Abstract
BACKGROUND:
Using simulation methods that replicate specific job demands can accelerate return-to-work following an illness or injury. However, the components of simulation vary markedly.
OBJECTIVE:
The current study explores the perceptions and experiences of service users to better understand what aspects are required to facilitate a well-designed, work-specific simulation.
METHODS:
Thirteen injured workers (10 men, 3 women) and four staff (3 allied health, 1 manager) involved in a simulation-based rehabilitation program were interviewed. Interview data were analysed using reflexive thematic analysis.
RESULTS:
Three major themes resulted: 1) simulation can facilitate successful rehabilitation, 2) the importance of offering multiple, realistic simulations to replicate varying occupations, and 3) effective simulation involves collaboration with a worker’s existing health professionals.
CONCLUSIONS:
Simulation tasks can be effectively integrated into injury rehabilitation, although are challenging to implement and require further validation studies. The present findings may provide some guidance for rehabilitation services looking to implement this method within a broader, biopsychosocial return-to-work program.
Introduction
The concept of ‘work simulation’, or simulated performance of specific job tasks in physical rehabilitation, is well established. The aim is to encourage an individual’s independence and self-confidence in work in a controlled setting, in addition to self-assessment and awareness of risk and re-injury (Franchignoni et al., 2006; Lichter et al., 1992). Early studies report the functional similarity of actual and simulated job tasks to determine fitness to work (e.g., Nadeau & Buckheit, 1995). Customised job tasks have also been used to promote self-awareness of cognitive deficits and re-evaluation of vocational goals following traumatic injury (Voss et al., 2019), as well as increase pain tolerance (Joy, 2001). More recently, work simulation has been successfully trialled as an early intervention to support employees with psychological injuries (e.g., depression, Wisenthal, 2021).
Paramount to this approach are commonly agreed-upon goals between the injured worker and the health provider (Johnson et al., 2001). Simulated tasks should also be graded in frequency and duration to progressively rebuild an individual’s physical and mental capacity to return to work. Equally important is the design of therapy tasks that capture the psychological concept of ‘good’ work, or work that is safe and enables the person to be productive and engaged. A body of literature confirms the close link between appropriately balanced job demands, job controls, and workplace supports with employee health, wellbeing, and productivity (Bailey et al., 2019; Litchfield et al., 2016). The resilience that ‘good’ work instils can also protect against the psychosocial challenges an injured worker faces, including invaluable social connections and emotional support they may otherwise not receive (White et al., 2019).
The use of a technique such as work simulation should, however, be underpinned by consumer feedback. This contextual information can help to inform best-practice in rehabilitation by providing an in-depth understanding of the meaning and acceptability of simulation methods. To date, surprisingly little is known about the acceptability of work simulation. Rather, the few available studies have focused on validity, feasibility and preliminary effects using retrospective database analysis, case reports and experimental research (e.g., Nadeau & Buckheit, 1995; Joy, 2001; Voss et al., 2019; Wisenthal, 2021). We address this research gap in the current study by exploring the experiences and perspectives of injured workers who completed a rehabilitation program based on simulation methods as well as the staff who delivered this program.
Methods
Design
Using a qualitative design, we interviewed injured workers and rehabilitation staff of an accredited return-to-work service provider in South Australia (see also Dorstyn et al., 2023).
Ethical considerations
Following ethics approval, the service provider emailed potential participants an information sheet and consent form outlining the voluntary nature of the study. The written informed consent included approval of audio-recording of the interviews and use of the research data (including individual quotes) after de-identification. We remunerated each participant with a $AUD 50 shopping voucher in recognition of their contribution to the study.
Setting
Return-to-work programs are implemented widely in Australia. These programs incorporate a range of services (e.g., fitness for work, job placement) and are guided by different workers’ compensation authorities within each state jurisdiction (Buys et al., 2015). The simulation program explored in the current study was time-limited and typically delivered over a 6–8-week period. On commencement, an assessment of key return-to-work challenges (e.g., pain symptoms, mood, condition-specific functional status; Cancelliere et al., 2016; Rashid et al., 2017) was conducted and, where applicable, a job-site assessment undertaken. Appropriate simulations were then designed, tailored to each injured worker, with therapy tasks gradually increased in duration and frequency to ascertain workers’ ‘sustainable capacity’. For those unable to return to their pre-injury role, vocational assessments were undertaken to explore alternate roles to simulate. Simulated tasks were performed under the supervision of a physiotherapist in a customised facility offering work environments that mimic real workplaces (e.g., hospital and aged care suite, forklift and warehouse simulation space, office workstation). Session duration and frequency varied, depending on individual needs, ability, and preference. Graded simulation tasks were supplemented with intensive physical training (specific to the job or not), exercise, functional conditioning and, if required, cognitive-behavioural therapy to manage psychological distress and reinforce coping.
