. Participants consistently reported that involvement with the Back2Work VRC (B2 W VRC) was an important factor in promoting positive expectations of RTW. This theme included three sub-themes: a) opening up possibilities; b) positivity, confidence and optimism; and c) hope. Participants also spoke of the role of Back2Work vocational counselling in supporting their RTW journeys. These themes are reported below.

6.1 Rate and timeliness of RTW

The results suggest that an EIVR program fully integrated into the traditional hospital rehabilitation multi-disciplinary team can be effective in improving employment outcomes for people with newly acquired SCI. The baseline employment rate by 24 months post-hospital discharge was set at 35% based on the research literature (Bloom et al., 2017; Johnston & Cameron, 2014; Victorian Neurotrauma Initiative, 2009; Young & Murphy, 2009) and the baseline survey conducted as part of this study (Dorsett & McLennan, 2019). An aspirational target of a 30% increase on that baseline was set by the Back2Work team prior to the program rollout. The Back2Work program achieved this target with a return to paid employment of 50% at 24 months post-discharge from hospital.

Timeliness of RTW was another important factor in evaluating the program’s effectiveness. The results of this study challenge the long-accepted belief that it takes substantial time for adjustment and community transitions before a person with SCI is ready to RTW. RTW rates for people with SCI are reported to be particularly low in the first year following discharge from hospital (14% reported by Arango-Lasprilla et al. (2010)) and there is often a lengthy period between injury and RTW (Bloom et al., 2017; Johnston & Cameron, 2014; Young & Murphy, 2009). It is therefore positive to note that 43% of the Back2Work evaluation sample had returned to employment within the first 12 months following hospital discharge. This study suggests that with appropriate vocational supports people with SCI may be ready to engage in vocational rehabilitation and able RTW much sooner post-injury than previously believed.

6.2 Importance of the pre-injury employer

Working with employers to preserve pre-injury employment was a key advantage of the Back2Work model (Bloom et al., 2019). The relationship with the pre-injury employer may be vulnerable post-injury, highlighting the need for early intervention through liaison, the provision of information, and negotiation of workplace modifications and other supports (Bloom et al., 2019). Consistent with previous research this study found that returning to the pre-injury employer was the most common RTW pathway reported, with 90% who RTW by 6 months, and 70% who RTW by 12 months, returning to their pre-injury workplace. Participants’ qualitative responses and the VRCs’ reported intervention data further highlighted employer contact and support as a significant intervention, particularly at the earlier time points. This study highlights the importance of connectedness with the pre-injury employer, and strongly supports the focus on the pre-injury employer built into the Back2Work model.

6.3 Flexible and individualised service

The Back2Work intervention data revealed a varied service with the capacity to respond to clients’ individual vocational needs regardless of their progress in their RTW journeys. Employed and unemployed participants demonstrated different patterns of service use, relating to their differing needs. Participants who RTW in the short term seemed to need increased case management support, whereas participants who had not returned needed greater support in job placement activities.

Regarding timing, participants were receptive and ready to engage with the program. This study adds to the emerging evidence supporting EIVR interventions for people with newly acquired SCI. For the small number of participants who indicated that the program was offered too early, the key reason was a need for further rehabilitation and adjustment prior to considering work-related goals and decisions. These findings echo those of other EIVR trials that underscore EIVR must be sensitively and flexibly offered, in order to mitigate any additional burden that EIVR may pose on a person’s rehabilitation (Johnston et al., 2016; Ramakrishnan et al., 2016). The majority of participants’ receptiveness to an early timing of the intervention indicated that the timing was appropriate and added to the developing body of research supporting the early readiness of people with SCI to engage with vocational services (Fadyl & McPherson, 2010; Middleton et al., 2015).

6.4 Limitations of the research

There were some important limitations to the research. Difficulties in participant recruitment led to insufficient numbers to perform some of the quantitative analyses, requiring the use of non-parametric tests. This potentially limited the power of the analyses to detect significant differences and limited the causal inferences that could be made. A larger sample size, particularly at the 2-years post-discharge time point, would provide for more robust data. However, results are promising and suggest that the Back2Work EIVR model is effective in assisting people with SCI to return to paid employment at a higher rate than traditional VR service delivery.

Another potential limitation was the representativeness of the sample. There was a higher rate of incomplete injuries and paraplegia than is reported in the general SCI population. This suggests a potential selection bias, such that participants who experienced less impairment may have been more likely to participate in EIVR. The effect of this bias was potentially exacerbated by the study’s attrition rate of 38%. Attrition was concentrated between discharge and 12 months, presumably due to the research burden experienced during community re-integration. These two aspects together potentially meant that the final pool of research participants may have represented those less disabled and more engaged.

Nonetheless, the use of a rigorous mixed-methods approach complemented the longitudinal research design to produce rich data that informed the researchers’ understanding of the impact of EIVR over time.

6.5 Recommendations for future research

A key recommendation highlighted by this research is the need and justification for broader integration of vocational rehabilitation in hospital-based multi-disciplinary teams, ensuring that all spinal cord injured persons have earlier access to these services. Further longitudinal research is needed, with data collection from a larger pool of participants, to expand the empirical support for the effectiveness of EIVR after spinal cord injury. Accordingly, an extension of the Back2Work program and evaluation has been funded until 2023.

Further recommendations stemming from the current research include the need to ensure adequate follow-up support post-hospital, recognising the inconsistent nature of community-based supports, to ensure no one falls through the gaps. With regard to service provision, further research is warranted into the required skills and characteristics of VRCs delivering EIVR, and on the specific interventions that are most effective. This will assist in defining the specific skill set for this niche area of practice and identify potential training needs for future practitioners. There would also be value in research to identify support needs for employers of people with SCI, given that the relationship with the employer appears to be a key mechanism of early intervention vocational rehabilitation.