Participant selection
Adult clients (18+ years) who had sustained a work-related physical and/or psychological injury or illness and had recently (i.e., last 12 months) undertaken a job-simulation program at the rehabilitation provider, were invited to reflect on their experience. To allow breadth and triangulation of perspectives, we also invited staff and managers delivering this program to participate.
Data collection
A Research Assistant (SW) conducted semi-structured telephone or video interviews using Zoom conferencing software. In addition to demographic and work injury details, injured workers reflected on their experiences and satisfaction with work simulation rehabilitation. Questions for staff centred on the feedback that they had received from injured workers about their work simulation program (see Table 1).
Interview schedule
Interview schedule
Two authors (MO, SW) jointly conducted two pilot interviews to assess the utility of the interview schedule. Both interviews were included in the final analysis as the questions were deemed appropriate, however two additional questions were added at this stage: (1) What existing support did you have before [rehabilitation provider]? and (2) Did your existing support collaborate with [rehabilitation provider]? The remaining interviews were conducted and transcribed verbatim by SW and ranged from 22 to 79 minutes (M = 47.35, SD = 18.79) in duration.
Consistent with best practice qualitative research, the interviewer (SW) maintained an audit trail (Tracey, 2010). Fourteen participants also opted to review their transcripts for accuracy although only three contacted the research team, with none requesting changes. All participants also reviewed the study themes. The combination of transcript and theme reviews allowed for ‘member reflections’ (Tracey, 2010).
Self-reflexivity is also essential to qualitative research (Braun & Clarke, 2019). The research team comprised four registered psychologists (DD, RR, MO, ACH) with extensive experience in health and rehabilitation services, a research assistant (SW) with undergraduate qualifications in psychology, and a rehabilitation counsellor (BF). The psychologists and research assistant were outsiders to the study context, having had no prior contact with the participants, whilst the rehabilitation counsellor was an employee of the participating organisation.
Two authors (SW and MO) analysed the data using a six-step reflexive thematic analysis with an inductive approach (Braun & Clarke, 2021). Both analysts compared their generated codes and initial themes to ensure data consistency and trustworthiness before collaboratively refining, defining, and naming the final themes. All researchers then reviewed and agreed on the final themes.
Results
Sample characteristics
Of 15 injured workers contacted, 13 (10 men and 3 women; aged 30–63 years) participated. Injuries included physical (e.g., joint/ligament/muscle) and/or psychological (e.g., depression, stress) conditions, with a traumatic (e.g., strain, tear) or gradual onset (e.g., spinal disc degeneration). Interviewed staff included three physiotherapists with extensive (> 40 years) rehabilitation experience and a project manager.
Themes
We generated three themes and two sub-themes that focused on the impacts of, and processes behind, successful simulation. Each theme, with illustrative quotes, is discussed below.
Theme 1: Simulation can facilitate successful rehabilitation
Simulation was perceived to facilitate successful physical and psychological rehabilitation. However, to be effective, simulation needed to be carefully planned and modified to meet workers’ changing needs and capacity over time. Critical to this tailored approach was an initial assessment that considered occupation-specific factors:
So, when I had the assessment, it was really comprehensive. There wasn’t much that they didn’t go through and again it would be occupation specific. So, you know whether you were a brickie, or a truck driver, or a nurse, it’s occupation specific so each person would be different, the assessment would be different, the program’s different, it’s individualised. (Participant 17, Worker)
Appropriate simulations were then designed with the worker based on the results of this comprehensive assessment. This collaborative process allowed the worker an opportunity to improve their physical capacity in a controlled, real-world context. At the same time, simulation helped staff determine whether the client could safely perform job tasks:
We can, I guess through actually performing real world tasks, identify people’s true capacity in a safe and controlled environment so decisions are made appropriately according to their safe work ability. So, can someone perform a task? Yes. Can someone perform a task with precautions? Or no, they’ve had an opportunity to try and they’re unable and these are maybe the reasons why or these are the barriers. So, decisions can then be made to help them transition back to, you know, the same job with their same employer or then moving to seek different employment with someone else. (Participant 9, Staff)
Benefits to employers were also noted, with simulation objectively demonstrating whether a worker had the capacity to return to their pre-injury role. Where simulation indicated that this was not viable, clear, and open communication with the worker and their employer was important. Staff explained “give that opinion and then that person can just get on with a new direction sooner rather than floating around not knowing” (Participant 4, Staff) and “that saves time and money for everyone rather than going back to the employer and they’re trying for three months and everyone is getting angrier and angrier” (Participant 11, Staff).
In these instances, simulation could be harnessed to explore alternate careers and whether a worker had the capacity to undertake them:
Rather than doing all that study but like in different occupations studying something else, then realising after you get that qualification you can’t do it whereas in the sake of a week with the simulator and then they find out if they’re interested in it, if they can physically do it. (Participant 3, Staff)
Even when an employer could not facilitate a return-to-work program or offer light duties, simulation allowed workers to rehabilitate in a work environment supervised by multiple health professionals. However, whilst some workplaces and roles were able to assist their employees in return-to-work, this was not possible for others:
And it was great because working for the government they’re not really resourced to bring people back to work, especially trade-related areas they’re just not resourced to do it . . . as big as the government is they cannot bring people back. (Participant 14, Worker)
In addition to improving physical capacity, simulation was seen to alleviate workers’ concerns and provide reassurance about their psychological and physical capabilities:
Honestly, it’s helped me a lot to get that confidence back and, yeah, the mental side of it and knowing I’m doing the things that I do at work as much as I can. (Participant 15, Worker)
Being active participants in a simulation creation also gave workers a sense of purpose. Workers recognised that ‘all those ideas come from the people, the injured and they [rehabilitation provider] listen to those people and they build up the place from the experience of the injured’ (Participant 13, Worker). Input from workers not only improved simulations for themselves but provided a valuable opportunity to help their peers. For example, one worker described the benefit of contributing to the development of safe work method statements (SWMS) - documents that list high-risk work activities in a workplace and necessary measures to control these risks:
I would go there, so get me up out of bed, give me a mission and then that mission was to create SWMS for them, help create them. Look at their, inductions making sure that they worked, and they worked well . . . The end goal what I was creating was actually being implemented, was actually being used . . . that worked for me because I had that mission just like you’re going to work, I had to achieve something, I have to create this because this is needed. (Participant 2, Worker)
At the same time, workers acknowledged that their initial lack of awareness and understanding about simulation as a rehabilitation technique instilled some hesitancy, nervousness, anxiety, fear, scepticism –and even thoughts about it being a “waste of my time” (Participant 17, Worker):
I was anxious what are we going to do, how are they going to help me with my job, how are they going to simulate what I do on the job and transfer that into an environment away from the job basically. (Participant 16, Worker)
Although many of these emotions were overcome with time, they still required consideration when offering simulation:
“At the beginning I was a bit frightened to go there, like the unknown. I thought, this sounds a bit weird, like how’s this going to work, but in the end, for me, it was like the best thing I could’ve gone to you know. (Participant 8, Worker)”.
Theme 2: Multiple realistic simulations are needed to replicate different occupations
Simulation was perceived as an effective but resource-intensive technique, due to the need to replicate diverse occupations and variations within each occupation (i.e., the environment, equipment, procedures). Specific simulations created in this study included retail, hospitality, nursing, aged care, construction, transport driving, warehousing, and furniture removal. Workers considered it important for simulations to evolve continuously, particularly given that some work roles were quite specific and unique:
Absolutely, absolutely because as a boilermaker the trade can be quite varied. Although the tasks as a boilermaker are generally the same, the nature of the work can be quite different. You could be in a confined space environment, you could be in a production environment, could be in a mining environment, for me I work in the rail environment, rail infrastructure maintenance. They needed to know all of that so they can actually simulate how I work and what I do with my work. (Participant 14, Worker)
Workers also recognised that simulation was a ‘stepping-stone’ in their overall rehabilitation and appreciated the effort that went into creating tailored work simulations:
It was all about assessing what I do, how often I do it, what the requirements would be for me, and then build and tailor the program and fabricating machinery, or fabricating devices for me to do the most closely simulated, or to the point where it might be something that’s a little harder . . . so when I actually go to do what I’ve got to do it will be like a piece of cake oh that’s easy . . . [the rehabilitation provider was] constantly learning from the people that do the job as to how to tailor something that best fits them, rather than a cookie cutter approach, or . . . even within like-for-like industries. (Participant 16, Worker)
Despite the importance of simulation training needing to be immersive and realistic, certain occupations were difficult to replicate due to the nature of the work or the equipment used. For example, mining-related occupations were “too far out the realms” (Participant 11, Staff) of simulation due to the size and expense of the equipment. In such instances, micro-skill aspects of workers’ roles could be simulated, such as ‘the amount of steps they’d have to climb, the weights they’d have to carry, the machinery they’d have to handle’ (Participant 11, Staff). The team-based nature of some roles further restricted the ability to offer simulation. Occupations requiring multiple staff were particularly difficult to simulate:
So, I think it may have got to a point where at (rehabilitation provider) it would have been hard to replicate two people carrying a big fridge down a flight of stairs or around a tight corner because I don’t think that they would have been able to do that with me. (Participant 7, Worker)
3.2.2.1. Subtheme 1: Workers’ employers can aid realistic simulation This subtheme focused on the resources required for a simulation program, such as when simulating tasks within the construction industry. Where equipment was lacking, rehabilitation staff would liaise with a worker’s employer –with most willing to assist:
So, we will communicate with their employer and say, ‘hey we’ve got a concreter’, a guy that works in a concrete company that pumps the concrete. So, his roles were carrying the concrete pipes and that sort of thing, so we communicated with the employer, ‘do you reckon we can pick up four, five pipes for a month that we can use in his work simulation’. The majority of the time the employers are happy to work with us. (Participant 3, Staff)
Other employers were unwilling or unable to contribute to a workers’ rehabilitation due to the costs involved, lost income associated with lending materials, and/or difficulties in the employer-employee relationship arising from the workers’ compensation process. Poor cooperation with employers could hinder or prolong a worker’s rehabilitation, with one worker explaining:
Yeah, my boss is a good person but he’s not . . . it’s out of sight out of mind. It’s like well if you come do that [practice using truck] I can’t be making money on the truck sort of thing. (Participant 7, Worker)
3.2.2.2. Subtheme 2: Workers’ knowledge and expertise promotes realistic simulation creation Expanding on Theme 1, this subtheme emphasised the worker’s role in simulation design. Rehabilitation staff recognised that workers had extensive knowledge about their occupation and so encouraged them to create or improve their tailored simulations. Workers often provided photographs to guide simulation creation and showed creativity and initiative by using their contacts to assemble resources. For example, one worker expressed the value of having a curtain-sided truck and made efforts to bring it to fruition:
I’m going to chase up a bloke that’s in the industry that does that sort of repair work to find out what they do with their old curtains, for starters, and see if we might be able to get part of a curtain off a truck he’s going to throw in the bin, sort of thing, and rig it up on a frame so it’s there to simulate pulling the curtains back and forth on a truck. (Participant 10, Worker)
Staff also collaborated with workers to ensure that their occupations, including required tasks and the timing of tasks, were simulated accurately. Mindful of injury constraints, including limits to the time engaged in simulation, sometimes only the most important work tasks could be simulated:
So, we basically sit down and with the worker be like you start at six, seven o’clock, or with the [employer] what are you doing at eight o’clock? What happens at nine? We’ll write out a program and we’ll try and simulate that as close as possible. They’re not going to come for eight hours a day, so we sort of pick the parts out of that that have to be simulated here. (Participant 3, Staff)
Theme 3: Effective simulation involves collaboration with a worker’s existing health professionals
Staff recognised the importance of collaborating with a worker’s existing network of health professionals to maximise recovery and return-to-work. This required early cross-disciplinary communication, with other health professionals invited and encouraged to participate in the simulation as much as practically possible:
As part of our initial assessment, we will actually do an assessment come up with a bit of a plan but then contact the treaters and say, ‘hey look this is what we’re thinking of doing is there anything you’re concerned about, did you want to come out and see them do a session of painting, or welding, or you know dealing cards whatever they’re practicing’. So, it’s trying to create a collaborative multidisciplinary approach to addressing function. (Participant 9, Staff)
Staff acknowledged the complementary roles of all parties involved in a worker’s recovery. For example, whilst the specific role of staff was to test and build capacity for work, existing health professionals would treat the worker over time. Respecting these differences, the staff communicated regularly, updating health professionals and case managers on workers’ progress via email, photographs, videos, and case conferences - an approach highly valued by workers. Staff also collaborated with each of these stakeholders to revise rehabilitation plans:
So, we’ve got our own gym here as well so he [injured worker] wanted to incorporate a gym program into his work simulation. But our physio said that’s not our role with you like we just manage the work sim program and report back to your treating physio. So, he got in contact with his treating physio and his treating physio provided a plan for him to incorporate into his work simulation so we don’t take that work away from them. (Participant 3, Staff)
Collaboration, while highly desired, was challenging. Staff indicated that difficulties sometimes arose when multiple organisations or services were involved in a worker’s rehabilitation, with each professional having a different perception of who was ‘in charge’. In addition to the sheer volume of people involved with any one worker, conflicts in trying to schedule acute health appointments and work simulation were often encountered.
Discussion
The present results provide valuable information on how, and why, work simulations can help rehabilitate injured workers. Both workers and rehabilitation staff that we interviewed perceived simulation as an effective rehabilitation tool, helping to maximise functional outcomes. Diverse simulation scenarios that closely approximated real-world tasks were, however, necessary to ensure success. Simulation was also seen as a collaborative activity that not only drew upon the expertise and knowledge of the injured but required early, inter-agency communication and collaboration.
Consistent with a ‘best practice’ holistic approach for injury rehabilitation (Cameron et al., 2020; Wade, 2020), simulation comprised only one technique within the biopsychosocial rehabilitation program examined in this study. By doing so, workers’ physical rehabilitation and education needs were addressed alongside their psychological support and workplace reintegration needs. As such, the value of simulation was multi-faceted: helping to gradually build one’s physical capabilities whilst providing an empowering learning experience, with workers able to build their self-confidence in return-to-work and overcome fears of re-injury (Cameron et al., 2020).
Key to this holistic approach was cooperation from the individual’s employer, case manager, and extended network of practitioners –each of whom shared responsibilities to help the worker achieve their rehabilitation goals. Staff did, however, note that this cross-professional collaboration is not easy and requires careful attention. Similar challenges have been identified in the international literature, with respectful relationships critical to information sharing and support between rehabilitation providers, employers, health professionals, and injured workers (Skivington et al., 2016). For this reason, continued support and monitoring of the injured worker is important, even after their return-to-work, to sustain effective working relations with all parties (MacEachen et al., 2006).
The complexities of facilitating a well-designed simulation were highlighted. Both physical and technical elements of a job task need to be considered so that the simulation is as realistic as possible. This realism is critical to enhancing performance and effectiveness (Lateef, 2010). Simulation can therefore be resource-intensive –particularly for context-dependent job tasks (e.g., operating a heavy vehicle). For this reason, computer technologies might assist to facilitate safe learning and physical recovery in a low-cost and safe environment. Immersive virtual reality interventions have certainly shown promise in the management of pain and disability for musculoskeletal conditions (Brady et al., 2021), although further controlled studies are needed to determine the value and cost-benefits of using such technology.
Simulation for return-to-work may also benefit from drawing upon the best practice guidelines of simulation in health care delivery and teaching and learning. As an example, the International Nursing Association for Clinical Simulation and Learning has published standards to facilitate high-quality, evidence-based processes (https://www.inacsl.org/healthcare-simulation-standards). These standards emphasise the need for: ongoing professional development for the staff who develop simulations; pre-briefing as well as debriefing (post-simulation) for participants; facilitation methods that match the desired outcomes; systems and infrastructure to support the simulation; measurable objectives to achieve the desired behaviours and outcomes; adherence to ethical behaviours and conduct; and careful, rigorous evaluations of the process and the learner.
Notably, workplace-level factors considered critical to simulation (e.g., team-based competencies, including interpersonal skills), were not identified by our sample. Such elements have been successfully simulated in other settings (e.g., medical education; Herrera-Aliaga & Estrada, 2022). Importantly, the simulation tasks examined in this study were conducted in a setting with injured peers, thereby providing a critical opportunity for social support and teamwork (White et al., 2019). This group interaction also added environmental “noise” (i.e., background noise of a busy workspace) and psychological cues (e.g., cognitively loading with multiple tasks), which helped to enhance the veracity of the work simulation task (Gormley & Fenwick, 2016). Nonetheless, the validation of simulation, as well as knowledge of how it impacts return-to-work processes could be extended by interviewing employers, worker’s compensation authorities, and medical practitioners - all of whom contribute to successful return-to-work (Skivington et al., 2016).
Conclusions
Work simulations within the context of a biopsychosocial rehabilitation program continue to be relevant in the workers’ compensation setting. The success of this approach is contingent on transparent and collaborative rehabilitation goals, replicating aspects of the work role in an immersive and interactive fashion, ongoing monitoring of client progress, and regular communication between all return-to-work stakeholders. Further trials will help to build upon the dearth of research in this area.
Footnotes
Acknowledgments
The authors acknowledge the contribution of Charles James, Research Intern, with the literature review.
Conflict of interest
B. Fedoric is employed by the participating organisation in this study. The remaining authors have no conflicts of interest to declare.
Ethics statement
This project was approved by the University of Adelaide Human Research Ethics Committee (H-2021-208) and conducted in accordance with the Australian Code for the Responsible Conduct of Research, 2018.
Funding
This work was supported by a project grant from the Lifetime Support Authority of South Australia (R21001).
Informed consent
The authors affirm that informed consent was obtained from all participants included in the present study.